Happy thanksgiving everybody! 🦃

We hope that our listeners in the United States enjoyed their holiday and Daphna and I are ourselves thankful for the continued support of our community.

This week Daphna and I had the chance to review some very interesting articles. The topics were broad and included timing of TPN initiation and the effects this decision may have on survival to discharge and comorbidities. We discussed variations in pulse oximetry accuracy and how a patient's skin color could affect pulse oximetry reading. We also reviewed a paper looking at how monitoring heart rate characteristics during a neonate's hospitalization can predict outcomes at 18-22 months of age. We also touched on neonatologist mental health during the COVID-19 pandemic, and thyroid studies in preterm babies. These articles were a lot of fun to review. Article titles and links are pasted below for your convenience. Enjoy.

This podcast is proudly sponsored by Chiesi.

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

The false hope of current approaches to explainable artificial intelligence in health care. Ghassemi M, Oakden-Rayner L, Beam AL.Lancet Digit Health. 2021 Nov;3(11):e745-e750. doi: 10.1016/S2589-7500(21)00208-9.

Early versus later initiation of parenteral nutrition for very preterm infants: a propensity score-matched observational study. Uthaya S, Longford N, Battersby C, Oughham K, Lanoue J, Modi N.Arch Dis Child Fetal Neonatal Ed. 2022 Mar;107(2):137-142. doi: 10.1136/archdischild-2021-322383. Epub 2021 Nov 18.

Racial discrepancy in pulse oximeter accuracy in preterm infants. Vesoulis Z, Tims A, Lodhi H, Lalos N, Whitehead H.J Perinatol. 2022 Jan;42(1):79-85. doi: 10.1038/s41372-021-01230-3. Epub 2021 Oct 12.

Multivariable Predictive Models of Death or Neurodevelopmental Impairment Among Extremely Low Birth Weight Infants Using Heart Rate Characteristics. King WE, Carlo WA, O'Shea TM, Schelonka RL; HRC neurodevelopmental follow-up investigators.J Pediatr. 2022 Mar;242:137-144.e4. doi: 10.1016/j.jpeds.2021.11.026. Epub 2021 Nov 17.

Effect of Coronavirus Disease-2019 on the Workload of Neonatologists. Machut KZ, Kushnir A, Oji-Mmuo CN, Kataria-Hale J, Lingappan K, Kwon S, Dammann CEL.J Pediatr. 2022 Mar;242:145-151.e1. doi: 10.1016/j.jpeds.2021.11.002. Epub 2021 Nov 6.

Utility of Repeat Testing for Congenital Hypothyroidism in Infants with Very Low Birth Weight. Rose SR, Blunden CE, Jarrett OO, Kaplan K, Caravantes R, Akinbi HT.J Pediatr. 2022 Mar;242:152-158.e1. doi: 10.1016/j.jpeds.2021.11.003. Epub 2021 Nov 6.

Preterm to term infant postmenstrual age reference intervals for thyroid-stimulating hormone and free thyroxine. Ziegler GM, Slaughter JL, Chaudhari M, Singh H, Sánchez PJ, Bunch DR.Pediatr Res. 2022 Apr;91(5):1130-1135. doi: 10.1038/s41390-021-01838-3. Epub 2021 Nov 13.

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

SUMMARY KEYWORDS

babies, infants, nicu, group, pulse oximeter, work, tpn, ndi, hero, people, thought, tsh, outcome, preterm infants, discharge, looked, interesting, number, paper, included

SPEAKERS

Daphna, Ben

Daphna 00:00

This episode of the incubator is proudly sponsored by kz.

Ben 00:09

This is the incubator, a weekly discussion about new advances in neonatology and the fascinating individuals who make this progress possible. I am Dr. Ben Porsche.

Daphna 00:29

And I'm Dr. Gaffney Ahsoka Barbeau we are Neonatal Intensive Care Physician

Ben 00:40

Welcome Hello, everybody, welcome back to the podcast. Definitely. What's going on?

Daphna 00:54

Well, I am grateful that I am recording from my childhood bedroom to you on the other hand, I recording the call the call room office

Ben 01:05

at work. That's right. That's right. Look at you being all thankful Thanksgiving time. You're always in. You're always in sync with the seasons.

Daphna 01:15

We sure do like to celebrate it in my household. But I feel like we have it's been a weird, it's been a weird year, but we have less be grateful.

Ben 01:25

That's true. And I don't celebrate. I celebrate very little. I couldn't care less if I work on my birthday. So to give people a behind the scenes look at our operations here. Whenever you see a very compassionate, timely post on our Twitter account celebrating World prematurity Awareness Day, or anything along those lines. I'm gonna Daphna gets all the credit I have. I am terrible when it comes to remembering birthdays, let alone prematurity Awareness Month is just I mean, actually, that that's what I got. Because the hospital was all all decked out. So Oh,

Daphna 02:06

yeah, yeah, it was a joint venture that.

Ben 02:13

But but we have a lot to be grateful for, I think, this year after COVID after all these things. I am very grateful that my family is healthy and that we're seeing the light at the end of the tunnel. My daughter is getting her her second dose on Friday. It's actually on Friday. Yes. So technically as this airs, my daughter will be two days after the second dose. Wait,

Daphna 02:34

Catherine, I will be as this airs. I will be going POST call to meet them. My dad.

Ben 02:42

Yes, exciting. So excited.

Daphna 02:45

Yeah. And the podcast has given us this kind of like renewed energy for for the work. And so I'm grateful, really for that. And obviously working in the NICU. Everyday gives me something because there's something to be grateful for what you see, I agree all the things our families have to deal with.

Ben 03:06

I agree the podcast has given us an opportunity to talk to a lot of people to broaden our horizon. The episode from last week with Andrew and Kristen beam is fascinating. I think I have received text about people saying oh my god, they're the people I want to collaborate with. And I'm like, go right ahead. The fact that we're able to put people together for collaboration just gives me a great sense of pride and joy. So I'm very happy. And and this is fun. This is just a lot of fun all around. Now, talking about fun. Let's talk about articles this week. This was you know what there was like, this is the week where I was like, Oh, do we take a week off? Do we skip Journal Club? I know people really like the journal clubs. So that already was a negative against me even wanting to skip. And then I looked at the articles and they were so interesting. I was like, There's no way we can skip that list of articles.

Daphna 03:59

Yeah, there's always something right. Even when we could really try to take a week off.

