#139 - 👨🏻‍⚕️ Dr. Afif EL-Khuffash MD

Hello Friends 👋

Daphna and I are thrilled to bring you a fantastic guest this week. We have had the pleasure of chatting with the brilliant Dr. Afif EL Khuffash. Dr. Afif is an accomplished neonatologist with a passion for hemodynamics. But he is also an artist with beautiful works of art (I personally love his Dublin landmark series), a lactation consultant, and a fellow podcaster. Check out the links below to access some of the resources and references mentioned in this week's episode.

Happy Sunday ✌️

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Bio: Prof EL-Khuffash is a Consultant Neonatologist at the Rotunda Hospital in Dublin, Ireland, and a Clinical Professor of Pediatrics at the Royal College of Surgeons in Ireland. His primary clinical and research area is the assessment heart function in term and preterm neonates. He is the lead for neonatal echocardiography and heart function assessment in the neonatal intensive care unit in the Rotunda Hospital.

Prof EL-Khuffash completed a fellowship in neonatal cardiology in Our Lady’s Children’s Hospital, Crumlin. He has explored the use of novel technology in monitoring the cardiovascular function of preterm and sick term infants and was part devising the only neonatal echo training course in Canada. He co-devised the world’s first echo teaching website and mobile device app. Recently, Prof EL-Khuffash has assumed a leadership role at a European level in devising training guidelines for echocardiography by the Neonatologist. He is the lead author/editor of the Haemodynamic Module in the NOTE project, offering a new international online Masters level educational programme in neonatal medicine as a collaboration between the European Society for Neonatology (ESN) and the Faculty of Health Sciences at the University of Southampton. Prof EL-Khuffash is an Associate Editor in the journal Pediatric Research, the partner journal of the Society of Pediatric Research (SPR) and the European Society of Pediatric Research (ESPR).

Prof EL-Khuffash graduated from Trinity College, Dublin in 2002 and enrolled in the Royal College of Physicians of Ireland pediatric specialist training scheme in 2005. He completed a Doctor of Medicine (MD) degree in University College, Dublin in 2008 and his neonatal specialty training in Toronto, Canada (2009-2011). Following this, he was appointed as a consultant Neonatologist and Assistant Professor of Pediatrics at the University of Toronto in January of 2011. He obtained a diploma in clinical epidemiology during his time in Toronto.

He is the recipient of several national and international research awards, with international peer reviewed publications and keynote presentations and the lead for cardiovascular research, supervising several post graduate PhD candidates.

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You can find below a few of the articles mentioned on today's discussion with Afif:

A Patent Ductus Arteriosus Severity Score Predicts Chronic Lung Disease or Death before Discharge.

El-Khuffash A, James AT, Corcoran JD, Dicker P, Franklin O, Elsayed YN, Ting JY, Sehgal A, Malikiwi A, Harabor A, Soraisham AS, McNamara PJ.J Pediatr. 2015 Dec;167(6):1354-1361.e2. doi: 10.1016/j.jpeds.2015.09.028. Epub 2015 Oct 21.PMID: 26474706

A Pilot Randomized Controlled Trial of Early Targeted Patent Ductus Arteriosus Treatment Using a Risk Based Severity Score (The PDA RCT).

El-Khuffash A, Bussmann N, Breatnach CR, Smith A, Tully E, Griffin J, McCallion N, Corcoran JD, Fernandez E, Looi C, Cleary B, Franklin O, McNamara PJ.J Pediatr. 2021 Feb;229:127-133. doi: 10.1016/j.jpeds.2020.10.024. Epub 2020 Oct 16.PMID: 33069668 Clinical Trial.

Patent Ductus Arteriosus in Premature Infants: Clinical Trials and Equipoise.

Liguori MB, Ali SKM, Bussman N, Colaizy T, Hundscheid T, Phad N, Clyman R, de Boode WP, de Waal K, El-Khuffash A, Gupta S, Laughon M.J Pediatr. 2023 Jun 1;261:113532. doi: 10.1016/j.jpeds.2023.113532. Online ahead of print.PMID: 37269903 No abstract available.

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Find out more about the Baby Tribe Podcast here:

https://www.buzzsprout.com/2124788?

Check out Afif's art 👇

https://www.afifsart.net/

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

[00:04:30] Ben: thank you so much for joining us on the podcast this morning.

[00:04:36] Afif: Thank you so much for having me. It's, it's an absolute privilege and honor to be, uh, to be on the incubator podcast. I'm a huge fan. I've learned a lot from you guys over the last, um, few months. So it's lovely to actually be on the show.

[00:04:48] Ben: Yeah. And it, the honor is, is, is definitely ours as well. You are a star in the field of neonatology. And so, um, yeah, it's like, you know, it's like having the Rolling Stones on. It's, uh, it's a big [00:05:00] deal.

[00:05:00] Afif: Uh, not, not quite, not quite, but thank you so much.

[00:05:05] Ben: I want to, I want to start with, um, Your inception story, you, at times when I review your work, if you sound like a closeted cardiologist, and so, um, I, I am wondering if, uh, if neonatology was always in the cards for you, or if this is, uh, or was it maybe the way to compromise and be able to do all these other things at the same time?

[00:05:29] Ben: So, um, I'm curious what drove you to, to, uh, to the NICU?

[00:05:32] Afif: Wow. You're, you're inside my brain. You've sort of, yeah, you've almost got, you've almost got my story, um, straight out of the blocks. I know. Yeah. So it's interesting. When, um, when I, I sort of. Went through stages where initially when I graduated from med school, I wanted to do radiology,

[00:05:50] Daphna: Mm,

[00:05:50] Afif: um, because I thought, um, you know, interesting field, but then my father is actually a pediatrician.

