📑 Journal Club - The Complete Episode from April 4th 2026

Hello friends 👋

This week on The Incubator Podcast, Ben and Daphna cover five topics spanning clinical practice, emerging technology, and neonatal policy. They open with a large Swedish national cohort study from JAMA Network Open examining early prophylactic hydrocortisone in extremely preterm infants, debating whether a blanket approach to BPD prevention holds up across gestational ages and in the presence of chorioamnionitis.They then take a critical look at predischarge car seat tolerance screening, questioning whether this decades-old AAP recommendation still earns its place in routine NICU discharge planning given its failure to reduce mortality or readmissions.

The conversation shifts to BPD-associated pulmonary hypertension, reviewing a PPHNet study that challenges whether current grading criteria and assessment timepoints adequately capture pulmonary vascular disease severity. They then explore oculomics — a compelling new frontier in which deep learning applied to routine ROP screening images can predict BPD and pulmonary hypertension weeks ahead of clinical diagnosis.

The week closes with a Neo News policy discussion on the regulatory pressures threatening freestanding birth centers nationwide, and the downstream consequences for maternal health equity, newborn screening, and neonatal advocacy.

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

Early Prophylactic Hydrocortisone and Bronchopulmonary Dysplasia-Free Survival in Extremely Preterm Infants. Smedbäck V, Björklund LJ, Flisberg A, Wróblewska J, Baud O, Wejryd E, Ådén U.JAMA Netw Open. 2026 Feb 2;9(2):e2560146. doi:10.1001/jamanetworkopen.2025.60146.

Predischarge Car Seat Tolerance Screening in Preterm and At-Risk Full-Term Infants: A Systematic Review and Meta-Analysis. King BC, Dalvie N, Hay S, Jensen EA, Zupancic JAF.JAMA Netw Open. 2026 Feb 2;9(2):e2558197. doi:0.1001/jamanetworkopen.2025.58197.

Pulmonary Hemodynamics and Long-Term Outcomes in Children with Pulmonary Hypertension-Associated Bronchopulmonary Dysplasia. Austin ED, Mullen MP, Avitabile CM, Krishnan US, Rosenzweig EB, Keller RL, Kinsella JP, Yung D, Steffes L, Bates A, Elia EG, Romer LH, McGrath-Morrow S, Bernier ML, Mandl KD, Raj JU, Sleeper LA, Abman SH; Pediatric Pulmonary Hypertension Network (PPHNet) Investigators.J Pediatr. 2026 Feb;289:114869. doi: 10.1016/j.jpeds.2025.114869. Epub 2025 Oct 24.

Deep Learning-Based Prediction of Cardiopulmonary Disease in Retinal Images of Premature Infants. Singh P, Kumar S, Tyagi R, Young BK, Jordan BK, Scottoline B, Evers PD, Ostmo S, Coyner AS, Lin WC, Gupta A, Erdogmus D, Chan RVP, McCourt EA, Barry JS, McEvoy CT, Chiang MF, Campbell JP, Kalpathy-Cramer J.JAMA Ophthalmol. 2026 Jan 22:e255814. doi: 10.1001/jamaophthalmol.2025.5814. Online ahead of print.PMID: 41569552

https://stateline.org/2026/01/05/freestanding-birth-centers-are-closing-as-maternity-care-gaps-grow/

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Watch this week's Journal Club on YouTube 👇

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

Ben Courchia MD (00:00.504) Hello everybody, welcome back to the incubator podcast. We're back for another round of Journal Club. Daphna, good morning, how are you?

Daphna Yasova Barbeau MD (00:08.865) Good morning. I love Daily Journal Club.

Ben Courchia MD (00:12.566) Yeah. It's funny you say that because we're recording them in a bunch. I'm going to put on my Neo News hat and say that we're recording this one after another. So this is very disingenuous.

Daphna Yasova Barbeau MD (00:26.807) I was thinking this as I was driving home and I relistened to our journal clubs. I like to remind myself what we talked about and whether I was paying close enough attention when you were reviewing your paper. I think it's the perfect thing for a daily snack of evidence-based medicine. I hope people will give us some feedback on that.

Ben Courchia MD (00:43.49) I'm happy to hear that. We're really trying. The evolution of Journal Club has been very much driven by feedback from the community. We initially published a single long episode, then broke it up into Journal Club shorts because people wanted the shorts. Now we're spreading the shorts over the course of the week. They're easier to consume and not all bunched up. So we listen.

Daphna Yasova Barbeau MD (01:17.547) Yes, if you have a colleague who said that business was too long, tell them we are just doing one article a day now. All right, what do you have?

Ben Courchia MD (01:22.638) That's right. I have steroids and BPD. I know we spoke about BPD last week. This is an article that I found in JAMA, specifically JAMA Network Open, called Early Prophylactic Hydrocortisone and Bronchopulmonary Dysplasia-Free Survival in Extremely Preterm Infants. The saga continues.

Daphna Yasova Barbeau MD (01:30.463) Okay. Yeah. Another saga of neonatal care.

Ben Courchia MD (01:50.422) Let's talk a little bit about this paper because it's trying to do some things and answer some questions that have not been answered yet. There are numerous studies indicating that corticosteroid replacement therapy may offer significant benefits for extremely preterm infants. These benefits include hemodynamic stability, promoting lung development, and reducing inflammation. Historically, dexamethasone is what has been used specifically for babies at risk of BPD. However, early intervention with dexamethasone is known to be associated with an increased risk of short and long-term adverse effects, specifically related to brain development. Because of the risks associated with dexamethasone, researchers have been looking at alternatives, and hydrocortisone is the steroid of choice for babies in these first two weeks of life. We know that hydrocortisone has a positive effect on lung development, has a positive effect on mortality, and effects on neurodevelopment are, according to the authors, not causational. Despite these promising trial results, population-based clinical data are severely lacking to fully assess the effectiveness in the real world, and the effect of prophylactic hydrocortisone in extremely preterm infants in everyday clinical practice has previously only been reported in three smaller single-center studies. It feels like we talk about hydrocortisone a lot, but you really have to go back and see who we're talking about. Because whether we're starting hydrocortisone right after birth, waiting for the babies to be seven days old, or giving it to babies on ventilators, the inclusion criteria really matter for these types of studies. For example, in this particular paper, the study by Kristi Watterberg is not mentioned because that's hydrocortisone given to ventilated babies at seven days of life. So just be familiar with the different types of studies. We know that there have been associations reported with hydrocortisone and its use in preterm infants, including bowel perforation, late-onset sepsis, and so on. These may be related to treatment interactions or clinical practices, specifically regarding bowel perforation and the association with indomethacin.

