#399 - 📑 Journal Club - The Complete Episode from February 28th 2026

Hello friends 👋

In this week’s journal club episodes, we review several interesting and important studies in neonatal medicine. Ben and Daphna start with a provocative echocardiography study out of Edmonton showing that standard chest compressions in newborns likely target the right heart and great vessels, not the left ventricle. A small sample size, but a finding that anyone who ultrasounds hearts all day will instantly recognize.

Daphna presents a retrospective multicenter study from Nationwide Children’s on antibiotic duration for Gram-negative bloodstream infections in the NICU. Short course (≤8 days) showed no treatment failures, while 14% of infants in the long duration group developed a multi-drug resistant organism infection. Eight days versus ten: does the difference matter? The data says yes.

Ben reviews a randomized controlled trial from UAB on early vitamin D supplementation in extremely preterm infants fed human milk. Eight hundred units daily for the first two weeks appears safe and effective at achieving vitamin D sufficiency, but did it move the needle on BPD? And is that even the right question to ask?

Daphna brings a QI paper from Levine Children’s on universal social determinants of health screening across nine pediatric divisions, achieving 92% compliance and connecting thousands of families to resources through findhelp.org. A reminder that the tools are already there – we just have to use them.

The episode wraps with Ben, Daphna, and Eli discussing Colorado’s landmark paid NICU leave law – the first in the nation to require employers to provide up to 12 weeks of paid leave for parents with a baby in the NICU. What does the evidence say, and how do we advocate for this in our own states?

Science, equity, and advocacy – all in one episode.

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

Chest compression in newborn infants: what anatomical structures are we compressing? Chua CT, O'Reilly M, Surak A, Schmölzer GM.Arch Dis Child Fetal Neonatal Ed. 2026 Jan 16:fetalneonatal-2025-329582. doi: 10.1136/archdischild-2025-329582. Online ahead of print.PMID: 41545184

Duration of Antibiotic Therapy for Gram-Negative Bloodstream Infections in the Neonatal Intensive Care Unit. Djordjevich CJ, Magers J, Cantey JB, Prusakov P, Sánchez PJ.J Pediatr. 2026 Jan 17:114993. doi: 10.1016/j.jpeds.2026.114993. Online ahead of print.PMID: 41554433 Free article.

Early Vitamin D Supplementation in Infants Born Extremely Preterm and Fed Human Milk: A Randomized Controlled Trial. Salas AA, Argent T, Jeffcoat S, Tucker M, Ashraf AP, Travers CP.J Pediatr. 2025 Dec;287:114754. doi: 10.1016/j.jpeds.2025.114754. Epub 2025 Jul 24.PMID: 40714046 Clinical Trial.

Improving Health-Related Social Needs Screening and Support Across a Pediatric Health Care System. Laroia R, Minor W, Carr A, Buitrago Mogollon T, White BB, Mabus S, Stilwell L, Ahmed A, Mehta S, Obita T, Reed S, Senturias Y, Mittal S, Horstmann S, Demmer L, Dantuluri K, Chadha A, Noonan L, Courtlandt C.Pediatrics. 2026 Feb 5:e2024070035. doi: 10.1542/peds.2024-070035. Online ahead of print.PMID: 41638605

Boese, L. (2024, December 18).Why Colorado’s paid NICU leave law could spark nationwide trend. HR Executive. https://hrexecutive.com/why-colorados-paid-nicu-leave-law-could-spark-nationwide-trend/

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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 👇

[00:02.136] Ben Courchia MD Hello everybody, welcome back to the Incubator Podcast. We're back today for another episode of Journal Club. Daphna, good morning, how are you?

[00:11.150] Daphna Yasova Barbeau MD I'm doing well, what you got for us today?

[00:13.650] Ben Courchia MD Ooh, I'm gonna start this week with an interesting paper that I saw in the Archives of Disease in Childhood - Fetal and Neonatal Edition. The author is Catherine Chua. "Chest Compression in Newborn Infants: What Anatomical Structures Are We Compressing?". That is the title.

[00:31.502] Daphna Yasova Barbeau MD Well, my daughter's been working on her hooks for her writing. This was a hook for sure.

[00:37.526] Ben Courchia MD This is a hook, right? Yeah, I saw the title and I dived in. But very, very nice paper. The background is interesting—approximately 1% of infants require chest compression at birth. The aim, theoretically, of chest compression is to restore systemic circulation, optimize coronary blood flow, and improve myocardial perfusion. This is postulated to occur through two mechanisms. First, directly compressing the heart between the sternum and the spine forces blood to flow into the circulation with each compression, also known as the cardiac pump theory. The second hypothesis is that chest compression produces a rhythmic increase in intrathoracic pressure, generating the gradient necessary between the arterial and the venous compartment, resulting in forward flow—called the thoracic pump theory. So you're kind of sucking blood back into the thorax.

[01:30.000] Ben Courchia MD The current consensus of science and treatment recommendations provides that neonatal chest compression should be centered over the lower third of the sternum and avoid the xiphoid process. Now, the authors of the paper note that observational cohorts of over 500 infants and young children show that the right ventricle or the left ventricle was directly located under the lower third or lower quarter of the sternum. However, no newborn infants were included in these studies, and the location of chest compression varies with age as the heart descends from infancy to adolescence. In children aged one year to puberty, the optimal site for targeting the left ventricle while minimizing injury is located one centimeter above the xiphisternal joint. Now, ultrasound imaging in a cohort of 64 adults showed that performing chest compression over the left sternal border at the inter-nipple line or the sixth intercostal space targeted the left ventricle in approximately 72% to 77% of participants. So, I mean, it's kind of mind-boggling that we might not be compressing the heart if we're doing chest compression where we're told to do chest compression.

[02:45.208] Ben Courchia MD This suggests that an alternative chest compression location could potentially improve cardiopulmonary resuscitation effectiveness. This compression point might be more specific compared with the wide range of the lower third of the sternum as recommended by the current guidelines. So overall, there's limited understanding of the precise cardiac anatomy in the immediate newborn period, and little is known about which structure lies beneath the recommended compression site in newborn infants. So given this gap, they aim to identify the location of the left ventricle within the chest and identify the structures below the lower third of the sternum using transthoracic echocardiography.

[03:22.000] Ben Courchia MD For anybody doing echoes and hemodynamics, people will be like, "Oh, we know where it is." But it's true that it's funny to see it highlighted in the form of a paper. This is a prospective observational cohort study conducted in Edmonton in the province of Alberta in Canada. Newborn infants born at term admitted to the postnatal unit with likely normal heart anatomy were eligible for inclusion. Transthoracic echocardiography was performed and for each patient the chest circumference was measured at the inter-nipple line using tape. Then the tape was also placed along the sternum with the left edge of the tape aligning with the left border of the sternum, and the suprasternal notch and xiphisternum were palpated and marked on with tape.

[03:58.000] Ben Courchia MD Now the authors then followed the American Society of Echocardiography guidelines, got a bunch of views on echocardiography: a parasternal long axis, a parasternal short axis, an apical four-chamber view, and a subcostal view. Now, we'll talk a little bit more about how these views matter, but these views were used to delineate the location of the right ventricle and of the left ventricle and their projection on the chest wall. Small pieces of tape were placed on the skin to mark exactly where the optimal clip of each of the four views was obtained. Thereafter, the distance between the tape marking the long axis and the four-chamber view was measured, as well as the midpoint between the long axis and the four-chamber view to estimate the location of the left ventricle.

[05:00.758] Ben Courchia MD So just for a review—since we're talking about hemodynamics again, we're considering doing some educational series on hemodynamics if you are interested, let us know. But when they talk about these parasternal long axis views: the heart sits in the chest kind of like a fist aiming at your nipple, I guess. And a parasternal long axis view is kind of like looking at the heart from the profile. So like you're looking at an elongated view of the left ventricle. The apical four-chamber view is kind of like the way you imagine the heart in your head, like two atria above, two ventricles below. The parasternal short axis view is kind of difficult to describe. And then the subcostal view is kind of like an apical four-chamber, just taken from a different angle from below the diaphragm. So basically, you don't really need to know so much about these views. You just need to understand a little bit that they provide different perspectives on the heart anatomy, and that basically kind of like recreating a 3D structure by putting all these pictures together, you can delineate exactly where the heart is located.

