#304 – 🗞️ NeoNews - What is new in neonatal and perinatal care
- Mickael Guigui
- Apr 27
- 34 min read
Updated: May 2
Hello friends👋
In this week’s episode of NeoNews, the team takes a deep dive into global fertility trends and the complex forces shaping the future of parenthood. The conversation starts with a discussion on worldwide declines in fertility rates, highlighting the economic pressures and societal shifts that are making the decision to have children more difficult across the globe. The hosts reflect on how financial instability, the high cost of living, and long-term uncertainty are reshaping family planning choices — even in countries with strong social support systems.
The discussion moves into the emerging markets around fertility treatments, shedding light on the ethical complexities of the global egg donation industry. Later, the team explores the rising challenges in pediatric and neonatology workforce training, offering insights into the evolving demands of the medical field. Finally, the group reviews new research on the microbiome, developmental care in the NICU, and how income mobility impacts child health outcomes.
Throughout the episode, the hosts share honest, thoughtful reflections on the heavy pressures families and healthcare providers face today. It’s a conversation about hope, hardship, and the small ways we can support the next generation, even amid a changing world.
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The articles covered on today’s episode of the podcast can be found here 👇
The Atlantic: Partisan fertility rate declines
New Yorker: Fertility rate declines
Bloomberg: Global Fertility trade
J perinat: Is it time for a separate residency and department in Neonatal Critical Care Medicine?
Pediatrics
Pediatrics: Fellows not ready for grad in 2y
Nature: Poo milkshakes
JAMA Peds: Vaginal seeding
JAMA Peds: No NICU baby needs mozart
Nature: Promotion criteria for professorship varies by country
JAMA Peds: Downward maternal income mobility x neonatal mortality
J Perinat: Long term neurodev outcomes in EPTI
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The transcript of today's episode can be found below 👇
Eli:
Hey everybody. This is Neo News, our segment devoted to promoting the doctor-patient relationship by keeping you up to date with what's buzzing in the news today. It is Wednesday, April 9th, and it is another quiet day in the news. Not much happening.
Daphna:
It's never a quiet day!
Eli:
Never a quiet day. I am scurrying to remind myself of all the Econ 101 I learned in college and have subsequently completely purged. How are you guys doing?
Daphna:
I'm hopeful that when this airs, that our investments will be in better shape. We'll see.
Ben:
My trick here is to learn to listen to the French news. It gives me a filtered version of what's truly happening. So that's what I've been doing, but it's definitely stressful.
Eli:
The 401Ks on the Neo News team have seen better days. We're actually speaking to you all from our bathrooms because you because we're sheltering emotionally. Anyway, why don't we move on? We've got another very full slate today. I'm very excited to talk about this stuff. for our deep dive segment, the theme of the day (we’ve really started to establish themes of the day) is fertility and fertility in all of its forms. When are people deciding to have children? Are they deciding to have children? How are they deciding to have children? What are the systems globally that are changing the ways in which people are able to have children, and what are the gaps in those systems? So we've got a really interesting slate of articles.
The first story that I want to bring up is from the March issue of the New Yorker. It is about fertility rate declines across the globe. It's a really interesting issue, because I remember learning - talking about Econ 101 - I remember learning in undergrad that fertility rate declines can be considered as a sign of progress. It's a sign of improved healthcare systems. It's a sign of increased occupation of birthing people. It's a sign of lots of different things that can often be positive. This article discusses the ways in which declining fertility can be a challenge. I just want to start with how the article starts. It says: “Today, declining fertility is a near universal phenomenon. Albania, El Salvador, and Nepal, none of them affluent, are now below replacement levels. Iran’s fertility rate is half of what it was thirty years ago. Headlines about “Europe’s demographic winter” are commonplace. Giorgia Meloni, the Prime Minister of Italy, has said that her country is “destined to disappear.” One Japanese economist runs a conceptual clock that counts down to his country’s final child: the current readout is January 5, 2720.” Get your sushi now! Then there's this really interesting discussion of globetrotting throughout this story, but in particular in South Korea. I just want to paint a postcard from South Korea that the author does a really fabulous and fascinating job, reporting this very long story admittedly. The view from South Korea is from the subway, and the author writes “Fuchsia metro seats are reserved for pregnant women. Those who aren't yet showing are awarded special medallions as proof of gestation. A looping instructional video on the train car reminded passengers of proper etiquette. Even amid the rush hour crush, these seats were often left vacant. They seemed to represent less a practical consideration than an act of unanchored faith, like a place for Elijah at the Seder table.” - which is coming up very soon. Guys, what did you think of this story? How did you interpret this?
Daphna:
It's interesting to know. I'm not sure as neonatologists we have any way to change what's happening. I just think, and they allude to this in the article, what are the possible reasons behind it? I think there's a lot going on in the world, and when there's a lot going on in the world, birthing rates drop. That's just where we are at this point in history. I have many thoughts and it's important for us to know. But I don't think there's anything we can do about it.
