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#214 - 📑 Journal Club - The Complete Episode (June 1st 2024)

Hello friends 👋

In this jam-packed episode of Journal Club, neonatologists Daphna and I discuss several impactful new studies in neonatology. First up is an important clinical report from the AAP on infant feeding for people living with HIV. The hosts dive into the nuanced recommendations, which state that while avoiding breastfeeding is still the only way to completely eliminate HIV transmission risk, breastfeeding can be supported in certain cases where the parent has a strong desire after comprehensive counseling and meeting strict criteria like sustained viral suppression. Next, they examine a study linking congenital CMV infection with increased risk of autism spectrum disorder diagnoses, highlighting the importance of screening for this common congenital infection.

A randomized trial comparing video laryngoscopy to direct laryngoscopy for urgent neonatal intubation is also discussed. While video laryngoscopy resulted in higher first attempt success rates, the hosts note some adverse events to consider as this technology becomes more widespread for these critical procedures.

The effectiveness of NICU music therapy on neurodevelopmental outcomes is also covered, with a study finding no significant language benefits at 24 months. The hosts question the impact and necessity of these programs.

Practical coding tips for NICU consultations from a recent paper are shared, with an emphasis on the financial impact of proper billing.

Lastly, the increasing frequency of heat waves and their association with preterm and early term births is explored, underscoring the environmental factors that influence neonatal health.

We hope you enjoy this episode!

Happy Sunday!


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

Pesch MH, Leung J, Lanzieri TM, Tinker SC, Rose CE, Danielson ML, Yeargin-Allsopp M, Grosse SD.Pediatrics. 2024 May 29:e2023064081. doi: 10.1542/peds.2023-064081. Online ahead of print.PMID: 38808409


Abuogi L, Noble L, Smith C; COMMITTEE ON PEDIATRIC AND ADOLESCENT HIV; SECTION ON BREASTFEEDING.Pediatrics. 2024 May 20:e2024066843. doi: 10.1542/peds.2024-066843. Online ahead of print.PMID: 38766700


Bieleninik L, Kvestad I, Gold C, Stordal AS, Assmus J, Arnon S, Elefant C, Ettenberger M, Gaden TS, Haar-Shamir D, Håvardstun T, Lichtensztejn M, Mangersnes J, Wiborg AN, Vederhus BJ, Ghetti CM.JAMA Netw Open. 2024 May 1;7(5):e2410721. doi: 10.1001/jamanetworkopen.2024.10721.PMID: 38753331 Free PMC article. Clinical Trial.


Geraghty LE, Dunne EA, Ní Chathasaigh CM, Vellinga A, Adams NC, O'Currain EM, McCarthy LK, O'Donnell CPF.N Engl J Med. 2024 May 30;390(20):1885-1894. doi: 10.1056/NEJMoa2402785. Epub 2024 May 5.PMID: 38709215 Clinical Trial.


Duncan SD, Lakshminrusimha S.J Perinatol. 2024 May 9. doi: 10.1038/s41372-024-01992-6. Online ahead of print.PMID: 38724604 No abstract available. 


Darrow LA, Huang M, Warren JL, Strickland MJ, Holmes HA, Newman AJ, Chang HH.

JAMA Netw Open. 2024 May 1;7(5):e2412055. doi: 10.1001/jamanetworkopen.2024.12055.PMID: 38787560 



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

Ben Courchia MD (00:00.526)

Hello everybody, welcome back to the Incubator podcast. It is Sunday, journal club is upon us. Daphna, how are you this fine morning?


Daphna Barbeau (00:07.246)

this fine morning. I'm doing really well. Okay, I didn't we didn't talk about this off air, but I'm gonna tell you. Okay, I have made a concerted effort in the last few months to change my sleeping habits, including some of the things I use at night a new comforter, things like that. And my sleep is significantly better. I think it's just, I'm just bringing it up because I wonder if other people in the community struggle.


Ben Courchia MD (00:24.91)



Daphna Barbeau (00:34.862)

with sleep and switching back and forth from days to nights, which is really a struggle for me. So I'm feeling better because I've made all these adaptations to my bedroom.


Ben Courchia MD (00:44.27)

Yeah, I did that. I have paid attention to that specific topic for a while now. And it's like you said, it makes a huge difference. Huge difference.


Daphna Barbeau (00:50.862)

Yeah, huge difference. We got a new bed, we got new curtains, so all the things. Yeah.


Ben Courchia MD (00:57.07)

Blackout curtains. Yeah, that's huge. Yeah. And you have to, I'm sorry to say, but you got to turn off the phone. You got to turn off.


Daphna Barbeau (01:07.566)

You know, I have a hard time with that. That is the thing. I have to...


Ben Courchia MD (01:10.606)

I know, but I also forget sometimes. Yeah, so, but it's hard. Sometimes you forget and you're just falling asleep and then the hospital calls by accident. They're like, sorry, sorry, doctor, but I didn't realize you were off. I went to call Dr. Barbo and it's like, I was just falling asleep.


Daphna Barbeau (01:21.614)

Yeah, by accident. Yeah.


Daphna Barbeau (01:27.718)

I know. Or everybody has this friend group that's not in medicine that they're able to text a lot during the day. I just think it's this.


Ben Courchia MD (01:39.022)

Yeah, I turn off everything, which is why sometimes my team wonders if I'm okay because I'm just off the grid. Yeah. I was actually sick that day, so I was not post -call. But anyway, we have a lot of, there's a lot of big papers today. I'm not exactly sure where you want to begin. Obviously we're going to have to spend a significant amount of the episode talking about this report from the AAP on, because it's a, it's a,


Daphna Barbeau (01:45.23)

I know I had to check on you the other day.


Daphna Barbeau (01:51.245)

I'm sorry.


Daphna Barbeau (01:57.038)

Mm -hmm.


Daphna Barbeau (02:05.742)

Yeah, why don't you start with that? I think that was big. Yeah.


Ben Courchia MD (02:08.494)

Do you want to start with this or do you want to start with something a bit lighter, like an ordov type of...


Daphna Barbeau (02:13.262)

No, I mean, I think when they make a proclamation, we gotta talk about it, yeah.


Ben Courchia MD (02:16.302)

That's huge. Yeah. Okay. Let's do this then. Let's get right into it. So we're talking about this paper published in pediatrics called infant feeding for persons living with and at risk for HIV in the US clinical report. First author is Lisa Abouagy. The second author is my former residency mentor, Dr. Lawrence Noble. So Larry, if you're less, yeah, I signed by PAS. He's always a very nice guy. So if you're listening, Larry, hello. Hello to you.


Daphna Barbeau (02:39.054)

That's cool.


Ben Courchia MD (02:46.19)

And it's a fascinating paper. I'm actually probably going to be reading most of it, but I've selected passages that I thought were very impactful. So the background is always interesting. I love these clinical reports for their background sections because it puts everything in perspective in the U .S. Every year, nearly 5 ,000 individuals are capable of becoming pregnant, are newly diagnosed with HIV infection, and nearly 5 ,000 people with HIV give birth in the U .S. So it's a lot.


It's not a negligible number. We know that for neonates, breastfeeding is best, right? But the potential for HIV transmission via human milk is what has prompted the CDC to make the recommendation against breastfeeding for people with HIV in the US since, do you know when that recommendation came out, Daphna? Can you venture a guess? 1985. So it's been a while. I mean, I was like, yeah.