[05:42.000] Ben Courchia MD So they took a convenience sample of 50 infants. They had a gestational age of about 39 weeks. 3.4 kilos was about the birth weight, and the echoes were performed within the first day of life. So the distance between the long axis and the apical four-chamber view was about 3.5 centimeters. The midpoint between the two was about 1.9 centimeters. And then they had all these different projections where they looked at different measurements. And there's a very... actually, you know what, Daphna? Since we are on... since we're going to be on YouTube, as my grandmother used to say, I'm going to show you exactly what is meant by that. Let me see if I can share my screen. You see, people, how unsophisticated we are. We'll do it this way.

[06:39.435] Daphna Yasova Barbeau MD Yeah, show me. Show us.

[06:53.996] Ben Courchia MD So basically they have a bunch of measurements and what they come to is kind of this figure. Can you see? So they come to this figure and what they see is that the left ventricle is located at the third left sternal border in one infant or 2%. It was located at the fourth left sternal border in 22 infants or 44%. It was located at the fifth left sternal border in 25 infants or 50% of the cohort, and at the sixth left sternal border in 4% of infants.

[07:34.233] Ben Courchia MD So basically, when you look at it and you look at the lower third, you're really not compressing the left ventricle. And you're kind of right over the right ventricle, which is very interesting. And that's not really the intention. So the authors state that their study provides newborn-specific anatomical data. Some people might say that the sample size is not big enough. To be fair, if you look at doing hemodynamics, this is where we expect some of these structures to lie anyway, so I don't think they're off. I think they're absolutely correct in how they delineated the position of the heart.

[08:10.965] Daphna Yasova Barbeau MD Okay, but I have a dumb question. Again, I was just teaching the cardiac exam last month. And I mean, this is kind of true in adults also, that the left ventricle is to the left of the patient's sternum.

[08:33.707] Ben Courchia MD Yeah, but the difference is that really what they're looking at is the position in terms of its height in the chest. And I feel like what gets missed is that it almost feels like when you are born your heart is more midline, its axis is a bit rotated, and over the course of the years it kind of lands on the diaphragm and sort of starts sitting on the diaphragm. Yeah, and I think that this is something that informs the chest compressions in adults where it is you are compressing the heart. When we are talking about babies, we're really looking at maybe one structure.

[09:03.403] Ben Courchia MD So I just want to get through this discussion and this conclusion. But really, the authors talk about the fact that the left ventricle does not lie directly beneath the midline of the sternum, but projects predominantly under the fourth or fifth left sternal border corresponding to the lower third of the sternum. The longitudinal extent and projection of the ventricle indicates that standard midline compressions are unlikely to directly overlay the left ventricle in most newborns. Instead, based on their measurements, chest compression applied to the recommended lower third of the sternum would primarily compress midline structures such as the right atrium and the right ventricle, the superior vena cava and the ascending aorta.

[09:31.253] Ben Courchia MD The authors note that current recommendations are based on cohort studies including mostly infants and children, rarely newborns. Analysis of 210 radiograph images of children from birth to 12 years of age revealed that the heart descends with age, as we just mentioned, and the heart is positioned under the sternum in infants and then migrates to the lower third of the sternum in adolescence. They conclude that chest compression delivered at the currently recommended lower third is likely to compress the right heart, the great veins, and that this anatomical relationship challenges the cardiac pump-based rationale underlying the 3:1 compression-to-ventilation ratio. Together with the evidence supporting the thoracic pump mechanism and the benefits of continuous chest compression with sustained inflation, these results highlight the need to re-examine both the optimal compression site and the ratio of compression to ventilation to optimize blood flow and improve outcomes. I think this is very interesting. And wondering if maybe, yeah, we need to have different points of compression based on the age of the patient, which sounds like a terrible thing to establish, but yeah.

[11:14.487] Daphna Yasova Barbeau MD I'm gonna reference our Delphi quote for this year, which was, "Innovation consists of seeing what everybody else has seen and thinking what nobody else has thought". That's exactly what this is, saying like, this is something we do pretty routinely—have we ever thought about the underlying mechanisms? And it's like these little things that like, I mean, if we changed the way we did CPR, that would be earth-shattering, right? Potentially. And I think that's very cool. And it makes sense.

[11:52.341] Ben Courchia MD Yeah. And like I said, what's mind-boggling is that if you ask anybody who ultrasounds hearts all day, they'll be like, "Yep, yeah," they'll be like, "Yeah, this is exactly right". Right? I mean, this is also what I was thinking of when I was thinking about it, because I could imagine myself doing chest compression and was like, "How did that never dawn on me?". So kudos to this group for making us see what others have not.

[11:54.341] Daphna Yasova Barbeau MD I think you're going to like this next paper that I have for us. Is it my turn or is it your turn? It's my turn. Okay. So this paper is called "Duration of Antibiotic Therapy for Gram Negative Bloodstream Infections in the Neonatal Intensive Care Unit". This is coming from Nationwide Children's. It's really cool. It's a collaboration between their NICU, their ID team, and their pharmacy team. I love, love, love that. So lead author Colleen Djordjevic—I think I did it—senior author Pablo Sanchez.

[12:39.005] Ben Courchia MD Yeah, Djordjevic?

[12:43.515] Daphna Yasova Barbeau MD Yeah, Djordjevic probably. But it's cool that the first author is the pharmacist.

[12:47.547] Ben Courchia MD For sure. For sure. I love that.

[12:50.089] Daphna Yasova Barbeau MD Love, love, love that.

[12:53.575] Ben Courchia MD And the famous Pablo Sanchez as last author, not surprising.

[12:54.575] Daphna Yasova Barbeau MD That's right. And this is in the journal Pediatrics. I failed to mention that. Okay, so what they wanted to evaluate is the effectiveness and safety of a short course—so less than or equal to eight days of antibiotic therapy—versus a long course—greater than or equal to nine days of antibiotic therapy—for "uncomplicated" but exclusively Gram-negative bloodstream infections, which they will call BSI throughout the paper, among infants in the NICU. Obviously, this is a hugely important question and the background is pretty useful. Studies have looked at seven and 10 day versus 14 day treatment courses without really noticing any outcomes, but we still routinely treat these infections and particularly Gram-negative infections for longer times.

[13:51.528] Ben Courchia MD Yeah, what, 10 to 14 usually, right?

[13:55.983] Daphna Yasova Barbeau MD Yeah, I mean, the Red Book says a minimum of 10 days for an uncomplicated Enterobacter in neonates. But yeah, for these Gram-negatives, sometimes we're easily doing 14 days. And then obviously we know the rest of the background is that prolonged antibiotic use has major consequences in the NICU, predicting late onset sepsis, NEC, neurodevelopmental impairment, and even new bloodstream infections by the use of central lines and death. And they highlight here, each additional day of antibiotic exposure in preterm very low birth weight infants—so those babies less than or equal to 1500 grams—in the first weeks of age has been associated with increased risk of major morbidities and mortality. So that's a good reminder for us.

[14:25.553] Daphna Yasova Barbeau MD This is a retrospective cohort study. It includes all infants who received antibiotic therapy for an uncomplicated Gram-negative bloodstream infection from January 2016 to May 2022. They used six NICUs in the Nationwide Children's Hospital system and one Level 4 from the University of Texas Health, San Antonio. So infants were considered to have an uncomplicated bloodstream infection if there was no evidence of what they call metastatic infection: so no CNS involvement, no endocarditis, no osteomyelitis, and no receipt of vasopressor treatment, which I thought was interesting.

[16:33.863] Daphna Yasova Barbeau MD And infants treated for Gram-negative BSI with effective antimicrobial therapy on less than or equal to eight calendar days from the initial positive blood culture—or from the first negative culture if that repeated culture remained positive—that was called the short duration group. And then greater than or equal to nine calendar days of therapy was called long duration. They excluded infants if death occurred before completion of the ordered antibiotic therapy, if the blood culture yielded multiple organisms, if they were thought to be bacterial contaminants, or Gram-positive, because they were really looking at Gram-negative bacteria. And then like I said, infants diagnosed with meningitis, osteo, or endocarditis were excluded since those antibiotic durations are different.

