#396 - 📑 Journal Club - The Complete Episode from February 14th 2026

Hello friends 👋

How much oxygen is enough when resuscitating extremely preterm infants? This week on The Incubator Podcast, Ben and Daphna explore the TORPIDO 30/60 trial comparing 60% versus 30% FiO2 at birth. While primary outcomes were similar, babies in the 60% group needed fewer chest compressions and less epinephrine—a signal worth discussing.

They examine an Indian non-inferiority study on surfactant thresholds (40% vs 30% FiO2), where waiting until 40% meant significantly fewer intubations and shorter respiratory support for the youngest babies. Ben presents compelling Melbourne data showing growth-restricted preterm infants face six-fold higher NEC risk—even with identical feeding protocols—and discusses how critical birth history gets "lost" as babies grow.

Daphna tackles therapeutic hypothermia in late preterm infants, reviewing Toronto's retrospective analysis showing 34-35 weekers experience higher mortality and more brain injury compared to 36-37 weekers. As units rewrite cooling protocols, are we moving too fast on limited evidence?

The episode concludes with Ben, Daphna, and Eli discussing the repeal of "sensitive locations" protections for immigration enforcement. Through the story of a mother detained while visiting her NICU baby in Chicago, they explore how these policies impact family-centered care and highlight advocacy opportunities through the Protecting Sensitive Locations Act.

Current research meets real-world NICU challenges—all in one episode.

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

Targeted Oxygen for Initial Resuscitation of Preterm Infants: The TORPIDO 30/60 Randomized Clinical Trial. Oei JL, Kirby A, Travadi J, Davis P, Wright I, Ghadge A, Yeung C, Cruz M, Keech A, Hague W, Lui K, Vento M, Gordon A, De Waal K, Chaudhari T, Hong TSL, Morris S, Kushnir A, Bonney D, Tracy M, Kumar K, Chhnia AS, Baral VR, Muniyappa P, Cheah FC, Sarnadgouda P, Rajadurai VS, Balakrishnan U, Oleti TP, Aldecoa-Bilbao V, Couce ML, Collados CT, Fernández RE, Moliner E, Ruiz Gonzalez MD, Singhal M, Agrawal G, Singh J, Pal S, Nayya S, Arora R, Amboiram P, Simes J, Tarnow-Mordi W; TORPIDO30/60 Collaborative Group.JAMA. 2025 Dec 10:e2523327. doi: 10.1001/jama.2025.23327. Online ahead of print.PMID: 41369162

Higher (40%) versus lower (30%) FiO2 threshold for surfactant administration in preterm neonates between 26 and 32 weeks of gestational age: a non-inferiority randomized controlled trial. Haq MI, Datta V, Bandyopadhyay T, Nangia S, Anand P, Murukesan VM.Eur J Pediatr. 2025 Nov 25;184(12):793. doi: 10.1007/s00431-025-06628-1.PMID: 41288797 Clinical Trial.

Care of neonates following in-utero growth restriction: A prospective cohort study exploring neonatal morbidity. Alda MG, Wood AG, MacDonald T, Charlton JK.J Perinatol. 2025 Sep;45(9):1219-1225. doi: 10.1038/s41372-025-02397-9. Epub 2025 Aug 21.PMID: 40841433 Free PMC article.

Whole-body hypothermia in late preterm and early term infants: a retrospective analysis from a neurocritical care unit. Martinez A, Cikman G, Al Kalaf H, Wilson D, Banh B, Abdelmageed W, Beamonte Arango I, Christensen R, Branson HM, Cizmeci MN.Pediatr Res. 2026 Jan 7. doi: 10.1038/s41390-025-04701-x. Online ahead of print.PMID: 41501407

Vernon, L., Swenson, S., & Miller, E. (2025, October). Immigration policies are creating impossible choices for NICU families. Cleveland.com.  https://www.cleveland.com/opinion/2025/10/immigration-policies-are-creating-impossible-choices-for-nicu-families-lelis-vernon-sarah-swenson-and-emily-miller.html

Barclay, M. L. (2025, December). Postpartum immigrant detention by ICE. The 19th. https://19thnews.org/2025/12/postpartum-immigrant-detention-ice/

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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 MD (00:00) Hello everybody, welcome back to the Incubator Podcast. We're back today for another episode of Journal Club.

Daphna Yasova Barbeau MD (00:10) We're back after the Delphi break.

Ben Courchia MD (00:14) For us, it wasn't a break. For the people who missed the episodes, they're like, "You guys took a break?" But we don't stop.

Daphna Yasova Barbeau MD (00:19) That's true. Delphi was so fun, we could spend the whole episode talking about that. But I miss Journal Club a little bit.

Ben Courchia MD (00:29) Yeah, that's the thing that really got us in this space to begin with. It feels like we are cheating on Journal Club when we're not doing it for a while. We're very thankful for the quality of the episodes. The next one coming out after this week of Journal Club is going to be with VON. We are finally releasing the first episode of our collaboration with the Vermont Oxford Network.

Daphna Yasova Barbeau MD (00:39) We had some good episodes come out in our absence. It's very exciting.

Ben Courchia MD (00:57) I think the quality of the episodes and just reflection of the quality of our field are just getting better and better. Can't be much happier about that. Thank you to everybody who attended the Delphi Conference. Thank you to everybody who gave us feedback. We're very thankful for the attendees who were there both in person and online. I think we were amazed by the viewing numbers online for the Delphi conference on the streaming. That was quite cool. These videos are still up right now on the live portion of the YouTube channel. We're actually cutting each talk individually and we're going to release them once they're ready, probably in a couple of weeks. So if you feel like there's no pressure and you just want to wait for these videos to land on your notification page, fine. Otherwise, you can always go and scroll through the different talks.

Ben Courchia MD (02:02) Before we begin Journal Club, I wanted to give a shout out to our friends at the GFCNI. It's this global collaboration for neonates that we interviewed on the podcast in the past. They have a new project they asked us to give a shout out to. It's the BronQ Family study. They're conducting an online survey exploring how BPD affects children and their families' quality of life over time, which I think is something that is always very interesting. The study is being conducted until the end of the month. Please check them out. It's happening in the US and six European countries. People are invited to participate. They asked that we spread the word within our network.

Daphna Yasova Barbeau MD (02:23) Yeah.

Ben Courchia MD (02:45) If this reaches you and you feel like you're not the right person, then share it with whoever. I feel like they have an information page on their website. The people who can take part in it are parents or primary caregivers. For people in your unit who want to maybe share their perspective, I think it's a great opportunity to involve families in research. Check out the GFCNI website for more information.

Daphna Yasova Barbeau MD (03:07) Love that. And did you give us that website?

Ben Courchia MD (03:15) No, because I don't have it in front of me. So it's GFCNI.org. And then on their website, you can look for the BronQ Family, B-R-O-N-Q family. You will have this whole page on this particular research and all the information is there. There, have I helped enough? Okay.

Daphna Yasova Barbeau MD (03:36) Perfect. Thanks, buddy.

Ben Courchia MD (03:43) I guess I'm going to get us started today. We have one paper that's been sitting in my folder for some time now that definitely needs review. It's a paper that was published in JAMA, and that is the Torpedo Trial. It's called Targeted Oxygen for Initial Resuscitation of Preterm Infants, the TORPIDO 30/60 Randomized Clinical Trial. Definitely a big trial, definitely something that was way overdue for us to review on the podcast.