Daphna Barbeau (03:41.998)

I guess that makes sense if you think about the, when the, you know, he's pandemic. Interesting.


Ben Courchia MD (03:47.054)

And so they mentioned how, meanwhile, low and middle income countries have developed guidelines that differ from those of the high income countries. So you all know this, but obviously you should, if you don't, let's put that out there so that there's no confusion moving forward. The recommendation to not breastfeed in the US is not the same in low income countries. So studies in resource limited settings demonstrating increased morbidity and mortality in HIV exposed infant receiving replacement feeding. So.


formula or non -human milk alternative prompted the WHO to recommend that in these settings, without the availability of safe drinking water and accessible formula, people with HIV should actually breastfeed. And so it's an interesting situation, I guess, where the resources of a country are precluding from potentially the best alternative because how are you going to prepare a formula if you don't have drinking water? It's really a problem. So...


Daphna Barbeau (04:43.982)

Yeah, it's really a balance, right? Rock and hard, please.


Ben Courchia MD (04:46.486)

And in the US where we do have formula and safe drinking water and so on, malnutrition is rare and mortality with respiratory or GI infections are low. And so the risk of HIV transmission has historically been believed to outweigh the benefits of breastfeeding. And that's a, I think that's a statement, right? That's the statement where that was, has been the conscious decision of the authorities to say breastfeeding may be good.


but it's not better than having a baby potentially infected with HIV. Now, interestingly enough, in 2023, last year, the Department of Health and Human Services panel on the treatment of HIV during pregnancy and the prevention of perinatal transmission updated its recommendation to provide guidance for people with HIV who would want to breastfeed. The decision does recognize the widespread use of early and more effective antiretroviral treatments, ARTs, in people with HIV.


and a clear understanding of the risk of HIV transmission via breastfeeding. But I must say that the recommendations are sort of like, they're wimpy, right? So when you go to the HHS, if you look at the recommendation, no, but I'm saying it's funny because I'll, so replacement feeding, so when they say replacement feeding, they mean like formula with properly prepared formula or pasteurized milk eliminates the risk of postnatal HIV transmission in the infant, right? So they say that. So it's like, well, that's the cure.


Daphna Barbeau (05:55.918)

Careful, careful.


Daphna Barbeau (06:05.358)

Mm -hmm.


Ben Courchia MD (06:15.694)

achieving and maintaining viral suppression through antiretroviral therapy during pregnancy and postpartum decreases breastfeeding transmission to less than 1%, but not zero. So they say this as if saying like, yeah.


And so they say that the replacement feeding with formula or bank pasteurized donor milk is recommended to eliminate the risk of HIV transmission through breastfeeding when people with HIV are not on antiretroviral treatment and or do not have suppressed viral load. So they say all these things and then they say, however, individuals with HIV who are on antiretroviral treatment with sustained undetectable viral load who would choose to breastfeed should be supported in this decision. So it's like, well, how, how do we do that? Like this.


So I think the AP report is very much welcome because it's going to actually start deciphering a little bit of that. So the things that I just read are from the HHS website. They talk a lot about opt -in testing and opt -out testing. I mean, depending on which state you practice in, this is basically telling people that they're automatically going to get screened for HIV unless they voluntarily opt out instead of having a policy where you have to have people voluntarily opt in, where they have to demand the HIV test. But I'm not going to get too much into that.


So what are the risks of HIV transmission to the infants through breastfeeding? So globally, there's an estimated 30 % of perinatal HIV transmission that occur through breastfeeding, which is staggering, primarily from persons with HIV who are not on any form of treatment or who are on treatment, but not really virally suppressed. So 30%, this is terrorizing.


Daphna Barbeau (07:39.31)

Mm -hmm.


Ben Courchia MD (07:52.558)

In the absence of antiretroviral treatment or infant prophylaxis, the risk of HIV transmission to infants through human milk appears to be the highest in the first four to six weeks of life, ranging between five to six percent. Transmission risk is higher for people who acquired HIV during lactation than for those who had a pre -existing infection. And we'll talk more about these scenarios because, I mean, to be honest, I don't really think about these things often, but what if the mother is at risk of contracting HIV?


but they tested negative until then. What if they are in the midst of catching HIV as they would like to breastfeed their baby? It's the worst possible scenario. Studies in both high and low and middle income settings have demonstrated that either retroviral therapy used by breastfeeding people with HIV and or infant prophylaxis during breastfeeding significantly reduces postnatal transmission risk to less than 5%. The risk is less than 1 % among people breastfeeding who are on treatment with the suppressed viral load.


Daphna Barbeau (08:22.286)

Mm -hmm. Mm -hmm.


Ben Courchia MD (08:52.078)

So I guess the key here is to mention how low it is, but also to mention how it's not zero, basically. The PROMIS study, they mentioned the PROMIS study, which was published, I think, in 2018, which looked at like six African countries and India, and basically looked at how the importance of maternal treatment and baby prophylaxis, but I'm not going to get into that. What they're talking about is that despite the demonstrated benefits of antiretroviral medication for prevention of perinatal HIV transmission,


Neither ART is the antiretroviral therapy in the breastfeeding person, nor antiretroviral prophylaxis in the infant completely eliminates the risk of HIV transmission during breastfeeding. And it's been documented. They're saying that although rare, it has been documented that despite viral suppression, undetectable plasma HIV RNA concentration, breastfeeding transmission has been reported to occur.


There are also reports of low level detectable HIV virus, like less than 100 copies per ml in human milk, while the plasma viral load is undetectable, meaning you do the sample in the blood, but it's not reflective of what you see. I know there's a lot of things like this in this report, which is why I'm reading so much from it. But although the clinical significance of this in terms of transmission is unknown, so you may say, well, can we just test the milk? But even then, we're not sure if...


Daphna Barbeau (09:58.766)

Well, I didn't expect to hear that.


Ben Courchia MD (10:14.126)

if those copies really play a significant infectious role. So they conclude this section by saying that in the US, the AAP recommends that complete replacement of human milk with infant formula or certified banked donor human milk are the only infant feeding options that completely eliminate the risk of postnatal HIV transmission via human milk. I'll go over each individual recommendation at the end of this paper.


Addressing the desire to breastfeed among people with HIV in the United States. That was a fascinating section. What if the person says, I would like to breastfeed my baby? In the US, there's a growing number of people who with HIV who would like to breastfeed with motivations, including a desire to bond with their infant, an opportunity to provide optimal infant nutrition and health benefits, the ability to fulfill their role as a parent and the need to meet cultural expectations, which I think we should not underestimate.


Importantly, some people with HIV report concern that within their communities, not breastfeeding will effectively disclose their HIV status to families and friends. Never thought about it in those terms.


Daphna Barbeau (11:25.582)

Yes, so I mean you can imagine the pressure, right?


Ben Courchia MD (11:28.526)

Yeah. Other interesting scenarios among immigrants and refugee population, which is something we're dealing with in the U .S. right now, the discordance between infant feeding guidelines in the U .S. and their home country may be resulting in confusion, especially among parents who breastfeed, who breastfed their previous infants. Some of these parents may actually plan to return to their home country postpartum and will have difficulty adhering to United States guidelines after returning home.


