#013 - Journal Club - Clonidine and NAS, aerosolized surfactant, Following baby back home, and more...

As always, feel free to send us questions, comments or suggestions to our email: nicupodcast@gmail.com. You can also contact the show through instagram or twitter, @nicupodcast. Or contact Ben and Daphna directly via their twitter profiles: @drnicu and @doctordaphnamd. Papers discussed in today's episode are listed and timestamped below.
enjoy!

01:50 - Reviewing recordings of neonatal resuscitation with parents. https://fn.bmj.com/content/106/4/346

10:55 - Associations between family presence and neonatal intubation outcomes: a report from the National Emergency Airway Registry for Neonates: NEAR4NEOS https://fn.bmj.com/content/106/4/392

19:28 - A Retrospective Review Following the Addition of Clonidine to a Neonatal Abstinence Syndrome Treatment Algorithm. https://www.frontiersin.org/articles/10.3389/fped.2021.632836/full

25:03 - Trial of aerosolised surfactant for preterm infants with respiratory distress syndrome. https://fn.bmj.com/content/early/2021/06/09/archdischild-2021-321645

30:15 - Interface leakage during neonatal CPAP treatment: a randomised, cross-over trial. https://fn.bmj.com/content/early/2021/06/28/archdischild-2021-321579

33:55 - Changes in Physicians' Perceptions and Practices on Neonatal Pain Management Over the Past 20 Years. A Survey Conducted at Two Time-Points. https://www.frontiersin.org/articles/10.3389/fped.2021.667806/full

39:02 - The Experience of Housing Needs Among Families Caring for Children With Medical Complexity. https://pediatrics.aappublications.org/content/148/1/e2020018937

47:10 - Home Visiting for NICU Graduates: Impacts of Following Baby Back Home. https://pediatrics.aappublications.org/content/148/1/e2020029397

52:25 - An Infant Carrier Intervention and Breastfeeding Duration: A Randomized Controlled Trial. https://pediatrics.aappublications.org/content/148/1/e2020049717

56:37 - Severity of Bronchopulmonary Dysplasia Among Very Preterm Infants in the United States. https://pediatrics.aappublications.org/content/148/1/e2020030007

58:41 - Human milk feeding and cognitive outcome in preterm infants: the role of infection and NEC reduction. https://www.nature.com/articles/s41390-021-01367-z

61:27 - Validity of Random Triglyceride Levels in Infants Receiving Parenteral Nutrition. https://www.frontiersin.org/articles/10.3389/fped.2021.601915/full

62:40 - Degree of ventriculomegaly predicts school-aged functional outcomes in preterm infants with intraventricular hem

As always, feel free to send us questions, comments, or suggestions to our email: nicupodcast@gmail.com. You can also contact the show through Instagram or Twitter, @nicupodcast. Or contact Ben and Daphna directly via their Twitter profiles: @drnicu and @doctordaphnamd. The papers discussed in today's episode are listed and timestamped on the webpage linked below.

Enjoy!

Transcript

Ben: 0:24

I'm doing great. I'm on vacation. So I'm recording with you today from the from the beach. So from the West Coast. Yeah. How about you in the unit? Well, the roles are reversed from the last time and now on. And it's fine. It's fine. It's just it was hard to complete the assignment of reading all these papers while on service, but we did it.

Daphna: 1:14

Good for us. I know. But I'm sure our listeners are feeling that way too. And that's why you're here. So

Ben: 1:21

I know the journal club episodes are getting a lot of love. We're very, very happy to see that. They're appreciated. And thank you for everybody who's following the Twitter account. Aging with us on Twitter. This is just fueling the fire to keep going. Great. Great. All right. So today, we have a bunch of very interesting articles. I think a lot of philosophical ones, right. I mean, a lot of very personal sort of emotional article. The one I'm going to start with one that was published in this issue of archives of disease in childhood. And it's called reviewing recordings of neonatal resuscitation with parents. first author is Maria than before. And the study was interesting, right? I mean, they recorded a bunch of of resuscitation, and then they approached families in order to see if they were interested in reviewing the recordings. The Parental review of recordings of neonatal resuscitation happened on 20 occasions. And that involved 31 children of whom four died during the admission. The median gestational age of these babies were 20 was 27 weeks. And then they interviewed the parents after the recording, and they try to see what were some of the experiences and how did the parents feel about the reviewing of the recording. And I think that the way that the record, first of all, the way the recordings were done was actually quite nice. Because if you look in the paper, figure one, there's actually a a diagram where you see, as part of the main screen, there's a crop screen area where you can see the actual video of the resuscitation. And around that you have vital signs, sort of flow flow diagrams for the event and so on at the time that has elapsed. So you do get a lot of data in addition to the video. And, and the impact on parents was quite interesting. So they quote a lot of different testimony, I'm going to give you some of the ones that I've highlighted. Some parents have said I wanted to see it, because I was not there. And other parents said, knowing what happened helps bonding with your child and it helps to cope. And then for some parents, they said they were touched that all the pieces of the puzzles fell into place. Because finally I got imaging fitting to the words that I heard before. And some people for the parents who lost babies, they said well, we lost two children and keepsakes any keepsake, everything you can collect from your children that's very valuable. And so what was interesting was obviously, that these recordings yielded mostly appreciation. Even no matter how small. And I guess the last thing I want to say about this paper is I was initially when you read the title, you're like, oh God, like I would never do this, right? Like I would not want somebody to take apart my codes, even if I'm going to say this without trying to boast but I feel very comfortable running a code. I feel like the codes I run are usually going very, very smoothly. And even with that level of confidence. I would not want somebody recording me and taking picking apart your code. That's how stressful This is. And so I was very curious for the parents who didn't have a good outcome. Were there answers are their responses was where sorry. And I want to read you this piece of the results. It says parents Furthermore, appreciate the efforts of provider to be open to parents by showing them the recording. Some parents even reported that this openness would make them less likely to hold provider responsible for medical malpractice. Quote, you're human. And humans make mistakes. And if a mistake is made, you have to be honest about it. In the end, I think that is the way that is way more valuable for parents than then to just keep on saying no, I did not make a mistake. When you are honest about it. I am okay with it. But if you lie about it, I will see you. I thought that was that was that was cool. Anyway. So yes, the first paper, what are your thoughts?