[17:29.987] Daphna Yasova Barbeau MD And the primary outcome was treatment failure. They defined treatment failure as a recurrence of a bloodstream infection with the same organism within two weeks or 14 days of stopping antimicrobial therapy. They looked at secondary outcomes such as acute kidney injury during treatment, a recurrence of a bloodstream infection with any organism within 14 days of discontinuing antibiotics, a subsequent occurrence of fungemia, the emergence of a multi-drug resistant Gram-negative detected from any body site within 90 days of the discontinuation of antibiotic therapy or discharge, whichever happened first. And they looked at 30-day in-hospital mortality. They looked at a number of maternal characteristics: age, mode of delivery, chorioamnionitis, GBS colonization, intrapartum antibiotics, and duration of rupture of membranes.

[18:04.987] Daphna Yasova Barbeau MD They talked about their routine use of antibiotics. So empiric therapy for early onset sepsis, which they define as a blood culture obtained less than 72 hours of age, was ampicillin and gentamicin. Empiric therapy for concern for late onset sepsis was nafcillin in the NCH hospitals, oxacillin in the Texas hospital, or vancomycin if an infant was known to be colonized with MRSA. So it was either nafcillin, oxacillin, or vancomycin plus gentamicin as empiric therapy for late onset sepsis. They had a standardized dose and frequency of administration, which was standardized across all those hospitals.

[18:35.794] Daphna Yasova Barbeau MD I wanted to tell you something else about their protocols. Regarding fluconazole prophylaxis, it was utilized for all infants less than 24 weeks gestation, as well as preterm infants less than or equal to 1000 grams birth weight or less than 27 weeks gestation who received greater than five days of third or fourth generation cephalosporins or meropenem. And in the Texas hospital, fluconazole prophylaxis was actually not used at all throughout the study period.

[18:53.015] Daphna Yasova Barbeau MD Okay, so during the six and a half year study period, a total of 143 infants with a positive blood culture were screened. 67 infants were excluded and 76 infants were included in the study. Of the excluded infants, 40% died before the seventh day of antibiotic treatment. What a terrifying number. Of the 76 study infants, 57% were in the NCH sites and 43% were in the Texas site. 20% of the included infants had early onset sepsis. 51% of the infants received a short duration of antibiotics—so less than or equal to eight days. The median duration of therapy in the short and long duration groups was seven and 14 days respectively. So for the short group, 7 to 7.3 were the interquartile ranges. And in the long group, 12 to 14 days were the interquartile ranges.

[20:58.567] Daphna Yasova Barbeau MD From the first antibiotic administration in the short duration group, 67% of infants received treatment on seven calendar days, 23% received on eight days, and 8% received on six days. Then they had one infant, 3%, that received just five calendar days. The blood culture isolated for this last infant was Prevotella, which was later considered by the primary team to be a possible contaminant. The infants who received six calendar days of treatment received a total of seven doses of Gentamicin. And then they looked at the long group. So among the 37 or 49% of infants that received long duration, one infant had nine days, 40% received 10 to 13 days, 36% received 14 days, and 22% received 15 to 18 calendar days.

[21:54.987] Daphna Yasova Barbeau MD So then they wanted to compare those who received short duration versus long duration. Their baseline clinical characteristics did not differ. E. coli was the most frequent pathogen in both groups causing bloodstream infection in 69% of infants in the short group and 49% of infants in the long duration group. 53% of all the infants had a central venous catheter at the onset of the bloodstream infection. This is actually a higher proportion of infants in the long duration of therapy group than in the short duration therapy group: 68% versus 38% already had a central venous catheter at the onset of the infection. Four or 27% compared to two or 8% of infants had the catheter removed during antibiotic therapy. So more babies proportionally in the short group had the catheter removed during antibiotic therapy.

[23:03.473] Daphna Yasova Barbeau MD Then they wanted to look at how many positive blood cultures. So seven infants in the long duration group had greater than one positive blood culture. Five of them had central venous catheters at the onset and one of them had a catheter removed during antibiotic therapy. No infant in the short duration group had more than one positive blood culture. That may be why they were in the short group, they don't say. 12 infants total, six each in the short and the long duration groups, had a concomitant urinary tract infection with the same bloodstream infection pathogen.

[23:59.987] Daphna Yasova Barbeau MD All right, so let's look at the outcomes. No infant who received short duration of antibiotic therapy had recurrence of bloodstream infection with the same organism in the 14 days after discontinuation of the antimicrobial therapy. Among those in the long duration group, two or 5% of the infants had a recurrence of the bloodstream infection with the same species within 14 days. One of these infants received gentamicin and meropenem due to an extended spectrum beta-lactamase (ESBL) producing E. coli, and the other was treated with cefepime monotherapy for Serratia. Additionally, none of the infants in either the short or the long duration group had antibiotic therapy restarted within 14 days for clinical concern of "culture negative sepsis" or concern for a new pathogen.

[25:12.903] Daphna Yasova Barbeau MD So most of the infants, 75% in the short duration and 78% in the long duration, received one antimicrobial agent once the blood culture yielded a Gram-negative bacteria. In the short duration group, the most frequently prescribed monotherapeutic agent was gentamicin (50%), followed by ampicillin (21%) and Zosyn (14%). In the long duration group, the most frequent antibiotics used as monotherapy were cefepime in 31%, Zosyn in 31%, and gentamicin in 14%. Among infants in the short duration group, all the blood culture isolates were susceptible to the empiric antibiotic choices that were standard in the unit. There were two infants in that long duration group whose blood culture isolates were not susceptible to the initial antibiotic treatment. They had one Pseudomonas and one Klebsiella. And those infants were effectively treated then with Zosyn for the Pseudomonas and cefepime for the Klebsiella respectively.

[25:44.987] Daphna Yasova Barbeau MD I told you they looked at AKI. So three or 8% of infants in the short duration group versus two or 5% in the long duration group had a serum creatinine greater than or equal to 1.5 times from baseline within the first seven days. Two or 5% of infants in the long duration group had a decrease in urinary output to less than one mL per kilo per hour for more than 24 hours.

[25:47.133] Daphna Yasova Barbeau MD They looked at, I told you, multi-drug resistance, fungemia, and mortality. So there were five or 14% of infants in the long duration group who developed an infection with a Gram-negative multi-drug resistant organism within 90 days of stopping therapy. There were no Gram-negative multi-drug resistant organism infections occurring in any of the infants in the short duration group.

[26:01.393] Ben Courchia MD Say that again.

[26:33.777] Daphna Yasova Barbeau MD So no babies in the short antibiotic group developed a multi-drug resistant organism infection, but 14% of infants in the long duration group—who got nine or more days of antibiotics—developed an infection with a Gram-negative multi-drug resistant organism.

[26:40.423] Ben Courchia MD It's a lot. It's a shit ton, excuse my language. Yeah, that's crazy.

[26:44.189] Daphna Yasova Barbeau MD Nine days.

[26:49.107] Ben Courchia MD So like a kid who gets eight days versus ten, it makes a difference.

[26:56.008] Daphna Yasova Barbeau MD Yeah, right. Eight versus 10 days. 14%. It's terrifying. So it makes sense, but I see the magnitude was surprising to you.

[27:04.391] Ben Courchia MD Yeah, agreed. Jeez.

[27:50.312] Daphna Yasova Barbeau MD Interestingly, to carry on, no infant in either group developed fungemia. Eight infants received fluconazole prophylaxis—that was 15% in the short duration and 2% in the long duration. But again, no infants developed fungemia. And they looked at overall 30-day in-hospital mortality: 7% overall, 8% in the short duration and 5% in the long duration. Of the three deaths in the short duration group, one was assessed as infection related secondary to E. coli. And both deaths in the long duration group were infection related with one of the infants having a recurrent bloodstream infection with Serratia. So this was an interesting study for sure.