Ben Courchia MD (04:12) The introduction is very interesting. It takes us through the history of our resuscitation practices and talks about how the optimal concentration of oxygen to initiate respiratory support of preterm infants at birth remains a topic of conversation, and that we've evolved. Before the 1990s, pure oxygen, 100% FiO2, was the standard based on the assumption that newborn cardiorespiratory depression was due to hypoxia. Then, in the 1990s, Dr. Saugstad, who we've had on the podcast—you should definitely check out his interview—showed that using room air instead of 100% oxygen for full term or near full term infants reduced the time to first breath and the rates of oxidative injury without any adverse outcomes.

Now, the Torpedo trial has existed before. It was first published in 2017. It was a randomized clinical trial of FiO2 21% versus 100% for initial resuscitation of preterm infants with the primary outcome being death or disability at two years. Now the trial at the time—the podcast did not exist at that point, so we did not get a chance to review or go that far back—but the trial was stopped early because of slow enrollment. The reason for this slow enrollment was due to the clinicians' reluctance to accept that infants might be assigned to the 100% FiO2 group. Not that they were going to get less, but that they were going to get too much.

Daphna Yasova Barbeau MD (06:08) They did not have equipoise.

Ben Courchia MD (06:14) That's exactly right. And no difference was seen. Despite that, whatever data they had showed no difference in the primary outcome. And when they did an exploratory analysis suggesting that maybe mortality was increased in infants born less than 29 weeks who underwent resuscitation with 21%? So it's kind of funny that the trial was halted because people didn't want to give 100%, when in truth giving 21% was probably not so beneficial. So now they're coming to us with the new trial, the TORPIDO 30/60, which was initiated to test the hypothesis that for infants born before 29 weeks, maybe if we could compare starting 30% versus 60%, we could see if that would improve survival without brain injury at 36 weeks corrected age.

Ben Courchia MD (08:12) So this is the background and now we're going to dive into the methods. This was a randomized clinical parallel two-group superiority trial conducted in 31 hospitals in six countries: eight in Australia, 13 in India, one in Malaysia, two in Singapore, six in Spain, and one in the United States of America. Randomization was stratified by site, by gestational age—they looked at babies more or less than 26 weeks—and pregnancy multiplicity. The newborns were considered eligible if they were born between 23 and 28 weeks of gestation and required respiratory support at birth. Those with major cardiopulmonary anomalies or congenital malformations that could eventually affect their development were excluded.

So what does the intervention for this particular trial look like? The infants eligible for active care were placed on a resuscitation bed after the umbilical cord was cut. Initial FiO2 of 60% or 30% was delivered via an oxygen blender. The trial protocol required that the initial level of FiO2 be maintained for at least five minutes. If possible, to maintain separation between the groups, you could then adjust after that time period in aliquots of 10% to 20% FiO2 every 30 to 60 seconds using pulse oximetry. So you could move away from that initial threshold based on your target SATs, saying, "Hey, I actually want to reach my SATs," or maybe, "I'm over-SATing," and you could obviously titrate based on that. The target SATs were basically what you expect: 80% to 85% at five minutes, 85% to 95% at 10 minutes, and until admission to the neonatal ICU.

The primary outcome was death and brain injury at 36 weeks. Brain injury was defined by neuroimaging. We're talking about IVH, echodense intraparenchymal lesions, PVL, or porencephalic cysts. They had some predefined exploratory outcomes that they looked at as well, and we'll talk about them in a little bit. So in terms of sample size, they wanted to see a difference in brain injury-free survival going from 24% to 32%, and for that they needed about 740 babies in each group—735 to be exact.

Okay, so they did get their numbers. 728 infants were randomized to the 60% FiO2, 741 were randomized to the 30% group. Most of the newborns were singletons, most were born in Australia, and 58% were born via cesarean delivery. 97% had some antenatal steroid exposure. Overall, 39% of the cohort required escalation of their FiO2 to 100% due to inadequate clinical response. That means, by the way, we're talking about both groups here. This occurred specifically in 38% of the 60% group and 41% of the 30% group. So kind of similar numbers between the two. 20 newborns or 1% of the cohort died in the delivery room. No adverse events attributed to the intervention.

So how do we do when it comes to the primary outcome? They were able to get the primary outcome data in over 95% of their cohort and there was no difference in the primary outcome of death or major brain injury by 36 weeks of gestation between those randomized to receive 60% or 30%. In the 60% FiO2 group, the rate of the primary outcome was 46.9%, and in the 30% group, 47.8%. When looking at the components of the primary outcome, rates of brain injury were similar: 42.4% in the 60% group, 43.2% in the 30% group. Death by 36 weeks, also similar: 15% in the 60% group, 15.8% in the 30% group.

In terms of exploratory and physiological outcomes, when they looked at the area under the curve analysis, they showed that saturation, fraction of inspired oxygen, and heart rate were higher in newborns assigned to receive the higher FiO2 for both the first five and 10 minutes from birth. So it looks like while there was no difference in the primary outcome that this study was powered for, some secondary data on SATs, oxygen requirement, and heart rate might have been better in the 60% group. Newborns in the 60% FiO2 group were less likely to receive chest compressions, 2% versus 5%. They were less likely to receive epinephrine, 1% versus 2%. And they were more likely to reach SATs of 80% by five minutes—58% versus 44%. They also had a higher initial saturation. No difference was observed in the time for the first spontaneous breath or respiratory management on admission to the NICU.

In terms of some of the safety outcomes, they mentioned that infants assigned to the 60% FiO2 group had a bit of a higher rate of ventriculomegaly—6.4% versus 2.4%. It's hard to understand whether this has to do with something else or with the intervention itself. Otherwise, they mention no group difference observed in rates of other types of brain injury, including grade 3 and 4 IVH and PVL. So I'm going to leave you here to explore this paper further. There's a lot of ancillary material, a nice editorial, and a nice summary paper. But the authors do conclude that this trial finds no difference in survival without brain injury at 36 weeks corrected age when babies are resuscitated with an initial FiO2 concentration of 60% when compared to 30%, followed by titration for SATs targets.

Although they mentioned that the infants who initially received 60% were less likely to experience early hypoxemia, bradycardia, or receive advanced resuscitation, these findings were not accompanied by improvement in major neonatal outcomes, underscoring again the continuing uncertainty about the optimal initial concentration. They say that this is finding the foundation for future trials. I think what you will see when you read the discussion is that these authors are basically asking the question: Did we just go too low with 60%? Should we have gone much higher? I think there was this concern of the initial TORPIDO trial where they were like, "Maybe 100% is too frightening for the community," so they went to 60%. But now you can hear the hesitation in the discussion, like maybe it should have been a bigger difference. Maybe comparing 30% to 60% was not good enough. You might see that the next TORPIDO trial is going to be 30% to 80% or something, or 30% to 90%. But there is definitely a bit of a signal when it comes to advanced resuscitation that is interesting. We'll see what comes out of that.

Daphna Yasova Barbeau MD (16:52) Yeah, it's super interesting. I mean, okay, there's a composite outcome, but not needing chest compressions and epinephrine in the delivery room is no small thing. Just from the strain on the body, the stress of the parents... we don't know what that does to the brain. That's, in my opinion, something that we have to look at.

Ben Courchia MD (17:12) No, it's a big deal, right? It's a big deal. I always put myself in the position of a parent and if you told me, "We're gonna either do 30% or 60%, the outcomes are the same, but we did find that 60% kids have less need for chest compressions..." I don't think in my right mind I would say no.

Daphna Yasova Barbeau MD (17:37) I'm sorry, it's not funny at all, but it's a huge deal.

