#442 - 📑 Journal Club - The Complete Episode from May 16th 2026

Hello friends 👋

Cerebral oxygenation, staffing economics, delivery room scoring, neurodevelopmental prognostication, and public health — a full week on the Incubator Journal Club.

Ben walks through the NIRTURE trial, a single-device RCT testing cerebral oximetry-guided care in infants born under 29 weeks. The intervention dramatically reduced the burden of cerebral hypoxia and hyperoxia compared to standard care. Secondary clinical outcomes were neutral and neurodevelopmental follow-up is still pending. The question of whether stabilizing cerebral oxygenation actually moves the needle for these babies remains unanswered.

Daphna covers a brief communication from the Journal of Perinatology on what happens to billing and productivity when NICUs shift to 24-hour in-house attending coverage. Clinical FTE went up, work RVUs went down — and the reason is counterintuitive. Attendings present overnight were weaning babies faster. Better care, less revenue. The coding system was not built to capture that.

Ben then pairs the 5-minute Apgar with umbilical artery pH in very preterm infants using EPICE cohort data. When both are low, risk is highest. When they compete, the Apgar wins.

Daphna rounds out Journal Club with a systematic review showing that combining EEG and brain MRI outperforms either tool alone for neurodevelopmental prognostication in preterm infants.

The week closes with Ben and Eli on the sweeping domestic and international public health funding cuts — and what they mean for the vulnerable populations in your NICU.

----

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

Cerebral Oximetry-Guided Treatment and Cerebral Oxygenation in Extremely Preterm Infants: A Randomized Clinical Trial. Jani PR, Goyen TA, Balegar KK, Maheshwari R, Saito-Benz M, Schindler T, Moore J, Merhi M, Cruz M, Song Y, McDonagh H, Luig M, Tracy M, D'Cruz D, Perdomo A, Morakeas S, Dasireddy V, Culcer M, Shingde V, Bennington K, Michalowski J, Fucek A, Querim J, Stevens S, Santanelli J, Elhindi J, Gloss B, Halliday R, Shah D, Popat H.JAMA Netw Open. 2026 Feb 2;9(2):e2557620.

From on-call to on-site: the impact of 24-hour in-house neonatology on billing patterns and physician productivity. Donohue L, Lakshminrusimha S.J Perinatol. 2026 Feb;46(2):289-292. doi: 10.1038/s41372-025-02530-8. Epub 2026 Jan 5.PMID: 41490931 Free PMC article. No abstract available.

Apgar Score Plus Umbilical Artery pH and Adverse Neonatal Outcomes in Very Preterm Infants. Ehrhardt H, Behboodi S, Maier RF, Aubert AM, Ådén U, Staude B, Draper ES, Gudmundsdottir A, Siljehav V, Varendi H, Weber T, Zemlin M, Zeitlin J; EPICE/SHIPS Research Group.JAMA Netw Open. 2026 Feb 2;9(2):e2557913.

Combined Use of Electroencephalography and Magnetic Resonance Imaging in the Prognostication of Neurodevelopmental Outcomes in Preterm Infants - A Systematic Review and Meta-Analysis. Forrest CD, Biagioni T, Liley HG, Lai MM, Colditz PB, Ware RS, Boyd RN, Roberts JA.Pediatr Neurol. 2026 Feb;175:116-129. doi: 10.1016/j.pediatrneurol.2025.11.005. Epub 2025 Nov 13.PMID: 41337899 

Domestic and international public health funding cuts

https://www.nytimes.com/2026/02/11/health/hhs-california-public-health-lawsuit.html

https://www.washingtonpost.com/health/2026/02/19/alternative-world-health-organization-proposal/

----

Watch this week's Journal Club on YouTube 👇

----

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

Ben Courchia (00:00.57) Hello everybody, welcome back to the Incubator Podcast. We're back this week for another episode of Journal Club.

Daphna Yasova Barbeau (00:06.786) We're here. We're here. We made it to Journal Club. I love Journal Club.

Ben Courchia (00:15.522) I love Journal Club. I feel like in a dream world, I get paid to read papers and do Journal Club.

Daphna Yasova Barbeau (00:20.791) Hmm.

Ben Courchia (00:27.77) What do you think about that?

Daphna Yasova Barbeau (00:28.952) I think, yeah, in a dream world. This is why people write papers. When you go to the bedside, you're like, "Well, maybe I don't have the exact right answer for this exact right patient, but this is what I do know".

Ben Courchia (00:47.75) The only reason I'm saying that I would like to get paid to do this is because it takes a lot of time. The pile of papers accumulates. If we don't record for a week, I see the pile accumulating and then I'm like, "But now...". We still don't have a nice process when it comes to that, because I read a lot of papers and then halfway through I'm like....

Daphna Yasova Barbeau (00:53.751) It does take a lot of time.

Daphna Yasova Barbeau (01:05.282) Yeah, we're like, "That's good".

Ben Courchia (01:15.864) "Nah, I'm going to put this one in the bin just for my own knowledge". It's not going to make it onto Journal Club, and that is why it takes a long time.

Daphna Yasova Barbeau (01:27.586) I think that's what some people don't realize. We do read papers that we don't report on, and not because they're not useful papers, just for one reason or another in that timeframe. A paper beats out another paper.

Ben Courchia (01:41.198) For sure, because we only have so many slots. All right. Do we have to talk about anything else? Nope. Where am I taking you this particular week?

Daphna, you're going to pick. We can either talk about NIRS or we can talk about Apgar scores and umbilical artery pH.

Daphna Yasova Barbeau (02:07.502) I think people want to hear about NIRS.

Ben Courchia (02:11.97) Okay, let's do NIRS. I found this paper in JAMA Network Open. It's called "Cerebral Oximetry Guided Treatment and Cerebral Oxygenation in Extremely Preterm Infants". This is the NIRTURE trial. It is the Near-Infrared Spectroscopy Targeted Use to Reduce Adverse Outcome in Extremely Preterm Infants.

Daphna Yasova Barbeau (02:15.97) It's a stretch, but they got there.

Ben Courchia (02:42.242) It's like in Formula One when they lose the tires and they just get the car back on the road. It's just enough to make it. Let's talk a little bit about the background. The stability of cerebral oxygenation by using NIRS, which is near-infrared spectroscopy, compared with systemic assessment of oxygenation using pulse oximetry.