[28:12.510] Ben Courchia MD Yeah, I mean, what do you make of it? Because I really got bogged down by the exclusion criteria where it's like, well, we included the babies if they hadn't passed away before reaching a certain number of days of antibiotics. But do we feel comfortable enough with the criteria to say, "Okay, this may be eight days, this may be more"?

[28:33.832] Daphna Yasova Barbeau MD Well, okay, just to go back. The criteria for exclusion of death was before the seventh day of antibiotics. So you could still have been in the short duration group theoretically.

[28:39.954] Ben Courchia MD Right, but my point is I'm all for antibiotic stewardship and trying to reduce, but we make these decisions usually at the presentation of the illness, right? And so the question is, do you think you'd be able to create categories of babies? You'd say, "Okay, there's maybe eight days versus more" with this data?

[29:08.827] Daphna Yasova Barbeau MD Maybe not with this data, maybe with a little bit more data. I mean, this has to be a baby who's... I mean, I wouldn't even say these were uncomplicated. Some of them, many of them had urosepsis, you know? I would have liked to seen those split up, but they had equal numbers of urosepsis in both groups. But I guess maybe we can think like maybe instead of 14 days, it could be 10 days.

[29:31.762] Ben Courchia MD Yeah, but it does show how archaic our process still is in addressing bacterial infection, right? It's like we make up a duration and we're like, "Let's see if there's recurrence." It's like we...

[29:49.575] Daphna Yasova Barbeau MD Yeah, I mean, there must be a way to surveil the inflammation and the bacteria itself. Especially what's interesting is most of these kids... most of the kids we treat clear by 24 to 48 hours, right? The next culture is negative, but still we treat for sometimes weeks.

[29:58.760] Ben Courchia MD Yeah, right? Exactly.

[30:18.523] Daphna Yasova Barbeau MD But I think the community, not just neonatology, medicine as a whole, is moving to shorter antibiotic courses. So what is the lower limit? I don't know.

[30:26.322] Ben Courchia MD I think we all want to, and we all are driven by this desire also to make sure that we eradicate whatever we're treating. And the question is, I think for our small neonates, we do have this concern that we cannot partially treat. Partially treating is a zero event. It's a zero occurrence event. It should never happen.

[30:53.799] Daphna Yasova Barbeau MD Yeah, because they don't tell us... they can't tell us if they feel crummy, right? Before they get really, really sick.

[30:58.386] Ben Courchia MD Yeah, precisely. Yeah, exactly. So anyway, it's very interesting. It feels like more and more every day we're learning that we can actually shorten the duration of whatever we're doing. So it seems like there's momentum there for maybe backing off. But we'll see. We'll see. Very interesting data. Thank you for presenting that.

[31:00.386] Ben Courchia MD I have a very nice article for you, Daphna. We've been talking a lot about vitamin D supplementation in our unit.

[31:11.808] Daphna Yasova Barbeau MD Okay. Mm-hmm, I saw that one.

[31:16.122] Ben Courchia MD So this is a paper by our good friend Ariel Salas. But we're not doing this paper because he's our good friend. We're doing this paper because it's an interesting question he's trying to answer.

[31:25.010] Daphna Yasova Barbeau MD It is coming up weekly in our unit.

[31:27.726] Ben Courchia MD The paper is published in The Journal of Pediatrics and it's called "Early Vitamin D Supplementation in Infants Born Extremely Preterm and Fed Human Milk: A Randomized Controlled Trial". So the background stuff is interesting. A lot of the things that Ariel mentions are things we're familiar with. Infants born extremely preterm, who are born at less than 28 weeks, face an abrupt loss of maternal vitamin D supply, which leaves nearly all of the 26,000 babies born at this particular gestational age group each year in the US at risk of vitamin D deficiency.

[32:11.824] Ben Courchia MD The current recommendations for vitamin D supplementation in these infants do vary. Some consensus guidelines do not recommend vitamin D doses greater than 400 International Units per day before the establishment of full enteral nutrition or before documenting biochemical abnormalities. The authors note that this may result in suboptimal supplementation during the first 14 days after birth, a critical window for both bone and lung development. Although vitamin D is primarily recognized for its role in skeletal health, there is emerging evidence suggesting that it also plays a crucial dose-dependent role in lung development. This is specifically true during the saccular and alveolar stages of lung growth, where vitamin D contributes to pneumocyte differentiation, regulates surfactant production, and influences alveolar formation. All these findings...

[33:03.401] Daphna Yasova Barbeau MD We forget about that. I mean, when you really think about it, vitamin D is so important.

[33:11.630] Ben Courchia MD This is the Dr. Seuss book that we should all have in the unit: All the Things You Forget. So all of these findings indicate that early vitamin D supplementation could mitigate adverse respiratory outcomes in preterm infants, including those born extremely preterm. So this trial aimed to determine whether an early enteral vitamin D supplementation dose could reduce the severity of BPD and improve lung mechanics at term equivalent age. They used something called impulse oscillometry as a bedside tool to quantify lung function. So we'll talk about that in a second.

[33:41.686] Ben Courchia MD So this was a parallel-group, masked, randomized controlled trial that included infants born extremely preterm between March 2023 and June 2024 at the University of Alabama at Birmingham Hospital. Infants with a gestational age of 28 weeks and six days or less were eligible for inclusion. Babies with major congenital anomalies, terminal illness, whatever, were excluded. Standard stuff. In terms of intervention... I mean, I feel like I read the exclusion criteria and I am getting tired, but I feel like I read the exclusion criteria and they're all the same. They're okay, they're all good, but I'm just saying, of course, the babies were very sick and all these things are excluded.

[34:49.612] Ben Courchia MD In terms of interventions, participants were randomly assigned to one of two groups in a one-to-one ratio. The intervention group received the usual human milk diet with an additional 800 units per day of vitamin D for the first 14 days after birth. And the control group went on the regular merry way of the UAB protocol, which is they usually get their human milk diet without any additional vitamin D for the first 14 days. These infants then received vitamin D only from standard sources amounting to the minimum recommended dose from fortification and so on and so forth, or from whatever was in the milk. The clinicians and the primary caregivers were masked, but the dietitians and feeding specialists were unmasked to the randomization. After postnatal day 14, vitamin D supplementation continued per routine practice at the University of Alabama with 400 International Units per day in both groups.

[35:41.824] Ben Courchia MD In terms of outcomes, the primary outcome was BPD, defined by the Jensen criteria—very happy to see the Jensen criteria being used—and death up to 36 weeks post-menstrual age to account for all study participants. The primary physiologic outcome was measured using the TremoFlo N-100 airway oscillometry device. So basically, it measures the elasticity of the lung tissue. It's a device, to be honest with you, I've never seen it before. And it looks like it measures how easy it is for you to inflate your lungs. So if inflation of the lung requires a lot of effort, it will detect that in a way. I'm speaking a little bit out of turn here because I'm not extremely familiar with this device. It measures basically resistance.

[36:21.824] Ben Courchia MD And the difference in resistance really is what they also measure. So they looked at two things. They looked at the mean area under the reactance curve, that's AX, which is a measure of the elasticity of the lung tissue where higher AX values indicate more stiffness of the lung. And then they used a difference in resistance, as I mentioned, the R7-19, which is a measure of the difference between the central and peripheral airway resistance, where a higher value indicates increased peripheral airway resistance. They had a slew of other secondary outcomes: grade of BPD, death, days of mechanical ventilation, length of stay, growth parameters, safety outcomes including NEC, SIP, late onset sepsis, metabolic bone disease, and other lab values.

[37:15.662] Ben Courchia MD Okay, so we're going to get into the results. 126 infants born extremely preterm were randomized, 63 allocated in each group. The mean birth weight was 759 grams. Baseline demographics were comparable between the two groups. The mean gestational age was 25 weeks in the intervention group, 26 weeks in the control. Infants born between 22 and 23 weeks were about 24% of the cohort in the intervention group and 14% in the control group. And then I think this is interesting as well: by postnatal day three, 47% of infants were found to have low vitamin D levels, and the mean vitamin D levels at day three was 35 ng/mL in the intervention group, 35 in the control group.

