#006 - Journal Club - The latest research in neonatology (January 8th 2026)

In this episode of The Incubator India Podcast, Dr. Akanksha Verma is joined by Dr. Kirti Naranje for a journal club focused on recent Indian neonatal research and clinical updates.

The discussion covers three important studies from Indian NICUs: a landmark RCT showing that early BCG-OPV vaccination in sick, low birth weight infants significantly reduces infection-related mortality; a well-designed trial demonstrating that nebulized salbutamol offers no benefit in Transient Tachypnea of the Newborn when modern CPAP protocols are used; and a systematic review examining CSF procalcitonin's limited role in diagnosing neonatal meningitis.

The second half covers key updates from the NRP 9th edition, including changes to cord management protocols, ventilation terminology and rates, endotracheal tube placement guidelines, and more flexible approaches to corrective steps during resuscitation.

This episode focuses on Indian data, real-world applicability, and how evidence translates into everyday NICU practice. Whether you're working in a tertiary center or a smaller unit, these conversations are designed to inform clinical decisions without unnecessary complexity.

Transcript

Dr. Akanksha Verma (00:01.4) Hello everyone. As neonatologists, we often work in moments. Those first few minutes of life, those critical early decisions, but our learning is built over the years through evidence, experience, and reflection. Welcome to episode six of Incubator India and the very first episode of year 2026. As we begin a new year, we felt it was important to pause not to summarize guidelines or deliver lectures, but to reflect on what Indian neonatal research is telling us today. So this episode is special for more than one reason. First, we are doing this in our journal club format, where we discuss recent neonatal research published from India, studies that arise from settings similar to ours, with constraints we recognize and questions we grapple with every day in our units. These papers may not always change practice overnight, but they definitely make us think. And that, perhaps, is where real learning actually begins.

Second, I'm delighted to be joined today by Dr. Kirti Naranje, a neonatologist from northern India who is joining Incubator India for the very first time as a co-host. She brings a thoughtful, grounded clinical perspective and I'm really looking forward to this conversation. And towards the end of the episode, we'll shift gears and take a closer look at some of the key updates from the recent NRP (Neonatal Resuscitation Program) 9th edition, not just what's changed, but why these changes matter, how they translate into everyday practice, especially in our delivery rooms and in NICUs (Neonatal Intensive Care Units). So just gear up, because this episode is about evidence, experience, and applicability. Indian data first, global guidelines later, and always with the patient and provider at the center. So let's begin and welcome Dr. Kirti.

Dr. Kirti Naranje (02:06.05) Thank you Akanksha. It's a real pleasure to be part of this podcast and it's especially meaningful to join in this journal club. As we know that Indian Neonatal Research often reflects realities that are very different from what global guidelines assume. And discussing this evidence together helps us bridge that gap between the recommendations and the real world practice. So I am really looking forward to reviewing these studies today with you, and not just from the methodological point of view, but also from the perspective of how they influence our day-to-day decisions in Indian NICUs. And as we move toward discussing the NRP 9th edition later on in this episode, I think this context will help us ask the right questions about applicability and feasibility in our settings. So let's begin today's journal club with a landmark Indian randomized control trial that challenges one of our long-held practices around vaccination in sick and low birth weight newborns. Now that's a really pertinent question that we often deal with in our day-to-day practice while dealing with the sick babies. Traditionally, BCG (Bacillus Calmette-Guérin) is often delayed in preterm or clinically unstable neonates, largely due to concerns around the safety and the immunogenicity. However, some observational data and trials have suggested that early BCG vaccine, especially the Danish strain, may have beneficial non-specific effects on neonatal mortality, particularly infection-related deaths that we are mostly concerned with. So this multi-center open-label randomized control trial, popularly known as the BSID-2 trial, was conducted across three tertiary NICUs in Southeast India. And it specifically enrolled newborns weighing less than 2,000 grams, which already makes it very relevant to our settings.