Ben:
There's not much we can do about it, that's for sure. I was listening to Ezra Klein doing the rounds on various podcasts because he wrote this book [with Derek Thompson called] Abundance. He was making a point that was so interesting, where he was saying that in the current era, we've been able to afford the luxuries of life that 20-30 years ago we would have seen as luxuries, and yet we cannot afford basic life. I thought that was so interesting. For example, you'll have the biggest flat screen TV, you'll have $2000 dollar phones. But can you afford a home? Can you afford to have children? Can you afford childcare? Probably not. I'm wondering if that plays a role in this current climate, where it's financially very concerning to have children. The cost of having children is tremendous, if you're talking about the US, from the moment you get pregnant, to the birth, to childcare, to school, and so on. It is extremely expensive. that this then also combines with a lot of uncertainty in the future. It's very difficult to plan to have kids and envision a life 20 years ahead, when you're not exactly sure what's going to happen tomorrow. So both of these things contribute. It's sad. The title of the article was “The End of Children”...that was so depressing.
Daphna:
What I thought was interesting is that, for example, you talk about the US. I was curious to know, in places with...
Ben:
Well, yes and no. I just want to mention that aside from the health care costs in the US, the cost of everything in France and in Europe is outrageous. It is just as outrageous as in the US.
Daphna:
For sure. I was curious, in countries that have better social support (healthcare, education, etc.), are they also seeing declines? The answer is yes, even despite having some of those social supports in place, which is super interesting.
Eli:
I appreciate so much of what you both said. one of my big takeaways is that, to the extent of having children was always a high stakes decision, the perceived stakes around this decision now seem so high in every corner of the globe. And that's a good thing. People are being deliberate, thoughtful, and intentional about when they have children. Obviously, that assumes that family planning services are available, which billions of PEPFAR (President's Emergency Plan for AIDS Relief) dollars were devoted to. We won't get into that, but it assumes certain fundamental things about people's ability to have families when they think it is the appropriate time to have families. But from the bedside, it struck me in two ways. (1) These decisions are so high stakes and so much hope is pinned upon the child when you decide to [have children.] When we think about the demographic profile of the patients that we're seeing, we see people in lots of different stages of life. [These people] are having children, in part, thanks to scientific advancement. People can say, hey, maybe I can delay this decision, or I can make this decision at a different point in life. (2) For me, as about caring for patients - I have an upcoming NICU block, and then I'll start my fellowship - it adds a layer of humility and connection when about how much thought went into the moment that now culminates with me getting called at 3AM to go to this category two fetal heart tracing, and how much hope is pinned in every second of every day, or on that feeder-grower that about for three minutes when I'm increasing the feed rate, and then go on to the sicker patients. That, for me, was some of my reflections coming out of this piece.
Ben:
Like we always say, there's never a good time to have kids. The best time to have kids is probably after retirement, and you're too old at that point. There's never a good time. To me, the lowering of birth rates is just a symptom of a society that is failing us. that this is something that should not be lost. It can't be forgotten that we have so many privileges being physicians. Number one, we have a steady income. We have a steady situation and will not falter too much. It [should be] unheard of that people can have full-time jobs and still be poor. That doesn't make sense. that this is also a symptom of people thinking, I'm not sure if by having children, I'm going to offer them a better future than what I currently have. The children are usually a promise. But that right now, we're worried that we have nothing to promise them. That's very scary, whether it is on a climate level, an economic level, or as human values are starting to falter. It's very, very sad.
Daphna:
What you said, Eli, resonated with me. We've spoken about this before. We interviewed Perri Klass, who wrote A Good Time to Be Born, in episode 33. We were talking about how the world has changed so much. People used to have a bunch of kids, but half of them or a quarter of them would die. It was not uncommon to see those child losses. Now we're having less and less children, and not that any death is any less important or less traumatic or acceptable, but for these families at bedside, this is so often their only “shot.” that's going to stick with me too, as if our job wasn't hard enough. But to think that even potentially after some losses, some families are not going to try again, like they may have in the past. that changes the narrative for the families in the unit.