The potential for health disparities has also been considered as it relates to the guidance to avoid breastfeeding in high income countries. People with HIV are more likely to be black and other people of color who are already at higher risk of morbidity and mortality associated with diseases such as obesity, asthma, diabetes, avoidance of breastfeeding, which is protective against these conditions could compound the risk of adverse health outcomes in an already vulnerable population. Another very interesting point. Finally,


Another interesting point they're making that some providers have reported that people with HIV who desire to breastfeed and who are not supported by their medical team may breastfeed without disclosing their to their medical team. And they might just do it anyway. This practice may result in an in an inability of the medical team to offer support to monitor to to monitor and to reduce the risk of breastfeeding transmission and risks disengagement from care.


All sounds very, very interesting stuff. So the bulk of the section that's coming up is basically how do we manage them? So infant feeding discussions should begin as early as possible. And I think that's one of the key recommendations and should involve a multidisciplinary team that might include the pediatric primary care provider, the pediatric HIV expert, the breastfeeding parents and...


the breastfeeding parents, the care, the obstetric providers and lactation consultants. It should be clearly communicated to the families. And I think that's something that we should remember. It should be clearly communicated that replacement feeding is the only option that truly eliminates HIV transmissions. The parents' motivation for breastfeeding should be explored and counseling provided on the risks and benefit of each feeding option, including breastfeeding.


Ben Courchia MD (13:53.806)

formula feeding or donor milk feeding. Every effort needs to be made to provide counseling to people with HIV and their partner in a non -judgmental respectful way recognizing potential drivers for their decisions such as avoidance of stigma, prior experience with breastfeeding and cultural contributors. Now, parents who desire to breastfeed should be informed.


that although the risk of HIV transmission via breastfeeding is likely highest in the first four to six weeks, there is a smaller but ongoing risk of transmission throughout breastfeeding. So if the question arises to say, well, if we know that the highest risk is four to six weeks, could I just pump and dump for that time and then resume at that time? Well, technically you're still not in risk zero land yet.


Anti -retroviral therapy that results in a non -detectable viral load significantly reduces the risk of transmission via breastfeeding, but there are rarer cases of HIV transmission in the absence of documented HIV in the plasma of breastfeeding persons at the time of HIV infection is identified in the infant. Additional information to discuss during counseling should include certain situation that may increase the risk of HIV transmission via human milk, such as thrush, mastitis, mixed feedings,


But importantly, there's no data on whether these scenarios increase transmission in the setting of effective therapy and a suppressed viral load. I think the key word, one of the things that comes back often and often during this section is really work with a multidisciplinary team. Like these patients need a team. You cannot take this on by yourself. There's really no consensus on the optimal composition and duration of infant antiretroviral prophylaxis during breastfeeding.


And this question is unlikely to be answered through prospective clinical trials, given the already very low risk of transmission through breastfeeding who are on fully suppressive ART. And so the question is, should we go, should we start giving these babies longer prophylaxis beyond six weeks? And the answer to that is we don't know. So if that question comes up, should I keep my baby on the meds for longer? We don't know if that's the right thing to do or not.


Ben Courchia MD (16:11.47)

Prolonged prophylaxis, however, is recommended by some HIV experts. So you would have some grounds to recommend this based on these experts as an additional layer of protection, particularly in circumstances of small viral load increase or episodes of viral non suppression in the breastfeeding person. The desired duration of breastfeeding should be discussed and the timing of transition to the infant formula, complementary foods and whole milk should be addressed depending on the infant's age at the time of weaning.


Importantly, they should not stop cold turkey. Weaning should be very gradual. There's a lot of papers talking about how abrupt weaning from the breast actually increases the risk. And so it should be done by transitioning to formula or other age appropriate diet over two to four weeks. Possible approach is actually to recommend replacing one daily feeding with formula every three to four days.


So some very practical information in this paper. What about pasteurization? What if the parent says, I'm going to flash heat my milk to flash heat pasteurization? And well, in terms of that, number one, by the way, flash heating pasteurization, if you're wondering, it's basically heating milk in a water bath and then removing it when the water reaches a boil and then allowing it to cool. Well.


It has been studied as a potential method for pasteurizing expressed human milk. However, although flash heat pasteurization destroys cell -free HIV, it may not destroy all cell associated with HIV in human milk. So unfortunately not a solution either. And then they have, that was probably the most valuable piece of information, for additional guidance on the counseling and management of breastfeeding in people with HIV, accessing the HHS.


Panel guideline is recommended as well as consultation with local HIV experts. And there's actually a hotline. So 1 -888 -448 -8765. You can call and they'll help you work through some of these questions. Before we wrap up this paper with a bunch of the recommendations, there's like some special considerations, which you may say like, should we just skip that? But they're kind of frightening as well. Acute HIV infections during breastfeeding.


Ben Courchia MD (18:23.534)

Acute HIV infection during postpartum period among breastfeeding people contributes a substantial proportion of new pediatric HIV infections globally. Acute HIV infection while breastfeeding is associated with an increased risk of HIV transmission compared with breastfeeding among people with chronic HIV infection. So that's something that you should be on the lookout to. There's a whole section. I mean, there's a lot of stuff obviously that we won't deal with as neonatologists about like recommending PrEP based on...


the status of the spouse and so on and so forth. You hope obstetrics and primary care will take care of, but it's there if people are interested in reading about it. Another interesting special consideration, pre -mastication of food by persons with HIV. So like, you know how you chew your baby's food before giving it to them? Well, pre -mastication or pre -warming in the mouth of food given to infants and toddlers have been reported in the U .S. Cases of probable HIV transmission to children.


via pre -masticated food has been reported in the US. However, all these cases were either from persons with HIV infections diagnosed before the implementations of effective lifelong ART and routine HIV viral load monitoring or people with unsuppressed HIV. And it's also like, do they have sores and stuff like that that could explain why there's some, yeah.


What if there's accidental exposure to human milk from a person with HIV? So they give you the CDC website on how to manage accidental exposure. Yes, HIV transmission from a single human milk exposure. So HIV exposure from a single HIV transmission from a single exposure has not been documented. Overall, the risk of HIV transmission in the case of an infant consuming human milk from a person other.


than the biological parent is low because in the US, hopefully many people know not to do that. Certified banked donor milk is also unlikely to contain HIV as they screen of the milk donors and heat treatment of the milk is performed by the milk banks. And then they talk about the sharing of non -pasteurized human milk among friends and internet -based stuff. That is discouraged, Tafna.


Ben Courchia MD (20:46.062)

Yeah. So let's go through, I'm going to read to you the final list of recommendations. There's a lot of them, but I think this is, so I think now you get a sense of all the things that were discussed. And I think, yeah, so I'll give you one more comment at the end. So we should all be aware of the potential risk of HIV transmission during the antepartum, antepartum and postpartum periods for infants born to people with HIV.