[00:05:57] Afif: And so is my mother and they're both retired [00:06:00] now. And. I suppose I caught the bug from them when I was in med school. I used to travel back. So I studied in Ireland, but I was emergently from Kuwait and used to travel back over the summer and do some electives with with my dad. And I absolutely loved the field in general.

[00:06:18] Afif: And I decided early on then that that's what I was going to pursue. And in Ireland, most all your training. Even in general, pediatrics on, um, on a sort of fellow level, um, must begin with the one year of neonatology. So everybody's going through pediatrics actually must do a whole year of neonatal intensive care because a lot of our pediatricians, once they qualify, will go to more remote areas where they still have to deal with deliveries and things like that.

[00:06:51] Afif: So, you know, a bit of training in neonatology is, is very helpful. And I absolutely fell in love with it. Um, [00:07:00] but my plan was to actually do pediatric cardiology because that was the field that I was really, really interested in. I did some residency training in cardiology and that sort of solidified what I wanted to do.

[00:07:12] Afif: But then things sort of took a turn that when I started neonatology, I said, Gosh, I actually really, really like neonatology. But you know what? I'm going to stick with cardiology. That's what I wanted to do. I love interventional cardiology. And... I'm going to continue to pursue that, but kind of halfway through that year, I was offered a, um, a sort of postgraduate, uh, research opportunity.

[00:07:38] Afif: Um, um, actually my mentor, uh, at the time was Eleanor Malloy. I'm sure you're familiar with her and her work. And she offered me a two year, um, kind of postgraduate degree. And she said, why don't you combine your two loves? You can do some PDA research, um, and we can collaborate with a cardiology colleague and do it that way.

[00:07:57] Afif: And at least you'll get some exposure to [00:08:00] cardiology and you can continue doing neonatology. So I took a year Uh, two years out of my training to do that, where I learned echocardiography and I started doing some kind of preliminary PDA research under her supervision and the supervision of one of our cardiology colleagues.

[00:08:15] Afif: And it's interesting that halfway through my postgraduate research, um, I got this advice, um, from someone that shall remain nameless saying, you know, you're wasting your time doing echocardiography in, in the neonatal field. There's no point in doing this. And this is now. This was 2005, so ECHO and the neonatal unit wasn't something that was, you know, common.

[00:08:39] Afif: And he was like, you're wasting your time scanning all these neonates. Nobody cares about them. Nobody cares about PDA. If you're serious about cardiology, you need to drop all of this and just focus on cardiology. And I sort of had a, um, uh,

[00:08:54] Ben: An epiphany?

[00:08:55] Afif: Well, I was going to say crisis

[00:08:58] Daphna: Yeah. Struggle.

[00:08:59] Afif: yeah, [00:09:00] and that's saying, gosh, did I waste the last 18 months of my life doing this?

[00:09:03] Afif: And, um, another very good mentor of mine has said, you know what you need to actually do the opposite of what that person told you in that this is a. Field that you can really advance in because there is nothing out there and it's very early Nobody's doing the sort of research that you're doing in this field There are a couple of people around and this is a field that you can really Expand in and excel in if you pursue it and that's why I actually decided at that stage to change Tracked and become a neonatologist with a strong interest in in cardiology I did a year of a cardiology fellowship in in Ireland before moving to Toronto to complete my neonatal training So I got a lot of experience dealing with congenital heart disease perioperative management pre and post operative management of these babies and I think that was [00:10:00] That stood to me, um, in terms of kind of advancing my echocardiography skills and learning my limitations as a neonatologist working, um, in this, in this area.

[00:10:11] Afif: Because as you know, there's still a lot of debate as to whether a neonatologist should be doing this or not. And I sort of see both points of view to, to a certain extent. And that's how I ended up doing, um, Doing hemodynamics, um, I started out wanting to do cardiology and then I fell in love with neonatology and wanted to combine both worlds and I'm glad I did it because, um, it's, it's something that I really love doing on a day to day.

[00:10:38] Afif: And I do see the impact. Of what we do on on outcomes. Um, I know again, that's sort of debate debatable on a larger scale, but I really believe on an individual level from baby to baby. You do see the benefit of using that skill in the right way.

[00:10:56] Ben: Yeah, it's, it's a, it's a poetic story. I think that, uh, [00:11:00] reminds us that there are no dead ends, right? I mean, uh, you, you may be, uh, in a little street and you may think that there's a wall at the end, but you'll find a little, a little turn and you'll get onto the next, to the next one. And that, that's, that's inspiring.

[00:11:12] Ben: Um, I want to talk about PDA and stuff, but I want to make sure that I don't want to cut off Daphna.

[00:11:17] Daphna: No, I mean, I had one thought about, uh, your story and we hear it over and over again that, you know, there's this kind of, I hate to say it, kind of this old school thought about neonatology, you know, that we come in, we treat the same few handful of diseases, but I think as neonatology progresses, we're learning, like, just how special the physiology is of I say these babies, but there's such a range of babies and types of babies.

[00:11:45] Daphna: And as we are, you know, seeing better outcomes for babies that we didn't use to even get to the NICU before, um, you know, we're learning about it. And I think it really allows People with [00:12:00] varied interests, um, to, to come into neonatology and expand the field in a way that we weren't even seeing like, I think, a decade ago.

[00:12:11] Afif: Yeah, I absolutely agree. And actually what you said there jogged my memory. One of my cardiology colleagues when I was sort of debating between the two said, ah, you're going to pick the easy option of denatology. There's only four, there's only four diseases you need to know about, you know, jaundice, NEC, RDS and PDA and nothing else.