Eli:
Maybe it's not all bad. We have the privilege and the responsibility of walking into the fire of intense hope and optimism and fear and anxiety. That is a privilege, but certainly adds pressure for sure. I just want to rewind for a second before we move on, one of things Ben commented on was cost of living. This is something that is certainly in the news a lot. There's a lot of fear with the policies that we don't have to get into, and probably shouldn't on the show since we lack the expertise or didn't pay enough attention in those undergrad classes. The basic cost of living is heinous, as the cost of eggs can tell anyone that. There are also all the other things that, explicitly or implicitly, are part of the social fabric of what we expect for our children. the way that this manifests in South Korea in the story is around what Gideon Lewis-Kraus, the author, documents as the system of education. There's a lot of discussion in this article of the phenomenon of what are called hagwons, which are these after-school academies. They have all these fancy names – Groton, Swaton International, Emilton Academy. It sounds like you can't have one of these unless it ends with T-O-N. He writes, “…each has its own faux heraldry. The most privileged students spend their afternoons, evenings, and weekends at as many as a dozen different hagwons. Eighty per cent of Korean families purchase private education; poor families tend to spend as much on hagwons as on groceries. Aggregate spending on educational enrichment exceeds the R&D expenditures of Samsung, a conglomerate that makes up a fifth of the entire Korean economy. At school dismissal, students climb into yellow buses that ferry them from one hagwon to the next. Through the plate-glass window of a building stacked with hagwons, I could see an orderly queue of elementary schoolers—so colorful, so small—awaiting their turn in the elevator,” Lewis-Kraus writes. This isn't just about the basics or the food we can put on the table. It's also about all the additional expectations that we pile on our kids these days that are well-intentioned, but certainly creating mental health consequences and distress for them. This may be figuring into these decisions about when to have a child, just because of how much goes into being a child and thriving as children today. Part of me wonders, can we take some of that pressure off of children and would that take some of the pressure off of parents, and maybe liberate people in terms of their decision about when's an appropriate time to have children? Could we take some of this into the public welfare, or could we provide some of these services, instead of out of pocket, as a standard? Obviously in a moment where we're dismantling the Department of Education and otherwise gutting the welfare state, that seems like a Hail Mary. But those were also some of the thoughts that I had reading this piece. Guys, any reflections on that segment of this?
Daphna:
That brings up an interesting point. that is pertinent to our community, especially those who have children, obviously. I think high-achievers push their kids really hard. That happens in my house. I have a school-aged child, and we're in a different activity every single afternoon. She's at an activity right now while we're recording. It's hard to weigh which are the most valuable – personally, for mental development, or is it about academic success? Nobody has the right answer. In fact, the studies show that a lot of this extra stuff that we do for kids doesn't improve their academic success, but it's part of the societal fabric. We're keeping up with the Joneses but getting your kid into all of these spectacular activities and keeping them at the top of the class, it's a lot for parents today. It was like that when we were growing up, but it's at a totally different echelon now. You're not wrong about that. I'm sure lots of people are thinking about that as they're listening to us at soccer games or swim team or going to math lessons, whatever it is.
Eli:
Are you suggesting that people are not laser focused on the soccer that's happening on the field? Devastating.
Daphna:
I think we're just very good multitaskers in our intensive care line of work. Excellent multitaskers.
Eli:
As I tell my bubby when I'm driving, I don't drive with my ears. So, we're probably in the clear. I highly recommend this piece as a Sunday read. It is a long read but provokes a lot of thoughts. Why don't we move on to the next the next piece? The next piece is a bit shorter, and we don't have to spend a lot of time on it, but it does really hammer home the point about how much this decision to have a child is tethered perhaps with hope or belief or your view of the future. This piece in the Atlantic describes how the ways in which people decide to have children varies depending on partisan success in elections. This piece says, “Starting after Trump’s election, through the end of 2018, 38,000 fewer babies than would otherwise be expected were conceived in Democratic counties. By contrast, 7,000 more than expected were conceived in Republican counties in that same period…During those first years of the first Trump administration, the partisan birth gap” – a term that I’ve never heard before – “widened by 17 percent. ‘You see a clear and undeniable shift in who’s having babies,’” one of the experts told the author. The author goes on to conclude, in a really eloquent way, “perhaps shifts in political power can influence fertility rates as much as say the economy does. Plenty of studies have found that political stability, political freedom and political transitions all affect fertility.” So it hammered home the point for me that this isn't just the decision we make today or even looking in the past; for example, I didn't get killed in the stock market so maybe now's a good time to have a baby. It's really based on how we perceive the near end long-term future guys. Any thoughts on this one?
Ben:
No, not too many thoughts. that it goes back to this perception that the future is bright. That if somehow in America the life of a political party has become so intertwined with your personal life, when in truth it shouldn't have that much of an effect, but somehow people do have strong feelings about when their party is doing well, that the future is very bright. And that if the counterparty is in power, then somehow, it's the end of the world. that probably is the reason why. It's very sad that this would play a role.
Daphna:
As we are more and more getting into identity politics, we'll see even stronger pull in either direction. Politics are always shaping our society.
Ben:
Thankfully we're changing party every four years, so it gives everybody a chance.
Daphna:
We'll see. We're not always changing parties every four years.
Eli:
Wow. Crystal ball, Dr. Courchia. Remind me to ask you before I place bets before the next World Cup! I'm going to ask you about that too. The relevance here to our audience is, the next time you walk in a room, you're schmoozing with a family, you’re talking about whatever the heck happens to be in the news that day – if it's partisan, that maybe idle conversation, but also relates more to why they're trying to gather information about vaccines and erythromycin and vitamin K than we think. Maybe that is figuring into the calculus around people's thoughtfulness and/or anxiety around the medical care that we're delivering. Maybe good to keep in mind just as context for where's this one patient at? What are they thinking? What are all the factors floating in the ether that are influencing the way in which they're interacting with me as a doctor and the way they're interacting with all other stuff?