Ben Courchia MD (04:07.43) The rationale for this study is aiming to analyze the association between the use of early prophylactic hydrocortisone in Sweden and changes in survival without BPD in preterm infants. The authors hypothesized that the introduction of prophylactic hydrocortisone would be followed by an increase in survival free of BPD. This was a historical cohort study utilizing prospectively collected data; eligible infants were babies born before 28 weeks of gestation who were admitted to the NICU on their first day of life. They had to be admitted to a hospital where prophylactic hydrocortisone had been implemented into practice. They did not apply any specific exclusion criteria, looking at data from 2018 to 2023 and extracting data from the Swedish Neonatal Quality Register, which impressively covers 98% of all infants admitted to NICUs in Sweden. How insane is that on a country level? I know. Across all analyses, the infants were divided into an exposed and a non-exposed group based on an intention-to-treat principle. The primary exposure investigated was prophylactic hydrocortisone administered IV. The protocol included a dose of 0.5 milligrams per kilo given every 12 hours from day one to day seven of life, followed by 0.5 milligrams per kilo once daily for days eight...

Daphna Yasova Barbeau MD (05:05.064) If only.

Ben Courchia MD (05:33.986) ...to 10, resulting in a total dose of 8.5 milligrams per kilo given over the course of 10 days. If IV access was unavailable, which usually happened when the baby was taking more enteral feeds, they switched the patient to oral administration. So IV or oral was used depending on what the patient could tolerate. This treatment was adopted across several centers in Sweden, but protocols did vary. In three out of the four implemented centers, the treatment was given to all admitted infants before 28 weeks of gestation. However, in one center, referred to as the northern center in the paper, the protocol was a bit more targeted. They gave the treatment to all infants born before 26 weeks. But for those who were between 26 and 28 weeks, it was only given if the mother was suspected to have had chorioamnionitis. In terms of the rollout, it varied slightly between the different years. Two centers in Sweden chose not to adopt the treatment protocol at all. In terms of the outcomes assessed, the primary outcome of the study was survival without BPD at 36 weeks. BPD was formally defined as the need for supplemental oxygen at 36 weeks. The team also tracked chorioamnionitis, defining it by maternal fever with clinical or microbiological signs of infection or histopathological placental inflammation. Secondary outcomes included the infant's age at their last day on mechanical ventilation and their age at their last day on any respiratory support. They also looked at the need for pharmacological or surgical treatment of the PDA, the use of systemic steroids, and safety outcomes including comprehensive lists of perforations, NEC, infections, pulmonary hemorrhage, insulin treatment, IVH, et cetera. In terms of results, 1,140 infants were born in the centers where prophylactic hydrocortisone was implemented. Of these, 1,106 infants were included in the final analysis. When looking at baseline demographics based on the intention-to-treat grouping, the gestational age was significantly lower in the group exposed to steroids. The median gestational age for the exposed infants was 25 weeks and four days, whereas the median gestational age...

Ben Courchia MD (07:47.662) ...for the control group was 26 weeks and one day. The overall cohort's median gestational age was 25 weeks and six days with a median birth weight of 780 grams. No other baseline characteristics differed significantly between the groups. Breaking down the gestational age distribution for the infants born between 22 and 23 weeks, there were 92 infants in the exposed group. That represents 19.4% of that cohort and 15% of the non-exposed cohort. For the 24 to 25-week group, this was 38% of the exposed group versus 33.7% of the non-exposed, and looking at 26 to 27 weeks, we're talking about 42% and 50%. Let's talk about the primary outcomes: 32.5% of infants in the exposed group survived without BPD. In the non-exposed group, the survival rate without BPD was 29.3%. The unadjusted odds ratio was 1.16. The adjusted odds ratio was 1.62. Covariates associated with the primary outcome included gestational age, birth weight Z-score, sex, multiple births, prenatal steroids, 10-minute Apgar, intubation at birth, the center of birth, and surfactant treatment. They ran a sensitivity analysis using a one-to-one propensity score matching, which yielded an odds ratio of 1.4 for survival without BPD favoring the exposed group. When expanding the view to the larger national cohort including all six Swedish centers, the adjusted odds ratio remained significant at 1.58. The number needed to treat to achieve one additional infant surviving without BPD was 32 based on unadjusted rates and 15 using propensity score-matched data. When breaking the composite primary outcome into its components, the adjusted odds ratio for BPD alone was 0.65. Specifically, BPD was diagnosed in 49.2% of exposed infants and 54.6% in the non-exposed infants. Mortality before 36 weeks did not differ significantly between the groups. Death occurred in 18...

Ben Courchia MD (10:09.806) ...4% of babies exposed to hydrocortisone compared to 16.1% for the babies who were not exposed. When they stratified the outcomes by gestational age, the benefit was most pronounced in infants born between 24 and 25 weeks. If you look at the data, specifically Table Two, you can see that the difference in survival without BPD was quite striking for 24 to 25 weeks. For 22 to 23 weeks, it was 5.4% versus 4.1%. We're not going to mention that because there are very few babies in that group. But for 24 to 25 weeks, the difference was 24.4% in the exposed group versus 13.6% in the control group. Again, we're talking about survival without BPD. For 26 to 27 weeks, it didn't really make that much of a difference, 52% versus 47%. In terms of secondary outcomes, there were no significant differences between the exposed and the unexposed groups regarding the incidence of a PDA, either overall or when looking specifically at the need for medical or surgical treatment. However, the exposed group did have significantly fewer days on mechanical ventilation compared to the non-exposed group, showing a relative risk difference of 0.77. In terms of safety, the treatment was generally well tolerated. The researchers found no significant differences between the groups regarding the incidence of spontaneous perforation, necrotizing enterocolitis, insulin treatment, pulmonary hemorrhage, IVH, ROP, or cystic PVL. Late-onset bacterial infection did occur more frequently in the exposed group, 23.8% versus 17.7% in the non-exposed group. However, this difference was no longer statistically significant once they adjusted for covariates, dropping the adjusted odds ratio to 1.3.

Ben Courchia MD (12:04.938) Even in the larger national cohort analysis where late-onset infection and insulin treatment initially appeared more common in the exposed group, neither safety outcome remained significant after adjustments. The authors conclude that this national cohort study provides evidence that the introduction of early prophylactic hydrocortisone to extremely preterm infants was associated with increased survival without BPD after adjustments, without any registered short-term adverse effects; long-term follow-up and further prospective studies are warranted to assess potential risks and benefits, particularly regarding neurodevelopmental outcomes and identification of high-risk groups. Daphna, what do you think?

Daphna Yasova Barbeau MD (12:38.89) Well, it makes sense if we're going to tackle lung inflammation, we should tackle it early, right? We know that every day of mechanical ventilation worsens pulmonary inflammation. But it's hard with those little babies where you still don't know if they are early because they're infected. I feel like we're not separating the groups out enough. Like the reason for prematurity when we do studies like this.

Ben Courchia MD (13:11.566) For sure. I think what you're seeing — I'm going to ignore the 22 to 23-week group — but you can see that the babies most at risk of BPD, the 24 to 25-weekers, show a better response to hydrocortisone than the babies who are a bit less at risk, the 26 to 27-week group. And the adjusted odds ratio, which allows you to reach that clinical significance for the primary outcome of survival without BPD, really is based on a lot of corrections, right? You adjust for sex, multiple births, birth weight with and without Z-scores, gestational age, Apgars at 10 minutes, intubation at birth, the center of birth, prenatal steroids, and surfactants. That's a lot of covariates to account for. Without looking at each variable individually, it shows me that there's this blanket...

