#434 - 📑 Journal Club - The Complete Episode from April 18th 2026

Hello friends 👋

The AAP has weighed in on therapeutic hypothermia for HIE, and Daphna walks through the clinical report in full. The core eligibility criteria haven't moved — but the edges have gotten more nuanced. Late initiation, the 35-week zone, mild HIE, sentinel events, MRI timing, and feeding during cooling are all addressed.

Also this week: a prospective pilot from Australia tests whether adding bedside ultrasound to plain radiography improves surgical risk stratification in NEC. The X-ray-only model couldn't separate the clusters. The combined model produced a more than six-fold difference in odds of surgery — complex ascites, absent peristalsis, and abnormal bowel perfusion did the heavy lifting.

Daphna then covers F-NeoBright, a small but compelling feasibility study testing intranasal fresh breast milk in infants with moderate to severe HIE. Ten babies, high adherence, no safety signals, and parents administering doses at home.

Ben rounds out Journal Club with the two-year follow-up of the CALI trial examining outcomes after early caffeine plus LISA versus CPAP alone. Mortality trended toward LISA. The statistics didn't get there — but the direction held.

The week closes with Ben and Eli on the Guttmacher Institute study linking restrictive abortion laws to higher maternal mortality across two decades of US data.

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

Therapeutic Hypothermia for Neonatal Hypoxic-Ischemic Encephalopathy: Clinical Report. Zanelli SA, Wusthoff CJ, Lucke AM, Kaufman DA; Committee on Fetus and Newborn; Section on Neurology.Pediatrics. 2026 Feb 1;157(2):e2025073627. doi: 10.1542/peds.2025-073627.PMID: 41581784 Review.

Combining abdominal ultrasound and radiography for surgical risk stratification in necrotising enterocolitis: a prospective cohort pilot study. Priyadarshi A, Angiti R, Chabra S, McAdams R, Webb A, Badawi N, Hinder MK, Tracy MB.Arch Dis Child Fetal Neonatal Ed. 2026 Mar 5:fetalneonatal-2025-329960. doi: 10.1136/archdischild-2025-329960. Online ahead of print.

F-NEO-BRIGHT: feasibility and safety of intranasal fresh breast milk in neonatal encephalopathy. Tarjanyi E, Jermendy A, Szabo M, Brandt FA, Szasz B, Nyilas N, Meder U.Pediatr Res. 2026 Mar 3. doi: 10.1038/s41390-026-04847-2. Online ahead of print.PMID: 41776367

Two-Year Outcomes of Less Invasive Surfactant Administration Among Preterm Neonates: A Secondary Analysis of a Randomized Clinical Trial. Dorner RA, Morales A, Banerji A, Uy C, Ines F, Finer N, Vaucher Y, Katheria AC.JAMA Netw Open. 2026 Mar 2;9(3):e263852. doi: 10.1001/jamanetworkopen.2026.3852.PMID: 41915392

https://www.bloomberg.com/news/articles/2026-02-12/pregnant-women-die-at-higher-rates-when-states-restrict-abortion?srnd=phx-industries-health

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Watch this week's Journal Club on YouTube 👇

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

Ben Courchia (00:00.705) Hello everybody. Welcome back to The Incubator Podcast. We're back this week for an episode of Journal Club. Good morning, Daphna. How are you?

Daphna Yasova Barbeau (00:09.678) Good morning. It's nice to be recording from home. But it's good to get back into the swing of things. Traveling is tough these days.

Ben Courchia (00:13.223) I know, we've been on the road. You've been on vacation.

Daphna Yasova Barbeau (00:21.547) Yeah, luckily that went okay. But you and I have been all over the country doing conferences. And actually, that's a great time to tell people — I think the conference coverage is, if we do say so ourselves, quite good. The dog is agreeing that the conference coverage is quite good. I hope people will take a look at those.

Ben Courchia (00:49.174) Yeah. And we invite everybody to join us at PAS. We'll be there as the official podcast partner — whatever that means. We'll just be there. It's a bigger conference, so I guess more fancy. But we will be the same. Our microphones will not be gold, I promise.

Daphna Yasova Barbeau (01:14.276) We're the same amount of fancy.

Daphna Yasova Barbeau (01:20.110) You didn't tell me about that. I'm excited.

Ben Courchia (01:23.349) No, it will just be our usual selves. We hope to have some swag to give out and to conduct some great interviews. We like to say we go to conferences for people who don't get to be there — but for PAS, I think it's also for the people who are there, because you can't get to everything.

Daphna Yasova Barbeau (01:43.650) Yeah, because you can't get to everything.

Ben Courchia (01:47.167) You might miss a session and be happy to hear from those speakers on the pod. So that will be nice.

Daphna Yasova Barbeau (01:55.278) Yeah, and I think people sometimes think we're just saying "come stop by" as a formality. But we genuinely love meeting listeners at these conferences. It keeps us really motivated. It's nice to meet people who are benefiting from the podcast. So definitely stop by.

Ben Courchia (02:19.061) Yeah, we're very approachable. Okay — we've been itching to do Journal Club this week, purely because the timing worked out. We have yet to review a February paper from the American Academy of Pediatrics called "Therapeutic Hypothermia for Neonatal Hypoxic-Ischemic Encephalopathy: Clinical Report." And Daphna, you presented this paper at the FN3. What is FN3 for people who don't know?

Daphna Yasova Barbeau (02:53.070) At our division meeting, yes. FN3 is the Florida Neonatal Neurologic Network. We meet monthly to talk about neurodevelopment in the state of Florida. So we were able to discuss this paper there.

Ben Courchia (03:09.121) Great. So for our audience, you're going to walk us through what the AAP has to say about cooling.

Daphna Yasova Barbeau (03:18.882) Yeah. For people who have been keeping track — or not — there had been a flurry of papers in the last year about HIE, looking at what you might call therapeutic creep: younger babies, smaller babies, mild babies. So I think this clinical report was timely as people were looking for some guidance. It comes from the Committee on Fetus and Newborn and the Section on Neurology. As with other AAP clinical reports, this is a free paper, so people can print it and discuss it at their division meetings. I'll say upfront — I'm not going to read all 17 pages — but it's a wonderful background resource for those just starting out with HIE, needing a refresher, or wanting to understand what qualifies a baby for therapeutic hypothermia, what the evidence is, what the major trials showed, and what we've learned since those initial trials. That last part is really key, because we've started applying cooling to babies who weren't necessarily well-represented in those initial studies. The paper also covers adverse effects and some more nuanced clinical scenarios. I'll highlight the key action statements, some of which appear in the recommendations and some of which don't.