Ben 04:05

I was when we started the podcast. I always thought you know, there's going to reach a point in time where some weeks there's going to be nothing of interest. Because how because how frequent can good stuff come out? Right? And it's really not true? No? Yeah, it's really not true.

Daphna 04:26

People keep writing so we'll keep a look. We'll keep casting, huh?

Ben 04:31

Yep. Yep, that's right. So that so let's start off with this paper that was published in the Archives. And it's called and it's an it's created, like you said to create some buzz on Twitter. It's called early versus later initiation of parenteral nutrition for very preterm infants. The propensity score matched observational study. first author is subito retire. And this is from a group out of the UK. And there's no specific city because you'll see that this is a very, very big data set that The encompassed a lot of units. So I actually spent some time reading some of the background this, this time around. But the bottom line is, the aim of the study was to evaluate the association between timing of initiation of parenteral nutrition and outcomes to discharge from the neonatal ICU in infants that were born before 31 weeks of gestation. And obviously, there's the Background section, I think is interesting. I don't want to go into too much detail. But there, it's always interesting to me when the studies look at data from older children from like the PICU, or from the adult world and saying, you know, in these critical care settings, when we do something this way, we get better outcomes. And then it really gives you pause for concern. Because most of the people who do show up in those ICU is coming with an acute problem while babies were born prematurely. Do we consider them acute or not, and depending on why they're born so early anyway, it's an interesting idea. So the population and the setting so any preterm infant born before 31 weeks of gestation was included, and they use the National Health Service, the NHS, neonatal units in England and Wales, over a 12 year period from January 2008 to December 31 2019. And so they looked at all these patients, they excluded, obviously, the usual type of patients that you could expect with major congenital gastrointestinal malformation, congenital condition requiring surgery, etc, etc. The data source is actually called the NN rd, and it's a UK it's the UK national neonatal research database. And then they give you more details in terms of the data source, where you can access it and stuff like that. Let's go into the intervention. So parenteral nutrition, initiated in the first two days after birth was within two days after birth was considered early. And if it was initiated, after the second postnatal day, that was considered late. The choice of the two postnatal days after birth, after birth to define early versus late was pragmatic, reflecting the definition, the system and the systematic review and meta analysis of early versus late parenteral nutrition in preterm infants, very important that babies who died in the first two days who had not received parenteral nutrition were assigned to the late group. I want people to pay attention to that because when we're going to get to the results, and the reason why this is going to create such a stir is because of that of that point, in part because of that point, and not that there's anything wrong with the study, but it says something where depending on how you look at the data, you may reach one conclusion or the one conclusion or the other. The two day Hammonds if people have questions about how to define two days, they talked about like doing consecutive Midnight's basically, and since it's a database, that kind of makes sense. So in terms of outcomes, the primary outcome was morbidity, free survival to discharge from the NICU. And that was defined as survival to discharge without any of the following comorbidities and I'm going to list them it's late onset sepsis, bronchopulmonary dysplasia, ROP requiring treatment, severe and EC seizures and severe brain injury. Their definitions were pretty standard, if you want to find out how they define each one of them, you can go into the methods and they'll and there was nothing, I think, very controversial about any of that. Second, secondary outcome measures included all of the morbidities and survival to discharge from neonatal care. And it included a bit more parameters like any necrotizing enterocolitis, they looked at weight gain the need for any surgical procedures, and the maximum stage of ROP and either i. So a bit more broader categories. And then we looked at long term outcomes and include a normal normal motor, auditory and visual impairment at two years corrected age for prematurity. So, the, the initial, the initial poor from the database included 69,000 infants. And after the exclusion, as they show in the figure, and, and the the they were able to create a matched cohort of 16,000 infants. And that's something that's very nice in terms of, of the paper. So whenever you look at the tables, there's the entire cohort, which includes the 64 65,000 infants, but obviously, they're not very well matched. There's 43,000. In the early group, there's 21,000 in the late group, but they created matched cohorts for early and late where you have 8000 147 infants in each group, and they're perfectly matched on every category. And so it's interesting to see that because you can say well, maybe the matching created some some disparities or some some some bias but that's not that's not true. So let's look at the results. There's no, the there was no evidence of difference in the primary outcomes of survival to discharge without major morbidities. Between early in which case it was 59.5% and late, which was 59.03%. However, and this is the important part, this is the important part, the rate of survival to discharge was significantly higher in infants who received early parenteral nutrition. So when we're looking at the rates of survival to discharge, it was significantly higher in babies who received early TPN. Infants who received early TPN also had significantly higher rates of late onset sepsis BPD treatment for ROP stage three or higher ROP surgical procedures and a greater drop in weight Z scores between birth and discharge. That's that's something already that we should pause probably and talk about. So. So the rates of survival to discharge were higher in the early parenteral nutrition group, but they had much more complications. They found no significant differences in outcomes at age two years corrected for prematurity. Now, when we discussed initially, we talked about this parameter of assigning babies who died within the first few days that didn't receive TPN, and so on. So listen to this, of the 4.9% of babies who died in the first two days 3.4% were assigned to the lead group as they did not receive parenteral nutrition. After the second day, there were more deaths in the early group. So when you're looking at so and and I'm going to ask you what your thoughts are, but obviously, they're very the paper is very well written. And they're very honest, which I really appreciate, because they are right away in the discussion saying, did we create some survival bias with this parameter by saying that, Oh, the because of the babies that died early, we have a survival bias. And then when we look at the babies that did survive, then the outcomes are completely different. And this is where for the people listening, it's very difficult to interpret this data now. Because looking at at face value early is better, because there's better survival to discharge, even though there's more comorbidities. And some people on Twitter have commented on that saying survival to discharge is all I care about. But now when you exclude these other babies, and you find out that the babies that survived past two days, the ones that received early parenteral, nutrition, now not only had more complications, but also had more deaths. What do you make of right? And so I think, what what do you think?

