#371 - 📑 Journal Club - The Complete Episode from October 26th 2025
- Mickael Guigui
- Oct 26
- 21 min read
Updated: 4 days ago
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 👇
Shin SH, Kim HJ, Heo JS.J Perinatol. 2025 Oct 7. doi: 10.1038/s41372-025-02440-9. Online ahead of print.PMID: 41057557
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.
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.
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.
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
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: 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: 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: 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: You had a long day at work, but here we are recording after hours around dinner time. Well my dinner time, not the French dinner time.
Ben Courchia: Dinner time for me isn’t for another three or four hours. So that’s good.
So, 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 one-pager 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, 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.
Other announcements: we are very excited about prep for 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. 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. 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: You’re pulling back the curtain here. But we got some extra help this year; we’re figuring it out.
Ben Courchia: Yes 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, 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 and ready to go back to work and start doing things in your unit tomorrow.
Daphna Barbeau: 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, and talk to new people.
Ben Courchia: 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: A lot of people who come to Delphi self-select. We’re a medium-sized 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: 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.
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: 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: About $500 for three nights in Fort Lauderdale by the water—beautiful rooms. I usually don’t stay and I drive back home every night because it’s close. I’m staying at the hotel this year.
Daphna Barbeau: People should take a look: they have two and three-bedroom options. You can come with colleagues and split the cost. We really try to make it accessible.
Ben Courchia: 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. 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 (Cardio-Renal Pediatric Dialysis Emergency Machine): A Multicenter Observational Cohort Study” from the ICONIC Learning Network.
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 follow-up 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 double lumen 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.
CRRT via Carpediem is used as a bridge to peritoneal dialysis or after peritoneal dialysis failure in infants with end stage 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 large bore 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, originally designed in Italy, it’s been revolutionary. It can be used officially for babies 2.5–10 kg (some use it lower weights). 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 short-term outcomes for infants treated with Carpediem across U.S. centers.
This was a multicenter prospective observational learning health network 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 weight-based 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 (end stage kidney disease—congenital kidney failure or severe CAKUT, anticipated to need long term dialysis shortly after birth or after PD failure) and non-ESKD (acute conditions like AKI, positive fluid balance, severe electrolyte disturbance).
They had two primary outcomes: survival to treatment course end, and survival to hospital discharge.
They had demographics and clinical characteristics from 67 patients 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 treatment course 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. The median age of the first treatment was 28 days with corrected gestational age of 39 weeks.
In terms of treatment courses and outcomes, 67 patients underwent 93 treatment courses; 14 patients received more than one course. Median dry weight ~3.4 kg; 13 patients were <2.5 kg (~20%). They gave a lot of information about how many filters were used, where procedures were located, how long the filters lasted, etc.
Treatment course outcome data available for 64 patients: 84% survived their treatment; 63% transitioned to a different device (assuming 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. Twenty-one survivors transitioned to another form of RRT (commonly peritoneal dialysis); nine received continuous or prolonged intermittent RRT via another device; two had intermittent hemodialysis.
Non-ESKD cohort (n=31): survival to discharge 60%; most common cause of death was sepsis/infection; nine of the nonsurvivors transitioned to comfort care.
In conclusion the authors state that 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.
And for babies with severe positive fluid balance: if your hospital acquires these devices, we might consider dialysis more readily. Very interesting—especially for babies with severe NEC who 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 these are the patients we stress about. And yeah, the PICU has dialysis; we don’t.
Daphna Barbeau: To be fair, some NICUs do dialysis, but very few. And this is a totally different system.
Ben Courchia: It’s interesting. And peritoneal dialysis is tough. 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: All right, buddy. I have a different paper. Journal of Perinatology: “Short term and long term effects of vitamin D supplementation for preterm infants.” A review and meta-analysis. Lead author: Sung Hyun Shin.
Ben Courchia: Your Korean is getting better.
Daphna Barbeau: Yes, this is from Korea. The goal was to study short and long term effectiveness and safety of high-dose vitamin D (≥800 IU/day) vs. low dose (<800 IU/day). Because it’s a meta-analysis, ranges varied, but low dose groups were all <800 IU/day. They wanted to determine an optimal dosing strategy.
Their population was preterm infants GA <37 weeks. The intervention was high dose vitamin D3 ≥800 IU/day started during the NICU stay. They looked at short term serum 25(OH)D, vitamin D deficiency (<20 ng/mL), vitamin D excess, skeletal mineralization, growth, clinical outcomes (RDS, BPD, late onset sepsis, length of stay, mortality); biochemical markers (PTH, Ca, Phos, ALP, urine Ca:Cr). And then long term they looked at 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.
Short term results: serum 25(OH)D increased significantly in high dose vs low dose groups; risk of vitamin D deficiency was significantly lower in high dose; importantly, no significant difference in vitamin D excess overall. Skeletal hypomineralization risk was significantly lower in high dose. Growth (weight/length/HC gain velocity) was significantly higher in high dose.