Daphna Yasova Barbeau (05:11.054) So the first key action statement: for infants with moderate to severe HIE, therapeutic hypothermia to a target temperature of 33.5°C is ideally initiated within six hours after birth and continued for 72 hours. That came after a review of whether we're using the right temperature. The second key action statement: the target temperature of 33.5°C for 72 hours remains the standard when cooling is initiated within six hours of birth.

Ben Courchia (05:44.087) Yeah, they do a solid review of the evidence to tell us something we probably already know — the inclusion criteria for the major HIE and therapeutic hypothermia trials, and that cooling for term and near-term infants initiated within six hours of life does have beneficial outcomes. But they also get into some of the more controversial stuff. Go ahead.

Daphna Yasova Barbeau (06:14.796) Yes. The third key action statement covers initiation of hypothermia between six and 24 hours after birth. Cooling initiated late — in infants who didn't initially meet criteria or couldn't start within the first six hours — may be considered after discussion with parents or guardians about possible benefits and associated risks. I thought that was important to highlight, because we do have studies showing some benefit to late initiation. But for most of us, our inclusion criteria still includes babies being less than six hours of age. The flow diagram in this paper actually lists that as one of the general eligibility criteria. That said, they wanted to acknowledge that there has been some evidence of benefit for cooling beyond six hours but before 24 hours — and they recommend shared decision-making in that group.

Ben Courchia (07:39.191) What does that look like practically at the bedside? When I read that statement, I find myself framing the discussion in a way that usually lands with a lean toward not doing it.

Daphna Yasova Barbeau (07:55.887) Yeah, I tend to agree. I think two years ago we were asking, what are even the risks I'm putting them through? But I think for a good-sized, mature infant who seizes at eight hours, or for the outborn infants who are getting to centers at seven hours — babies who didn't get cooled simply because they weren't at a center that provided it — this is a different group than the small babies or the mild babies. And the paper is very clear that the effects of therapeutic hypothermia are quite diminished when initiated after six hours, but it's not nothing.

Ben Courchia (09:01.014) Right — it's not nothing, and it's not been well studied. The outcomes aren't the same as for a baby cooled within six hours, but there may be some benefit for a given baby.

Daphna Yasova Barbeau (09:10.327) And some researchers would argue that starting within the first two or three hours yields even better outcomes. The data on late cooling showed that the effect was small — a 71%, 64%, and 56% probability of a decrease in death or disability by 1%, 2%, and 3%, respectively. Minuscule numbers. But for families in the middle of this situation, any percentage point matters.

Daphna Yasova Barbeau (09:55.725) Yeah, they're looking for anything. We give them population-based data, but they have one baby. So they're asking: will this help my one baby? Another key action statement: cooling during transport can facilitate initiation of therapeutic hypothermia in infants with moderate to severe HIE. Whenever possible, servo-controlled cooling is preferred over passive cooling to minimize the risk of over-cooling. This is really important. We say "just turn off the heater" — but babies who get too hot have worse outcomes, even those who don't ultimately qualify for cooling. And the initial cooling trials showed that babies who got too cold also had worse outcomes. So it's not enough to just cool — we have to be precise.

Ben Courchia (10:55.399) So the key action statement from Daphna Barbeau is: you can do passive cooling, but you need to keep close track of the temperature — an invasive probe or equivalent monitoring — and not be afraid to turn the warmer back on if you're overshooting.

Daphna Yasova Barbeau (11:06.636) Exactly.

Daphna Yasova Barbeau (11:27.854) Moving on to the last two key action statements, which are also highlighted in the recommendations: therapeutic hypothermia is not recommended for infants born before 35 weeks gestational age. For neonates born between 35+0 and 35+6 weeks, there is limited evidence regarding safety and effectiveness. It may be considered in discussion with families about potential risks and benefits. I think that's where most of us have landed after the most recent papers. The 34-weekers — that's a clear no. And we should be having real discussions about babies in the 35th week specifically, as opposed to babies greater than 36 weeks.

Ben Courchia (12:15.029) I think that's where the discussion currently lives — the 35th week. What's your opinion?

Daphna Yasova Barbeau (12:24.707) I think it depends on the severity of presentation.

Ben Courchia (12:29.815) Okay, let me put you through some scenarios. Mild HIE at 35+2

Daphna Yasova Barbeau (12:42.923) Well, that actually brings us to the last key action statement.

Ben Courchia (12:46.167) Okay, let's set mild aside for now. Moderate to severe HIE at 35 weeks — I think the report is honest that in secondary subgroup analysis by gestational age, the study did not demonstrate a benefit of hypothermia or a difference in mortality for infants in the 35th week, though it wasn't really powered to show that — only 45 infants were enrolled in that subgroup. So this remains a zone of uncertainty.

Daphna Yasova Barbeau (13:29.967) Yeah, and hopefully more retrospective data coming out will shed light on that group, because people have been cooling 35-weekers.

Ben Courchia (13:41.559) And based on the JAMA Pediatrics article that everybody has reviewed — specifically about the 33 to 35+6 population — many people saw an increase in mortality and said, I'm not touching these babies with a cooling blanket. But it's important to note: for babies at 35+0 to 35+6, if you chose to cool, you would have no evidence standing against that decision. The signal of increased mortality was in the younger gestational ages, not this specific subgroup.

Daphna Yasova Barbeau (14:14.733) Right — it really didn't show one way or another specifically in that group.

Ben Courchia (14:21.655) But when a paper says "increased mortality," the intervention becomes almost radioactive. Nobody wants to get near it. I think that's worth clarifying for people.

Daphna Yasova Barbeau (14:36.547) Yeah. And this is where it comes down to shared decision-making with the family. We're sometimes afraid to tell parents what we don't know. Here's what we know, here's what we don't, and how much risk are they willing to tolerate in either direction? Some families will say, my baby has been through enough — if there's no data either way, I don't want to do it. Others will want to know they did everything possible. My gut says more families lean toward that second position. And that's why we have to have that conversation.

Ben Courchia (15:19.479) Yeah. Okay — last key action statement, and then you

mentioned mild HIE.

Daphna Yasova Barbeau (15:25.743) Yes — therapeutic hypothermia for neonates with mild HIE is not currently recommended outside of a research study.

Ben Courchia (15:36.004) Let's dissect that. What is considered mild HIE?

Daphna Yasova Barbeau (15:37.173) So technically, the original inclusion criteria for the major cooling studies didn't include mild babies. These are infants who have acidosis, are a little stunned, may have some abnormal biomarkers, but don't meet the threshold — using Sarnat scoring, base deficit, and encephalopathy criteria. They don't seize — because seizing already puts you in a different category — but they've clearly had some kind of perinatal event. The Sarnat is actually quite straightforward: you score them and it tells you mild, moderate, or severe.