Daphna 12:44

Yeah, so I mean, that's the hard point, right? I mean, if you if you make it through the first 48 hours, right, 48 hours, that's still that's still something right? We can't, we can't do anything for you, if you don't get through at least the first 48 hours. I wonder, had they given us an early group, a late group, and then a no TPN? Group, right, which would have been these babies who all died in the first 48 hours? Certainly, we would have seen some differences in that group. But I wonder how it would have panned out for the remaining remaining babies who didn't, you know, die within the within that intervention, period? You know, I don't I don't know. We don't know, because we don't have that information. But it would be interesting to see a secondary analysis like that,

Ben 13:28

because the data is so I guess controversial, right? Because what am I supposed to do? It was interesting, it was interesting to read their discussion, where they're really not being shy about trying to go deep into what could be the cause for all these findings. And I was very interested in their, in their, their hypothesis when they're quoting other trials, like the P panic trial in the pediatric intensive care unit, where they're comparing early versus delayed TPN. And where they found that the early administration of amino acids was really, really causing a significant metabolic derangement. And so I think, I think that was interesting, right? Because you could sing oh, maybe, because initially to me, I was like, could it be intra lipids? Right? I know that intra lipids hypertriglyceridemia, it's quite common, especially in small babies, that could be the metabolic derangement, that's maybe a bit harmful, but they're actually providing some substances, and no, maybe it's actually amino acids based on what's happening in the older children's population. And, and so that's, I think that's, that's very, very interesting.

Daphna 14:27

Well, I think that's what, you know, the big datasets are so useful, right? Because we get so many numbers, we're able to control for so many things, you know, make the groups very similar, but some of the granularity of you know, so why didn't those babies why didn't they get TPN? In the first two days? What were the factors that kept them from getting TPN? Or if it's the TPN? That's either good or bad. What is in the TPN? Right, not everybody wrote the TPN the same way and we don't know what the makeup of the TPN is. So We can make an assumption that it's the protein. But how do we know not everybody maxes out the protein on the first day? You know, so we don't know what each group got in terms of a load. And so there's just too many, too many factors, you know, the previous literature done and neonates, you know, show that earlier TPN had some long term benefits. But, you know, I think I think this data is important. I'm hoping that maybe they can re give us give us some more granularity about some of those details.

Ben 15:38

Yeah, I think it's actually definitely opening, swinging the door wide open, right to, we probably need to start reconsidering our early administration of TPN. And what does that mean, specifically? Right, that and like you said, granularity is going to be very important, not just like, oh, there's some parenteral nutrition is like, how much lipids how much amino acids how much? dextrose? But really, what are the ratios? Right? Yeah, to get into the nitty gritty of stuff. Yeah, definitely. Anyway, first article, very cool stuff.

Daphna 16:10

Lots of lots of buzz on Twitter. So hopefully, we can keep the conversation going, because I think it's an important one. And we're all going to have to write you know, TPN in the next few days. how we feel about it right. And I wanted to go to the journal appearing etiology article about racial discrepancy in pulse oximeter accuracy and preterm infants, nude authors, Zachary of the soloists. This is coming from Washington University. And so they had a hypothesis that since melanin is a secondary observer of nears or near infrared light, may impact the degree of melanin in the infant skin may impact the pulse oximeter accuracy. Meaning that would they find a difference between light skinned babies and dark skinned babies? So they really had only two groups, which, you know, we know is complicated, right? Because there's so many, you know, degrees of of skin color, but I think this is a very important study. And I'm glad that they that they looked at it. So they enrolled babies,

Ben 17:26

and I think they were they mentioned in their methods that they they would have included other ethnicities, but their their NICU didn't have enough of that population to make it relevant for their study. Unfortunately,

Daphna 17:37

that's right. They felt like the study populations they created were representative of their overall NICU population 42%, black 58%. White. Certainly we know that. That is complicated, right. But but this is still, I think, very useful information. So they enrolled babies less than 32 weeks and birth weight less than 1500 grams between 2012 and 2019. A retrospective evaluation of those babies who had both pulse oximetry measurements and a simultaneous ABG measurement. So they had lots of babies available, but they had only 294 infants that had at least one measurement of both pulse oximetry at the same time as AVG measurements. So they were trying to compare the oxygen saturation to the PO two. So the 294 infants, many of them had multiple samples. And so they had 4387. Saturate oxygen saturation hearings. And the median was 11 samples per infant, the median evaluation was postnatal age of four days. And they actually specified that in their unit baby's got ABGs Q eight hours in arrears. Yes,

Ben 19:08

for Sportings, first week, in the first few years, the first few days of life, I'll find out for you.

Daphna 19:15

The two groups of the good 42% Black 58% White, and neonates two groups are similar, except for a slightly lower birth weight 805 grams versus 875 grams, which was statistically significant, and the median one minute Apgar score two versus three. And in the black infants, we have the

Ben 19:38

it's every four days, so it was eight hours for four days.

Daphna 19:42

And so what they wanted to do was map that out and look at the two groups and see was there was there what was the reliability of the pulse oximeter? And then were there differences between the two groups may also looked at and It kind of intergroup measurements by gestational age. So that was helpful. And then they also looked at the reliability over kind of the saturation curve. So from high saturation, so low saturations, what are the PA o twos doing? So what they were wanting to look for was how good how sensitive was it at detecting true hypoxia, so an oxygen saturation, or a co2 less than 85%. So this was noted slightly more often in the black intense being identified in 15% of samples as compared to 12 and a half samples for white lupus. So they had D saturations more frequently. And then they wanted to look at a cold hypoxemia. So where the europeo T was less than 85%, but your oxygen saturation on the pulse oximeter was greater than 90%. So not You're not seeing hypoxemia clinically at the bedside, but when you're doing the abg, that you are so also more common in black infants occurring in 9.2% of the samples compared to 7.7 samples for white infants did not quite meet statistical significance P equals 0.08. And then overall, I thought this was really important. Overall, the sensitivity of the pulse oximeter for detecting true hypoxemia. So less than 90%, when when your to your set is less than your arterial saturation is less than 85% was 38%. Yeah. And at night had

Ben 21:43

to magnify the paper. I was like, am I reading the script?

Daphna 21:45

I read that right? Oh, gosh. And then they looked at mean bias to see, you know, what are really the differences between the measurements, there was over estimation by the pulse oximeter to be 2.4 times greater for black and pence compared to white infants. And then they looked at, like they said, the range of the saturations from really 40 to 100%. And I think everybody, I hope will post some of these scatterplots. They're really impressive. So you can certainly see how basically, at every gestational age, the black infants had more discrepancies in their measurements than the white infants. And then as a group as a whole how, how the pulse oximeter readings become much less accurate at lower arterial oxygen saturations, which, you know, arguably, is when we need them to be the most accurate. And so I thought this was really, really an interesting paper. And you know, especially if your babies are kind of hugging the hypoxemia line, you know, you're using the least amount of oxygen possible. And there's this degree of Oh, call hypoxemia. And then, certainly, when we talk about, you know, discrepancies in our care, and how does do we have racial differences in our care and our outcomes? I think this is really important. The work that was done, what do you think? Yeah?

