#371 - 📑 Journal Club - The Complete Episode from October 26th 2025

Hello friends 👋

What’s new in neonatal innovation and research this week?

Join Ben and Daphna for a lively Journal Club episode of The Incubator Podcast, recorded after a long NICU day but packed with energy and insight. They begin with an update on the newly released NRP 9th Edition, preview their excitement for the upcoming Delphi Neonatal Innovation Conference, and then dive into five remarkable studies shaping neonatal care.

From the use of CARPEDIEM for renal replacement therapy in the tiniest infants to a meta-analysis on high-dose vitamin D supplementation, the hosts explore how evolving evidence can transform bedside care. They examine a novel trial of nebulized nitroglycerin for PPHN, the role of electrical impedance tomography (EIT) in optimizing PEEP for infants with severe BPD, and new insights into NEC risk factors even among exclusively human-milk-fed babies.

With their trademark mix of curiosity, humor, and critical reflection, Ben and Daphna make complex studies both understandable and relevant for everyday NICU practice.

Stay informed and inspired—listen now, and explore more neonatal research and conference updates at www.the-incubator.org.

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

Short-term and long-term effects of vitamin D supplementation for preterm infants: a systematic review and meta-analysis.

Shin SH, Kim HJ, Heo JS.J Perinatol. 2025 Oct 7. doi: 10.1038/s41372-025-02440-9. Online ahead of print.PMID: 41057557

Infant Renal Replacement Therapy Using Carpediem™: A Multicenter Observational Cohort Study from the ICONIIC Learning Network.

Slagle CL, Vuong KT, Krallman KA, Casey L, Gist KM, Jetton JG, Joseph C, Luckritz K, Martin SD, Morgan J, Merrill KA, Plomaritas K, Ramirez D, Tran CL, Shin HS, Snyder AN, Van Wyk B, Yalon L, Goldstein SL, Menon S.J Pediatr. 2025 Sep 26:114838. doi: 10.1016/j.jpeds.2025.114838. Online ahead of print.PMID: 41016463 Free article.

Nebulized nitroglycerin as an adjuvant drug in management of persistent pulmonary hypertension of newborns: a randomized controlled trial.

Farag MM, Ghazal HAE, Abdel-Mohsen AM, Rezk MA.Eur J Pediatr. 2025 Sep 1;184(9):586. doi: 10.1007/s00431-025-06381-5.PMID: 40888971 Free PMC article. Clinical Trial.

Azithromycin for Prevention of Bronchopulmonary Dysplasia and Other Neonatal Adverse Outcomes in Preterm Infants: An Updated Systematic Review and Meta-Analysis.

Joseph M, Murali Krishna M, Karlinksi Vizentin V, Provinciatto H, Ezenna C.Neonatology. 2025 Aug 12:1-10. doi: 10.1159/000547537. Online ahead of print.PMID: 40795809 Free article.

Identifying optimal positive end-expiratory pressure with electrical impedance tomography guidance in severe bronchopulmonary dysplasia.

Shui JE, LaVita CJ, Alcala GC, Nichols JH, Jassar RK, Turcu RM, Lerou PH, Cereda MF, Carroll RW, Ribeiro De Santis Santiago R, Berra L.J Perinatol. 2025 Sep 30. doi: 10.1038/s41372-025-02433-8. Online ahead of print.PMID: 41028823

Risk factors associated with the development of necrotizing enterocolitis in preterm infants on an exclusive human milk diet: a single-center case-control study.

Ailumerab H, Miller JL, DeShea L, Beasley WH, Chaaban H, Bergner EM.J Perinatol. 2025 Aug 30. doi: 10.1038/s41372-025-02401-2. Online ahead of print.PMID: 40885806

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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 👇

Ben Courchia (00:00.766) 

Hello everybody. Welcome back to The Incubator Podcast. We are back today for an episode of Journal Club. Daphna, good morning. How are you?

Daphna Barbeau(00:07.086) 

It’s not morning. You’ve thrown me off already and we’re just starting. You don’t have to lie to the people—we don’t have to record in the morning. It is released in the morning, okay.

Ben Courchia (00:10.494)

Definitely not morning. No, but it’s going to be released in the morning. I remember when I was a kid watching shows—you knew they were recorded in the afternoon and they’d say, “Good morning.” I thought that was so silly… and look at me doing that today.

Daphna Barbeau (00:30.574) 

You had a long day at work, but here we are recording after hours around dinner time—my dinner time, not the French dinner time—but my dinner.