We should be aware of the recommendations of routine opt out HIV testing for all pregnant people in the U .S. For any person in labor postpartum with or postpartum with undocumented HIV infection status during the index pregnancy, you must perform HIV testing as soon as possible unless the person declines. If they are positive, infant feedings should be discussed. If the person desires to breastfeed, it should be expressed and stored until you can get a confirmation.


that the test result is available. The infant should receive formula or certified banked donor milk while awaiting the confirmatory test. You can continue doing skin to skin. You can call the national hotline. You should initiate a prophylaxis in that neonate within six hours. If the infection is ruled out with confirmatory testing, then breastfeed. If acute HIV is suspected, an RNA polymerase PCR should be obtained as part of the confirmatory test before you can...


begin breastfeeding. So if you have a negative and you still suspicious, if the rapid results are negative, then you start breastfeeding. If rapid HIV testing during labor, I'm so sorry, my iPad is not silenced.


Ben Courchia MD (22:27.118)

Okay, if HIV testing during labor is not available, or that the pregnant person declines testing, providers should consider potential risk factors versus the benefit of early breastfeeding. Now, for pregnant and postpartum people with HIV, we should advise people that the only way to truly eliminate the risk of transmission is by completely avoiding breastfeeding. And I think that's something that we really have to emphasize because this paper comes out and the...


rumble around the hallways of the hospital is that, it's now okay to breastfeed babies born to HIV mothers, which is not really what they're saying because they're not moving away from this recommendation that you don't truly eliminate HIV transmission unless you're replacing. Healthcare providers should explore the barriers to replacement feeding. Why would they want to breastfeed and not use formula? We should be prepared to counsel patients with HIV.


who express a desire to breastfeed their infants. The counseling should include the reasons for wanting to breastfeed. We should educate the parents regarding the potential risks of HIV transmission throughout the duration of breastfeeding and inform the parents that antiretroviral treatment and baby prophylaxis significantly reduce but do not eliminate this risk. Now, breastfeeding should be supported for people with HIV when parents have a strong desire for breastfeeding.


after comprehensive counseling. So I'm sure that in documentation, this is something we're going to have to add. And if all of the following criteria are met, anti retroviral therapy is initiated early or even before the pregnancy begins. Again, we need all these criteria. There is an evidence of sustained viral suppression in the parent. What does that mean? Viral load less than 50 copies per mL. Number three,


the parent demonstrates a commitment to consistently taking their own treatment and to be giving the prophylaxis to the baby and that the parent has continuous access to antiretroviral treatment, which obviously sometimes can be an issue, insurance and so on. So all these four conditions treatment on the mother started during the pregnancy or even before sustained viral load, less than 50 commitments to continue treatment on both mom and baby and continuous access.


Ben Courchia MD (24:55.15)

to the treatment for mom. We need a multidisciplinary team. Providers should recommend the following strategies to reduce the risk of HIV transmission via breastfeeding. Obviously,


Ben Courchia MD (25:10.254)

Exclusive breastfeeding through the first six months, continuous antiretroviral therapy for the breastfeeding parent with sustained undetectable viral load throughout the duration of breastfeeding, regular assessment, prophylaxis for the baby, consultation with an HIV expert, gradual weaning as we spoke about. Infants should be screened for HIV using nucleic acid testing at 14 to 21 days, one to two months, four to six months of life, and then every two months throughout lactation and


at four to six weeks and three to six months after weaning. So quite of an extensive schedule for these babies. Breastfeeding infants who receive extended prophylaxis beyond the usual six weeks should periodically be screened for hematologic and liver toxicity. Let's not forget about the side effects of these medication as these complications can be associated with ARV drugs that are commonly used for infants. A decision to breastfeed by a person with HIV who is on


antiretroviral therapy and who's virally suppressed should not constitute grounds for referral to child protective service agencies. So do not call DCF or whatever you call it because a person wants to breastfeed. Breastfeeding is not recommended for people with HIV who are not taking treatment and who do not take or who do not take their antiretroviral treatment consistently.


people without a sustained undetectable HIV viral load or people newly diagnosed with HIV infection in pregnancy or postpartum. This is very important. Parents with HIV who are not virally suppressed should avoid pre -masticating food for their infants. This recommendation should be discussed in a culturally sensitive and non -judgmental manner. We did this with my daughter. I mean, we pre -chewed her food. That's something that we did back home as well.


For pregnant people who are postpartum, they don't have HIV, but they are at high risk of having HIV, like what? Like people who inject drugs or people who have sex with a partner living with HIV. Counseling is very important. Frequent HIV testing should be performed during pregnancy and breastfeeding. Education about HIV prevention should be given, prep and so on. If acute HIV infection is suspected in the person who is breastfeeding, you should


Ben Courchia MD (27:31.598)

not consume the baby should not consume human milk until HIV has been ruled out. If once it's ruled out, you can resume. If HIV infection is confirmed, then you stop and you go through the testing, consultation, and so on and so forth. I've just been speaking for 27 minutes. I'm going to stop here, but it's a very important paper. It reads very nicely and it's not a paper that says it's okay to breastfeed babies.


who are born to mothers with HIV, it has a lot of nuances.


Daphna Barbeau (28:05.87)

Well, I think two things. I think you're right, highlighting that it's not just that the previous recommendations are out the window, but recognizing that there is a group of parents who are low risk, and then we do shared decision making with them. And so I think this provides a good foundation for that shared decision making, and outlining those, what was it, four to six,


see one, two, three, four, six kind of points about what that would look like logistically, and what is the viral load, which is very, very low. You'd need a very, very low viral load to do that. So I think it's less than 50. So I think this is very up -haul.


Ben Courchia MD (28:43.534)

Mm -hmm.


Ben Courchia MD (28:53.102)

Less than 50, right? That's what we said.


Daphna Barbeau (29:01.134)

Are you tired?


Ben Courchia MD (29:02.318)



Daphna Barbeau (29:06.062)

Okay, all right. Well, then I'll go I'll talk a little bit. Thank you for for doing that one I think that's something people definitely need to know about because I think they're gonna be asked about it on the regular coming up So I had a paper that you put in the folder that I thought was a really interesting autism spectrum disorder diagnoses and congenital cytomegalovirus lead author Megan Pesh and


This is in, well gosh, I did not, I think so too, but I don't want to, okay, thank you. I'll keep going. Yeah, it's pediatrics, yes, okay. So the objective was really to look at the association between congenital CMV and autism spectrum disorder diagnoses here in the US. So.


Ben Courchia MD (29:38.414)

I think it's in pediatrics.


Yeah, it's in pediatrics. I'll find it for you. You keep going.


Daphna Barbeau (30:02.51)

I too was going to share a little bit of background. You know, we think about CMV in the NICU. It's rarely CMV, even though we test for CMV a lot. But this is even in the kind of quote unquote healthy population. So congenital CMV is still the most common congenital infection in the United States. It affects one in every 200 live births.


And approximately 10 % of infants with congenital CMV are born with symptomatic disease. So having clinical laboratory or kind of neuroimaging abnormalities and congenital CMV is associated with a heightened risk of cerebral palsy, epilepsy, intellectual disability, and sensory neural hearing loss. But only 10 % of those babies with congenital CMV are born with symptomatic disease. That means 90 % are asymptomatic.