Ben Courchia MD (17:41) It's a huge deal. The issue is how you present the data. Obviously, you have to say that this is not what the study was powered for. This is not the hypothesis that this particular study was testing. And I think you have to remember that while I mentioned the percentages, as we get into the nitty gritty of this kind of data, it becomes small numbers. The number of babies who received epinephrine: four in the 60% group, 14 in the 30% group. We're not even talking about 30 patients. Hard to know if these numbers are gonna be generalizable. In terms of receiving chest compressions: 11 in the 60% group, 30 in the 30% group. Again, that heavy sample size that you had for your primary outcome of 700-plus babies suddenly dwindles down to less than 30 patients. I think this will be very interesting to see if that carries through on further studies. Whether you want to turn up the oxygen when you go to that next delivery for that ELBW, that is up to you.

Daphna Yasova Barbeau MD (18:43) I was surprised that it didn't change the initial respiratory need on admission. I thought that was interesting.

Ben Courchia MD (19:01) Yeah, I mean, I haven't looked in depth into what that meant in terms of actual support. So when you look at the table, I think this refers to table three, they break down basically the different modes of ventilation: high flow, high frequency, CPAP, IMV, and so on. And you wonder if this is due sometimes to protocol. Like for example in our unit, if you're born at 23 weeks, you come in and you're gonna be on the jet, right? We have first intention jet. So if a baby comes in our unit and is on the jet, it's not a reflection of their clinical status, it's our protocol. I don't know how much of that is a reflection of the need of the patients, because then it's not broken down by gestational age. So it's hard to know.

Daphna Yasova Barbeau MD (20:02) Well, I just wanted to refer people back. You mentioned our Giants in Neonatology episode. It's number 203 with Dr. Saugstad. I'm going to disclose, this was pretty eye-opening for me. I didn't realize the history of how we have selected our initial oxygen parameters. So I think it's important for people to know what we know and know what we don't know, you know?

Ben Courchia MD (20:26) And no offense, our field has already entered a transition phase where our pioneers have passed away. We are a specialty that still has the privilege of being able to talk to people who have influenced our specialty in a major way. I mean, no internist can actually go and interview William Osler. It's not something that they have the opportunity to do, yet we kind of do. You can go to a Saugstad and be like, "Hey, you've moved our field in a direction in a pretty significant way and we get to talk to you." It is mind boggling.

Daphna Yasova Barbeau MD (20:48) Yeah, super cool.

Daphna Yasova Barbeau MD (20:55) This article is coming from the European Journal of Pediatrics and it was one that has been in my folder for some time also. It is entitled "Higher 40% versus Lower 30% FiO2 Threshold for Surfactant Administration in Preterm Neonates Between 26 and 32 Weeks of Gestational Age: A Non-Inferiority Randomized Controlled Trial." The lead author is Mir Inamal Haq, senior author Vishnu Mohan Marukasan. And I think this goes back to what we were talking about. There are lots of things that, depending on where you trained, become dogma when you do certain things.

So I really like this paper. It's coming to us from an institution in India. And basically, they had a duration of 20 months. They took babies that arrived to the unit spontaneously breathing between 26 and 32 weeks of gestation. And then within one hour of birth, they included babies that were requiring at least CPAP of +6. They had—I won't go into their protocol—but they had very strict criteria for who would get on CPAP +5 and then who would advance to +6 using some respiratory severity scores. And then those babies would be randomized to either wait until 30% for surfactant or wait until 40% for surfactant. That was the setup. They excluded babies with major congenital anomalies, shock prior to randomization, severe asphyxia (using an Apgar score less than four at one minute), those intubated in the delivery room, or any concern for pulmonary hemorrhage at the time of randomization.

They actually were using LISA. They were giving surfactant through a six French orogastric tube using direct laryngoscopy while the infant remained on their nasal CPAP settings. They described their non-pharmacological comfort measures. They used medications like sucrose and then swaddling and gentle containment. They also looked at repeat surfactants. A repeat dose was considered at 12 hours if the need for oxygen remained above 30% in either group. Both groups were given the standard of care in the unit. So all things were pretty much the same: Kangaroo Care, caffeine, early enteral feeding, and developmental care. They also had a predefined clinical protocol for weaning non-invasive respiratory support, especially since this relates to their outcome measures.

So the primary outcome of the study was to compare the total duration of respiratory support between the two FiO2 thresholds for surfactant administration. Secondary outcomes were the requirement of surfactant within six hours after birth, the requirement for a repeat dose of surfactant after 12 hours, and then a list of common morbidities: BPD stage two or greater, IVH grade greater than or equal to grade two (for the Volpe classification), ROP, air leaks, a hemodynamically significant PDA requiring treatment, all-cause mortality, and total duration of hospital stay.

In total, they had 205 babies that were randomized. In the 40% group, the total cohort was 105, and 35 out of the 105 were treated with surfactant. In the 30% group, they had an N of 100, and 45 out of 100 were treated with surfactant. The baseline characteristics of neonates were comparable in both groups. I'll just mention some of those things. There were less SGA babies in the 40% group. There were more babies who got complete antenatal steroid coverage in the 40% group. There were slightly more moms with gestational diabetes. There were less who underwent vaginal delivery, but none of those were statistically significant.

The closest thing to a p-value of 0.05 was the Apgar score at five minutes. It was seven in the 40% group and eight in the 30% group. The mean birth weight was about 1200 grams and the mean gestational age of the whole cohort was about 30 weeks. 55% were male, 54% of the mothers received complete antenatal steroids, and approximately half—just more than half, 55%—were delivered by C-section.

So they told you the primary outcome was the mean duration of respiratory support. The mean duration of respiratory support was 140 hours in the babies who were in the 40% group and 153.9 hours in the 30% group. So this was not statistically significant. You can decide if it's clinically significant, a difference of about 13 hours. But that's important because later they buried the lede, in my opinion. Then they looked at this group, the younger group of infants, 26 to 29-weekers. The way they describe this in the first section is a little bit confusing, but what I can understand is that the difference between the 30% and the 40% group in this smaller cohort of 26 to 29-weekers was 56 hours. So that's two and a half additional days of respiratory support. So for the smaller group, it did make quite a bit of difference.

Ben Courchia MD (26:33) In which direction again?

Daphna Yasova Barbeau MD (26:35) Less time for the babies who are in the 40% group.

Ben Courchia MD (26:40) Wow, that's counterintuitive.

Daphna Yasova Barbeau MD (26:42) I know. Agreed. You think if I give them surfactant, they don't need to stay on as long, for sure. And then again, for their primary outcome, they found that the 40% group was non-inferior to the 30% group regarding duration of respiratory support.

Ben Courchia MD (26:48) Yeah.

Daphna Yasova Barbeau MD (27:10) The mean ventilator-free days were slightly higher in the 40% group, 26.6 days versus 25.7 days. That was not statistically significant. I told you 32% of the 40% FiO2 group got surfactant versus 45% in the 30% FiO2 group. This was statistically significant. In the 40% FiO2 group, 1.9% versus 7% in the 30% group required a repeat dose of surfactant. This was statistically significant. So again, even though the repeat surfactant threshold was 30% for both groups, less babies in the 40% group required the repeat dose.

There were no statistically significant differences in the incidence of BPD, IVH, ROP, ROP requiring treatment, air leak syndromes, or hemodynamically significant PDA requiring treatment. There was no difference in mortality or any difference in the total duration of hospital stay in days. Basically, this was a non-inferiority trial. They found that 40% was non-inferior, but I think it's very interesting to see that in their youngest group for this cohort, the 26 to 29-weekers, it made somewhat of a difference. And again, we were talking about parents in the last group. Intubation and InSurE/LISA is a procedure that we're pretty comfortable with. We do really well, but I think from the parent perspective regarding their baby needing to be intubated even briefly, it can be dramatic. I think this is a big deal for families and it's a big deal for infants to see if we can avoid that procedure for them. Thoughts?