Ben Courchia (00:33.022) 

Yeah. And dinner time for me isn’t for another three or four hours. So that’s good.

Daphna Barbeau (00:43.468) 

All right, well, tell us what’s new.

Ben Courchia (00:47.284) 

Lots of things are new. First, as we’re recording this on Wednesday, October 22nd, the updates to NRP have been released—NRP 9th Edition. Pretty much everyone should have received an email with a onepager summarizing differences between NRP 8 and NRP 9. That said, we’re going to have a special episode next week

where we talk to Henry Lee, who is one of the members of the steering committee. We’ll go over all the updates you should be familiar with for NRP 9th Edition. So don’t fret if you’re like me thinking, “My God, I have a busy week and on top of that I have to figure out what to do differently in the delivery room.” We’ve got you covered, and we’ll do that next week with Daphna and Dr. Lee from California. Very excited about that.

Daphna Barbeau (01:30.050) 

Searching your email.

Ben Courchia (01:45.844) 

Other announcements: we are very excited about prep for Delphi—the Delphi Neonatal Innovation Conference—which promises to be an exceptional edition this year. I’m so excited. Usually when you prepare something and spend a lot of time, you beat it to death and you’re just ready for it to be over.

Daphna Barbeau (02:12.066) 

Just ready for it to get here.

Ben Courchia (02:13.320) 

Yeah, you’re kind of like, “My God, I can’t wait for it to be over.” But I’m genuinely excited about this edition. We have a very exciting program and list of speakers. We’re going to talk about so many topics—advocacy, neonatal neurology, neonatal pulmonary medicine, career development, stem cells—so many interesting topics that…

I can’t wait to be there and hear these folks. There will be lots of other activities too—Trivia Night, the TEDx event, special panels on AI and on twins. It’s going to be a lot of fun. And it’s going to be relaxing—that’s where I feel our expertise shines, because we’re not…

Daphna Barbeau(03:09.848) 

Is that an expertise? Okay.

Ben Courchia (03:12.988)

I was thinking about that—what makes us good at this? We’re not the ones speaking; people don’t come to hear us. The speakers are exceptional. And we’re probably not the greatest logistics people—we take twice as long to do something as anybody else.

Daphna Barbeau (03:18.261)

Mmm… no?

Daphna Barbeau (03:33.698)

You’re pulling back the curtain here. But we got some extra help this year; we’re figuring it out.

Ben Courchia (03:38.824)

Truly—we have extra help this year, but we have no business doing the logistics for a conference. We’re good at finding speakers—that’s what we do with the podcast and everything else—but picking the number of tables, etc., is exhausting. The conference itself is awesome. I think we make it more complicated for ourselves,

Daphna Barbeau (03:53.838)

It’s exhausting.

Ben Courchia (04:07.674)

which is more work, but it leads to a combination of intellectually stimulating conversations and lectures in a relaxing, peaceful environment so you leave energized—ready to go back to work and start doing things in your unit tomorrow.

Daphna Barbeau (04:29.707)

Yeah, we want people to be comfortable. We’ve posted about this a few times—it feels like we’re inviting you to our home. We want you to be comfortable, to chat, have a good time, think about new ideas, talk to new people…

Ben Courchia (04:43.154)

Yeah, and…

When you’re in the conference hall you’ll be intellectually stimulated. When you leave, it’s like a resort feel—water, sun, comfort. That plays a huge role in how people leave the conference. And, without boasting too much, there’s a lot of work product being done by people who met at the conference who reach out and say, “Hey, we met at Delphi and we’ve been sharing ideas and working on a project.” That’s very cool.

Daphna Barbeau(05:15.277)

A lot of people who come to Delphi selfselect. We’re a mediumsized conference by design—we want people to interact and engage. Don’t be afraid to come by yourself. People met at the first Delphi, came back for the second, and are coming back for the third. That’s really cool.

Ben Courchia (05:48.436)

Yeah. And like we’ve always said for Delphi—if the ticket price is an issue for you and you think it’s too expensive (and by the way, it’s not—many conferences are more expensive than ours), but if that’s the obstacle preventing you from attending, send us an email. You don’t need to apply for a grant—we’ll work with you, like we do for everything. Just FYI—if you’d love to go but don’t have that kind of money on hand, let us know. We can’t pay for your trip or hotel, but if registration is the issue, it won’t be.

Daphna Barbeau (06:36.263)

And on that note, the hotel is really, really cool. They’ve offered us such a good price. You can’t come to anywhere in Florida at this price point. You can walk to the beach…

Ben Courchia (06:39.506)

Whoa.