For clinical outcomes—RDS, BPD, LOS (late onset sepsis), length of stay—no differences, but mortality was significantly lower in the high dose group. PTH was significantly lower in high dose; other markers similar.
They subdivided the high dose group: 800 IU, 960–1000 IU, and 2000 IU. All showed higher 25(OH)D vs low dose. 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.
In long term outcomes, there was no significant difference in serum 25(OH)D between high and low dose groups overall; one study showed lower vitamin D deficiency at follow-up in the high dose group. No significant difference in vitamin D excess long term. Bone mineral density at corrected 3 months showed no significant differences. One study looked at bone mineral density at 9–11 years and no differences there either. One study at 2 years: no significant differences in mortality or neurodevelopment.
I was impressed by the short term 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: 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: Start high. All right, your turn.
Ben Courchia: 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. This comes from a group in Egypt. Hello to all our listeners in Egypt.
PPHN is a serious, life-threatening condition caused by failure of the pulmonary vasculature to adapt to birth, failure of pulmonary vascular resistance (PVR) to decrease. Diagnosis is primarily clinical, but echocardiography is essential.
The treatment goals are to optimize oxygenation, promote pulmonary vasodilation, support myocardial function, and minimize oxygen toxicity. Conventional management includes oxygen, mechanical ventilation, and vasodilators such as inhaled nitric oxide (iNO), which remains the standard of care for selective pulmonary vasodilation.
The point they’re making is that in many resource-limited 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 cheap. This study investigated full-term neonates.
It was a 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. Infants had to be ≥37 weeks’ GA and FiO₂ ≥0.50 despite lung recruitment efforts, or echocardiographic signs of PPHN (TR jet >50 mmHg, D-shaped LV). Infants diagnosed after 72 hours or with major congenital anomalies were excluded.
Infants were randomized to two groups: Nebulized nitroglycerin group received standard PPHN management plus nitroglycerin (nebulized nitroglycerin dose: 2.5 mcg/kg/min for 10 minutes, repeated every 4 hours) and the control group received standard care only. All received enteral sildenafil as part of standard therapy.
Primary outcome was change in estimated systolic pulmonary artery pressure (sPAP) by echocardiography. Secondary outcomes included other echo parameters; oxygenation indices (OI, OSI), duration of mechanical ventilation, NICU length of stay, need for inotropes, and mortality.
So, 85 infants were randomized and 80 completed the study. Baseline vitals were 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.
By day 3, more infants in the nitroglycerin group were on nasal CPAP, while more controls remained on high frequency ventilation; mean airway pressure decreased more rapidly with nitroglycerin, consistent with improved compliance. Figure 2 shows clear separation by day 3 for OI and OSI. Less difference for pH and pCO2.
Daphna Barbeau: You really had to ride it out. Day 1, no real difference, but by day 3, there it was.
Ben Courchia: Echo findings showed 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 that nebulized nitroglycerin is a promising adjunct for PPHN, producing significant improvements in pulmonary hemodynamics, oxygenation, and cardiac function without systemic side effects. Further studies are needed, but in resource-limited settings, it’s a potential option alongside sildenafil when iNO is unavailable.
Daphna Barbeau: Now we need a head-to-head. I keep hoping azithromycin will work—you know how much I like azithromycin!
Ben Courchia: I saw that paper and didn’t want my heart broken again.
Daphna Barbeau: Again! This is a meta-analysis in Neonatology, “Azithromycin for prevention of bronchopulmonary dysplasia and other neonatal adverse outcomes in preterm infants—an updated review and meta-analysis.” Multi-institutional 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. But 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 were composite BPD or death; BPD; death; NEC ≥Bell II; IVH grade 3–4; ROP; duration of mechanical ventilation; postnatal corticosteroid requirement. BPD was 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 infants, some targeted Ureaplasma-positive infants. Among trials reporting Ureaplasma, 27% were positive.
In terms of outcomes, there was no difference in composite BPD or death, BPD, death, NEC, IVH, ROP, duration of mechanical ventilation and postnatal steroid requirement. And even in the subgroup of Ureaplasma-positive infants—still no difference for composite BPD or death!
The authors’ conclusion is that azithromycin did not significantly change these outcomes compared to placebo.
Ben Courchia: What about nebulizers? (Kidding.)
Daphna Barbeau: Right? Also, no sublingual nitroglycerin for tiny babies.
Ben Courchia: I’m starting to wonder whether Ureaplasma truly causes pneumonia or has a role in BPD—why wouldn’t azithro work otherwise?
Daphna Barbeau: It feels like it should work. But… womp womp.
Ben Courchia: What a frustrating endeavor. The papers show we want this to work.
Daphna Barbeau: We want something accessible and inexpensive, but no.