Daphna:
I do think that particularly with these issues it's hard to be a parent. it's getting harder, not easier. Every generation thinks it’s hard to be a parent, but there's so much pressure on this parental perfection, which I don't think the norm a number of decades ago. You went to work, you raised your kids, you'd send them to school and the teachers did their thing and you did your thing. It wasn't like it is now. Especially with the accessibility of information, it's totally overwhelming for parents. Everybody wants to make the right decision. They just don't know who to trust. it's an opportunity for us to align with families as a positive influence that's rooted in science and evidence. It's impossible for families who are trying to make a decision with all this information, and not a background in science, to make heads or tails of some of it.
Eli:
Absolutely. Let's move on to our third story in the fertility segment here, which is a unbelievable globe-trotting investigation by Bloomberg on in vitro fertilization and around the after-markets, primary markets, and secondary markets that have emerged around the availability of embryos and eggs. one of the big takeaways that I had reading this story is, not only how much is staked on the hope and optimism of bearing children, especially if you are a birthing person in a family who has had a rockier road to fertilization and conception. [It also demonstrates] who across the world is in a position to have children and who is not, and how that has manifested in the exchange of dollars, how we've made a market and a system of capital around who gets to have children and who doesn't get to have children and who's available to try to grease the wheels of having children and who is on the other side of that. I just want to read the opening segment of this, which I just found incredibly striking. The story begins, “She wakes early, then waits quietly for her mother to leave for work. The nurse in the gleaming glass building in Varanasi, India had told her to arrive by 7 a.m., so she doesn't have much time. Her fingers worked quickly. She drapes a sari over her adolescent frame, making her look older and curvier than the salwar kameez tunics she usually prefers. She's tired of these trips, but this one on October 8th, 2023, will be her last. For 10 days, she's been sneaking to an upscale fertility clinic to receive injections that trigger her ovaries into mimicking the monthly reproductive cycle that typically readies a single egg for fertilization. In her case, the powerful synthetic hormones weren't meant to deliver not just one egg, but cash to be sold in the lucrative global market for human ova. That stash is more valuable than anything among her family's modest possessions.” Quite a striking beginning, guys. What did you think of this article?
Daphna:
So I have to admit, this took me down the rabbit hole about things that I really didn't know enough about. For me, it was really eye opening. It goes back to what you said earlier in the show, Eli, that the value of a child is so precious. It's so important to people that there's this global trade for it. It's really complicated. There are so many complicated factors in this article and our socioeconomic structure and class system. I don't know if I have anything smart to say, but I did learn a lot and I hope other people will learn something too.
Eli:
My takeaway from this article is, in fact, you can put a number on it and people are putting numbers on it. Those numbers range from anywhere from a couple thousand dollars to $25,000. People are putting numbers on this; private equity firms are laying into this industry, pinning their hopes and billions of dollars of capital into supporting this system. Just to provide a little bit of the architecture of this story, Bloomberg follows this one egg donor in India. They follow so-called “egg girls” (not my terminology, the article’s terminology), in Taiwan. It follows one donor who is this gorgeous, successful Argentinian model who is traveling the world to donate her eggs. It follows families who have struggled to have children and are pinning all their hopes on the eggs of people like that from Australia. So that that's the architecture of the piece. Ben, what did you think?
Ben:
I did not know about all this. I was taken on a ride to learn more about this market and this transactional nature of people selling their eggs. I must say that the story of the girl from India was obviously very striking. I’m curious about what you guys think about this from an ethical standpoint. We recoil at the idea of people selling their organs, saying it's completely unethical to incentivize poor people to sell their kidneys because they need the money and so on. But it does feel a little bit like that, where these eggs have become valuable. The money being offered to what appears to be poor individuals is so enticing that they just go with it, despite potentially the objections of their family, culture, etc. Everybody is allowed to be autonomous and have agency, and people can do whatever they want. But at some point, I was confused throughout the piece at what point is this crossing a line versus not.
Daphna:
The bulk of the money is not going to the person who's giving up their egg. People are making a lot of money on this. I wonder if there was a way to make more equity in the transaction. Does that make it more ethical? I don't know the answer to that, but people making money off of people selling their stuff is tough. I wonder on the other end too, do people even always know where the eggs are coming from? I don't know that even people who have gone through the process might know about some of what's happening internationally, and you really have to put a lot of trust into those clinics.
Ben:
It definitely begs the question of, if the market is there, if the transactions are happening, at what point do government and regulating bodies step in to regulate this better, so people don't get abused versus turning a blind eye to the whole thing.
Daphna:
It's complicated. People are investing a lot to make their families complete. I'm not sure this is what everybody has in mind. I don't know what the right answer is. You're stumping us today, Eli.