Dr. Akanksha Verma (04:24.076) The study aimed to test whether early administration of BCG Danish strain along with OPV (Oral Polio Vaccine) given within 48 hours of NICU admission could reduce all-cause neonatal mortality. Over 7,000 babies were screened and around 5,420 newborns were randomized, about half to early vaccination and half to a control group where vaccination was delayed until discharge. The randomization was stratified by gender and ICU stay and the birth weight categories, which is methodologically reassuring given the heterogeneity in this population. Importantly, this was an open-label trial, but the primary outcome, that is death, is a hard outcome, which reduces the bias. And the primary outcome was all-cause neonatal mortality within 28 days. And a key secondary outcome that was added partway through the trial was infection-related neonatal mortality. And when we see the median age at vaccination was on the first day, that is 0.9 days, and the median birth weight was around 1,560 grams. So these were genuinely very small babies and sick babies.

Dr. Kirti Naranje (05:52.5) Yeah, exactly. And what strikes us immediately is the scale of the trial. I mean, almost 7,000 babies were screened and more than 5,000 were randomized. And the fact that it has been conducted in sick preterm babies, low birth weight, not just community settings. So we often tend to extrapolate data from relatively stable newborns. But here, the population includes very ill, low birth weight babies, which is exactly where most of our uncertainty lies. And the stratified randomization and the adjustments that were made for the gestational age, birth weight, sex, and postnatal age also strengthen the internal validity. What say Dr. Akanksha?

Dr. Akanksha Verma (06:35.8) Yes, I think the fact that there is a huge sample size makes this data very, very relevant to our settings. And when we come to the results, mortality was high, which again reflects real world NICU settings in low and middle income countries. Death occurred in around 8.8% in the early vaccination group compared to 10% in the control group. In the adjusted Cox survival analysis, early BCG-OPV reduced all-cause mortality with adjusted hazard ratio of 0.83 and with a statistically significant p-value of 0.03. So what is even more striking is the effect on infection-related mortality. The hazard ratio here was 0.53, which suggests a 50% reduction in deaths due to infections. And the number needed to treat was 21, meaning vaccinating 21 such babies early could prevent one death. And there were no deaths because of tuberculosis and importantly, no serious adverse events related to vaccination.

Dr. Akanksha Verma (07:45.2) Yeah, actually the reduction in the infection-related mortality is really the most compelling part of this study. It definitely strongly supports the concept of non-specific or off-target immune benefits of BCG, something that has been discussed academically for years but has rarely been demonstrated, especially in a sick neonatal population. And also they made sure to look at the adverse events. So basically there were no serious adverse events. So the safety data is also reassuring. Many clinicians and most of us may often hesitate to vaccinate unstable or preterm babies because of the perceived risk. And this trial may help us address that fear.

Dr. Kirti Naranje (08:28.5) Yeah, that said, there are limitations worth acknowledging. This was an open-label trial. While mortality is an objective outcome, decisions around escalation or withdrawal of care could theoretically be influenced. And this trial was conducted in tertiary NICUs with trained staff administering vaccines. So the results may not be immediately generalizable to all delivery room or peripheral settings. Also, the OPV was given along with BCG, so it's difficult to fully disentangle the individual contribution of each vaccine. From an Indian perspective, this study raises very important operational questions. Should we continue to delay BCG in preterm or sick newborns simply because they are small or ventilated? Authors even suggest policy-level changes like opening a vial of BCG even for a single infant and redefining timely BCG from 12 months to 28 days. And implementing this would require training, changes in the workflow and buy-in from both neonatology and obstetrics, but the potential impact on mortality is substantial.

Dr. Akanksha Verma (09:40.5) Yes, absolutely. I agree with you, Dr. Kirti. And I think to summarize, this very well conducted Indian RCT clearly shows us that early BCG and OPV administration within the first 48 hours of life in newborns weighing less than 2,000 grams significantly reduces neonatal mortality, and more so largely by reducing the infection-related deaths. So it does challenge our traditional hesitations, reassures us about safety, and forces us to rethink what timely vaccination really means in high mortality settings. And as we said earlier, it may not change the practice overnight, but it definitely changes the conversation. So with that, let's move to our next journal club paper, which again comes from India, but looks at a very different aspect of neonatal care.

Dr. Kirti Naranje (10:30.3) So for the next paper, we'll be discussing again a randomized control trial, which was published in the Journal of Perinatology in the year 2025, which examines the role of nebulized salbutamol in the management of Transient Tachypnea of the Newborn. That's a very interesting question.