Ben Courchia MD (29:03) Yeah, I mean, I think that one of the big components of this paper is—no issues there—the fact that it's coming out of India. There's a big difference between whether you are a low resource environment, a middle resource environment, or a high resource environment. The needs and the objectives can be very different. So I can see that for resource-limited settings, this could be very helpful. Though for us, I feel like we do need to go beyond the pure FiO2 strategy. I don't mean to say this about India because I don't know exactly the geography of India. There are some very high and very well developed centers. There are some amazing clinicians out of India, so I'm not really trying to say anything negative. But I'm just saying, I do believe that the discussion of 30% versus 40% is one that is limited. I feel like what kind of ventilation, regardless of where you are...

Daphna Yasova Barbeau MD (30:12) Yeah, I mean, I think that's true regardless of where you are, right? Is there respiratory distress? Is there hypercarbia? There are so many other factors.

Ben Courchia MD (30:18) And I feel like if you have the tools to make a proper assessment of the patient and tailor your strategies—whether it is the use of specific modes of ventilation, specific use of pressures, specific use of other things like lung ultrasound, chest x-ray findings—and then make a decision informed on all these different factors, that is better. You have to look at time as well, how is the baby doing in the first couple of hours. I think this is, in my opinion, the way to assess whether a baby needs surfactant rather than just because the therapist decided to boost the baby and now the baby is on 35% and it's like, "Oh, that's it, threshold reached, you must give surfactant." I don't like these heuristics when we're talking about the NICU. But I can see how it can be helpful if the setting dictates that this might be helpful. Interesting.

Daphna Yasova Barbeau MD (31:12) Yeah, and I think in general, our team uses a higher threshold. Not all of us, but in general, our team uses a higher threshold. And there are just some babies that are really just comfortable, happy, not hypercarbic, on 35%. And then by the next day they're in 21% and they didn't get...

Ben Courchia MD (31:33) What about the patient that's on CPAP 30% that then goes to an IMV and is fine for a couple of hours and then comes back to CPAP and is OK? At what point do you arrest the thought of FiO2 when you say, "Now this is the threshold?" Or do you say, "No, I can work with this patient a bit more." But it's interesting. It's interesting to see that data. Because again, a lot of the stuff you presented, I was surprised by. I was not expecting those kinds of numbers. And it's a pretty large cohort, so good for them.

Ben Courchia MD (32:09) I have a bunch of articles ready and they're all very interesting. The next article I want to talk about is an article I saw in the Journal of Perinatology. It's called "Care of Neonates Following In-Utero Growth Restriction: A Prospective Cohort Study Exploring Neonatal Morbidity". The first author is M.G. Alda and what I really liked about this paper is that it really addresses something that we see every day. The background is a very interesting one if you're a young trainee, because it goes over some very basic principles of growth restriction. So when we talk about fetal growth restriction, it defines a fetus who does not reach their biological growth potential. It is a common pregnancy complication that increases the risk of neonatal mortality and morbidity in the short and long term.

Although we talk about growth restriction and we talk about small for gestational age, SGA, and we commonly use these terms interchangeably, not all growth restricted infants are born SGA and not all SGA babies are truly growth restricted. The small for gestational age label is just a measure of whether you are below the 10th percentile for your gestational age at birth, but you may still not have reached your full biological potential.

The authors note that premature infants are more commonly growth restricted because preterm birth is often due to perinatal pathologies that affect fetal growth. Thus, when preterm infants' birth weights are used to derive growth curves, SGA infants are systematically underdiagnosed. Now granted, we have a whole episode about the release of the new Fenton growth curves. I think that this particular paper was conducted before these new growth curves came out, because this is precisely one of the pitfalls of the old Fenton growth curves that is addressed in this current edition.

So in this study, the authors aimed to prospectively explore the trajectory of SGA preterm neonates admitted to a tertiary NICU, and they aimed to evaluate comorbidities occurring due to that growth restriction accounting for the impact of prematurity. It's very interesting how they did it. That's why I really like this paper.

The study participants were basically any premature infant born between 24 and 36 weeks corrected at a hospital in Melbourne. The study ran from 2023 to 2024. The infants were enrolled as either SGA or AGA based on their birth weight percentile, using the GROW (Gestation Related Optimal Weight) chart. You can actually try to consult these growth charts. You have to request access, which I did not, but basically they have this link available for you to review. They say that these growth curves generate term optimal weight and then adjust for factors which influence fetal growth to produce a percentile according to the exact day of gestation known to be important to best detect pathological growth associated with poor outcomes.

The SGA group included all enrolled preterm infants with a birth weight less than the 10th percentile on this particular growth chart that they've developed. The control group basically involved AGA preterm infants with a birth weight between the 10th and 90th percentile. Now, what they did is they had an intervention group of SGA babies, and then they had two control groups. They had a control group for gestational age. So basically we're comparing them based on their gestational age. And then they had a control group based on weight, which was very interesting. So if you are 29 weeks and you weigh 600 grams, you would have had two comparison groups for you. One, like a normally grown 29-weeker, and then a normally grown 600-gram baby, which would have probably been, I don't know, like 25 weeks or 26 weeks. So that I thought was very interesting.

They had a bunch of exclusion criteria, which I'm not going to get into. In terms of outcome measure, they used the Fenton growth chart to assess neonatal growth during the hospital stay. They recorded weekly length, head circumference, and weight from birth to hospital discharge. They recorded baseline heart rate on day one and weekly until eight weeks of life or discharge. The authors also recorded blood gas measures in terms of pH, lactate, and blood sugar levels. The neonatal morbidities that they looked at included BPD (defined as oxygen requirement at 36 weeks), any grade of IVH, PVL, ROP, NEC, length of hospitalization, and death.

So what they ended up having was about 150 patients: 54 in the SGA group, and then another 50 for each of the control groups. Maternal characteristics were similar between the SGA and control groups, though the SGA cohort had higher rates of ultrasound-diagnosed fetal growth restriction and preeclampsia. Among the SGA cohort, 37 had antenatal Doppler assessments. Of these, 76% showed umbilical artery abnormalities. 46% showed middle cerebral artery abnormalities. No Doppler anomalies were noted in the controls. Of all included in the SGA cohort, 43 infants, or 80%, had a birth weight less than the third percentile on the GROW chart, which would categorize them as severely growth restricted.

So what are some of the metabolic and physiological outcomes? In terms of neonatal outcomes, preterm SGA infants were more likely to have hypothermia on admission to the nursery. The rate was 44% for the SGA group compared to 15% for the ones matched by gestational age and 17.2% for the ones matched by birth weight. Infants in the SGA group were also at significantly higher risk of lower blood sugar levels at birth and in the first week of life compared to their cohort. The proportion of infants who had hypoglycemia was more common in the SGA group, especially in the first week of life compared with both groups. Additionally, the SGA infants had higher lactate levels on day one of life and between day two and day seven compared to both controls. No difference was seen, however, in the blood pH during the first week of life.

Very interesting, the respiratory and growth outcomes. Most infants in all groups required some form of respiratory support, not super surprising. There was no significant difference in the amount of steroids received. While it was not statistically significant, the incidence of BPD was higher in the lower gestational age group, 40.7%, compared to 30% in the SGA group. The requirements for inotropic support were the same. You know, we say that growth restriction accelerates your pulmonary development a little bit. That could very well be what manifested here. Regarding growth recovery, SGA infants recovered to their birth weight faster than both control groups who recovered at a slower pace. All groups had reduction in Z-scores of weight, length, and head circumference at discharge. That's extraordinary in growth restriction, which is the problem of this particular unit and not surprising, something that many of us struggle with.