Ben Courchia (06:45.490)

About $500 for three nights in Fort Lauderdale by the water—beautiful rooms.

I usually don’t stay—people may not know that when we do Delphi I drive back home every night because it’s close. I’m staying at the hotel this year.

Daphna Barbeau (07:06.125)

People should take a look: they have two and threebedroom options—you can come with colleagues and split the cost. We really try to make it accessible.

Ben Courchia (07:15.602)

Great conference. We’ve had a lot of registrations and we’re very excited. Go check it out—find info at DelphiConference.org or on The Incubator website, theincubator.org/delphi. Both links lead to the same place.

Daphna Barbeau (07:20.385) 

Mmhmm.Sneaky.

Ben Courchia (07:38.228)

Yeah—what do you think, we’re making multiple websites over here? All right, let’s get started with Journal Club. What do you say, Daphna? Let’s.

The first paper is from The Journal of Pediatrics: “Infant Renal Replacement Therapy Using CARPEDIEM: A Multicenter Observational Cohort Study”

Daphna Barbeau(07:47.245)

Mmhmm.

Ben Courchia (08:06.664)

from the ICONIC Learning Network.

Daphna Barbeau (08:09.291)

You’ve been teasing this paper to our team.

Ben Courchia (08:11.826)

Yeah—it’s so interesting. First author is Kara Slagle, from the team at Cincinnati. I believe Cincinnati has been one of the most active centers using CARPEDIEM for infant renal replacement therapy. We’ve had Delphi talks on nephrology—Dr. Chryso Pefkaros Katsoufis gave a beautiful lecture on infant renal disease and proper followup that I recommend on our YouTube channel. This paper looked at CARPEDIEM as continuous renal replacement therapy (CRRT). First, what is continuous renal replacement therapy? It’s increasingly used in infants, even though peritoneal dialysis remains the most common modality in this age group. Many may be familiar with peritoneal dialysis—a peritoneal catheter is placed and babies undergo dialysis. The innovation with CARPEDIEM is that you can do this without a peritoneal catheter—you need venous access (internal jugular or femoral), using a doublelumen catheter: draw from the vein and return to the vein. It allows dialysis for very small babies, down to ~2.5 kg (there are reports in smaller infants too). With some POCUS and a PICC/line team you can get access to run dialysis. Background: CRRT via CARPEDIEM is used as a bridge to peritoneal dialysis or after peritoneal dialysis failure in infants with endstage kidney disease. A survey of 39 North American pediatric renal programs showed more than half report using CRRT as a bridge to PD at least occasionally and successfully. Prior reports show success in preterm neonates who failed PD. Starting CRRT before PD catheter placement may even promote optimal healing because you’re already making progress while the patient recovers from the PD catheter placement. For infants, this therapy provides clearance and nutritional support while maintaining fluid balance, but it is physiologically and technically challenging. The main challenges are filters with large extracorporeal volumes relative to patient size and the need for largebore catheters. Before 2020, pediatric specialists adapted adult devices (e.g., Aquadex) for modified hemofiltration in small infants. Since the U.S. Food and Drug Administration approved CARPEDIEM (CardioRenal Pediatric Dialysis Emergency Machine), originally designed in Italy, it’s been revolutionary. It can be used officially for babies 2.5–10 kg (some use it lower). To support learning and collaboration around this technology,

the ICONIC network was created—Improving CRRT Outcomes in Neonates and Infants through Interdisciplinary Collaboration. The objective of this study was to evaluate indications and shortterm outcomes for infants treated with CARPEDIEM across U.S. centers. This was a multicenter prospective observational learninghealthnetwork registry of infants receiving RRT with CARPEDIEM between September 2020 and June 2024.

It includes four sites and patients who completed a treatment course (defined as a series of procedures separated by no more than 72 hours). Indications for treatment were determined by the treating team (more than one indication allowed). Researchers also recorded whether other RRT devices were used before or after CARPEDIEM. Before each course, they calculated percent fluid balance using weightbased and intake/output methods. Clinical sepsis was defined per SIRS (Systemic Inflammatory Response Syndrome) criteria. They collected vasopressor data up to four hours before CRRT initiation and tracked interventions for hypotension during therapy (fluid boluses, vasopressor escalation, hydrocortisone, etc.). They divided the cohort into two groups: ESKD (endstage kidney disease—congenital kidney failure or severe CAKUT, anticipated to need longterm dialysis shortly after birth or after PD failure) and nonESKD (acute conditions like AKI, positive fluid balance, severe electrolyte disturbance).