Ben Courchia: I remember as a fellow advocating for it: “Prevalence of Ureaplasma in delivering mothers—just give it, don’t test.” And Dr. Bancalari rightfully said, “No, not without evidence.”
Daphna Barbeau: Fine. Ok, next paper.
Ben Courchia: Ok next, Journal of Perinatology “Identifying optimal positive end expiratory pressure with electrical impedance tomography guidance in severe BPD.” The first author is Jessica Shui (Boston). I’m very excited about EIT and hopefully she’ll be on the podcast next year to talk about it.
PEEP is crucial in mechanical ventilation to maintain alveolar recruitment while avoiding overdistension and atelectasis. The problem is that a lot of our infants often have regions of both collapse and overinflation.
Electrical impedance tomography (EIT) is promising—a noninvasive, radiation-free, operator-independent, real-time functional lung imaging tool at the bedside. If you’ve never seen it, it’s like those Polar heart rate 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 EIT-guided PEEP titration can identify an optimal PEEP that minimizes both overdistension and atelectasis.
This is a case series: four BPD cases, plus four additional non-BPD cases as comparators.
BPD Subject 1 is a male SGA (9th percentile) infant, extremely preterm, tracheostomy for chronic ventilator dependence. On SIMV pressure control; PEEP escalated to 14, FiO₂ 45–50%, MAP ~22. EIT-guided 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 was a former 25-week infant with IUGR, failed noninvasive support after low-dose dexamethasone; chronically intubated via trach. One week prior to EIT, hypoxic event where 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 and the 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-guided PEEP titration.
Takeaway: clinicians often have the right idea—to support the baby—but bedside assessment of “how much PEEP” is often overestimated. EIT helps find the right number without inducing atelectasis.
Daphna Barbeau: It always feels scary to go down on PEEP in an unstable baby, even when you know it might help.
Ben Courchia: Yeah because 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 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: If you’re a company who does EIT, let us know.
Ben Courchia: I’ve spoken to some already—it was frustrating that I wanted to get our hospital to purchase, but it’s been research only. That’s changing, and I think next year people will be able to purchase. It’s very cool—noninvasive, no needles, nothing.
Daphna Barbeau: We just reviewed that chest X-rays aren’t reliable for expansion.
Ben Courchia: And the dynamic studies we’ve done—like pulmonology-directed 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: What bronchoscopy can’t do is longitudinal evaluation; babies change every day. You can’t bronch every day, but EIT you could do daily.
Ok, one more? I have one from the Journal of Perinatology: “Risk factors associated with the development of necrotizing enterocolitis in preterm infants on an exclusive human milk diet: a single center case-control study.” Lead author is Haider Ailumerab (Oklahoma Children’s / University of Oklahoma).
What’s unique about this paper is that the entire cohort was on an exclusively human milk diet: mother’s own milk or donor milk with human milk-derived fortifier (removing “what were the babies fed” as a factor). Retrospective matched case-control in a level IV NICU, so infants diagnosed with NEC were matched to control infants based on specific criteria.
Inclusion criteria were <32 weeks’ GA and <1500 g at birth who received exclusive human milk until 32 weeks’ PMA, between January 2016 and March 2023.Controls were defined as 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. Small study but interesting nonetheless.
Cases (those babies with NEC) had a mean GA 27.2 weeks and mean BW 928 g.Controls (those without NEC) had a mean GA 27.4 weeks and mean BW 960 g. No significant differences in many maternal/infant characteristics.
NEC was 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 neutrophil-to-lymphocyte ratio (NLR) before delivery was higher in NEC cases (mean 13.6) vs controls (6.3). Second, maternal urinary tract infection within one week before delivery were 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).
Then they created these models: Model 1 included maternal NLR and maternal UTI, and 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.
My takeaway is to recognize these as potential risk factors even in exclusively human milk-fed infants, and continue close monitoring.
Ben Courchia: 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 population-specific effects of maternal race. But maternal UTI and maternal NLR are not things I routinely ask about or look at.
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: By the time NEC rolls around (mean 22 days with SD 9 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. And its so interesting because this is stuff that happens prenatally that’s affecting them 3 weeks later.
Ben Courchia: Agreed. Our problem lists aren’t tailored for neonates—maternal history should almost be a sub-problem list. Whatever the mother has connects to the baby one way or another.
Daphna Barbeau: In adults, a heart attack risk list includes the patient’s own HTN, hypertriglyceridemia, etc. For babies, the risk factors are maternal; they should be connected.
Ben Courchia: Exactly. Today a mother was wearing a mask; I wanted to know if she had a viral illness, it would be 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 for us. We’d have valuable information from an epigenetic and infectious risk standpoint.
Daphna Barbeau: And often moms are readmitted—with infections, blood clots, etc.—and it trickles down.
Ben Courchia: 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: Some families don’t know to disclose. Others disclose everything.
Ben Courchia: 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.