In terms of other morbidities and mortality, necrotizing enterocolitis was significantly increased in the SGA group. Are you ready for this, Daphna? The rates of NEC in the SGA group were 11% compared to 1.8% in the gestation matched control. Beware of these SGA babies. The authors state that the SGA had a six-fold higher risk of NEC in their study. All six cases of SGA infants who experienced NEC occurred in infants born at less than 28 weeks of gestation. It is important to mention that feeding practices within the SGA and the birth weight matched control were exactly the same.

In terms of neurological outcome, IVH was significantly more prevalent in the birth weight matched control group at 39.5% compared with the SGA group at 15%. I think that you're going to start seeing that obviously there's no offsetting being born at 23 weeks, for example. If you are very immature, it's a big problem. No significant difference in PVL and ROP between the groups. Length of stay and post-menstrual age at discharge were similar between the groups. Regarding mortality, there were four deaths in the SGA group representing 7.4% compared to one control participant representing 1.8%. Again, not significant due to the low numbers.

The discussion is interesting because of this particular form of control groups. The authors obviously mentioned in their conclusion the difference in the outcomes that we just discussed. They state that early iatrogenic delivery, which is performed to prevent stillbirth, must be weighed against the potential risks associated with prematurity and growth restriction, which I thought was interesting. Thoughts?

Daphna Yasova Barbeau MD (42:18) I mean, it feels right. It's supposed to look at data. I know, but we've definitely experienced this. We have a high rate of growth restricted infants. Sometimes you look at these babies and you're like, "Man, they're small". They're way smaller than they're supposed to be. And those are the ones that you just gotta keep a close eye on. They're always doing something.

Ben Courchia MD (42:45) I think what's tricky also is that there's a window for NEC that we talk about, like three weeks of life, 29 to 31 weeks, whatever. But if the baby is born very early, you forget their SGA status. And I think that it should now—when you read this paper, it sounds like it should be like a banner over the baby's isolette. Do not forget that I was growth restricted. Because when this baby is gonna do something interesting at three weeks of life, you might want to have all this information handy and not just assume that the patient is just doing well.

Because like I said, there's all these things that we... there's a decay of information in the NICU. We have all this information at birth and then it rarely... I think that you've seen this, the presentation you get on day one is one thing from the team, from the resident, from the nurse. And then as the patient gets more complex and complex, you sort of start substituting some of the more recent issues for some of the more demographic type of issues. And maybe the maternal history gets a little bit more cloudy now because we're talking about the re-intubation and this and that. And then, that's how SGA just—poof—you forget about it.

Daphna Yasova Barbeau MD (43:57) Yeah, you know, this occurred to me teaching in the med school with the first years. And I was like, man, we don't have all this previous medical history, but our babies do have a ton of previous medical history. Were they growth restricted? One. Were they exposed to chorioamnionitis? Two. What were the maternal problems during pregnancy? Three. And I mean, that changes your pre-test probability of when you come to the bedside and what could be wrong with them. We forget over time, or some interesting cases, like the fetal demise of a twin—what does that put babies at risk for? And just exactly like you said, their previous medical history has to follow them through the entire admission. And every time you go to the bedside to check a baby out, you have to say, what are this baby's additional risks to prematurity?

Ben Courchia MD (45:01) Yeah, and I think that exactly like they say in the article, they regain weight pretty quickly. And so we forget, it's like, "No, this is so big, it's so big, so cute". It's like, no.

Daphna Yasova Barbeau MD (45:09) Yeah, that's right. They're quadruple the size that they came in. It's interesting, especially, you know, obviously there are different causes for growth restriction, but when it's nutritional or it's placental insufficiency, once they're re-exposed to all of the nutrients and the flow, they grow like they're supposed to. Not all the babies, right? For different reasons, you know, genetic problems, things like that. There are lots of reasons babies don't grow, but yeah, sometimes they're doing so well. It seems to erase some of the history that was pretty dramatic on admission.

Ben Courchia MD (45:53) What is the sentence we hear commonly in the NICU? "Do you want the whole history? Or do you just want the updates?" And to everybody's credit and to everybody's blame, I often say, "I know this patient, just give me the highlights". And that's it. This is how you get, "All right, the kid has been stable overnight, he's tolerating feeds, and he had one emesis," and that's it.

Daphna Yasova Barbeau MD (46:11) And we're like, "Nah, nah, we know this baby".

Ben Courchia MD (46:24) Crazy.

Daphna Yasova Barbeau MD (46:29) Okay. So this is a research article from the Society for Pediatric Research: "Whole-Body Hypothermia in Late Preterm and Early Term Infants: A Retrospective Analysis From a Neurocritical Care Unit". The lead author is Alejandro Martinez, senior author Mehmet Cizmeci. This is a pertinent and timely paper out of Canada. Basically, with all of our new thoughts and with the newest papers coming out about cooling late preterms, a lot of major centers are going back and looking retrospectively at their data and breaking babies up into these cohorts. So basically, they wanted to compare the outcomes of whole body cooling in infants with neonatal encephalopathy born at 34 and 0/7 to 35 and 6/7 weeks (so that was the lower gestational age group) versus 36 and 0/7 to 37 and 6/7 weeks gestation.

So, you know, all these babies are less than 38 weeks. I think a lot of people are using the 36-week cutoff because one, that's what the trials used, and two, given the newest articles on cooling late preterms. I'll give you a little bit more information. I told you this is a retrospective observational cohort study. They had 122 late preterm and early term infants with HIE admitted to the Hospital for Sick Children between January 2015 and December 2023 who underwent whole body cooling. So in general, at that time, whole body cooling was provided to all infants greater than or equal to 35 weeks gestation with moderate to severe encephalopathy. Those were the unit guidelines. But there were babies who underwent whole body cooling below the 34-week threshold. Again, that was happening all over the country, all over the world potentially at the discretion of the attending neonatologist.

So I told you Group 1 included infants from 34 and 0/7 to 35 and 6/7 weeks. And Group 2 was for infants 36 and 0/7 to 37 and 6/7 weeks. I won't belabor the cooling criteria. I think they're pretty standardized at this point. Interestingly though, a lot of studies look at inborn versus outborn. Their unit is an exclusively outborn referral center. So all the infants were outborn and brought in. Initial neurologic assessments and encephalopathy staging are performed at the bedside by experienced neonatal transport clinicians using modified Sarnat and Thompson scoring systems before transfer.

Ben Courchia MD (49:12) What are you gonna get into then?

Daphna Yasova Barbeau MD (49:18) But I want people to know these things exist in the article, even if we're not gonna talk about them. All right, all the babies got their initial cranial ultrasound within the first 48 hours of admission. And then all infants underwent post-rewarming brain MRI as a part of the standard care. They were aiming to obtain post-rewarming brain MRIs within the first seven days after birth, hoping to obtain all on postnatal day four. And they used the Weeke scores for MRI evaluation. Now that is something to highlight, I think, for all of these papers. And I think they did a nice job doing that. So the Weeke score has really been developed and standardized for infants that are greater than 36 weeks gestation. In particular, they highlighted myelination in the PLIC, or the posterior limb of the internal capsule—a really common place for ischemic injury—is expected to be absent or only partially present in the late preterm and even near term infants. So they took special care, scoring that as abnormal when there was diffusion restriction in that area. They had two MRI readers who conferred on the MRI scoring.

