#313 - 📑 Journal Club - The Complete Episode from May 25th 2025
- Mickael Guigui
- 1 day ago
- 48 min read
Hello friends 👋
In this week’s Journal Club, Ben and Daphna unpack a wide range of recent neonatal studies with pragmatic, practice-centered discussion. First, they explore a study on low-dose dexamethasone for BPD in preterm infants, showing potential benefits in brain development and motor outcomes—despite ongoing concerns about long-term effects. Next, they discuss a large dataset analysis of oxygen and respiratory support trajectories in extremely preterm infants, offering real-world FiO2 trends and benchmarks that may help frame clinical decisions and counseling.
They also examine the diagnostic limits of consumer-grade pulse oximeters, like the Owlet, comparing their accuracy to hospital-grade monitors—raising real concerns about missed events. A safe sleep initiative study offers evidence that modeling and education during birth hospitalization can improve post-discharge sleep practices, especially across different demographic groups. Finally, they review parent engagement with NICU-focused online health communities, identifying both the benefits and potential friction these platforms create in team-family communication.
From cerebral oxygenation during kangaroo care to the use of enemas in ELBW infants, this episode covers it all—with a focus on what clinicians can take back to the bedside.
Listen in and join the conversation.
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The articles covered on today’s episode of the podcast can be found here 👇
Groves AM, Bennett MM, Loyd J, Clark RH, Tolia VN.J Pediatr. 2025 Feb;277:114414. doi: 10.1016/j.jpeds.2024.114414. Epub 2024 Nov 20.PMID: 39577761
Chandwani R, Kline J, Altaye M, Parikh N.Arch Dis Child Fetal Neonatal Ed. 2025 May 13:fetalneonatal-2024-328438. doi: 10.1136/archdischild-2024-328438. Online ahead of print.PMID: 40360237
Travers CP, Nakhmani A, Armstead KM, Benz RL, Foshee KM, Carlo WA.Arch Dis Child Fetal Neonatal Ed. 2025 May 12:fetalneonatal-2025-328540. doi: 10.1136/archdischild-2025-328540. Online ahead of print.PMID: 40355254
Decker CM, Dunlevey E, Nguyen L, Stence KJ, McCarty E, Jean-Charles TG, Trego T, Ma ZQ.Pediatrics. 2025 Feb 1;155(2):e2024067659. doi: 10.1542/peds.2024-067659.PMID: 39799962
Rholl E, Krick JA, Leuthner SR, Pan AY, Challa SA, Kukora S.J Perinatol. 2025 Apr 19. doi: 10.1038/s41372-025-02292-3. Online ahead of print.PMID: 40253559 No abstract available.
Stapleton I, Murphy S, Vaughan S, Walsh BH, Natchimuthu K, Livingstone V, Dempsey E.J Perinatol. 2025 Apr 5. doi: 10.1038/s41372-025-02287-0. Online ahead of print.PMID: 40186001
Stock T, Kamp AM, Waitz M, Riedl-Seifert T, Jenke AC.J Pediatr Gastroenterol Nutr. 2025 May 8. doi: 10.1002/jpn3.70055. Online ahead of print.PMID: 40344423
Adams SY, Tucker R, Lechner BE.Pediatr Res. 2022 Jun;91(7):1827-1833. doi: 10.1038/s41390-021-01684-3. Epub 2021 Aug 17.PMID: 34404928
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Watch this week's Journal Club on YouTube 👇
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The transcript of today's episode can be found below 👇
The Incubator (00:00.658)
Hello everybody, welcome back to the Incubator Podcast. We are back today for an episode of Journal Club. Stefano, how's it going?
The Incubator (00:06.958)
I well. some, I don't know, dust or crumbs here. But I'm good. I had crumbs on my desk here. I I was having a snack the last time we had a meeting.
The Incubator (00:15.762)
What are you talking about? have dust on your desk?
And you thought this was, I see. You're not talking about literal crumbs on your desk. was like, why and how is that compelling for the audience to know?
The Incubator (00:29.518)
It's It's not. But you know, speaking of my desk, I'm in my new little studio here, still getting used to it for all of our video productions.
The Incubator (00:40.986)
Yeah, mean, you'll start noticing that we've started releasing. I mean, I think the audio episodes of the podcast have always been on YouTube somehow. don't know. kind of like our team has linked our YouTube page. So basically, every time an episode gets released, it goes on YouTube, but it's in an audio format. But now there's more more video content coming out. so if you really want to, yeah, I mean, I don't know. Some people do gravitate towards YouTube more.
The Incubator (01:00.462)
if you really want to look at us while we're talking.
The Incubator (01:09.394)
And that's okay. If you want to, like, I know some hospitals have big screens in the lobby and stuff. So if you want to put us there and that as your patients are entering the building.
The Incubator (01:18.894)
For sure. For sure. Or for, I mean, yes. I mean, or our Beyond the Beeps colleagues, you know, that would be a nice, you want to be on there. Yeah. At every entryway.
The Incubator (01:29.018)
No, no me, specifically me. put like, even if you have to crop whatever, I just needs to be me.
The Incubator (01:37.39)
gosh.
The Incubator (01:40.614)
This was a joke, please. I cannot. Even the release of these episodes on YouTube is a big ordeal for me just to accept. anyway. All right, yeah, we have a very nice episode of Journal Club. should not. We're not going to waste too much of your time with our usual banter. Daphna, is there anything that we should mention? Obviously, Delphi Conference is coming along. We'll have a special video episode coming up very soon. Our agenda is mostly finalized.
The Incubator (02:09.87)
Yeah. And people, I mean, people don't have to wait. They could be registering now, making their plans. Our new hotel is close to the other hotel if you came last year, but it's cool. really, it's a vibe. Yeah, it's a very South Florida vibe. So we think people really enjoy it. Space, if you want to bring your families or loved ones.
The Incubator (02:10.258)
The Incubator (02:24.123)
It's a vibe for sure.
The Incubator (02:33.298)
Yeah, I mean, I think that the vision for the conference is crystallizing more and more. think that we've been able for the past two editions to do something that is fairly consistent, but now it's becoming more more obvious that we want this to be a retreat that people can go to and just take a break from the grind and just recoup, energize, all the while being almost entertained by...
The Incubator (02:39.15)
for
The Incubator (03:01.422)
lectures and conversations that are going to take place at a very high level with very high grade sort of speakers and and lectures. So, yeah, yeah. Think think about it in those terms. So the hope is that you learn a lot. You feel refreshed. You go back to your home base energized, full of ideas. And yeah, my goal is that you come back to your institution and somebody's like, what's gotten into you?
And that's what I'm hoping for. Exactly right. That's exactly right.
The Incubator (03:30.734)
It's not that Delphi glow, you know? Like...
Yeah, that's the goal. And I guess we should remind people about the giveaway for our survey.
The Incubator (03:40.878)
that's right. Yeah, we're turning four. We're toddlers now. We We're officially PQ Material. And as we've adopted this new modality of giveaways where every year on our anniversary, which is basically May 4th, I never really realized that our first episode came out on May 4th. But we basically have a very short survey trying to gather some feedback from the community.
The Incubator (04:01.774)
Mm-hmm.
The Incubator (04:08.85)
It's a great way for us to get that feedback, incentivize you to give us that feedback and a very simple way for our audience to enter the giveaway. It's a fairly straightforward, it's a Google form. It takes literally, I've done, I'm not participating in the giveaway, but I've done the form just to see how long it takes. It literally takes three minutes and we have a ton of cool gifts. have a laptop, we have some headphones, some speakers, some merchandise for the...
The Incubator (04:24.782)
Yeah.
The Incubator (04:37.912)
Yeah, we love to give stuff away.