Ben 23:33

Well, I think I think this data is is incredible. Number one, because it it was very novel for me on many levels, obviously. First and foremost, the racial differences in the pulse ox measurements, I think, is something that I've wondered in the past, and I've never seen before. And also this comparison of the of the pulse oximeter compared to the arterial saturation. I'm sure it's data that is out there. But it's something that I have not had the time to look at. And so it's interesting to see this and the fact that the pulse oximeter fails in the lower otoo SATs is something I've witnessed, and we probably all of us are familiar with. What it reminded me of is that we tend to think especially us, meaning the generation that recently graduated from fellowship, that pulse oximeter is is here, and it's been here forever. But it's funny to me, because my attendant in fellowship reminded me of the days where they didn't have continuous pulse ox, and terrifying. Well, I know, right, terrifying, and they had to do these, like, they would check the pulse oximeter like once every 12 hours or something they would do like this in the NICU random check hole. I know, holy moly, and they were like and yeah, and when the continuous pulse oximetry came around, that was revolutionary, and so and then we're not that old, like, I didn't train with nine year old attendance. So this this this this tool, this technology is fairly recent. Right? And I think it's interesting to see that I think now more than ever, we tend to rely on our non invasive monitorings. And take them at face value. But it's also important to remember what their limitations are. And to understand that so that you could get more objective metrics, like on a blood gas to actually make sure that what you're seeing is real, and so on and so forth. I think the way they did the study was very, very cool. I think the fact that so they're using the software called bandmaster e x, which many of you may be familiar with, basically, something that the beams talked about on the last episode where it captures everything from the from the monitors, and it saves that so basically, they were able to look at the blood gases, find the times that they were done, go back into the headmaster, go basically scroll to the time of the of the end get with basically 60 seconds or whatever time they usually take to draw gas from the line considering the clearing of the line. And so so they were able to get like a little sample of like, are these were the tracing at the time of the gas. So that's, that's, that's amazing. And, again, maybe it's data that's been out there before and that I'm not aware of, but that that's that's really thanks to some new technology that we have. So I don't know if this is not extremely novel, either. Anyway. So yeah, it was a very cool paper.

Daphna 26:21

Yeah, we'll meet clinically at the bedside for sure.

Ben 26:26

Yeah. 100% 100%. All right, my next guest. So yeah, so since we're talking about non invasive monitoring, and stuff like that, there's a pre proof in the Journal of Pediatrics. That's called multi variable predictive models of death or neurodevelopmental impairment among extremely low birth weight infants using heart rate characteristics. First author is William King. This one I knew I pronounced correctly. And this is the group. very prestigious group of authors, right. William King is first author Wally Carlos, second author, Michael O'Shea. And Robert Shalonda, is the last author. And they're basically reporting on behalf of the HRC, which is HR systems for heartrate characteristics neurodevelopmental follow up investigators. So for the people who are not familiar whenever we talk about the heart rate characteristic monitors, right, it's also known as the hero monitors. And they're basically looking at heart rate variability. I just liked the idea of the hero monitor because it reminds you that chaos chaos theory is something I'm very passionate about. But it shows that there's disorder in the world. And so the fact that our heartbeats are not always irregular, and they're variable is what's natural. And when they become very, very, when they become less variable, and they're basically the you lose that that chaotic nature of the heartbeat, then something is wrong. So I really liked that concept. It flows.

Daphna 28:00

Yeah. And I also repeat, yes, absolutely. And for people who are still trying to wrap their minds around heart rate variability in neonates, I, it's very similar to when you go and you're looking at the tracing on labor and delivery, and they're talking about variability. So, you know, is the baby's age cells, you know, going up by what is it five boxes, you know, the end the DISA

Ben 28:24

spot there, I don't want to, I think going

Daphna 28:26

back to baseline. So when they see that line start to flatten and have less and less increases in the ACLs, then they start to worry, and that's when the category starts to change. So So the same is true in our neonates, and this is actually been very well studied in the adult ICU literature. And so it's, it's, it's making its way it's trickling down. So

Ben 29:00

the history of the hero is an interesting one where it's a husband and wife, neonatology, and cardiology couple, which is reminds me of my own couple where my wife is a cardiologist and opinion intelligence. And I feel like we could have done that, even though we couldn't have done that, because I'm probably not. But anyway, this paper starts off with ideas about heart rate characteristic monitoring, which we're commonly familiar with as the hero monitor. And it talks about these ideas were using Hero monitoring, you can really detect early on things like sepsis or systematic system, sorry, systemic inflammatory response, and that the hero monitoring really, with this ability to predict things a bit earlier has allowed to really reduce rates of death and morbidity in the NICU. So following on this data that they collected, they're trying to establish the following. So they're saying given the ability of the heartbeat characteristic monitoring to identify infants at risk of sepsis and systemic inflammatory syndrome, they hypothesize I used that a cumulative heart rate characteristic index in real time throughout the NICU hospitalization, alone or combined with other factors like birth demographics and clinical characteristics can predict a composite outcome of death or NDI at 18 to 22 months of age, which is a very interesting idea, obviously, because instead of just using the hero monitoring for a short predefined period of time, where you may have a worry or thinking the baby's at risk of sepsis, they're saying, What if we use that continuous monitoring for the entirety of the hospitalization, and see if that predicts any type of long term no other mental outcome. So this data is part of a trial that is registered on clinical trials.gov That is sponsored by University of Virginia. And basically, it's a multi center trial involving several centers in the US. The study started in 2005. And ran until 2011, I think there was about 3000 participants and several the babies I'm sorry, the babies that were enrolled were extremely, very low birth weight, and they all have 24 hour continuous hero monitoring. So understanding that they have the hero monitoring, how did they define their outcome, so obviously, they had moderate to severe NDI and that was defined as having one or more of the following blindness, deafness gross motor function classification system level two or more barely scales of infant and toddler development, Third Edition below 85, a cognitive cognitive score below 85, I'm sorry. And then patients with moderate to severe they can be even further classified if they really really had low scores, based on whether their cognitive score was less than 55. Or if their gross motor function classification system was five, the assessment was performed at 18 to 22 months corrected age by clinicians blinded to the original treatment allocation. They tested the association between hero scores and the composite outcome of death or NDI by calculating something that's interesting, the cumulative mean heart rate characteristics score the CM HRC, as they define it in their paper, for the entire hospitalization for each patient. Then compare the daily mean hero score for patients with or versus without death, or moderate to severe neurodevelopmental impairment across the first 120 days of age, and around the time of sepsis. They also did a lot of sophisticated analysis, where they assess the hero score as both a mediator and moderator of the relationship between sex and death or moderate to severe and the eye, and between gestational age and death to end death or moderate to severe in the eye. So let's look at the results. Overall, 598 infants had hero scores, complete demographic records, and known neurodevelopmental outcomes. This is the main point of the results. So infants with the composite outcome of death or moderate to severe NDI had higher cumulative mean hero scores, when compared with those who had no or just mild neurodevelopmental impairment. And the comparison was quite striking. So the hero score was 3.1 in the ones with moderate to severe NDI versus 1.3, and the kids with no or mild NDI. This was true when controlling for confounders when restricting the analysis to survivors, and when restricting the analysis to comparing only patients with moderate to severe NDI but not profound in the eye to those who just had either no or mild. nd I know that mental impairment, patients with death or neurodevelopmental impairment had higher noncumulative daily hero scores than patients who survived without neurodevelopment their developmental impairment each day from the first postnatal day until day 120, the end of the NICU data collection period. So then they they created this, this predictive sort of model, and so they identified four predictor variables that were associated with long term neurodevelopment and those were birthweight six ventilatory status, and the CM HRc. The cumulative mean heroes score. The cumulative mean heroes score was a significant predictor in each daily assessment of both the hero score the demographics and the clinical model after day three. So looking at things on day seven and day 28 day seven hero plus demographics plus clinical model yielded a non cross validated Roc area of 0.84. To predict a composite outcome of death or NDI, it predicted the ROC area of point A three to predict death alone, and point seven nine to predict NDI among survivors. Looking at day 28, the same model HRC plus demographics plus clinical model yielded a non cross validated Roc area of point eight one to predict a composite outcome of death or NDI Roc area of point eight, five to predict death alone, and an ROC area of point seven four to predict NDI among survivor. So it was very interesting to see that looking at the hero score over the duration of the hospitalization, and that these different times point could actually predict downstream neurodevelopmental impairment at 18 to 22 months of age. And so their conclusion is that an extremely low birth weight infants higher mean, heart rate characteristics score throughout their stay in the NICU, were associated with a higher risk of the composite outcome of death or NDI. Definitely, what did you do you think about this paper?