Ben Courchia (16:29.355) Right — they don't seize, they've had a perinatal event, the acidosis is present but not severe, and the exam is not completely normal. And so —

Daphna Yasova Barbeau (16:47.289) A lot of units were adhering strictly to the original enrollment criteria, but others weren't — and that's where the therapeutic creep occurred.

Ben Courchia (17:03.605) What do you make of the recommendation that it's "not currently recommended"? Many people are doing it anyway. And the paper doesn't really surface any new information about side effects — bradycardia, vasopressor need, the things we commonly see. Where does that leave us? Because it's not saying it should never be done.

Daphna Yasova Barbeau (17:43.887) I think cooling mild babies is harder to defend. You'd better have a well-documented reason. Some people say, they're full term, they're big, they're just mild — what are the risks? But I think there are risks we don't study well. We study the objective, measurable ones. What hasn't been well studied is the effect of putting a mildly affected baby — who is unlikely to benefit — through a four-day invasive experience that parents don't fully understand. It changes their entire perception of their baby. Vulnerable Child Syndrome, long-term parental anxiety — that hasn't been well studied in this group.

Ben Courchia (18:48.415) And there's a lot of overlap. If you're cooling a mild patient and they develop side effects — bradycardia, EKG changes, needing vasopressors — those side effects can independently affect neurological outcomes. You've introduced risk for a baby who might have done fine without intervention.

Daphna Yasova Barbeau (19:13.391) Sure, independently.

Ben Courchia (19:16.871) And that being said, the paper is clear that mild HIE patients do have some worse developmental outcomes down the road. That's an unfortunate reality.

Daphna Yasova Barbeau (19:47.791) And that point brings up something that Betsy Pilon and Hope for HIE always talks about: there are babies we rule out for cooling where we never actually tell the families we considered it — even knowing that some of those babies will have developmental delays. Some people ask, why would we worry the family? But what families consistently report is that they would have wanted to know, because they find the HIE community later in life and realize there had been a conversation they weren't part of.

Ben Courchia (20:26.967) Can I offer some coaching? One thing I do in the unit: if you're thinking about something for your patient — whether it's cooling, a G-tube, whatever — discuss it with the family. Don't commit to anything. Just say, this is something we're considering, and we want to think through it together. Families appreciate that. It gives them time to process, and it shows transparency. And from a documentation standpoint: if you've thought about cooling a patient and made a conscious clinical decision that the risk-benefit wasn't there, document your thought process. Protect yourself and honor that decision.

Daphna Yasova Barbeau (21:20.279) And I think parents really appreciate knowing that the doctor considered it, explained why their baby didn't qualify, and they understood it. It removes that nagging doubt later.

Ben Courchia (21:43.031) What else?

Daphna Yasova Barbeau (21:44.503) Okay, a few things that weren't labeled as key action statements but bear discussion. First, monitoring: continuous video EEG monitoring is recommended for the duration of cooling and rewarming. In cases where the first 24 hours of continuous video EEG does not show abnormalities, discontinuation prior to completion of cooling and rewarming may be considered in some clinical contexts. We know access to continuous EEG is a challenge across the country, but it remains the gold standard — especially because many seizures in HIE are purely electrographic. Next — timing of imaging, which comes up every year at FN3. MRIs should be performed prior to hospital discharge for neonates who received therapeutic hypothermia. Brain MRI performed as soon as possible after rewarming — so around day four — or if that's not feasible, within the first week, allows for optimal classification of injury based on diffusion-weighted imaging.

Ben Courchia (22:43.399) Is it four days or ten days?

Daphna Yasova Barbeau (23:06.541) DWI abnormalities peak between days three and five. Pseudo-normalization of DWI is delayed in cooled neonates — about eight to twelve days — compared with five to seven days in non-cooled neonates. That distinction matters if you're going to get an MRI in non-cooled babies too.

Ben Courchia (23:28.321) Okay, so let me play five-year-old here. I get the MRI the day after rewarming — day four or five. If I miss that window, when is my next opportunity?

Daphna Yasova Barbeau (23:44.009) Probably around day seven.

Ben Courchia (23:47.959) So if you've missed day four or five — don't get it on day six or seven. Wait until day eight or later?

Daphna Yasova Barbeau (24:01.455) Pseudo-normalization occurs between eight and twelve days — so day seven is right in a gray zone. My guidance would be: aim for day four or five. If you've missed it, wait until after day twelve to avoid the pseudo-normalization window.

Ben Courchia (24:20.279) Got it. Day four or five ideally, and for non-cooled babies you can get it earlier since pseudo-normalization happens sooner. And please don't get an MRI on day eight or nine and reassure yourself it's normal — that's a dangerous interpretation.

Daphna Yasova Barbeau (25:07.459) Right. Okay, another hot topic: the risk of necrotizing enterocolitis is low in neonates with HIE. Low-volume enteral feeds may be considered in hemodynamically stable patients with a normal abdominal exam and imaging. This has been associated with earlier achievement of full feeds, higher breastfeeding rates, shorter duration of parenteral nutrition, and decreased length of stay. There are also small studies showing decreased inflammatory markers — we're not there yet in terms of outcome data, but the direction is promising.

Ben Courchia (25:42.549) And I think we've reviewed some of those studies. The baby on four vasopressors with significant hypotension — obviously not a candidate. But that baby who's cruising through cooling, doing phenomenally well — think about it. Low-volume feeds.

Daphna Yasova Barbeau (25:58.895) Absolutely. And the last point I'll highlight: while cooling studies support the safety of holding infants with their cooling blankets, as well as trophic feeds in select infants, existing data suggests that parents of neonates treated with therapeutic hypothermia experience acute and ongoing feelings of loss and grief. A trauma-informed care approach should inform communication with families throughout this experience.

Ben Courchia (26:23.201) The cool cuddle studies — those were great.

Daphna Yasova Barbeau (26:28.303) The cool cuddle. And actually, since it's April, Hope for HIE is actively encouraging holding while cooling this month.

Ben Courchia (26:44.981) Very good.

Daphna Yasova Barbeau (26:46.255) There are recommendations beyond the key action statements, but we've covered most of them — target temperature, target duration, eligibility criteria, which really hasn't changed.

Ben Courchia (27:03.543) And we only have about half an hour to go through all of this. We invite people to read the paper. The big discussion points are the areas where evidence is still evolving. If you need a refresher on why babies with a pH below seven, an Apgar score below five at ten minutes, and who require mechanical ventilation after a suspected acute hypoxic-ischemic event need cooling — we invite you to our Neonatology Review podcast, and we've also done a special series on cooling there. The paper does cover the basics — target temperature, speed of cooling, speed of rewarming, and a review of the major studies.