Ben Courchia (03:09.402) It gives you another alternative to understand and potentially reduce brain injury. The appeal of this approach is that pulse oximetry reflects systemic arterial oxygen saturation. NIRS gives you regional cerebral oxygenation directly, giving you a window into what is actually happening at the brain level where it matters most. Before I get into the paper, we're working on a mini-series on NIRS specifically. Stay tuned; there will probably be a five-episode mini-series on that later this year.

Ben Courchia (03:42.549) The big topic of discussion is the SafeBoosC trial. You need to understand the SafeBoosC trial before you understand this. SafeBoosC-2 was published in 2015 in the New England Journal of Medicine.

Ben Courchia (04:03.002) It was a randomized trial of about 170 preterm infants randomized to either treatment guided by cerebral oximetry monitoring during the first three days of life, or usual newborn care. The primary outcome was the burden of cerebral hypoxia and hyperoxia, defined as the total duration and magnitude of cerebral oxygenation below 55% or above 85%. The SafeBoosC trial was not really powered to detect differences in clinical outcomes. It was a proof-of-concept study demonstrating that the intervention could move the physiological target. SafeBoosC-3 was published in 2023 with 1,600 infants in 17 countries.

Ben Courchia (04:03.002) The primary outcome was death or severe brain injury on cerebral ultrasound at 36 weeks. The results were unambiguously neutral: 35% versus 34% in each group, showing the intervention did not reduce death or severe brain injury. This is where NIRS has lived for some time: it is a great tool, but it doesn't seem to be making a lot of a clinical difference. The SafeBoosC-3 investigators identified some explanations for this neutral result in the preamble of this paper.

Ben Courchia (04:03.002) Many sites were using different NIRS platforms and sensors, introducing variability in absolute oxygen readings. Training was recommended but not mandatory at certain sites with little prior experience. The monitoring window of 72 hours may have been too short. Additionally, the hypoxic threshold of 55% was calibrated to a specific adult sensor, the INVOS, but had to be extrapolated to different devices, adding measurement uncertainty.

Ben Courchia (06:29.966) NIRTURE was designed to address some of these gaps. SafeBoosC showed NIRS-guided treatment could stabilize cerebral oxygenation, but what if we had more consistency with the same sensors and devices? We tested the hypothesis that the burden of cerebral hypoxia and hyperoxia could be reduced by combining cerebral oximetry with a dedicated treatment guideline using NIRS from a single device. They used the SenSmart Model X100 by Nonin Medical.

Ben Courchia (06:29.966) Unlike the SafeBoosC trial, they looked at this for a little bit longer and tried to look at more outcomes. This was a multi-site, single-blinded, two-arm randomized controlled trial with 1:1 allocation stratified by gestational age (less than 26 weeks or over 26 weeks) and study sites. The trial was conducted across five tertiary units in Australia, New Zealand, and the US. This included Westmead Hospital, Nepean Hospital, the Royal Hospital for Women, Wellington Hospital, and Connecticut Children's Hospital.

Ben Courchia (06:29.966) Investigators at each site had prior experience with cerebral oximetry, and staff without experience underwent structured training and internet-based certification. Eligibility criteria included infants born at less than 29 weeks who were younger than six hours old. Exclusion criteria included congenital anomalies requiring major surgery, genetic disorders associated with neurological impairment, or multiple births beyond twins.

Ben Courchia (08:00.546) Infants were randomly allocated to standard care or the intervention group. Cerebral oximetry in both groups was performed using a single neonatal NIRS sensor placed on the forehead. Data was recorded continuously for five days, or 120 hours. In the intervention group, real-time cerebral oxygenation readings were visible to the staff, who managed the patient to keep cerebral saturation between 65% and 90%. In the standard care group, the monitor was hidden from view.

Ben Courchia (08:23.354) They used a pragmatic consensus-based approach to define the range. The lower threshold of 65% was based on SafeBoosC-2 and adjusted for higher absolute values with neonatal sensors. The upper threshold of 90% was chosen based on local data from Westmead Hospital. Sensor sites were inspected every four hours. A treatment guideline for cerebral hypoxia was activated when oxygenation was less than 65%.

Ben Courchia (08:23.354) Steps included checking the sensor and assessing if there was a decrease in oxygen delivery or perfusion. They looked at saturations, hemoglobin, systemic perfusion, PDA, and $PCO_2$. Based on these, they might increase $FiO_2$, give a transfusion, treat the PDA, start inotropes, or change ventilator settings.

Ben Courchia (10:47.426) When cerebral hyperoxia was noted (above 90%), they would wean $FiO_2$, wean pressure, or adjust the ventilator. If it was due to hyperglycemia, they would adjust the GIR. The primary outcome was the burden of cerebral hypoxia and hyperoxia expressed as percentage hours. For example, an hour event with a mean cerebral oxygenation of 55% equals 10% hours of hypoxia.

Ben Courchia (10:47.426) They ensured deviations lasted at least one minute to count as clinically significant events. Secondary outcomes included mortality, brain injury on imaging (IVH, cerebellar hemorrhage, PVL), BPD, necrotizing enterocolitis (Bell classification), and ROP. 104 infants were randomized: 53 to the intervention group and 51 to standard care. Baseline characteristics were similar, though the intervention group had a higher proportion of chorioamnionitis exposure and higher birth weight percentiles.

Ben Courchia (12:16.044) In the intervention group, the median burden of cerebral hypoxia and hyperoxia was 5.7% hours, compared to 82.3% hours in the standard care group. The adjusted relative change was 42.8% with a p-value less than 0.001. This is striking, showing that if you have the information, you are better at keeping oxygenation within range.

Ben Courchia (14:38.106) The improvement was predominantly driven by a reduction in cerebral hyperoxia, which decreased from 23.7% hours to 3.5% hours. This contrasts with SafeBoosC, where the primary improvement was driven by a reduction in hypoxia. The effect was larger in the most immature infants.

Ben Courchia (14:38.106) No significant differences were observed for secondary outcomes before hospital discharge. The adjusted relative risk for mortality was 1.28. No skin injuries occurred from the sensors. NIRS-guided treatment significantly improved the stability of cerebral oxygenation during the first five days. Neurodevelopmental outcomes are still being collected.

Ben Courchia (17:06.362) Whether this translates into better neurological outcomes is uncertain. Resolving this will require well-conducted randomized trials and individual patient data meta-analyses.

Daphna Yasova Barbeau (17:39.733) So what do you think?

Ben Courchia (17:45.038) As a clinician, I believe maintaining normal NIRS at the bedside is good. I don't see how swings wouldn't have a negative impact. But as a researcher, if the clinical metrics don't improve, do we really need to favor this intervention? It is one more data point.

