#458 - [Journal Club] - 📌 Should late preterm infants born by cesarean receive prophylactic CPAP?

Late preterm babies born by cesarean fill our NICUs, and most of them are there for respiratory distress that resolves in a day or two. Could 20 minutes of CPAP in the operating room keep them out? This week on Journal Club, Ben and Daphna break down the PLaNT trial, a five center randomized pilot of prophylactic CPAP at 5 to 6 cm of water in spontaneously breathing infants born at 34 to 36 weeks by cesarean. They then sit down with senior author Dr. Edgardo Szyld to talk pneumothorax risk, the 35 to 36 week subgroup, consenting families, and what PLaNT 2 must prove.

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Prophylactic CPAP at Cesarean Birth in Late-Preterm Newborns: A Multicenter RCT. Shah BA, DeShea L, Schmölzer GM, Josephsen JB, Fabres J, Wetzel EA, Rykovich H, Thomas A, Law B, Garrido C, Szyld E.Pediatrics. 2026 Aug 1;158(2):e2025070998. doi: 10.1542/peds.2025-070998.PMID: 42457181 Clinical Trial.

Association Between Delivery Room Continuous Positive Airway Pressure and Neonatal Outcomes in Late Preterm and Term Infants: A Systematic Review and Meta-Analysis. Chin Y, Hill M, Sett A, Thomas N, Razak A.J Paediatr Child Health. 2026 Jul 28. doi: 10.1111/jpc.70516. Online ahead of print.PMID: 42517258 Review.

Transcript

Ben Courchia, MD (00:00.568) Hello everybody, welcome back to the Incubator Podcast Journal Club. Daphna, good morning.

Daphna Yasova Barbeau, MD (00:06.356) Good morning. Good morning. How are you? I'm away at surf camp. In full disclosure, I'm not doing much surfing, but I'm accompanying. I have surfed. I've dabbled in surfing. Really? It's lovely. It's lovely. They should. There are some adult surf camps. We could get you to one.

Ben Courchia, MD (00:08.534) I'm good. You're at surf camp.

Ben Courchia, MD (00:15.736) Do you not know how to surf?

Ben Courchia, MD (00:20.064) I have never surfed. Never. Yeah.

Ben Courchia, MD (00:26.702) 100%. But people who surf say that it's the best thing. Everybody who does it is, kind of not in an obnoxious way, but kind of like people who are gluten free. When they tell you, my God, it's revolutionized everything. Yeah. They're strong advocates of that particular activity.

Daphna Yasova Barbeau, MD (00:30.676) It's the best thing.

Daphna Yasova Barbeau, MD (00:41.534) It's the best thing ever. Yeah.

Daphna Yasova Barbeau, MD (00:46.294) Yeah, it's a freeing thing. But I had the good fortune now of just hanging out at the beach house and recording with you, and I had to last minute deliver some cords, but I got them. We're ready to roll, so that's good. We're good to go.

Ben Courchia, MD (00:58.318) What a life.

Ben Courchia, MD (01:10.998) Yeah, people are not going to notice any difference.

Daphna Yasova Barbeau, MD (01:13.854) I hope not.

Daphna Yasova Barbeau, MD (01:18.686) Other than this big sailfish behind me, I guess.

Ben Courchia, MD (01:22.08) Yeah. Yeah, we can see that the background is not your usual one. So we have a very exciting week of Journal Club ahead of us today. I'm going to start off Journal Club with a paper that came out in Pediatrics, the journal of the American Academy of Pediatrics, called "Prophylactic CPAP at Cesarean Birth in Late Preterm Newborns, a Multicenter RCT." First author is Birju Shah and senior author is Edgardo Szyld.

Daphna Yasova Barbeau, MD (01:25.14) Yeah, that's right.

Daphna Yasova Barbeau, MD (01:37.654) Mm-hmm.

Ben Courchia, MD (01:50.936) We're going to have the pleasure of discussing the paper with the senior author, Dr. Szyld, at the end of the conversation. So it gives us a bit of an opportunity to break down the study and then get his take on what this means. I feel like this is a paper that addresses a problem that affects everyone, no matter our degree of training or the level of care that we provide. We're talking about late preterm infants.