Dr. Akanksha Verma (10:50.8) Exactly, considering that TTN (Transient Tachypnea of the Newborn) is a self-limiting condition, this study evaluates whether nebulized salbutamol reduces respiratory distress or speeds recovery in late preterm and term infants with Transient Tachypnea of the Newborn. This is an important study to review because, as I said, being a self-limiting condition, interventions like salbutamol continue to be used in many NICUs, especially in resource-limited and high-volume settings. So what do you say, Dr. Akanksha?

Dr. Akanksha Verma (11:25.4) Essentially, I mean, we all know that Transient Tachypnea of the Newborn is fundamentally a disorder of delayed clearance of fetal lung fluid. Physiologically, beta-2 agonists are attractive because they stimulate the ENaC (Epithelial Sodium Channel) or the epithelial sodium channels and the sodium-potassium ATPase activity, promoting alveolar fluid absorption. Earlier animal models and some ex vivo human lung studies have supported this mechanism. And several small clinical trials have also suggested benefit of salbutamol in reducing respiratory rate. But these were very heterogeneous. The definitions of Transient Tachypnea of the Newborn were varied. The respiratory support was not consistently defined. And many of these were even done before routine delivery room CPAP (Continuous Positive Airway Pressure) became the standard of care. And importantly, Cochrane reviews have retained the certainty of evidence for salbutamol in Transient Tachypnea of the Newborn as low, highlighting the need for well-designed studies.

Dr. Kirti Naranje (12:38.998) And this was a parallel group, double-blind RCT conducted over a 15-month period, and newborns more than 34 weeks of gestation were enrolled. And only if the respiratory distress persisted beyond six hours using the Downes and Bonadio criteria. So they had a very strict criteria for definition and for inclusion. And also they made sure to exclude other causes of respiratory distress such as RDS (Respiratory Distress Syndrome), Meconium Aspiration Syndrome, pneumonia, sepsis, metabolic disturbances, and congenital heart disease. So basically, defining the condition or keeping a strict definition is important because then it definitely minimizes the diagnostic misclassification and avoids enrolling babies with delayed transition because they have enrolled babies beyond six hours of life.

Dr. Akanksha Verma (13:45.2) Yes, and the randomization was stratified by gestational age. That is, they have two groups with 34 to 36 weeks babies versus more than or equal to 37 weeks. The allocation was concealed and the parents, clinicians, outcome assessors and statisticians were blinded. And intervention was a single nebulized dose of salbutamol at 0.15 milligrams per kilogram delivered under ECG and SpO2 (Oxygen Saturation) monitoring. The comparator was normal saline, identical in appearance and volume.

Dr. Akanksha Verma (14:20.694) Okay, and the primary outcome they took was duration of tachypnea defined explicitly as a respiratory rate of more than 60 per minute. Secondary outcomes were again very comprehensive: peak Downes score, FiO2 (Fraction of Inspired Oxygen) requirement, need and duration of respiratory support, feeding milestones, NICU stay, and adverse effects. The study was basically powered based on a large effect size from an earlier similar Korean study. And this would be important when interpreting the negative results. Analysis was mainly intention to treat and appropriate non-parametric tests and the Kaplan-Meier analysis was used for time to resolution of tachypnea, so statistically strong. What about the outcomes?

Dr. Kirti Naranje (15:10.5) The primary outcome showed no difference. Median duration of tachypnea was approximately 12 hours in both groups. This is not just statistically non-significant, it is clinically indistinguishable. All secondary outcomes followed the same pattern. The Downes score, the FiO2 requirement, duration of CPAP or high-flow nasal cannula, feeding initiation and NICU stay were similar. Subgroup analysis by gestation also showed no signal of benefit. Okay, so notably no adverse effects were seen, but absence of harm does not really compensate for absence of benefit. So what do you think? Why did salbutamol fail here?

Dr. Kirti Naranje (16:02.136) Yeah, very well said. A key explanation lies in the early respiratory support. So nearly all babies received delivery room CPAP and most were on non-invasive support at enrollment. And as we know that CPAP itself improves lung fluid clearance by establishing functional residual capacity, reducing interstitial fluid load. In that context, the incremental benefit of salbutamol may be negligible. This suggests that earlier positive trials may reflect an era of less aggressive respiratory stabilization rather than actual benefit of salbutamol.