Daphna Yasova Barbeau (27:54.701) Yeah. One part of the recommendations we didn't cover is this: identification of a sentinel event is not necessary to initiate therapeutic hypothermia. Evidence of moderate to severe encephalopathy by neurologic exam or seizures is required. If moderate or severe encephalopathy is present and the biochemical and clinical criteria are borderline without another identifiable cause, clinicians may consider therapeutic hypothermia. I'll throw myself a small pat on the back here — I was recently on a paper where we looked at babies with sentinel events versus those without. And in our cohort, babies with no sentinel event actually had higher lactates, worse base deficits, were more likely to require ventilatory and inotropic support, and were more likely to experience seizures. So: no sentinel event does not mean no injury.

Ben Courchia (28:57.591) Explain that for the audience, because at face value it sounds counterintuitive. If there's a sentinel event, shouldn't that be worse?

Daphna Yasova Barbeau (29:18.989) Right, I think that's the intuition. But the thing is, a sentinel event is one we witness — fetal bradycardia, abruption, shoulder dystocia, maternal hypotension. It's possible that events are being missed, either due to the type of monitoring used or the timing of that monitoring. So there's probably a group of babies whose insult didn't happen right around the time of delivery, and those babies may actually do worse precisely because the event went unrecognized. If you're not thinking about it, you're going to miss it — and that's a significant problem.

Ben Courchia (30:04.353) Think of it like herpes. So what you're saying about that recommendation specifically is: the presence of a sentinel event is no longer a requirement for eligibility for therapeutic hypothermia. Very interesting.

Ben Courchia (30:30.470) It's my turn, and I think I'll take a slightly lighter route and give people a bit of a break. I found this very interesting paper in the Archives of Disease in Childhood, Fetal and Neonatal Edition, called "Combining Abdominal Ultrasound and Radiography for Surgical Risk Stratification in Necrotizing Enterocolitis: A Prospective Cohort Pilot Study." This is a paper I've been waiting for.

Daphna Yasova Barbeau (31:18.225) Love it.

Ben Courchia (31:26.910) The first author is Archana Priyadarshi with last author Mark B. Tracy. This comes to us from Australia. The background sets up the problem well. Mortality from necrotizing enterocolitis remains high at 20 to 30%, sometimes up to 40%. Survivors often require surgical intervention and can face short bowel syndrome and adverse neurodevelopmental outcomes. Plain abdominal radiography is the first-line investigation for suspected NEC. The presence of pneumatosis intestinalis or portal venous gas on radiographs has traditionally defined the diagnosis, although the diagnostic exclusivity of these findings has recently been questioned. In the absence of a reliable biomarker, diagnosis really depends on clinical judgment. If you see pneumatosis or portal venous gas, the diagnosis is largely made for you — but many times you don't see that, and then the question becomes: what am I looking at? Because the disease can progress rapidly and the consequences of misdiagnosis are severe, NEC is more frequently suspected than confirmed. The authors therefore bring up the role of ultrasound, which provides a complementary, radiation-free modality that allows bedside assessment of bowel wall thickness, vascularity, and peristalsis — features critical for assessing the presence and progression of NEC. In Australia and New Zealand, clinicians routinely use point-of-care ultrasound to evaluate the heart, brain, and lungs, and there is growing interest in extending that capability to abdominal imaging for early detection and monitoring of NEC. The objective of the study: can combining abdominal ultrasound and abdominal X-ray — a multimodal imaging approach — improve diagnostic precision and surgical risk stratification in neonates with suspected NEC?

Daphna Yasova Barbeau (32:57.413) Mm-hmm.

Ben Courchia (33:20.644) This was a prospective pilot observational cohort study of 67 neonates admitted between 2021 and 2025 to either a tertiary perinatal or surgical neonatal intensive care unit with a clinical diagnosis of suspected NEC. Following consent, all neonates underwent abdominal X-ray — standard of care — followed by POCUS within four hours of the initial X-ray. Data collected included gestational age, birth weight, type of treatment (medical or surgical), and outcome at discharge. Case definitions were determined prior to the study beginning. At study completion, each case was categorized as definitely NEC, suspected NEC, or not NEC — three categories — based on final clinical diagnosis, operative findings where applicable, radiographic evidence of pneumatosis or portal venous gas, and overall clinical course. Neonates treated medically with nonspecific radiographic findings were designated as "suspected NEC." That category captures where most of us live when it comes to this diagnosis. Based on final outcome, cases were then classified as either surgical or nonsurgical. In terms of the statistical approach — I know we often skip this, but I think in this case we shouldn't. The core question is straightforward: can imaging findings automatically sort patients into higher and lower surgical risk groups, without the investigators deciding in advance who belongs where? To do this, the authors used an approach called unsupervised clustering. Rather than testing a pre-specified hypothesis, the algorithm looks at all imaging variables across all patients and asks whether the data naturally separates into two groups — crucially, without knowing who actually went to surgery. It takes all the initial ultrasounds and X-rays and makes its predictions. Once the two groups are formed, you then look back and ask: did the patients in one group go to surgery more than the other? The authors ran this process twice — once feeding in only X-ray findings, and once feeding in X-ray and ultrasound findings combined. That head-to-head comparison is the central test of the paper. Clinical concordance with actual surgical outcome was then quantified using logistic regression, reported as odds ratios, and by directly comparing surgical rates between the two groups. To identify which specific imaging features were driving the separation, the authors applied principal component analysis to the combined imaging dataset — essentially asking: out of all the variables fed into the model, which ones are doing the heavy lifting? The result is a ranked list of imaging features by their contribution to group separation, which tells you not just that the combined model worked better, but why.

Daphna Yasova Barbeau (37:15.719) That was excellent — very helpful.

Ben Courchia (37:33.702) Cohort characteristics: 67 neonates with clinically suspected NEC were enrolled. Mean gestational age was 29.5 weeks, mean birth weight 1,400 grams — always a sobering reminder that bigger babies do get NEC.

Daphna Yasova Barbeau (37:36.077) Mm-hmm. And that's the worst — when they're doing fine and then they get into trouble.