Babies born between 34 and 36 completed weeks of gestation. And as the authors mention, they account for about 8% of all live births and make up over two thirds of the preterm population, a proportion that continues to rise. And when we're talking about this patient population, they account for the largest proportion of babies admitted to the NICU, with about one third requiring NICU care, most often for respiratory distress.

And now if this population is segmented into one more group, which is what this paper is looking at, it's the babies who are born via C-section. Late preterm infants are 40 times more likely to experience respiratory distress compared to term infants, and this risk is increased fivefold when the baby is born via C-section. Typical neonatology board stuff, delayed fluid clearance,

which contributes significantly to the pathophysiology of respiratory distress. Now, starting CPAP immediately after birth may reduce the subsequent respiratory support, but the evidence for prophylactic CPAP in the delivery room is limited. And that's what we're going to talk about today, meaning you snap on that CPAP on that late preterm baby irrespective of what's going on. Not irrespective, there are going to be some criteria. But basically, a baby that may not necessarily need it is going to get it.

Daphna Yasova Barbeau, MD (03:46.538) Sorry, Ben, I'm just realizing, since we've been discussing this offline also, that we're so much moving away from prophylactic and universal policies for babies that this really represents a step back, I think. Not backwards, but a reassessment that maybe there are some prophylactic interventions that are still useful for certain subgroups of babies, which is interesting.

Ben Courchia, MD (04:15.534) I think that I disagree, and I disagree because...

Daphna Yasova Barbeau, MD (04:19.709) Okay. Because their inclusion criteria was very good.

Ben Courchia, MD (04:25.582) No, because I feel like, Daphna, we go to these deliveries and you get this 35 weeker. Okay, so interestingly enough, we're going to discuss, I'm getting ahead of myself here. But there's the 34 to 35 weeks. I think that for most units, you take this baby to the NICU anyway, which is our case. So 34 and two, they come to the NICU. And no offense, I don't care about this patient population because they're coming to the NICU, so we're going to care for them. But it's those that come at 35 to 36.

Daphna Yasova Barbeau, MD (04:28.98) Hm.

Daphna Yasova Barbeau, MD (04:35.061) Yeah.

Daphna Yasova Barbeau, MD (04:42.751) Yeah.

Ben Courchia, MD (04:54.614) And how many times have we left the delivery room and come back to the unit and you're like, they're going to call us. They're going to call us. And so...

Daphna Yasova Barbeau, MD (05:00.009) That baby's gonna come. Yeah.

And we're gonna have to go back over there, do a little bit of CPAP and then see if they can stay again. Yeah.

Ben Courchia, MD (05:07.564) And they're going to call you at 20 minutes, and then you go, and then you bring them, and then you have this typical event that happens. You bring the baby, you're a little bit defeated. The nurse puts the baby on the monitor, the prongs are off and the kid's satting a hundred. And now you're like... and they're like, this is what you brought to the NICU? And it's like, I promise you, over there we give CPAP. And so my point is that there are these babies that you wonder about. They may not really need NICU admission, they need a little bit of support, and

Daphna Yasova Barbeau, MD (05:23.911) Yeah.

Daphna Yasova Barbeau, MD (05:33.021) Yeah, but they still need help with the transition. Yeah.

Ben Courchia, MD (05:37.515) now I've separated them. And to be honest with you, if you bring these babies at 35 weeks, I'm not going to include everyone in this conversation, but if you get a blood culture, you've kind of taken a path. Yeah. You've put them on a path. And so what I'm interested in with this study is to see, could we turn the tide? And so, like you said, maybe it's a step back from the standpoint that we're going to be a bit more aggressive in the delivery room, but is the carrot, while CPAP may be the stick, is the

Daphna Yasova Barbeau, MD (05:48.255) Committed them. Yeah.

Daphna Yasova Barbeau, MD (06:03.324) Mm-hmm.