Dr. Akanksha Verma (16:41.87) Yeah, a true pharmacologic effect. So definitely the strengths of the study lie in having a very strict diagnostic criteria with rigorous blinding and sticking to the contemporary respiratory practices and also very clinically meaningful outcomes were chosen, I must say. The obvious limitations being it was a single center study, powered for a large effect size. And also, they just used a single dose of nebulized salbutamol. Again, a single dose regime could have had some effect on the outcome. And again, as of now, we do not have any long-term respiratory follow-up. What is your take on this, Dr. Kirti?

Dr. Kirti Naranje (17:30.5) Yes, Akanksha. However, even accounting for this, the consistency of null findings across outcomes strengthens the conclusion. This study is highly applicable to Indian NICUs because it reflects current best practice, that is early CPAP, close monitoring and supportive care. It suggests that routine use of salbutamol in TTN is unnecessary and adds complexity and may distract from optimal respiratory support. In resource-constrained, high-volume settings, avoiding non-beneficial interventions is an important quality of care issue. So in my view, only early CPAP and monitoring and supportive care would help a lot of babies. So what is your final take home?

Dr. Akanksha Verma (18:20.5) Yes, I would just like to say that this well-designed RCT shows us that nebulized salbutamol does not shorten the tachypnea or reduce respiratory support in TTN, especially when modern respiratory care is used. Supportive care with early CPAP remains the cornerstone. And so the use of salbutamol should be discouraged routinely for TTN. Again, the study also reinforces a broader lesson: physiologic possibility must be tested against the contemporary clinical practices being done.

Dr. Akanksha Verma (19:05.5) So we have just discussed Transient Tachypnea of the Newborn, a condition where careful observation, clinical judgment, and sometimes restraint guide management. But as we move along the spectrum of neonatal illness, there are situations where diagnostic uncertainty carries much higher stakes. One such situation is suspected meningitis in young infants, where decisions are rarely straightforward and the consequences of both overtreatment and misdiagnosis can be profound. So what do you say, what do we have for our next paper for this journal club today, Akanksha?

Dr. Akanksha Verma (19:45.8) Yes, very well said. As you have clearly mentioned that the stakes are very high in situations like meningitis. So for our next discussion, we have chosen a systematic review and diagnostic accuracy meta-analysis from India, asking a very practical question: Can CSF (Cerebrospinal Fluid) procalcitonin help diagnose meningitis in infants younger than 90 days? So this is a question we all struggle with. Traumatic lumbar punctures, borderline CSF parameters, prior antibiotic exposure. So all these situations where the traditional interpretation becomes difficult, thus we want to look for more options wherein we can diagnose meningitis with accuracy.

Dr. Kirti Naranje (20:26.132) And importantly, this is not a single center experience. This systematic review includes multiple Indian studies, which immediately makes it relevant to everyday practice in our NICUs. We know neonatal meningitis is devastating, but diagnosing it is notoriously challenging. CSF cultures take time and are often negative once antibiotics have been started. Traditional CSF markers like cell count, protein, glucose vary with age, gestation, and illness severity. And hence, making a conclusion based only on these might be difficult, especially like we have talked that many babies have received antibiotics before coming to us or before being diagnosed as meningitis. So the interpretation of these cell counts, protein, and glucose is really very challenging.

Dr. Akanksha Verma (21:25.5) Yes, and actually in the real world, in Indian NICUs, traumatic lumbar punctures are also very common. So correcting cell counts again for a traumatic tap many times may be unreliable. So the idea of choosing a rapid quantitative CSF biomarker like procalcitonin may actually look very attractive. And this was a PRISMA-DTA compliant systematic review registered on PROSPERO. The authors included infants under 90 days of age across gestational ages evaluating CSF procalcitonin against either culture-proven or composite reference standards. And they have screened over 800 studies, but only 7 studies including 963 infants met the inclusion criteria. And an important point here, 5 of these 7 studies were conducted in India. So the pooled estimates are heavily influenced by Indian NICU practices, patient profiles and the laboratory methods.

Dr. Akanksha Verma (22:34.614) And again, if we look closely at the table summarizing study characteristics, there's substantial heterogeneity. And this really explains the variability in results as well. Most of the studies included were single center and tertiary care hospital-based. But populations varied widely. Some included only neonates. Others infants up to 90 days. Gestational age ranged from extremely preterm to term. And also the definitions of meningitis differed between the studies. Some used strictly culture-proven meningitis while others relied on composite definitions incorporating the cytochemistry and the clinical features. Do you think that makes a difference Dr. Kirti?