Primary outcomes: survival to treatmentcourse end and survival to hospital discharge.

Results: characteristics from 67 patients were reported. The cohort was predominantly male with median GA 36 weeks. ~80% were admitted to the NICU on day of life 1 with admission weight around 3.01 kg.

For those not admitted immediately, primary indications were severe respiratory failure or kidney failure. CAKUT (congenital anomalies of the kidney and urinary tract) was present in 54% of patients—13 had lower urinary tract obstruction; 10 had unilateral/bilateral solitary kidney with multicystic dysplastic kidney disease. Initial treatmentcourse indications (multiple allowed): ESKD as a bridge to PD in 54%; positive fluid balance 46%; AKI 43%; electrolyte abnormality 21%. No inborn errors of metabolism cases.

Treatment courses and outcomes: 67 patients underwent 93 treatment courses; 14 patients received more than one course. Median body weight ~3.4 kg; 13 patients were <2.5 kg (~20%). Treatmentcourse outcome data available for 64 patients: 84% survived their treatment; 63% transitioned to a different device (often peritoneal dialysis). Major complications were reported in 26 patients (41%); sepsis/bacteremia and new or worsening intraventricular hemorrhage were most frequent. 63% survived to hospital discharge. There was no difference in survival by weight at first treatment course. Of the 23 who did not survive, 18 transitioned to comfort care. Causes of death were most commonly pulmonary hypoplasia and/or sepsis.

By subgroup: ESKD cohort (n=36), median weight 2.6 kg, age 18 days. Survival to discharge 67%; 9/11 nonsurvivors transitioned to comfort care. Twentyone survivors transitioned to another form of RRT (commonly peritoneal dialysis); nine received continuous or prolonged intermittent RRT via another device; two had intermittent hemodialysis. NonESKD cohort (n=31): survival to discharge 60%; most common cause of death was sepsis/infection; nine of the nonsurvivors transitioned to comfort care.

Conclusion: In this U.S. cohort, survival in infants treated with CARPEDIEM exceeded 60%, and more than half of indications were ESKD as a bridge to dialysis. I wouldn’t be surprised if this becomes more common in NICUs. Historically, dialysis lived in the PICU; it looks like it’s coming to the NICU.

Daphna Barbeau (20:59.051)

Great.

Ben Courchia (21:01.428)

And for babies with severe positive fluid balance—if your hospital acquires these devices, we might consider dialysis more readily. Very interesting.

Daphna Barbeau (21:20.958)

Yeah, exciting to have more to offer for sure.

Ben Courchia (21:25.074)

Especially for babies with severe NEC, for example, who then undergo surgery, become very edematous, develop AKI, and you’re trying to titrate electrolytes—it can take days to normalize. Maybe dialysis is the option for swifter correction with less risk because it’s…

Daphna Barbeau (21:51.840)

Mmhmm.

Ben Courchia (21:53.618)

These are the patients we stress about—and yeah, the PICU has dialysis; we don’t.

Daphna Barbeau (21:59.915)

To be fair, some NICUs do dialysis, but very few. And this is a totally different system.

Ben Courchia (22:05.404)

It’s interesting. And peritoneal dialysis is tough—I’m sorry. Those peritoneal catheters often get infected or don’t function. It’s not always straightforward, and by the time you’re ready to start dialysis, who knows where you are.

Daphna Barbeau (22:29.398)

All right, buddy. I have a different paper. Journal of Perinatology: “Shortterm and longterm effects of vitamin D supplementation for preterm infants.” A review and metaanalysis. Lead author: SungHyun Shin.

Ben Courchia (22:51.294)

Your Korean is getting better.

Daphna Barbeau (22:56.812)

Yes, this is from Korea. The goal was to study short and longterm effectiveness and safety of highdose vitamin D (≥800 IU/day) vs low dose (<800 IU/day). Because it’s a metaanalysis, ranges varied, but lowdose groups were all <800 IU/day. They wanted to determine an optimal dosing strategy. Population: preterm infants GA <37 weeks. Intervention: highdose vitamin D3 ≥800 IU/day started during the NICU stay, sometime after birth.

Outcomes: shortterm—serum 25(OH)D, vitamin D deficiency (<20 ng/mL), vitamin D excess, skeletal mineralization, growth; clinical outcomes (RDS, BPD, lateonset sepsis, length of stay, mortality); biochemical markers (PTH, Ca, Phos, ALP, urine Ca:Cr). Longterm—serum 25(OH)D, bone mineral density, mortality, neurodevelopment.