Daphna 36:12

Yeah, I think it's just another example of if you have all of this information, all these data signals, and then you can say, well, which ones are most important? And in what combination? Can we put them to get the most precise information? I think that's really what we're trying to do with this kind of artificial, you know, intelligence to help help us guide our management. So I thought that that was really interesting, I think people. And it's also a reminder that you can't just, you know, just use one thing, either, right? It's not as rely if you if you just have a hero monitor setup, that maybe that's not enough, right. So it's much more useful when we take in a lot of those other parameters. So

Ben 37:05

that was, and also I think, sometimes you, I mean, it's expensive to have your monitors, but I don't know if you know, when, at our previous institution, we used to take them down, if if if our fear of this baby being, quote, unquote, out of the woods, right, we would take away the hero monitor. So this is an argument to say, no, maybe you should leave it on for the duration of the hospitalization. When I was working at University of Miami, it was actually incorporated into the actual monitor, so you never really took it down. But for some people who may have these external monitors, and they're saying, Oh, we're just using them here. And there may be an incentive to monitor this more closely through the duration of the hospitalization.

Daphna 37:39

Right. And just like all of the other monitoring we have, it's really that trend, right. So I think that's why people leave, you leave them on to see how, you know, what's the change over time. Before we move on, I just I know I have other we have colleagues who are studying for the ports. And so I would be remiss if I didn't clarify that ACLs on the fetal monitoring, as a reminder, or short term rises in the heart rate of at least 15 beats per minute, lasting at least 15 seconds. And obviously ACLs are a criteria of category one tracing. That's the board Pearl for the day.

Ben 38:21

Thank you for that.

Daphna 38:22

No problem, no problem. So I wanted to talk I have so many papers on my dash. Let me see whether you

Ben 38:34

want to do this effect of COVID-19 on the workload.

Daphna 38:37

Yeah, let's do that. Let's do that. I thought this was an important paper. It came up on Twitter, for sure. And so this was a pre proof in the Journal of Pediatrics, the effect of COVID-19 on the workload of neonatologist. It was a collaboration Northwestern Lurie Children's Cooper children's Penn State Women's Women's Hospital, Texas, Texas, children's Baylor and Tufts. And so really, their objectives were to describe how did COVID-19 impact the neonatology workforce. And so they've surveyed a they had 758 neonatologist. They surveyed them in December of 2020. So just about this time last year, looking at a variety of factors and impacting their professional and home lives during the pandemic. So they had a 67% were women. And in that, in that group, a higher proportion of women than men were in the younger age group. 63% To 29% had no leadership position 61% to 46% had dependents at home 68% 56% And did not have a partner or another adult at home 10% 3% We knew that impacted people a lot during the pandemic. And then a higher proportion of women than men reported a decrease in time spent on scholarly work 35% 29% And on their career development 44% at 34%. In addition, a higher proportion of women than men reported spending more time caring for children 74% to 55% reduce time spent on career development was associated with younger age, which was also again found in more often than the women and number of dependents they had at home. And then women more likely to report an increase in time spent doing domestic work and a reduction in time on self care. So across the board COVID-19 did impact the neonatology workforce, but it seems like it disproportionately affected younger physicians, physicians, who are parents, and women physicians. And so I thought this was interesting. I always put like this disclaimer in during the COVID time that yeah, you know, I'm a physician, but like, I'm not a frontliner. And so, I think this was a reminder that while we weren't in the throes of things like, you know, our colleagues who were on the frontlines in the ER and the adult ICUs, that, then everybody's life was impacted. Right. And then certainly, when, when we're talking about academic performance, scholarly work, that it may take some groups of us maybe a little more time to catch up because they were put at such a disadvantage during, during the pandemic. Thoughts?

