#402 - 🔵 [NEO CONFERENCE] - Is fresh milk the key to improving long term neonatal outcomes

Hello friends 👋

Does our fear of necrotizing enterocolitis do more harm than good? In this live episode from the Neo conference, Ben and Daphna sit down with Dr. Ariel Salas to challenge the "culture of fear" surrounding neonatal nutrition. Dr. Salas argues that while we obsess over ill-defined NEC risks, we may be sacrificing the proven benefits of early feeding on sepsis reduction. From the emotional weight of "wasted" breast milk to the "illusion of control" provided by strict protocols, this conversation urges neonatologists to move toward a family-centered, evidence-based approach that prioritizes human milk over clinical hesitation.

Link to episode on youtube: https://youtu.be/KT8-Ag1DL-E

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Short Bio: Ariel Salas, M.D., MSPH is an Associate Professor of Pediatrics at the University of Alabama at Birmingham (UAB), where he also serves as Director of the Helping Babies Feed Program and NEC/Short Bowel Prevention Program, Medical Director of the Mother's Milk Bank of Alabama, and Associate Medical Director of the Continuing Care Nursery. He completed medical school at Universidad Mayor de San Andres in Bolivia, followed by pediatric residency training at The Children's Hospital Dr. Ovidio Aliaga U in Bolivia and The Children's Hospital of Philadelphia. He earned his Master of Science in Public Health and completed his Neonatology Fellowship at UAB. His research focuses on enteral nutrition and feeding problems in preterm infants, with particular emphasis on optimizing growth outcomes to reduce adverse neurodevelopmental outcomes in extremely preterm infants. His long-term goal is to lead multicenter randomized clinical trials advancing the understudied field of nutrition in very preterm infants.

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The transcript of today's episode can be found below 👇

Ben Courchia MD (00:00.738)

Hello everybody, welcome back to the Incubator Podcast live at the Neo conference. We have the pleasure of having in the booth, Dr. Ariel Salas. Ariel, welcome back to the show.

Ariel Salas MD (00:10.798)

Thank you. It's always great to find you at this event and to catch up.

Ben Courchia MD (00:15.242)

Yeah, there's definitely a crew of people that we run into, and you get invited to everything. You're on the circuit. People want to hear your talk about exactly how to feed a baby; you're going to give us all the numbers, you're going to say here's how much you go up, and you won't get NEC.

Ariel Salas MD (00:31.758)

I wish we could have those numbers. I know everybody wants the rate, the volume, and the amount, but...

Daphna Yasova Barbeau MD (00:40.718)

But you're the guy pushing the limits.

Ariel Salas MD (00:45.272)

I think we need to create more evidence. Again, I could be wrong—I could be taking things to an extreme—but I think our practice has been driven by fear for so long.

Daphna Yasova Barbeau MD (00:59.21)

What I hear you saying is that we have a practice we're using that is potentially not based in evidence.

Ariel Salas MD (01:05.816)

Correct, yes. And I think a lot of things in neonatology started that way. We were in a very critical situation. Babies were dying. We wanted to change that, and we did a lot of things at once.

Ben Courchia MD (01:17.224)

It may have been one of your papers, but I remember reading a background section on a paper recently that said exactly those terms: we're basically so fearful of nutritional complications like NEC, that our approach to feeding has been driven by fear when the evidence behind all this is absolutely not supported. There is no evidence to withhold advancements because of a fear of NEC; the data does not bear out when it comes to that, and yet we are—

Daphna Yasova Barbeau MD (01:50.094)

And what's worse, it may be potentially detrimental.

Ariel Salas MD (01:55.362)

Correct, yes, and I think that's the point that I'm going to try to make today.

Daphna Yasova Barbeau MD (01:59.138)

You're brave. You're coming to meet with us just 30 minutes before your talk. That's what an expert you are.

Ariel Salas MD (02:04.418)

No, this is great, actually. It helps me to stay focused on what I want to say. I really worry that sometimes we're missing the benefits of early feeding on sepsis reduction. To me, sepsis is a much better-defined outcome in neonatology in comparison to NEC, which is evolving but so hard to define. I think that has been a challenge for a lot of current and past clinical trials too.

Ben Courchia MD (02:06.318)

It's like a little bit of a...

Ariel Salas MD (02:29.216)

Because as we do all these things to reduce NEC, we realize we still don't know what NEC is, or whether we agree on that. There's so much heterogeneity in that particular outcome that I think it is hurting our field. If I tell you that there are therapies that can reduce sepsis and had no effect on NEC—which again, is not well-defined—why is it so hard to accept that as evidence to justify your practice? I think that's definitely a challenge.

Ben Courchia MD (03:08.662)

I feel like I've asked you this question and I can almost guess the answer, but obviously, everybody wants to find a way to reduce the incidence of NEC and improve feeding protocols. What is your advice to a fresh unit as a starting point? Where should they begin? Just start by doing this little thing, this little milestone that might get you on your way to bigger and better things.

Ariel Salas MD (03:37.834)

I think the first step is to start seeing breast milk, human milk, and fresh milk as something beneficial and not hurtful. You shouldn't see the concept of feeding as potentially harmful. I still remember this baby that was very sick in the unit a long time ago when I was a fellow, thinking about this limits of viability situation. We were all worried; the baby was sick on the Jet from the get-go. There were a lot of concerns about the family, too, because there were a lot of lawyers in the family. Everybody was concerned about the idea of adding milk, and then we never gave a single drop of that milk. The baby died despite all those preventive measures that we were doing.