[37:54.510] Ben Courchia MD Okay. In terms of nutritional intake, the median time to full enteral feeds was 10 days in both groups. Human milk fortification was initiated postnatal day 15 in both groups. There were no differences between the groups in daily enteral fluid intake, caloric intake, protein intake, or maternal-to-donor milk ratios during the first 14 days. So you can see a lot of similarities between all the groups. In terms of the primary outcome, at 36 weeks post-menstrual age, the distribution of BPD severity did not differ between the two groups. Grade 1 BPD took place in 33% of the intervention group, 30% of the control. Grade 2, it was 18% in the intervention, 14% in the control. Grade 3, 6% in the intervention, 13% in the control group. Slight difference, but not statistically significant. And then death before 36 weeks post-menstrual age: 14% in the intervention group, 8% in the control group. Again, different, but not statistically significant.

[38:51.824] Ben Courchia MD In terms of some of these outcomes that I mentioned earlier, looking at the elasticity of the lung, they did not differ in terms of the AX measurements, the elasticity of the lung stiffness. And in terms of the resistance difference that we mentioned earlier, lower measurements were obtained in the intervention group compared to the control group, but again, that was not statistically significant.

[39:58.895] Ben Courchia MD Let's talk a little bit about secondary outcomes. Growth outcomes did not differ significantly between the two groups. In terms of other outcomes on postnatal day 28, the risk reduction of metabolic bone disease, which was defined as an alkaline phosphatase of 500 or more and a phosphorus level of less than 5.5, observed in the intervention group did not reach statistical significance. The difference was 9% versus 20%—quite a significant difference, but again, small numbers that you cannot really get to statistical significance. Regarding safety, none of the infants in the intervention group had calcium levels exceeding 12—like there was no hypercalcemia. No serious adverse events related to vitamin D supplementation. No significant difference in rates of late onset sepsis, SIP, or NEC. And then incidental fractures were observed in only 5% of the infants with no significant difference between the two groups.

[40:46.824] Ben Courchia MD And so what Ariel and his colleagues conclude is that administering 800 units of vitamin D with human milk in the first two weeks after birth does not reduce the risk of severe BPD or severe BPD/death at 36 weeks in babies who are born extremely preterm with a relatively low prevalence of vitamin D deficiency. It appears to be safe. It appears to be an effective method of achieving vitamin D sufficiency. Secondary analyses suggest that this approach may help prevent metabolic bone disease a little bit based on what we discussed. Again, with the caveat that it hasn't reached statistical significance and that further research is warranted.

[41:49.539] Ben Courchia MD So it doesn't really look like there's an urgency to rush to giving vitamin D earlier on. I think it's important for you all to know also that in their particular unit, they are reaching full enteral feeds by about day 10 of life. So they're a very quick and strong unit when it comes to reaching full feeds. So I think this is where we are. I don't know. We start vitamin D at two weeks of life. It seems like, I don't know... to me, I read this and I'm like, there's no need potentially to move that sooner. We also have a unit, thanks to our feeding guidelines, that is helping us get to full feeds quite early, which makes our rates of metabolic bone disease quite good. But yeah, curious to hear what you think about that.

[42:06.619] Daphna Yasova Barbeau MD Yeah, I mean, I think we're asking a lot of one vitamin to prevent BPD. I think it's a big ask. I think, for example, I know that BPD is a big hitter, but preventing metabolic bone disease would be enough, right? It's a very Jewish saying: Dayenu. It would have been enough just to prevent metabolic bone disease. I don't think we'd have to prevent BPD to say, "We really have to do this". It would have been super cool if we could do that.

[42:40.047] Ben Courchia MD Yeah. You know those t-shirts, those sort of self-help t-shirts that say "You are enough"? Maybe that's what we should give to the vitamin D bottle, be like, "You are enough, vitamin D. You just prevent bone disease and that's good enough."

[42:54.399] Daphna Yasova Barbeau MD Yeah, you heard it here. I was disappointed that wasn't the primary outcome, but I was disappointed that it wasn't statistically significant to lower metabolic bone disease, even though it increased the vitamin D concentration a lot—by like 30. That's a lot.

[43:13.283] Ben Courchia MD That's a lot. But think about it also. It's disappointing because you see the physiologic rationale and you're like, "Yeah, that makes sense. If I give this, then this other thing should not happen." And when it doesn't sort of follow through, you're like, "Why? Like, why not?". You read the background and you're like...

[43:34.941] Daphna Yasova Barbeau MD Yeah, why when we give it, does it not work?

[43:40.759] Ben Courchia MD No, if it makes sense, why is it not happening? So anyway.

[43:45.223] Daphna Yasova Barbeau MD I still wonder if there are, again, certain babies that definitely this will benefit. Maybe it's the growth restricted babies we talked about a few journal clubs ago. Maybe they didn't get as much, but now if we deplete it, it really helps them. I don't know. So I think that is an ask to the neonatal community to start phenotyping these babies so that way we can...

[44:10.901] Ben Courchia MD That's true. It doesn't make things worse.

[44:15.175] Daphna Yasova Barbeau MD And it's safe. I mean, I think that's the biggest question. And we know they're at risk for metabolic bone disease. Also, this is a unit who is very, like you said, aggressive with feeding, aggressive but successful. For sure.

[44:27.937] Ben Courchia MD Yeah. I want to be careful... they've reached a point where they're able to do this routinely and have tremendous outcomes.

[44:38.279] Daphna Yasova Barbeau MD Yeah. And so I wonder for some units, maybe it's not two weeks. Maybe two weeks is not your metric. Maybe your metric is, "Well, we put it on close to discharge." I don't know. So maybe... maybe we can move the needle for some babies, I guess.

[44:40.279] Daphna Yasova Barbeau MD In the last few weeks of Journal Club, we've had some really interesting articles, very... I feel like science-heavy articles. And I wanted to bring in something a little bit new. Not that I don't want people to come at me—not that QI is not science-heavy, I'm just saying. It's a different type of paper and we don't routinely do QI papers on the podcast because sometimes they're kind of hard to translate in audio format. Like you really need to see your change diagrams and looking at things over time. But this one really kind of stood out to me. This is in Pediatrics. It's called "Improving Health-Related Social Needs Screening and Support Across a Pediatric Health Care System". Lead author Rishi Laroia, senior author Cheryl Courtlandt. So this is coming to us from North Carolina. And the first thing you may notice is this is not a NICU specific paper, but I think that we can all learn a lot from this, especially as we're recognizing the importance of how social determinants of health impact medical care and outcomes, and that our NICU patients are potentially even at higher risk than the general population for having...

[46:20.395] Ben Courchia MD You don't need to sugarcoat this more than it needs to be. I think everybody agrees that like, come on, we're pediatricians at heart. I mean, at the end of the day, we are pediatricians.

[46:25.067] Daphna Yasova Barbeau MD I'm not sure everybody agrees. But I think to your point, so when we round, how often of us are we saying, "Okay, a poem, FEN, ID, access, family, SDOH"? We're not on every round, even though we know it's changing outcomes for the baby. So even though we buy in, we're not always putting our money where our mouths are. Myself included, I was feeling very ashamed reading this article. And I've made a commitment, which I'll tell people about at the end. Okay.

[47:04.919] Ben Courchia MD I mean, to my credit, I had this whole thing worked out, by the way. This is a funny story. It's not funny for our patients, but it's kind of funny because I wanted us to have social determinants of health... have an idea of social determinants of health. So I had coordinated with our social worker so that like once a week on Monday, we would run the list, we would create a list for us of each patient and their social determinants of health, whether food stamps, WIC forms, whatever that is. And we would get that paper every, at least Monday morning. It's not every day, but at least once a week when you round your own service, you get that paper. And maybe three weeks... maybe, no, I say three months, three months. Maybe two, three months after this is now well implemented and we're getting it consistently... she, our social worker, quit. So now, now I have, so now we have to start from scratch again, but...

[48:02.721] Daphna Yasova Barbeau MD Okay, I'll give you a little credit, okay? That was notated in our office right there. You don't let us hang many things in the office. We like to keep a clean desk space just so everybody knows, but that was hanging on the wall. And it really made you think about how you could support each family every day when you knew what they were struggling with.