Ben Courchia (18:14.956) Do we need to put NIRS on everyone? Probably not. But for certain babies, like those with hypotension or extremely low birth weight, maintaining that level might be critical. I find it hard to believe a baby swinging up and down does as well as one maintained in a normal range.

Daphna Yasova Barbeau (19:14.511)

It is a reminder that what we see on the pulse ox is not necessarily what the brain is seeing.

Ben Courchia (19:26.786)

Exactly. Cerebral autoregulation is a peculiar system that doesn't adapt very well to the rest of the body

----

Daphna Yasova Barbeau (00:10.114) I'm going to take a break from neurologic papers. I feel like every time a paper like this comes out, we have to cover it. I think people are talking about staffing, staffing models, compensation, and reimbursement.

Daphna Yasova Barbeau (00:37.07) This is coming from the Journal of Perinatology. It's a brief communication entitled, "From On-Call to On-Site: The Impact of 24-Hour In-House Neonatology on Billing Patterns and Physician Productivity". No surprise, this is by Lee Donahue and Satyan Lakshminarusimha.

Daphna Yasova Barbeau (00:37.07) Every time this topic comes up, everybody wants to hear about it. I want to tell people that we had two great interviews at Cool Topics just last month. Episode number 423 with Dr. Lakshminarusimha, "Should Neonatology Break Free from Pediatrics?". And number 427 with Dr. Steinhorn, "Are neonatologists being fairly compensated for the work they do?". To further round out the discussion, people should take a look at those.

Daphna Yasova Barbeau (00:37.07) What is the point of this paper? Attending coverage in many NICUs has shifted from a model where attending physicians do their rounds and dedicate the rest of the day to academic activities, taking night calls from home, to a newer model where attendings are present in the NICU 24/7. This change has been driven by factors including increased patient acuity, reduced availability of residents, decreased NICU exposure during medical training, and some state mandates.

Daphna Yasova Barbeau (00:37.07) They wanted to look at the CPT codes that were used, the work RVUs that were generated, and the billing practices. Their thought was that when the attending is in-house at night for admissions occurring before midnight, the initial care code is billed on the day of admission and a subsequent care code is billed on the following day. They had a hypothesis that there would be a slight increase in WRVUs generated with the shift to 24-hour in-house neonatologists to compensate for needing these in-house people.

Daphna Yasova Barbeau (00:37.07) They collected divisional work-related RVUs, collections, CPT code frequency, average daily census, number of admissions, average length of stay, number of deliveries, case mix index, and days of intubated assisted ventilation for two years prior to and three years following the 2021 transition to 24-hour in-house attendings. This is a 49-bed unit at UC Davis. They follow the CARTs model at their institution.

Daphna Yasova Barbeau (03:01.422) CART stands for Clinical, Administrative, Research, Teaching, and Service. The way that works, it assigns specific FTE time to various requirements of an academic neonatologist to determine what portion of the individual's full-time equivalent is considered their clinical FTE, or CFTE. They basically give credit to these other requirements that take up people's time.

Daphna Yasova Barbeau (03:01.422) When attending physicians took calls from home, the night on-call hours received 0.25 credits. The two physicians on service covered alternate night calls. When attending physicians stayed in the hospital, night calls received an additional 12.5% credit compared to day shifts. This was suggested by experts for "hazard compensation". These are the methods used to calculate the additional clinical FTEs required when transitioning to in-house.

Ben Courchia (04:19.902) Can we talk about that for a second? We don't get hazard pay in medicine. In any other job in the world, if you are asked to work nights, weekends, and holidays, you get hazard pay, but in medicine it is baked in. You just do this.

Daphna Yasova Barbeau (04:29.592) For sure, you get paid more elsewhere. Everybody has to do it here.

Ben Courchia (04:39.966) It's crazy because many people, you and I included, would agree to be paid less to do fewer nights and weekends. There are some people who would be very interested in getting paid more just to do nights and weekends.

Daphna Yasova Barbeau (04:54.882) Actually, I think it would help a lot of teams where there is a distribution of people who want one more than the other, or maybe you can incentivize people to do some of these off-shifts.

Ben Courchia (05:09.606) And you don't even have to make a permanent decision. You shift in your practice. If you're single and you need to repay loans, you work the shifts that pay you the most. Then you get married and have a family, and you say, "I'm going to start backing off and do more daytime shifts," even if I get paid a bit less. That is not even a decision that we can make. Anyway, we should still not call it the "graveyard shift" because it's not a good term.

Ben Courchia (05:37.81) Let's not take that from the real world.

Daphna Yasova Barbeau (05:41.272) So that was their setup, but I think even this CARTs model is a new term for a lot of institutions where we're giving people credit for work that they do that impacts the clinical work we all do. The clinical FTE required to cover the NICU increased from 6.24 to 7.67 with the transition to an in-house staffing model.

Daphna Yasova Barbeau (05:41.272) This required hiring two additional neonatologists, which makes sense because people are now sleeping in the hospital. I actually thought it would be more potentially. There was a 15% decrease in division work RVUs, while the number of admissions and the average daily census were relatively unchanged.

Daphna Yasova Barbeau (05:41.272) So there was an increase in clinical FTE needed and a decrease in work RVUs. Systems rely on work RVUs divided by clinical FTE, and the decrease in WRVUs led to a decrease in collections. The numerator went down and the denominator went up, making it less for everybody.

Daphna Yasova Barbeau (05:41.272) A closer examination of billing patterns revealed an increase in subsequent intensive care codes and a decrease in subsequent critical care codes between the two eras. The number of initial critical care codes also decreased, and initial intensive care codes increased, but the difference was not statistically significant. Why did the billing change? Why were the subsequent codes not also critical care? Their point is that possibly, now that you have this in-house attending, they are moving babies forward.

Ben Courchia (07:45.608) That is super interesting.

Daphna Yasova Barbeau (07:57.987) They are weaning respiratory support and trialing babies off support, and they were doing a good job. They were moving these babies from critical care to intensive care even by the subsequent days, which is not good for these equations, but it is very good for babies and families. We are doing a good job.

Ben Courchia (08:16.63) But that's their whole point. Better care is going to come with less pay, basically. I think this is the key not to miss. You could read the paper quickly and think they are advocating for leaving these babies alone overnight so we can bill more. That is really not what they are saying.

Daphna Yasova Barbeau (08:36.47) No, they are saying we should be compensated for the work we are doing overnight.