So I told you there were 122 babies. In Group 1, there were 17 babies in the 34-week group and 46 babies in the 35-week group. So we know that looking for these late preterms gives us a lot of small numbers. In Group 1, 14 out of the 63 babies died: two in the 34-week group and 12 in the 35-week group. In Group 2, there were 59 babies: 25 in the 36-week group, 34 in the 37-week group. A total of seven babies in Group 2 died: five in the 36-week group and two in the 37-week group. So that was seven in Group 2 compared to 14 in Group 1 (the 34 and 35 weekers). They did have some babies lost to follow-up, but they were able to administer Bayley tests in five 34-weekers, 18 35-weekers, 12 36-weekers, and 23 37-weekers as their long-term neurodevelopmental outcome measure. Those babies who were assessed were assessed at 18 months using either the Bayley-III or the Bayley-4.

Okay. What are we going to get into? I'll tell you. We're going to get into the results. I told you a little bit about the group at presentation. In Group 1 infants, a moderate Sarnat was observed in 70%. The remaining 30% presented with severe Sarnat staging. So that was in the younger group. In Group 2, the older group, 83% presented with moderate Sarnat staging and 17% with severe staging. Overall, Group 1, the younger group, had lower umbilical cord artery pH—a median of 6.9 versus 7.0 in the older group. They had a higher Thompson score prior to therapeutic hypothermia. And compared to Group 2, more infants in Group 1 developed hemodynamic instability requiring inotrope or vasopressor administration: 67% in the 34 and 35 weekers versus 32% in the 36 and 37 weekers. They more often had hypoglycemia requiring dextrose boluses followed by increased glucose infusion rate: 54% in the 34 and 35 weekers versus 36% in the 36 and 37 weekers. 13% of infants in Group 1 required a glucagon infusion compared with 5% in Group 2. Other major clinical parameters and comorbidities did not reach statistical significance between the two groups. And in the subgroup analysis, more infants born at 35 weeks gestation developed hypoglycemia requiring dextrose boluses followed by increased glucose infusion rates compared even with those babies born at 36 weeks.

The EEG findings: severely suppressed background patterns—things like burst suppression, continuous low voltage, and flat tracing—were more common in Group 1, 40% versus 33% in the older infants. This did not reach statistical significance. And then in regards to seizures, there were 38% in Group 1, 27% in Group 2. This also did not reach statistical significance. And even subgroup analysis didn't really reveal any major differences between the group of 35-weekers compared to 36-weekers.

All post-rewarming brain MRIs were obtained within the first eight days. 95% of these scans were performed between days three and five. The median corrected gestational age at brain MRI was 35.7 weeks for Group 1 (the little group) and 37.7 weeks in the older group. Overall, all infants in Group 2 underwent a post-rewarming brain MRI. There were six patients in the first group who did not. There was good inter-rater reliability for the MRI scores. And in general, germinal matrix hemorrhage or IVH was observed on cranial ultrasound scans in 7% of infants in both groups. Overall, the white matter injury sub-score and the total injury scores were higher in Group 1, the younger group, compared to Group 2. This was statistically significant. Cerebellar sub-scores were also higher in Group 1. This was statistically significant, although the median scores were the same.

The outcomes. So overall mortality was seen in 22% (14 out of 63) in Group 1 versus 12% (seven out of 59) in Group 2, an odds ratio of 2.12. Mortality was more common in infants who presented with severe encephalopathy compared to those with moderate encephalopathy: 38% in Group 1 versus 11% in Group 2. This was statistically significant. And being in Group 1, the younger group, was associated with higher odds of mortality after adjustment for encephalopathy severity. Among survivors, the Bayley assessments were completed in 47% of surviving infants in Group 1 and 67% of surviving infants in Group 2.

And then they had composite outcomes for the long-term outcome. So the composite outcome of mortality or moderate to severe neurodevelopmental impairment, and mortality or at least one severe developmental delay. So they had two composite outcomes, which showed a trend toward being more common in Group 1, but this did not reach statistical significance. Group 1 did have higher odds of adverse outcomes. The composite outcome of mortality or moderate to severe neurodevelopmental impairment reached statistical significance after adjusting for encephalopathy scores.

Ben Courchia MD (57:54) And Group 1 is the little group, yeah. And Group 2 is the more traditional group that would get called sort of full term or near term.

Daphna Yasova Barbeau MD (57:56) The little group. Correct. And then the composite outcome of mortality or at least one severe developmental delay showed a trend higher in the little group, but this did not reach statistical significance. For the composite outcome of mortality or moderate to severe neurodevelopmental impairment, this is seen in 41% in the little group and 21% in the older group. The cognitive, language, and motor test scores as well as their subdomains actually showed no significant differences between the groups for all comparisons.

And then they wanted to look at the subgroup analysis, looking at the groups more specifically at each gestational age: 34, 35, 36, 37. So a trend towards decreased mortality was observed among infants born at 35 weeks, 36 weeks, and 37 weeks. So it was 26% at 35 weeks, 20% at 36 weeks, and 6% at 37 weeks. The difference in mortality rate was not statistically significant between infants born at 35 weeks gestation and those at 36 weeks gestation. And this remained unchanged after adjustment for encephalopathy score.

Ben Courchia MD (59:55) But I think you've given us a lot already to think about. I'm very curious to ask you a few questions after you're done.

Daphna Yasova Barbeau MD (1:00:14) Yeah, I want to see if there was something else here that I wanted to highlight for you. The composite outcome of mortality or moderate to severe neurodevelopmental impairment—again, 45% in the little group versus 21% in the older group. And mortality or at least one severe developmental delay: 55% versus 29%, both statistically significant. These differences in composite outcomes between the 35-week subgroup compared to the combined 36 to 37-week subgroup remained after correcting for encephalopathy severity. They didn't say this explicitly, but you can see that they didn't compare to the subgroup of 34-weekers. But if you'll remember, they only had 17 total 34-weekers and two of them passed away. So they only really had 15 34-weekers to use and only five of them were able to complete the Bayley assessment. So, it is likely that they were just not able to make those comparisons for the 34-week group, but I think we can potentially use the 35-weekers as a proxy for the 34-weekers, who again, in some of the other studies, that was the group that did almost the worst.

Ben Courchia MD (1:01:27) But the 34-weeker group in this particular study is quite small.

Daphna Yasova Barbeau MD (1:01:31) Very small, yeah. I mean, again, five with full data and follow up. But in general, kind of in conclusion, there was greater physiologic vulnerability—so more common hemodynamic instability, hypoglycemia, and higher white matter injury scores on post-rewarming brain MRI for those babies born at earlier gestational ages. So what did you think? You said you had some questions.

Ben Courchia MD (1:02:01) Yeah, I think that the discussion of this paper is extremely relevant in light of the recent paper that was published in JAMA Pediatrics on cooling for babies below 35 weeks. And you're right. And when you submitted this paper on our group chat, I was like, "Oh, are they going to show that maybe the data is not so clear?" But it goes along. And though in this particular case, I think this is an instance where the lack of significance doesn't really bother me so much just because the signal goes in the same direction as the data that we also have. I'm just curious as to why you picked this paper and what do you make of this data? Because for people who don't know, you are our HIE neurodevelopment expert. Any question that we have goes to you. And so I'm wondering... I'm just curious what you think about this.

Daphna Yasova Barbeau MD (1:03:08) Well, I think the concern in the community is: could we swing the pendulum too far, right? Do we have enough data to swing all the way back? Because units across the country are rewriting their protocols on, I think, good data, but still small numbers of babies. I think we're going to see more of these papers from centers that have done a lot of cooling and were pushing the envelope with younger babies. Maybe we'll start seeing the 12-hour cooling papers come out from units that were already doing it. And then looking at those outcomes, is it the same as a randomized control trial? No, it's not the same, but...