[00:12:27] Afif: So, so, um, it just shows you that I think a lot of specialties do not comprehend what we do on a day to day basis and you only realize the Depth of the field, once you actually. Um, start practicing within it and I think the other potentially unique thing about our field is that, pardon the pun, it's still in its infancy, you know, with all the advances that we have done so far, there is still so much to learn and there's scope for so much [00:13:00] new development and discoveries.

[00:13:01] Afif: And that's what I suppose motivates me day to day is that. We can still, all of us, contribute so much to the betterment of these vulnerable babies and improving their outcomes. And that's what I like about the field, is the scope to do more and more.

[00:13:18] Daphna: Okay, now you can talk about the PDA.

[00:13:21] Ben: uh, well, I think, um, yeah, the problem with, with interviewing a thief is that there are so many things that we need to touch on that I feel like every second is running and I'm

[00:13:31] Daphna: We gotta keep

[00:13:31] Ben: to, we have to make sure,

[00:13:33] Daphna: Mm

[00:13:33] Ben: but you have a, you have a great paper that's published. Um, Um, that's that's a published in the journal of pediatrics Called patent ductus arteriosus in premature infant clinical trials and equipoise Um, I think it's a it's a it's a very nice if if you are a trainee I think it's a very nice paper, uh that goes over a lot of uh, The controversy and the and the issues that uh pda research has been plagued by the first [00:14:00] thing I guess we should we should talk about because as a fellow I had to look up this term multiple times But what is clinical equipoise?

[00:14:08] Daphna: Mm hmm.

[00:14:09] Afif: Yeah, and I think if you truly delve deep into... You're subconscious and really ask yourself, do I truly have equipoise? You'll find a lot of the time that very few of us actually do, if you ask yourself honestly. And the way I look at it is, you know, and it's something that's hard to admit because you're admitting that I don't know whether what I'm doing is useful or harmful or inconsequential to these babies.

[00:14:36] Afif: And that's something that's really hard to admit to yourself. And, you know, I see a lot of people pushing an RCT, looking at a new intervention, because they really believe in that intervention. And I, and then I'm kind of take a step back and thinking, you know, you shouldn't actually. Believe in that intervention because you haven't tried it out yet in a systematic way [00:15:00] yet You're already biased and you're probably designing the study to to make it work or you're gonna have an unconscious bias That may sway the results in one direction or another now, please don't get me wrong.

[00:15:11] Afif: I'm not I'm sure nobody's doing this, um, in a bad way or anything, but it's how we operate as human beings. I mean, true equipoise is, is, is a really tough thing to deal with on a day to day basis in our practice, because let's say PDA treatment, for example, do, do I truly have equipoise? I mean, I put my hand up and say, no, I certainly do believe that a certain subset of of them need to be.

[00:15:37] Afif: I'd like to think that I have enough insight to recognize that number one, I want to make sure that I'm not doing harm to these babies because a lot of the treatments that we use to close the ducts aren't, um, you know, they're not pure. They have a lot of side effects, they have a lot of other effects.

[00:15:55] Afif: And then is the benefit of achieving shunt [00:16:00] elimination, does that outweigh the potential side effects and risks that you're exposing these babies to when you're actually Giving them those treatments. And I think a lot of the recent studies are beginning to show us that some of what we are doing, maybe actually harmful to these babies.

[00:16:17] Afif: So really, it's hard to have equipoise in a lot of things that we do because we do them on a day to day basis. We have a feeling that one thing works over another. Um, and then that's why, and we have a lot of these debates sometimes in person, sometimes on Twitter on the, um, Merits of RCTs, you know, are they, are they the only way of achieving the answer that we want to achieve?

[00:16:45] Afif: Um, you know, there are a lot of other ways, I think, that we can Approach to try and look at the benefit of a certain drug and one of my great colleagues and friends, um, Amish Jane is actually doing this and we're collaborating with him looking at, for [00:17:00] example, the choice of inotropes in, um, in babies with sepsis.

[00:17:04] Afif: So a lot of units still use dopamine as first line. And a lot of units have moved to using noradrenaline as first line. Who's right and who's wrong? Well, Amish has actually, you know, has has devised a prospective study comparing the approaches of units that will continue to use dopamine versus units that have changed to using noradrenaline.

[00:17:24] Afif: And we're going to look at this over a three to four year period and look at the outcomes between the kind of centers that use dopamine versus the centers that use norepinephrine in a very specific um population. Babies that have vasoactive shock secondary to sepsis or secondary to active necrotizing enterocolitis.

[00:17:43] Afif: So we need to, I suppose, take a step back and answer small questions step by step in innovative ways. Um, and maybe embrace the lack of equipoise knowing that it can be diverse and then pitch one. School of thought [00:18:00] against another to try and get some answers. I'm not saying that that's the only way, but we need to look at more innovative ways of actually achieving those.

[00:18:08] Afif: Because if you look at a lot of the RCTs that we've had to date, many of them show no difference between the groups. And I think. There's a lot of design and methodological issues in them, but I think that's a signal to us to try and think of other ways of trying to answer important questions.

[00:18:26] Daphna: I had a question actually about, um, that, that point about these kind of neutral studies. You want. You have a question,

[00:18:33] Ben: Yeah, I just wanted to clarify something because I think if I understand correctly what you just said is that in theory clinical equipoise means that there are several interventions And they're all equally controversial from the standpoint of us not being sure whether they are the proper intervention for a specific disease.

[00:18:53] Ben: And we're not sure that intervention A is good and it doesn't cause harm. We're not sure that intervention B [00:19:00] equally. And what you're saying is that one of the issues we're having with Designing trials for the PDA is that this, this, um, this balance is not perfectly equal and there's always, it's always tilting one way or another.

[00:19:14] Ben: And that's sort of one of the root causes of, of how we've been trying to study PDA because we all have an opinion and, and we're really no longer in this state where we're equally ambivalent towards every intervention out there. Is that, is that correct?