So does still require us to really think about it. And as many as 15 % of children with asymptomatic congenital CMV infection develop sensorineural hearing loss by age five years. So definitely still at risk for some of these major comorbidities. But they wanted to look even further, see what other associations, especially that with autism spectrum disorders. So they really...


hold data from the 2014 to 2020 administrative data from the Medicaid Statistical Information System. So the study population consisted of children who were continuously enrolled in Medicaid or the CHIP program from birth through greater than four years to less than seven years. So they were in the program at least from birth to four years old. They looked for CMV diagnosis based on the diagnostic code recorded within


45 days of birth, so that's how they felt it was sure to be congenital CMV. And then autism spectrum disorder was defined as two or more inpatient or outpatient visits with diagnostic codes for ASD greater than six days apart at a minimum age of one year. And then they wanted to look at these co -occurring diagnoses that have previously been reported to be associated with congenital CMV and autism spectrum disorder.


Daphna Barbeau (32:20.046)

So they lived a preterm birth, low birth weight, hearing loss, CNS anomaly or injury, and that was diagnosed as brain anomaly or microcephaly within 45 days of birth, cerebral palsy, epilepsy, or choreorectal.


So they had nearly 3 million children, 2 ,989 ,659 children who were continuously enrolled in Medicaid or CHIP from birth through that greater than four to less than seven years included in the analysis. They identified 1 ,044 children with congenital CMV and 74 ,872 children with autism spectrum disorder.


So the prevalence of diagnoses of congenital CMV was similar by sex, but varied by region with a lower prevalence in the West as compared with all of the other regions. And some other findings, the prevalence of diagnosed ASD was higher in males than in females. That is something we know to be true that 37 .2 versus 12 .3 per a thousand children and higher in the Northeast as compared to all of the other regions. So.


Moving on, the prevalence of both congenital CMV and autism spectrum disorder diagnoses were higher among children with diagnoses of preterm birth and low birth weight, those with low birth weight only or preterm birth only compared with children who are not coded as either preterm birth or low birth weight. So they found those to be individual associations.


Interestingly, the prevalence of CNS anomaly or injury codes and hearing loss were also higher among children diagnosed with congenital CMV or ASD. And they give a nice example here. Hearing loss was 45 times as prevalent among children with congenital CMV. Hold on, let me read this again. 45 times.


Ben Courchia MD (34:21.454)

Ha ha ha.


Daphna Barbeau (34:27.118)

This sentence is confusing, but this is what I think they're saying. The hearing loss is 45 times as prevalent among children with congenital CMV and five times as prevalent among children with autism spectrum disorder than among those without those diagnoses. Then they wanted to look at the children who were diagnosed with congenital CMV, were they more likely to subsequently have a diagnosis of ASD? So they use these Kaplan -Meier curves.


And among those who had an ASD diagnosis, the median age of the first claim with an ASD diagnosis was 39 months for children with a congenital CMV diagnosis and 37 months for children without a congenital CMV diagnosis. So they did find that children with a congenital CMV diagnosis were more likely to subsequently have a diagnosis of ASD.


The overall prevalence of ASD diagnosis at the end of the study period was 64 .2 per 1 ,000 children with a congenital CMV diagnosis as compared to 25 per 1 ,000 for children without a congenital CMV diagnosis. Then they made some other stratification. Stratification by sex revealed a much stronger association between congenital CMV and ASD.


This was actually observed for females as compared to males. So for females an adjusted hazard ratio of 4 .65 compared to males and adjusted hazard ratio of 1 .95, which is interesting because again, ASD is much more commonly seen in males than females. Stratification by preterm birth and low birth weight resulted in slightly lower adjusted hazard ratios.


Stratification by CNS anomaly or injury revealed larger but not statistically significant differences with an adjusted hazard ratio of an ASD diagnosis among children diagnosed with congenital CMV of one. And in the stratum with CNS anomaly or injury of 1 .6. So I think, I mean, I think this is interesting prognostic.


Daphna Barbeau (36:39.502)

Lee, this association, I think the take home point is that there is definitely an association between congenital CMV and autism spectrum disorders. And that both of those diagnoses were higher in infants with preterm birth and low birth weight, you know, for some of our special populations.


Ben Courchia MD (37:02.99)

I mean, it goes back again to this multifactorial nature of autism spectrum disorder, where is it a combination of genetics, infection, it's a little bit of everything. It's quite frightening, but I don't know what your thoughts are on the fact that, again, I don't think it changes our perspective on CMV, but it does maybe change our perspective on CMV screening.


Daphna Barbeau (37:07.534)

Hmm. Mm -hmm.


Daphna Barbeau (37:25.902)

Yeah, I agree with you. I mean, I think if you're even thinking CMV, just test for it because I think the prevalence is much higher than we think. And I think that the anticipatory guidance is important, especially that frequent hearing screening, which is a major cause of morbidity.


Ben Courchia MD (37:43.502)

Yeah, and I think it's easier today, right? I mean, somehow, maybe my center did not have this, but I don't remember that I could test from the saliva as a resident, for example. And now it's fairly easy. You swab the cheek, and you're able to send CMV testing. That's quite nice. Yeah, I mean, I don't know what your thoughts are on that, but.


Daphna Barbeau (37:47.502)



Daphna Barbeau (37:54.414)

Mm -hmm.


Daphna Barbeau (38:07.726)

Yeah, no, no, I agree. I mean, we like, I think not many nurseries have moved to universal screening, but I think a lot of nurseries are moving at least to universal screening for those babies who fail hearing exams. So I think that's a start. But, you know, what did I say the rate was? One in 200, right? So, and 90 % are asymptomatic. So.


Ben Courchia MD (38:22.574)

Yeah, like a targeted type of screening.


Ben Courchia MD (38:29.454)

Mm -hmm.


Daphna Barbeau (38:35.15)

I mean, I guess somebody will have to do a cost benefit analysis, but I don't think it would be unreasonable to do universal screening. But that's just my perspective.


Ben Courchia MD (38:43.086)

Yeah. Yeah. Fair enough.


Daphna Barbeau (38:47.662)

okay. Are you ready to go again?


Ben Courchia MD (38:48.942)

All right. Yeah. I want to bring up a paper that was published in the New England Journal of Medicine, and it is called, where did it go? there it is. It is called Video versus Direct Laryngoscopy for Urgent Intubation of Newborn Infants. First author is Lucy Garotti. Maybe I'm pronouncing this incorrectly. Sorry about that. This is a study where they perform the trial to determine whether...


Daphna Barbeau (39:07.534)



Ben Courchia MD (39:17.07)

indirect laryngoscopy with a video laryngoscope would result in increased success on the first attempt at urgent oral endotracheal intubation in neonates. This was a single center study, randomized clinical trial at the National Maternity Hospital in Dublin. It's a university hospital in Ireland with approximately 7 ,000 births per year. Now,


who intubated these kids. So at the hospital, infants are intubated by doctors in training in pediatrics and neonatology. So I guess the equivalent of like pediatric residents versus neonatal fellows who rotate through the hospital for six or 12 months and by neonatologist. So I think this paper appeals to a lot of centers who are training rounds for future physicians. Now,


Before this trial began, the mode of intubation was basically just direct laryngoscopy. You put the blade in, you visualize the cord, you put the tube in. Now they brought in this new tool, which is the CMAC, which is this video laryngoscopy. We use the CMAC at our hospital, so we're familiar. It's a great tool. And they basically enrolled any baby of any gestational age in whom intubation was attempted in the delivery room or in the NICU as potentially eligible for this study.