Ben Courchia (37:43.582) 88% were born preterm and 18% were growth restricted. 49% underwent surgery and 10% died before discharge. At discharge, 23 of the 67 — 34% — were diagnosed with definite NEC, of whom 16 had operative confirmation. 9 babies, 13%, were classified as suspected NEC. 35 babies, 52%, were categorized as non-NEC, including those considered to have feeding intolerance. So a nice mix: 34% definite NEC, 13% suspected, 52% non-NEC. In terms of imaging findings: ultrasound scans were categorized as reassuring in 40% of the cohort and non-reassuring in 60%. X-rays were considered reassuring in only 4 infants — 6% — and non-reassuring in 63 infants, 94%. You can see the difference: ultrasound was quite discriminatory, really separating the cohort 40/60. When you're watching peristalsis in real time, that matters. The fact that 94% of X-rays were non-reassuring across the entire cohort — including patients who ultimately just had feeding intolerance — speaks directly to the well-known low specificity of plain radiography. Among infants with non-NEC feeding intolerance, ultrasound findings were reassuring in 100% of cases, whereas 83% of X-rays in that same group were non-reassuring. In contrast, both imaging modalities were non-reassuring in all infants with definite NEC. Now for the cluster analysis. In the X-ray-only model, the proportion requiring surgery did not differ significantly between clusters: 58.8% versus 39.4%, p-value 0.11. In the combined X-ray and ultrasound model, by contrast, two distinct groups emerged with markedly different surgical rates: 78.3% versus 34%, corresponding to an odds ratio of approximately seven. That contrast is the central finding of the paper. X-ray data alone could not generate clusters that meaningfully tracked surgical outcome. Adding ultrasound data produced a more than six-fold difference in the odds of surgery between the two clusters — a clinically substantial separation the X-ray model simply could not achieve. Looking at the principal component analysis of the combined imaging dataset: the first two principal components together explained 70% of the total variance, meaning most of the discriminating signal is captured in a manageable number of dimensions. The biplot reveals a clear separation between neonates who underwent surgery and those managed medically. Complex ascites on ultrasound, absent peristalsis, abnormal bowel perfusion, and abnormal bowel gas pattern were the features most strongly associated with the surgical cluster. These are features many of us already weigh heavily at the bedside — the PCA formalizes that clinical intuition and confirms that it is these ultrasound-derived dynamic findings — peristalsis, ascites, perfusion — rather than the X-ray, that carry most of the discriminating weight. The conclusion: abdominal ultrasound combined with radiography improved the identification of neonates at high surgical risk from NEC. Ultrasound provided valuable dynamic functional information that complemented static radiograph findings and enhanced diagnostic precision. Broader adoption of multimodal imaging and standardized reporting may support more accurate diagnosis, targeted management, and improved outcomes for neonates with NEC. For me personally — I often do ultrasound on these babies when I'm worried, but I think this paper makes the case for doing it every time there's a question.

Daphna Yasova Barbeau (42:56.016) Yeah, very hopeful. We need something. Even when we get the diagnosis right, the outcomes are poor. But if we don't get it right, the outcomes are catastrophic. I wonder — for now, is using ultrasound to rule babies out the better use versus using it to rule babies in?

Ben Courchia (43:31.012) I think both. But the biggest practical challenge I see is that peristalsis is easy to assess on POCUS — you put the probe on the belly, wait a bit, and watch. But looking at gut perfusion, assessing the vessels, identifying ascites — that's a bit more involved. I worry that people will say, I don't know how to do that, and just assess peristalsis and call it a day. But that's not really what this study is showing you. The good news is those additional skills are not hard to learn — it just takes some effort.

Daphna Yasova Barbeau (44:15.804) And I think peristalsis is actually the least sensitive finding — we see absent peristalsis in ileus too, for example, not just NEC.

Ben Courchia (44:26.674) Exactly — and there's a difference between any peristalsis and normal peristalsis. Ascites is always very telling and something you can easily miss on X-ray. Surgeons often report opening the abdomen and finding significant ascites. So just learn to look for those fluid pockets.

Daphna Yasova Barbeau (44:50.336) I'm very excited about the paper I'm going to present. I've been waiting for this one.

Ben Courchia (44:56.403) You are getting your dream lineup of neonatal neurology topics this week.

Daphna Yasova Barbeau (45:07.798) Yes, I'm lucking out. That's right.

Ben Courchia (45:11.711) For the foreseeable future. But these are important studies, and I think people need to understand that we do have an editorial process in place — it's not just articles we pick randomly, but ones that are going to impact our field. So today you're talking about the F-NeoBright trial, which — not the best acronym. It's a bit of a stretch.

Daphna Yasova Barbeau (45:33.258) Yeah, it's a stretch. It's a stretch.

Ben Courchia (45:40.319) I'm happy you said that. I'm going to present another article later this week with a similarly stretched acronym, so I'm not just being critical.

Daphna Yasova Barbeau (45:46.678) Props to people for trying though. When we talk about the article, having common shared language helps.

Ben Courchia (45:56.947) F-NeoBright: Feasibility of Neonatal Intranasal Breast Milk Impact on Brain Growth in HIE Therapy.

Daphna Yasova Barbeau (46:04.022) So this is published in the Society for Pediatric Research and comes to us out of Hungary. F-NeoBright is a feasibility and safety study of intranasal fresh breast milk in neonatal encephalopathy — a pilot study looking specifically at safety and feasibility in this group of babies. In the introduction, they note — as we just discussed this week — that we still don't have many adjunct therapies to therapeutic hypothermia in HIE. We know that breast milk is rich in bioactive components, including neurotrophic growth factors, cytokines, immunoglobulins, hormones, and multipotent stem cells. Exclusive breastfeeding in early development has been shown to positively impact cognitive outcomes. Animal studies have also shown that neurotrophic substances found in breast milk, when administered intranasally, can enter the central nervous system and reduce the extent of neurologic damage. We've also recently seen the impact of intranasal breast milk on post-hemorrhagic hydrocephalus — reducing the degree of ventricular dilation in babies who had IVH. So they wanted to look at this in babies with HIE. It's a single-center feasibility study in one NICU in Hungary — and notably, this unit treats outborn patients only, which is interesting because outborn babies are often excluded from HIE studies. They enrolled 10 consecutive neonates born between December 2024 and February 2025, diagnosed with moderate to severe HIE. And yes — I know it's only 10 babies. I noticed. But this is a feasibility and safety study.

Ben Courchia (48:15.945) But it is a feasibility and safety study.

Daphna Yasova Barbeau (48:28.790) Exactly. I'm excited about the paper. So the exclusion criteria mirrored the standard criteria for ruling babies out of therapeutic hypothermia: congenital malformations, concurrent cerebral lesions, need for ECMO, and contraindications to fresh breast milk provision. The intervention used mother's own fresh breast milk expressed within four hours, transported at room temperature in a standard 1 mL plastic syringe. They administered 0.4 mL of freshly expressed milk twice a day in each nostril over one minute, with each nostril treated 15 minutes apart. What was really interesting about the protocol: the first doses were performed by nursing staff or the attending physician, with parents observing. Parents then received training and continued the administration themselves throughout the hospital stay and at home. The plan was for babies to receive intranasal breast milk up to day 28. Intervention was initiated as soon as possible but always within 48 hours of age. Parents were contacted at least twice a week for ongoing support and confirmation of home doses. The maximum number of doses — twice daily over 28 days — was 56. Given anticipated challenges with breast milk transport, a pragmatically achievable target was set at 50 doses per patient. For those in stem cell research: 50 doses were estimated to deliver 1.4 × 10⁶ stem cells per kilogram, which was considered a sufficient dose.