Eli:
I’m here for the stumping. In the words of Yoda, stumped I am. I am confused about the ethics of this, because on the one hand, of course this is horrible. It's exploitative; maybe its human trafficking depending on how certain states are defining human life. You don't want people to be taken advantage of. On the other hand, is this opportunity for people who otherwise literally can't get by? The last thing I want to do with this story is read another segment, which opened my eyes to the other side of this. The reporters are back in India, and they are meeting a group of birthing people who are selling their eggs on the down low. And they say, “When we ask why they sold their eggs, one woman says, “If I get money today, we will eat today. That's all.” Another says she was too weak to donate blood, so she donated eggs instead. They speak of debts of husbands who are alcoholic and abusive, of wanting to set aside money for their daughter's doweries, even though such payments have been illegal since 1961. They speak of wanting to secure a better future for their children and wanting to help other women because of the stigma of infertility that spans India's class divides. They have jobs such as cleaning homes or sewage drains or silver plates that pay $3, maybe $5 a day. For their eggs, they're paid $300 or $350. Unable to read or write, they signed consent forms with their thumbprints. They counted the number of bus stops to know where to get off for their injections. One woman said that after donating, “My entire body was in pain, my stomach was cramping, it felt like pins and needles in the injected area.” Would they do it again? “What other option do we have?” one woman asks.”
That for me was the other side of this. Maybe this is the feminist thing, to support people's decisions with their own body, especially people for whom this is the only asset that society allows them to have. Or maybe it's exploitative. I have a hard time.
Daphna:
I think it's this middleman between two consenting people (theoretically; some of these egg donors are quite young), but between, somebody is making a boatload of money off of people who need money and people who really desire this dream baby. I guess that's my biggest problem with the whole situation.
Eli:
The Patagonia bros getting the cream off the top here. Okay, we could talk about this all day. I encourage everybody to read this very long piece, but another mind-opening, mind-bending piece.
Let’s move on to our next segment which we call “Research in the News.” We'll start the segment with a triad of articles about fellowship redesign. One of the things that's been in the news plenty over recent years has been discussion of the pediatric workforce, in particular, the neonatology workforce. Another thing that's been in the news is that ACGME changes to the expectation of pediatric residencies. So these three articles – one in the Journal of Perinatology, two of them in Pediatrics – go in depth about how those ACGME changes and the current trends in match rates in pediatrics. I believe the match rate this past year was quite good, but the secular trend has been poor. The articles discuss how those trends stand to affect the supply of neonatologists and the readiness of neonatology fellows for practice in the face of those workforce shortages. The TL;DR here is the match rate into pediatrics in recent years has been down trending, and the ACGME changes will pull residents out of the NICU, which may reduce their exposure and therefore their interest in matching into the specialty. There's actually increasing evidence that a significantly lower percentage of US medical graduates are joining neonatology compared with all other medical specialties. When we look at programs that have thought about transitioning from a three-year fellowship to a two-year fellowship to try to build out the pipeline, there's concern their EPA’s (Entrustable Professional Activities) are suboptimal and they’re not ready to practice independently at two years. We’ll caveat that those articles also note part of the rating of EPA’s may be skewed by the fact that the people rating the EPA’s know that these fellows have one more year, and the fellows themselves know that they have one more year. So they're being humble or otherwise modifying the expectations. Nonetheless, there is concern that around 40 % of fellows are ready to practice independently at two years. What do you think of all of this discussion around the trends? I forgot to mention the punchline, which is that do we need an independent neonatology combined residency and fellowship? That is what one of the authors in the Journal of Perinatology proposed, a combined five-year neocritical care residency and fellowship that that may increase the number of folks who are getting ready to practice to fill these NICUs where we have and are having worsening shortages.
Daphna:
It goes back to what we started the segment with – our whole thought about life, our future, what we invest for, where we're going is changing, and that's affecting medical training. There are so many people that we've spoken to about this that are smarter than I am. Dr. Satyan [Lakshminrusimha] and Dr. [Robin] Steinhorn, who wrote this article “Is it time for a separate residency and department in "Neonatal Critical Care Medicine?," have really spent a lot of time thinking about this. What's interesting about this proposal, other than just cutting fellowships, is just shifting the fellowship, so you spend a lot more time in neonatology but still with some fundamental pediatric background. It's tough. I think I really do use my peds training a lot in the NICU. Does that mean I needed three and three years? I don't know. But I'm glad that people are studying it, because some of this data will help shape the decisions that we make moving forward. But we know that we have to change something, or we can't keep continuing down this path.
Ben:
I wanted to commend you, Eli, on picking these articles because the juxtaposition of them really paints a very elegant picture. The articles from the AAP are really making the point that we need to not move away from the duration of training, and that maybe the duration of training is appropriate. But the article titled “We Need Historic Investment in Fellowship Redesign to Achieve Workforce Goals” is really well supported by the other article about neonatal critical care medicine published by Satyan [Lakshminrusimha] and Robin Steinhorn, where there are specialties that are doing well for themselves within pediatrics, and they need to be supported. The risk we're all running is, what Dr. Lakshminrusimha and Dr. Steinhorn are potentially advocating for, is that if neonatology feels that it's not supported well enough, we might break away from pediatrics, potentially merge with maternal fetal medicine, and become a different specialty altogether. That would be a huge loss for pediatrics in general. It’s not ideal, but we've reached a point of fracture where the current system can no longer continue. The field of pediatrics is getting more and more complex, and it's becoming very difficult to provide adequate training in the short amount of time that we have. We do a little bit of everything, but a lot of nothing as well in residency, and it's unclear what we're good at when we come out of general pediatrics training. A lot of people continue on to fellowship even for hospital medicine, which didn't used to be something. We used to have enough inpatient pediatric exposure that we could function pretty well as hospitalists. Somehow, it's absolutely true that we need historic investment in pediatrics. The AAP has to look at that very carefully, because the threat is real. The field of neonatology feels abandoned and not supported the way it should be by governing bodies. There might be equipoise for investigating whether we should move towards a neonatal critical care medicine fellowship.