The Incubator (04:39.388)
From the shop, from the incubator shop, we have some tickets for the conference, we have books. So it's not like there's going to be only one prize and that thousands of people are going to vie for that one prize. There's tons of prizes. So hopefully something goes your way. And we usually leave this open for some time so that it gives everybody some time and we're all busy. How many times have I received a docusign and by the time I get to it, it's like, we need to send you
The Incubator (05:02.082)
Yeah.
The Incubator (05:06.542)
It's expired. Basically every time that I've ever received a DocuSign.
The Incubator (05:07.89)
We need to send you a new link." It's like, ugh, ugh.
Yeah. So yeah. So please go check it out. It's on our web page. It's on our website and it's on our social media. We've tried to publicize this as much as possible. We want to make sure everybody gets a chance to participate. All right, down to five minutes into this episode, we should begin. We're going to review the latest evidence published in peer-reviewed publications in neonatology. And if it's OK with you, I'm going to start today with an article on postnatal steroids.
The article I found was in the archives of this in childhood, and it's called Postnatal Dexamethasone Treatment for Preterm Infants at High Risk of Forebronchopulmonary Displasia is Associated with Improved Regional Brain Volumes. So definitely a spoiler into the title, but definitely a spoiler that made me want to read this paper. And it's always interesting to read up on the history of postnatal corticosteroids. And we know they've been used for the...
prevention and treatment of BPD in at-risk infants. However, the therapy has always been controversial because of the possible adverse effects on the developing brain. And there's been some concern over a greater risk of cerebral palsy and mortality, which has in the past admonished clinicians against the use of postnatal corticosteroids for BPD treatment, especially when the protocols for postnatal steroids were tailored to give high dose
earlier on, sometimes within the first postnatal week for long periods of time. And sometimes to babies who even at baseline may have had a low risk for actually developing BPD. And so we know that one of the landmark papers in this discussion was the DART study, which found that basically giving very low dose dexamethasone after the first week of life to babies who were ventilator dependent, who were extremely low birth weight and who basically
The Incubator (07:09.673)
were at high risk of developing BPD, shortened the duration of intubation and did not increase the short-term complications or neurodevelopmental impairment or death at two years corrected age. And then meta-analyses later on suggested that postnatal corticosteroids, when you were giving them to only the infants who had a high baseline risk of BPD, something basically around 50 % or higher,
and that you initiated not in that first week of age still maintain an overall net benefit for treating BPD while being protective at reducing cerebral palsy and death. So I think that it's a very good overview. And yet, despite all this, think that there are still some issues when we are presenting the possibility of starting steroids to families and patients. There's always what is the risk and
Unavoidably, if parents were to go online, the possibility of negative effect on the brain could come up despite all this sort of context that is sometimes not so easy to relay. Now, the group in question out of Cincinnati had previously reported that postnatal dexamethasone administered through the DART protocol for severe BPD was associated with a decreased risk for diffuse white matter abnormality on T2-weighted MRI.
And we know that this is a known predictor of adverse neurodevelopmental outcomes. Now, the problem was that this particular study that we're referencing did not examine the effects of dexamethasone on other sensitive and objective measures of early brain injury and maturation or neurodevelopmental outcomes. So the objective of the study that we're looking at today was to evaluate the effects of low dose dexamethasone therapy for BPD on brain volumes at term equivalent age and motor outcomes.
at two years corrected in a regional cohort of preterm infants. So this was a study that that prospectively enrolled a cohort of about 392 preterm infants born at or below 32 weeks of gestation between September 2016 and November 2019. They were recruited from five level three and level four neonatal intensive care unit as part of the Cincinnati Infant Neurodevelopmental Early Prediction Study, also as the SYNEPs.
The Incubator (09:30.386)
The infants who were excluded from the study had chromosomal congenital anomalies affecting the brain, spine, the heart. And BPD was defined based on the type of respiratory support provided at 36 weeks post menstrual age. out of this big cohort of about almost close to 400 infants, only 41 infants were actually treated with dexamethasone according to the DART protocol. And so these are the babies that we will be looking at. It's relatively a small cohort. So we should take that into consideration as we go through the results.
The motor outcomes that are tested in this particular study are assessed through the Bailey Scales of Infant and Toddler Development third edition. it's important to note, I think, that in this prospective studies, kids were not randomized, right? It's not like kids were randomized to the DART or not. And so to account basically for the selection bias,
and better understand the independent effects of the dexamethasone on the study outcomes, they did a propensity scoring approach to actually look at that. And this balances the treated and untreated groups based on baseline demographic and clinical factors. So they basically took a group of babies who did not receive DART, and they tried to match them through this propensity score. Okay, so let's look at some of the results. So we said that 41 infants received dexamethasone.
sometime between 32 and 40 weeks post-menstrual age. And the mean gestational age at birth was 25.5 weeks with a standard deviation of 1.6 weeks. And the mean birth weight was 800 grams with a standard deviation of 229 grams. Now, of these infants who received dexamethasone, so 41 of them,
81 % developed a severe BPD. And all 41 of these infants actually developed BPD and were treated with a low cumulative dose dexamethasone under the DART regimen, which totaled 0.9 milligram per kilogram administered orally or injected over 10 days after the first postnatal week. So it's kind of a...
The Incubator (11:46.844)
chicken and the egg, know, it's like if you're at high risk of developing BPD and you're being given dexamethasone, well, maybe then you were always at high risk. And so it's not surprising that you develop BPD, but it is depressing when we're talking about giving DART to try to stave off BPD to hear that basically 100 % of these infants did develop the disease. So in terms of outcomes, the two primary outcomes and on multiple linear regression analysis controlling for additional co-founders,
confounders, dexamethasone was significantly correlated with a larger cerebellar volume with a difference of 0.5 and a p-value of 0.021. And it was associated with significantly larger sub-chornicle gray matter volume with a difference of 0.138 and a p-value of 0.03 relative to total brain volume. In terms of Baily-3 composite scores, they were...
significantly lower with a p-value less than 0.001 in the dexamethasone group compared with untreated infants. However, when they actually did an adjusted analysis, actually that result reversed and showed that dexamethasone was actually positively correlated with barely three motor scores with a p-value of 0.02.
Lastly, when they looked at cortical surface area, dexamethasone therapy was not associated with that particular outcome, and the p-value was 0.3 after multivariable weighted linear regression. So I think that this is very interesting results, especially as we're counseling families for the use of postnatal cortical steroids. And in summary, the authors are showing that, are concluding that
The study demonstrates that dexamethasone for BPD prevention treatment is associated with larger cerebellar and subcortical gray matter volume at term equivalent age and improved motor development at two years in a cohort of preterm infants. And given the lack of alternative therapies, that's a key, I guess, because it's not like we have so many other things to offer, to facilitate extubation, the study underscores the importance of considering dexamethasone after the first postnatal week to reduce the risk of adverse neurodevelopmental sequelae.
The Incubator (14:07.864)
of BPD in at-risk infants. yeah, it's great.
The Incubator (14:13.228)
Yeah, I agree with you. think that the takeaway is just right. We don't have a lot to offer other than, you know, our nutrition, developmental care. You know, we're really doing the fine tuning, I think, of what our medications can do. So, yeah, thanks. Thank you for sharing that one.
The Incubator (14:33.383)
Yeah.
The Incubator (14:36.014)
I have a paper in a similar vein, the Journal of Pediatrics, this paper, trajectory of postnatal oxygen requirement in extremely preterm infants, lead author Alan Groves, senior author of Viroltolea. And so basically what they wanted to do was describe the trends in oxygen requirement and mode of respiratory support.
delivered to extremely preterm infants in these kind of first three months after birth. And even more interestingly, they wanted to look at it by gestational age. previous studies have shown kind of this biphasic pattern of respiratory support. So infants requiring a lot of supplemental oxygen on that first day, it kind of decreases. We all have this.
experience we call the honeymoon in the unit, and then increasing in this second peak. They wanted to look at that a little bit more closely. They used the Pediatrics Medical Group database, and they looked at discharged infants that had been hospitalized between January 1st, 2016 and December 31st, 2021. Infants were included if they were born at 22 and 0 to 27 and six-sevenths.
weeks of gestation age and they were inborn at one of these pediatrics units or transferred in on the first or second day zero or day one of postnatal life. Major congenital anomalies were excluded. So basically for each infant, they looked at the type of respiratory support in the daily progress note and they also recorded the daily FIO2.