They included 21 studies from nine countries (Canada, Egypt, Finland, India, Iran, Israel, Turkey, UK, US), totaling 1,130 infants.

Shortterm results: serum 25(OH)D increased significantly in highdose vs lowdose groups; risk of vitamin D deficiency was significantly lower in highdose; importantly, no significant difference in vitamin D excess overall. Skeletal hypomineralization risk was significantly lower in highdose. Growth (weight/length/HC gain velocity) was significantly higher in highdose. For clinical outcomes—RDS, BPD, LOS (lateonset sepsis), length of stay—no differences, but mortality was significantly lower in the highdose group. PTH was significantly lower in highdose; other markers similar.

They subdivided the highdose group: 800 IU, 960–1000 IU, and 2000 IU. All showed higher 25(OH)D vs lowdose. The risk of vitamin D deficiency decreased in both the 800 IU and ~1000 IU subgroups. The risk of vitamin D excess increased significantly only in the ~1000 IU subgroup—not in 800 IU.

Longterm: no significant difference in serum 25(OH)D between high and lowdose groups overall; one study showed lower vitamin D deficiency at followup in the highdose group; no significant difference in vitamin D excess longterm. Bone mineral density at corrected 3 months and at 9–11 years: no significant differences. One study at 2 years: no significant differences in mortality or neurodevelopment.

Bottom line, I was impressed by the shortterm growth outcomes. In our unit, we monitor vitamin D closely and adjust individually; notably we often increase to 800 IU. Perhaps we should start at 800—or at least 600. We typically start at 400.

Ben Courchia (30:06.866)

Vitamin D keeps coming back in the NICU with good properties. And it feels like many of our babies end up on 800 IU.

Daphna Barbeau (30:22.892)

Start high.

Daphna Barbeau (30:27.660)

All right, your turn.

Ben Courchia (30:36.690)

Next article: European Journal of Pediatrics—“Nebulized nitroglycerin as an adjuvant drug in management of persistent pulmonary hypertension of the newborn: a randomized controlled trial.” First author: Marwa Mohamed Farag.

Daphna Barbeau (30:56.723)

That is interesting.

Ben Courchia (31:06.078)

This comes from a group in Egypt—hello to all our listeners in Egypt. Introduction: PPHN is a serious, lifethreatening condition caused by failure of the pulmonary vasculature to adapt to birth—failure of PVR to decrease. Diagnosis is primarily clinical, but echo is essential. Treatment goals: optimize oxygenation, promote pulmonary vasodilation, support myocardial function, minimize oxygen toxicity. Conventional management includes oxygen, mechanical ventilation, and vasodilators such as inhaled nitric oxide (iNO), which remains standard of care for selective pulmonary vasodilation.

In many resourcelimited settings, iNO is unavailable due to cost and specialized equipment. This gap has prompted interest in alternatives. Nitroglycerin, a nitric oxide donor, has emerged as a potential alternative. When administered by inhalation, it acts directly on pulmonary vasculature causing selective vasodilation while minimizing systemic hypotension. Previous pediatric and adult studies (e.g., congenital heart disease, cardiac surgery) suggest safety and efficacy when nebulized. It has rapid onset, is easy to administer, and is inexpensive.

This study investigated fullterm neonates. Methods: randomized controlled clinical trial in the NICU of Alexandria, Egypt, January–December 2024. They enrolled 80 term infants diagnosed with PPHN within the first three days of life. Eligibility: ≥37 weeks’ GA and FiO2 ≥0.50 despite lung recruitment efforts, or echo signs of PPHN (TR jet >50 mmHg, Dshaped LV). Infants diagnosed after 72 hours or with major congenital anomalies were excluded. Randomized to two groups: nebulized nitroglycerin group received standard PPHN management plus nitroglycerin; controls received standard care only. All received enteral sildenafil as part of standard therapy.

Nebulized nitroglycerin dose: 2.5 mcg/kg/min for 10 minutes, repeated every 4 hours.

Primary outcome: change in estimated systolic pulmonary artery pressure (sPAP) by echocardiography. Secondary outcomes: other echo parameters; oxygenation indices (OI, OSI), duration of mechanical ventilation, NICU length of stay, need for inotropes, mortality.