[00:19:30] Afif: I mean, and, and I suppose a case in point, and I do have, I suppose, insights and I was somewhat criticized for what I did with our kind of relatively small PDA RCT in that when we did our randomized control trial. Based on our PDA severity score, when we published the original paper in the Journal of Pediatrics, we showed no difference between the two groups.

[00:19:53] Afif: So. As a person, I suppose, with true equipoise, I could have stopped there and said, right, look, I've done [00:20:00] my piece. There is no difference. I know my numbers are small, but there's not even a signal. But I suppose because I had a bias towards my... Thinking that, you know, I still think that some ducts are worth closing.

[00:20:14] Afif: We did a subgroup analysis and within the intervention group, we broke down the group into those that responded to treatment versus those that didn't. And I don't think anybody has done that prior to us. And what we have shown is that babies that respond to treatment. have a significantly lower incidence of respiratory morbidity.

[00:20:33] Afif: But on the flip side, those that did not respond to treatment had a rate of adverse outcomes higher than the baseline in the placebo. So, and I think that's in my opinion, why a lot of the interventional studies don't show a difference because those that respond to treatments have better outcomes, but those that don't have worse outcomes and unbalanced, they are the same on average to the placebo.

[00:20:56] Afif: So, I think we really need to [00:21:00] accept subgroup analysis. Interestingly, when we included the subgroup analysis in the original paper, and we went back and forth between the reviewers four times, whereby at the last thing they said, okay, you need to take this out, or we are not accepting this paper. So, we had to actually take it out, the subgroup analysis, and then we submitted it to a different journal.

[00:21:20] Afif: And interestingly, the first thing the reviewer said, is like, why didn't you publish this in the original journal? Are you trying to get more, are you trying to get more publications and, you know, more articles? And we were like, we honestly tried to publish this all in one big encompassing articles, but we weren't allowed to.

[00:21:36] Afif: So I had to explain that. And it, it, and again, a lot of it depends on the reviewer that you get. Isn't that right? So if you get a reviewer that is biased against PDA treatment, which I think we got, obviously in our original paper, we honestly were not allowed to talk about post hoc analysis at all. And then In the subsequent publication, we must have gotten reviewers that were favorable to PDA treatment.

[00:21:59] Afif: So [00:22:00] I think a lot goes behind the, the scenes determining what comes out and what doesn't. I don't know if that's a little bit cynical of me to, to, but I'm talking as an experienced researcher, seeing how things kind of work in the back. So I think we need to do our best to try and. Publish the work and do what you guys are doing, which is fantastic, independent people then scrutinizing the data and giving their own independent opinion on the results.

[00:22:27] Afif: And that's why I really enjoy listening to your podcast because I really think that it gives a nice insight into the work because you guys are very honest. If you feel that, you know, something needs to be examined further, you do openly say it. And it's nice to hear because. It's up to us as researchers to scrutinize the data.

[00:22:50] Afif: And that's another level. Critical appraisal is a skill that I feel a lot of people don't have. And it is something that we need to teach people to do. It's a learned [00:23:00] skill. Because once the paper's out, then there's another level of, I suppose, Validation in, and that's, and that's, that happens with the people that are practicing neonatology day to day.

[00:23:13] Afif: So I know I've sort of digressed a little bit, but it all kind of comes down to, all comes down to what we do with the data that we have and how we use it to better improve outcomes in babies.

[00:23:25] Daphna: Well, that, that was actually the, the gist of my question in, in subgroup analysis and, you know, always assuming that we know the right question ahead of time, right? That the data might tell us more than we had even anticipated, as well as the importance of, um, publishing and reviewing kind of these negative or neutral studies where we don't see a difference.

[00:23:49] Daphna: I think a lot of people are, you know, they get a, maybe something they didn't anticipate and they didn't show a difference and then they don't even want to publish it. And I think that is. It's important. [00:24:00] But you actually kind of answered all of those questions. So my question now to you is, what do you think is the best way to teach critical appraisal of the literature?

[00:24:09] Daphna: Um, I feel like, you know, our clinical demands, our administrative demands in training are becoming so great that Things like critical appraisal and the basics of research design, I mean, are really falling by the wayside as opposed to, let's say, other doctoral programs where, um, research methodology is like, uh, uh, a framework where they do number, a number of courses in, to prepare for doing research.

[00:24:42] Afif: I mean, I was lucky enough in that when I was doing my fellowship in Toronto, I came on staff there for the latter 18 months of my time there and the department was very supportive of me doing a postgraduate degree and I picked research methodology and clinical [00:25:00] epidemiology and I can tell you it's one of the best courses I have done in the University of Toronto there.

[00:25:04] Afif: I've learned such great. skills that are vital, not just for researchers, but for clinicians as well. So I agree with you. Some of these are core skills that clinicians should learn. I honestly think that it might be a little bit abstract if you try and teach that in med school, because let's face it, people are focusing on learning the core, um, materials to kind of pass.

[00:25:28] Afif: And I really think that this is a learn, this is a skill that can be learned in your residency and fellowship years by doing a structured. Journal club kind of type of teaching the way we do it here in the rotunda is that we have a weekly journal club and our focus isn't on the information and content of the paper, but the critical appraisal part of it.

[00:25:50] Afif: So the residents and fellows pick a paper each week, and they present maybe the 1st, 10 minutes on the actual information that the paper is [00:26:00] providing. But then we spend the next 45 minutes dissecting the methodology, looking at the study design and really. seeing whether the paper has internal validity, meaning, you know, can we believe the results and external validity?

[00:26:15] Afif: Can we apply it to our clinical situation? And if you do this over a year, you tend to probably hit a lot of the important. Um, things that come with research, with research methodology. We try to be someone systematic in that we try and cover a lot of the different study designs and talk about whether, you know, the authors have adhered to those study designs or not.