I think that was because we thought that was potentially harmful, even though the risk was high to begin with. Now I would argue that maybe that was the way out—changing the course of the disease. We thought that we were protecting that baby by not offering milk. You know how hard that is for the family, too. That was the one thing that mom could do during those three or four weeks that the baby lived. We never offered a single drop. I cannot imagine that feeling of going back home to all that milk, seeing that not a single drop was given because doctors thought it could have been potentially harmful.

Daphna Yasova Barbeau MD (05:18.542)

Well, it's interesting. What a beautiful story. I imagine it's obviously stuck with you and you've dedicated your entire career to optimizing nutrition for little babies. But especially here in the States, it's hard to get fresh milk. Not all feeds are equivalent, and if we could get fresh milk at every bedside, maybe that would be...

Ariel Salas MD (05:53.602)

The key. Yeah, that has been a controversial subject in recent weeks for us because it's true that we don't have a system in place. We're very used to having the milk dropped at our unit, then stored, frozen, and prepared in the lactation rooms and then brought to the bedside. The system is not ready for random visits of family members dropping off fresh milk. But that means the system needs to change. We can't just say, "Well, the system does not allow this new thing that you're trying," and therefore we should just get rid of it, even though it is potentially better practice.

So, there I am trying to change the system. It takes so long to develop a system that no one wants to reconsider the need for rebuilding the whole thing. But it's in the best interest of families. When we center around what's important for families and what's best for the patient, we can finally start opening those opportunities to change.

Ben Courchia MD (07:13.1)

Yeah, absolutely love that. In doubt, err on the side of giving human milk.

Ariel Salas MD (07:18.925)

Yeah.

Daphna Yasova Barbeau MD (07:19.916)

Well, and I think what you said—and I try to explain to my nurses—it's not just that we're doing milk drops. It's that the mommy and the daddy get to give milk drops. This thing that she's worked so hard for, they get to see their baby get that.

Ben Courchia MD (07:35.374)

Daniel Rouch, whom we had on the podcast and was one of my mentors in residency, said, "Ben, you have to understand that for a baby, parenting looks very simple. It's like changing the baby's diaper and feeding that child." If you take any of these two away from the parents, there's no more opportunity to be a parent. Feeding even just those few drops can have a monumental effect in the bonding phase.

Ariel Salas MD (08:01.294)

And I'm worried about that after premature birth. If they don't have any other children and this is their first child, how do you develop parenthood? Where does that start? How do we support that development? Promoting more visitation and promoting breast milk is just as important as other things. I think it's better if they have a good sense of parenthood, especially if the preemie is their first one.

Daphna Yasova Barbeau MD (08:31.374)

It's so interesting we're talking about feeding. We really talk about the nutrition and the medical aspect of feeding, but in most communities, feeding, eating, sharing food, and breaking bread is the whole thing. I wonder what cultural aspects we steal from families when we have medicalized feeding.

Ariel Salas MD (09:00.386)

Yeah, I think that's our nature, though. We try to rationalize. One thing I learned recently is that protocolization gives us this sense of control; it creates this illusion of control because we think that when something is protocolized...

Ben Courchia MD (09:20.618)

"I just followed the protocol. It was not my fault. I just followed the instructions."

Daphna Yasova Barbeau MD (09:22.244)

"It wasn't my fault."

Ariel Salas MD (09:25.592)

That's right, and I think it's just an illusion; it's not real.

Ben Courchia MD (09:31.022)

Making a decision is a decision. Not doing anything is also a decision.

Ariel Salas MD (09:36.222)

That's the only thing I learned recently. Sometimes we act because that's perceived as something that can be assessed. Inaction and a reflective attitude are hard to measure. You don't get credits or points for inaction.

Ben Courchia MD (09:53.768)

There is the famous French 16th-century analogy called the L'âne de Buridan, the Buridan's donkey. It's the story of a donkey facing two sacks of fodder but doesn't know which one to pick to eat. The donkey dies of starvation. Not picking or not doing something can have very catastrophic consequences.

Daphna Yasova Barbeau MD (10:08.99)

So you didn't pick any? Still a choice.

Ariel Salas MD (10:20.724)

Yeah, so I think there's some of that for sure.

Daphna Yasova Barbeau MD (10:23.799)

Well, everybody's looking forward to the things that you are presenting and what you're doing next. What's on the horizon?

Ben Courchia MD (10:31.074)

People have even mentioned on the podcast that they have PubMed searchers...

Daphna Yasova Barbeau MD (10:34.286)

That's right. You are there. They get a notification and protocol right away.

Ben Courchia MD (10:43.118)

It's on the podcast. You will be able to listen and peruse the episode. But one person—I'm not going to say who, his name might be Timothy—said that he has a PubMed search keyed with your last name so that when you publish...

Daphna Yasova Barbeau MD (10:55.416)

That's how you know you've made it as a researcher.

Ariel Salas MD (10:58.35)

No, I think there's a lot that needs to be done. The more people get into this field, the better, because we want the same thing and we all need help. In academics, we have the ideas; we just need the new generation to come in and get motivated on this. Thank you, Ben.

Ben Courchia MD (11:22.4)

Ariel, thank you so much. Good luck with your talk.