Ben Courchia, MD (06:06.67) is the carrot going to be that that kid is not going to come to the NICU? And we will see what they find. So it's a very interesting conversation. So I guess I don't entirely disagree with you, but I'm okay with the idea of stepping back if we can make that kind of a gain. So they talk about some of the prior meta-analyses that showed that this is a safe intervention, and Dr. Szyld is going to talk to us about that a little bit later, so I'm going to skip this. So this is an international

Daphna Yasova Barbeau, MD (06:09.279) Yeah.

Daphna Yasova Barbeau, MD (06:19.837) Yeah. All right. Let's hear it.

Ben Courchia, MD (06:36.426) multicenter pilot RCT that is aimed at evaluating whether prophylactic CPAP applied in the delivery room for late preterm infants born via C-section is feasible and safe, and reduces the duration of respiratory support from 30 minutes after delivery through the first week of life compared to standard care. So the trial was conducted in five tertiary centers in both North and South America.

And the study really sought to evaluate feasibility and safety of the intervention to determine whether a large trial was justified, by exploring preliminary effects of this intervention. We're talking about babies born between 34 and 36 and six weeks of gestation. The neonatal inclusion criteria had to be that the baby was spontaneously breathing. And babies with major congenital anomalies and other conditions were excluded.

The point about spontaneously breathing is really to make the case that these are not babies you would have given CPAP based on NRP, right? The idea is that if you need to activate the NRP algorithm, then that's not the patient we're talking about. Then you need to address the clinical concerns of the baby at that time. We're talking about the baby that's coming out, giving a good scream, breathing comfortably. Should you give them some CPAP? So for the...

For the infants who were not spontaneously breathing within five minutes, they were excluded. They have some information about twin handling and so on, but umbilical cord management followed the standard of the institution. And the intervention involves receiving 20 minutes of prophylactic CPAP. And what that means is that you set your PEEP at five to six centimeters of water.

You initiate it within the first five minutes after birth and you go on for 20 minutes. Infants in the control group were treated as they would have been otherwise, without any prophylactic CPAP. In both groups, therapeutic CPAP is permitted if the infant demonstrates low oxygen saturation, labored breathing, and so on and so forth. The way CPAP was delivered,

Ben Courchia, MD (08:57.263) basically, your T-piece resuscitator, Neopuff and a mask. So far, I think everybody's familiar with that. Supplemental oxygen is allowed but to achieve goal saturation. And if the baby needed escalation of support, then that was per the institution and per NRP guidelines. Outcomes. The primary outcome of the study was the duration of respiratory support from 30 minutes of life after delivery through the first week.

Respiratory support was defined as the use of any positive pressure support, including CPAP. Nasal cannula was not included in the primary outcome of positive pressure, but it was included in secondary outcomes. The duration of respiratory support was also examined with hours of supplemental oxygen included. And other secondary outcomes included the proportion receiving respiratory support at 30 minutes after delivery, the proportion receiving support during the first week, NICU admission from the delivery room,

whether NICU admission was unplanned, the reason for the NICU admission, and so on and so forth. There's a long list of secondary outcomes. I will let you guys review it. So in terms of the statistical analysis, they found that based on prior data in late preterm infants, the mean duration of respiratory support in the first week is estimated at about 50 hours. They were saying, can we get a reduction of about 14 hours, which would be 30%, as clinically meaningful?

A sample size of 60 infants per group, so a total of 120, would provide 80% power to detect an 18-hour difference with a two-sided alpha of 0.05. So that's how statistical power was calculated. In terms of the results, enrollment started in 2023 and ran until 2025. 60 infants born to 49 mothers received the intervention. 55 infants born to 45 mothers received standard care.

They go over all the baseline characteristics. The first thing I'm going to talk about is safety outcomes, because that's something that we'll talk about again with Dr. Szyld. No pneumothoraces in either of the groups and no deaths in the 30-day window. So that's the first thing, and I think that's important to mention right off the bat, because that's the first thing that comes to mind. In terms of primary outcomes, table two is really the table that shows that. The intervention group,

Ben Courchia, MD (11:19.235) the mean duration of positive pressure support initiated in the first week of life did not differ significantly from the control group. And that was 12.3 hours versus 22 hours. And like I said, this was not statistically significant. But let's dive deeper into some of the results. When including hours of supplemental oxygen, no difference was detected.