Daphna Yasova Barbeau (51:14.198) 11 babies were assessed for moderate to severe HIE. 10 were enrolled. The one who was not enrolled required therapy for severe meconium aspiration syndrome with PPHN. Based on exam, aEEG, and MRI, two patients were classified as severe and eight as moderate HIE. Of the two with severe HIE: one died at day seven due to multi-organ failure, felt to be unrelated to the study protocol; the other had a severe respiratory condition requiring prolonged intensive care. At enrollment, all patients were already intubated and ventilated. Prior to initiation of fresh breast milk therapy, four patients required non-invasive support following extubation, and six neonates received vasopressors and/or inotropes for circulatory support. aEEG activity normalized in six neonates at a median age of 35 hours. Onset of sleep-wake cycling was observed in eight neonates at a median age of 25 hours. Seizures were observed in two neonates before intranasal therapy was initiated — both received a single loading dose of phenobarbital and required no further anti-seizure medication. MRI was performed in all infants at a median age of 4.3 days with a median WIKI score of 2.0, indicating some neurologic damage. Looking at feasibility: the first dose was administered at a median age of 24.7 hours — range 14.8 to 40 hours — within the 48-hour target in all patients. The median treatment duration in surviving infants was 28 days, which was the goal. The median total doses administered in surviving infants was 51 — just above the target of 50. The primary reason for dose omission during the hospital stay was unavailability of fresh breast milk, as some outborn patients had it transported from significant distances. In terms of safety: no respiratory, cardiovascular, or neurologic adverse events were recorded in association with the administration during the hospital stay. Parents were trained to safely administer the milk during the NICU admission and continue at home. Without home cardiorespiratory monitoring, parents were asked to report complications such as choking, aspiration, nasal bleeding, or any symptoms requiring an emergency department visit.

Daphna Yasova Barbeau (53:29.098) Regarding enteral feeding: it was initiated as early as possible using mother's own breast milk at a median time of 27 hours. Median time to full enteral feeds was day eight. The take-home from their discussion: intranasal breast milk administration twice daily in infants with HIE appears to be feasible and safe both in the hospital and at home. Notably, all parents approached for participation consented — including those who had not planned to breastfeed or had been unsuccessful with breastfeeding previously. That is not a small thing. They also observed high adherence to the protocol among all surviving infants for more than three weeks. Seven out of nine surviving infants completed the full 28-day treatment course — one while still in the NICU, the remaining six at home. Through a multidisciplinary approach, it was feasible to initiate treatment in 100% of patients within the target of 48 hours of age, and 50% of infants had their first treatment within 24 hours of life. The long-term effects of intranasal EBM are still to be studied, but this is the critical first step.

Ben Courchia (54:56.699) You're clearly a strong advocate for this intervention. Why is that?

Daphna Yasova Barbeau (55:05.846) I think what we've learned — on the podcast and through our work with the Delphi Conference — is that sometimes the simplest, most obvious intervention is the right one. We still have to study it, and we still need to confirm babies can tolerate it. But as the data comes in, and given the lack of other well-supported adjunct therapies, giving these developing brains stem cells just makes a lot of sense.

Ben Courchia (55:41.171) It checks a lot of boxes already. It's physiologically sound, it doesn't appear to be a high-risk intervention — so we have to study it rigorously, but why not? Very helpful.

Ben Courchia (56:10.715) I have a surfactant-related paper. This is a paper I found in JAMA Network Open called "Two-Year Outcomes of Less Invasive Surfactant Administration Among Preterm Neonates: A Secondary Analysis of a Randomized Clinical Trial." First author Rebecca Dorner, last author Dr. Anup Katheria. Less invasive surfactant administration — commonly known as LISA — has been studied extensively and compared with traditional care has been associated with reduced incidence of bronchopulmonary dysplasia and chronic lung disease. There is, however, limited data on the potential long-term effects of this treatment into early childhood. Before I get into the trials mentioned here, I want to reference a review article I often use myself, published in Pediatric Research, called "Should Less Invasive Surfactant Administration Become Routine Practice in US Neonatal Units?" — by Dr. Kaki Laya and last author Kanekal Suresh Gotham. There's a lot of data on LISA trials, and you really do need to review it carefully to understand where we are. The main issue, as always, is what LISA is being studied against. In many trials, babies on CPAP are randomized to either LISA or intubation and mechanical ventilation — and if they require only 21% FiO2 on mechanical ventilation, they may not even get surfactant. Other trials compare LISA with INSURE. And then there's the question of who's being included — are we talking about 32-weekers or 23-weekers? Suresh and his co-author do a very good job summarizing all of that. I've based a lot of our unit's surfactant guidelines on his work. There are also signals in some trials suggesting increased mortality in one group, so this is a nuanced space — maybe something for a mini-series down the road. For now, the authors highlight two relevant prior studies: the follow-up of the NINSAP trial out of Germany, which found that infants born at 25 to 26 weeks had improved neurodevelopmental scores and those at 23 to 24 weeks showed improved psychomotor development after LISA; and the follow-up of the OPTIMIST-A trial, which found that minimally invasive surfactant resulted in a significantly lower rate of adverse respiratory outcomes during the first two years of life. Those two studies set the stage for the current follow-up.

Daphna Yasova Barbeau (56:22.030) Mm-hmm.

Ben Courchia (60:27.965) The authors are also the investigators of the CALI trial — Caffeine and LISA in preterm infants — which found that early caffeine administration within two hours of life, given prior to LISA, compared with early caffeine and CPAP alone, resulted in lower frequency of intubation within the first 72 hours of life and overall less BPD at 36 weeks. That trial was published in the New England Journal of Medicine Evidence in 2023. The question here is how early caffeine might interact with LISA to affect long-term neurodevelopmental and pulmonary outcomes. The present study looks at two-year corrected age outcomes in infants enrolled in the CALI trial, with the hypothesis that early caffeine plus LISA would reduce the composite outcome of death or moderate to severe neurodevelopmental impairment.

Daphna Yasova Barbeau (61:30.062) Very nice way to set the stage.