Ben Courchia (08:39.644) Yeah, because the problem is that you are going to wean the ventilator a little bit overnight and then suddenly the code is going to be different in the morning. But where do you capture this? The coding system is not designed to capture these interventions that are happening overnight. Then suddenly you bill less during the day, you have fewer collections, and then people say our staffing needs to change in the wrong direction when in truth it should go the opposite.

Daphna Yasova Barbeau (09:02.338) This system of CPT and RVUs just does not take into account the efficacy of the work you're doing. Otherwise, the unit metrics were relatively unchanged over the study period. I'll remind people that the study period was two years before 2021 to three years following. Notably, our practice in the NICU has not changed significantly during that time.

Daphna Yasova Barbeau (09:02.338) The number of admissions and average daily census remained stable. The case mix index increased, but this was not statistically significant. The days of intubated assisted ventilation were also unchanged. There were some staffing changes, but the median number of years out of fellowship was unchanged. The physicians had similar experience levels, so not much otherwise in the unit had changed because of the staffing changes.

Daphna Yasova Barbeau (10:26.754) Contrary to their hypothesis, the total divisional work RVUs decreased with in-house attending physicians. During this period, the number of subsequent critical care codes decreased while subsequent intensive care codes increased. This shift in billing resulted in an associated decrease in collections.

Daphna Yasova Barbeau (10:26.754) The decline in WRVUs despite a stable workload suggests that current RVU-based metrics undervalue physician effort in the in-house model. As institutions consider 24-hour staffing, it is important to account for these nuances in productivity metrics and finances when developing compensation models and staffing plans.

Ben Courchia (11:12.584) The business in general is very fortunate to have a body of neonatologists who are truly caring individuals. Can you imagine if neonatologists started saying, "I'm not getting paid for this, so I'm not going to try to wean the ventilator"?. I can confidently say on behalf of most neonatologists around the world, nobody will ever say that. All of us will go and do the right thing.

Ben Courchia (11:42.514) But can you imagine if that started happening? I am sure it is happening elsewhere. I think our adult colleagues are being stressed a lot more than pediatricians. We have the gratification of working with families and small children, which keeps you feeling.

Ben Courchia (11:42.514) I think our innate nature and the fact that we're dealing with a baby makes it so we will never not go. But there are some adult units where it is very busy and stressful. Physicians don't get recognition and are asked to do more faster and faster. At some point, they look around and say, "I'm not doing this". It's probably even more prevalent in adult medicine. Patients want to talk to their physician and spend ten more minutes, and the healthcare systems and insurance do not let them.

Daphna Yasova Barbeau (13:04.525) My take-home points were that we missed an opportunity probably two to three decades ago to adjust for the acuity and population change in the NICU. The acuity was already wildly increased before the study era. Nobody ever adjusted for that in neonatology, unlike other areas of medicine where the population is not changing so drastically.

Daphna Yasova Barbeau (13:04.525) The other thing that made me think is critical care codes. You can have a feeder-grower on CPAP plus five or six, and that's basically the same daily code as an intubated 22-weeker on inotropes. They are vastly different patients.

Ben Courchia (14:06.546) That's exactly right. A lot of the model is inherited from the past, but babies have gotten dramatically more complicated and diversified. Coding systems do not capture that intricacy or the complexity of the patients.

Daphna Yasova Barbeau (14:33.199) And the number of patients, right? In adult medicine or the PICU, this downgraded patient might have just been on a different unit or the floor. My last take-home point is that what can't be extracted from these numbers is the good work being done. People in-house checking on patients might prevent a catastrophic diagnosis at midnight instead of 8:00 AM.

Ben Courchia (15:02.588) For sure, and we don't want that to stop.

Daphna Yasova Barbeau (15:27.001) All right, more to think about.

Ben Courchia (15:29.306) More to think about for sure.

----

Ben Courchia (00:14.518) I want to mention this because at this point it's going to be public news anyway. We both co-chair the pediatric division at Nova and I've officially resigned from my post, leaving you in charge.

Daphna Yasova Barbeau (00:19.086) I guess that's true. But tell us why. Are you allowed to tell us why?

Ben Courchia (00:44.756) Lots of new opportunities presented themselves and I wanted to pursue those. Most notably, I have been recently elected as the representative of District 10 for the AAP. I'm very excited about that. By the way, if you're in District 10—Georgia, Alabama, Florida, Puerto Rico—reach out to me. Use whatever contact information you see, go to the podcast email, and our administrator will forward those to me.

Ben Courchia (01:14.694) I'm hoping that this medium allows me to tell people that I am available and accessible. Let's see if we can have a good representation at the national level. There was a great Harvard Business Review article about how to sunset a project, and I feel like at some point there is a need to understand when you no longer should be doing something. Adding one more plate to juggle is not the right thing to do.

Ben Courchia (01:43.998) The nice thing to do for the university, for you, and for the team is to say, "I am no longer as available as I thought I was going to be, and it is time for me to close this chapter."

Daphna Yasova Barbeau (01:52.248) I think people would rather you do that than not be able to give it everything that is expected.

Ben Courchia (02:04.758) True, but then you think, "Oh my god, what if this other thing doesn't work out and I regret leaving?" But if you do this the right way, opportunity...

Daphna Yasova Barbeau (02:11.116) I could probably share it with you again if needed, if you had to come back.

Ben Courchia (02:17.332) If the decision was solely yours. But this is career evolution. Just do the things that you're interested in, and if you're no longer available for a group of people, do them the justice and the service of saying, "I'm no longer available."

Daphna Yasova Barbeau (02:37.624) Definitely agree with that. Well, congratulations, buddy. It's good news for us here in the district to have you at the helm.

Ben Courchia (02:45.93) I'm following in the footsteps of a giant here. On every front, a literal giant and a giant of our field. We'll see. Ravi Patel is going to probably move on to even greater things. The only reason I believe he is moving on is because you can only run for president so many times. He's been doing a great job. If he could have continued, he would have continued to do a good job.

Ben Courchia (03:15.062) So, that is what is up for today. Before we wrap up, let me just bring up quickly a paper. This is a paper found in JAMA Network Open. It is called, "Apgar Score plus umbilical artery pH and adverse neonatal outcome in very preterm infants." I am very interested just by the title alone.

Ben Courchia (03:43.786) The paper mentions that babies born very preterm, less than 32 weeks, have a high risk of morbidity: IVH, BPD, and long-term health difficulty over the life course. An unmet challenge for clinicians and researchers is to estimate an infant's risk of developing these morbidities to target preventive care. Patient characteristics and perinatal management—like gestational age, birth weight, fetal growth restriction, infection, whether you delivered at a tertiary center, and the receipt of antenatal steroids—are all variables established in the context of neonatal morbidity.