The intervention mean was 15.4 hours. The control mean was 30.4 hours. An intervention median of zero hours and a control median of 1.8.

In terms of NICU admission and surfactant use, infants from each group were admitted to the NICU after delivery at comparable rates, 50% in the intervention, 67% in the control. Although the rate of unplanned NICU admission was significantly higher for the control group, 15%, compared with the intervention group, 7%. The groups did not differ on surfactant use. Therapeutic CPAP and support at 30 minutes: 27%

of the prophylactic CPAP group received therapeutic CPAP during the first 30 minutes, for a median of 1.8 minutes. And this duration was included in the mean duration in table 2. Therapeutic CPAP was provided to 34 infants, 62%, in the control group. So big difference there. And at 30 minutes, respiratory support was being given to significantly more of the control group infants, 47%, compared to 27% for the control

So I think that what was at least important to me was this next section, the subgroup analysis, where they mention that four out of the five participating centers in the study had an institutional practice of admitting all infants born before 35 weeks of gestation to the NICU. And that was important to me because that is kind of my practice as well in our institution. So they said, thus, a planned subgroup analysis of the respiratory outcomes by gestational age was conducted,

Ben Courchia, MD (13:23.363) focusing on the infants born between 35 and 36 and six, meaning the babies that by protocol would not have necessarily been automatically admitted to the NICU. What they found in this subgroup analysis is very interesting. Infants in the control group were significantly more likely than those in the intervention group to require positive pressure ventilation, CPAP, or supplemental oxygen initiated in the first week. 24% in the intervention group versus 46%

in the control group. Those in the control group also were more likely to be admitted to the NICU, 54% versus 24%, so almost more than double, with that admission being more likely to be unplanned. The reason for NICU admission also was significantly more likely to be respiratory distress for infants in the control group, 39%, versus the intervention group. So we see that as we restrict

the population to really a population that may not necessarily go straight to the NICU, the contrast between the groups becomes a lot more interesting. I'm going to stay here for now, and I'm going to go to the conclusion. The study basically concludes by saying that for spontaneously breathing late preterm infants born via C-section, prophylactic CPAP is feasible,

especially when it's done on the mother's chest or close to the parents in the operating room. Safe, no air leak syndromes. While the duration of respiratory support during the first week was not different from the standard group, the intervention reduced the need for respiratory support at 30 minutes after delivery and unplanned NICU admission. Pre-specified subgroup analysis for the infants between 35 and 36 weeks

showed a significant reduction in respiratory support during the first week and a significant reduction in NICU admission. A larger RCT is needed to confirm these findings. So, Daphna, I'm going to take a quick break before we welcome in Dr. Szyld to discuss this, but I'm curious to get your thoughts on it.

Daphna Yasova Barbeau, MD (15:39.482) Yeah, physiologically it makes total sense, right? We're trying to improve

the lung capacity, these babies are trying to get rid of extra fluid. We definitely know those are the babies that are at risk for RDS. So it's exciting that we could provide something like this that, like you said, is an intervention, but if the alternative is the intervention of coming to the NICU for a few days, then it would be a great advantage for families and babies, I think.

Ben Courchia, MD (16:18.776) And I just want to mention, because I forgot to mention this in the intervention, but they do provide in supplementary figure number one, if you go into the supplementary material, there was an opportunity for people to do this intervention on the mother's chest, meaning we didn't need to delay skin to skin by 20 minutes in order to do this. I think that the issue with it is that you need to be able to deliver positive pressure on the

Daphna Yasova Barbeau, MD (16:35.614) Right.

Mm-hmm.

Daphna Yasova Barbeau, MD (16:46.838) Mm.

Ben Courchia, MD (16:48.662) on the parents' chest. And I don't know, for us in our ORs, we wouldn't be able to do that. Technically, we would have to really move some stuff around.

Daphna Yasova Barbeau, MD (16:58.098) Yeah, we'd have to have a different setup, right? We'd just have to have a CPAP setup as opposed to what we have now, which is kind of on the wall. So yeah, but it could be done for sure.