Dr. Kirti Naranje (23:30.5) Yes, Dr. Akanksha, and that's a major issue. When the reference standard itself is inconsistent, diagnostic accuracy estimates become unstable. And another real world feature is that many studies included infants who had already received antibiotics. That reflects clinical practice, but again complicates interpretation. One striking feature is the wide variation in the CSF procalcitonin cutoffs across the studies. And only a minority had pre-specified thresholds. And most cutoffs were post-hoc.

Dr. Akanksha Verma (24:15.5) What you said is actually critical. When the thresholds are post-hoc, or basically when they are data-driven rather than being predefined, the sensitivity and specificity often appear better than they truly are. So this is why the index test domain was judged to have a high risk of bias. And that tells us why we can't simply adopt a single cutoff into routine practice, especially when they are being tested across different laboratories.

Dr. Kirti Naranje (24:50.5) Very true. Hence the authors focused on two commonly reported cutoffs, that is 0.2 nanograms per milliliter and 0.33 nanograms per milliliter. So what they found at 0.2 nanograms per milliliter, the sensitivity was around 77% with specificity around 70%. And at 0.33 nanograms per milliliter, the sensitivity was similar, like 76%. However, the specificity has improved to 75%. So essentially, that means at both the cutoffs of 0.2 and 0.33 nanograms per milliliter, it showed moderate sensitivity and moderate specificity. Not bad, but clearly not a rule-in or rule-out test. What do you say?

Dr. Akanksha Verma (25:45.5) And the confidence intervals are wide, reflecting small sample sizes and significant heterogeneity. I mean, this is where the paper becomes especially important for a journal club discussion. Almost all included studies had a high risk of bias, particularly in the index test domain.

Dr. Kirti Naranje (25:57.92) Yes, because most cutoffs were derived post-hoc, increasing the risk of overestimating the diagnostic accuracy. And also, I feel patient selection was also another concern because we saw that some studies included only culture-positive cases. Others excluded consecutive patients and one focused solely on traumatic taps. And because of all this, the GRADE certainty for both sensitivity and specificity was rated as very low. And that's the key takeaway.

Dr. Akanksha Verma (26:35.5) So interestingly, existing meta-analyses suggest that traditional CSF markers—cell count, protein, glucose—have sensitivities approaching 90%, which is actually higher than CSF procalcitonin. So CSF procalcitonin is definitely not superior to conventional CSF parameters, and its potential value may lie as an adjunct, particularly in scenarios like traumatic lumbar punctures where standard interpretation becomes unreliable. In Indian NICUs, we have to ask practical questions. Does this test change management? While serum procalcitonin assays are available, CSF procalcitonin is not routinely standardized or validated across laboratories.

Dr. Akanksha Verma (27:25.5) Yes, and I must say that cost is another consideration as well. And lumbar punctures themselves are often delayed or deferred in unstable infants. So definitely at this point of time, we can say that CSF procalcitonin cannot replace cultures or the standard CSF analysis. At best, a raised value may strengthen suspicion and support early CSF-penetrating antibiotics. But a low value cannot safely reassure us enough to stop treatment. So finally, your take home from this systematic review, Dr. Kirti.

Dr. Kirti Naranje (28:05.5) Yes, I think CSF procalcitonin shows moderate diagnostic accuracy, but the quality of evidence is very low. So I think this is our take home from this systematic review. It should not be used as a standalone test. It may be considered an adjunct in selected scenarios, particularly traumatic taps, always alongside clinical judgment and standard CSF parameters. And there's a clear need for well-designed multi-center Indian studies with predefined thresholds and uniform reference standards.

Dr. Akanksha Verma (28:36.088) So as we move on to our next segment, this paper really highlights how much uncertainty still exists when we are trying to diagnose serious illness in newborns. It also brings us back to a very basic truth. When stakes are high, especially in the delivery room, we rely heavily on clear evidence-based protocols. Hence, that actually brings us very naturally to the final segment of today's episode, looking at what's new in the NRP 9th edition. Dr. Kirti, would you like to take us through that?