[00:26:38] Afif: And interestingly, you, you learn a lot from looking at papers that way. I think 50% of the time, the authors do not mention the type of study that they have carried out. Or, or, or, or, you know, use, I suppose, nonsensical terms to describe their study and then you automatically think, well, if you don't know the type of study that you're doing, how can I [00:27:00] believe, you know, the results like something like this is a prospective cross sectional study and you're like, you know, it's either cross sectional or prospective, you know, pick, um, because, you know, the temporality between exposures and outcomes.

[00:27:13] Afif: You know, are different when you're looking at it from a cross sectional sense or from a prospective sense. So again, we touch on these things and we try and teach the fellows and the residents the difference between the different study designs, the advantages and disadvantages of each one. And that usually comes with them reviewing a paper.

[00:27:34] Afif: Crit, um, critically appraising it, and then we take it from there. And then there's the whole sense, the whole thing of biostatistics, which I believe that most physicians should have a basic understanding of the statistical tests. Now, I'm not expecting people, and I actually don't have that knowledge either of the mathematical equations behind them, but knowing which test to apply to which situation I think [00:28:00] is a basic requirements to be able to learn.

[00:28:03] Afif: And it's. A high bar somewhat, and it may be hard to achieve, but I think it's essential in order to make us better clinicians, because you need to be able to read the paper, not take it at, um, at, at face value and, um. And, and make your own mind up. I always tell my, my residents reading a paper is stop at the results.

[00:28:28] Afif: Do not read the discussion because the discussion is all about the authors selling you their paper. It's marketing. This is

[00:28:35] Ben: That's

[00:28:36] Afif: make your decision. Yeah. Make your decision first and then read the discussion and see, do you agree with what the authors say? You know, they will tell you we are the first to do this and we are the greatest at doing this.

[00:28:45] Afif: And this is why, and because all the others didn't do what we did and we think that we have solved. This

[00:28:52] Ben: Yeah, there's, there's definitely a, a, a tendency to think that because you're first, it's good, which has no bearing, like you

[00:28:59] Afif: no, [00:29:00] absolutely. Yeah. Yeah.

[00:29:01] Ben: And, um, and I do want to say that some, some authors do a very, I mean, to the credit of some authors, some of the discussions sometimes are very good where you'll say, well, those results go against all these other studies.

[00:29:11] Ben: And then the authors actually go one by one and they say, all right, it, our results are not concordant with this study, with this study, and here's what we think, but we're not sure. So, but you're right.

[00:29:20] Daphna: Yeah, we find those types of discussions really valuable, right? Like,

[00:29:24] Ben: Those are the ones that are valuable

[00:29:26] Afif: I am being dramatic. I'm adding the, what we call the Irish 30%

[00:29:30] Ben: Afif, do you think that what exactly what you're saying, that there's a a pressing need to, to impart the tools on our trainees for critical appraisal of the literature is, is.

[00:29:58] Ben: More [00:30:00] important now than ever because we're entering the era of medicine that is based on large data. And I think this is this is the 21st century is the era of data and precision medicine. And I think I think Yeah, I don't know. Maybe, maybe we should teach it in medical school because we are going to, to, um, to go through such a vast amount of data that how do we handle the numbers is critical because I forget who said it, right?

[00:30:26] Ben: If you torture the numbers long enough, they'll, they'll say what you want them to

[00:30:30] Afif: yeah, no, absolutely. And yeah, I mean, maybe on reflection. It is something that we should teach in medical school for sure, especially when you look at the amount of papers that are being released pre review, right? You know, a lot of authors are releasing their data in these repositories prior to peer review and people take it at face value.

[00:30:53] Afif: And we've seen that a couple of times. It's actually the interesting thing was the one that sticks to my mind [00:31:00] is the. At the beginning of COVID, there was this notion that the amount of premature babies being born has significantly increased. And there was a couple of papers published locally here in the kind of prior to peer review stage, looking at a, I suppose, small subpopulation, demonstrating a significant jump in the number of preterm babies being born as COVID started.

[00:31:27] Afif: And all the local newspapers. Picked up on it and said, wow, look, COVID is causing a huge surge in premature births. And then when a lot of Bigger studies looked at this more systematically, they found that, you know, they may have been a smaller association, but by and large, it wasn't really there and to just show you that if you had the skills of critical appraisal and looked at the paper, you might have been able to pick all the challenges and the methodological issues with that and not come up with that conclusion.

[00:31:56] Afif: So it can have a big dramatic impact. So [00:32:00] yes, I think critical appraisal is an essential tool. Thank you. That we need to learn early on in our career and not just for researchers, but for clinicians in general.

[00:32:09] Ben: Agreed. Uh, one more thing I wanted to talk, uh, about the PDA with you is, um, is you, you are notable for, um, you, what you've mentioned, the PDA score that you've developed and, and, and if I understand correctly, we were talking off air about some of the work you are doing, especially, uh, looking at hemodynamics and active screening, uh, of inference at risk of having a PDA.

[00:32:38] Ben: applying this PDA score. Can you tell us a little bit about what the PDA score is and then, uh, where's the research taking you these days?

[00:32:47] Afif: Yeah. Gladly. Thank you for, for bringing that up. Um, One of my biggest issues with, um, the PDA is our lack of ability, consensus, agreement on what is a [00:33:00] hemodynamically significant duct, right? If you ask somebody, what is that? Most people are going to tell you it's a duct greater than 1. 5 millimeters. And unfortunately, that is the basis, um, that is the basis, um, that a lot of.