Daphna Yasova Barbeau MD (13:44.63) Mm-hmm.

Ben Courchia MD (14:07.342) ...option of giving hydrocortisone to everybody because it's prophylactic is not it. This paper shows you that there are certain patients that need it more than others, even though it was given to everybody. I still think you could choose a baby based on specific characteristics and get the most bang for your buck. I would not do it wholesale for everybody. But that's me.

Daphna Yasova Barbeau MD (14:29.354) I think we've spent a lot of time focusing on this in a number of episodes. It's like a new thread. We've been focusing on gestational age groups, right? We know the 22-weekers aren't the same as the 24-weekers, and aren't the same as 26-weekers. But the babies delivered for preeclampsia are not the same as the babies delivered in preterm labor that is precipitous due to chorioamnionitis. I think whether or not we give them steroids may make a difference. Their risks for BPD are different. I wish we had more granularity of the data, always.

Ben Courchia MD (15:10.796) Yep. We'll put that on our list for Santa Claus.

Daphna Yasova Barbeau MD (16:08.981) I want to talk about car seats today. This was an article in JAMA Network Open, Predischarge Car Seat Tolerance Screening in Preterm and At-Risk Full-Term Infants: A Systematic Review and Meta-Analysis. Lead author Brian King, and this whole group — Dr. Dalvie, Dr. Hay, Dr. Jensen, Dr. Zupancic — so quite a group.

Ben Courchia MD (16:47.174) All are friends of Beth Israel.

Daphna Yasova Barbeau MD (16:46.604) That's right. Where does the pre-discharge car seat tolerance screening come from? It has been recommended by the American Academy of Pediatrics, first endorsed in 1991. That was based on observations from some small studies showing that preterm infants and full-term born infants with risk factors like low birth weight can have vital sign instability when they're semi-upright in a car seat. So we really moved to universal screening for the premature baby and some of these at-risk full-term infants. Now, the pendulum is in some ways swinging a little bit. There was a Cochrane review published in 2006 that found no randomized clinical trial that addressed this question. The Canadian Paediatric Society removed recommendations for car seat testing in 2016. Kaiser Permanente in California moved away from routine car seat testing in 2016, and they have subsequently published data on more than 40,000 infants after that change, showing no change in the rates of measured adverse outcomes after not doing routine car seat testing. That's really what they wanted to evaluate. This was a systematic review and meta-analysis to estimate the association of car seat testing with length of stay and post-discharge outcomes, and to estimate the overall proportion of infants who fail an initial and subsequent test. They looked at English language articles published before June 2025. They had the following inclusion criteria: one, a newborn population before hospital discharge; two, car seat testing with established failure criteria. They included all study types, but categorized them into three subgroups: one, randomized control trials; two, non-randomized intervention studies that included a comparison group of infants that did not undergo or did not have a documented passed car seat test prior to discharge; and three, single-group observational studies that reported car seat tolerance failure rates. The exclusion criteria were: one, observational studies that described clinical instability without reporting car seat test failure; two, observational studies of adherence to testing recommendations; three, surveys of clinical practice; and four, studies that were limited to certain subgroups like, for example, just congenital heart disease. They looked at the literature and found 857 unique articles.

Daphna Yasova Barbeau MD (19:38.155) Further review identified 76 articles for full-text review. 55 of these were excluded based on the exclusion criteria. That left them with 21 studies. Most studies were single-group and lacked a comparison group of infants who did not undergo car seat testing. Three studies, which was 14% of the studies, included a comparison group discharged without a passed car seat test and were categorized as non-randomized interventional studies. This included 54,000 participants, 27,000 of which were the control group without a car seat test. Most of the studies were of preterm infants, so gestational age less than 37 weeks. This was about 67% of the studies. Studies could have included babies admitted to the NICU or the well-baby nursery, and that will become important later on. Regarding car seat test failure criteria, all the included studies were consistent with their definition of apnea. They used 20 seconds, but interestingly, they used variable thresholds to define bradycardia and desaturation events. And we will talk about that.

Ben Courchia MD (21:03.102) Do you think we'll revise this definition one day, like this 20-second definition of apnea?

Daphna Yasova Barbeau MD (21:07.816) Yeah, maybe. I think it was really interesting to see what the criteria were. Again, pretty consistent with the apnea duration, but the bradycardia cutoff wasn't even that consistent. 76% of studies used less than 80 beats per minute, but there was a wide variation of bradycardia duration: any duration in 14%, 10-second duration in 28%, five-second duration in 10%, persistent bradycardia in 10%. There was also a really wide range of desaturation cutoffs. What do you even decide is a failure? Apnea? Sure. Everybody agreed on 20 seconds of apnea. But was it any desaturation? That was nearly 10% of studies. The desaturation cutoff was 93% in 9% of studies, 90% in 24% of studies, and 85% in 10% of studies. People were using cutoffs anywhere from under 93% to 85%. To me, those are two very different types of desaturations. That's one thing I think to be considered. Among the 21 included studies, there was an overall estimate of 8.62 failures per 100 patients. Now, among the subgroup of patients undergoing testing in the nursery, the estimate was 9.86 per 100 patients compared with 7.11 failures per 100 patients among infants who were being tested in the NICU. So there were actually more failures in the newborn nursery than there were in the NICU. Interestingly, eight studies included patients undergoing the initial testing in the nursery or the NICU. In six of those studies, the first test failure rate was higher in the nursery as compared to the babies in the NICU.

Daphna Yasova Barbeau MD (23:29.804) Among preterm infants, the overall estimate was 8.56 failures per 100 patients compared with an estimate of 10.72 failures per 100 patients among full-term born infants. That gave me pause that they were seeing more failures in full-term born infants. But again, full-term infants that get selected for car seat testing have other comorbidities or risks for failing the test. That's why we're including them. Six studies included both preterm and full-term born infants undergoing their initial test, and in five out of the six studies, there were higher first test failure rates among term infants compared to preterm infants. What about repeat car seat tests? 11 studies with a total of just over 900 babies reported results for repeat testing among infants who failed the initial screening. The timing of repeat testing was variable. We always have this discussion. In six studies, repeat testing was performed between 12 and 48 hours. In two studies, the repeat testing was delayed for more than 48 hours. In three studies, they didn't report the repeat test interval. The overall estimate for the 11 included studies was 24% of babies — so 24 out of 100 patients who failed the first car seat test failed a second test, so one in four. Two studies reported results of repeat testing among infants regardless of whether they failed the initial test, which I thought was interesting. In Davis et al., 11% of moderately preterm infants (six out of 53 infants) who passed an initial car seat test failed one of two repeats 24 to 48 hours later. I thought this was a very interesting fact. Additionally, in DeGrazia et al., the second study, among the 41 preterm infants who passed their initial car seat test, 10% failed repeat testing just 12 to 36 hours later. What about length of stay? Only two studies compared pre-discharge length of stay between patients who underwent testing before discharge compared to patients discharged without it. They weren't able to pool it just because the samples were so different.