Ben 41:43

Yeah, I have a lot of thoughts on this paper. First of all, I think this paper was great to see, because number one, there's the raw data as then there's the multivariable logistic regression. So they did multi variable logistic regression, choosing a few risk factors, which were already previously described in the literature. And they included age meaning younger versus older, the career level early versus mid versus late. The practice type, whether people were holding a leadership position, yes, no, having a partner or live with other adults, and having at least one young dependent and having at least one school age dependent. I think, when they did apply the multivariable logistic regression, women and men were similar when they reported the reduction in time spent on scholarly work. Though women tended to report a reduction in time spent on scholarly work more than men, this bivariate finding was not statistically significant. In the multivariable model, a reduction in time spent on career development was associated with younger age and number of dependents, women were more likely than men to report this change, but the trend was not statistically significant. Women were also more likely to report an increase in time doing housework and the reduction in time on self care. So the reason I'm pointing this out is because I believe that it is showing how our field is changing in the right direction. I want to believe that there's more I mean, I want to believe that the first generations in the mid 70s, and 80s, were probably more male dominated, like like it was back in the day. But I do feel like because we initially when I read, it's like, oh, they were less than leadership positions. And I was like, Oh, wait, is that but then when you see that all that stuff goes away, when they do the multivariable analysis, you wonder, the multivariate analysis, because probably because now we have many more younger women. And obviously, because our field is our new generation is is very much on par with the proper representation of women in the field. Maybe that's why they haven't reached a level or seniority to actually get leadership position. And all these things sort of mitigate when you look at things based on age and so on. So I was very happy to see that, because at least it gives me hope that that our field is moving in the right direction. I also think it underscores the fact that no matter what, no matter what we would like things to look like, at the end of the day, women still take on a lot of more tasks when it comes to children home than what I guess we would like it to be 5050. But it's I don't think it's it's there yet, and I don't know if it's ever going to get there. And I think it makes a huge difference whether spouses are physicians or not. Because I remember that for my wife and I who are both physicians, it was difficult to try to manage during the pandemic and we tried to split as much of the work as possible. The other thing that's very cool is that when the the last part of the results, talks about talks about us, us young trainees, it says In addition 31% of respondents reported decreased career satisfaction and which listen, I felt 23% faced new or worsened mental health concerns. I'm not surprised by that. Of those respondents scheduled to take the neonatal perinatal certifying exam in 2020, which was about 130% deferred, and those who took it 22% did not pass, which, in and of itself, that alone is extremely aggravating. I mean, when when we went through the pandemic as new attendings, when we included the variable of the boards into it, that was like, that was wrecking. Yeah,

Daphna 45:37

it was kinda like, put you over the edge factor.

Ben 45:41

Yes. And then. And then I can I mean, and then for I was very fortunate that I passed my test, but I have friends who did not. And I cannot even imagine how I would have dealt. I mean, I think I would have definitely had mild depression, if that had been added on top of everything else. So I think I think this is very interesting. This is a very interesting paper, because like you said, we tend to think, Oh, we're on the frontline, we're kind of protected in the NICU. But it would be a lazy approach to not still do inventory of how our physicians are doing. And try to look at that, because, because it was a very stressful time.

Daphna 46:19

Yes, very, sir. Sure. And you know, it does, I mean, this doesn't represent every household. I know, in my household, I have a very supportive male spouse who certainly does his his share of the work, I know that you do it, you know, a good a good, share the work as well. And, you know, he, he did a lot of the home schooling and the, you know, what, to that credit, and then at some point in time, I went part time, and I deferred my boards, admittedly. So I'm definitely in that group who will be studying and so my mental health improved significantly when I defer the boards and I went part time during the pandemic. But, but that's at a cost, too, right. So,

Ben 47:01

and this doesn't even touch on the fact that like, in the house of pod podcast, talked about this, where as as physicians, we went home and we're like, are we going to contaminate our families? We're working in the highest risk environment. Is my kid gonna get like all these things? We're young Tao is emotionally very distressing. So anyway, second thoughts.

Daphna 47:27

That really bummed us out didn't. Anyways, my my hope, my hope is that we can, with the with our mitigation strategies, we can, you know, keep cases, get cases better start more to a normal life, recouping our scholarly work, and really working on mental health, which is something that we are really trying to do here at the incubator. So that's more stuff that's coming, right. All right, we digress. Yep. Yep. Your turn. I guess we digress.

Ben 48:03

Um, ah, yeah. Okay. Um, I guess I will go into the Journal of parasitology. And talk about this QI project that was mentioned as well on Twitter. It's called a quality improvement initiative to reduce acid suppressing medication exposure in the NICU. first author is Julie Thai. And this is a, a paper that comes out of Boston, Massachusetts from the Brigham and Women's Hospital. So probably colleagues of Kristen and and Dara Brodsky and Camille Martin. So again, the background information really goes over what's already known about the use of acid suppressing medication which the they show it as ASM, which again, to me, it reminds me of anti seizure medication. So it was hard to acid suppressing medications. And it's interesting to go in the background because I had forgotten but they said that the average duration of treatment lasting greater than 12 months, like the majority of the prescriptions are that continue that discharge and beyond. And you tend to think, Oh, they're going to get taken off of it, like in a few weeks,