[00:33:14] Afif: People used to enroll their babies into trials, right? If you look at all the recent studies, it's a anybody with a duct greater than 1. 5 Is eligible anybody with a duct less than 1. 5 isn't eligible and if you actually dig deep into that You realize that ductile diameter in isolation has almost no bearing on hemodynamic significance Even if you kind of bring it back to basics, physics, Poiseuille's law, determining the flow across a tube is determined by so many different things, the pressure gradient across it, the viscosity of the fluid, the length of the vessel, the diameter is just one part of that formula, and that's the one thing we focus on.

[00:33:58] Afif: The other big challenge, [00:34:00] which people forget, is that you're talking about A millimeter, right? And we are saying that we can distinguish between a 1. 6 and a 1. 4 millimeter duct in a baby weighing 500 grams. If you break it down to this level, you realize how ridiculous that concept is. Most, in fact, all or almost all echocardiography vendors cannot guarantee measurements lower than a millimeter.

[00:34:26] Afif: Yet, we are talking in tenths of millimeters determining whether a baby goes in a study or not. So therein lies the problem, the score that we have developed, I think encompasses a better understanding of hemodynamic significance. It brings in flow parameters. It brings in, um, how the heart handles that blood flow.

[00:34:48] Afif: It also brings in the gestation, which I suppose determines how a baby handle a doctor or not. And it also brings the degree of. pulmonary overcirculation there. So at least it's a, [00:35:00] a step up from simply looking at ductile diameter. And although diameter is part of the score, the way we've developed the score is that it actually has very little influence on changing.

[00:35:13] Afif: The eventual number you get from the score, because it's the least important one. So if you plug in the formula, a three millimeter duct versus a 1. 5 millimeter duct will not change the score by a huge amount at all. The others have a much bigger determinant. So already it filters out the error and it filters out the importance of the duct.

[00:35:34] Afif: Something as simple as, if you apply our score, A third of babies less than 29 weeks gestation with a duct of 1. 5 mm or greater will spontaneously close. Right? So if you're enrolling babies based on ductal diameter alone, a third of those babies that you enroll are destined to close their duct spontaneously.

[00:35:57] Afif: So you're exposing them to unnecessary medication. [00:36:00] And potentially increasing their risk profile due to the toxic side effects of the medications you enroll. So, by applying my score, for example, you're already filtering out 30% of babies from all the previous trials that would have spontaneously closed their duct.

[00:36:17] Afif: The second thing that's nice about our score is that it very accurately predicts those that will spontaneously Close and not need anything if you score less than five based on our score, you will not get chronic lung disease You will close your duct spontaneously So at the very least you're filtering out a huge chunk of babies that do not need treatment and when we looked at the score in our RCT Yes, we demonstrated that it was feasible to enroll babies based on the score and what was nice even in the initial trial, ones that we deemed low risk, um, we had 13 of those, 12 spontaneously closed and one remained open.

[00:36:57] Afif: So the majority of them spontaneously closed. [00:37:00] And out of the high scored ones, both the intervention and the placebo arm still had a high rate of, um, adverse outcomes. I remember looking at a study recently randomizing babies based on ductal diameter alone. They had a reference cohort, which they deemed low risk, and they had an intervention cohort, which they deemed high risk and necessary to be enrolled in, in the trial.

[00:37:24] Afif: If you look at the eventual outcomes, the low risk group, the intervention group, and the control group all had the same rate of morbidity. So how can the lowest group have the same rate of morbidity as the ones that you enrolled in the trial? So we need to really focus on selecting the right babies. The next step is we need to get better at achieving ductal closure in these babies.

[00:37:49] Afif: One of the things that we learned from the post hoc analysis was that if you are high risk and you respond to the intervention, then Yes, you could potentially modify the [00:38:00] risk profile and end up with lower respiratory morbidities. However, if you do not respond to treatment, you ended up with a slightly higher risk profile than the placebo arm that were not exposed to treatment.

[00:38:13] Afif: So although we are benefiting those that we are achieving ductal closure in, we are potentially harming those. that aren't responding to treatment. So we need to learn why aren't they responding to treatment? Can we do something to improve the closure rates? Um, These babies tend to be smaller and they tend to be, um, have, have larger ducts anyway.

[00:38:36] Afif: So, I think we need to work on improving our ability to eliminate the shunt by achieving complete ductal closure. And we need to, um, devise better ways of identifying the high risk babies. Since the post hoc analysis decided to implement our risk score in our day to day clinical practice. So since July 2020, we, any baby that [00:39:00] is less than 29 weeks, get a screening, gets a screening echocardiogram, uh, over the first 24 to 48 hours of life.

[00:39:08] Afif: And if they score high, they get treated with either ibuprofen or paracetamol if there are contraindications to ibuprofen. Our first line is still, um, ibuprofen. And. When we compared the epochs now, we're looking at our preliminary data, small numbers yet still, but we are showing a significant reduction in respiratory morbidity.

[00:39:28] Afif: Our days on ventilation have gone down to from around 10 to 2 days and our oxygen days have almost halved. So, you know, we are seeing. Some benefit, I recognize the problems with epoch data and you guys have outlined those and you know, previously when you've kind of reported on epoch data, it's not, um, it's not a very good way I think of looking at interventions, but it's one way of at least making sure that you're not worsening.

[00:39:57] Afif: The outcomes and that you are not [00:40:00] causing significant harm to these babies. So we are showing some morbidity We are waiting for a good three year period to really examine the data But we're also going to look at significant physiological data. These babies get scanned regularly in a systematic way So we're going to look at the duration of shunt exposure.

[00:40:18] Afif: We're going to look at babies that Respond versus babies that don't respond and really try and look at the physiological underpinnings of the associations between ducts and adverse outcomes. And we'll have this sort of unique cohort, those that are low risk, those that are high risk that respond to treatment versus those that are high risks that did not respond to treatment.