Daphna: 5:44

Yeah, I thought it was interesting. You know, what I took from this paper is, I think, maybe one day we'll be at a place where everybody's recording the resuscitations one for skill training, right, and feedback and, you know, looking at quality improvement, and to for for parents, but maybe we won't. But regardless, I think what I took away from this is parents want to know what is happening during resuscitation. And even when they go, Well, parents have questions about what happened, and even more, so if they didn't go well, then it's obvious that we have to take the time to sit with them and talk with them. And I never thought about it. And I think I think I put myself in the parent perspective, quite quite often. I think it's one of my skill sets. It is and, and I, I never thought you know, my, when I see the parent in the unit, when the daddy comes with me to the unit, I am very much about forward thinking in my in my anticipatory guidance, but I am rarely reviewing what happened in the resuscitation. And so I think their instant some of them such a state of shock, that they really need that information. And I really liked thinking about the impact this has on dads, right, because fathers are frequently kind of a forgotten component of the, we call it you know, we're so worried about the mommy baby dyad, the fathers are frequently left out of that equation for so many aspects of neonatal care. But so many times the dads are present for resuscitation. And we have to tell them, what, what happened, because they were there and they probably do have a lot of questions. So I really liked that they touched on the impact for dads and also the impact that it had on moms when they got to see or think about how hard that was for dads. I think moms and dads respond to NICU admission so differently. And sometimes that causes a lot of strife for families, because they can't understand where the other is coming from. And I think for some of those dads, they, they can say, well, you weren't there, you didn't see what I saw. And I thought that was really impactful. i They talked about bereaved parents, bereaved parents, are difficult to study. Mostly because it's an IRB nightmare, but also because it makes us uncomfortable to study them. We're afraid that it's traumatic for them. But I think the literature is very clear that if we do it the right way, then discussing the NICU admission and discussing the life of their baby is valuable to parents, and for some of them very therapeutic. What I they didn't tell us is about if any of the babies died during the resuscitation, just that babies passed during the admission. And that would be a different subset of families that I think we'd obviously have to take even more caution with, but but maybe, maybe even more so that they'd need and would want and need to see the videos. So anyways, I dabbled in something. I you thought of something during

Ben: 9:16

Yeah, I mean, it's funny that you mentioned father involvement. My mentor from fellowship recently passed away and on the last sort of visit that I had with him when I went to see him when he was sort of really sick. He gave me a book and he said, this is this is an important book and you should read it. And and it's touching exactly on what you're saying. It's the handbook of father involvement. And he said, Ben, when you're in the NICU, don't forget about the father's. And so it reminded me of the discussion that we had about father involvement and what you were just mentioning, because yes, book there that you have, it is a thick book. It is. I haven't had the I haven't had the mental, the emotional sort of strength to open it and go for it but it's there and And then maybe this is the opportune time. Anyway, yeah, that was, that was a great study, I enjoyed the idea of putting yourself out there showing parents these types of codes. And I think also what you're saying is to the qualities of, of yourself and other providers in communicating with parents, we tend to undersell the code and what we end up doing, we make it we minimize it sometimes. And then when the parents see it, most of the time for us, it has been in real life that like, oh, shoot like, this is this is a big deal. And they see how much we're running around the intensity of it. And that's difficult to communicate. And it's not something you want to brag about saying, Oh, we worked so hard, right? It's like, it's not something you brag about. And it's something that could be seen on videos. And I think maybe that's why they got such positive responses as well.

Daphna: 10:49

Yeah, definitely something to think about. And so we have another paper regarding parent involvement during some of our high stress situations. Also, in the archives. It's entitled associations between family presents, and neonatal intubation outcomes, a report from the neonatal emergency airway registry for neonates are the near for NEOs. And so what they studied, obviously, for people who are familiar with near for Neos, they were looking at many, many factors for intubation success. So for this particular paper on the lead authors, Brianna Bray, and again, from the near for Neos group. And so what they were looking at is a retrospective analysis of these intubations performed in NICUs, during this study period, but then they looked specifically about intubation success. Success in the first few attempts, adverse intubation, associated events, and severe oxygen desaturations. With families present versus family, not present. So again, this was retrospective, and they had a number of units. And obviously, there was a big variation between number units that had a lot of parents present and units that don't have a lot of parents present. In in this study, so just to give you some data, they collected information on just over 2500 intubations, just under 10% 9.4%, had family presents, which again, varied by site, the median was three 3.6% of the intubations, with families present, and ranged anywhere from zero to actually 33%, which I thought was pretty good. And then family member was more often present for older infants and those with chronic respiratory failures, which didn't surprise me. Yeah, I think we feel that, right. And by that time, the parents, they may not let you let them, you know, send them out.

Ben: 13:08

To tell you, I've seen everything at this point is just do it just do

Daphna: 13:12

it. Yeah. And then, also not surprising, fewer intubations were performed by residents when the family was present. And, you know, I think we all feel that pressure when you know, we have families present about can we let the learner do the procedure or not. And then interestingly, among the intubations, with family present versus without fail me present, the first attempt success rate was 55% versus 49%. With a p value of point oh, six, two. So actually, the success rate was better with family present. And then the success within the two attempts was 74%. With family present versus 66%. Without family present, with a P value of point oh, one, four. So again, more likely to achieve success with the family present. And then adverse events and severe oxygen D saturation. Whoo, they didn't find any difference. So I thought this was interesting. I had to read it the results a few times because I was surprised that they didn't make that point that actually, things were slightly better with the families present. I don't know if we we act better under pressure. what exactly it is, but