Results: 85 randomized; 80 completed. Baseline vitals similar. By day 3, infants receiving nebulized nitroglycerin had significantly higher systolic and mean arterial pressures—suggesting improved cardiovascular stability. No hypotension episodes related to nitroglycerin. The nitroglycerin group had higher pH and lower PCO2 (better gas exchange). By days 2–3, oxygenation parameters (SpO2/FiO2, FiO2 requirement, oxygenation index, oxygen saturation index) improved markedly with nitroglycerin; these indices deteriorated in controls despite standard therapy.

Ventilation: by day 3, more infants in the nitroglycerin group were on nasal CPAP, while more controls remained on HFV; mean airway pressure decreased more rapidly with nitroglycerin—consistent with improved compliance.

Figures show clear separation by day 3 for OI and OSI. Echo: initial sPAP was slightly higher in the nitroglycerin group, but there was a significant reduction by day 3; the sPAP/systemic systolic pressure ratio also improved. Biventricular function improved (e.g., TAPSE, EF, FS). Measures of cardiac output (right/left ventricular outputs, stroke distance) also improved. A survival curve favored nitroglycerin.

Authors conclude nebulized nitroglycerin is a promising adjunct for PPHN—producing significant improvements in pulmonary hemodynamics, oxygenation, and cardiac function without systemic side effects. Further studies needed, but in resourcelimited settings, it’s a potential option alongside sildenafil when iNO is unavailable.

Daphna Barbeau (39:52.981)

Now we need a headtohead.

Ben Courchia (39:55.366)

Yeah, absolutely.

Daphna Barbeau(39:59.560)

I keep hoping azithromycin will work—you know how much I like azithromycin. This was…

Ben Courchia (40:08.436)

I saw that paper and didn’t want my heart broken again.

Daphna Barbeau (40:14.673)

Again. This is a metaanalysis: “Azithromycin for prevention of bronchopulmonary dysplasia and other neonatal adverse outcomes in preterm infants—an updated review and metaanalysis.” Multiinstitutional authors from Brazil, India, Massachusetts, Mayo Clinic, etc. The hope was that pooling data would show benefit.

Why azithro? Maternal chorioamnionitis has been linked to BPD risk; Ureaplasma colonization has been linked to BPD and to preterm birth. Targeting Ureaplasma with azithro has not consistently helped. They included randomized controlled trials comparing azithromycin vs placebo to prevent BPD in preterm infants, with at least one clinical outcome of interest; excluded nonrandomized, overlapping, nonplacebo controls, or nonazithro antibiotics. Outcomes: composite BPD or death; BPD; death; NEC ≥Bell II; IVH grade 3–4; ROP; duration of mechanical ventilation; postnatal corticosteroid requirement. BPD defined as oxygen need at 36 weeks’ PMA.

They included six RCTs (n=1,360), mean GA 26.8 weeks. Four trials used 10 mg/kg azithro; two used 20 mg/kg. Some treated all; some targeted Ureaplasmapositive infants. Among trials reporting Ureaplasma, 27% were positive.

Results: Composite BPD or death—no difference. BPD—no difference. Death—no difference. NEC, IVH, ROP—no differences. Duration of mechanical ventilation and postnatal steroid requirement—no differences. Subgroup of Ureaplasmapositive infants—still no difference for composite BPD or death. Conclusion: azithromycin did not significantly change these outcomes compared to placebo.

Ben Courchia (44:18.930)

What about nebulizers? (Kidding.)

Daphna Barbeau (44:20.765)

Right? Also, no sublingual nitroglycerin for tiny babies.

Ben Courchia (44:29.276)

I’m starting to wonder whether Ureaplasma truly causes pneumonia or has a role in BPD—why wouldn’t azithro work otherwise?

Daphna Barbeau (44:37.087)

It feels like it should work. But… womp womp.

Ben Courchia (44:40.762)

What a frustrating endeavor. The papers show we want this to work.

Daphna Barbeau (44:48.489)

We want something accessible and inexpensive—but no.

Ben Courchia (44:55.528)

I remember as a fellow advocating for it: “Prevalence of Ureaplasma in delivering mothers—just give it, don’t test.” And Dr. BenGlari—rightfully—said, “No, not without evidence.”

Daphna Barbeau (45:01.609)

Why are we using it? Nope. Fine.

Ben Courchia (45:22.228)

Next: Journal of Perinatology—“Identifying optimal positive endexpiratory pressure with electrical impedance tomography guidance in severe BPD.”

Daphna Barbeau (45:32.789)

I knew you were going to pick this.

Ben Courchia (45:34.514)

First author Jessica Shue (Boston). I’m very excited about EIT. PEEP is crucial in mechanical ventilation—maintaining alveolar recruitment while avoiding overdistension and atelectasis. These infants often have regions of collapse and overinflation.