Dr. Kirti Naranje (29:15.5) Yes, of course, Akanksha. In this segment, we are going to walk through some of the recent updates in the Neonatal Resuscitation Program 9th edition. And these recommendations come jointly from the American Heart Association and the American Academy of Pediatrics. And they are not arbitrary changes. These updates are based on rigorous review of available science by the ILCOR (International Liaison Committee on Resuscitation) member organizations. And the evidence is first distilled into a consensus on science and treatment recommendations and then translated into guidelines you see in the AAP (American Academy of Pediatrics) textbook. So Akanksha, let's get started.

Dr. Akanksha Verma (30:05.5) So starting with the recent NRP changes, and before diving into specifics, it's important to say this upfront that the overall NRP algorithm remains largely unchanged and is fully aligned with the 2025 AHA and AAP resuscitation algorithm. At the same time, there are several clarifications and refinements that do impact what we do every day in the delivery room. One of the first things you notice is right at the top of the algorithm. Yes, there are now two new boxes and birth itself has been placed within an action box. And that's a subtle but important message that assessment and intervention begin immediately at birth, not after a pause.

Dr. Kirti Naranje (30:50.5) And umbilical cord management also gets much more prominence in the 9th edition. The algorithm now explicitly addresses cord management after birth rather than treating it as a background obstetrics step. There's also a clear shift in language around delayed cord clamping. Now we have to use deferred cord clamping. For most newborns who do not require immediate resuscitation, the recommendation is now to defer cord clamping for at least 60 seconds, replacing the earlier 30 to 60 second range. And the 9th edition also adds important clarifications around umbilical cord milking. For term and late preterm infants, 35 to 42 weeks who are non-vigorous despite stimulation, umbilical cord milking may be a reasonable alternative to early cord clamping. But for preterms, the guidance remains cautious. For babies less than 28 weeks, cord milking is not recommended because of increased risk of IVH (Intraventricular Hemorrhage). And for 28 to 34 weeks, especially if the infant is non-vigorous, the evidence is still insufficient to recommend routine intact cord milking. So what are the other changes, Dr. Akanksha, would you like to elaborate?

Dr. Akanksha Verma (32:10.5) Yes, yes, Dr. Kirti. So moving on, after we have talked about the algorithm, moving on to the initial steps. Again, as we have seen with the previous NRP editions as well, routine suctioning at birth continues to be further de-emphasized in the 9th edition as well. The initial steps are now very clearly laid out: warm the baby, maintain normal temperature, dry, position, and stimulate. And airway clearing is recommended only when it's clearly indicated and not as a routine step or a part of the initial steps.

Dr. Kirti Naranje (32:50.5) Yes, and a very practical update also relates to oxygen saturation monitoring. The target SpO2 table now begins at 2 minutes after birth, acknowledging how difficult it is to get reliable pulse oximetry readings earlier than that. And after chest compressions, once a reliable pulse oximeter signal is obtained, FiO2 should be adjusted to target the recommended saturation range.

Dr. Akanksha Verma (33:20.5) OK, so they have again emphasized, I mean, that is actually a practical problem. It is often not possible to get a reliable signal in a wet baby within one minute of birth. So I think that's a very logical change that they have brought about. And also what we see is there is an important conceptual shift in the terminology of ventilation as well. So the very popular term, that is positive pressure ventilation, has now been replaced with assisted ventilation or you can simply call it ventilation, reinforcing the idea that respiratory support exists on a continuum. And ventilation can now be initiated using either a face mask or a supraglottic airway if intubation is not feasible. And also there have been changes in the recommended ventilation rate. So that has also been refined in the recent update. From the earlier recommendation of 40 to 60 breaths per minute for providing ventilation in the 8th edition, it has now been changed to 30 to 60 breaths per minute in the 9th edition. So probably they want to emphasize more on giving slower breaths, but delivering a good tidal volume. So maybe a breath rate of even 30 per minute is acceptable. And even if we see in the context of chest compressions, wherein we give like 120 events, so again there we see it aligns with that as well. So we give 90 compressions and 30 breaths in a minute. So it is somewhere in alignment with that as well.