Ben: 14:35

yeah, number one, the near for News Group is amazing. I think they're based out of chop. I have worked with them in the past and I'm continuing to collaborate with them. They have the way they were able to perform this study is because once you're part of this collaborative, you have a almost a debriefing sheet that you have to fill out after every intubation. I think regardless of the items that are on this debrief paper, the fact that you have to debrief every intubation almost like as if it was a code, which makes you much more cognizant of, oh, did I? Did I use sedative? How much? Was there already saturation? And I have to be honest with you, I was doing things a certain way. And after implementing this sort of this Qi initiative, you think about every intubation as a as a full on sort of almost intra operative procedure. It's like there's the pre there. Yes, yes. And we should. And what was interesting to me about the paper, is that you I was expecting to see that when the so I was, I was wondering if you were going to see more issues when the family was present. Because you have to assume also that the family that's demanding or that is not really the family that staying maybe a bit more insistent sometimes. And there is evidence from other articles that sort of the family that is a bit pressurizing the team usually gets worse outcome. So I was one, I was like, God, maybe they're gonna get worse outcomes. And it turns out, like you said, No, that the outcomes were similar. And I think this is what was key to me is that I have sometimes been inclined to keep a family outside the room, because let's say the fellow is going to try and you're like, I don't want something negative to happen in front of the family. And this is going to be a teaching opportunity for this fellow. So we're not going to expose the fellow and everything. But then you see that there's no reason to believe that there will be because presence or absence of the family in the room is similar. So they really did not I don't think went go, they did go into the types of providers that, that that did the procedure. And they looked at the association between that and and they looked at the association between the level of training, I guess, so if it was an attending of fellow resident, and the likelihood of success on the first attempt. But they haven't done. I think the comparison between I think it's not enough numbers, to be honest. But like, if it was a fellow, whether presence or absence would make a difference, right, maybe for another study. But at least from this data, we should be more encouraged that having the family around is not going to be detrimental.

Daphna: 17:23

Yeah, I think I would have liked to have seen all seeming, like you said, more granularity in the data about you know, there are some units who are keeping the parents in the room, you know, 1/3 of the time. And you know, do they have better success, because that's just the unit practice. So it's less stressful. They're used to having parents around? Is the unit who, you know, only had one parent present. Is that because the parent really pushed in? That's not the unit practice. I don't know. But I would have liked to have have seen that. I also thought it was interesting that when parents were present, that that they were more likely to use video laryngoscopy. So might that have impacted some of the success? And that's a good reminder that we should be using it. When we have the availability and when we can use it then then potentially we should be using it. Yeah. Because like you said, if we treat every single one like a code situation, and we say, you know, how can we really optimize this? And the studies have shown that potentially that's a better way. So

Ben: 18:34

that's why this news for news collaborative is so good. And that was it's funny that we're mentioning this article today. I just got approval for the C Mac in our new unit. So that's very exciting.

Daphna: 18:45

One, I think, I think any unit who has learners present than having the C Mac is particularly valuable.

Ben: 18:53

Absolutely. We're not see Mac if you want to sponsor the podcast, let us know we're not sponsored by you guys yet. Not yet. Not yet. But the striker wants to send us some freebies, go for it. Anyway, all right. What's next?

Daphna: 19:10

Well, we have a number of papers and actually frontiers in pediatrics. This time around just since it's been actually quite present in our unit. This these last few weeks, I wanted to discuss this neonatal abstinence paper. So it was a retrospective review, following the addition of quantity into a neonatal abstinence syndrome treatment algorithm. first author Muhammad Bader, and this is out of the University of Arizona, in Tucson, Arizona. So they wanted to look at the change in their unit practice. So they were looking at Babies between 2015 and 2018, who were diagnosed So with neonatal abstinence syndrome, and again, it was a retrospective chart review looking at an influence implementation of a new NHS treatment algorithm, their original treatment algorithm. So pre implementation of the protocol was kind of a standard working up of morphine based on the Finnegan scores. And kind of the, the bailout or the adjunct therapy would be the addition of phenobarbital and then the post implementation was actually starting both if a baby needed to be started on medication based on the Finnegan scores, starting both morphine and clonidine at the same time. And then, if the baby had stabilized, moved, moved to weaning, still, they used fino BB as their kind of rescue. And so their results showed a reduction in the length of hospital stay 30 days versus 20 days. And in addition, there is a decrease in duration of the where the morphine exposure, obviously, and the cumulative dose of morphine required. So 2060s versus 15 days, and again, a total dose of 6.9 milligrams per kilogram versus 3.4 milligrams per kilogram. And so I, I, I like this study, I like clonidine. I think we have some good studies, especially in mom's with poly substance abuse, that the addition of clonidine to morphine, as is even an initial therapy may reduce the cumulative exposure and decrease length of stay. And they didn't touch on this, but some of the other studies have shown that we're quicker to control the symptoms when we start with with both so I thought it was a good reminder. That's not what we're using in our unit at this time. But we are rewriting our na s protocol. So actually,

Ben: 22:07

actually, yeah, that's right. The unit as we when we took it over didn't have clonidine Incorporated. But now our new en es protocol has it incorporated. And it is it is a game changer. I mean, when you compare it to 30 days versus 20 days, it's huge. The other thing I was interested in is even though they were not really significant findings is some of the other neonatal outcomes that they looked at, and the breastfeeding at discharge. And even though the numbers were not significant, so I know we're not really supposed to look at it. But look, the pre implementation group had breastfeeding at discharge and 19% of patients versus 26. For the post implementation group, any breastfeeding at discharge went up from 37% to 47%. And, and again, and it also important to note is that discharge with birth parents was similar in both groups. I think that's also important that they didn't really cop out by saying, well, these other babies went into foster families, and they were really, the attention that they received was different now. So what was interesting to me is that when you're talking about 10 days of hospitalization, it's long, it's a lot of resources, but it impacts also bonding with the mothers, not many units have 24 hour visitation, it's very difficult to perform 24 hour visitation parents have lives. And so I think this is where you feel the impact of the addition of this of this, of this alpha two, agonist. And how the wide spread ramification of that was, I thought that was interesting. Another thing about this journal, by the way, frontiers in pediatrics, which we're trying to broaden our spectrum, but they do something from this is a more methodological standpoint. If you look on the side of these articles it has edited and who reviewed, I want to commend them for putting it out of reviewers. Yes. Yes. what a what a great thing that that is being done, and that maybe other journals should look into, because you have when you have reviewed papers, many times in the past, and I always was very conscientious about how do I form frame my review how to be compassionate, not be too harsh, or, or, you know, try to be polite and things like that. And so that if my name had to be associated with the reviewer would stand by it. And you hear so many stories of people who were like on Twitter this week, somebody said that the reviewer was so harsh with that person that it took her like two weeks to get out of the funk because she had worked so hard on the paper now. Yeah, it's like so. So kudos to frontiers in pediatrics for this. For this openness and for the reviewers who are allowing their names to be put out there.