Daphna Yasova Barbeau MD (25:48.651) But in one study, they reported no difference in unadjusted overall length of stay when comparing 21,000 infants before and 20,000 infants after discontinuation of routine car seat testing. In the other study, they reported no significant difference in length of stay, maybe six hours longer for the babies who failed the car seat test. However, when they stratified the analysis in this study, they found that routine car seat testing was associated with a significantly longer adjusted length of stay for those babies who were being tested in the NICU. Those babies on average stayed an additional nearly 36 hours longer, which makes sense based on the average retesting interval. They mentioned based on these two studies, there's a low certainty of evidence that car seat testing is associated with overall average pre-discharge length of stay, which is actually not what it feels like, but that's why we do studies. And post-discharge outcomes. Three studies described post-discharge outcomes with a comparison group. They weren't able to pool these either based on differences in study design and outcome reports. But two studies reported death within 30 days of discharge. The Jensen et al. paper observed no deaths in the cohort of infants discharged without a passed car seat test. Braun et al. observed fewer deaths after stopping routine pre-discharge car seat tests, an odds ratio of 0.26. After adjustment for other clinical factors, the difference was not significant. All three studies reported no significant difference in rates of readmission within 30 days after discharge, and a meta-analysis of data from the three studies similarly showed no difference in an unadjusted readmission rate. Two studies included death or readmission within 30 days as a composite outcome, and there were no significant differences between the groups in either study or in the pooled rate of death or readmission within 30 days. So they conclude...

Daphna Yasova Barbeau MD (28:05.961) ...that testing was not associated with a reduction in 30-day mortality or hospital readmission. Approximately 10% of infants fail initial testing, of whom one in four will fail their repeat testing. I wanted to underscore that even babies who passed their test often failed a subsequent test. I thought that might be potentially the most interesting piece of data. They note that failure and repeat testing potentially contributes to prolonged hospitalization in this subset of infants without clear evidence of benefit. As such, current recommendations for routine car seat testing in all preterm infants may merit reevaluation. I will say one thing that our population's car seat testing has been very effective at, and that is identifying how many families do not actually have car seats at the time of discharge. If we didn't test them for car seats, I think they would go home without one. Actually, we've had the Broward County Sheriff's Department come in and do discharge car seat teaching with families. They say the proportion of babies that are not in car seats on any random stop is frightening. So, I mean, for that reason alone...

Ben Courchia MD (29:14.703) Yeah, teaching. Yeah. Frightening.

Daphna Yasova Barbeau MD (29:27.55) ...in our neck of the woods, identifying a car seat. That's not the purpose of the test. It causes everybody a lot of anxiety. The nurse that has to do it, the family, it may cause the baby anxiety. I don't know.

Ben Courchia MD (29:42.11) But that's not the reason for the test. I invite you all to listen to a recording that we did at Hot Topics in Neonatology with Michael Narvey about car seat testing. All of my thoughts are encompassed in that episode, because like we were discussing, putting a baby on a leveled floor that doesn't move in any direction...

Daphna Yasova Barbeau MD (29:48.512) Hmm. Yes. Mm-hmm.

Ben Courchia MD (30:09.672) ...for two hours, how is that simulating a car ride? Either you put the baby in a car seat on a flat surface and say, "I'm doing a fitting," and you fit the baby for the car seat. But you're just simulating a baby being in a car seat for two hours. You're not simulating a drive. Does every baby need a car seat test? I don't know. This is something that we do that is not causing a lot of angst amongst the community, so we keep doing it, but we don't have a good reason for it. We all feel very embarrassed when the baby fails the car seat and the parents are like, "What now?" And we just do it again. "If you pass, go home tomorrow." It feels so silly, but it is what it is.

Daphna Yasova Barbeau MD (30:48.199) We just wait. And they're like, "How long do you wait?" And you're like, "I don't know." Sure. Now, I will say, car seat testing and identification of the car seat is very important. There are lots of babies who...

Ben Courchia MD (31:09.678) Agreed. "Oh, I don't have the base." Or sometimes you see parents bringing a car seat that's way too big for their former preemie. And you're like, "Oh my God, this kid is way too big."

Daphna Yasova Barbeau MD (31:14.738) Yeah. Or you can even see that within a set of multiples. Like one kid fits fine in the car seat and the other kid just does not. It matters. Not every car seat is built for every baby. So that's a different discussion.

Daphna Yasova Barbeau MD (31:37.913) I know you had a few more papers that you were very interested in this week.

Ben Courchia MD (31:45.372) Yes, very, very much so. The first paper that I'm going to review is a paper that came out in the Journal of Pediatrics. It is called "Pulmonary Hemodynamics and Long-Term Outcomes in Children with Pulmonary Hypertension Associated Bronchopulmonary Dysplasia." Long title. The first author is Eric Austin. Last author is Steve Abman, and it's coming from the Pediatric Pulmonary Hypertension Network, the PPHNet investigators. It's a very important paper. I know that Dr. Gabriel Altit from our hemodynamics training in Montreal has made it a mandatory read for all the fellows. I don't think he's wrong. I think it's an important paper.

Ben Courchia MD (32:14.59) Let's go through the background. We know that pulmonary hypertension (PH) is quite common, especially in infants who have bronchopulmonary dysplasia, with a prevalence ranging from 6 to 39%, usually diagnosed around 36 weeks of post-menstrual age. In fact, the prevalence of pulmonary hypertension increases as your BPD severity increases, approaching nearly 40% in infants with severe BPD, according to previous classification schemes. If you want to diagnose pulmonary hypertension, there is no question among experts that the gold standard for diagnosis is cardiac catheterization. However, we all know that this is not a simple procedure to perform. It's risky, especially as the babies are smaller. Because of these risks, most of the babies with pulmonary hypertension and associated BPD are diagnosed with an echocardiogram without doing cardiac catheterization. So we lack published studies on BPD-associated pulmonary hypertension that both confirm the diagnosis and provide detailed invasive hemodynamic metrics. That said, the clinical indications for performing the cardiac cath in the BPD populations have been well described and recently reviewed in the literature. This is the key. I think I've mentioned this already once: no matter what people say about hemodynamics and echo, the goal is always to approximate a cath, right? The cath is the gold standard for any measurements related to the heart. It's not surprising to read about that in the introduction.

Ben Courchia MD (34:37.694) Despite many studies showing that pulmonary hypertension is more common in the severe form of BPD, pulmonary hypertension was not actually incorporated into the NRN grade definition of BPD, the Jensen criteria. Furthermore, we haven't really studied the relative differences in pulmonary hemodynamics as defined by cardiac catheterization according to the grade of BPD severity. To give you an idea of the scale of this disease, the PPHNet recently reported on a registry of about 1,500 subjects with all forms of pediatric pulmonary hypertension. In that registry, babies who have pulmonary hypertension associated with BPD as their primary classification were 22%, making it the second most common subtype of pulmonary hypertension in the PPHNet.