Daphna 49:14

but nobody noticed that they're still

Ben 49:17

high. No, this is crazy. So that was nice. I mean, there's a nice bunch of reminders of the negative effects, especially in preterm infants. And you can go into that these are not really new. So in their objective, they sought to adapt some methods to are primarily inborn units. So this is a level three unit that has mostly inborn they get some referrals from level one level twos and they're not like a close surgical unit that relies on our bond patients. So so the the aim to reduce the non indicated assets depression medication prescription in our NICU by 50%. within a 12 month period, and so they're working at the Brigham and Women's Hospital, Nicu 60 beds level three NICU, and they created basically a multidisciplinary team. That was quite lean, I think neonatal pharmacist, a fellow in an attending, and they do mention that speech. Dieticians, nurse practitioners and registered nurses were involved in the team, but they had like, I think, a core team that was really taking ownership of the project and that involved the pharmacist, the fellow and the attorney. And they created this key driver diagram to identify possible intervention to reduce the use of acid suppressing medication in the NICU. And the key drivers included. The providers knowledge of best practice, the providers determination of medication efficacy after initiation and the NICU staff willingness, the NICUs the NICU staffs willingness to participate in the initiative. There a guideline defined a limited number of accepted indication, right, because obviously, these medications are not supposed to be banned, but they did. They outlined accepted indications and they included evidence of evidence of compromise of compromised gastric mucosal integrity such as gastric bleeding. Number two, any sub specialist recommendation for establish conditions such as a recommendation by surgery for like US official atresia, or post op intestinal healing, gi recommendation for gastritis, or end recommendation for laryngoscopy laryngoscope laryngoscopic, Lee, diagnosed airway malformation, interestingly enough to improve buy in from all the neonatology provider, the guideline allowed for limited duration of assets, depression medication for seven days, so I thought that was very clever. So they said, You know what, if you if you want, and you want to order the medication, fine, you will do it for seven days, but you must assess the response of the baby to the medication, otherwise, it will have to be discontinued. And that was recorded in the EHR. So I think that was that was very nice. I think I think this definitely allows the adoption of with new measures when you give people an option to actually deviate sometimes. So they're the baseline data, they use their electronic health medical records system to identify the h2 receptor blockers and the PPI prescription in NICU from 2017 to 2018. They extracted a bunch of different variables, and the primary outcome measure was number of non indicated prescription per month of assets, depression medication, secondary outcome included total number of inpatient prescriptions per month, the duration of the price of each prescription as an additional measure of exposure and the number of prescriptions continued at discharge. So in the results, they have figure two, which I think is very, very impressive when you look at the baseline period, and then you have another bar graph for the post implementation period. And so in the baseline period, the prescriptions were dedicated, were initiated for clinical symptoms of reflux and 58% of the cases, followed by concerns for airway compromise in 18% of cases poor feeding and 12% gi irritation and 9% specialty recommendation and 3%. And other reason than 3%. Fairly standard stuff to be honest with you, kind of what I was used to in the post implementation period. The the reasons for implementation work, though, for initiation were now radically different. So they were 35% for gi irritation, followed by 30% specialty recommendation. And then provided initiated time trial was 25%. Stress also prophylaxis while on steroids was 5%. Unknown was 5%. So I think that that's very interesting, because number one, I'm always very interested in those QI projects, when they're so successful in getting the units to actually change their practice. I think this is this is always interesting to look into, because there's a lot to be learned. So, in the case of the non indicated until prescription, the non indicated assets depression medication prescription decreased from a mean of 2.4 per month in the baseline period, to a mean of 0.3 per month, but decreased by 88%. In the post implementation period. The other thing, yeah, which is, which is huge. The duration of assets depression medication decreased, as well as the median number of days each infant was exposed to, as EMS decreased from 23 days at baseline to seven days in the post implementation period. And then in terms of the medications continued at discharge, it decreased from 63% at baseline to 40% in the post implementation period, which is also huge considering that those babies are now much narrower group of babies that meet better indications for for the prescription itself. So I thought this was very interesting. And I like these projects where you expect a certain level of prescription to remain, but you're trying to reduce the the non essential stuff I think this is very good. And I really liked the way the approach was done a very lean team, a few items on the on the driver diagram and and also a very comprehensive approach when it comes to the physician saying, You know what, and if you want to start it, we'll put a timestamp so that you can actually reevaluate whether you're really seeing a difference. And that happens so often where, oh, I'm not covering anymore, and that the seventh is somebody else. And they say, oh, you know what? He ordered it? Yeah. I don't know

Daphna 55:16

if it's better or not. Right.

Ben 55:19

Absolutely. So the fact that we had to reevaluate on a daily basis was so important.

Daphna 55:23

Yeah. And I think that was an important piece, right? The trials, the indication for the trials, there were 10 of them still started for clinical reflux, or oral feeding and the saturation, which remember was what they were starting them for most often, in the baseline period, and they had 10 of the trials, which is not that many. And then after their seven day parameter, they got at least three of them to discontinue, based on this, these new guidelines. The other thing to notice, if you're going to use acid suppressing medications is is safer in certain babies and others, they, they also were able to change that the median gestational age receiving these medications, were, you know, 32.1 weeks as compared to the they were giving it to babies, you know, much gestational age was much younger 28.4 And then a birth weight of 1555 Compared to 900 grams and the baseline so that's a that's a big change. The other thing, I think, to note, I love it, when they show us our PDSA, their their PDSA cycles, because then you say, Well, how can I? How can I put it to use in my unit? And so there's where they're quite simple. The first PDSA one guideline created, revised and approved with input from the neonatologist, sure, how are you going to get them to follow it if you don't bring it to the table to talk about it. The second cycle was using in an EMR documentation tool, which did prove to be quite useful. They So between those two implementations, they had a huge drop off and into rolling into January of 2018. The third PDSA cycle was the education guideline to you know, everybody else, the nursing and the other providers, and they were sending monthly reminder emails, and then the fourth, they saw a creep back up around that time. So the fourth PDSA goal was we education to prescribers and staff. So a reminder that just because you're creeping back up doesn't mean what you did wasn't working, they may need to re educate, especially if we are having a lot of churn new turnover. And then I thought this was really valuable. And then they really saw the numbers plummet after the fifth cycle indication provided and the EMR order. So yeah, if you're gonna order it, you had to write down what you were ordering it for. So I thought that was very valuable.

Ben 57:52

And it helps me learn self helplessness as well, where, where you think, oh, Harvard did do everything correctly, because they're this fancy hospital and, and you can see that no, like, they they have room for improvement. And I really like that they're doing this this inventory of, of, hey, here's where we could improve. And they're following the same principles that every one of us follows for Qi, right? It's, again, I think it decreases this moral injury of saying like, Oh, my unit is not as good as these other No, like, there's room you can pick a project and you can you can act on that. Yeah. And there's a lot of,

Daphna 58:24

yeah, I totally appreciate right, that they said we did this quality improvement, we're gonna put it out there that this was a problem in our unit, and we're imperfect, you know, because for our unit, this isn't a problem, right? We use very little acid suppressing medication, but we could use this same PDSA cycle format for something else that we're

Ben 58:47

working for other stuff.

Daphna 58:48

I agree. I agree. Yes. All right. And every unit has stuff, right. Every

Ben 58:53

unit knows, you know, you know, who we're you know, who you are out there. We're all in the same boat, all

Daphna 58:59

of us, right? We're all working,

Ben 59:01

whether it is assets, depression medication, or, or unplanned extubation. We all have or clubs, we all have stuff that we can improve on. Do we have time for one more?

Daphna 59:12

Yeah, we're quickly running out of time. You have one and we had a bunch more we want

Ben 59:19

to do. I wanted to do maybe those those thyroid papers quickly. Oh, yes. So the first one was, was an interesting one. Obviously, it's called utility of repeat testing for congenital hypothyroidism in very low birth weight infants. first author is Susan rose, and this is from a group out of Cincinnati Children's. So, let me see. The objective of this study was to assess for possible missed hyperthyroidism in very low birth weight infants, whose initial newborn screen was within normal reference range. So basically what they were explaining is that in their institutions, they check every baby that was in the RBW at term corrected for TFTs looking for some babies where hypothyroidism could have been missed, because they talk about how on their newborn screens, they, there most of them are pretty much normal, which was so staggering to me because in Florida, hold on your positive,

Daphna 1:00:21

every, almost every baby and so I thought this was a interrupting I'm sorry, but I thought this was so no good for us because because all of our babies are flagging every single baby. And so you say Oh, well, they're small, right? Or you know, and then they're there's so many babies who never get followed up on right? That's not team practice in those minutes. Okay, go ahead.