[48:22.773] Ben Courchia MD Yeah. Because the concept of dignity, which is something that I was taught at a very young age in school... It's like, it's not always the family that appears disheveled and whatever that has the higher need.

[48:40.065] Daphna Yasova Barbeau MD Yep. That's true. There were a lot of surprising facts on that sign out.

[48:44.861] Ben Courchia MD Exactly, right? It's the family who appears to be very well put together, who's trying to really get themselves out of potentially the difficulties that they are. And then you see the social determinants of health sheet and you're like, "I would have never realized". And all the assumptions that this might lead to can be quite nauseous.

[49:05.419] Daphna Yasova Barbeau MD Yeah, I think it led us to identify patients we might have missed if we weren't doing universal screening for sure. And especially... I mean, these patients are doing the best they can. They're putting their best face forward. They want us to think... we've heard that from parents time and time again. "I wanted the medical team to think that like I had it all together, that I would be able to safely take care of my baby. I wasn't going to ask for help because what if they didn't let me take home my baby or they didn't think I could care for my baby?" So I mean, they're really doing everything they can to put their best face forward.

[49:41.079] Ben Courchia MD Was that Lauri Sullivan who said that at Delphi this year? We have lots of parents at Delphi. Parents play a central role. We're very inspired by the work that Jen Canvasser has done at the NEC Symposium. So we always thought families should be involved. And that was one of the things that Lauri Sullivan, who was a parent, who was saying they brought the wheelchair. And she was like, "I would just stand just to show the medical team that I was good".

[49:51.747] Daphna Yasova Barbeau MD Yeah, I think so. Pressure. Yeah. Yeah. And that's not even social determinants of health, right? Just like two days post-op saying like, "I can walk. I'm fine. I can walk." Okay. Now we've digressed and nobody remembers what the paper is anymore. Okay. So this is why we struggle with QI papers. Like, do I go through the PDSA cycles? What do I tell you? So I figured out what I'm going to tell you.

[50:07.371] Ben Courchia MD Yeah, yeah, that was quite powerful. All right, I'm sorry, we digressed, I'm sorry. Okay, you will start again, that's okay.

[50:32.131] Daphna Yasova Barbeau MD I think this is an incredible thing at Levine Children's. So they basically in 2021 made a division-wide, department-wide commitment to universal screening for social determinants of health. So they looked at nine of their divisions. They looked at hospital medicine, which again, obviously admitted patients. They looked at the newborn nurseries, the child protection team, the outpatient developmental behavioral pediatrics, outpatient ID, pulmonology, sleep medicine, genetics—all outpatient—and the heme-onc service, which included inpatient and outpatient patients.

[51:22.329] Daphna Yasova Barbeau MD And some of those divisions picked specific domains that they felt were a threat to their patients. So I'm going to highlight the newborn nursery. They really wanted to look at food security or food insecurity and housing insecurity. And the screening method they used... they picked a universal screener, but I mean, it was literally the pediatrician interviewing these families and putting it into the EHR. So when we say we don't have the time and we say it can't be done, they did it. It was done. But not only did they really want to optimize their screening of social determinants of health, what they really wanted to do was offer resources, which is not revolutionary, but what is the purpose of screening if we can't offer concrete solutions to families?

[52:14.851] Daphna Yasova Barbeau MD And so in general, they had a number of PDSA cycles, the first of which of course was education, showing them how to document it in their EHR, showing the basic flow process, then knowing, recognizing that different units had different needs and the outpatient had different needs than the inpatient. So making different pathways for each of those people. They used their EMR to their strong suits. They used ICD-10 codes to help document some of these disparities. And then they moved forward with determining resources. And that's actually really what I want to spend some time on. Because they recognized that depending on what was flagged, different people needed different resources and potentially their different units needed different resources. So like the sleep medicine team adopted this open source national information on "Move Your Way 60 Day"—how do you get 60 minutes of daily physical activity to improve your sleep?

[53:22.329] Daphna Yasova Barbeau MD One of the teams really, really was targeting food insecurity. So food gaps, how are they gonna get families to food pantries? And to be clear, they had social workers. So the social workers were available like they are in most hospitals. But they really needed a system that would allow for universal screening and then universal distribution of resources. What they wanted to study was just were they better at doing screening? And I'll give you the short answer is yes, but I'll tell you how well they did. And then were they able to provide resources for families? And the short answer is also yes. And then when they re-evaluated some of these families, did some of those social determinants of health disappear? And the answer is also yes, which is what we would want for every single family.

[54:35.554] Daphna Yasova Barbeau MD I want to really highlight these resources that they used because I looked at a bunch of different states, a bunch of different zip codes, of course, including our own. And they were using this website. It's called Find Help. I have it pulled up here again. It's called findhelp.org. And you basically can put in your zip code and what you're looking for. Is it food? Is it housing? Is it legal help? Is it educational resources? Is it connecting people to work, transportation? I mean, admittedly, they have resources on here in our local community that I had no idea about. And at a bare minimum, this is my statement of commitment to our listeners is I'm going to make a sheet for each of these things in our unit. And I know our social worker had created those things to hand out to families, but we know social workers change jobs. And just like you said, like this should be available for every family in our waiting rooms, in our check-in spaces so that they don't have to even disclose if they don't want to, but they should have access to these resources. So it's beautiful. It's absolutely beautiful.

[55:51.530] Ben Courchia MD It's a very nice website. I'm checking it out right now. This is findhelp.org. Yeah, that's...

[55:58.306] Daphna Yasova Barbeau MD So I really wanted to highlight that because I think that any team could do this, even if you're not... you know, we're saying, "Well, now we have to screen families to offer resources". Well, maybe we can at least offer resources, even if you're not a unit that is yet totally doing universal screening. Very easy. So basically what they did is exactly that. They found the resources, they put them on handouts and brochures, and they started giving them to families who screened for some of those social determinants of health.

[56:28.195] Daphna Yasova Barbeau MD So I'll get just to the results. I mean, and they're beautiful control charts. They're beautiful. They're extraordinary. Looking at percent compliance over time, where you can just see, obviously they have these ups and downs. I mean, not a lot of downs, mostly just ups, plateaus, ups, plateaus, ups, plateaus for their different PDSA cycles. And then they looked at by service line, but I'm not going to get into that because I think the overarching goals were completed for them. So they wanted to look at performance for appropriate screening and intervention. So this increased to a mean of 92% across nine pediatric divisions. And then they followed it for almost a year and for seven consistent months at the end of the project, they showed again a mean of 92% universal screening across those nine pediatric divisions.

[57:32.329] Daphna Yasova Barbeau MD They looked at inpatient versus outpatient and they were able to show that the inpatient team did 93%, the outpatient team did 88%, and both groups showed improvement from initial performance: a 17% improvement in the inpatient and a 13% in the outpatient. And like I said, they both showed, both inpatient and outpatient showed resilience in their process, especially once they added some of the screening directly to their EMR. Final division performances ranged from 85% to 98% with all of them showing increases. For example, hospital medicine increasing from 78% to 90% and pulmonology from 58% to 93%. And these are extraordinary increases for sure.

[58:48.546] Daphna Yasova Barbeau MD And then they wanted to see if the screening interventions decreased specifically food insecurity, because in their local community, it's a major problem, a major social determinant of health. So they wanted to look at food insecurity. And it was the most screened domain and they had the most robust interventions to target it. So from April 2022 to October 2023, 24,251 patients were screened for food insecurity. Of those patients, 10,000 of them—50% of them—had at least one follow-up screening so that way they could look at the difference. Now, nearly 20% of the patients who had both screeners—so of the 10,000 patients—screened positive for food insecurity on their initial screening. So I'll say this is higher than the national data, but comparable to their North Carolina data. But it's a reminder of how many patients we see on a day-to-day basis have food insecurity. And I mean, we have the data that that's even higher in the NICU community.

[59:52.329] Daphna Yasova Barbeau MD So they were able to follow these 10,000 patients—again, 18% of which screened positive for food insecurity on their initial screening—and then they looked at the follow-up. 56% of the people who screened positive initially, after they got the intervention, subsequently recorded no concerns of food insecurity on their most recent screen. 38% showed no change and sadly 6% changed from negative to positive. But this really stuck with me that there are things we can do on an individual basis. Yeah, we got to tackle these big systemic problems, but on an individual basis, to just connect people to resources. And for some families, I mean, being in the medical system is our opportunity to connect them to medical resources. And for our little babies, where nutrition and medical care is just paramount to the long-term outcomes, I thought this was really valuable.