Daphna: 24:50

Transparency, right. Oh, yeah. What did you want to touch on next?

Ben: 24:58

I'm gonna go back to archives For a second, and they had an interesting article called trial of aerosolized surfactant for preterm infants with respiratory distress syndrome. This author is Luke Jardine. And this is a paper out of Australia. The objective of the paper was to evaluate the safety of an aerosolized surfactant, administer via nasal continual CPAP, and a prototype breath synchronization device. So they have this thing called arrow fact that was supposed to deliver the aerosolized surfactant. So, first of all, I think we know that non invasive surfactant administration is coming to us sooner rather than later. We know that aerosolized surfactant, even if some of the trials have been sort of have shown mitigating results, depending on which trial you look at, we know that this is a technical issue that once technology catches up to the fact that we can aerosolize surfactant, we'll be able to deliver it this way. So that taken into account then they said, let's look at 26, weaker 26 to 30 weaker. And let's see if we can deliver aerosolized surfactant. And they had two phases to the study, part one where the kids received a single dose, and then part two where they could receive up to four dose. And that's the only reason why I want to mention this paper, because I think it's showing us some light as to what's going to happen in the future. And they said, we'll see. treatment failure, treatment failure was defined as an RSS the respiratory severity score of more than 2.4, requiring more than eight centimeters of water of CPAP, co2 level of 65, plus a pH of less than 7.2, or three apneas, within six hours, and the first enters overnight, okay. And so what they looked at is that they had very small study, it was a very small number. So they had 10, infants in in phase 121, in phase two, and they had 93 controls. And so the interesting thing is that in part two, the pulled on in or to the babies who met failure criteria, so the babies who failed was it was 29%, in part, in part two, compared to 48%. In part one, it was a significant reduction in the amount of sort of ventilatory failure in the second part. And what that comes to tell you is that we tend to think of, we should administer surfactant, the same way you're administering surfactant via an ET tube is going to be how you're going to do it via aerosolized and know, we're starting to see that. Alright. So aerosolized is probably going to, we're going to have more losses, it's going to be less than less efficient. But then if you mitigate that, by providing multiple doses, you should be able to achieve much better results. And so I thought that was a very interesting paper, number one for anybody who's trying to study this, but also for us to start changing the thinking around these new deliveries of surfactant to these babies. I thought that was interesting.

Daphna: 27:45

Right? Is is needing more doses, you know, is that worse than then being intubated? Right, is it worse than being intubated? Multiple times? Is it worse than being on the ventilator? Because somebody left you intubated? You know, so it's definitely something

Ben: 28:02

that makes you and makes you and makes you rethink, right? I mean, right now, if a 26 weaker gets a first dose of surfactant, it's like, okay, fine, that can expect that second dose of surfactant has some stigma around it, right? It's like, ah, it doesn't really work the second dose as well as the first and is it should we even bother, etcetera, etcetera. But in this case, you start saying no, the first round of surfactant may involve a multitude of doses in sequence, because you're losing a little bit through the system, and maybe the system, this arrow fact, and all these different devices will get better and better with time that we only will need to give one dose. But for the time being, I think it's a such a significant paper, because if you start using this in your unit, and you give only one dose, and you see that it sucks, they're gonna say, Oh, this thing sucks. But no, this paper shows, you know, you need to give repeated doses for to see a very nice, significant effect. I thought that was worth mentioning.

Daphna: 28:54

I totally agree. And, you know, they're helpful, right? These this even when, you know, we we were doing some less invasive surfactin administration, and it didn't go exactly, you know, like we the same way we usually see right when you put the tube in, and you and you administer a surfactant. And that was a learning experience for us, and that it took the baby a lot more time to get the surfactant and administration. And we didn't see that immediate response that we were hoping for. Sure. Yeah, that's right. And so we need to talk about it. We need to share our experiences. And that's why I think, you know, this and social media is useful because then we don't say, Well, I'm not doing that again, but we just need to, we just need to prepare for

Ben: 29:53

and you may be very dismissive. If you're not using aerosolized surfactant, you may see that article and be like, Well, I'm not using that skip. But there's like a Uh, oh, piece of little nugget in there. Anyway,

Daphna: 30:04

there was one more paper in archives about respiratory management, which I was disappointed to read. So I think we should talk about it. And it was interface leakage during neonatal CPAP treatment, a randomized crossover trial, lead author, Marcus, Falk, and this is out of Sweden. And so they wanted to look at leakage for to neonatal CPAP interfaces and evaluate leak corrective maneuvers. So this is part of a larger trial trials and CPAP interface leakage. And they were looking at Babies between 2018 and 2019. And they basically wanted to see which mask interface had more leakage. So they had 73 babies that were initially screened, they included 50 babies, and actually, they were using babies older than 28 weeks. And the median postmenstrual age was 33 weeks, which I thought was interesting, but we can talk about that afterwards. So the analysis showed a significantly lower leakage with the prongs than the nasal mask. And then a leak corrective maneuvers reduce leakage significantly for both prongs. And I think we see this all the time, clinically, right, we have babies, and if we can manage them without a lot of leak, then they can do quite well. But there are lots of babies that any degree of leak really sets us up for failure. But anyways, in our unit, specifically, we have just a handful of babies who hate those prongs. They just hate the Bronx. And they seem to do but so much better on the mask. Ventilation, I have, you know, two in mind right now. And so anyways, I was surprised to see this because I thought the, in my experience that the mask is does better. But maybe that's a baby preference. Maybe one is more comfortable for an individual baby.