For babies, should be noted that for babies on low flow nasal cannula, they assigned an FiO2 of 0.25. And of course, the infants on room air and not requiring any respiratory support were assigned an FiO2 of 0.21. Okay. They do note that during this time period, obviously a lot of papers had come out about the O2 saturation targets of 90 to 95%.
The Incubator (16:53.644)
but they don't have kind of the overall policies of the individual units. Also, of course, they've units all over the country, no correction made for the altitude of the location. That was interesting to identify. If you're studying for the boards, you should know why this is important. Transports. yeah.
The Incubator (17:11.026)
my God, I've been involved in some quality meetings and it's such a headache for all the centers that are at high altitude with their BPD rates. It's like, you apply correction? It's very complicated.
The Incubator (17:20.482)
Yeah.
The Incubator (17:25.282)
Very complicated, right? Yeah. And I don't think anybody has the answer yet. So basically what they did is they made these FIO2 trajectory curves. They stratified the whole cohort by gestational age based on completed weeks. And then they mapped out the 10th, 25th, 50th, 75th, and 90th percentiles of daily FIO2 curves day after day for 84 days postnatal age. And then they kind of did the same thing looking at support type
by gestational age through week 11. And then they did rates of BPD calculated as the percentage of infants requiring supplemental oxygen or any respiratory support at 36 weeks gestation using the 2018 NIH definition for BPD. their denominator was infants surviving to 36 weeks in whom they had this respiratory support information.
So they included a total of 16,386 infants from 221 NICUs. The median gestational age and birth weight were 25 weeks and 765 grams. There were 3,800 infants, so about 23 % who died before hospital discharge. And they had...
data about the respiratory support in the vast majority of babies, almost 14,000. And 43 % of the total cohort met the criteria for diagnosis of BP. So I think a few things about this paper I just wanted to highlight. So of course, when we say a picture's worth a thousand words, the graphs on this paper are phenomenal. I think people will be able to literally print them out and use them in the unit.
for discussion with your team, if you have learners, for your nursing staff, for parents. And I think the other thing this group did really well is like, the paper is very short, but they spent a lot of time in the discussion talking about why they think this is valuable, ways that we can use it. So I'll tell you a little bit more about the group. For 22 weekers, they had six,
The Incubator (19:45.806)
122 weekers, they had almost 2,023 weekers, 2,824 weekers, 3,225 weekers, 3,626 weekers, and just over 4,027 weekers. quite a varied group, but nice proportion of those very little babies as well. So.
think people are especially interested in the smallest babies and they get right into that in the data. So infants born at 22 weeks gestation, the median FIO2 should have cleared by phasic pattern with a peak on day one, about 50 % FIO2 reduction to a nadir of mean median FIO2, 0.3 by day four, followed by an increase to a second peak of around 0.45 at days 12 to 20.
And then after this kind of 12 to 20, so in the second to third week, there was this gradual reduction in the median FIO2 across to day 84. And this pattern was almost identical in the infants across all gestational ages, but with the median FIO2 at each time point being lower in infants born at higher gestation. So what this means is on this really neat graph looking at postnatal days and median FIO2,
The 22-weekers are at the top, peaking at this 0.45 in this 12 to 20 range. And then right underneath them, the 23-weekers are peaking at about 38%. Right underneath them, the 24-weekers coming in about 33%. The 25-weekers coming in at 30 % for their peak. The 26-weekers about 25%. And the 27-weekers.
somewhere between 21 and 24%. So it's a really beautiful graph. And then you can see that after day, let's say 20 to 24, there's kind of this stepwise reduction in FIO2 in all of the groups. So that was for the FIO2 patterns. And then they wanted to look at, like I told you, respiratory support. So an infant's born at 22 weeks.
The Incubator (22:04.802)
High frequency ventilation and conventional mechanical ventilation were the predominant modes of respiratory support in the first four weeks of postnatal life. Thereafter, they demonstrated this gradual increase in nasal prong ventilation, CPAP and high flow nasal cannula therapy through those first three months to 12 weeks postnatal age. Very few infants born at 22 weeks were on low flow nasal cannula or weaned from respiratory support by 34 weeks corrected gestation.
And not surprisingly at higher gestations at birth, there were lower proportions of infants receiving high frequency ventilation or mechanical ventilation and earlier introduction of nasal prong ventilation, CPAP and high flow nasal cannula. And these tables are quite nice also. they are like this, these colorful tiles basically that shows how, you know, the, differences in ventilatory support over time.
by gestational age, but exactly as described, you know, seeing those higher ventilatory modes in the lowest ages, lower ventilatory modes in the higher gestational ages. that's what a nice way to use our video here. Thank you. And so I think they just did a really nice job in the discussion. Okay. So.
The Incubator (23:16.162)
Mm-hmm. And if you're watching this on YouTube, you can actually see the...
The Incubator (23:32.482)
Basically, the take home is that there's this biphasic pattern occurring independent gestational age at birth, though the FiO2 peaks are different. So they have this early oxygen requirement. Maybe they get surfactant, blah, blah. They fall to anator days three to seven, the second peak at 14 to 21 days. And it's seen in all the groups by gestational age.
I think it's really neat. said, you know, why is this useful? Basically, you you know, sometimes we feel that, gosh, this baby was getting better and now this baby's getting worse. Like, do I work this baby up? Is this a normal transition that I should expect? So they say, for example, an increase in oxygen requirement at day 30 would be more clinically concerning than one at day 10, where we can expect for babies to have their peak.
Certainly these trajectory curves could help us in research, in clinically relevant outcomes, in counseling, like I said, the staff and parents. So I thought this was neat. I hope people will take a look at the curves.
The Incubator (24:42.414)
Mm-hmm. Yeah, I think it's always very valuable when we're able to take, I don't know, close to like 20,000 kids and actually have that data. So I really appreciate the paper. by the way, I have now been traumatized by scientific papers. So as I opened the paper, I'm like, please make sure there's graphs. I mean, if there is no graph, I will lose my shit.
The Incubator (24:50.242)
Mm-hmm.
The Incubator (25:06.044)
And I'll say this paper was mostly graphs, so loved it.
The Incubator (25:08.282)
Yeah, because sometimes you see a title and you're like, this is going to be like the graph that I'm very excited to see. And then you look through the paper and it's like tables, tables. like, my God, just, I would love to see your graph. That being said, I think it's a fascinating figure. One is actually quite interesting. It's sort of this mirror image for sort of all the different gestational age staggered over higher FIO2s. I think that's very interesting. I'm going to say that I feel that the usefulness of that particular graph probably
to me stops at about a month of age. think that probably in the first couple of weeks after birth, we're sort of, there's little variability in how we handle these patients. I think we all practice fairly similarly, but then after that, there's so much differences that it's hard to know if this can be applicable. And you can see this, I mean, you can see towards the tail end of the curve. If I just pull up the graph again, but you see that towards the tail end of the curve,
The Incubator (25:39.758)
Mm-hmm. Mm-hmm.
The Incubator (26:07.448)
Mm-hmm.
The Incubator (26:07.57)
pretty much all the different gestational age except 27 weeks sort of level off at 25 % FIU2. And is that real? I mean, I've seen 26-weekers who are on room air at 36 weeks. And so there's probably differences there that are contributing to this particular outcome. I think that this data is very helpful because it gives a broad sweeping overview of what many units are doing.
The Incubator (26:12.782)
Mm-hmm.
The Incubator (26:35.92)
but, and could be definitely used as we counsel families about what to expect and what's a reasonable outcome and so on. But there's definitely things that are gonna be different from one unit and one patient to another, especially towards the tail end of this particular graph. So.