Electrical impedance tomography (EIT) is promising—a noninvasive, radiationfree, operatorindependent, realtime functional lung imaging tool at the bedside. If you’ve never seen it, it’s like those Polar heartrate monitor chest straps runners use. It looks like a Holter, but smaller. It measures impedance changes as small electrical currents pass across the thorax. EIT visualizes air distribution—the output shows where aeration is happening so you can see, in real time, which regions inflate, and detect atelectasis and overdistension.

I’ve spoken to companies; it has been used under research protocols and is making its way into clinical use. The authors suggest EITguided PEEP titration can identify an optimal PEEP that minimizes both overdistension and atelectasis. This is a case series (four BPD cases, plus four additional nonBPD cases as comparators).

BPD Subject 1: male SGA (9th percentile), extremely preterm, tracheostomy for chronic ventilator dependence. On SIMV pressure control; PEEP escalated to 14, FiO2 45–50%, MAP ~22. EITguided titration identified optimal PEEP 10 (minimized collapse and overinflation). The baby remained clinically stable for ~10 months on PEEP 10 with lower FiO2 (30–40%).

BPD Subject 2: former 25week infant with IUGR, failed noninvasive support after lowdose dexamethasone; chronically intubated via trach. One week prior to EIT, hypoxic event → PEEP escalated to 11 on 40–50% FiO2, MAP 19; then PEEP 14, FiO2 80–100%, MAP 25. iNO added; sedation and neuromuscular blockade started. EIT evaluation performed; no recruitment maneuver (CXR overdistension). Lowest PEEP evaluated was 8, which resolved overdistension without atelectasis and improved compliance and regional ventilation (tidal volume gain). After decreasing support to PEEP 8, MAP 14, FiO2 decreased from 86% to 25% over three days (lower than baseline before the decompensation). Paralysis lifted after a week; expected dynamic collapse led to PEEP 9, MAP 15, FiO2 ~50% with spontaneous breathing. Remained on PEEP 9 about 1.5 months after EIT titration.

Takeaway: clinicians often have the right idea—support the baby—but bedside assessment of “how much PEEP” is often overestimated. EIT helps find the right number without inducing atelectasis.

Daphna Barbeau (52:54.490)

It always feels scary to go down on PEEP in an unstable baby—even when you know it might help.

Ben Courchia (53:00.456)

Yeah—if sats drop for a moment you think, “The kid doesn’t like it—go back,” because we’re reactive. And how many times do you lower PEEP by 1, then some random event happens overnight and PEEP goes back up by 1 because…

Daphna Barbeau (53:23.295)

That’s right—goes right back up.

Ben Courchia (53:28.640)

The baby’s toe turns the wrong way… that has nothing to do with PEEP, but that’s how we work. This is a very interesting paper. Next year I want to talk to more people about EIT; I want it in my unit. It could be very helpful. Jessica’s group in Boston is doing a great job bringing this to the NICU.

Daphna Barbeau (54:01.451)

If you’re a company who does EIT, let us know.

Ben Courchia (54:03.750)

I’ve spoken to some already—frustrating that I wanted to get our hospital to purchase, but it’s been researchonly. That’s changing, and I think next year people will be able to purchase. It’s very cool—noninvasive, no needles.

Daphna Barbeau (54:28.170)

We just reviewed that chest Xrays aren’t reliable for expansion. Then…

Ben Courchia (54:38.172)

And the dynamic studies we’ve done—like pulmonologydirected bronchoscopy with dynamic PEEP studies—aim to find at what point airway patency is lost. It’s not as precise without direct visualization, but bronchoscopy is invasive. If you can get correlating information with a simple chest strap, that’s neat.

Daphna Barbeau (55:21.930)

What bronchoscopy can’t do is longitudinal evaluation; babies change every day. EIT you could do daily.

Ben Courchia (55:38.718)

Please.

Daphna Barbeau (55:45.651)

Journal of Perinatology: “Risk factors associated with the development of necrotizing enterocolitis in preterm infants on an exclusive human milk diet: a singlecentered casecontrol study.” Lead author: Haider AlLumarab (Oklahoma Children’s / University of Oklahoma).

What’s unique is the entire cohort was on an exclusively humanmilk diet: mom’s own milk or donor milk with humanmilkderived fortifier—removing “what were the babies fed” as a factor. Retrospective matched casecontrol in a level IV NICU.