Daphna:
It paints this bigger picture that pediatrics is not as well reimbursed as adult medicine. They're not having the same degree of this problem in adult medicine; the problems are still there because of duty hours and things like that.
Ben:
But think about that, Daphna. Imagine there was a residency in “adult medicine.” It would sound silly, because this is too big of a field to have a residency in. But in pediatrics, fortunately, because we've learned so much, we've reached that point where it is too big of a field now to go and do three years and learn enough about pediatrics. We're going to start seeing fragmentation. Even within neonatology, we have subspecialties in neonatal hemodynamics, neonatal neurology, palliative care. This is similar to the PICU standpoint, the heme-onc standpoint, adolescent medicine. I had this developmental pediatrician in my residency that used to have the book on developmental pediatrics that he used during his residency. It was like a brochure! When we were there, it was a two-volume massive set of books. That's true for every subspecialty of pediatrics. Each subspecialty has a two volume, thousand-page book to cover the topics. It's a historic investment, not just money, but a rethinking how do we train the next generation of pediatrician. I hope this will help attract more prospective students to pediatrics.
Eli:
My experience is quite limited, obviously. I am in residency right now. I do agree with Daphna that I feel like there are lot of generalizable skills that you learn on other rotations that I bring to bear, and hopefully will continue to bring to bear in the NICU, even as I spend all my time there moving forward. My own path was such that I never had exposure to the NICU before residency. I would not have elected for a NICU residency if I didn't do pediatrics residency. Maybe that is a lack of intentionality or exposure on my part, but of all the people who go to institutions, there's no systematic way for them to get NICU exposure. Others may have a certain experience in the NICU that shapes their entire trajectory as a med student, compared to what we all know, which is being a med student and being a resident is a profoundly different experience. Maybe you can find much more gratification in a NICU experience. It is challenging, because none of the medicine relates to anything that you learned before, but you have ownership over the patients compared to when you're there as a med student. You literally know nothing and everything you say is wrong because the protocol in this NICU is different from the protocol in that NICU. It's an important discussion and I wonder, if only selfishly based on my own path, where I would have ended up if this was the fork in the road.
Ben:
But we should be able to think about this proactively. We should look at what other countries are doing. In Europe, it's common practice for medical students to have a year of rotations where you'll go around the hospital, you'll expect experience different things, and you’ll have maybe a dedicated residency period where there is this exploratory phase of learning more about different subspecialties. Maybe these can be tailored, whether you want to go into pediatrics or dive into one specialty. The options are endless, especially if the governing bodies are at the table. There's definitely innovative way to do this. I just hope that, like the article says, that the resources are placed to back these changes.
Eli:
The prelim year may be a way more feasible way to do this. Lots to think about. Let's move on to the next Research in the News piece, which is a promise to listeners. This is about the microbiome, but really what it's about are poo milkshakes. I don't even need to summarize. We didn't get to this last time and Ben was devastated. Let me speak very briefly about these two stories, both of which are focused on the microbiome. The first was a study in Nature that discusses the possibility of feeding babies born by caesarean with milk containing “a tiny bit” of their mother's poo. I don't know tiny was a medical word. They didn't quantify it in the discussion. That is one possibility; the other possibility that frankly has been studied more is what's called vaginal seeding, published in JAMA Pediatrics. That is the idea that you with infants born by cesarean that you expose them in one way, shape, or form to the mother's vaginal fluid and the vaginal microbiome. You can insert sterile gauze into the mother's vagina, extract some of the fluid, then wipe the gauze over the baby's face, mouth and body; there are other ways of delivering the seeding. This has been studied a bit more and there is maybe some preliminary evidence. A triple blind study in 2023 that showed that there was improved infant neurodevelopment. Suffice to say, there's a lot of science left to be done here. What did you think of these two articles and the discussion of the microbiome in general?
Ben:
There's a lot of discussions about the microbiome, especially in neonatology. When I came across this poo milkshake article in Nature, my curiosity was definitely piqued. It's scary at face value to hear that if you take a tiny sample of maternal feces and you put it in your baby's milk, then you do have some direct effect on the baby's microbiome. The dose that they're recommending is about 3.5 milligrams of mother's poo into the milk. But in big bold letters, obviously, it mentions not to try this at home. I don't know how interesting this is and how relevant this is right now, because I don't think this is solving a crisis. But I always think of what parents bring up to me at the time of delivery, and where they might have some research to back the request. So that if a mother or a parent at the delivery wants to find out whether we could introduce a few milligrams of poop into the milk to try to enhance the microbiome, we should, as experts, be familiar with the ongoing research that is happening in this field and know that some of the results are actually positive. What's important for people to know is that obviously this is very much still looked at as a research question and on a research basis. It doesn't seem anywhere near the point to be actually used in clinical practice. Especially in the US, if we're still not allowed to use probiotics for babies to prevent NEC, we should probably not start playing with this. If that were to come up, it would be good for our listeners to be aware that there is actually ongoing rigorously done scientific research on this particular question.