The Incubator (26:50.99)
also thought, actually, if you'll scroll to figure two. So this is the graphs by the like percentiles. And I mean, it just goes to show you, I mean, these 22-weekers are so variable, the most variable, right, of all the cohort. But I think that's interesting too, that I don't know, looks like some babies like really do quote unquote well from the beginning and some babies really do quote unquote poorly from the beginning.
The Incubator (26:56.22)
the station late.
The Incubator (27:19.298)
They mostly end up in the same place, but yeah.
The Incubator (27:19.398)
But I exactly. And I think that this is where, like, this is very helpful. You bring this to a prenatal consult, and you talk about antenatal steroids. And you can say, well, I'm hoping that the use of antenatal steroids can help bring your baby from maybe, yeah, shift you from maybe one of the higher ranks to a lower risk here. And maybe parents can actually visualize this a little bit better, because it is very esoteric when we talk to parents in prenatal consult.
The Incubator (27:31.618)
Yeah. Shift you from there. Yeah.
The Incubator (27:46.062)
All right.
The Incubator (27:47.374)
Okay, all right, I am next. My next paper is an article that I found, I believe in the archives of diseases in childhood again, two articles back to back. This one is coming to us from Alabama and is called Diagnostic Accuracy of an Over-the-counter Infant Pulse Oximeter for Cardio-Respiratory Events. Super high yield. I mean, how, I mean, now.
The Incubator (28:08.844)
very, very high yield, I think.
The Incubator (28:14.924)
you afterwards why I have a particular interest in that paper but the consumer baby monitor market is booming. There's a growing number of over-the-counter smartphone integrated infant monitors driven by understandable parental anxiety and around recognizing illness or preventing sudden unexpected infant death also known as SUID. But the American Academy of Pediatrics
recommends against routine use of home monitors. Why? Because there's not enough evidence that these devices actually reduce morbidity or mortality. And even more critically, the diagnostic accuracy of these over-the-counter monitors compared to hospital-grade equipment hasn't really been validated. So until recently, none of these devices were cleared by the FDA to diagnose, treat, or prevent disease. The concern is that
If these devices are inaccurate, they might give parents a false sense of security or worse, encourage unsafe sleep practices. And in fact, previous work testing two such monitors found that only one had a decent accuracy and that finding alone underscores maybe the importance of rigorous clinical testing. And so this study aimed to test the diagnostic accuracy of an over-the-counter infant pulse oximeter, the Owlet OSS 3.0.
I've discharged parents on home monitors and the home monitors that we get from our DMEs look awful. They look like they were made in the fifties and it's not the most aesthetic.
The Incubator (29:46.454)
That's right. Parents are like, this is the updated tech for my 2025 baby.
The Incubator (29:52.562)
And how many times have they just pulled up their phone, pulled Amazon and be like, can I just get this, the sock? Yeah. Can I just get the sock? And I think that there was a point where the FDA had sort of removed their approval, but now the outlet is back in sort of the good graces of the FDA. And it's hard for us to like, can we say yes? Can we say that? Sure. You can use that. It's a substitute. Because the parents will tell me, they'll be like, I'll pay for it. Like, don't worry about the insurance stuff. If I'll pay for this thing, a couple hundred bucks, I don't know how much it is.
The Incubator (29:57.25)
I want this one, yeah.
The Incubator (30:22.034)
I'm not going to say anything. I don't know how much it costs. Maybe you can look that up while I'm doing this. And I don't know what the answer is. Is it safe? Can I in good conscious tell them, yes, it's equivalent? So that paper was, to me, a long-awaited sort of study. So this was a prospective, yeah, a couple hundred bucks. Yeah, I was not wrong. It's not cheap. So this was a prospective single-arm observational study conducted at the University of Alabama.
The Incubator (30:39.054)
It's about $250 to $300.
The Incubator (30:49.938)
Infants were eligible if they were under 44 weeks post-menstrual age, weighted at least 1,500 grams, and were off ventilatory support and phototherapy for at least 48 hours. Major malformation, neuromuscular conditions, skin infection, terminal illness, limited care decisions were exclusion criteria for that particular study. Now, there's an important technical detail, right? So the study examined two types of output from the pulse oximeter, and that's...
labeled in the paper as raw data versus smoothed data. And let's just take a second to understand a little bit what is raw data and what is smooth data. So in terms of raw data, basically it refers to unprocessed readings every 10 seconds with minimal filtering for things like movement or any signal interference. And then you have smoothed
data, which is processed through a proprietary algorithm. And this algorithm dampens sudden changes, filters out motion artifacts, suppresses noisy reading that don't meet the quality threshold, the idea being to reduce false alarm. But again, this may come at the cost of missing real but brief events. So they'll look at both the raw and the smoothed out data. Now, after enrollment, each infant basically
was hooked up in the hospital to the hospital-grade EKG and pulse oximetry and concurrently with the outlet device for a duration of 48 hours. They followed the instructions of the outlet basically one on one foot, checked every couple of hours, and so they followed rigorously what the recommendations were. And the core primary goals of the study were to assess whether the device
could detect bradycardia, which was defined as a heart rate going below 50 beats per minute for at least three seconds, and hypoxemia defined as an oxygen saturation of less than 80 % for at least three seconds. And then they had secondary goals that include exploring how the device performed under other thresholds, whether it was mild hypoxemia, higher heart rate limits, and maybe longer duration of these episodes. So we're going to get into the study results right now.
The Incubator (33:09.658)
So 75 infants were enrolled between April and July, 2023. Data from 66 infants ended up being included. Obviously, some of the data was, for some babies, was corrupted. And so they had to exclude them. About 20 % of them were on supplemental oxygen. And their average gestational age was about 30 weeks and four days. And they were all around, and they were enrolled at around 35 weeks post menstrual age.
So now let's talk a little bit about diagnostic performance. And I think that during the paper, I read this paper post call, and so they were talking about sensitivity and specificity, which obviously I'm familiar with the concepts. But in that particular paper, I was like, what is it again? I don't know if your post call when you're listening to this. So I thought, you know what? I'm going to go over what sensitivity and specificity means for this particular context. Because then we're going to
The Incubator (33:57.068)
Review.
is a great board prep review.
The Incubator (34:05.834)
Yeah, but we talk about sensitivity of tests for boards, which I think we're all familiar with, but this is the sensitivity and specificity of the device. So what do we mean? So basically the sensitivity of the device will be the ability of the device to detect true events. So like if a bradycardia or hypoxemia episode actually happens, sensitivity will tell us how often the device catches it, right? So it's about detection. And then we'll have specificity, which is it will tell us
The Incubator (34:09.102)
Mm-hmm.
The Incubator (34:34.066)
how often the device correctly identifies that there's nothing wrong, meaning no false alarms. So once we have that, let's dive a little bit into the results. So for detecting heart rate below 50 beats per minute for three seconds or more, the specificity was 100 % for smooth data and 99 % for raw data. Sensitivity, however, was just 6 % for smooth data and 39 % for raw data.
When it comes to saturation of less than 80 % for three seconds or more, specificity again was high, 100 % for the smooth data, 96 % for the raw data. But the sensitivity was only 14 % for smooth data, and much better for raw data, 74%. So again, that difference there of proprietary algorithms trying to of correct some of the events and try to get a better reading could come at the expense of
of a stronger sensitivity. And so what that means is that when the device flagged an event, it almost always was correct, but it missed events, especially with the smooth algorithm. So the pulse rate output of the smooth device was very strongly correlated with the hospital heart rate with an average error of just 2.7 beats per minute.