Ben 1:00:48

So what's funny is that for them, they're facing the opposite problem that is that their newborn screen doesn't pick up enough. And so they have to do testing on every LBW at term corrected. I think I'm saying term corrected. I think it's 36 weeks. Yet they do it at 36 weeks. Yeah, corrected. I'm sorry, I didn't mean to say term corrected. And they look for TSH level that are five or above. And it's the opposite of us where only one screen is flying all the time. And we don't do very much TFT testing. Okay, so, so they were trying to find out whether their practice of doing TFT testings on every baby at closer to term at 36 Weeks was valid was was correct, or maybe just an overkill. So their primary outcome was the proportion and total number of the LBW infants with normal NBS who had a retest TSH of five or more, which by NICU protocol warranted further follow up evaluation. And then what they did is that they looked back on these newborn screens and they said what if we move the cut offs like if we actually use different cut offs around newborn screen with that prevent us from having to do these tests? And so I thought that was again, if this is something that applies to your state, I think this was this is an interesting so they analyzed serum TSH, obtained at 36 weeks or at hospital discharge if it was earlier in a court of very low birth weight infant. And, and the and they looked at different cut offs for for the newborn screen, which were either 15 or more or 10 or more milli international units per liter. So they had 398 infants median gestational age was 29 weeks birth weight was 11 138 grams. And the retest TSH was obtained at about 49.5 days after birth, median retest TSH was 3.1 Micro unit per liter, seven 18.3% of the cohort had retest that was positive. So out of those 398 infants, about 18% Did flag and would need further follow up. Which is which is not an insignificant number, right? I mean, 20%. Right, is quite large, then when they

Daphna 1:02:58

really don't want to miss, sorry, something you really haven't. Yeah, one

Ben 1:03:02

in five is huge. Adjusting newborn screen cut offs to either 15 or more or 10 or more identified less than 50% of infants with TSH five or more at 36 weeks resulting in 6% false positive and more than 70% false negatives, which that applies to us, right? I mean, even if your newborn screen standards are changed, and you think you're increasing your sensitivity, you're still losing a lot of babies. Multiple multiple regression modeling indicated that 35% of variance and retest TSH values was explained by newborn screen TSH concentration, birth weight and gestational age. So what they what they concluded is that for babies who are very low birth weight with normal newborn screen, it's, it's still necessary, in their opinion to continue testing at 36 weeks and adjusting the newborn screen TSH cut offs would not be would not be really helpful. And I mean, we could I was hoping to go into real detail. I mean, I just read through the abstract, but I think it gives you a hint as to what they're trying to say. And the reason I'm doing this is because there's another paper in pediatric research that I've highlighted on my Twitter page by George Ziggler called preterm determines and postmenstrual age reference intervals for thyroid stimulating hormone and free thyroxine and free thyroxin. Free thyroxin. This is out of a group a nationwide and this was great because this is basically them using their patient population over a course of pretty much seven years from 2011 to 2018. And they looked at babies to TSH and free T for values that they had and they created normal values based on gestational age, and they were able to to include 2592 preterm infants, and they created these very nice tables where you can have by gestational by post menstrual Each group less than 28 weeks 28 To 3031 to 30 330-436-3739, more than 40 weeks, and you have your TSH reference intervals, you have your medians for the TSH, you have your free T 4 million, your free T for reference intervals. And these are very, very helpful. Because, again, as we're talking this is not something that hypothyroidism is not something that we can just shrug it off, it has to be evaluated carefully. And I found it very difficult to always I was always looking for reference values, always talking to the endocrinologist. And so I think, understanding that maybe we should screen those babies, those very low birth weight babies, and make sure there's no issues either closer to term or using newborn screen because you could also do it at two weeks of age. But that's not really what was done in the previous study. And having those reference values is going to be tremendously helpful. So I thought that was interesting. Yeah, I thought really power through these two articles. I feel like

Daphna 1:05:54

I think we can continue the discussion, right? On on Twitter, at least. But I thought this was really interesting, because, you know, we're, we're saying how useful are thyroid studies and baby less than 1500 grams, you know, even the newborn screen here in Florida recommends, okay, you just read Testament 15 greater than 1500 grams, they actually don't use gestational age, they use weight, as the recommendation here in the state of Florida. But this normative samples are really useful so that we can say, you know, we're, we're where are the outliers? And you always have to wonder with certain things like, feeding or respiratory drive, you know, are there some babies who are, you know, you know, the thyroid may be clinically relevant, even though they're so preterm, and might they do better? If, if, if that's something that we picked up? Are we more sensitive to? So I wonder, I wonder if we won't be treating more thyroids in the future. We still, we still had more papers we wanted to do. But I we're really out of time early.

Ben 1:07:00

Next time, it's Thanksgiving. That's great.

1:07:03

That's great.

Ben 1:07:05

Thank you, everybody, for listening. I think this is we're very thankful for our audience. We never thought we would have that big of an audience. We're very appreciative of you tuning in every week and giving us the opportunity to keep your company. So this is a lot of fun. And what is it next week? What should we teach the guests for next week? You don't remember who the guest

Daphna 1:07:28

we are you guys. We've been recording like crazy. It's so exciting. Next leads,

Ben 1:07:35

it's Perry class. Yeah, Dr. Perry class, if you don't know is one of the few celebrities celebrity pediatricians. writes, write books, right for the New York Times. And yeah, she she'll come talk to us about a lot of cool stuff related to newborn medicine. Talk to us about her new book. It was a very, very fun discussion. And yeah, she's, she's a star. So you guys will enjoy that for sure.

Daphna 1:08:05

For sure. I feel like that was one of those interviews where we had more things to talk about. Never we we couldn't fit it all in. But

Ben 1:08:13

yeah, and I'm hoping that we can also share that episode with our colleagues who are in pediatrics who may not always be interested in neonatology topic. I think this is going to broaden our range a little bit. So hopefully, yeah, we bring more people to our to our community. So yeah, definitely. Thank you so much for recording today. Happy Thanksgiving.

Daphna 1:08:32

Thanks, buddy. Thank you.

Ben 1:08:35

Yeah. See you later. Bye, everybody. Right. 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 podcast 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. Nikhil spelled Dr. NICU, and Dafna 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