If they had any upper airway anomalies or they had other congenital issues, they would be excluded. They were randomly assigned one -to -one to undergo intubation with the video laryngoscope or direct laryngoscopy. And then they stratified by gestational age by looking at the preemies who are less than 32 weeks and the babies who are more mature who are above 32 weeks. There's no algorithm that they provided in terms of how did they decide to intubate. So whether the kids needed to be intubated really, like you want to know, it's the discretion of the physicians there. Now, what is the...


pecking order for intubations. Intubation was usually first attempted by a doctor in training in pediatrics or neonatology. So the resident or the fellow made the attempt. They were allowed the maximum of three attempts and then a neonatology could intubate at any moment with that their discretion. I didn't get three attempts as a trainee. Did you get three attempts?


Daphna Barbeau (41:27.31)

No, I'm shaking my head, definitely not. Maybe, maybe, maybe once or twice, depends on the attending, but not usually.


Ben Courchia MD (41:32.366)

If the attending was running late, you may have gotten three intubation before they rushed into the room. But no, and would I interestingly enough, so then I was, I was thinking about this as I was reading, I'm like, I didn't get three, three attempts. And then I looked back and I was like, look yourself in the mirror, buddy, because would you give three intubation attempts to a train?


Daphna Barbeau (41:52.206)

Yeah, I was not planning on disclosing that, but I wouldn't either. I mean, listen, training is absolutely critical, but we but it is in balance with doing the right thing for the patient. Right. So, you know, you don't I'm sorry.


Ben Courchia MD (41:54.35)



Ben Courchia MD (42:04.014)

Yeah. Yeah. Yeah, I think I'm usually a two attempt type of person.


Daphna Barbeau (42:11.15)

Yeah, I think you get to look twice and then that's that.


Ben Courchia MD (42:13.294)

I give you one attempt, corrective feedback, second attempt, and usually then my level. It's not anybody's fault. It's my level of comfort goes out the window and I'm like, I can't stay here like this anymore. So they used to premedicate for intubation if they happened in the NICU. So they used to have phenol atropine and sucks for the kids in the NICU, obviously in the delivery room, not so much. Decision to use stylet at the discretion of the clinician. Do you, did you use stylet as a trainee?


That was a big adjustment. I was very proud of the fact that I was a good Intubator as I entered Fellowship. Because I had seeked out these Intubations. So when I arrived, I was like, I know how to Intubate. And then they passed me a tube without a stylet. And I'm like, what kind of joke is this? Where's the rigidity here? And they're like, we don't use stylets here. And I was like, god damn it.


Daphna Barbeau (42:43.278)

Yeah, you know I like a stylet.


Daphna Barbeau (42:50.35)

Mm -hmm.


Daphna Barbeau (43:05.838)

But you know, I found I was trained with stylet's, I like stylet's, but I've actually found some intubations are easier without a stylet. I don't know.


Ben Courchia MD (43:16.045)

I don't know.


they did not receive, that was an important piece of information in the methods, they did not receive supplemental oxygen during intubation attempts in either group. Which is interesting because the New England is where that paper came out where if you give them a little bit of CPAP or high flow then the intubations are a little bit easier. Anyway, the outcomes.


Daphna Barbeau (43:35.47)

That's right.


Well, I think especially if you're worried there may be more than one attempt, then it would be nice to have an extra support.


Ben Courchia MD (43:42.51)

Agreed, agreed. They are very upfront about this. They mention it in the limitations and they even mentioned that in the next phase of this potential type of study, this is what they will include. So they know, but I would just mention it. The primary outcome is obviously successful intubation on the first attempt and then they had a bunch of secondary outcome, lowest O2 sat during the intubation attempt, lowest heart rate, number of attempts to...


to intubate successfully, duration of the successful attempt, and so on and so forth. So they had about 200 neonates. 43 % were born before 28 weeks of gestation. So they had some small babies in there. 67 % were born before 32 weeks. 30 % underwent intubation in the delivery room, 71 % in the NICU, and 69 % received the medication before intubation was attempted. I was very impressed by that.


No matter how good we are with pre -medicating these babies, I don't think we all are doing such a good job and it's not easy to have this rolled out. So the fact that they had 70 % of kids medicated is kudos to them. They were able to analyze data on 107 neonates in the video laryngoscopy group and 107 in the direct laryngoscopy groups. The majority of intubations were the first intubation for all these babies on the first day of life. And who attempted the intubation? So 32 doctors in...


Daphna Barbeau (44:47.758)

Mm -hmm. Mm -hmm.


Ben Courchia MD (45:06.99)

32 residents in pediatrics made 136 attempts ranging from 1 to 10. Nine fellows in neonatology made 67 attempts and four attendings made 11 attempts. So primary outcome, significantly more neonates in the video laryngoscopy group were successfully intubated on the first attempt than in the direct laryngoscopy group. Successful intubation on the first attempt occurred in 74 % in the CMAC.


the Visual Dura -Lara and Glossy Group compared to 45 % in the regular group. By the way, if you're wondering what size blade they were using, like all that stuff is in the methods. I'm not gonna bother you with whether they had the zero, the double, like all these details are in there. In terms of adverse events, and this is when I'm gonna...


Daphna Barbeau (45:43.886)

Mm -hmm. Mm -hmm.


Daphna Barbeau (45:52.014)

And there are some video laryngoscopy setups that have, I understand, zero, double zero, and I saw a triple zero the other day, so.


Ben Courchia MD (46:01.486)

Yeah, yeah, they may not be the same one that they used in the study, but they definitely exist. So let's look at the adverse events, because I think that now that we say, much better rate of first attempt intubation, you're like, this is cool. But then I'm going to give you the adverse event. I don't know now. So the median lowest O2 sat in the first intubation attempt was 74 in the video laryngoscopy group, 68 % in the direct group. So not so much in terms of O2 sat. Oxygen saturation less than 70 % was observed.


in 45 % of the babies that were undergoing the video laryngoscopy compared to only 53 % in the direct laryngoscopy group. So they were less likely in the direct laryngoscopy group to desat lower. So they reached less than 70%. 53 % of the time when you were doing the direct laryngoscopy, only 45 % in the video laryngoscopy. The median lowest heart rate during the first intubation, 153 in the video group, 148 in the regular.


Some may say not statistically significant. Daphna will say I'm looking at these 2 % difference carefully.


Daphna Barbeau (47:18.638)

Something to think about.


Ben Courchia MD (47:19.15)

No real difference in oral trauma. In terms of secondary outcomes, the median number of attempts to achieve successful intubation was one in the video group, two in the direct laryngoscopy group. The median duration of the successful first attempt was slightly longer in the video group, 61 seconds versus 51 seconds. And you may say, 61 versus 51. These seconds feel like minutes when you're having a kid that needs to be intubated. So...


Statistically, yeah, I don't know how we quantify that. And that's really it. I'm going to stop here for this paper. Among neonates undergoing urgent endotracheal intubation, video laryngoscopy resulted in a greater number of successful intubation in the first attempt than direct laryngoscopy. I think some of the things that I mentioned in the discussion that always need to be mentioned, we need new tools. Don't give us the bull... I'm sorry. Don't give us the bullshit of like, well, in my days, we just...


In our days, even in my days, we used to intubate so many more babies for so many other reasons. Intubations have gone way down. And so maybe the CMAC is a way that we're going to give our trainees the level of support and comfort to achieve these successful first intubation. So maybe video -laryngoscopy is coming to stay. So they have a lot of stuff they say about like, what would we do differently in a future study and so on and so forth, but fine.