Ben Courchia (03:43.786) However, the accurate estimation of both short and long-term outcomes based on clinical items or biomarkers soon after birth remains an unmet need. The Apgar score, evaluated at 1, 5, and 10 minutes of life, is the first clinical assessment we do after birth in the delivery room. For term infants, there is a reliable association between a low 5-minute Apgar score and adverse neonatal outcomes, which we talked about extensively these past couple of weeks with HIE. This measure is increasingly used to assess risk, despite warnings from the community about its use to specify individual risk.

Ben Courchia (03:43.786) The accuracy of the 5-minute Apgar score for estimating in-hospital mortality decreases with declining gestational age. One of the reasons for this is the uncertainty about how to score preemies. The Apgar score at 5 minutes was not designed for a 23-weeker; it was designed for full-term infants, raising questions about the measure's utility in that population.

Ben Courchia (05:39.15) No association was detected between the 5-minute Apgar score and severe brain injury, like IVH or PVL, in the iNeo research collaborative looking at babies born 24 to 28 weeks. So the authors are thinking, what about the umbilical artery pH, which reflects acidosis and possibly hypoxemia immediately after birth?

Ben Courchia (06:04.554) We know that this is also associated with clinical outcomes. A low umbilical artery pH demonstrates a much better association with HIE in term infants. Whether adding this information to the Apgar score can improve risk estimation for adverse neonatal outcomes among very preterm infants has not been investigated. That is what we are going to look at today.

Ben Courchia (06:04.554) This is an analysis using data from the EPICE cohort. It included stillbirths and live births of babies born between 22 and 31 weeks of gestation in 19 regionally diverse regions in 11 European countries over a 12-month period between 2011 and 2012. The analysis sample contains all live births from this cohort with data on both the 5-minute Apgar and umbilical artery pH.

Ben Courchia (07:03.2) In terms of exposure, the studies used the 5-minute Apgar score and the umbilical artery pH. They prefer the 5-minute over the 1-minute Apgar, as the 1-minute score is notoriously unreliable. They used an Apgar score cutoff of 7, with scores lower than 7 having an association with poor outcome. They categorized umbilical artery pH as low (less than 7.2) or normal (7.2 or higher).

Ben Courchia (07:03.2) This creates a four-category variable: a good Apgar with a low pH, a good Apgar with a high pH, a bad Apgar with a bad pH, and a bad Apgar with a good pH. The main outcome was the combined outcome of mortality and any adverse morbidity comprising IVH grade 2 or more, cystic PVL, NEC requiring surgery, ROP greater than stage 2, and moderate to severe BPD.

Ben Courchia (07:03.2) The prevalence rates of retinopathy of prematurity was 2.8% and necrotizing enterocolitis was 2.0%. Because of that, they excluded these components, as the numbers were too low to pick up on changes. Three components were selected in the end: mortality, IVH, and BPD. It is a great lesson in statistics; if your baseline risk is low, you will have a hard time seeing differences.

Ben Courchia (09:24.854) Among the 10,000 plus infants in the EPICE cohort, 4,174 infants had data on both the 5-minute Apgar and the umbilical artery pH. They had a median gestational age of 29.9 weeks and a median birth weight of 1.24 kilos. 750 infants (18%) had an Apgar below 7, while 13.5% had a low umbilical artery pH.

Ben Courchia (09:24.854) When these combined: 8.8% had an Apgar score of 7 or higher but a low pH; 13.4% had an Apgar score lower than 7 but a normal pH; and 4.7% had an Apgar score lower than 7 with a low umbilical artery pH. Infants with an Apgar lower than 7 and a low pH were more likely to be from a singleton pregnancy and in the lowest gestational age stratum, below 24 weeks.

Ben Courchia (09:24.854) Pre-eclampsia/Eclampsia/HELLP syndrome was less frequently observed in infants with an Apgar score lower than 7, regardless of the pH. Meanwhile, cases with an Apgar score of 7 or higher and a low pH had the lowest frequencies of PPROM and congenital anomalies, and the highest rate of pre-labor C-section and being small for gestational age below the third percentile.

Ben Courchia (09:24.854) The group at highest risk of mortality and adverse morbidity had both an Apgar score lower than 7 and an umbilical artery pH less than 7.2. This was 55.1% of the population, followed by infants with an Apgar score lower than 7 and a normal pH at 48.4%.

Ben Courchia (11:25.172) You have said that these preemies are a little bit more accustomed to acidosis than their full-term counterparts, so it is not surprising that the Apgar score is carrying more of the lift here than the pH. Infants with an Apgar score of 7 or higher and a low pH had a higher proportion of the primary outcome than those with a good Apgar and a normal pH.

Ben Courchia (11:56.374) After adjustment, they found no difference in the composite mortality and morbidity outcome associated with an Apgar score lower than 7 and either low or normal umbilical artery pH. Regarding mortality specifically, the association was high between mortality risk and an Apgar score lower than 7 and a low pH (adjusted risk ratio of 2.4). Cases with low pH but an Apgar of 7 or higher had no increased risk of mortality.

Ben Courchia (11:56.374) When looking at IVH risk, the association was robust in cases of babies who had a low Apgar and a low pH (adjusted risk ratio of 2.5). An association was also found in infants with an Apgar score of 7 or higher and a low pH. For BPD, there was no association.

Ben Courchia (13:24.686) I asked Claude to make me a little table to summarize this. It is quite nice. If you are a little dizzy from this review, look at this table. We look at whether the Apgar is high or low, then it's subdivided into the pH. Having a low Apgar and a low pH represents the highest risk for in-hospital mortality, severe IVH, and the primary composite outcome.

Ben Courchia (14:22.356) I was thinking about it in terms of three buckets. If the Apgar is low and the pH is low, this should be the sickest patient. I was expecting the association to be high, which is what we see except for BPD. The lowest risk is if you have a good Apgar and a good pH. The extremes behaved the way you expect.

Ben Courchia (14:51.412) What was very interesting was when the two were competing. If you have a good Apgar and a bad pH or vice versa, the Apgar score wins. If you have a competing value, the Apgar indicates whether the risk is worse. Babies with Apgars less than 7 had a higher risk of death or severe morbidity, regardless of pH.