Dr. Kirti Naranje (35:10.5) Also, there are clear recommendations now for initial peak inspiratory pressure which many of us struggle with. The suggested starting PIP (Peak Inspiratory Pressure) is 25 centimeters of water with gestation-specific ranges from 25 to 30 centimeters of water for babies more than 32 weeks and 20 to 25 centimeters for those less than 32 weeks. And the approach to ventilation corrective steps has also become more flexible. So instead of a rigid 15-second cutoff, corrective steps are now initiated if heart rate does not improve within 15 to 30 seconds of starting ventilation. And importantly, providers are encouraged to prioritize corrective steps based on the infant's condition rather than following a fixed sequence every time. So I think this is a very welcome change in the NRP. What do you say, Dr. Akanksha?

Dr. Akanksha Verma (36:15.5) Yes, exactly. I mean, sometimes like following MR. SOPA every time may not be logical because it is possible that the mask is already appropriately placed and there's a good seal. So it may not really make good sense to apply the MR. SOPA steps if we are not getting good chest rise. So the recommendations now make it easier to look for more possible reasons for not getting an adequate chest rise. So I think that's a really important change that following a fixed sequence may not be logical every time and it can save us some precious seconds. And along with that, we also see refinements in endotracheal tube size recommendations. Now they are aligned more clearly with the weight and the gestational age. For example, for babies under 800 grams or between 20 to 25 weeks, they typically need a 2.5 millimeter tube. And now they have also added with a note that a 2.0 millimeter tube may also be kept available as an option for this category of babies. And from 800 to 1,200 grams or 26 to 28 weeks, a 2.5 millimeter tube; from 1,200 to 2,200 grams or 29 to 34 weeks, a 3.0 millimeter tube; and above 2,200 grams or 34 weeks and above, a 3.5 millimeter endotracheal tube is now recommended. And also again we see a subtle but an important change that the endotracheal tube depth is no longer referenced to the lip. So the recommendation, as we used to measure the nasal-tragus length plus one, there were tables and we used to take that distance up to the lip. So that has now changed and it is to align the tube marking with the anterior edge of the upper or the maxillary gum in the midline. So I think that is actually very practically pertinent because often the lip marking as a reference may sometimes result in a slight displacement of the tip and it would be better to align it according to the edge of the gums. So I think there have been some really important aspects that have been looked at in these changes.

Dr. Kirti Naranje (38:30.5) Right. So to summarize, yeah, I think very relevant topic and very relevant changes that we see in this NRP. And so to summarize, the 9th edition of NRP introduces targeted refinements rather than major algorithmic changes. The emphasis is on cord management, precision in ventilation, clearer oxygen and pressure targets, and greater clinical flexibility, all aligned with contemporary evidence and real-world practice. When we look at this NRP 9th edition updates through the lens of Indian practice, a common theme emerges. Most changes are not about doing more, but about doing things more deliberately and more effectively. They emphasize fundamentals that we already know matter: timely cord management, effective ventilation, appropriate oxygen use, and thoughtful clinical judgment while allowing flexibility to adapt these principles to real-world settings.

Dr. Akanksha Verma (39:35.5) Yes, and I think that adaptability, as you said, is crucial for our delivery rooms and NICUs where resources, staffing, and case mix can actually vary widely. So the 9th edition doesn't really ask us to reinvent neonatal resuscitation. It asks us to refine it, align it with the evidence, and apply it thoughtfully within our own constraints.

Dr. Kirti Naranje (40:05.5) Yes, Akanksha. And that's all. As we have discussed across today's journal club from early vaccination strategies to avoiding unnecessary interventions in TTN to navigating diagnostic uncertainty in meningitis, the common thread is the same: Indian data matters, context matters, and guidelines are most powerful when they are interpreted, not just implemented. This is what makes conversations like this important—not just reviewing evidence, but asking how it fits into the realities of our practice.

Dr. Akanksha Verma (40:45.5) Very aptly said. And as we begin 2026 with this episode of Incubator India, our aim remains unchanged: to create space for thoughtful discussion, critical appraisal, and practical reflection in neonatal care. So thank you all for joining us for this journal club edition. We hope that these conversations help inform your practice and encourage dialogue within your own units. We'll be back with some more discussions, more Indian data, and more shared learning. Until then, thank you for listening.

Dr. Kirti Naranje (41:20.5) Thank you all.