Ben Courchia MD (34:37.694) The researchers hypothesized that patients with grade 3 BPD on the Jensen classification would have more severe hemodynamic indices of pulmonary hypertension on cardiac catheterization near the time of diagnosis, as well as worse overall survival. To test this hypothesis, they aimed to do three things. First, they wanted to study the epidemiology of patients who have BPD-associated pulmonary hypertension using the new BPD definition of the Neonatal Research Network, the Jensen criteria. Second, they aimed to evaluate the invasive hemodynamic metrics from cardiac catheterization performed around the time of the diagnosis, stratified by BPD severity. Finally, they wanted to examine how these invasive hemodynamic metrics at diagnosis relate to long-term outcomes, including survival.

Ben Courchia MD (37:03.164) In terms of the study itself, they utilized data from subjects born before 32 weeks of gestation who had a confirmed diagnosis of pulmonary hypertension. These patients consented to participate in a multi-center longitudinal study, specifically the PPHNet registry across 14 pediatric pulmonary hypertension centers in North America. Enrollment began in 2014, and this specific report includes follow-up data all the way through April 2024. The registry includes subjects diagnosed with pulmonary hypertension before 21 years of age based on established pediatric guidelines. For this particular cohort, the diagnosis of pulmonary hypertension was made using an echocardiogram at the discretion of the treating pediatric specialist. The cohort included babies born before 32 weeks, and they excluded infants if they lacked a complete electronic case report form, or if they had a diagnosis of congenital diaphragmatic hernia, omphalocele, or defined genetic syndromes. Basically, this led to a population of 320 babies. It's unusual to see the actual sample size in the methods, but here it's reported already.

Ben Courchia MD (37:03.164) The diagnosis of severe BPD was done using the Jensen criteria. I think that we are now all familiar with the Jensen criteria, but it's a good opportunity to review. This system of classification defines three grades. Grade 1 is defined as nasal cannula support with flow of less than two liters per minute. Grade 2 is nasal cannula support with flow of two liters per minute or more, or non-invasive respiratory support like CPAP. Grade 3 is the use of invasive mechanical ventilation.

Ben Courchia MD (38:35.525) The researchers and the team recorded the use of specific pulmonary hypertension medications, grouping them into different classes: calcium channel blockers, inhaled nitric oxide, phosphodiesterase V inhibitors like sildenafil — this is board review stuff — endothelin receptor antagonists, prostacyclins like treprostinil, and selexipag. It's important to note that cardiac catheterization was not a requirement for enrollment, and it was performed based on the clinical team's discretion at each institution. For those who did undergo the cath, their response to acute vasodilator testing was categorized as reactive versus non-reactive based on established criteria. They used different criteria: the Sitbon, the Barst, and the modified Barst criteria. The primary outcome of the study was a composite of time to the earliest occurrence of either death or lung transplant, analyzed according to BPD severity. A secondary analysis looked at competing risks, including death, lung transplant, and resolution of pulmonary hypertension, with resolution defined simply as cessation of pulmonary hypertension medications.

Daphna Yasova Barbeau MD (38:38.05) We don't usually see lung transplant as an outcome in our studies.

Ben Courchia MD (38:38.05) I know. You read about it and you're like, we discharge these babies and I never mention, even on a grade 3 BPD patient, whether they might be subject to a lung transplant. I never mention it. To be very honest with everybody. I don't know if you guys do, but I never mention that. I never even discussed that with families. Let's get into the results.

Ben Courchia MD (39:06.814) For the 320 subjects, the mean gestational age at birth was 25.8 weeks, ranging from 22 to 31 weeks. The mean birth weight was 721 grams. The researchers had sufficient data to determine the BPD grade at 36 weeks for 278 of these subjects, which is about 87% of the cohort. Among these 278 subjects, 27% were grade 1 BPD, 44% were grade 2, and 29% were grade 3. Almost an equal one-third, one-third, one-third, maybe a little bit more prevalence of grade 2. There were no significant differences among the three BPD grades when looking at sex, age of diagnosis, ethnicity, or race. Prenatal histories were also not notably different among grades one, two, or three. Looking at early neonatal and infant conditions, a history of necrotizing enterocolitis was significantly more prevalent in the more severe BPD group. It occurred in 28% of those with grade 3 BPD, 10% of grade 2, and 16% of grade 1. We don't know very much about the gut-lung axis. We talk about it, but these kinds of associations make you wonder how much the two are at play with one another. Additionally, 30% of the overall cohort was small for gestational age, but this did not really vary by the different BPD grades.

Ben Courchia MD (41:30.834) Looking at medication within a month of the diagnosis, 35% of the cohort were treated with a single pulmonary hypertension-specific drug. Another 11% were treated with two or more drugs. The remainder, 54% of the cohort, were not treated with any drug specific for PH around the time of diagnosis. The median follow-up time for the cohort was 3.6 years, during which 48% underwent cardiac catheterization at least once. In terms of the subjects who underwent cardiac catheterization — 69 out of 320 within a month of diagnosis at a median age of 0.7 years — their hemodynamic measurements were consistent with what's known as precapillary pulmonary hypertension. What is precapillary pulmonary hypertension? It means that the pulmonary hypertension is most likely taking place between the right ventricular outflow tract and the lungs. Postcapillary would be something like pulmonary vein stenosis. Their indexed pulmonary vascular resistance was 7.2 Wood units times square meter, and they did not have an elevation in pulmonary capillary wedge pressure, which averaged 9.4 millimeters of mercury. The pulmonary to systemic blood flow ratio, the Qp:Qs, was 1.32. Ten of these subjects had a Qp:Qs greater than 1.5, showing a lot of pulmonary overcirculation. Of these 69 subjects who were catheterized early, 59 had a known BPD grade: 19 had grade 1, 20 had grade 2, and 20 had grade 3.

Ben Courchia MD (41:30.834) Let's look a little bit at survival and long-term outcomes. In terms of mortality, 8% of the cohort died during the study period. While the BPD grade was unknown for three of the patients, of the 22 who had a determined grade, 13 were grade 3, five were grade 2, and four were grade 1. That's interesting to see that this is, as we expect, skewed towards the more severe form of BPD. Interestingly, six of the 25 patients who died had a concurrent diagnosis of pulmonary vein stenosis. This is postcapillary pulmonary hypertension. Among these six patients, the BPD grade was unknown for one, and the other five all had grade 3 BPD. Right heart failure was progressive in 10 subjects. Of these, five had grade 3 BPD, two had grade 2, two had grade 1, and one had an undetermined grade. Three subjects unfortunately died during cardiac catheterization. A reminder of how tricky this procedure can be. When exploring survival at five years post-diagnosis, the transplant-free survival rate was 94% for babies with BPD grades 1 and 2, compared to only 87% for babies with grade 3, but this difference was not statistically significant. Competing risk analyses evaluating time to death or lung transplant also showed no statistical significance according to BPD grade. Even the time to cessation of pulmonary hypertension-specific medication, which increased from grade 1 to grade 2 to grade 3, did not reach statistical significance. Finally, looking back at the hemodynamic data at diagnosis, these metrics did not differ according to BPD severity grade.