Ben Courchia, MD (17:08.368) Yeah, yeah, it could be done. But this was an option, and I think that this is important, that I failed to mention that, and I just wanted to make sure that, yeah. And the CPAP setup that you're talking about is very much low resource. If you go to the supplemental material, you have both the picture of the setup, which is basically two tanks, a Neopuff and a humidifier, and it shows you how they were delivering this on the mother's chest in the OR. So very neat indeed.

Daphna Yasova Barbeau, MD (17:21.897) Exactly. Right.

Daphna Yasova Barbeau, MD (17:38.176) Thanks, buddy.

Ben Courchia, MD (17:38.584) All right, so without further ado, we're going to do a quick transition and welcome Dr. Szyld to the podcast.

Ben Courchia, MD (17:49.724) All right. So we have the pleasure of having on with us today for Journal Club the senior author of the PLaNT study, Dr. Edgardo Szyld. Edgardo, welcome back to the podcast.

edgardo szyld (18:04.790) Okay, thank you very much for having me.

Ben Courchia, MD (18:07.324) You are professor of neonatology out of Indiana University. And you are the organizer and founder of the neonatal resuscitation symposium, which will be taking place September 10 and 11, 2026 in Indiana. People can register online. We're going to mention this just in passing because we think you're doing great work. But we're very eager to talk to you a little bit about the PLaNT study, and to talk

a little bit about some of the things that are not necessarily just in the paper specifically, results and so on, but more about what surrounds the study. I think that as we were having conversations before this episode, Edgardo, you shared with us a very nice meta-analysis that is senior authored by Abdul Razak,

which looks specifically at the delivery of positive pressure in the delivery room. And I think that this brings a very interesting degree of context to the intervention that we've discussed today through the PLaNT study. And for the people who may not have seen this paper, it's in the Journal of Paediatrics and Child Health. It's called "Association Between Delivery Room CPAP and Neonatal Outcomes

in Late Preterm and Term Infants, a Systematic Review and Meta-Analysis." And you can correct me if I'm wrong, but this study does a very good job looking at the literature, including about six studies in total, for babies that are born at or after 34 weeks and whose intervention

is the administration of CPAP, with a comparator of infants who do not receive CPAP. And one of the main outcomes, the primary outcome of the study, is to look at the degree of barotrauma through pneumothorax. And what the study finds is that the administration of delivery room CPAP is associated with potential harm in observational studies, though there's some confounding that they're talking about.

Ben Courchia, MD (20:31.622) And that's a stark comparison to the PLaNT study, where the number of pneumothoraces was zero between the two groups. And so starting there, Edgardo, how do you take the two papers, this meta-analysis and the PLaNT study, and how do you reconcile the data, specifically in how the intervention is being administered? Because I think that this is the key.

edgardo szyld (20:56.181) Now, actually, that's a very interesting question. As you may know, we performed, with the participants, the co-authors for the PLaNT study, a previous meta-analysis with the same group, with Dr. Shah, Dr. Schmölzer and myself. For ILCOR, we published in 2022 a systematic review and meta-analysis for CPAP in the delivery room.

And similarly to this paper, the difference between ours and this one is that this one is more up to date and they included two more papers, two more observational studies. But what we found at that time, and it's in the same direction as this new systematic review and meta-analysis, is that the observational studies found, as you mentioned, an association between the use of CPAP and pneumothorax. Which is concerning, but it's

finally an association. When you look at the randomized controlled trials, there were only two of them, and both of them were included in our meta-analysis and in this new one, and nobody found any pneumothorax in a randomized controlled trial, in a prospective randomized controlled trial. So on one hand, we have concern, because the number of patients included in both meta-analyses in observational studies is huge compared to the

smaller number in the randomized controlled trials, but they are really controlled studies, and no pneumothorax in this situation. Our PLaNT study was inspired by a small subgroup analysis from Celebi's paper, in which 35 late preterm babies born by C-section showed a great benefit, reducing NICU admission. And the intervention was exactly the same, 20 minutes of CPAP

at five to six centimeters of water. And everybody's asking us, why five centimeters of water? Why 20 minutes? Why not higher pressure? Why not a longer time? And actually, if you have a medication with a specific dose that is demonstrated to be safe and useful, why should you escalate the dose? So that's the answer. We understand that some people consider that probably 20 minutes is not enough.