Ben: 32:17

Yeah. And the interesting thing that they mentioned in that article was that they were also looking at whether they is the leakage these weeks, I guess could be could be sort of fixed with the provider or user intervention. And when guided by the measured leakage, simple care maneuvers can reduce interference leakage in the vast majority of patients with both nasal masks and proms. And so I think that was also the hopeful message that I took from this paper is that, yeah, we do. I mean, I've seen it with the masks all the time, and the baby moves around, and so on and so forth. It's gotten uncomfortable and stuff, but you can reduce the leak if you're being careful. And there's I feel like in the NICU, there's like some of these nurses that know how to put a baby together in the incubator in a way that the baby's comfortable, nothing moves, you know, it's like magic. And so I could totally see that happening. Where that baby that's, you know, the one that's well bundled, that is very comfortable breathing comfortable, like, yeah, maybe no leakage. But the baby that's not really strapped, that's just allowed to navigate within the incubator, and have a bit more leakage.

Daphna: 33:25

Yeah, the other thing is, is there a better way for us to monitor leakage and, you know, get get to baby before, you know, before the event starts alarming before, you know, so that we can maintain that peep and recruitment. So I thought that was interesting. Okay, let's see, we have some others in frontiers of Pediatrics. I have a list here. So let

Ben: 33:55

me let me start them while you're looking for the next one that was actually interested in this one called changes in physician's prescription perception and person on

Daphna: 34:01

my list.

Ben: 34:04

If you want to go ahead, you can give I'll give the summary and then you will give your impressions on so the changes in physicians perception and practices on neonatal pain management over the past 20 years a survey conducted at two times two time points as a metaphor. first author is Eleni Agha ki do and this is from Greece. This is an interesting study, because number one, it was a survey sent to Greek neonatologist it was sent to different time points 20 years apart. So that's kind of cool. It basically send them a survey and it was sent to about 217 In the first 145 in the second time around and and they asked them about their perception on pain, pain management and interventions for info procedures in the NICU. I wanted to say that the 20 year gap that We are talking about is from 2002 1019. So what was interesting is that the summaries were that all respondents at both time points believe that neonates experienced pain. I was like that's a good start. Because we know that historically, you only targeted and not used to believe that neonates experience pain, which has serious acute and long term consequences, while the vast majority considered analgesia slash sedation, during painful interventions, as obligatory so that's really good to your utilization of NICU protocols, and pain assessment tools, however, remained low. And some of the specifics that were interesting to me were systemic or local analgesia for acute procedural pain was used by a lower proportion of physicians in 2019, except for intubation. In contrast, the use of sweet solutions and non pharmacological measures prior to or during bedside procedures significantly increased over time. Another great point. And another one that was interesting was that opioid administration significantly increased while the shift from morphine to fentanyl was observed. I want to get your thoughts on that. Inside Inside the the meat the overarching conclusion of the paper is that the management of pain and practices regarding pain in the NICU have improved but they remain sub optimal. I think some of the graphs that were interesting, they have two figures, figures one and two. Figure one looks at painful and stressful procedures. And it basically is a bar graph and it tells you how many how frequently with neonatologist use sedation or analgesia during a painful procedure and they looked at arterial line chest drainage, heel prick intubations, lumbar puncture, mechanical ventilation, suprapubic paracentesis tracheal, suction and veneer puncture. And what we see interestingly, is that between 2009 2002 1019, the use of sedation allergies are increased for mechanical ventilation, significant chest drainage, and intubation, it did increase, but it was not significant. And for everything else, it went down. And then you look at the second graph, which is the non pharmacological interventions. And then you see that for all of them, it increased over time, which was very cool. Because in the main results, they mentioned, obviously, trade dimension. tactile stimulation measurement mentioned nestling, the pacifier, the different things that they that they use, but they all went up so you can see a shift in the way we approach pain in the neonate. And I thought that was that was exciting. But our use of opioids is, I would say concerning. And we've had discussions obviously, about whether we are choosing the right one and considering how strong federal is not sure if that's if that's great news, but yeah.

Daphna: 37:53

Yeah, you know, it's this pendulum, right? We just swinging from one when one side to the other about treating pain, and probably the right answer is something in between, and certainly, any non pharmacologic interventions should be a top priority, we should be doing that for everything, including routine handling. And they're definitely certainly, you know, instances where we, we need medication, you know, we need an opiate. And I think, across the country, across the world, we were both over and under treating being at any given time, I thought it was incredible that they got 90% of people to respond to their survey. So I think that in and of itself, was was miraculous, so they need to share it with the rest of us.

Ben: 38:50

I have a friend who's from Greece, I'll ask him, ask him what's what's in the regions that is making them so honest,

Daphna: 38:56

that they were willing to share. So the next paper I wanted to talk about is in the Journal of Pediatrics, the experience of housing needs among families caring for children with medical complexity. first author Kara Grace Hounsell. So,

Ben: 39:18

yeah, this is in pediatrics. I mean, it's, it's in the Journal of Pediatrics, not in the journal,

Daphna: 39:23

the journal called pediatrics. Apologies for any confusion.

Ben: 39:29

No, because I'm worried. Journal of Pediatrics. Like she just made that paper up.