Ben Courchia (61:54.749) The primary CALI trial was a multicenter randomized clinical trial of preterm neonates born between 24 weeks and 29 weeks and six days, conducted in three NICUs in California — Loma Linda, University of California Irvine, and Sharp Mary Birch Hospital for Women and Newborns in San Diego. To be included, preterm infants had to be spontaneously breathing on CPAP of five to eight with an FiO2 below 40% and maintaining normal heart rates. Infants randomized to the LISA group received IV access and 20 mg/kg of caffeine before two hours of life, followed by 2.5 mL/kg of surfactant — poractant alfa — administered via a 16-gauge angiocath under direct or video laryngoscopy, over one to two minutes in three aliquots. The catheter was then removed and the infant remained on CPAP. Infants randomized to the CPAP group received the same loading dose of caffeine and were managed on CPAP alone. Strict intubation criteria were standardized across both groups: CPAP of six to eight, FiO2 greater than 40% to maintain saturations between 90 and 95%, pH of 7.15 or less, PCO2 greater than 65, or clinical events such as apnea, bradycardia, or desaturations.

Ben Courchia (63:47.633) This is a pre-specified secondary analysis, meaning it was planned from the outset. Clinicians were blinded at follow-up to the original intervention. Follow-up occurred via in-person visits including history and neurodevelopmental assessment using the Bayley Scales of Infant and Toddler Development — either 3rd or 4th edition — as well as the Ages and Stages Questionnaire version 3, the M-CHAT (Modified Checklist for Autism in Toddlers, Revised), and the GMFCS (Gross Motor Function Classification System). On the Bayley, composite scores below 85 indicated moderate delay and below 70 indicated severe delay. The primary outcome was the composite of death or moderate to severe neurodevelopmental impairment, defined as at least one of the following: Bayley composite score below 85, GMFCS of two or greater, blindness with visual acuity below 20/200, or hearing impairment requiring amplification. Secondary outcomes included the individual components of the composite, ASQ-3 scores, M-CHAT risk assessment, and pulmonary outcomes after discharge including need for bronchodilators, corticosteroids, and rehospitalization. Among the 180 infants randomized, 147 had follow-up assessment data available — 74 in the LISA group and 73 in the CPAP group. Mean corrected age at Bayley assessment was 24.6 months in the LISA group and 24.7 months in the CPAP group. 49% were female, 51% male. Antenatal steroids of one or more doses were administered in 98.6% of the LISA group and 100% of the control group. Now for the primary outcome. Death or moderate to severe neurodevelopmental impairment occurred in 17 of 74 infants — 23% — in the LISA group, and in 23 of 70 — 33% — in the CPAP group when including the four deaths. That's an odds ratio of 1.56, 95% confidence interval 0.77 to 3.17, p-value 0.22. There were no deaths in the LISA group and four deaths in the CPAP group, three of which occurred before discharge. A striking difference, but not statistically significant. I want to flag a small clarification: in the body of the paper, the numbers can appear confusing because the authors perform some subtraction excluding babies who passed away, which changes the denominator. If you go to Table 2, you'll see the correct figure: 23 out of 70 in the CPAP group — 33% — which includes the four deaths. That is the right number. The narrative and the p-value stand.

Daphna Yasova Barbeau (68:04.408) Tell me buddy, what happened here?

Ben Courchia (68:09.001) Ha — yeah. It doesn't change anything. The p-value and the direction of the finding are correct. Sorry for any confusion. Looking at the neurodevelopmental components: there were no differences in any individual impairment outcomes between groups, including moderate to severe neurodevelopmental impairment with an odds ratio of 1.36 and a p-value of 0.43. The Bayley Cognitive Score showed a mean difference of three points, p-value 0.36. The Motor Score showed a mean difference of two points, p-value 0.46. GMFCS score of two or greater had an odds ratio of 0.55, p-value 0.68. Neurosensory impairment and hearing impairment also showed no significant differences. On the ASQ-3, infants in the LISA group showed no significant difference in rates of typical development compared to controls — 31.9% versus 17.9%, odds ratio 0.47, not significant. Scores indicating possible delay and referral for further assessment were seen in 62% of the LISA group versus 70% of the control group — again not statistically significant. Notably, infants in the LISA group were more likely to have a z-score within the reference range for the fine motor domain compared to controls, with a p-value of 0.03. No difference was seen between groups on the M-CHAT for autism risk. For pulmonary outcomes, no differences were seen in any of the measured outcomes after discharge. The conclusion: this follow-up study, coupled with the lack of adverse events reported in the primary CALI trial, supports that laryngoscopy for LISA does not appear to result in worsened neurodevelopmental outcomes in preterm infants at two years of age in this population of babies born between 24 and 29+6 weeks. Mortality trends favored LISA, though again, not statistically significant.

Daphna Yasova Barbeau (73:37.583) Okay. And it doesn't appear it would change the statistics regardless.

Ben Courchia (73:48.827) No, it doesn't change the narrative. Sorry for the confusion.

Eli (76:16.002) Let's talk about this story that got some coverage in particular. I saw some nice coverage of this article in Bloomberg. This is a follow-up and a bit of a natural experiment study on the evolving landscape around restrictive laws for abortions. The question that we've all been asking ourselves is, while we know from patient experience that this is deeply challenging and for many of us maybe we consider it immoral, and while we know that it has produced barriers, the question is: are those barriers leading to actual changes in health outcomes for birthing people and for their infants? This study looked into that question. It looked actually not just in recent years, but at the last two decades of the landscape around restrictive abortion laws since 2005, when eight states had a number of limitations on how patients could get abortions.

Eli (77:45.000) Into 2023, which is the year that the Supreme Court overturned Roe v. Wade in the Dobbs decision. What this study found is that pregnant women in the 27 states that fell into the most restrictive category — having not just one law, but a series of laws that made them the most restrictive — were more likely to die during or shortly after childbirth, related or associated with the development and the implementation of these restrictions. They also, I think it's worth noting, died from things that were patterned.

Eli (78:36.074) They died from two main buckets of things. On the one hand, heart attacks and related cardiovascular conditions, including pulmonary emboli. And the second being an entirely different category, which is deaths due to violence, including homicides and suicides, as well as unintentional poisonings and drug overdoses. There's a lot to talk about here, Ben. What was your first approximation read on this article? And then we can get into some of the particulars here.

Ben Courchia MD (79:10.650) I think this is always interesting because as these decisions take effect, you can't expect to see too many consequences right off the bat, both fortunately and unfortunately. You have to wait a little bit. And that's where we're getting into right now as we are getting months and months away from that particular decision. This was an interesting document. It was published by the Guttmacher Institute, which again, I'm not so familiar with in terms of all the things that they do. But it is interesting to see what the change in legislation has led to when it comes to maternal health. We're going to talk a little bit about that. What's interesting too is in the article from Bloomberg News, there's a very interesting graph looking at the state abortion restrictions from 2005 to 2023. It's interesting to see that it is not something that can solely rest on the shoulders of the decision overturning Roe v. Wade. It looks like it's a very systemic problem that precedes that particular decision and doesn't seem to change its direction post the Supreme Court decision. There's a lot of stuff for us to unpack here. I'm going to let you dive into some of the intricacies of the article.