edgardo szyld (23:22.026) Other people consider that 5 to 6 centimeters is not enough. Our study demonstrated that, at least in the pilot study, it was enough, and actually we are trying to expand and go for PLaNT 2, a larger multicenter study including 35 and 36 weekers, because our goal is to reduce NICU admission. So I think that I answered your question and even more.

Ben Courchia, MD (23:44.308) Yeah.

Ben Courchia, MD (23:47.892) Very much so. And I think that it is important to actually drill down and go at the design of the PLaNT study and put that in comparison with, for example, this meta-analysis, because I think that this is the key. In this meta-analysis, we're looking at the administration of delivery room CPAP, while the PLaNT study is very selective about the patients on whom the intervention is going to be tested, specifically

excluding babies born via natural birth and really selecting, as we mentioned in the introduction, babies who are born via C-section, because of the incredibly higher risk of morbidities associated, specifically respiratory morbidities associated with delivery via C-section in this particular population. And I wanted you to speak to that in terms of

the deliberate choice, not just of the intervention, as you mentioned, but also of the patients and the context in which they are born. And the second part to this question is, what led you to say it is time for us to look at this right now? It's something that we've known, that babies born via C-section are at high risk of respiratory issues. What made you decide that this was the time to actually investigate this type of an

edgardo szyld (25:09.077) So first of all, I think that it's important to highlight that we are comparing prophylactic versus therapeutic, or reacting to the patient's needs. And when you provide any prophylactic intervention, you need to provide it to a higher risk group, like vaccination. With any prophylactic, you are doing an intervention to anticipate and to reduce the risk or the damage

in the population that has higher risk. What we know from epidemiological studies is that the higher risk population is exactly the one we are targeting. It's the late preterm born by C-section. And we start there. Should this apply to larger babies or more mature babies, or a specific subgroup of C-section? I don't know. We designed a pragmatic study trying to target first what they did in the pilot, to test feasibility,

safety, and we demonstrated that it was feasible and safe. Now we have a very good signal of efficacy, it's really efficient, so now we are trying to target the efficacy and target this for NICU admission. What is the main concern? That we can prevent NICU admission with this prophylactic intervention. Is there another subgroup that may benefit

more than this? Probably, and we'll see later in further subgroup analysis. For now, first of all, I will not recommend starting this intervention immediately, because we don't have enough data and it's not strong enough. It's promising, but it's not for you to go back to your unit and start doing prophylactic CPAP. But it's time to continue exploring this, and we have enough evidence to

allow us to go for a larger study.

Ben Courchia, MD (27:09.748) Mm-hmm.

edgardo szyld (27:11.605) And to answer why now, I would say there's a lot of interest in understanding that our NICUs are populated with a lot of late preterm babies. And actually, a lot of the information we have is that the majority of admissions are late preterm. And the second reason is that the rate of C-section has increased in the last several years. So if we have more C-sections,

we have more late preterms, and we may prevent NICU admissions and provide room for more acute babies, and offer this group of patients a better outcome, having early bonding with their families. So it should be win-win for a short intervention that looks, for now, to be safe.

Ben Courchia, MD (28:03.317) Mm.

Daphna Yasova Barbeau, MD (28:04.460) I love that. And one of my follow-up questions is exactly that, about the safety. Obviously the PLaNT study found no increase in air leaks like pneumothorax, which is of interest to people because of the previous studies, but it's still an uncommon problem. Do you think the PLaNT 2 study will be able to enroll enough patients to have certainty

that the benefits outweigh the risk of pneumothoraces?

edgardo szyld (28:39.317) I would say yes. We are planning to enroll 300 patients in the next study, and if you include the first 100 from PLaNT 1, you can combine all of the randomized controlled trials in the meta-analysis, if we continue finding very few or no pneumothorax. And for the safety of the study, we have stopping rules where, if we had had four pneumothoraces in the first group, we would stop the study.