[61:08.374] Daphna Yasova Barbeau MD Chetal Shah's advocacy talk at Delphi really reminded me that, you know, we do all this work in the NICU and then we send these babies home to a world that is like not optimized to optimize their outcomes, you know? So I think in these little ways, like we're obligated, I feel like, to try to connect these families to resources before they go home and not on the day of discharge, not the week of discharge. Like this is something we can be working on while babies are in our unit. So that's my commitment. I said it here so you people have to hold me to it. Did I make our resource pages?

[61:52.729] Ben Courchia MD Yeah, we will check in with you in a few weeks and find out how that project is going. But I mean, it is sadly elementary. Like you're looking at it and you're like, "It's that easy?". Because it's like when you say it, it's like, "Oh my god, I got to screen, then I got to find the resources, and I got to plug our unit with these resources, and then I have to do..." No, it's there. But thank you for highlighting this paper.

[62:04.586] Daphna Yasova Barbeau MD Yeah. Duh.

[62:22.872] Ben Courchia MD It's very valuable. And findhelp.org, we have absolutely no affiliation with this website. It's just... well, granted, I just started browsing this website while you were talking, so I haven't really reached out to any of the things that are listed, but some of them I do recognize, and so, that's quite good. It's quite good.

[62:51.094] Daphna Yasova Barbeau MD Well, I'm glad you like that, buddy.

[62:53.109] Ben Courchia MD No, this is good. This is good. I always wonder if, you know, like some other people are doing good pediatrics podcasts, but I'm like, "Could we do a version of the Incubator for general peds?". And I'm like, it would definitely would not be done by us. Like we don't do enough gen peds and we're not plugged in, but look, maybe...

[63:16.382] Daphna Yasova Barbeau MD You're saying we could just take those podcasts over. I think we got enough on our hands here, you know? And we do have some great Gen Peds colleagues doing great podcasts already.

[63:19.417] Ben Courchia MD We have plenty on our hands, but look at us. No, could still represent. But that's not what I'm saying. I said, look, we are able to represent the general pediatrics team on the Incubator. Like, I don't want to do more podcasting. I am saturated. I definitely do not want to do that.

[63:37.388] Daphna Yasova Barbeau MD Well, it's a reminder how much of our neonatology job is still general pediatrics, I think, especially today.

[63:42.445] Ben Courchia MD The parents sometimes remind you of that. You come and they're like, "Who are you?" And you're like, "I'm the neonatal physician." And they're like, "You're a pediatrician." It's like, "Yeah, I'm a pediatrician." It sounds OK.

[63:50.636] Daphna Yasova Barbeau MD Yeah, that's right. Now, still, even in 2026, one of the most trusted resources for families, so we just have to remember that. We still hold that badge for now.

[64:06.626] Ben Courchia MD Yeah, yeah, because as a field we're quite poor and I think that this is the biggest mark of trust we can hold. So I think that that's a big reason, but we do care about babies so I'm happy to hear that this translates.

[64:08.626] Eli Let's dive in, and the first segment that we're going to talk about is. One of the agencies in Colorado is instituting a paid NICU leave law that the state, in their press release, is very enthusiastic about—not particularly bashful—and says they hope may spark a national trend. In particular, starting in January, Colorado will be the first state to require employers to provide paid leave to parents with a child in the NICU. Employees will be eligible for up to 12 weeks of paid leave. That differs from some of the regulations under the National Family and Medical Leave Act (FMLA), which provides job protection but unpaid leave, and also has fewer provisions to ensure that when people return to work, they return in a smooth way that protects their career. Guys, what do you think of this law? How does it strike you?

[68:44.330] Ben Courchia MD Okay, Daphna is pointing that I should be taking this on. I think it's a great step. With all the news that we're being blasted by recently, I think this is a welcomed addition for the state of Colorado. Something that for us not living in Colorado, we're very envious of. And I think that the 12 weeks of FMLA, by the way, are also kind of a misnomer, right?

[69:00.667] Daphna Yasova Barbeau MD Yeah. For sure.

[69:11.651] Ben Courchia MD I think that if you have disability, most people don't get paid during that time. And I think that the article does a good job in reframing some of these constraints where we talk about job protection, meaning that basically you're not getting paid, but you also can't get fired so that when you do come back to work, there's a job waiting for you—which is kind of crazy that we're talking about that. I think the idea of 12 weeks of paid leave for a child in a NICU makes a lot of sense. Interestingly enough, the article mentions that one of the reasons why this is going to be good is because it's going to help with better outcomes for babies. I am beyond skeptic about if people are going to take that on and apply it in other states because they say, "No, this is good for these infants." That being said, taking the other side of the coin, not being a neonatologist, I think that as an employer, this can only be good for you. When employers support their employees during a difficult time, there is a form in which an employee will pay this back in loyalty that is very hard to get from recruitment and other HR methods. So I think that this is an investment from these companies into their employees. I've been around people who have had to deal with tough situations. And when their employer supported them during these tough times, these guys are so motivated to be productive when they come back and to help their company. I believe that from that standpoint, we will see some interesting repercussions that might light the fire for other states to take this on. Maybe I'm too optimistic, but we will see. What do you think?

[70:56.655] Daphna Yasova Barbeau MD Yeah, for sure. I really liked this sentence: "Healthy families and healthy workplaces aren't separate goals. They reinforce each other. Supporting families is good for business, good for babies, and good for the future. We're all building together." I really love that. When we talk about supporting the future, supporting children in this country, this is how we start—by hopefully moving to real, across-the-board paid parental leave.

[71:06.013] Ben Courchia MD Exactly.

[71:25.731] Daphna Yasova Barbeau MD But certainly for parents of medically complex children—I mean, they don't even have to be that medically complex. Even if it's a baby who's having a run-of-the-mill, benign NICU admission, having parents at the bedside changes outcomes. Improves outcomes for babies. And so...

[71:41.450] Ben Courchia MD And for these families, it's the worst time of their lives. It doesn't matter what the admission is for.

[71:45.596] Daphna Yasova Barbeau MD For sure. Exactly. It's such a trauma for them. And if we get to the nitty-gritty of it, and some of our colleagues across the country are trying to study it... like, if we want to prevent NEC, we need mom's own milk. That's the only thing that prevents NEC. We know that. To ask working people to be pumping and sleeping and visiting their babies and caring for their other kids, it's literally impossible. So I think not only is this great for families, it's great for babies, but it's going to save the system potentially a lot of money. And that's something that I think is really important. I didn't recognize this, but they said even if other states don't do the same thing, there are a lot of organizations that are multi-state, right? So if they have anybody in Colorado, then they may have to adapt their policies for the whole landscape, which will then potentially force other states to do the same or other companies to do the same.

[72:51.080] Ben Courchia MD I mean, yeah, and it looks like Illinois is following suit a little bit, right? Yeah, I think that they're saying that Illinois is going to follow in a less committed manner, providing up to 20 days of unpaid leave, I'm sorry. So it is a step in the right direction, but not commensurate to what Colorado is doing. Eli, what were your thoughts on this?

[72:54.575] Daphna Yasova Barbeau MD That's right, into the summer it looks like. So it's very exciting.

[73:18.146] Eli Yeah, I mean, I think it's worth saying that the Illinois law is dramatically different when you talk about 12 weeks of paid leave versus less than three weeks of unpaid leave. I think those are pretty different laws, but recognizing that there's a moral imperative to provide for family bonding and family reckoning with infant illness is a good thing. I agree with everything you said, Daphna, about this being better for babies. To point out a few different studies, if you look at the research on this—with all the biases recognized—Maya Rossin-Slater, who is a fabulous researcher here at Stanford, was one of my teachers when I was doing my master's in health policy. She has done lots of research on the economics of family medical leave. And she has found, among other things—there was a recent paper—increases in birth weights, increasing gestational length, decreases in likelihood of low birth weights, and decreases in likelihood of premature births with all sorts of policies that promote family well-being before delivery. Then if you look at the impact of family and medical leave on postnatal outcomes, the charts look like... it's your classic straight line which is really low, and then there is a point in time, and then the line jumps up or jumps down. It's as classic a pre/post-intervention beneficial outcome chart as you could imagine.