Ben Courchia MD (1:03:55) That's interesting you say that, because I was wondering if you were... I was thinking you might say something like that. And I think to me it's very concerning, because this data is gonna come out, and if God forbid it goes in a diverging direction, we're not ethically gonna be able to run another trial, I feel it.

Daphna Yasova Barbeau MD (1:04:15) To do the trials. It's going to be... nearly impossible to do the trials.

Ben Courchia MD (1:04:22) Yeah, right? Because if somebody comes out with some retrospective data and says, "Hey, we have this group of hospitals, and we have 600 kids, and it turns out maybe not, you know?" And then a Cochrane Review comes around, and it's like, "Well, between these two trials, we don't know." How are you going to run this trial? How are you going to say, "All right, we have this data that shows maybe increased mortality, and we're going to randomize?" It's like, ooh, that's going to be a challenge. So we'll see what happens. But it's always interesting to follow that data, right? Because I think if you use just one paper and you say, "This discussion's over," then the discussion is never over.

Daphna Yasova Barbeau MD (1:04:57) But I think barring whatever's happening outside this recording studio right now, I think in the unit, it's giving us all pause. And it makes sense, right? We know those 34-weekers, even the 35-weekers... I mean, there's a reason we're supposed to cook so long, is what I tell the parents.

They are more at risk for some of that physiologic instability. And not for nothing, but potentially even if they make it through the cooling, less likely to respond to the intervention. So our risk-benefit ratios are different.

Eli (1:05:46) We want to discuss two articles. We'll sort of touch on them one by one, and then we'll talk about them both together.

Ben Courchia MD (1:06:03) Yeah, I think one of them exemplifies the other.

Eli (1:06:06) Yeah, exactly. So the first article is an op-ed by Lelis Vernon, Sarah Swenson, and Emily Miller. Lelis, as some people may know, is a wonderful advocate for all things related to ensuring NICU parents can be involved and have the resources they need to stay involved. And Dr. Swenson and Dr. Miller are neonatologists. They write that one of the fundamental, relatively invisible changes that's happened under the current administration is the repealing and rescinding of policies around "sensitive locations" when it comes to immigration enforcement.

What that means is historically, where immigration enforcement authorities—namely ICE, Immigration and Customs Enforcement—were allowed to conduct arrests, searches, or deportation exercises, there were settings in which they were not allowed to do that. One of the settings in which they were not allowed to do that was healthcare settings. Historically there was a policy under the agency on the books that prohibited them from enforcing immigration and deporting people, arresting people, or handcuffing them while they were in the hospital or en route to the hospital.

As the three document in the op-ed, this is having a considerable chilling effect. I think people often think back to the "public charge" policies under Trump one, where basically there was this threat that if you used any sort of social service, or even the appearance of using a social service, that would threaten your ability to achieve citizenship at an undetermined later date. People looked at the chilling effects of those policies, and they were profound. If you look at the data in terms of what that meant for people trying to engage in any number of different services, including healthcare services... and I think what Lelis, Sarah, and Emily are talking about in this op-ed is a similar sort of chilling effect. I think they also say, and I just want to read this part out loud. They say, "Even when babies leave the NICU, the same fear that pushes immigrant families away from the hospital follows them home. Most extremely premature infants have medical needs that require frequent follow-ups with their doctors. Families may visit the children's hospital every week for specialist care during the first few months after leaving the NICU. But now more families are delaying or forgoing medical appointments, afraid that they will be searched, interviewed, or arrested. Others face an impossible choice: seek medical care for a sick child or minimize the risk of being separated from their family," which I think just touches on so many different issues. Daphna, Ben, what did you guys think of this op-ed? What do you think of the bigger issue here?

Ben Courchia MD (1:09:20) So first of all, I think this is a great article. Emily is a friend of the show. She's been on the podcast before and does great work. I think this article is another non-political view at something that is very, very basic. The idea that a healthcare facility is a sensitive location, to me, is another way of saying you could find sanctuary in a hospital. If you seek medical help, you should not be fearing that your immigration status will interfere with your opportunity to seek medical help, especially when we're talking about our specialty, about the NICU.

I think this goes without saying. And again, this is a great opportunity for advocacy. The article mentions the Protecting Sensitive Locations Act, which was reintroduced in Congress earlier this year. I think this gives you a very direct sort of bill that you can latch onto and bring up for your support to your local lawmakers to get this pushed through Congress. I think that a church is a sanctuary; a place of worship is a sanctuary. It's been like this for hundreds of years. As a society, I think that we ought to preserve these sanctuaries for people irrespective of their creed or their immigration status. Because as we'll see in the follow-up story, it's devastating to hear when the two collide and what effects this can have on families.

Daphna Yasova Barbeau MD (1:11:01) Yeah, and unfortunately, it's not a new issue. It's definitely not. It's an acute issue now, acute on subacute issue. I was showing Eli some of my favorite TV shows from childhood and growing up. My parents love to watch ER. There were a number of ER episodes, and Scrubs and Grey's Anatomy, about this very topic. In the hospital, in the ER, those patients should be protected because they're coming to get what many of us—what I consider—is a basic human right.

In the NICU, where this is very important is recognizing when we say, "Why isn't this family at bedside? Why does the mom just drop off milk and leave? Or why is the milk coming by an aunt or an uncle?" I think we just have to have a lot of sensitivity in the way that we're approaching families that are really in fear and under significant duress in addition to having this traumatic experience in the NICU. We must make sure that our updates to these families are comprehensive, and that we're going out of our way to reach them, knowing that they may not come to bedside. I don't blame them for feeling scared and concerned, especially given the next story that really circulated the news.

So I think I'm trying to be really attentive to that, making sure that we challenge the narrative that "this family doesn't ever come to bedside," that we recognize why that might be for some families, and that we really try to do more phone updates. We must be really cognizant about using our interpreter services for families that can't come to bedside or feel like they can't come to bedside. So I'm really leaning into that. And I echo Ben's sentiment that this is the time when you say, "I'm just a clinical neo. I don't really do advocacy." This is the time where advocacy equals our clinical bedside work. And so we should use our stories. That's what everybody tells us. Use our stories to create influence and impact. So that's where I leave you, Eli.

Eli (1:13:35) Yeah, yeah. And I think it's a perfect time to transition into the next article, which is really an illustration of all this. I will say before, just because you touched on it, Daphna, for anyone interested in best practices on including families who are not at bedside in the normal conversations in the NICU, there is forthcoming research in Pediatrics on virtual family-centered rounds. There's an increasing movement to ensure whatever a family's capacity is—including, as we've talked about in previous episodes in January on Neo News, families in states where they cannot get medical leave to spend large amounts of time or any time with their infants—that they are included in a formal way while they're in the NICU.

Daphna Yasova Barbeau MD (1:14:21) Mm-hmm.

Eli (1:14:30) There are evolving best practices around how to include them. I think we've all had that experience of the family that basically says we should call them every day during rounds. Short of them saying that, we don't necessarily call every family every day during rounds. I think there's increasing evidence that making that the standard, certainly for some families, can be beneficial if the families feel like that is part of something they want to be involved with. It yields all sorts of benefits on self-efficacy in the short run, and certainly engagement and empowerment in the longer run.

Anyway, so let's transition to what this looks like. I think the way to really understand how these immigration policies look in the flesh is through a really harrowing and comprehensive article by Mel Leonor Barclay and Shefali Luthra for The 19th. If anyone doesn't know, The 19th is a wonderful nonprofit newsroom that has done lots of reporting on maternal care, women's rights, and other topics like that over many years. I should say I have immense admiration for Shefali Luthra, who was at Kaiser Health News—now KFF Health News—for a very long time, and now is doing some amazing reporting at The 19th.