Sensitivity for Brady cardiac detection ranged widely from zero to 100 % depending on the duration and severity of the episodes. And similarly, saturation correlation was moderate with an R-square of 0.48 and an average error of 2.5 points. Sensitivity for detecting hypoxemia got better when the raw signal was used, when the episodes were longer, or when the oxygen threshold were higher. Overall, specificity remained high across most definition, but sensitivity generally higher for raw signal.
and longer or more severe events. And so to wrap up, it's a fairly straightforward study, but a very valuable one that shows that in this particular single center perspective study, the infants at high risk of cardiopulmonary events using this over the counter pulse oximeter had excellent specificity, but low sensitivity for short bradycardia and hypoxemia episodes. That means it it rarely gave a false alarm, but it often missed events unless they were longer, more severe or
The Incubator (36:47.245)
Yeah.
The Incubator (36:58.158)
unless the raw data was used. Now these results underscore that while consumer-grade pulse oximeters like the outlet might be helpful in certain conditions, they are not reliable enough, at least in their current form, for catching brief, brief, but potentially critical events. The authors conclude, and I'm sure it's an open door to all these other partners in the industry, that further trials are needed to see how that can impact real-world outcomes in healthcare use. So I thought this was very interesting.
The Incubator (37:27.596)
Yeah, you know, because I think in general we feel like, we tell parents like, you know, the there are a lot of false alarms, right? That it's very annoying. It's going to alarm all the time. This causes a lot of stress for families. And that's actually not true. I mean, it probably does alarm when the baby's moving things like the same things we see with our monitors in the NICU. But now I think we can really give parents the information that, yeah,
The Incubator (37:56.978)
would you rather have something that's going to alarm a little bit more, but it's going to be reliable versus something that's going to alarm less. But if it doesn't alarm, you may be missing something that's terrifying. That's going to cause me more anxiety than anything else. So yeah.
The Incubator (38:04.47)
We miss them. Yeah.
Yeah, totally agree. For sure. For sure. And I mean that concept of feeling like, okay, it's safe. Like I'll know if something's going on or maybe I can choose less safe sleeping choices because I'm on a monitor, things like that.
The Incubator (38:26.642)
And maybe you can even quantify which baby this is good for. If you have a baby that has an extremely low risk, who's actually just really the parents are very anxious. Maybe the outlet is a great venue because you're like, okay, yeah, your risk is extremely low. But a baby that goes home on oxygen, who has an extreme history of being an extremely low birth weight infant with BPD, like, no, that's not going to do it. My answer will be not for you. Not yet, at least.
The Incubator (38:41.206)
Yeah, this is not for them.
The Incubator (38:53.358)
man, outlets. We get asked about them every single day.
The Incubator (38:58.898)
because what we have to offer for DMEs looks antiquated. Yeah, so we have a...
The Incubator (39:05.986)
That's true. But I mean, sometimes we don't even have the car seat, but they've got the outlet.
The Incubator (39:14.31)
Yeah. And I feel like we're going to have a Tech Tuesday episode with Dr. Brzezinski from Harvard about a a a phototherapy device that she came up with. talk about some of the benefits of this particular device. It's called, it's called the, I,
The Incubator (39:25.838)
Okay.
The Incubator (39:39.15)
Me too, I'm forgetting. The pod?
The Incubator (39:43.056)
No, it's, is it Little Sparrows?
The Incubator (39:46.19)
Yeah, little sparrows. I love that.
The Incubator (39:49.52)
Yeah. But okay, you'll find the, you'll find the, but the, but the device, the belly hut, that's exactly right. From the L'Espérance. It looks beautiful. Like it looks actually beautiful. And that's what parents want, especially in this era of like designer babies where everything the baby wears from the stroller to the, to the pajamas is like beautifully designed. You bring our equipment and it looks just so bad.
The Incubator (39:52.492)
Yeah, I'm pulling it. The Billy Hutt, the Billy Hutt from Little Sparrows.
The Incubator (40:18.528)
I know, I know, the social media era.
The Incubator (40:21.607)
That's right.
The Incubator (40:24.706)
to this paper since we're talking about safe sleep. it's called a hospital-based initiative for infant safe sleep practice. Lead author Karen Decker, senior author Zhenqiang Ma. And this is coming in pediatrics. So I'll say this was done like in the newborn nursery on
well babies, but I think the point is well taken. They basically wanted to see if they did this hospital-based kind of initiative of education and behavior modeling. it so inpatient? Is it associated with increased likelihood of safe infant sleep practices at home? And we know that babies that are born early, babies with medical complexity, they're at even higher risk for sudden infant death syndrome.
so, sudden unexpected infant death, as it were. Yeah. It's suid, suid, which I don't, I don't even think people say suid. I think they say S-U-I-D, which is way harder to say than SIDS.
The Incubator (41:23.674)
Yeah, it's no longer Sid. It's SUI. It's SUID.
The Incubator (41:36.688)
Yeah, like when they changed the altis to breweries, I can get with that. Like I can, I can still say that, but it has to be equivalent in terms of pronunciation for the, for the, for the foreign speakers, English challenged people like me.
The Incubator (41:40.224)
Yeah. gosh.
The Incubator (41:52.92)
So in 2016, the Pennsylvania Department of Health funded this initiative about safe sleep. It included infant safe sleep policies, nursing staff education, parent education through posters, videos, brochures. And I think importantly, nursing staff modeled and reinforced infant safe sleep for parents by placing the infant to sleep in the in-room bassinet on their back without additional objects for the duration of the birth hospitalization.
So Pennsylvania also has this PRAMS system, Pennsylvania's Pregnancy Risk Assessment Monitoring System. So it's a survey collected by maternal self-report on infant safe sleep practices. So they looked at a retrospective population-based study using these linked data sets. And they looked at mother-infant dyads who were exposed to the safe sleep initiative versus those who weren't.
And the survey looked at the following practices. So one, mother reported most often placing the infant to sleep on their back as opposed to their side stomach or a combination. Two, always placing their infant to sleep on a separate approved sleep surface such as crib, bassinet, or pack and play. Three, usually placing their infant to sleep without soft bedding or objects such as toys or pillows. Four, usually placing the infant to sleep alone in their own crib in the same room.
And then they wanted to look at if there was an association between exposure to the initiative and each of these fourth self-reported safe sleep practices. they also wanted to look at some other, factors that have been associated with sleep practice. they looked at year of birth, maternal race and ethnicity, maternal education, age, parity, marital status, insurance status, smoking status, provider advice.
prenatal care initiation, prematurity, breastfeeding. So between 2017 and 2021, there were 637 respondents who were exposed to the Safe Sleep Initiative and 4,861 control, kind of unexposed.
The Incubator (44:05.773)
And among the PRAMS respondents exposed to the Safe Sleep Initiative, the prevalence of reporting each of the four infant safe sleep practices increased between 2017 and 2021. So back sleep from 4 % in 2017 to nearly 40 % in 2021, a separate surface 3 % in 2017 to 43 % in 2021, no soft bedding 3 % to 30 % and room sharing without bed sharing.
4 % to 37%. Now, infant safe sleep behavior differed by maternal race for both groups, but notably a higher proportion of Black PRAMS respondents exposed to the Safe Sleep Initiative reported each safe sleep behavior compared with those respondents who were unexposed. They also saw a similar pattern among Hispanic respondents.
They do note in the discussion, however, that particularly for respondents that identified as Black who were exposed to the initiative were more likely to report practicing these infant safe sleep practices after discharge, but after adjustment in multivariable models, these respondents were less likely to report placing their infant on their back to sleep compared with.
White respondents were less likely to report multiple infant safe sleep practices when assessed in this kind of cumulative model, which shows that we still have work to do, especially for different subgroups of families. More than 90 % of respondents who placed their infants on their back to sleep in a separate room or without soft bedding indicated that they had been told by a healthcare worker about the practice after pregnancy. This was consistent in both groups.
And among respondents who reported room sharing without bed sharing, fewer indicated that they had been told by a healthcare worker about the practice. Minimal differences were observed between exposure groups by maternal education, but by age, infant safe sleep behaviors were consistently less common among respondents age 19 years and younger or 40 years and older for both groups.