[00:40:39] Afif: And we're going to compare them to a historical treatment naive cohort in whom we have the same set of physiological data. So again, that's another way of looking. At interventions that is different to an RCT that may give us some clues as to how to better design trials going forward.

[00:40:57] Daphna: Yeah, I think you're highlighting

[00:40:58] Daphna: A, a move [00:41:00] in, in medicine in general. I mean, especially for us, that not all babies are the same and that, you know, for lack of a better term, that maybe there are different phenotypes of physiology that, uh, uh, allow some babies to respond and, and not others. And we, when we group them all together, we lose some of that

[00:41:20] Afif: Yeah, one thing I didn't mention, and thanks for bringing that up, is about 10 to 15 percent of babies that we screen have clear evidence of pulmonary hypertension that is subclinical, right? They may be on room air, on CPAP, or very low ventilator settings, yet they have bidirectional or right to left shunting across the duct.

[00:41:39] Afif: We don't touch these babies, we leave them alone, whereas I firmly believe that some of these babies end up getting lumped into these trials, being treated, and treatment we know is detrimental to babies with. Elevated pulmonary valve. Pulmonary pressures. So we're going to look at this population differently as well.

[00:41:56] Afif: And it's similar to the stuff that was done in Iowa, whereby [00:42:00] you determine treatment or lack of treatment based on the physiology, not just on one parameter. So these babies were leaving alone. We may give them a bit of nitric to try and lower the pulmonary vascular resistance. So we have a different way of approaching things based on the physiology that we see.

[00:42:17] Afif: Because if you look at the surface, a lot of these babies look the same clinically at 24 hours. You know, baby with right to left shunting may be 24% CPAP. Babies with pure, um, you know, right to left shunting may also be in room air 24%. One may benefit from treatment, one may be harmed. Again, looking at the physiology is becoming increasingly more important, recognizing the heterogeneity of the physiology that we see.

[00:42:48] Ben: and so for the people who are not familiar, we'll, we'll put the papers where you outline the PDA score, but it's basically a right. And you correct me if I'm wrong. It's a score that basically you could get a range from like [00:43:00] zero where you're low risk to as, as high as 13. And it, and it includes, uh, several, uh, variables, if I'm not mistaken, five gestational agent weeks, the PDA diameter, the left ventricular output, the maximum PDA velocity.

[00:43:13] Ben: And the left ventricular, a wave in centimeters per second. Um, and,

[00:43:19] Afif: Yeah. So, I mean, the gestation we felt was the best clinical predictor. Um, we looked at a lot of other clinical variables and gestation always trumps them all. So that's the one we included. Left ventricular appet was a surrogate marker for pulmonary over circulation actually. So the The higher the LVO, the more blood was flowing through the lungs and therefore coming back into the left heart.

[00:43:42] Afif: And one crucial thing that I feel is unique in our score is looking at left ventricular diastolic dysfunction. All babies have baseline diastolic dysfunction, some worse than others. And what we have found is the worse your diastolic dysfunction was, then the less likely you were able to handle all that preload coming back into the left [00:44:00] ventricle.

[00:44:00] Afif: And that was a significant contributor to the evolution of chronic lung disease in the setting of, of, of a PDA. So that's why we included it in the score and in our regression analysis, it was the one that kept flagging as significant when you put them all together independently. And I think it makes physiological sense as well.

[00:44:20] Ben: Yeah. Yeah. And that's, and that's, um, illustrated by the coefficients assigned to each one, by the way. And, and, uh, so if, when you look in the paper that that's actually well outlined one last question about the PDA, because I do want to move on to other topics, but we've talked about obviously patient selection and, and, and the initial phases, but what can you say briefly about how we decide, um, how the outcomes measured in PDA trials have to be decided?

[00:44:43] Ben: I think there's a lot of variability there. What, what are we measuring, right? Is it, is it, It's not just about the pda closing is that what does that mean practically and we've talked about obviously the work that you're doing Looking at respiratory outcomes. Some people say we should look at neurodevelopmental outcomes But what what is your what are your thoughts on on what are the outcomes that [00:45:00] we measure in those studies?

[00:45:02] Afif: I have a lot of thoughts on this, uh, uh, and I know that Shuvik Mitra has done a lot of work looking at the input of parents into, into outcomes. And it's very interesting when you speak to a parent about what is important to them. I think we often dismiss duration of ventilation as. an unimportant outcome if the rates of chronic lung disease are the same between the two groups, right?

[00:45:29] Afif: So if I told you that if I do something that will reduce the duration of ventilation from let's say seven days to four days,

[00:45:36] Afif: but I will not change the rate of chronic lung disease, are you interested? And I can guarantee you most neonatologists will say, no, I don't, I don't care if the rates of chronic lung disease are the same.

[00:45:46] Afif: But if you ask a parent, You know, you'll be able to hold your baby three days sooner. You'll be able to work on skin to skin three days sooner. You'll be able to do work on non nutritive sucking. All of these things [00:46:00] in combination will ultimately improve outcomes. So we need to listen to parents more. We need to take the small wins.

[00:46:08] Afif: And I think focusing on outcomes that are important to parents are actually the outcomes that will matter down the line. The arbitrary cutoff at 36 weeks, I don't know. We kind of over focus on it, and I know there's a big move to move away from it. Looking at the respiratory morbidity beyond discharge.

[00:46:27] Afif: Again, asking parents. They will tell you, well, I don't want my baby to suffer when they get RSV. I don't want to be bringing them to hospital every second day. I don't want my baby to be on inhalers. Um, you know, all of these things are the outcomes that we need to begin to capture to see if we can improve.