In this article, they document the story of Neira Guzman, who is a 22-year-old migrant from Mexico. After the birth of her daughter, it sounds like she had a challenging transition and was admitted to the NICU, as many children are. Guzman says to Barclay and Luthra in the reporting, "We weren't worried about the immigration raids," which were happening all around them. This was in Chicago. She said, "We weren't worried. Our worry was, how are we going to get this baby home and out of the hospital?" That was our number one priority: that she would be safe and healthy, and everything else had fallen to the background. However, in the days after their infant's birth—15 days after—Guzman, her mother, the baby's grandmother, and a younger brother got into their car to go to the NICU to visit their daughter. That's when they were picked up by immigration enforcement agencies and taken to detention.

The rest of the story documents in really painful detail their battle and ultimately their ability to get out—after much advocacy and legal involvement—to get out of detention and back to the business of caring for their child. But all of this to say, this isn't theoretical. This is happening. It's already happening. Lord knows there are probably so many stories gone untold like Guzman's. And as Lelis, Sarah, and Emily document, there are probably so many families who at various stages in caring for a child with medical complexity are making concrete decisions to avoid exactly what happened to Guzman happening to them. Guys, what did you think of this story and how does it fit into this broader conversation around immigration enforcement and the impact it's having on our families?

Daphna Yasova Barbeau MD (1:18:14) Yeah, I thought the extreme of this is that a baby could be in the NICU, their parents could be deported, and they are in the NICU. And then what happens to them? They go into our foster care system. I mean, it's just baffling. But I thought people should read it; people should see the firsthand accounts. I echo all of my own sentiments from previously. I think this just further solidified how distressing this is for families, how scary it is for families, and how they may have a new distrust—an increased distrust—of all of us as a part of the system. We've had to be really sensitive to that. And potentially, especially for some of us in states like Florida, it's a really big reality for families in our unit right now. At the extreme of that, what happens to these babies? I don't know the answer to that. I don't think anybody has thought that all the way through.

Ben Courchia MD (1:19:32) Yeah, it's a very distressing story. I have a few thoughts on this. Number one, I think the issue of immigration could be framed from the standpoint of, well, if you are in the country in an illegal manner, then you put yourself at risk of the law. But I think it's important to mention in this particular story that the protagonist, Miss Guzman, had filed for asylum and had basically a few petitions in process. So I think that's important. Because what it shows is that the enforcement of immigration policy cannot be excused.

I think that irrespective of what's happening—and I'm very disappointed in this story, not from the article, but from the events—in a sense that if you arrest someone and they tell you, "Hey, I just gave birth, I'm visiting my baby in the ICU," I couldn't help but shake the feeling when I was reading the story of what would it have cost the officers to check on that? What would it have cost to say, "You know what, we're going to put your car here, we're going to go check"? And if that is truly the case, how come there's no mechanism to say, "Okay, you have extraneous circumstances, and we're not going to put you in a detention center like the story describes"? It's a lack of humanity and it's very...

Daphna Yasova Barbeau MD (1:21:21) I think it's because it doesn't matter if that's the extenuating circumstance. I think that's the...

Ben Courchia MD (1:21:27) But to me, the way I would have liked this story to unfold is that maybe this person has an arrest warrant. It doesn't really matter. You arrest them and they say, "Hey, I'm on my way. Look, I just gave birth. I'm on my way to the hospital. My baby's in the ICU." I don't think it's a far-fetched idea to say that these officers could have checked on this. And when confirmed, they could have escalated this to their supervisors and said, "How do you want us to handle this? Because obviously it is a sensitive situation." Just giving that little bit of space and time to just do the right thing. But why?

Daphna Yasova Barbeau MD (1:22:05) I don't think it works like that. Seriously, I think that's the problem. It wouldn't have mattered.

Ben Courchia MD (1:22:14) You're not arresting a car of six adult-aged males. I believe she was in the car with her mother. So anyway, I think it was a big disappointment. And obviously the story is tragic because everything continues to unfold in the wrong direction. And you keep hoping that at some point somebody with some sense is going to...

Daphna Yasova Barbeau MD (1:22:19) Yeah, it wouldn't have mattered. I think she had another young child.

Ben Courchia MD (1:22:41) ...is going to do the right thing. And eventually we find out that people with diabetes in detention centers are given sandwiches, which, my dad is an endocrinologist, and this is absolutely appalling. So anyway, I think that it was very distressing to read that type of story. It feels on this front, I felt quite powerless, I must say. Because I'm not even sure what could have been done in that situation. So something to read about, definitely. And it was very well written and had lots of details. Eli, correct me if I'm wrong, I believe there's no paywall. It's very frustrating; since we started doing Neo News, I've had to subscribe to a bunch of stuff. But for this one, it's free. You can access it with no problem.

Daphna Yasova Barbeau MD (1:23:28) But it's why we're doing Neo News, because everybody can't subscribe to everything all the time.

Ben Courchia MD (1:23:38) [Affirmative remark].

Eli (1:23:38) Well, and I don't apologize. Because if you do have capacity to subscribe to any number of newspapers, you know, they need subscribers. They work hard and you've heard all the pleas on all the podcasts. It's quite a profound place. I will take this moment to plug: your local radio station probably had their funding pulled this year. Lots of newsrooms depend on funding that's been pulled. So it is high time to think about investing in your knowledge of what is going on out there for invariably a very low cost.

However, I will say that aside, I couldn't agree more with so much of what you both said. I think again, in the spirit of identifying opportunities for advocacy, here is a golden opportunity for anybody to try to get involved with advocacy to promote protections for families like the Guzmans and many others. The Protecting Sensitive Locations Act is in Congress, in process, and has support of over a hundred lawmakers between the House and the Senate. So call your Congressperson. Encourage them to try to ensure that there is a law, not just policy, but law on the books, to protect folks trying to get healthcare for their loved ones. Ensure that part of the law is also promoting transparency around where enforcement actions and other immigration procedures are happening.

If they are happening in these places, what does that look like? It's really important from the transparency and watchdog enforcement standpoint on the government side to pass laws like this. So I think again, another golden opportunity for folks to try to get involved, talk to their Congresspeople. If your Congressperson is not on board yet, you can put this on their radar. You can speak to your story and what you're seeing in your families.

Ben Courchia MD (1:25:41) Yeah, I just wish they had said something like, "There's a warrant for your arrest. You should talk to your attorney. We'll be back." I went through immigration myself, you know, it's not a pleasant experience, but there needs to be more dignity. Anyway.

Daphna Yasova Barbeau MD (1:25:48) Ben, I think you're missing the point. None of that would have mattered. Yeah.

Eli (1:26:00) Yeah. Well, if there was something called Miranda rights in immigration policy, then I think we'd be in a different place. But again, these are policies that are not laws. And so the first step to enshrining protections is getting them as laws on the books rather than internal policies that can change with the wax and whim of any administration. And this is the first step to do that. I think I would point people to lots of amazing reports about this happening in other settings.

For example, I will point people towards a really harrowing story in New York Magazine titled "The Trap at 26 Federal Plaza," which documents how people are being handcuffed and detained when trying to go to immigration hearings. Courthouses were another place on the list of sensitive locations that are now no longer protected. So you go to your asylum hearing and you are whisked away to detention while you are waiting in line to be heard for asylum.

Ben Courchia MD (1:26:54) Yeah, it's crazy.

Eli (1:26:57) That is another place that this Act would enshrine protections for. So we could talk about this all day. We are not going to, because we need to let you go. Need to prepare for next week's episode, but so much to talk about here. Something we will be keeping a very close eye on. And we hope you will too.