The Incubator (46:19.31)
80 % of respondents practicing infant safe sleep behaviors in both exposure groups had initiated breastfeeding. A slightly higher proportion of those exposed to the initiative who reported placing their infants on their back to sleep on a separate surface or without soft bedding were still breastfeeding at the time of the survey compared to those unexposed. And similarly, more exposed respondents who were room sharing without bed sharing were still breastfeeding compared to those.
who were unexposed, but this was 56 % to 52%. Most respondents who reported infant safe sleep were married, had a prior birth, had a term birth, had initiated prenatal care, were not smoking at the time of the survey and had private insurance. So about smoking, smoking at the time of the survey was also associated with decreased likelihood of placing an infant to sleep on a separate surface without soft bedding.
or room sharing without bed sharing. regarding insurance, respondents with Medicaid or other non-private insurance were less likely to report back sleep or sleep without soft bedding. And respondents who were unmarried were less likely to report sleep on a separate surface. So one last.
piece about the logistic regression model. Pram's respondents exposed to safe sleep initiative had a 72 % increase in the odds of reporting, most often putting their infant to sleep on their back, a 48 % increase in the odds of always placing their infant to sleep on a separate sleep service, and a 41 % increase in the odds of reporting, usually putting their infant to sleep without soft bedding compared with those who are not exposed.
There was no significant association between exposure to the safe sleep initiative and usually room sharing without bed sharing. The logistic regression also suggests that respondents who were exposed to the initiative were 38 % more likely to practice more of the recommended safe sleep practices than respondents who were not exposed to the initiative. So, I mean, I think the data is like not surprising, but my point is I think we do a lot of
The Incubator (48:26.112)
unsafe sleep practices in the NICU because we have to and because we can because the babies are on monitoring. So I think this is even a more important group that, you know, those few weeks leading up to discharge, we have to be modeling for parents that their babies can sleep in these situations that we're going to ask them to do at home. And I've worked in lots of units and even units who really
are all about the safe sleep. mean, we miss babies, right? There are certain babies that we still want to put on their bellies because they sleep better or they feed better. But I think our modeling and our education is really, really important. So I think something that I will spend more time doing at the bedside in those lower level babies.
The Incubator (49:06.45)
Yeah.
The Incubator (49:12.464)
Yeah, absolutely. agree. I think it's not the point of the study, but it's a shame that the babies who went to the NICU were sort of considered as unexposed. And like you said, I think that in the NICU, obviously, we cannot put the burden of safe sleep practices on a critically ill newborn that's being admitted to the NICU. Fine. But like you said, maybe closer to discharge as parents are going to start to emulate everything that the nurses and the providers are doing.
The Incubator (49:22.048)
Yeah, they excluded them, right?
The Incubator (49:39.568)
be in anticipation of going home. That's when you kick in safe sleep practices and not put a baby on their bellies for a good night's sleep because they're on a monitor. think so. I completely agree with you. And it's interesting. Yeah, it's interesting to see.
The Incubator (49:54.552)
Well, I was going to say we have to set them up for success, right? If the baby didn't learn how to do that with us, how are they going to get the baby to sleep at home that way?
The Incubator (50:01.682)
Absolutely. Absolutely. Yeah, we're running short on time. And so I wanted to maybe go over two quick papers. The first one I'm just going to mention very quickly. It was in the Journal of Perinatology, and it's called The Effect of Maternal Positioning on Cerebral Oxygenation in Premature Infants During Kangaroo Care, a Randomized Control Trial. It's a paper that comes to us out of Ireland and the
goal of the paper was to assess whether there was an optimal maternal position, either like a mother reclining at like 30 degrees versus 60 degrees for kangaroo mother care. They did this obviously in one center, and they basically tested this hypothesis by using cerebral near-infrared spectroscopy. And they were able to basically look at 20 infants with an median age of 28 weeks.
But basically, they showed that 30 degrees or 60 degrees does not really impact cerebral oxygenation. So I thought it was a very interesting study in terms of trying to optimize the position for these dyads. And I thought this was interesting, but I don't think it's worth spending too much more time on this because obviously we have other papers. The last paper I'd like to talk about is a paper that I've seen.
I believe in the Journal of Perinatology as well, and it's called, Neonatologists' Perception of Uncertainty, a National Survey. I thought this was a very interesting paper. There's been limited research on how neonatologists experience uncertainty, at least beyond the lens of how it influences communication with parents. But if we look across medical specialties, we find that something more interesting that more, there's more intolerance of uncertainty that has been correlated
correlated with burnout. And that's a big deal, especially in a field like neonatology where we make very high stakes decisions and ambiguity is part of kind of the daily routine. So the goal of the study was simple but powerful to describe the neonatologist's reaction to uncertainty in patient care. The survey that they did looked at several key elements, anxiety, concern about bad outcomes and how comfortable clinicians are.
The Incubator (52:21.476)
in disclosing uncertainty to patients and colleagues. what they found is quite interesting. So the way the study was conducted is that they used the revised physician's reactions to uncertainty scale, the PRU scale, which is a validated tool that captures four main components.
anxiety, concern about bad outcomes, reluctant to disclose uncertainty to patients, and reluctance to disclose uncertainty to a physician. Basically, on this PRU scale, the lower the score, the more tolerant you are to uncertainty. And they distributed this particular survey to the AAP section on neonatal perinatal medicine, listserv between March and April 2023. So I just want to make sure that I
It was in the general perinatology that is correct. Okay, good. So a total of 345 neonatologists completed the survey and they came from a wide range of age groups and career stages. 38 % had been practicing for more than 20 years. Most respondents were female, 64%. 70 % identified as white and 65 % worked in academic centers because the other ones did not have the time to fill out the survey probably.
We're at the end. thought I would just poke fun. That's okay. So when the researchers analyzed the PRU scores, they found a significant difference across years in practice with more experienced clinicians tending to have lower scores, meaning greater tolerance for uncertainty. And within the components of the score, was specifically the response related to anxiety and concerns about bad outcomes that
The Incubator (53:50.644)
man, we're all busy. Come on.
The Incubator (54:10.67)
Mm-hmm.
The Incubator (54:19.472)
that showed differences. So I thought this was very interesting. I lost my notes. What does this all mean? The study suggests that basically uncertainty is a significant concern for neonatologists, especially early in our careers. And the authors basically are using these results to say that we need to explore this further, not just for our own well-being, but
so that we can offer confident, compassionate support to families navigating the NICU experience. And it's one of those areas where culture, mentorship, and self-awareness all come into play. And this study is a strong first step in understanding how this all unfolds. So I thought this was very interesting.
The Incubator (55:07.084)
Yeah, I mean, we see this in our teams, right? Whereas somebody's like, well, you know, there's this uncertainty and other people are like, yeah, well, there's uncertainty. But I mean, it certainly impacts how we individually counsel parents. And, you know, if you've got people coming on and off and parents are hearing different things, I think that could be stressful for everybody, the team and the families and, you know, impact their satisfaction with our communication for sure.
The Incubator (55:36.326)
Yeah. And they have this beautiful figure in the paper. It's a very short communication in the journal of paleontology, but basically they have these bar graphs that looks at different aspects of that scale. we have diagnostic uncertainty, prognostic uncertainty, evaluation and management uncertainty, uncertainty around what to offer and uncertainty around limit setting. And then the X axis basically has you're in practice, whether you're a fellow, you're less than five years, five to 10, 11 to 20 or more than 20 years. And it's interesting to see basically how this
The Incubator (55:38.936)
Yeah.
The Incubator (55:42.808)
Mm-hmm.
The Incubator (55:49.559)
Are you feeling it?
The Incubator (56:06.258)
there's a shift in agreement over the years of practice. And I think that for us, I have seen this consistently across my career where I would be, especially in the early years of my career as a fellow, I would be anxious about every single aspect. If a gas had a pH of 7.2, I would be very worried the whole night. And then you have some attendings that give you sign out and they're closer to retirement and they are so chill about everything.