And we are lucky that the DSMB demonstrated that it was safe. Zero pneumothorax was reassuring, moving forward. So if we continue having no pneumothorax, I will say, for now, it looks like we have enough evidence to say no, no more pneumothorax with prophylactic CPAP in late preterm C-section at 5 to 6 centimeters of water for 20 minutes. I cannot speak about anything else, because

it's so often the case in our specialty that people generalize and say, okay, if this approach is good for this group, I will expand it to another one without doing the randomized controlled trial. So for now I can say what we found in late preterm infants born by C-section. 20 minutes of CPAP at 5 to 6 centimeters of water was safe.

Daphna Yasova Barbeau, MD (29:59.934) Mm-hmm. Perfect. Ben, did you have a follow-up to that? Yeah.

Ben Courchia, MD (30:00.406) Yeah, I had a follow-up question to that. I think that's potentially a critique of follow-up work, specifically looking at pneumothorax, right? I think that some people might say we only know about the babies we X-ray, and the incidence is already, as Daphna mentioned, low at baseline, but we're also not investigating the diagnosis of air leaks in every baby.

Daphna Yasova Barbeau, MD (30:09.548) Mm-hmm.

Ben Courchia, MD (30:29.270) What would be your response to that?

edgardo szyld (30:33.695) So we decided to make it pragmatic and to only explore symptomatic babies, because we know that there are asymptomatic spontaneous pneumothoraces in many babies, and we are not exploring this routinely by doing an X-ray on every baby. So I think that we didn't find it worth exploring that component, because we may find a pneumothorax that

you don't need to treat, and you don't need to expose the baby to an X-ray unnecessarily. But we know that after the new algorithm in the NRP in the last 10 to 15 years, we increased, they considered, the use of CPAP. The use of CPAP has increased dramatically in many delivery rooms. And people started to probably overuse CPAP, and like

any other tool or drug, if you are overusing it, you may see more secondary effects. So that's the problem, because it was expanded, that if it's useful for preemies, it should be useful for late preterm and term, and we don't know.

Daphna Yasova Barbeau, MD (31:51.341) I love that. Taking a more standardized approach, and the inclusion and exclusion criteria. I think you've mentioned a very family-centered benefit, obviously, of reducing NICU admissions. I wonder about the unintended consequences of parents seeing their babies receive respiratory care that they may not otherwise have expected or

received in the past, and what that discussion should look like with families who are anticipating a late preterm delivery. How do we introduce this therapy that's really prophylactic to families?

edgardo szyld (32:37.430) It's a very interesting point, because the IRB brought this question and we also asked our parental panels to advise us when we developed the new protocol. The issue is that, on one hand, we have been able to demonstrate in this pilot study that we can provide CPAP on the mother's chest after C-section if the unit allows it, addressing the IRB concern and the family concern.

We have been able to demonstrate that this intervention is feasible without interrupting the bonding and contact between the mother and the baby. On the other hand, we explain to the families that their baby already has a higher risk of developing respiratory distress, of needing respiratory support, and of eventually going to the NICU. So if this is the case, we're offering an alternative that may benefit them and prevent NICU admission,

and they accept and they provide consent prospectively to receive the intervention.

Ben Courchia, MD (33:43.242) Very interesting.

edgardo szyld (33:45.842) Of course, now, after the pilot, we are more convinced that we can offer an even safer approach. But we always provide open information that there was an association with air leaks, that there is a risk. However, we didn't find it in any randomized controlled trial in this population.

Ben Courchia, MD (34:04.086) Sure. For sure. Dr. Szyld, thank you so much for coming by. And we will be looking out for the publication and for information on the upcoming PLaNT 2 study. It's been a pleasure talking to you and reviewing your work. We're going to remind everyone to check out and register for the neonatal resuscitation symposium, taking place September 10 and 11, 2026 at Indiana University. Thank you so much for giving your time to the show, and thank you for your work.

edgardo szyld (34:34.615) Thank you for the invitation. Happy to be with you. Thank you.