Inclusion: <32 weeks’ GA and <1500 g at birth who received exclusive human milk until 32 weeks’ PMA, between January 2016 and March 2023. Controls: infants who did not develop NEC while receiving the same diet. Target ratio ~1:4 cases:controls. Controls matched by birth weight (±200 g), GA (±2 weeks), and birth date (±6 months). Known major congenital anomalies excluded.

They identified 53 cases and 1,019 controls; after strict criteria, 27 cases and 98 controls remained. Cases: mean GA 27.2 weeks, mean BW 928 g. Controls similar: GA 27.4 weeks, BW 960 g. No significant differences in many maternal/infant characteristics.

NEC diagnosed at mean age 22 days; 26% were Bell stage III. Surgery required in 15%. Mortality due to NEC 22%. Among survivors: short bowel 11%, TPN dependence 15%, cholestasis 22%, recurrence 7%; 48% had no major intestinal complications at discharge.

Positive blood cultures in 30% of cases; average antibiotics 8 days—vancomycin and amikacin most common.

Prenatal factors: two stood out on univariate analysis—maternal neutrophiltolymphocyte ratio (NLR) before delivery was higher in NEC cases (mean 13.6) vs controls (~6); and maternal urinarytract infection within one week before delivery—more common in NEC cases (19%) vs controls (2%). Other prenatal factors were not different.

Early postnatal factors (first week): need for vasopressors/inotropes was higher in cases (26%) vs controls (8%). Presence of a PDA requiring treatment up to the time of NEC diagnosis was more common in cases. Nutritional parameters in the week leading up to NEC showed no significant differences except slower feeding advancement in cases (9 mL/kg/day) vs controls (12 mL/kg/day).

Models: Model 1 included maternal NLR and maternal UTI; Model 2 added postnatal vasopressor use. Maternal UTI prior to delivery and infant vasopressor use in the first week were associated with higher likelihood of NEC, as was higher maternal NLR. In Model 2, maternal race showed a trend (p=0.076): infants of Black/African American mothers had higher NEC risk vs others. Combined risk was highest in infants of Black mothers who received vasopressors and whose mothers had UTI and high NLR.

Takeaway: recognize these as potential risk factors even in exclusively humanmilkfed infants, and consider closer monitoring.

Ben Courchia (01:04:49.214)

Yeah. I’m curious what you make of this. Two factors don’t surprise me—vasopressors (if a baby is that sick early) and the populationspecific effects of maternal race. But maternal UTI and maternal NLR are not things I routinely ask about or look at.

Daphna Barbeau (01:06:06.826)

You might know from prenatal records.

Ben Courchia (01:06:09.948)

If there was a maternal UTI in the week prior to delivery—we often don’t know unless we ask specifically, and even OBs may not always know. If the urine dip is clean at admission, that’s that. Only robust OB histories would include “have you had infection in the last 7–14 days?”

Daphna Barbeau (01:07:24.266)

By the time NEC rolls around (mean 22 days here), we’ve already forgotten most of the prenatal history. We use it for early antibiotics, but three weeks later we’re not thinking about it.

Ben Courchia (01:09:05.906)

Agreed. Our problem lists aren’t tailored for neonates—maternal history should almost be a subproblem list. Whatever the mother has connects to the baby one way or another.

Daphna Barbeau (01:09:39.889)

In adults, a heart attack risk list includes the patient’s own HTN, HLD, etc. For babies, the risk factors are maternal; they should be connected.

Ben Courchia (01:09:54.566)

Exactly. Today a mother was wearing a mask; I wanted to know if she had a viral illness—very pertinent for a baby on respiratory support. (It was just bleach irritation.) Imagine if a mother is seen by her PCP and new diagnoses automatically appear in a linked maternal section—we’d have valuable information from an epigenetic and infectiousrisk standpoint.

Daphna Barbeau (01:10:30.131)

And often moms are readmitted—with infections, blood clots, etc.—and it trickles down.

Ben Courchia (01:10:43.154)

We should tell parents explicitly: we want to know everything about you medically while your baby is here—it impacts how we care for your baby. Introverted families shouldn’t be disadvantaged compared to those who volunteer every detail.

Daphna Barbeau (01:11:09.939)

Exactly—some families don’t know to disclose. Others disclose everything.

Ben Courchia (01:11:20.582)

All right—that was a good discussion. Don’t forget to register for Delphi, and we’ll see you next week with NRP updates. Very cool. Bye.

Daphna Barbeau (01:11:30.771)

For sure. All right, buddy—get some rest.

Very cool.