[75:08.777] Ben Courchia MD [Laughter]

[75:08.879] Daphna Yasova Barbeau MD Yeah.

[75:13.104] Eli That's to say nothing of research from other people like Mariam Khan, who is at American University, who found up to five percentage point decreases in infant neonatal under-five mortality rates after the adoption of paid maternity leave. Diana Montoya-Williams and Scott Lorch, two fabulous researchers, pediatricians, and neonatologists at CHOP, also found decreased postnatal mortality rates after the adoption of medical leave policy. So all these are good existentially. The question, as we're discussing, is whether from a feasibility standpoint this will be unduly burdensome on businesses and what it means in terms of people's abilities to thrive as a family after birth.

[75:48.372] Ben Courchia MD Mm-hmm.

[76:06.690] Eli You know, I think there are a lot of open questions about that, right? Because that historically has not been the way that the U.S. has operated. If you go to the Scandinavian countries with lots of super generous family leave policies, the issue there is that obviously there is a cultural understanding that these policies exist. And so if you were to look at the businesses there and how businesses respond in those countries versus the U.S., where businesses in one state may operate in lots of different states, beginning to interpret additional responsibilities they have to their employees... it's very hard to predict what all of this means. But I think to the extent that we know the burdens of caregiving and how burdensome caregiving is when you have a sick child... especially if you feel like there are things you didn't learn in the NICU about skills you needed or knowledge that you needed about your child's condition or the expectations about what life would look like after the NICU. I think we can all agree that the economic burdens of caregiving far outweigh the short-term costs to a given business of ensuring folks get the skills, the knowledge, and frankly, just the emotional preparation they need to leave the NICU with a child who may have chronic medical needs. The question from an economic standpoint is: who is going to capture the value of the child being well taken care of at five years with chronic medical needs versus the business who's paying the upfront cost of 12 weeks? I think all of those things are hard to know. But I think it is a step in the right direction and, in the spirit of lots of national conversations about ensuring childcare is affordable and accessible, we should be supporting families doing this. As a moral point, we should be doing it as a public health point. The economics and the politics of it are sort of the third rail that I applaud Colorado for taking on the nose and saying, "Hey, we don't exactly know what this is going to look like from the economics and political standpoint, but let's give it a college try."

[78:19.099] Daphna Yasova Barbeau MD Yeah, and sometimes we don't know till we see how it plays out.

[78:23.582] Ben Courchia MD Yeah. I mean, first of all, we are very passionate on the podcast about neonatal advocacy. And I think that if you are interested in neonatal advocacy, this is a perfect opportunity as a neonatologist to share what you know about how this can impact positively families. And then when we talk about how can we make the economic story make sense, we have to remind people that number one, it's a very small percentage of babies that do end up in the NICU, right?

[78:33.209] Daphna Yasova Barbeau MD The perfect time. Absolutely.

[78:51.272] Ben Courchia MD The article mentions that it's gone up to 13%, but we're talking about only 10% to 13% of births. Of those, the bulk of them are late preterms, whose stay is maybe a couple of days. And the absolute minority involves these 20 to 23 weekers that really have critical conditions that keep them in the NICU for months and months at a time. So when we're talking about 90% of the population of babies... number one, only 10% get admitted to the NICU. Of these, I would say 70 to 80% of them remain in the NICU for less than a week. So it's not a tremendous commitment. If you have to advocate, in my opinion, it's very unsettling to me when we make these differentiations between the birthing parent versus the non-birthing parent. And I think that both parents should be able to be present for their child at that moment. Right. I mean, I think that this is not a big ask. And I would recommend people listen. We've had the chance to have on the podcast some stories of former parents. I think the one that comes to mind right now is Sarah DiGregorio, who wrote the book Early. And she does talk specifically about that moment when basically a family is over and she takes a break from her job and her husband has to go back to work. And now she's alone. Now, as a mother who gave birth to a preterm infant, she is now alone most of the day dealing with rounds, dealing with the baby while her husband continues to work and provides health insurance and all that stuff that comes with a job. And it is infuriating. It's just like, do we have to do that? I think that if the baby has the luxury of being born in a two-parent household, both parents should have the benefit of this benefit. And I do feel, like you said, Eli, that when you look at Scandinavia, health care is a direct responsibility of our government. The government spends a lot of time and money on many, many other things, but health care is one of them. So yeah, I mean, I think that this is where we have a lot of opportunities to advocate. And if you're not living in Colorado, then the floor is yours.

[81:05.337] Daphna Yasova Barbeau MD Yeah, I think it's the perfect time to just say to your legislators—just write them an email, just give them a call—say, "Did you know this was happening? Did you know this is a problem in our state? This is something that I feel really strongly about." Every single one of us should be. I think now's the push, right, to see what dominoes fall.

[81:26.264] Eli And by the way, I mean, the argument may not have to be, "Hey, this is what you... I'm a neonatologist and this is what you should do because I hear from my families." It's not that they keep working. They just leave the workforce temporarily and then they struggle to get back into the workforce, which nobody wants.

[81:35.535] Daphna Yasova Barbeau MD Nope. Yeah. That's exactly right. Well, and some people leave the workforce permanently, right? Like that happens a lot.

[81:52.964] Eli There's a public health outcome, but I think also you say from a jobs perspective and from ensuring your businesses thrive perspective in a very tight labor market that continues to be tight sort of against all odds. You know, if you listen to the year-end economics podcast, but that labor market continues to be tight. This is a thing that you would want your state to do from an economic perspective. The other piece, by the way—the other argument that you could use just to give you ingredients for how you might have this conversation if you are so inclined to advocate for it—would be to say, "Hey, we know that budgets are bursting at the seams from healthcare costs, right?" Healthcare costs are the biggest line item on most state budgets now. And with the repeal of Medicaid that we have talked about on this show, but not... we won't get to on this podcast... you know, with the repeal of Medicaid, it's only going to get worse and they have less federal support. So shifting some of the burden actually out of the healthcare sector and to businesses may be a really good thing to ensure that budgets are more stable. We know that children with chronic medical needs are the single largest population in terms of the financial costs to pediatric budgets in states. And we know that the healthcare costs are much higher for families that are not well-equipped or don't feel like they have self-advocacy or don't have the resources or supports to care for children with medical needs. Right? So there's another argument is that this is...

[83:22.664] Ben Courchia MD Yeah, and I don't pretend to be a politician, but I am pretty sure that if you mentioned this to a broad audience, the reception of that law would be positive. I think that if you tell a group of random Americans—a hundred Americans—and you say, "We're going to support families who have a baby that is born and has to go to the ICU," I have a very hard time thinking that 90% of them will say nothing but, "Yeah, let's do that." Like, I think that's reasonable because it's something that hits at the core of who we are as human beings. And I think that if you're a politician, it feels like a slam dunk that you're not really going to be in the news in a negative way because you're advocating for this. But let's see. We can only hope.

[83:57.020] Daphna Yasova Barbeau MD We'll see, we can only hope. Eli, need you to write us a template letter then for the community so we can circulate it, make it really easy for people.

[83:58.670] Eli 100%, that's exactly what I was thinking. Yeah, we can only hope. You know, we could do that. We could work with Shetal Shah on this one. I mean, I think there's a long legacy of carbon copying laws between states, especially now where the federal legislation landscape is limited, but certainly the state legislation landscape is pretty robust. So we can talk about that. By the way, the other thing we do on the Neo News podcast is give you ideas for your tenure track. And so if you are a young health services researcher and you're interested in health policy, go out, study the impact of the Illinois law, study the impact of the Colorado law. That's its own form of advocacy, by the way—producing the evidence that you need to have these conversations. So it's high time that we not only try this on for size, but we study whether or not it works. And if it works, we should try to disseminate that. And if it doesn't work, we should try to figure out how to make it work.