Ben Courchia (15:49.238) The conclusion is that in very preterm infants, the accuracy of the 5-minute Apgar score could be improved by combining it with the umbilical artery pH. Risk assessment models should consider adding these items. To me, the clinician assessment through the Apgar score still matters quite a lot, even in these smaller infants.

Ben Courchia (16:18.442) I have thought many times about the significance of scoring a baby on the Apgar score when they are this small, but you can see how it correlates quite nicely.

Daphna Yasova Barbeau (16:43.661) I think it still all depends on the fact that we don't have a good consensus about scoring. If you have an intubated ELBW, do you get two points for respiration? Do you get zero points?

Ben Courchia (17:04.149) Yeah, a baby at 27 weeks on CPAP—do you give them two? Technically they are doing exactly what they are supposed to do, but they are in respiratory distress. If they are a little bit cyanotic, do you give them just one point? You will never see a preemie on CPAP get a 10. That doesn't exist.

Daphna Yasova Barbeau (17:39.737) Well, even the term baby with acrocyanosis is doing exactly what they're supposed to do.

Ben Courchia (17:44.97) We reviewed a paper called, "Nine is the new 10 of Apgar scores," in episode 220. That is how good the website is. In a few seconds, I found it by clicking on the resuscitation icons and the Journal Club tab.

Ben Courchia (18:44.086) All right, buddy, I'll see you tomorrow.

Daphna Yasova Barbeau (18:44.207) All right. I guess when they're bugging us during resuscitation for Apgar scores, we shouldn't be so annoyed. We should pay attention.

Ben Courchia (18:49.622) Pay some attention. If you're hesitating between eight and nine, you're fine. But a six versus an eight looks like an important difference.

----

Daphna Yasova Barbeau (00:47.788) We have a paper coming out of Pediatric Neurology. We are always looking at these interesting journals that we may not always hit as neonatologists. This is entitled, "Combined Use of Electroencephalography and Magnetic Resonance Imaging in the Prognostication of Neurodevelopmental Outcomes in Preterm Infants: A Systematic Review and Meta-Analysis".

Daphna Yasova Barbeau (00:47.788) Coming out of Australia, the goal is to evaluate the predicament we have. We have these wonderful advances in neonatal and perinatal medical care. We've decreased gestation-specific morbidity and mortality associated with preterm birth, but long-term neurologic morbidity remains high. This is clear evidence of the detrimental impact of prematurity on the development of the brain.

Daphna Yasova Barbeau (00:47.788) We really lack good prognostic indicators to provide information to families. The authors write that prognostication of neurodevelopmental outcomes in infants born preterm remains one of the most challenging and simultaneously vital aspects of care in neonatology. The aim of this systematic review is to assess the prognostic potential of a combined multimodal neuro-investigative approach using both structural brain MRI and EEG to identify abnormal brain structure and function in preterm-born infants to predict neurodevelopmental outcomes.

Daphna Yasova Barbeau (00:47.788) Articles were eligible for inclusion if they were retrospective or prospective cohort studies containing a minimum of 20 infants in the final analysis. They did not include case reports, case series, or cohort studies involving fewer than 20 patients. They excluded studies where the full text could not be found, accessed, or translated into English. They included studies that had infants born preterm between 22 weeks and 36 and 6/7 weeks gestation.

Daphna Yasova Barbeau (03:02.41) The studies employed inpatient EEG and MRI with at least one EEG, either amplitude-integrated or video EEG, during the preterm time. MRI could either be completed at preterm or term-equivalent gestation, which is an interesting point for this study. Studies reporting investigations after 44 and 6/7 weeks post-menstrual age were excluded from the review.

Daphna Yasova Barbeau (03:02.41) They also excluded babies if the majority had medical diagnoses outside of prematurity, such as congenital heart disease. The outcome measure for the purposes of the review was neurodevelopment assessed at any time from 12 months corrected age using standard tests. Abnormal developmental outcome was defined as one or more of the following: cognitive, motor, or language scores of more than two standard deviations below the mean on a validated test; a diagnosis of autism spectrum disorder; developmental delay; or developmental coordination disorder.

Daphna Yasova Barbeau (03:02.41) They also included abnormal motor exams identified by clinical exam or standardized testing, a formal diagnosis of a recognized seizure disorder, and severely abnormal neurodevelopment defined as cerebral palsy or severe motor impairment, blindness, or deafness which is not correctable with hearing aids. They also included treatment-resistant epilepsy.

Daphna Yasova Barbeau (03:02.41) First, they assessed the use of EEG and amplitude-integrated EEG. Five studies used aEEG and seven used EEG. All studies performed a combination of qualitative and quantitative assessment to determine normal and abnormal outcomes. Seven of these studies, which included 952 infants, were sufficiently comparable to perform the meta-analysis. For any abnormal neurodevelopmental outcome, EEG prognosticated with an overall sensitivity of 64% and a specificity of 70%.

Daphna Yasova Barbeau (05:19.224) When they were looking specifically at severe neurodevelopmental outcomes only, this led to a similar sensitivity of 68% and specificity of 68%. They also did a sub-analysis; pooling EEG and aEEG did not significantly affect these results. Then they wanted to look at MRI.

Daphna Yasova Barbeau (05:19.224) A meta-analysis assessing the prognostic potential of MRI showed that for any abnormal developmental outcome, MRI had an overall sensitivity of 64% and a specificity of 89%. For severe neurodevelopmental outcome, the sensitivity and specificity were slightly improved at 74% and 86%, respectively. They wanted to look at potential variability in the time points because not all MRIs were obtained at the same time. They performed a subgroup analysis, and this did not result in a significant change in the prognostic variables.

Daphna Yasova Barbeau (05:19.224) The real purpose of the study was to combine the EEG and MRI. Seven of the included studies used a combination to prognosticate neurodevelopmental outcomes. Three of the studies were sufficiently homogeneous to undergo meta-analysis. The meta-analysis showed that for any abnormal developmental outcome, EEG and MRI combined prognosticated with an overall sensitivity of 70% and specificity up to 96%. When prognosticating severe outcomes only, sensitivity was up to 94% and specificity was up to 95%.

Daphna Yasova Barbeau (07:26.072) In conclusion, the systematic review assessed the combined approach of using both EEG and brain MRI to provide prognostication of abnormal neurodevelopment in preterm infants. They used 12 appropriate studies in total. Pooled sensitivity and specificity for the combination were higher than those for either EEG or MRI alone, particularly when prognosticating for severe neurodevelopmental outcomes. I think it is a step in the right direction when thinking of how we can include more information for families.