Ben Courchia MD (43:56.35) How do we put it all together? Let's highlight some of the key takeaways regarding the distribution and severity of disease. The authors found an equal representation of subjects from all grades of BPD severity. I think that's the number one thing that is important to note. This is in contrast to prior studies, which show that the most severe forms of BPD are probably the ones associated with BPD-associated pulmonary hypertension in very high proportions. Here in this study, we see that mild BPD patients, or grade 1 BPD patients, are actually represented in the cohort. For the 69 subjects who had a cardiac cath within a month of diagnosis, there was a clear precapillary hemodynamic condition, yet neither these hemodynamic metrics nor overall survival were statistically significantly different across the BPD severity grades. In fact, grade 3 BPD had similar invasive hemodynamic metrics to grade 1 and grade 2 at diagnosis. This suggests that the severity of lung disease at 36 weeks, when BPD is graded, is not directly indicative of the severity of pulmonary vascular disease. This is a point that is very well recognized by the Jensen criteria and authors, saying that we use 36 weeks as a time point to assess BPD because that's what we do. But if you could wait a bit longer, you would probably be more accurate. Because you see some babies with some form of mild BPD, the question has to be asked: are you assessing BPD at the right time point? It's a very interesting question.

Ben Courchia MD (43:56.35) The authors reference a recent three-grade system proposed by the BPD scoring criteria by Jensen as graded based on the predictability of death or serious respiratory morbidity for 81% of the subjects, including 20% mortality for those with BPD. However, the system that Jensen outlined does not incorporate pulmonary hypertension in the diagnosis of BPD, which could be a crucial driver of outcomes. So the Jensen criteria were established based on an outcomes-driven classification. The authors are saying, well, if it's outcomes-driven, then maybe we should include pulmonary hypertension in the criteria. They also talk about data from the BPD collaborative, where they looked at patients discharged on mechanical ventilation via tracheostomy. That study, I believe from 2020, found that the majority of infants survived and improved, and that having pulmonary hypertension did not associate with later liberation from respiratory support compared to BPD alone, suggesting that pulmonary hypertension might not be the key driver of respiratory support requirements. By focusing on the 69 subjects catheterized within a month of diagnosis, the team really wanted to look at patients that were more naive to PH therapies and disease duration. They outline the severe elevation of pulmonary artery pressures and much lower rates of responsivity to formal acute vasodilator testing, only 8% to 10% in this study compared to 30 to 82% in previous reports. For instance, a previous single-center study had found a 35% positive testing rate. Ultimately, even though only 8% of the participants died and one had a lung transplant, the overall freedom from death or transplant in this cohort was slightly higher than in most other studies from the past 15 years.

Ben Courchia MD (46:20.67) The conclusion of the study is that using the large data set from the PPHNet, they found a similar distribution of grade 1, grade 2, and grade 3 BPD-associated pulmonary hypertension with a high proportion of freedom from death or lung transplant. Among those undergoing cardiac catheterization, invasive hemodynamic profiles did not really associate with BPD severity grade, although the majority of deaths occurred among those who had the most severe form of BPD. Further studies are warranted, and reduced survival among those with grade 3 BPD and pulmonary hypertension may be driven by factors independent of pulmonary vascular hemodynamic parameters. I think this was quite interesting. The idea of the presence of BPD in various grades and pulmonary hypertension was obviously quite interesting.

Daphna Yasova Barbeau MD (48:30.67) Yeah, I agree. I thought it was kind of unexpected.

Ben Courchia MD (48:34.417) Yeah. Do you have any thoughts on it?

Daphna Yasova Barbeau MD (48:36.216) I'm wondering, should that change our follow-up referral plans? Do these babies who we think are low grade need to be watched more carefully than I thought? I don't know.

Ben Courchia MD (48:52.252) What this says to me is that the information we gather at 36 weeks is not the most reliable. At 36 weeks, we try to have a serious conversation with the parents about, "Okay, this is the time we make a decision on clinical diagnosis of BPD." But the truth of the matter is that at 36 weeks, you don't know very much. I had read some papers that look at how it would be better if we actually made that assessment closer to 40 weeks. If you think about it, when we talk about really invasive management of BPD, whether it is doing a tracheostomy or anything like that, we don't do it at 36 weeks. Most people wait until 42, 46 weeks, sometimes 52 weeks. We don't really act on anything too much when it comes to 36 weeks, yet we want to label the condition at that moment. The obvious issue is that we need to find a time point where most babies are still in the NICU because if they get discharged, then you can't assess them. First of all, that's not necessarily true. But also, most of the babies with BPD who are on significant respiratory support are not discharged by 36 weeks. They're still in the NICU.

Ben Courchia MD (50:15.198) Very tough, but very interesting nonetheless. And very surprising. I'm going to remind people, the main finding is the association between grades of BPD and pulmonary hypertension...

Daphna Yasova Barbeau MD (50:53.828) You can help yourself. You had to go in for a second shot at the conclusion.

Ben Courchia MD (51:00.289) It's still baffling that among the patients they had, there were 27% grade 1 BPD, 44% grade 2, and 29% grade 3. This is insane. If you had asked me, of the babies who have BPD-associated pulmonary hypertension, how many have grade 1, grade 2, or grade 3? I would have said 80%, 15%, 5%.

Daphna Yasova Barbeau MD (51:32.112) Yeah, in the opposite. Grade 3, 80%.

Ben Courchia MD (51:32.112) Right.

Ben Courchia MD (51:50.568) I have another interesting article for you, Daphna. This one is coming straight out of JAMA Ophthalmology. Not always, yeah. The paper is titled, I know, but this one has one of our good friends on the paper, Dr. James Berry.

Daphna Yasova Barbeau MD (51:56.894) Hmm.

Daphna Yasova Barbeau MD (52:03.703) That's not always on our radar.

Ben Courchia MD (52:15.038) And the paper is called Deep Learning Based Prediction of Cardio-Pulmonary Disease in Retinal Images of Preterm Infants. I know. Yesterday we spoke about BPD and pulmonary hypertension. And here, this is also going to be a center point of this particular research. The authors mentioned that it is a leading cause of...

Daphna Yasova Barbeau MD (52:20.808) Very cool. It's coming.

Ben Courchia MD (52:37.296) ...morbidity and mortality in premature infants and current prediction tools rely primarily on demographics such as gestational age at birth and birth weight, which are easy to obtain, but obviously are not the most sensitive or specific to be clinically actionable. Now they're mentioning that recent advances in deep learning have demonstrated the ability to diagnose non-ocular disease from retinal images, a field that is often referred to as oculomics. In this project, the authors analyzed a large dataset of fundus images obtained as part of routine ROP examinations. Their objective was to determine if these images could identify patients who would later develop BPD or pulmonary hypertension. Crucially, to ensure that this was predictive rather than just diagnostic, they limited their analysis to the images obtained at 34 weeks post-menstrual age or less, specifically chosen to precede the standard clinical diagnosis window for BPD and pulmonary hypertension. Have I piqued your curiosity? You're nodding, but you're muted.