The Incubator (56:11.831)
for sure.
The Incubator (56:35.076)
And I think that this has to do with the years of experience and all the cases you've seen. I think that this is, to me, it feels logical because it feels like as early as you are in your career, you haven't seen everything. You haven't seen the variability that nature has to offer. And so you agonize over, my God, am I doing something wrong?
The Incubator (56:55.702)
I agree with you. And I think this, this figure is very interesting because I thought that maybe with the different types of uncertainty, we wouldn't see such a difference. For example, I don't know, evaluation and management or, the diagnostic uncertainty, but it's almost like these different graphs, regardless of the type of uncertainty are like,
copies of one another so that the more years you had in practice, you were more comfortable with uncertainty across the board, which I thought was really interesting. As opposed to some of the things where we really don't know all the right answers, prognostics, limit setting, what to offer, I thought that we'd see more variability there compared to some of the others like diagnostic, evaluation management, but we don't.
The Incubator (57:50.31)
Yeah, I mean, if you change the x-axis and didn't know that it was years of practice, you might think these are different people altogether. Because when you look at people who have been in practice for more than 20 years, certain degrees of uncertainty, they like strongly disagree, which is a response that you see almost never in the fellows or even in the early years of practice. I think that maybe it brings about hope as well. I don't know what you think.
The Incubator (57:53.901)
Yeah.
That's it.
The Incubator (58:03.182)
Mm-hmm.
None.
The Incubator (58:14.926)
interesting.
The Incubator (58:19.31)
you feel anxious because you're early in your career, if you just stick with it a little bit longer, hopefully your experience will bring you a little bit.
The Incubator (58:21.326)
Maybe. If you don't get too burnt out, there's this... Yeah. We need you. We need you all to stick around. Thank you for sharing. It did bring me some soulless this paper.
The Incubator (58:31.258)
If you don't burn out and quit medicine altogether in the meantime, that's a good point.
The Incubator (58:45.052)
Okay, good.
The Incubator (58:47.086)
I also had two papers quickly that I will try. You know, I don't do anything quickly, but that I'll work through. This one, I this was interesting. It was actually in the Journal of Pediatric Gastroenterology. And it was entitled, Hydrostatic Low-Volume Enemas in Infants with Birth Weight Less than equal to 1,000 grams or gestational age less than or equal to 28 weeks, a controlled interventional study. Lead author, Tabia Stock, senior author, Andreas.
And is coming from Germany. It's a little, it's a small study. They had 42 infants in their control group and 74 in their intervention group. And the intervention was really looking at like just standardizing what were they doing for saline enemas. And I thought this was interesting altogether because
I let's just say in the States, but I think globally we, some people use enemas, some people use glycerin, some people use nothing. and so we really don't know how to evacuate stool the right way and babies. So, I thought this was interesting. It looks like in this unit, in general, people were giving a lot of enemas, but with no standardization for how they were doing it. so.
told you it was one group, I mean one unit, January 2019 to June 2020. And the infants had to be born at the hospital. The hospital stay had to be longer than 24 hours. The infant needed to suffer, quote unquote, delayed meconium passage, so an absence of meconium for greater than 24 hours during the time in which the infant only passed meconium as the main stool type. So basically they looked, so this wasn't just the first meconium stool.
While the baby still had meconium type stools, didn't get to transitional stools yet, did they go greater than 24 hours at any point in time during that period? And then they were eligible for an enema. And that had to happen at least once in the first 20 days of life. In the control group, physicians performed all enemas manually, normal saline-avering volume. The catheter was inserted
The Incubator (01:01:05.038)
quote, as deeply as possible, the timing of the first enema application and the frequency were individually chosen based on physician assessment. Now, their new enema protocol performed in the intervention group was designed to be minimally invasive. So they used a urinary catheter, like I guess it's a six French attached to a three-way stopcock. And on the other side, they had a syringe connected without its plunger, like a venting.
and a total of 10 mLs per kilo of normal saline poured into the syringe and the plunger was gently pressed onto the syringe to secure the fluid. The prepared enema system was fixed to the incubator at a height of 15 centimeters to achieve a pressure of 15 centimeters of water. The catheter tip was lubricated, rectably applied with a depth of 2.5 centimeters. The stop clock was open and the plunger removed to allow the solution to run.
through. An enema was only applied in the absence of bowel passage for more than 24 hours or if the last enema was applied more than 24 hours ago. They talk about their feeding regimen, which I think is always interesting to note. I think it's pretty consistent with most practices. So I'm just not going to get into that right now. The primary outcome was a protocol safety assessed by GI complications. So they looked at neck focal intestinal perforation,
and MPS, meconium plug syndrome. Hold on. And then for the secondary outcome, the protocols effectiveness, several stools and nutritional parameters were assessed at six time points, days two, four, six, 10, 15, and 20. They documented the first and last meconiums. They wanted to look at total number of stools.
time to get to full enderol, which they included 120 mLs per kilo per day, and the need for parental nutrition, including the last day of TPN use. So I told you 42 infants enrolled in the control, 74 in the intervention, but they had 30 % protocol violations in the intervention group, defined as one or more wrongly performed enemas. So that is just something to note. Wrong. You've done it wrong. And I think they have pictures. I think the protocol is actually pretty clear.
The Incubator (01:03:19.743)
Wrong, you've done it wrong.
The Incubator (01:03:26.188)
But anyways, gestational age was similar in both groups. The birth weight in the intervention group actually was significantly lower compared to the control group, 870 versus 957. There were four more characteristics that were a little bit different. preterm premature rupture of membranes, which was seen more commonly in the control group, help syndrome, which was seen more commonly in the intervention group.
quote unquote, other reasons, which was just a little bit more common in the intervention group. Okay. Sorry, let me get back to where I was here. Let's see. They looked at some respiratory support, not.
Okay, median oxygen saturation on the fourth day of life was 96 % in the control group. It was only 93.9 % in the intervention group. So that was statistically different, but at no other time points. There was some differences on day 20 of life. 37.5 % of infants in the control group were able to breathe unsupported, only 18 % in the intervention group. And this was statistically significant. More infants in the intervention group needed antibiotic treatments on days four, six, and 10 of life.
and let's see, then to the other parameters, a significantly higher weight gain was observed in the second week of life in the intervention group, compared to the control group in the control group, greater than one, greater than or equal to one enema was applied in 90 % of infants compared to 97 % of infants in the intervention group. However, significantly fewer enemas were performed per child in the intervention group.
4 compared to 8 in the control group. The first meconium was comparable between groups, however the last meconium occurred significantly later in the intervention group after 7 days compared to 6 days in the control group. Significantly fewer stools were passed in the intervention group in the first 20 days of life. Meanwhile, imptens in the intervention group excreted 61 stools on average. Imptens in the control group had
The Incubator (01:05:46.479)
72 stool passages. Feeding tolerance was significantly better in the intervention group. More infants on full enteral nutrition on day 10 of life, so 31 compared to 14 % in the control group. TPN intake differed between the groups, the intervention group showing higher intake at the first four measurement points. The percentage of infants requiring TPN and IV fluids were comparable between groups across all six measurement points.
duration of parental nutrition was also similar. There were no significant differences in that primary outcome. 4 % of patients in the intervention group developed NEC compared to 9.5 in the control group, but this was not statistically significant. 2.7 had SIP compared to 7.1, not statistically significant. And Meconium plug syndrome occurred in 6.8 compared to 2.4, but it's not significant.
Although not significant, they note as a p-value of 0.088, a trend for reduced intestinal morbidity in the intervention group, 6.8 % needing surgery compared to 16 % in the control group. Mortality rates were similar.
The Incubator (01:07:04.974)
And they said, said combined mortality and morbidity were significantly lower in the intervention group. They were different, 6.8 % versus 19, but they were not, that was not statistically significant. Yeah, very small group. So anyways, I thought it was interesting to actually have a standardized protocol. I'm not sure this changes anybody's practice, but it, but it was interesting nonetheless.