Ben Courchia (08:09.228) Wrap this up for us. I have a feeling from what you've described in the paper that we have been trying to give prognostic information to families. MRI is the best we have, but it is not perfect. Adding EEG seems to make things better, but it is still not quite there. Am I making that assessment correctly?

Daphna Yasova Barbeau (08:29.282) You nailed it. We are not very good at it yet. I do want to say I think there is potential regarding this concept about EEG versus aEEG and when we obtain those things. That may help move the curve up to improve sensitivity and specificity, but I think we just haven't nailed down what is the right time point for either of those.

Ben Courchia (08:51.744) And doing an amplitude-integrated EEG is much easier to get, whereas a full EEG is more invasive. Do you think tweaking the timing of the EEG could play a bigger role?

Daphna Yasova Barbeau (09:10.05) Absolutely. These studies did have some heterogeneity on when they got them. There are some specified time points by which we know that if you don't have sleep-wake cycling, for example, then that really prognosticates a poor outcome. You could use aEEG in the hands of somebody who really knows how to use it as a developmental milestone.

Daphna Yasova Barbeau (09:39.406) You can say the baby is not meeting this developmental milestone at the time point they should, which gives you different information than the MRI, which is really anatomic. I still think in these very little babies, we have some power to change the findings on MRI with good intervention.

Ben Courchia (09:59.618) For sure. I think it is like BPD as well; if you have to make a prediction, the later you can make that call, the more accurate you will probably be. Moving that to as close to discharge as possible, you probably will be much better at predicting outcomes on a 47-week baby that is about to be discharged than the same baby at 37 weeks.

Ben Courchia (10:29.804) Who was it that we interviewed? Terrie Inder, right? This is what she was saying. The prognostic value of these studies is not great, but it is the best value you can give to families, and they want that information.

----

Eli (00:01.762) Let's keep moving. We got a two-for this week. The overriding theme here is on public health funding cuts. These big infrastructural funds that are essential to so many...

Ben Courchia MD (00:12.459) All right.

Eli (00:31.822) ...public health services and yet are incredibly invisible and incredibly unsexy are being cut up, down, and sideways, both on the domestic and the international landscape. These cuts continue. These cuts were not just limited to the very splashy announcements around the January 20th, 2025 executive orders, they were not just limited to the very public gutting of USAID by DOGE or the withdrawal from the WHO. These cuts are ongoing. It's just the kind of thing where if you're not paying attention, you're going to miss it. That's our job on Neo News, to try to bring it to your desk and make you aware of it, because otherwise the news cycle will push forward with snow days and Epstein and who knows what else.

Eli (01:25.000) The first of these through lines that we're going to address was covered in The New York Times earlier in February. The saga around these domestic health cuts was that on February 9th, the Department of Health and Human Services (HHS) informed Congress that it was planning to pull back roughly $600 million in funding to four states, and four states only: California, Colorado, Illinois, and Minnesota. It doesn't seem accidental why they've chosen these states. Very quickly, the states sued and alleged that this was retribution and political intimidation, and that this was not motivated around any sort of cost savings, but it was motivated around politics.

Eli (02:15.000) The states also detailed what the role of these grants are. I just want to share a little bit what this money pays for. On a basic level, the lawsuit says these grants were intended to help states hire workers, modernize data systems, and manage disease outbreaks. Those sound like three really abstract things, but what they say in the lawsuit is that the Public Health Infrastructure Grant, which is the funding mechanism through which this $600 million came from, is the backbone of federal public health funding, providing critical financial support not only to the plaintiff states directly, but to hundreds of local public health agencies through pass-through funding.

Eli (03:05.000) Just as an example, in Illinois, the states say this funding pays for a variety of things, including lead poisoning prevention grants to 25 local health departments—something it seems we would all want—as well as local health department workforce developmental support grants that support 674 health jobs at 96 local agencies. Loss of these funds would force Illinois to cancel 55 contracts supporting strategic planning, data modernization, emergency preparedness, workforce training, community engagement, halting multi-year initiatives that are foundational to a modern public health system. Really far-reaching effects, not limited to just an office in Chicago, but stretching into many municipalities and many different initiatives.

Eli (03:55.000) So that's what happened on February 9th and the states sued. On February 11th, the administration came back and said they're cutting more things, this time about $200 million. The list of things they were cutting from these four states, and these four states only, were block grants specifically from the CDC on the prevention of HIV and other sexually transmitted infections. It is worth saying that this is in the context of a world in which HIV rates are going up, syphilis rates are going up, and lots of other STDs. We don't really know because we're not doing routine surveillance and monitoring. It also comes in a world where now we're making vaccine recommendations contingent on whether or not people have some of these diseases, like hepatitis B. So these are exactly the sorts of programs that would potentially yield diagnoses that play a multi-generational role in dictating people's care, and yet they're being cut.

Eli (04:55.000) I want to make one note while we're talking about Hep B vaccines. I'm really grateful to a listener who brought to our attention that in a previous episode on Hep B vaccines, we said that the presence of a hepatitis B infection in mom meant universal vaccination at two months. I think it's worth clarifying that we were saying universal vaccination at the birth dose and two months, not only at two months. That comment came in a conversation around the timing and delays of vaccination. So I just want to clarify that the recommendations from the CDC are that for a birthing person who has a Hep B infection, the recommendation is the birth dose and at two months. Anyway.

Ben Courchia MD (05:42.71) And we've corrected the audio and the transcripts. So if you're listening to that episode for the first time tomorrow, you won't notice anything wrong. But thank you for clarifying.

Eli (05:51.873) Amazing. We will be transparent with you. Anyway, back to these grants. We won't know in four states because we're cutting exactly the kinds of things that would get people diagnosed with this. Okay. I've said a lot. I'm going to shut my mouth. Ben, what do you think of these cuts? What do you think of the decisions around the kinds of programs that are being cut, and what do you think about the fact that the cuts are targeting these states in particular?

Ben Courchia MD (06:14.912) Obviously, these two articles talk a lot about funding both on a national and international level. I'm going to start with the international because I feel like this is the easiest thing for the US to cut. But it is a big decision. In The Washington Post article, there is an official cited who says that cutting some of these grants is not trying to withdraw from being a leader in global health. But I very much wonder whether by not funding international projects, specifically when it comes to infectious disease, we are de facto losing ground on leading the world on the global stage when it comes to global health. So that's number one. I do think that the implications of doing this on an international level will have national consequences because people travel to and from the US, and being able to detect an outbreak far away from the American continent can actually save a lot of lives if detection can be done in a timely fashion. So that's number one. When it comes to what is happening...