Daphna:
I agree with you. The risk is having a parent ask about it and you saying, “What the heck?” They would lose trust in us immediately if we're not learning about some of these studies or if we're dismissive about it. But if you said, “I don't know about that, tell me more, where did you find that?” If we're dismissive about it, like we are about a lot of things, then we lose that trust. I think it's super exciting. Once you get past the shock value, if there's something that we find to be safe and helps level the playing field between vaginal babies and C-section babies, then sure. But I'm looking forward to seeing the articles and the data for sure.
Eli:
The question of like, is this solving a crisis or is it not solving crisis? There may be this whole crisis we don't know about in terms of neurodevelopmental outcomes with gut dysbiosis from C-section in particular in preemies. Certainly we know the rates of NEC, and there's room for improvement on those, but overall, I agree with you both. It'll be interesting to continue to watch this science and the ongoing discussions around probiotics closely. I know previously we discussed that there was some congressional activity in the previous administration around probiotics. If this administration is going to do anything, they may actually consider this question a little bit more strongly. That may be an upside when it comes to babies' guts. Who knows?
Ben:
Let's see. that if you are an early career neonatologist, this would be an interesting thing to look at in the absence of probiotic. Are you going to be the one who's going to start introducing whether we should maybe add to the first few feeds of our babies a tiny amount of mothers' feces? I don't know. It's an interesting question.
Daphna:
It sounds cheap.
Eli:
PSA, you could be the poop milkshake person. You might wanna rename it. You might wanna rebrand it from poo milkshake and find some fecal-oral transplant, something like that. Anyway, let's move on to our next segment, which is called You May Have Heard. Guys, you may have heard that no NICU baby needs Mozart. What I'm referring to is an article in JAMA Pediatrics, which really describes the pros and cons of music therapy, most broadly defined in the NICU population in particular in preemies, compared to the harms of noise pollution or excess noise. It paints a picture, both in terms of the potential benefits of music therapy and the harms, both in the short-term (for example, cardiovascularly) as well as in the longer term (in terms of cochlear developments and overall auditory competency) if we're piping in Mozart… not to put Mozart on a pedestal here. It could be Burna Boy, it could be Kendrick, it could be anyone. All of this to say, this may not be the unambiguous, unconditional good that sometimes we think about classical music is great. What did you guys think of this one?
Ben:
Okay, so first of all, hate the title. I understand that they were trying to be catchy. And they're playing on the Mozart effect that claims that listening to the Mozart music can boost your cognitive function or boost your development, but that in truth, Mozart has a complex rhythmology and that there's lots of dynamic shifts and fast tempo. So, it's not really the optimal type of music for brain development. Just for that alone, not happy with that paper.
Eli:
Sounds like someone's getting paid by Beethoven.
Ben:
I agree with the claims they are making. I think that it's true that we have to be careful about the steps of exposure. Those are my takeaways. Love Mozart.
Daphna:
I love this paper. We take this blanket approach to say, okay music is good, I'll just turn it on super loud and play it for 24 hours a day. That's just not the right take home from these articles about sensory developmental stimulation. There's a right time, there's a right frequency, there's a right decibel level, which they do talk about in the paper. Even things that are made for babies, if you take your decibel meter to them – and I do in our unit – they're all too loud. So they cannot be played without lots of adjustments, and those can be made. Some people think the baby needs music to sleep, but having it on the whole time while they're sleeping is not good for our baby brains. I like how he calls it a call to action. I think we have to think about what we're doing when we're doing it.
Another the other thing that I'll credit my husband with, we've talked a lot about developmental stimulation in the NICU. He's a psychologist. He says, the one thing you neonatologists are missing is that you guys are playing things for the babies (for example, human mother's voice, music, occasionally an iPad). The babies give you feedback, give you input that they like or don't like this. Neonatologists just blow through the cues that the babies give you. If you play music and the baby's having a really irritable day and he's not calming to the music, then the music now has a toxic effect on the baby. So we're hopeful that these things will help babies, but it has to be in conjunction with following babies’ cues about what they like and what they don't like. I do think we need some more data on those babies that are still so small and so young. To the author's point and to your point, Eli, it doesn't have to be Mozart. That's not necessarily the right thing for every baby. I hope more neonatologists will take it up to study, because we're missing a critical period where we can provide positive developmental stimulation in most NICUs.