The Incubator (01:07:05.104)
You can, that's a lot.
The Incubator (01:07:15.014)
Yeah, it's a small cohort.
The Incubator (01:07:29.254)
Yeah, I mean, don't know if I have much use for the intervention as is, because number one, I think that for many of us, we use glycerin suppositories or enemas to stimulate stool passage. I would have liked maybe that this could have been the control group, because basically they use the control group as their former sort of saline enemas versus the new one.
But the court is very small. even then, like you mentioned, the rates are not that significantly different. But they also have a pretty high baseline rates of neck at like 9.5%, which may be higher than what most people are accustomed to. And again, that's perfectly fine. That being said, we know that babies, especially preemies, delayed gut motility or abnormal gut motility.
The Incubator (01:08:08.632)
Yeah.
The Incubator (01:08:18.773)
message.
The Incubator (01:08:22.864)
And the question has to be asked, should you try to evacuate the intestine a little bit more thoroughly? And would that have an impact on maybe better outcomes? I don't know. mean, that's a good question.
The Incubator (01:08:36.878)
It feels like it, but I don't think we have that answer. Does it even help? All these things that we do, does it even?
The Incubator (01:08:46.118)
Yeah, and is stasis of stool in the intestine potentially a recipe for bacterial translocation, i.e. the neck? Yeah, it's a great thing probably to look into. All right. But if you're quick.
The Incubator (01:08:54.914)
Mm-hmm.
The Incubator (01:09:02.86)
You're gonna let me do my last one?
I'm I'm gonna be so fast. Okay, so this one was the new normal, parental use of online health communities in the NICU. So I just wanna, we're gonna just hustle through this one. We do talk about this in a Neo news episode that will be adjacent. So it really caught my eye.
The Incubator (01:09:08.946)
Okay, let's see.
The Incubator (01:09:25.166)
It's actually going to be just so that you have your recordings ready. This will be something that we've discussed on last week's episode, which was Neo News.
The Incubator (01:09:33.656)
Perfect, thank you. Lead author Shannon Adams, senior author Beatrice Lechner. This is coming from Brown University. So basically what they wanted to do was identify if and why NICU families use online health communities to assess how the use of these virtual spaces impacts relationships between parents and their child's medical teams. So they were really interested in
that specific relationship, which is a little different than what we discussed on Neo News. But basically, they did kind of this two-part study. The first part of the study involved a distribution of surveys to NICU parents, but NICU parents were selected already kind of via an internet search conducted to identify active support or advocacy groups that were targeting NICU families.
Groups were defined as quote unquote active if they had one or more posting online within the previous three months, which is not that active, but surveys were also administered via the quote, NICU families Reddit stream with the permission of their administrators over a three month period. And then the second part of the study involved collection and evaluation of NICU centered online health community content posted on that Reddit group. Why did they use
Reddit, the sub Reddit, Nicky Parents has more than 4,400 active subscribers, but they also have thousands of other readers and contributors. And they picked Reddit because obviously parents are working, are associating on other platforms, but...
Reddit was publicly accessible, so you didn't have to join the group, right, which is true for things like Facebook. And potentially they were more confidential because people don't have to use their real names. So that's why they used Reddit. So in total, they had 250 people participating in the survey. They had to remove a few. They had 242 surveys left.
The Incubator (01:11:52.366)
60 % of the people that were already a part of these groups answered yes when asked if they used specific social media sites or these health communities, online health communities toward NICU parents and families to discuss their child in any way during their NICU stay. And then they were asked, they were given a list of 10 reasons why they may have used those communities. And the most commonly selected responses were as follows.
78 % I wanted to make contact with other NICU families with similar problems. 67 % I wanted to reduce anxiety regarding information given to me by my medical team. And 63 % I wanted to share my success with other NICU families with similar experiences as me. Now 53 % I wanted to vent my frustrations to other NICU families with similar experiences.
And then 44%, I wanted to know more about the information provided by my medical team. 61 % noted an overall positive effect on communication with the team. 56 % noted an overall positive effect on trust in the team. And 60 % noted an overall positive effect on confidence in their team. So they were communicating online, but how did it affect their relationship with their home team?
And in all, nearly 60 % documented that the use of these online health communities had overall positive effect on the general quality of their relationship with their child's NICU team. 2.8 % reported an overall negative effect on communication, 4.3 % an overall negative effect on trust, and 2.8 % on negative effect on confidence.
very low numbers, negatively affecting interactions with the team. And then when they talked about the Reddit post, they looked at 176 posts extracted across two one-month periods. And then each post had varying level of engagement. So then they divided the post into five subcategories. So were they requesting or sharing advice, medical advice? Were they
The Incubator (01:14:06.444)
venting frustrations regarding the medical care team or setting, they three, sharing positive news or accomplishments, four, seeking general support, advice, or other. So in total, 30 % of the posts fell under node four, which was seeking general support or advice, followed by node three, which was sharing positive news or accomplishments at about 27%.
and node one requesting or sharing medical advice, about 26%. And so they share that in node one, this asking specific medical advice related to their patient, post-authors, even though they were kind of anonymous, were really willing to share personal health information. So specific to the child, gestational age, birth weight, diagnoses as a means of seeking out targeted
They talked about the other types. I won't get into each of them specifically, but I thought their discussion really wrapped things up nicely. The most common responses about why they were on those communities was either the desire to connect or communicate with other families or this need for additional resources.
So again, 78 % wanted to make contact with other families, 63 % wanted to share their successes, and 53 % wanted to vent my frustrations. However, the frustrations weren't always with the NICU team. They were just frustrated about the NICU admission. So interestingly, only 11 % endorsed that they had questions unanswered by their medical team.
Only 6 % stated that they did not understand information provided by their medical team. So it sounds like we're doing a pretty good job of giving information and they understand the information that we're giving, but that families want more. 66 % of families checked, yes, I wanted to reduce anxiety regarding information given to me by my team. 44 % checked, I wanted to know more about the information provided by my medical.
The Incubator (01:16:22.03)
team. And the common themes in posts, the first is vulnerability. I told you they shared a lot of information. In fact, 30 % of posts included some photo content most of the time of the baby themselves. And the second theme is consistency of engagement with other members of subreddit. across 176 posts, there were 2,154 comments, an average of 12 comments per
And so his parents were sharing their posts, asking for advice, revealing their frustrations. They were consistently met with steady stream of kind words, encouragement, and well wishes. So an interesting, an interesting addition to our discussion.
The Incubator (01:17:10.034)
Yeah, for sure. And I think that those nodes were quite interesting because I think that if you classify sort of posts and based on these particular categories, I'm not surprised how maybe social media platforms or other like Reddit platforms can feel so toxic because if you're a parent going through the NICU and then the kinds of posts you see are either people venting or frustration, any frustration like, oh my God, like this is not really great.
Sharing positive news, it's not great either. If you're struggling and you see, that baby is doing very well, then you say, oh, why is my kid not doing too well? And then other sharing medical advice or requesting medical advice or seeking support, I think that these are not always categories that bring reassurance. And so I'm not surprised that there was a very neutral tone to some of the responses about the different themes.
The Incubator (01:17:43.266)
Yeah.
The Incubator (01:17:59.256)
That's true.
The Incubator (01:18:08.71)
Yeah, think that, I don't think that there should be a reform of how we use social media, but I think it should be understood that local within the NICU support group, like the one that, for example, you're leading that was recently featured in the news down here in Florida, is probably the right way to do it.
The Incubator (01:18:21.454)
please.
Yeah, that's an interesting perspective that I appreciate. Thank you. All right, buddy, we made it.
The Incubator (01:18:31.474)
Okay, welcome.
The Incubator (01:18:34.96)
Yeah, we made it. Thank you everybody for listening and we will see you this week with more incubator content.