Daphna Barbeau (48:25.358)

Mm -hmm.


Daphna Barbeau (48:43.726)

Yeah, and I mean, to your point, I mean, there's no room for pride when we have better success for the babies, right? That's the most important thing. But I also think people also underestimate some of these video laryngoscopy systems where it's important for the person who's using it, but all the other people who can...


Also see what's happening at the same time. There's learning value in that even if you're not the person like some of these have screens that you know other people can see what's happening. You know they can at least get the visualization which I think there's learning potential there too that shouldn't be underestimated.


Ben Courchia MD (49:23.726)

Mm -hmm. Mm -hmm.


Daphna Barbeau (49:25.39)

okay. I have, well, I have a few papers, but I'm going to do this one. I was really interested in this music therapy and infancy and neurodevelopmental outcomes in preterm clinical children and preterm children, a secondary analysis of the long step randomized clinical trial. This was in pediatrics as well. Lead author, Lucia, by Lenin. so I'm going to try to do this one.


quickly since we're getting to the end of our hour here. But the long step, the longitudinal study of music therapy's effectiveness for premature infants and their caregivers was a randomized clinical trial. It was conducted from August 2018 to April 2022 and eight NACUs across five countries, Argentina, Colombia, Israel, Norway, and Poland. I think this is quite impressive and included clinic follow -up visits and extended interventions after hospital discharge.


So basically what they looked to do was provide this music therapy intervention in NICUs. And then they randomized, I'll get into this, babies to some getting no intervention after discharge, some babies getting intervention after discharge as well in the home. I will say they previously reported the initial results of this trial, which made me sad. No clinically important effects on the primary outcome.


of parent -infant bonding or the secondary outcome of parental stress and mental health and child development at six months and 12 months corrected age. So this current paper was looking at the predefined secondary analysis, looking at neurodevelopmental outcomes at 24 months corrected age. So they really were asking if we enroll infants in the NICU to music therapy, they get music therapy after discharge.


Does it improve language outcomes at 24 months? So they enrolled infants born before 34 weeks, 35 weeks gestation that were quote unquote medically stable to start the intervention and likely to stay the NICU longer than two weeks. Eligible parents were those who could provide consent and were active participants in the music therapy sessions.


Daphna Barbeau (51:45.302)

The music therapy intervention consisted of three weekly individual sessions of approximately 30 minutes each. So a maximum of 27 sessions for a NICU admission and seven individual sessions of approximately 45 minutes each across the first six months after discharge to home. And that was compared to standard care, which basically was whatever was routine at the hospital without music therapy approaches.


I told you that they were looking at neurodevelopment using the Bayley 3. They were looking at the 24 -month mark, but because of COVID restrictions, they did extend this to 32 months. So what they did is they had a total of 213 infants randomized to receive music therapy in the hospital or not.


And then they further divided the groups, so to four total groups. So you could either get music therapy or standard care inpatient and music therapy or standard care outpatient after discharge. So the total control group would be standard care during hospitalization, standard care after hospitalization. The most intervention group is getting music therapy inpatient and outpatient after discharge.


Ben Courchia MD (53:04.782)

Mm -hmm.


Daphna Barbeau (53:08.654)

were able to enroll now 206 infants to they had some deaths from the first group so 206 made it to the outpatient. So I'll tell you they had 50 % female 50 % male the mean gestational age was 30 .5 weeks the mean birth weight was 1400 grams and unfortunately


54 % were included in the follow -up at 24 months corrected age. So basically, of the four groups, nearly 50 % in each group was lost to follow -up. They had some composite outcomes, which I think are interesting just for this cohort, kind of moderately preterm infants. Across the groups, the mean language composite score was 94 .7. The mean...


for cognitive composite score was 100 .8. The mean for the motor composite score was 95. And most participants had Bailey scores within the normal range. In the overall sample, 30 % demonstrate language composite scores below the normal range. They used less than 85. 17 % had scores below the range in cognitive and


26 % had below the quote unquote normal range in motor scores. And the punchline is there were some differences in the language scores between groups, but none were statistically significant. And there were no statistically significant differences in the other secondary outcomes, which were really the other Bailey scores.


Ben Courchia MD (54:54.926)

And by that, you mean that the language score was slightly better for the babies who were exposed to music therapy? Is that?


Daphna Barbeau (55:04.462)

So I will, I can tell you exactly that, but again, they were not statistically significant, but I will read it to you. And that's not necessarily true. Sadly, hold on, let me get you that.


Ben Courchia MD (55:08.846)

Mm -hmm.


Ben Courchia MD (55:17.198)

Yeah, so I mean, yeah, I think it's a figure, it's table two, if I'm not mistaken, right? And the scores are actually, I have it there, I mean, I didn't wanna, but the, I think there was a lot of discussions around music therapy, so that's why I wanted to make sure that we were, like, it's not clear from prior evidence that the scores might be in the direction we assumed. So standard care alone, the reference group, the language score was 97 .25, music,


Daphna Barbeau (55:21.934)

Yeah, it is. Hold on. Let me, you have it there? Okay.


Daphna Barbeau (55:45.646)

Mm -hmm.


Ben Courchia MD (55:46.894)

therapy at NICU with post discharge sort of standard of care. The score was 93 .5 standard of care in the NICU, but music therapy after discharge 98. And then music therapy, both in the NICU and post discharge is 91. So I mean, they're all good scores, but yeah. So.


Daphna Barbeau (56:03.726)

They had the lowest scores.


Daphna Barbeau (56:10.382)

Listen, I'm not sure what to make of this. I, you know, I try to be evidence -based in my conclusions. I also wonder, I also wonder if two years is even the right thing to be looking at. That's just me.


Ben Courchia MD (56:25.07)

I mean, can I ask you, my question is why are we even studying this?


Daphna Barbeau (56:29.614)

I think that's fair. I think I, I don't know. I think because I think people will say like, it's not worth our time to do it because it doesn't show any differences.


Ben Courchia MD (56:38.702)

Do you think it has to do with the hospitals investing resources in music therapists?


Daphna Barbeau (56:48.558)

what I don't know you're asking me a leading question and I don't know which way you're leading me a big cost associated with music therapists.


Ben Courchia MD (56:49.87)

There's a, sorry, yeah, there's a cost. Like if you're a hospital and you have, right? Because I think there's one thing to say, can we play music to the infants versus having music therapy, which is someone with training in music therapy comes to the bedside and provides the proper music therapy. That's the only reason why, but I mean, exposure to music, I think does, I mean, I don't know how extensive the studies need to be.


Daphna Barbeau (57:04.846)

Mm -hmm. Mm -hmm.


Daphna Barbeau (57:17.774)

Well, I mean, there have been previous studies, of course, that have shown exposure to music has been beneficial to babies and premature infants. So you're right. I don't think I don't I'm not sure we have to keep belaboring the point. But what does that look like? What type of music? I don't even know. Totally figure that out. But you're right. Is it could it be the parents singing versus the music therapist? I think I think potentially. And I love music therapist, but.


Ben Courchia MD (57:32.11)

All right.


Ben Courchia MD (57:43.15)

Mm -hmm.


Yeah, I love music and I love music therapists. All right, we're going to have, can I do one quick one? One.