Daphna Yasova Barbeau MD (53:43.646) Yeah, as soon as that. Absolutely. I think it's super exciting. Plus it would be cool as the neonatologist to just see more images of what we're looking at. What do they say? The eyes are the window to the soul. To the whole body, I guess. But isn't that true? When we have a kid that we're like, hmm, something's up with this kid, genetics maybe. Let's get an eye exam.

Ben Courchia MD (53:47.964) Ahem.

Ben Courchia MD (53:54.845) Yeah.

Ben Courchia MD (53:58.898) The window to the soul, but it looks like the eyes are the window to your pulmonary vasculature.

Ben Courchia MD (54:10.558) The study utilized data from the Multi-Institutional Imaging and Informatics in Retinopathy of Prematurity, the iROP study, collected between 2012 and 2020. The analysis included infants recruited from seven neonatal intensive care units. Infants were eligible if they met criteria for ROP screening, having a birth weight of 1500 grams or less...

Daphna Yasova Barbeau MD (54:12.198) Infection. Let's get an eye.

Ben Courchia MD (54:39.774) ...or a gestational age less than 31 weeks. The authors developed a multimodal model. First, they used a deep learning model with a ResNet 18 architecture to extract visual features from the retinal fundus photos. Then, as a second layer of that multimodal model, they combined these visual features with demographic data. They added birth weight, gestational age, and post-menstrual age. Third, these combined inputs were then fed to a support vector machine classifier to predict the final diagnosis. I usually would ask if you have any questions about that; please do not ask me any questions about that. I am reporting the paper, and I would not be able to explain the intricacies to you. I'm just going to be very honest.

Daphna Yasova Barbeau MD (55:33.214) I appreciate your honesty.

Ben Courchia MD (55:37.864) But that's also how I read a lot of these AI papers. I think that's an important point. I don't understand the intricacies of the ResNet 18 architecture and so on. Don't get bogged down with those particular details. Just keep reading through to understand how they're leveraging these tools, which is what I did. To ensure that the model was not simply detecting the severity of retinopathy of prematurity itself, they trained the secondary model using only the images that had no clinical signs of ROP as well. The definition of BPD that they were using was the oxygen requirement at 36 weeks, and pulmonary hypertension was diagnosed using echocardiography at 34 weeks, defined as a pulmonary artery pressure greater than one-half systemic pressures. Any questions about any of that? No, thank you. We're moving right along.

Daphna Yasova Barbeau MD (56:30.395) No, I think we're gonna go. We're moving right along.

Ben Courchia MD (56:36.518) In terms of the outcomes. The analysis included 493 infants in the BPD cohort. The mean gestational age was 25.7 weeks for infants who had BPD compared to 27.3 weeks for those who did not. The PH cohort was a subset of 184 infants from a single site out of these 400 and something patients. In terms of the prediction of BPD, the authors reported performance on a held-out test set using the area under the receiver operating characteristic curve, the AUC. They found that using the demographics alone, an AUC of 0.72 was achieved. Using an imaging-only model, they achieved the exact same type of AUC, 0.72. But when they were using the multimodal model using this SVM, the support vector machine, they were able to achieve a much higher area under the receiver operating characteristic curve of 0.82. This improvement was statistically significant compared to imaging alone and approached significance compared to demographics alone. When it came to the prediction of pulmonary hypertension, the demographics alone model performed modestly with an AUC of 0.68. The imaging-only model performed remarkably better with an AUC of 0.91. Using the multimodal model, it also achieved an AUC of 0.91, showing no additional benefit over imaging alone. Importantly, these results persisted even when the models were trained on images lacking any significant signs of ROP, suggesting that the algorithm was detecting identifying features independent of standard ROP pathology. So you didn't really need to have underlying ROP to basically make the prediction. It's a relatively small review of this paper. The authors conclude that retinal images obtained during ROP screening can predict the diagnosis of BPD and pulmonary hypertension in preterm infants. In their discussion, they offer a compelling hypothesis for why this works. This suggests that...

Ben Courchia MD (58:55.718) ...mechanical ventilation or CPAP may lead to subtle changes in the retinal or choroidal vasculature that a deep learning algorithm is able to detect even before overt clinical symptoms appear. The findings of the paper suggest that oculomics could lead to earlier diagnosis and potentially avoid the need for invasive diagnostic testing, such as cardiac catheterization in the future. I don't know about that, but I know that we're all trying to figure out a way to screen for pulmonary hypertension in the least invasive way. This doesn't seem like it's a big stretch using data that is already collected. So I thought this was quite interesting.

Daphna Yasova Barbeau MD (59:34.983) I think that is super cool, especially that it's not a separate eye exam. It's the same eye exam. They're going to get them anyways, the babies that are most at risk. And if they start getting them around 31 weeks and we can already have more information, that may manage how we wean babies off of ventilatory support. Do we offer them other medication support? I think it's super exciting.

Ben Courchia MD (59:43.74) Mm-hmm.

Ben Courchia MD (1:00:02.844) Yeah. I think it's only the beginning of things that we're going to see AI able to do a decent job at that otherwise was completely untapped potential. Who has ever looked at ROP screening images to actually look at BPD, pulmonary hypertension, and so on? This is completely a new frontier.

Daphna Yasova Barbeau MD (1:00:14.525) For sure.

Daphna Yasova Barbeau MD (1:00:24.241) Yeah, and it's not like we're great at predicting it anyway. So it's awesome. Very cool.

Eli (1:01:01.71) This article is looking at the interesting trend of the emergence of birth centers over the last couple of decades and the more recent challenges that birth centers are facing. This really well-written story, which was in Stateline, a nonprofit newsroom, was written by Anna Claire Vollers and Nada Hassanein — who I have to say I know and adore and is fabulous. It covered this phenomenon of at the same time that hospital labor and delivery units are shutting across the country, freestanding birth centers are struggling to stay open. And that's despite the fact that these birth centers...

Ben Courchia MD (1:01:31.791) Mm-hmm.

Eli (1:01:57.706) ...in recent years have emerged as a potential new option for families seeking prenatal and perinatal care. However, in recent years, these birth centers, especially in a few states that have had more stringent or less flexible regulations around this new model of care delivery, have really struggled to both get the approvals they need to get open and stay open, to expand or add services, and to reach a phase where they're financially viable. For example, there is one center that is covered in this story in Alabama. This center, despite doing all the things that any of us would want from a step-down birth unit, was forced to close because the state of Alabama alleged that the lead doctor here was operating an unlicensed hospital. It's quite a challenging landscape out there for trying to get any sort of rigorous perinatal and antenatal care, with the challenges to Planned Parenthood, to hospital labor and delivery units, and now to birth centers. Ben, what did you make of this story, the patterns of birth centers in recent years, and the challenges they're facing as documented here?

Ben Courchia MD (1:03:45.188) I think the points you brought up were excellent. We are seeing that this is not just an issue of birth centers, but it's an issue of places that parents can seek to get a delivery. There's a decline in the number of birth centers. There's a decline in the number of L&D units, which are closing nationwide, which, by the way, is also happening in Europe. In my home country of France, it is becoming very difficult for parents to find labor and delivery units that are remaining open, specifically in what are known as medical deserts. I think that birthing centers, if they are well structured — obviously I'm talking about a delivery that is surrounded by healthcare providers, midwives, and people who are conscientious; we're not talking about places that could potentially be dangerous to families — really have a value in supporting communities. The article makes an excellent point about how these centers can address maternal health inequities, specifically for Black and Indigenous communities. They could also potentially be less costly for parents compared to a hospital stay. Now, I think it is highlighting the fact that...