Eli (81:14.090) Yeah, absolutely. This study was by a series of researchers at the Guttmacher Institute, which is a think tank and research center at Columbia University, a really fabulous research center. They've done a lot of coverage of these longer-term looks at the consequences of restrictive policies around abortion. The first thing that stood out to me is this cardiovascular set of complications that birthing people were having from these laws. What I was trying to wrap my head around in reading this article and understanding the pathophysiology here is how restrictive laws would cause more deaths. The fact that they're happening in a series of cardiovascular consequences says to me, when I think about pulmonary emboli in pregnancy, what I think about are often potentially placental complications or other complications related to routine care that are often detectable. Or they are sequelae of lacking primary care, such as routine blood pressure monitoring that could come with regular antenatal care. In the setting of abortion, the question is how are these pregnancies playing out in places where folks maybe would seek an abortion or are not able to attain one.

Eli (82:45.000) I would be curious to understand what the nature of antenatal care for that cohort in particular is. Is that a cohort that is less likely to receive antenatal care because they lack healthcare access, or it's not a desired pregnancy, or there's some other confounding life factor that is leading them to seek the abortion that in the same way makes it difficult for them to seek regular antenatal care? This cardiovascular pathway seemed to me to be not only a catchall of morbidity and mortality, but it felt plausible in terms of the reasons people might become sick and deteriorate if they were not able to get an abortion. What did you think of that pathway of morbidity and mortality?

Ben Courchia MD (84:11.302) I think you're exactly right. Even the way the Bloomberg article frames the issue about maternal mortality being associated with restrictions in abortion laws maybe underpins a little bit a singular association between the two. But I think, like you said, it's much, much broader. When people get pregnant, this is a time — specifically for the demographic that we're talking about in this particular case — to get primary care. This is a cohort in general that does not seek primary care to begin with. We've discussed this on the podcast. This opportunity to get primary care is quite important. But for an unwanted pregnancy, for people who don't really have access to care, who may be in a situation that prevents them from getting prenatal care, it leads to the dire consequences of pregnancy, including poor adaptation to pregnancy. Also, maybe the underlying causes of why these particular people would have been seeking an abortion to begin with, like domestic violence, could really have compounded consequences when they develop within a certain context. The article shines a light on what kind of support system our communities are providing, irrespective of the state laws, to have some form of screening mechanism for some very lethal consequences of pregnancy that just seem to be going unnoticed and leading to increased maternal mortality rates. It's quite tragic when you look at it. The people we're talking about in those states, the article mentions, are more likely to die during or shortly after childbirth. You're leading to this terrifying consequence of a mother giving birth and basically leaving a child as an orphan just by being the casualty of poor preventive healthcare and just being at a point where survival is not guaranteed.

Ben Courchia MD (86:31.852) To me, this is just crazy. Beyond just the mortality rate, I'm wondering if it was titled "Pregnant Women Die at Higher Rates When States Restrict Abortion" or "Pregnant Women Die More and Lead to More Orphans." It's absolutely insane. The fact that the study looks at data from 2005 all the way to 2023 really points to the fact that something's got to change. The Roe v. Wade conversation is one thing, but it looks like it's much bigger than that.

Eli (89:27.342) Ben, I totally agree with everything you've said. I think you've made two really interesting points. The first is I'm so glad you mentioned the circumstances that people seeking abortions find themselves in, because I think that was the really important additional finding in this paper. In addition to the pathophysiologic medical consequences of being unable to get abortions and all the sequelae that may come from there, this finding that the rates of violent death were higher speaks to the fact that when people seek abortions, that is a decision firmly embedded in a life that is complicated, and there is context there. Which I think is a really important reminder for all of us who take care of birthing people and people who are bringing desired or undesired pregnancies into the world. It's an important statement about what the consequences of these laws are beyond just what happens in the body. When someone is seeking an abortion and cannot get one, that is a decision that has social consequences.

Eli (91:00.000) That is something that makes me incredibly sad. And also to your other point, it speaks to a much bigger story than just this one SCOTUS decision in Dobbs. Our listeners may be asking themselves, "Well, what can I do? This is terrible. I'm not the Supreme Court. I'm not a state court. I'm not a lawyer. What can I do about these laws?" When you look in the study, as you mentioned, these are not just one law; it is a package of laws. In fact, what the study found was that states with greater than five of these restrictions were considered the most restrictive cohort.

Ben Courchia MD (91:51.684) Mm-hmm.

Eli (91:54.968) The six restrictions that were associated with higher death rates, and the four that were associated with greater violent death rates, included bans on public funding for abortion, and bans on exchange insurance plans providing care for abortions. What are called biased counseling laws, which dictate how medical providers are allowed to have conversations around abortions. Second-trimester bans, which are laws that require you to be under a certain gestational age before you're not allowed to get an abortion. Waiting periods, which say if you're seeking an abortion, you have to wait a certain amount of time to mull over that decision before you make up your mind. And an ultrasound requirement, which says you need a certain amount of prenatal imaging, which of course is not always accessible for people. There was one other restriction that was associated with violent deaths, which is a physician-only requirement, meaning only physicians are allowed to provide abortions. Of course, there are lots of parts of the country where there are many other wonderful providers who may be providing antenatal care, including abortions. It's really all seven of these different restrictions that contribute in one way or another to the sequelae that we're seeing.

Eli (93:35.000) So if you are a person listening to this podcast and you say, "I want to do something about this, but I'm not SCOTUS, I'm not a federal court, and I'm not a lawyer," you have an opportunity to raise with any number of your policymakers the medical and social consequences to your patient population of any number of these restrictions. Choose which one of these restrictions you want to go after the most.

Eli (94:09.796) Choose which one grinds your gears the most. And that's the one that you can choose to make a phone call about. If it's exchange plans not being allowed to provide certain amounts of care and you're someone who says, "Hey, it's a market economy, why can't exchange plans pay for whatever people want them to pay for?" Go after that one. If you're somebody who says, "Hey, I love my non-physician colleagues, they should be allowed to do all the things they're capable of doing at the top of their license," go after the physician-only plans. This is an area that is replete with opportunity for neonatologists and all people involved in neonatal care to consider how they might be able to put their thumb on the scale with policymakers. We invite you to consider your role in the context of this, given now that there is increasing research about the consequences these decisions are having on our patient population, to do something about it. Okay, I'm stepping off my soapbox.

Ben Courchia MD (95:05.094) Well, thank you. Thank you very much, Eli. And again, we're going to point the listeners to this article in Bloomberg News called "Pregnant Women Die at Higher Rates When States Restrict Abortion". See you next week.