Daphna Barbeau (57:47.246)



Yeah. All right.


You do one quick one and then I have one more quick one.


Ben Courchia MD (57:57.87)

Okay, so go ahead. I'll finish off.


Daphna Barbeau (57:59.662)

No, you go. Okay, fine. Mine's really quick. I'm not even going to read much about it. This is in the Journal of Perianatology, but it is a correspondence. And I think the authors are of importance, Dr. Duncan and Dr. Lakshminarajimkha, who we've had on before. And so they, that's Dr. Satya. I'm trying to give him the respect of using his full name.


Ben Courchia MD (58:18.478)

Satyan is that person. Everybody knows him as Dr. Satyan.


Ben Courchia MD (58:27.438)

We're not doing a good job.


Daphna Barbeau (58:29.55)

But they are a part in, they play quite a role in the section of neonatal perinatal medicine, looking to talk about controversies in coding, controversies in billing, controversies in staff makeup and staffing models. So I think this is an interesting correspondence and it really basically talks about,


Ben Courchia MD (58:48.046)

Mm -hmm.


Daphna Barbeau (58:56.654)

coding for the NICU consultation and making sure that we should code with kind of these consultation codes and not our routine kind of daily codes that we use in the NICU, which probably happens quite a bit. And furthermore, if you're going to continue consulting,


over time, so seeing the patient more than once, that you can continue coding and billing for those services. So I wanted to draw people's attention to that. There are lots of questions about that, especially as every miniscule RVU is counted. So I thought people could take a look at that. They have this nice table that shows the consultation codes.


Ben Courchia MD (59:49.102)

Yeah, yeah.


Daphna Barbeau (59:51.982)

that are really based on medical decision making and time.


Ben Courchia MD (59:58.286)

Yeah. And I think it's critical. I mean, it's funny that I use the word critical and I mean to do that, sorry, but it's, it's very important whether you use a critical care consult versus a non -critical care consult code. And it's true for some of them, it may be just counseling more than consulting, but when you're going at the bedside of a 22, 23, 24 week or this is a critical care consult, there's, there's important decisions being made right there that you're discussing. So give it's, it's, it's one more piece to the edifice that.


Daphna Barbeau (01:00:02.094)



Daphna Barbeau (01:00:07.47)

That's true too, yeah.


Ben Courchia MD (01:00:26.382)

Satyan and in this case Scott Duncan have been working on to try to say like this all goes back to how we as a unit justify our revenue our worth and maybe we can actually have Salaries and pay commensurate to the work that we do We have a great interview with Satyan on the podcast. I forget which episode number and Satyan will be talking at Delphi this year on Wednesday, September 25th. So looking forward to that


Daphna Barbeau (01:00:28.878)

Mm -hmm.


Ben Courchia MD (01:00:56.27)

Since we're talking about Florida, I saw this paper and I was like, we should talk about it because it's in German network open and it's called, well, I said Satya was coming to talk to us at Delphi, which is.


Daphna Barbeau (01:01:03.534)

Were we talking about Florida? Sorry, it is episode 131 that we had Dr. Seif.


Ben Courchia MD (01:01:13.998)

Thank you. So this paper is called Preterm and Early Term Delivery After a Heatwave in 50 US metropolitan areas. We are down here in Florida and we've had this heatwave and it's been hot, like more than it's been awful.


Daphna Barbeau (01:01:19.47)

Hmm hmm hmm hmm.


Daphna Barbeau (01:01:25.41)

We skipped winter entirely for the last two years.


Ben Courchia MD (01:01:29.038)

Yeah, but it's been it's usually warm down here, but this past what two weeks has been like you can't step outside. Yeah, awful. And so I saw this paper and I was like, this is an appropriate paper to read. The first author is Lindsay Darrow. And it's coming out of a group in the US. It's it's not really written by physicians. I think it's written by PhDs. So it's very technical in terms of weather and stuff. But I thought it was interesting because I think it it it informs on a few things.


Daphna Barbeau (01:01:32.814)

Yeah, yeah, it's faltering.


Ben Courchia MD (01:01:58.638)

There's been previous reports that I've suggested an association between high outdoor temperature in the week preceding birth with preterm birth. And the studies currently available generally support a positive association between heat waves and premature birth, but with considerable heterogeneity in the magnitude of the effect estimate observed and so on and so forth. And that extreme heat may actually also trigger rupture of membrane leading to labor. And so the question they were asking is like, how does the rate of preterm and early term birth change and respond to heat waves?


And I thought that was kind of interesting. So they used natality data in the US between 1993 and 2017 from the National Vital Statistics System and National Center for Health Statistics. They used census data from the 50 metropolitan areas, from the 50 largest metropolitan areas in the US. And they basically looked at temperatures from...


I'm going to read you this because again, I am not a meteorologist. So they looked at daily minimum and maximum temperatures were obtained at a one by one kilometer resolution for the continental U S from Daymet, a national aeronautics and space administration supported product from the earth science data and information system and the terrestrial ecology program. Somehow you might be, you might be thinking when I read these papers, do I just turn off the more I don't understand, the more I'm curious. I'm like, I don't usually read papers about that. So.


hot days in each of these major areas were defined as those exceeding the 97th per 0 .5 percentile threshold for the temperature distribution over a 25 study period. And they had a whole way that they were defining the heat waves. But yeah, I was like, good enough for me. Again, my expertise means nothing. I'm


going to try to give you the results because I think that's what's interesting. They looked at 55 plus million births that occurred between 1993 and 2017, covering about, throughout this time, about 52 .8 % of all births in the US, so quite a large sample size. The heat waves were more common in the later years of the study. So for us looking at the environment, I think this is an interesting point. For example, between 1993 and 2004, 1 .8 days per year,


Ben Courchia MD (01:04:17.486)

met the definition for a heat wave compared to 2 .4 days from 2005 to 2017. After four consecutive days of mean temperature exceeding the local 97th percentile, the rate ratio of preterm birth was 1 .02 and the rate ratio of early term birth was 1 .01. And when they did some stratification looking at the same exposure among those who were 29 years of age or younger, those who had a high school education or less,


belong to a racial or ethnic minority group, the rate ratios were 1 .04 for preterm birth and 1 .03 for early term birth. And so the conclusions and the gist of the paper is that in this study, preterm and early term birth rates increased after heat waves, particularly among socioeconomically disadvantaged subgroups and extreme heat events have implications for perinatal health. So I love to always try to us to keep...


Daphna Barbeau (01:05:13.742)

That's not good.


Ben Courchia MD (01:05:14.126)

That's not good, but I really like that we're always paying attention. Like we are not practicing in a vacuum, right? I mean, what's happening around us influences what we have to do at the bedside. And I love these studies that try to take a look at that. So yeah, we'll talk more about the environmental impact of on the human body and perinatology at Delphi this year. So another topic that we're excited about. I have more papers, but I think that's it for us today.


Daphna Barbeau (01:05:19.918)



Mm -hmm.


Daphna Barbeau (01:05:41.934)

Me too, but we are over time.


Ben Courchia MD (01:05:44.334)

We are over time. We did, we covered a lot of grounds today.


Daphna Barbeau (01:05:48.462)

you did. All right, sounds good.


Ben Courchia MD (01:05:49.134)

All right, buddy. I will see you next week. Bye.





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