Eli (07:32.366) Wait, Ben, let's just lay out the international. The other piece of this discussion of public health funding cuts is on the international landscape. I laid out some of the domestic cuts; on the international landscape, as many people know, we withdrew from the WHO. I think it's around $700 million that we pay in dues to the WHO every year. Obviously, the WHO is funded by lots of different governments. There's lots of multilateral collaboration. We have now pulled out of that. It seems like the administration has realized that is detrimental for all sorts of reasons that are not really helpful to anyone and not really politically favorable. So now they're proposing basically a new multilateral international agency that the US is going to play some important role in, even though everybody who's ever been involved with the WHO knows that the US played a very important role in the WHO. That new agency is going to cost on the order of $2 billion. So about three times as much as our dues to the WHO. Anyway, that's the international health funding cuts that Ben is talking about. Okay. Keep going.

Ben Courchia MD (08:43.384) And then on a national level, the opportunity for the government and for HHS to basically cut funding, which is a tactic that we've seen done quite frequently in recent months, is really going to, in my opinion, allow certain policies to be effectuated without so much backlash anymore. When we look at what these funds were going to be allocated to, it is checks and balances in a way. Without that, I think we're going to turn the light off from specific populations with specific risk factors, specific issues that need to be addressed, and just completely ignore a problem that potentially could be growing in our midst. The choice of the four states of California, Colorado, Illinois, and Minnesota is very deliberate. These cuts, if unopposed or if allowed to happen without voting in the proper legislative fashion, will lead the way to more cuts in other areas. I think this can have a tremendous effect on our population and US citizens in general. It's important to understand that this is much broader than just these four states. The administration has recently revised the priorities outlined by the CDC, saying they would no longer continue to focus their efforts on specific communities, and that these funds will be "reinvested" for other programs; that is left to be seen. But it's very concerning that surveillance work will probably be of lower quality, if any, in the future because of all these funds being lost.

Eli (11:03.82) So much to say here. To tackle the domestic lens first, as you've said, surveillance is really the foundation of public health, right? If we don't know what's circulating, if we don't know what the prevalence is, we don't know what to prioritize. We don't know how to focus and we don't know where to put future investment. All we'll end up doing is seeing these people by the time they have deteriorated. We've lost any opportunity for anyone who has taken an epidemiology class and remembers the framework of primary prevention, which is preventing disease at all, secondary prevention, which is preventing disease from getting worse, and tertiary prevention, which is preventing more severe disease from deteriorating. Our entire health system is premised primarily on secondary and tertiary prevention. Basically, we say when you're really sick, when you need dialysis, we'll pay whatever you need to get dialysis, but we don't do a very good job preventing people from getting dialysis. Of course, secondary and tertiary prevention are incredibly expensive, which is part of the reason public health scholars think the US healthcare system is so expensive, because we don't invest in primary care. We don't do a good job with secondary prevention either.

Eli (12:30.000) Of course, primary and secondary prevention depend on your ability to know what people have or what they're at risk for. So we're going to pull out the rug from all sorts of monitoring efforts, including STI monitoring, which is a huge class of diseases that are almost universally, easily preventable. Yet, in a situation where we don't know whether people have HIV, we're just going to wait for them to get Kaposi sarcomas again, and it's going to circulate in certain groups. We know who is at risk of circulating STIs. If we're not preventing them and we don't know what to do, that's entirely predictable. And then of course that will happen in four Democrat-run states that have been targeted time and time again by this administration through any number of efforts, whether that's sending the National Guard to these states, sending ICE, or cutting funding. Then what you're going to have is an increasing burden of illness in these states. And then people are going to point fingers and say, "Well, look at those states and how they've mismanaged their public health system." Right? This whole cascade of events is entirely predictable.

Eli (14:30.000) Ben, as you said, it is on the one hand this vindictive political measure. On the other hand, it is precedent-setting in terms of the administration saying, "Well, if we can get away with this, what's next? What other kinds of funding can we cut? How can we do it in quiet ways that are not going to be in the news cycle?" So you may find yourself asking, "How does all of this relate to me? What am I going to do about $800 million in domestic public health funding cuts, especially if you're not working in one of these four states? Or what the heck am I going to do about the international funding cuts if you're not a global health person?" The answer, as always, is to think about specifically the kinds of illnesses that are at risk here.

Eli (15:34.53) If local health departments are no longer able to do lead screening, that is maybe a little bit less of a concern to most people who work in the NICU. But if you have a developmental follow-up clinic and you have someone who's lagging on their developmental milestones in a municipality that is no longer doing lead screening, you should add to your assay list: do I need to think about lead in this population? In the same way, when you get new arrivals from different countries, I think now more than ever... I've been at multiple institutions now where we've developed our own newcomer lab panel that sends for a series of infections that maybe in a previous era would have been done in that country from multilateral organizations facilitated by the WHO. Or they would have been done in an organized way because we would have had a more organized process of intake for new arrivals or those migrating from different places.

Eli (16:30.000) But in a world now where people are coming and often don't have access or resources, and they just come when they come, maybe they're already pregnant, or their fetus has some condition we've diagnosed on prenatal ultrasounds. I think we need to be sensitive to the fact that here is a set of people who may not have had all the sorts of screening that we might expect. Which means you have to actually read the prenatal lab testing. We're in a world where you can't just assume because people had one prenatal ultrasound, they've had all their infectious testing done. We're literally developing protocols on this at my hospital as we speak because we've fallen into the trap of saying, "I see a Hep B assay, so I'm going to assume they've also had HIV and second-trimester syphilis screening." And of course they haven't, and we just didn't check.

Eli (17:15.000) I think there's an opportunity at the clinical level to think about what you can do for these vulnerable populations. And then obviously, if you are inclined to get involved in the bigger conversations, certainly if you're in one of the four states where this funding has been cut, you have an opportunity to demonstrate how these cuts are affecting your patients at the state level, to see if the state has additional funding to pay for some of these programs, or to bring it to the federal level. And if you're in another state, maybe you can just add your voice to the conversation, try to be an ally, and see if we can get some of these services restored in those states.

Ben Courchia MD (17:43.82) I agree that it does affect the patients that we see in the NICU, and it's gonna affect the type of care you're gonna have to deliver in the NICU because again, we're talking about vulnerable populations not having access to healthcare. That does have consequences for congenitally acquired infections. So definitely something to pay attention to.