Daphna: 39:36

Anyways, this comes to us from our friends in Canada. So what they were really looking at was some of the additional stressors that families have medically complex children have so they did 20 semi structured interviews with parents who have children with medical complexity, and then they were looking at kind of themes that emerged from these interviews. So they look, they met with 18 mothers and two fathers and individual interviews. And interestingly, one of the major themes that that resulted were housing needs. So they saw the impact of health, on housing, and the impact of housing on health, which I thought was interesting that those are really two distinct things. And so some of the things I really want to touch on were what they meant by that. And so the first was the impact of health on housing, illustrated through three interrelated sub themes and housing preferences. So what, what did parents actually what were they looking for in their housing, for example, the layout of the house and for most parents, that they interviewed, this was really related to, did they have enough space for all of the equipment, their children have mobility limitations, so they needed a single story home, or were they able to be close to the hospital where their child was receiving care. The second was housing possibilities. So given the resources that a family has, were they able to meet those needs, and then the third housing outcome as a trade off, and so really, what were they able to get, were they able to meet their needs, with the resources that they had. And for a lot of parents, that just wasn't able to happen. So they really had to make some trade offs. And then the second major theme was the converse, the impact of housing on health. And so sub theme, one health of the caregiver. So parents describe both mental and physical health consequences of their housing needs. A lot of this was related to stress and guilt, about being able to meet their their kids needs, some of it was about the physical stress of having a home, a home that wasn't quite suited to a child with those needs. And things like carrying equipment carrying children in a house that wasn't quite set up, right, and then health of the child. So some parents suggested that their current housing situation impacted the possibilities and opportunities for their children, either because they were limited by space, maybe they weren't able to do some of the movements that their child needed, and that some even housing situations, affected their child's cognitive and gross motor skills. And so this is just another reminder, we've talked about it before that, you know, the NICU is a stressful place, and having children with complex medical needs is stressful, but there's so many other challenges that our families have that we, you know, should be advocating and finding ways to, to support them in. You know, some of the major things here were financial, obviously, so a lot of parents of medically complex kids may be single parents, or they may be parents who have to stop working. And, and, you know, we feel like our job is to set them up with that initial set of supplies and that everything will take care of themselves. But the truth is that that's just not the system that we live in. And this was done in Canada. I can't even imagine what the survey would look like, for parents here in the United States.

Ben: 43:51

Yeah, those numbers were quite impressive. 55% saying they had to stop working 55% saying they were unable to purchase a home 25% saying they could not make modification to their current home or to make it accessible. The 55% said to rely on and are affected by the level of financial support they receive from the government and 60% Describe challenges in with availability of accessible housing. I mean, it's, it is such a loaded paper, I think we should post that little that little figure where it looks like housing preferences. It has like ideal green space, housing structure, community and neighborhood. And then the other side of that table is like, what is the need, and it's a space accessibility proximity to a major hospital. And it's like, holy crap. So I think it's to me it was a sunburn shirt paper, mostly because you wonder number one, always we saw it's hard to measure the quality of life for the family after a baby that's has complex medical needs, comes home. But looking at this and how the impact it has on housing where parents have to sort of have changed jobs quit stop their job, I think. What was it 35% Describe balancing expenses with location proximity to healthcare. It's, it's not. Anyway, it's just it's very scary. And number two, as the discussion is growing as to we should really resuscitate, 22 weekers, like they can survive and their neurological outcome are terrible, but they survive. And then you look at this and you're like, Oh, I'm a, I'm a big advocate of active resuscitation for 22 years. But then you read this, and you're like, woof, woof. What, uh, what is the long term impact? It's very scary. Yeah. And

Daphna: 45:42

in it, maybe we can look at it in a different ways. If, if we were in a system where we could navigate some of these stressors for parents, we could offload some of those stressors, what our outcomes be even better, right? If they had I can hardly get through the day, sometimes with the mental load that I have to carry. And I don't have a medically complex child at home. And so, you know, we last the last few journal clubs, we talked about the mental health and the, you know, overall physical health of parents who have complex children and distress May

Ben: 46:21

and we've, we've, I think on our first on our first episode, we spoke about, like the MacGyver sort of things that parents do to make their home accessible. And then Betsy Pilon spoke to us about like, the concerns of the parents when they got into the NICU, where she was like, am I going to keep my job? Am I gonna have to stop working? Like, Oh, for sure.

Daphna: 46:41

It's hard to think about, it's hard to think about. But I think the one thing we can do for families is empathize. We can ask them about what were their resources are limited, and we may not always be able to help. But I think just identifying the problem.

Ben: 46:59

I think as, as we like to do, when there's a problem, there's a solution in the same journal journal called pediatrics. There's a paper called home visiting for NICU graduates impacts of following maybe back home. First author is Lorraine Lorraine McKelvey. And this is from a group in Little Rock, Arkansas. And this was an interesting study, where they have this this program called the following baby back home, the fbH, which is a home visiting program that supports families of high risk, low birth weight preterm infants after discharge from the hospital and and so they looked at the Health Care use immunization and infant mortality rates of these ELB W's between some that were enrolled in this program versus controls. And they did that between 2013 2017. They looked at about 500 children that were enrolled in the program. And they were matched, one to one with controls. And they were matched not just on on the fact they were mentioned on the multitude of these I'm going to skip because it's not really the point of the paper. And the results were that in the first year after discharge, and compare with the propensity score matched cohort, the babies that were enrolled in the follow up at back home program, were significantly more likely to have higher numbers of medical appointments, and more compliance with immunization history, the odds of dying in the first year of life for control infant was 4.4 times higher than those managed in the program. And I thought that was that was very impressive, obviously, just just with mortality alone, and and I think I want to, I want to there's there's the having more appointments, being able to make those appointments as well was in there. And so you see that discharge from the NICU is not the end all be all, and the follow up needs to happen. And I feel like these these programs are going to be very helpful in supporting families exactly around the needs that we talked about before. How can they make the home more accessible? Could could they get some assistance for the parents for all these things? And you can see that maybe the solution to these post NICU syndromes are going to come from outpatient follow up programs. So yeah, very it's a very European style of thing where the doctors or the program comes to the home, which in the US we're not really familiar with, it's actually interested in growing up in France, if you ever have a problem at home, like the doctor comes in the middle of it to your house, you don't go to the ER and as as bad as it is because they they can only do so many things. But yeah, it's sort of the pendulum is swinging back you know where back in the old days the doctor used to come to the home and then the patient moved to the clinic or to the hospital and now we see that Yeah, I mean following up into the home helping parents into the home can have significant health

Daphna: 49:54

Yeah, and this group really is doing a great job in their their other crap This is all across the, you know, the country here who are doing similar things. But they were doing two home visits per month in the first two months, one home visit per month until age one, and then alternating home and phone or virtual visits every month until age three. So this is not without cost, obviously, and a lot of men and men and women power and, you know, I was, it was interesting that they had higher medical utilization. Right. But the end goal was that they were keeping babies alive. Right. So, you know, for health care system, they're gonna look at well, I was hoping you would reduce ER visits, and I would was hoping that you would reduce, you know, medical appointments. But I think this is just saying that right, that they, they understood that they were important to go to that when the babies weren't doing well, they sought care. And so, you know, it's hard to argue with reducing in home mortality for medically,