Eli (1:05:05.78) You...

Ben Courchia MD (1:05:11.076) ...what is going to be the alternative? There's this tension in the article between hospitals, which are concerned about making sure their labor and delivery units remain viable and are opposing the growth of more birthing centers. But the question is, if birthing centers do not open, then what is the alternative? I don't know if people who had decided not to deliver in the context of a hospital are going to suddenly come to a hospital because that is just the option they have outside of a birthing center. I think new alternative methods are going to appear. There are a lot of people who might feel comfortable delivering at home. It may turn what could have been a pretty safe delivery plan into something that is now unsafe. It looks like this is going to be very much a regulatory issue, where there will need to be clear criteria that centers can fulfill in order to provide this option for families in a safe and rigorous manner, without having to fear the pressure of outside players on whether these areas can be open. Because they serve communities, and we don't tend to suspect how empty some of the areas of the US and around the world can be, where for parents to find a safe place to deliver can mean hours and hours of driving.

Eli (1:06:57.622) Yeah, I agree with so much of what you said. I think there is one de facto option that seems like it may take an increasing share of parents desperate to find some sort of option. And those are so-called crisis pregnancy centers, which are far from what we would consider typical physician-driven antenatal care. There's been lots of reporting on this, but these are centers that are often formed by religious organizations or sponsored by political organizations, more commonly from the right. They have been found to tend to pressure parents against abortions or other forms of birth control and really don't follow the typical guidelines around antenatal care that we expect. So just to say, the disappearance of evidence-based antenatal care, whether that's delivered in a hospital or a birth center, may be driving them towards other facilities that are not exactly concordant with the evidence-based care that we'd all expect, or to no facility at all. Obviously, we all have experience treating babies born at home and the complications that come with being born at home, whether that is as simple as hyperbilirubinemia early on or breastfeeding jaundice, or more severe things associated with a lack of vitamin K or a lack of genetic screening.

Ben Courchia MD (1:09:06.32) Yeah, the newborn screen. I think it's quite interesting because it really isn't about choosing between a hospital and a birthing center. I think it's about maybe allowing both to exist and serve different needs. If you let entities try to dominate the market, everybody is going to lose, especially the mothers and babies in the communities that can least afford it. There was also an interesting point in the article about transfer agreements, and this idea that as a hospital, you should not be allowed to refuse transfers because the transfer is coming in from a birthing center. These are places where regulation should intervene to force the hands of the hospital and say, "No, you must accept a transfer, no matter where they're coming from if you are the referring center." It will be interesting to me to follow, because I did see in Florida for the past couple of years this surge in parents delivering in birthing centers, but we are seeing it dial down, and it will be interesting to see where patients are coming from if they're not coming from these birthing centers. I know a few hospitals are trying to create their own birthing centers. We'll see if that is a marketing ploy in order to rack up more business. I highly recommend people check out the live stream of the Delphi Conference on day one, where Dr. Jennifer Fang talked about the program that she's running at Mayo about teleneonatology. It's really not related to this particular issue, but in the opening slides of her talk, she does mention the disparities in access to healthcare for delivery specifically in the US. She has a few maps that are quite staggering where you can see the discrepancy between certain areas where the density is absolutely insane in the Northeast, South Florida, and California, but then there are areas where there's absolutely no dot on the map where parents can actually go deliver. You wonder how they are supposed to do this safely. It did sort of bring...

Ben Courchia MD (1:11:32.548) ...to mind the extent of the problem. So I highly recommend checking it out. Day one, it's the opening talk of the conference. It was quite good.

Eli (1:11:41.079) Listen, I'm such a policy wonk. One of my favorite policies to think about is the Emergency Medical Treatment and Labor Act. I forget the acronym, EMTALA. Anyway, I love EMTALA. I've written about EMTALA in lots of settings. I'm not proving that by forgetting the acronym. But anyway, here we are.

Ben Courchia MD (1:11:55.992) Yeah, EMTALA, EMTALA, yeah. I'm going to keep talking; I'm going to find it. It's the Treatment and Labor Act. You're right. Emergency Medical Treatment and Labor Act.

Eli (1:12:06.831) Treatment and Labor Act. I think it's labor.

Eli (1:12:35.791) Because this applies to deliveries as well. That law is a law under the Centers for Medicare & Medicaid Services that says you can't turn people away. It's interesting that hospitals appear to be turning people away preferentially based on anti-competitive intent and microeconomic motivations in these markets, which is certainly unethical and may well be illegal under the law. In the theme of asking questions about where the regulation and enforcement is under so many things that we care about in health, this is an opportunity to think about calling our congresspeople and trying to understand where the regulation and enforcement is around EMTALA, or any other act that, based on the law, should guarantee people escalation of care should they need it, including from any setting to another. There is a much bigger conversation around how the Federal Trade Commission, the FTC, should be managing these anti-competitive forces in lots of different micro-markets. It's something they have not figured out in many years, but it's something that health economics wonks think about a lot. In the meantime, when regulatory enforcement agencies aren't working, we have the courts. This article documented a case that is now winding through the Alabama courts on the State Public Health Department forcing a couple of birth centers to close down. It will be really interesting to follow those cases and see how they may set precedent for the rest of the country.

Ben Courchia MD (1:14:03.908) Since we're talking about neonatal advocacy, I'm going to plug again the Delphi conference, not because we organized it, but because of the speaker. On day two, the first talk of the day is given by Shetal Shah. He basically gives you a roadmap on how to do neonatal advocacy. Because you were talking about reaching out to your congressperson. He does an exceptional breakdown of the implications of neonatal advocacy, but he also goes through the rungs of the ladder, basically telling you, "Okay, if you have a couple of minutes, here's what you can do. If you have a bit more time to get involved, here's what you can do." He shows you all the ways in which you could perform neonatal advocacy for something that we truly care about, tailored to whatever time and resources you're willing to allocate. That's day two of the conference. First talk of the day, highly recommended. Love Shetal. He's a great guy.

Eli (1:14:59.543) Yeah, first time we're hearing Shetal's name on the podcast. Just kidding. I think he's paying us under the table here with Monopoly money. Not with real money, unfortunately. Maybe we should start taking royalties on all these referrals. Anyway, great talk.

Ben Courchia MD (1:15:20.352) Like an NIL, what is it? Those college athletes have these NIL deals, just to monetize their...

Eli (1:15:26.529) Well, no, it can't be on our wall because then we have to pay him. It has to be like Seinfeld. He's gotta pay us for all the mentions. Anyway. Listen, I think that is a good note to close on for this week. We will be back in your headphones very soon. Thanks for joining us.

Ben Courchia MD (1:15:32.464) That's right. Thank you, Eli.