Eli:
So if you're sitting here listening to this episode and you're a trainee and you think, I am not cut to be the poo milkshake guy, you could be the Mozart guy! The world is your oyster and this is your chance. Get in while it's hot. I think we all can agree, whether it’s Mozart or Beethoven or Kendrick, the worst thing is – God bless cuddlers, I love cuddlers – when the cuddlers come in and they put on Family Feud. And it's loud. Because the demographics of cuddlers, they need the extra volume on there, and then they leave it on, and they leave the remote hanging right next to the bassinet. We can all agree that the worst developmental sound for babies is Family Feud.
Okay, all right, moving on. Next article here is a really interesting story of what is academic medicine doing with its life about promotion criteria, and how promotion criteria for professorship varies by country. It is a very long and interesting paper. We will not go into great depth about this, other than to say when you compare regions, if you compare different kinds of institutions and national protocols, that things that people are prioritizing in terms of the criteria for pressure professorship (whether that is the amount of publication, the nature of publication, the place you're publishing, the order in the authorship lists, the uptake, the citations, the alt metrics) varies across the world. There are also places across the world where publication is important and other things are important, like community contributions. For me, what was insightful, is I have a feeling some days in my blessed academic medical institutions that there is only one good way to exist in the world as a fellow and attending. This article is a happy reminder that not only do other ways exist, but as the authors say, and I just want to read one little conclusion here, as the authors say, “Metrics foster monocultures, whereas the global research ecosystem thrives from diversity across global, national, and regional levels down to institutions and research teams. We need approaches that foster diversity, rather than imposing norms that limit creativity and impact by promoting a predominant culture. University rankings push institutions into unwinnable competition, preventing them from leveraging unique strengths.” Guys, what did you think of this piece?
Ben:
I think it raises such an important question. The bottom line is if you deserve a promotion based on the impact you've had on your field, how do we measure that? And it used to be publication was enough. It's clearly no longer enough. It's time, again, for a comprehensive review of what do we define as impact? What about someone who has an impactful following on social media or somebody who does something for their community? It may not lead to a peer review publication, but has nonetheless a direct impact. It's time to maybe standardize that a little bit better. I think that institutions unfortunately will have to cater to their local resources in order to develop comprehensive guidelines. The variability is acceptable, but that we have to be a little bit more open to what we define as impactful activities that can have a meaningful contribution to a potential promotion.
Daphna:
I cosign. And not just because we host a podcast. We're not in academia at this point, but sometimes we're missing out on people with really great skills and a lot of passion because research isn't their thing, but they could provide a lot of value to the community. Agreed.
Ben:
Somebody who does education but no research, does that mean that person never deserves a promotion? It shouldn't be like that.
Eli:
Like a fellow who does a weird segment on a podcast. Maybe that person should get instantaneous professorship? I don't know. I'm just saying this is why I'm not in charge. Okay. Anyway, highly recommend reading this paper. I think it's another one of those where it just is a little bit mind-opening in terms of how you think about a particular issue.
Next article – there's a lot of conversation around the effect of overall income on decisions to have children and then outcomes. Almost universally you see stratification of cohorts by income level, and you see too often that income level corresponds with increased rates of neonatal morbidity and mortality, as well as intermediate and longer term markers of infant, child, and young adult morbidity, mortality, and frankly thriving in general. The studies we have not seen necessarily as much are looking at the directionality of income, which is to say, if you live in a community that used to be thriving and now Main Street is shuttered up, there are no jobs, and you have to travel two hours for your job, does that have an effect on your health and your child's health? According to this latest study in JAMA Peds, they found that the adjusted relative risk for severe neonatal morbidity and mortality at the second birth was 1.08 for newborns of mothers with downward neighborhood income movement by two quintiles, and 1.14 for those of mothers with downward movement by three or more quintiles. That's a lot of jargon, all of which to say there appears to be perhaps a dose-dependent relationship of the direction of opportunity and income availability in the neighborhood that people live and on the health outcomes of their children. Guys, any thoughts on this one?
Ben:
Fascinating study to look at the change in neighborhood status. They basically looked between births: during pregnancy number one, people were living in that area, then they moved up or they moved down before the second birth, then the third, and so on. To see how that has a direct impact on morbidity is fascinating stuff. Highly recommend people read that study.
Daphna:
I agree. The data speaks for itself for people who were interested in this group.
Ben:
Figure one is just incrediblem, how basically it's just linear. Insane.
Daphna:
That's right. My question was, what did the whole cohort look like? 25% experienced downward neighborhood mobility, 20% upward neighborhood mobility, and 55% no neighborhood income mobility. Bringing it back to the NICU, what are the things that when the families are in our care, how can we not just take care of their babies, but connect them to resources and help them really thrive, so that they don't have this downward mobility next time? How can we do that as a community? That's my takeaway.
Eli:
While we're trying to work out the socioeconomic situation of these communities, are there additional supports that we can put in place? Can we consider this as much as social determinant of health as other interventions we can make at the community level to ensure that the future of these communities manifest through their children?
Ok, that is all we have time for today. Thank you everybody for listening. As always, we are open, we welcome, and we plead for your feedback. If you think there are things that we did well that we can do more of, let us know. If you think there are things we can do differently, let us know. If you have recommendations for articles, let us know. Otherwise, signing off. Bye guys.
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