Ben: 51:07

and this is the type of it says exactly what you're saying is so true, it's going to have to be local initiatives, right? There's not going to be a federal government mandate that's going to suddenly have people go into the homes now, it's going to be on a very local level where single institutions are going to support these types of initiatives. Yeah, and then hopefully, that can spread as a grassroots. And

Daphna: 51:29

I think there's just going to be a bigger and bigger need that as our babies, like you said, more and more 22 weekers more and more complex babies that there's just going to be this there is already developing a gap and care for these babies in these families in the in the transition home. But luckily, there's some innovators who are looking to change that how we care for the care for babies in that transition. There was,

Ben: 51:56

well, we're getting, we're getting close to the end of the podcast. We're going to try not to do another hour and a half, like last time, people people have have told me that it was great, but like they had they had to take it in bites. So yeah, let's let's try to run a bit more quickly through some of the lesser sort of what we thought was less significant articles, if you will. Yeah,

Daphna: 52:19

I mean, there's some journals we haven't even opened yet. But there was one. One more, I really liked in again, pediatrics, and infant carrier intervention and breastfeeding duration, a randomized control trial. You know, I like that study. Front lead author, Emily Little. And what they did is they looked, obviously, at duration of breastfeeding. And they hypothesized that providing carriers to parents during pregnancy would increase the likelihood of breastfeeding and expressed human milk feeding through the first six months of life. So they did a randomized parallel group trial between 2018 and 2019. In conjunction, same thing with the home visiting program in particularly for their low income community. So at 30 weeks gestation, 50 parents were randomized to get an infant carrier and instruction on proper use. And 50 parents were assigned to a waitlist control group, so they didn't get any.

Ben: 53:30

I love that. That controller was so it was so bad. It's like you're on the waitlist. It was such a smart way of doing it. Yes, you got the got the bought the buy in from the parents, but it was like for for control groups, they should have given them the infant carrier at the end of the study just just for me, I don't know.

Daphna: 53:50

But they sent these families electronic surveys via text during pregnancy at to between 30 and 38 weeks, and then after pregnancy at two weeks, six weeks, three months and six months to assess Youth use and the end game is that both breastfeeding and so any breastfeeding and exclusive breastfeeding was increased in the group who got the carrier. So parents in the intervention group were most likely more likely to be breast feeding or feeding EBM 68%, as controlled to the as compared to the control group of 40% at six months, and exclusive human milk feeding didn't differ but there was a trend to increase all the way across and then at six months 49% in the intervention group and 26% in the control group. So interestingly, I'm not sold that it's the carrier. I think it has to do with meeting mommies in pregnancy to talk about breastfeeding. I think, personally, our success rates will be improved. If we engage parents early in pregnancy, you really gotta be committed to this breastfeeding thing if you're really going to do it and, and once the baby's there, it's just, it's just too little too little time to get all your supplies ready to get into the mental space to do it. So I really commend this study, I'd love to see an arm where they just do this and don't give the carrier which would be less expensive,

Ben: 55:21

right? I think what what people may not I mean, I think we are talking about this paper because we both know the article pretty well. But the infant carrier that they're talking about for you, everybody listening knows what we're talking about. It's that apparatus that you put around your shoulders and where the baby sort of sits on your chest, and you sort of walk with the baby sort of strapped to your chest. And I think it's interesting, because the hypothesis is that by creating this ultra bond, where you're with the baby, so close, you want to promote breastfeeding. I thought that was interesting. I think you said everything I was thinking.

Daphna: 55:55

I mean, I love baby wearing, I think I love it. I totally support it. I think we should be doing it more frequently. I think it would encourage kangaroo care. But I think that the key is just just talking to moms early and often and preparing them for what what breastfeeding actually looks like. And that's not just taking one breastfeeding class. So where did you want to go next? And

Ben: 56:24

that's Eric Jensen. My, yeah. Eric Jensen, who I want to reach out to and have on the podcast because he's, he's such a prolific author has a paper that he first authored in pediatrics called severity of bronchopulmonary dysplasia among very preterm infants in the United States. I'm not going to go too much into the details, but it's an interesting study where retrospectively looks at infants 20 to 29 weeks from 700 hospitals in the Vermont Oxford Network, it looks at about 25,000 babies, and it sort of classifies them based on severity of BPD, based on the Jenson sort of criteria, where the interface matter, and so on and so forth. So, interestingly enough, 10% of these babies died before 36 weeks 50% 49% did not develop BPD, they had to put grade one and grade two BPD together because they were not able to get the granular data, they needed to differentiate them. But it was 37% for for this grade one, two, and then 3.7%, developed grade three VPD. So it's interesting that this data is coming out now, where we're looking at BPD through the Deaf through this definition that makes a bit more sense. And I think this is this is good to have that data. One thing that people should read is within the article in the results, it talks about late deaths, right, so 22,000 Babies survived 36 weeks, and according and they were classified according to BPD severity. So 1% of them died before hospital discharge. So of the babies, but among the late deaths 62% were diagnosed with grapefruit with BPD 35% with grade one and two and 3% with no BPD. I thought that was very interesting, right. I mean, we tend to think in neonatology that once you pass certain time points should be okay. But the rates of death in the severe VPD group. Are we staggering. So yeah, that was interesting. Something to read. What else was I want to mention? Is there one that you wanted to go over quickly before we close this?

Daphna: 58:35

There were some papers in pediatric research. I thought this was interesting, the human milk feeding and cognitive outcome and preterm infants, the role of infection and neck reduction. So they collected a lot of data. So we'll be quick. But the first author, Winnick, we're not lappa dare, so hopefully, thank you, out of London. And so they really looked at breast milk utilization, and lowering the risk of infection and neck. And then in addition, looking at long term cognitive outcomes in preterm infants. So these infants were randomized to either preterm formula or the standard term formula or this is you really got to take a look at this study. I can't do it. It's due diligence in the time we've allotted. But they looked at a bunch of diet variations is how I'll put it and maybe we can put some of these charts on our Twitter feed.

Ben: 59:44

And they follow maybe 30 or

Daphna: 59:47

30 years ago, they were doing IQ tests at age seven, age 15, age 20 in age 30 years, so obviously a lot has changed neonatal care during that time, but their results In brief for that an increase in maternal breast milk or donor breast milk intake was associated with a lower chance of neonatal infection or NAC, which, again, is not new data. But what was really interesting was the kind of long term outcomes and that the neonatal infection or neck was independently associated with lower full scale IQ scores and performance IQ scores at seven and at 30 years. And really, what they showed was basically, I thought this was incredible that each 10% increase, and maternal milk or donor milk intake was associated with approximately an eight and 12% lower chance of neonatal infection or neck respectively. So I thought that was impressive. That's, that's, that was impressive. I thought it was impressive that they got to 30 years. And I mean, you know, obviously, the participants at the 20 and 30 year marker are low. But I think, you know, we have to look at feeding in terms of cognitive outcomes in the in any major prematurity, comorbidity, including neck changes our long term developmental outcomes for sure.

Ben: 1:01:21

The last two articles, I just want to bring up which I thought were interesting. The first one is in frontiers. It's called validity of a random triglyceride levels in infants receiving parenteral nutrition by Mohammed, later, this is from Arizona. Oh, that was interesting. They asked an interesting question, which was do we need to have a fasting period before we draw triglyceride? Or is the fact that the triglycerides, the lipids are running for 24 hours, or getting us higher numbers that are going to potentially lead us to stop intra lipids? And what was interesting was that obviously, the numbers were different, whether it was, you know, the, in between fasting and non fasting, but they were not that significant. And so their conclusion was that there's no difference in demand. There's the management of intra lipids, when you draw the triglyceride level, either after a fasting period, which in this paper they did, like by doing like, the four hour pause, or whether it's while the infusion is going, I thought that was interesting. It's a question I think I had once and never really pursued it, but I thought that was that was a valid question that I'm sure some parents may ask. And then they go ahead. Um, so

Daphna: 1:02:25

I was gonna say, I think this is has been replicated in previous literature, but it's always nice to, you know, duplicate, for sure.

Ben: 1:02:36

Right. That's yeah, I think that's why before. The last one I wanted to mention is in pediatric research, it's called degree of ventriculomegaly predicts school age functional outcome in preterm infants with ivh. It's from Greece, a in from Chicago. And basically, they looked at the degree of ventriculomegaly and functional outcomes. It was a retrospective studies of infants with great regret for ivh. And I guess, the main conclusion was that greater ventricular dilation and PVL were independently associated with the worst functional outcomes, regardless of neurosurgical intervention, the reason so Okay, fine. So bigger dilation, PVL, all that stuff is bad. What's the what's the insight here, that we're using something called the F Gu, H are right, so the frontal the frontal horn, to occipital horn ratio, the frontal to occipital horn ratio. And basically it measures the distance between the two horns. And it gives you this ratio when they compare that I thought that was interesting, because you know, how we've evolved our interpretation of EPD echoes by including all the different ratios, I feel like this is something that should be included. Now. In our head ultrasounds, you know, if you started including this, you'd have more tangible and objective information for family. So I thought that was interesting that it brought up a new measure that you could get from the head ultrasound you're already getting. And they were showing that the fo HR at consult was point six, two and point seven, five at the first intervention. And that on very on much on any variable analysis, maximum ratio, and fo fo HR at the last follow up, and that neurosurgery concert predicted with functional outcome with a P value of less than 0.01. That was interesting. Something that could directly impact how you practice if you're involved in making improvements in radiology.

Daphna: 1:04:25

Yeah, and I thought this was definitely something we had to talk about because it actually I mean, it contradicts some of the previous literature on ventriculomegaly. And when is the right time to intervene? And I'm not sure that this necessarily answers this question, but I think it it gives me some pause to some of that previous literature, and I don't envy neurosurgeons. I don't want to be a neurosurgeon. I don't want to make the decision about when to intervene. And obviously there are a lot of risks. without intervening, but I thought it was interesting. This is a concern I have have had while awaiting, you know, something like a definitive intervention like a shunt about, you know, how much damage is done. So I think I think the question stands about when is the right time to intervene. So I'm glad, I'm glad that this paper came out so that we can continue to talk about it. The only other thing I really wanted was interested in talking about was this preprint on lung ultrasound, but I don't know that we have the time, we could certainly review it next. Next time.

Ben: 1:05:37

I did it for next time. That was that was from from chest big. It's for next time. Okay. Okay, that was a great Journal Club. Thank you, Daphna, for taking time from vacation. I want to read one feedback that we got from a Twitter follower called ACL says thank you so much for the weekly podcast and for the super presentation of the paper greetings from Kiel, Germany. So to have somebody from the old continent listening. Join us next week for journal for Brooklyn, where we interview Don raffel on the book called The Strange Case of Dr. Cooney. And it's, I'm rereading the book again for the third time now.

Daphna: 1:06:20

It is so good. Yeah. It's a really interesting book. It's not too late to pick it up. We really appreciate people who have been sending questions. So we're looking forward to getting some more of those questions. You can tweet us, you can email us, just reach out to us so that we can include you.

Ben: 1:06:38

That's right. Well,

Daphna: 1:06:39

thank you, and have a good one.

Ben: 1:06:44

Thank you for listening to this week's episode of the incubator. If you liked this episode, please leave us a review on Apple podcast or the Apple podcast website. You can find other episodes of the show on Apple podcasts, Spotify, Google podcasts, or the podcast app of your choice. We would love to hear from you. So feel free to send us questions, comments or suggestions to our email address NICU podcast@gmail.com. You can also message the show on Instagram or Twitter at NICU podcast. Personally, I am on Twitter at Dr. Nikki spelled Dr. NICU. And Daphna is at Dr. Dafna MD. Thanks again for listening and see you next time. This podcast is intended to be purely for entertainment and informational purposes and should not be construed as medical advice. If you have any medical concerns, please see your primary care practitioner. Thank you