[00:46:46] Afif: Post discharge respiratory morbidity, but also the things that matter to parents while they're in hospital, you know, I think duration of ventilation is very important. Um, it's funny. I think ventilation sort of comes in and out of [00:47:00] fashion. You know, there was a big push to extubate babies as soon as possible.

[00:47:04] Afif: And I think we're beginning to realize that that. That might not be the best course of action in the smallest babies, but now we're leaving them ventilated for too long, so it kind of, you know, it swings. And just to kind of get back to your question, I think, you know, small wins in terms of outcomes that matter to parents is what we need to look at.

[00:47:25] Afif: Putting more emphasis on how can I de escalate? Intensive care, if I can reduce the amount of support that the baby is on, even for a day or two, that has a big impact on bonding with parents, and I think ultimately, it will lead to an improvement in outcome, because, for example, if you can improve breastfeeding rates, you know, we know that that has a significant impact on a variety of outcomes that are important to us, yet we probably don't make the link that Gosh, if I treat the PDA and get the baby extubated early, [00:48:00] then all of these things will fall into place as well.

[00:48:04] Daphna: Well, I'm thrilled to hear you say that. I have a ton of questions about your thoughts on working with parents in the unit, but I have one more cardiology question. Um, I think, um, as someone who's interested in cardiology, obviously the PDA has kind of commanded the discussion about the heart in the NICU, but for trainees or young faculty who love cardiac physiology, But want to stay out of the PDA discussion.

[00:48:33] Daphna: Um, where do you think is kind of important areas in the field, um, regarding, uh, cardiology and the neonatal heart in the NICU that have not been well studied?

[00:48:46] Afif: Yeah, I mean, inotropes is a big thing, and the fact that I'm calling them inotropes shows you that we know very little about how these agents work. Um, I really think that... Our use of vasoactive agents in the [00:49:00] neonatal intensive care unit needs a huge, um, uh, revision. I listened avidly to your breakdown of the study.

[00:49:07] Afif: I believe it was from Texas, wasn't it? Um, looking at the use of, um, dopamine is still the primary agent used in a lot of neonatal intensive care units. And. Automatically what springs to mind when I hear dopamine being given to a baby is that I don't want to think about the underlying pathophysiology, I just want to give dopamine to raise the blood pressure so I can go back to bed.

[00:49:27] Afif: You know, I know that's a cynical view of looking at it, but it's a way, in a way, dopamine, I can't see dopamine useful in any indication. There are far better agents that have more specific mechanism of action that give you a specific response. You know, again, going back to pathophysiology, do I need to increase inotropy?

[00:49:48] Afif: Do I need to increase, uh, do I need more vasopressor? Do I need to actually relax the heart? Do I need to reduce afterload? Again, breaking it down to The [00:50:00] underlying pathophysiology tailoring the management to better suit the baby is something that we need to work on. So that's another big thing, I suppose, that the worth study.

[00:50:11] Afif: Another thing that we are hopefully actively working on is preterm babies with hypoxemic respiratory failure. Is it lungs or is it arteries? Will this baby benefit from nitric oxide or not? Again, I think we know very little about the underlying pathophysiology and our problem is that it's. Rarely a one thing that is causing this hypoxia makers pretty fairly.

[00:50:34] Afif: You've got a bit of parenchymal lung disease. You got a bit of arterial lung disease and tailoring the treatment to benefit that baby specifically can is, um, is a challenge. So there's, I mean, if you don't want to, if you don't want to touch the PDA, there's so many other things that you can devote your efforts towards, you know, um.

[00:50:55] Afif: Uh, hypovolemia or vasoactive agents, um, hypoxemic respiratory [00:51:00] failure, looking after, um, looking after babies that may have pulmonary hypertension. And I actually believe that a big. understudied group are, um, termed babies with neonatal encephalopathy that undergo therapeutic hypothermia. I think we know very little about the hemodynamic impact that cooling may have on a damaged myocardium because it's hard to actually tell was the ischemic hit predominantly in the brain or did the heart suffer as well?

[00:51:33] Afif: Again, bringing it back to not all babies are Some babies that have had a significant myocardial hit Cooling those babies, yes, may benefit the brain, but it actually may have a significant impact on heart function. We know that cooling results in increasing afterload. And in an ischemic heart that had effectively a bicardial infarction, it may just.

[00:51:56] Afif: pack in under the increased afterload. So [00:52:00] better human dynamic monitoring. Now, I'm not suggesting for a second that we don't cool these babies, but we need to actually support the myocardium while we do it. And I actually firmly, yes, go on.

[00:52:12] Ben: no, but you're raising a good point, which is, um, you, you can, you can have the marginal benefits of cooling. Um, but if the patient dies of, of, of cardiopulmonary failure, then, then, then what is the point, right? And I think, and, and, and the same way that you could potentially stop calling for certain instances.

[00:52:31] Ben: If, if you are not able to sustain the heart, then maybe

[00:52:34] Ben: maybe we'll

[00:52:35] Afif: And we've all

[00:52:35] Ben: these pockets.

[00:52:36] Afif: all had these babies that. Ended up needing ECMO after cooling, you know, and we had to abandon cooling. We've all had these babies that have had a significant drop in their cardiac output and blood pressure. Now, you know, could some of these babies been kind of rescued and maintained cooling?

[00:52:52] Afif: I firmly believe so. If we came in early with a proper hemodynamic assessment and use the right vasoactive agents to support the [00:53:00] heart during cooling, then we could have avoided discontinuation of cooling or deterioration in their, in their status. And. You know, pulmonary hypertension was a contraindication to cooling.

[00:53:11] Afif: Luckily, in our center, it no longer is, because we jump in early with medications to try and help maintain the heart while we cool the babies. Oftentimes, we are successful in maintaining cooling and controlling the pulmonary pressures during that process. Sometimes it doesn't work, but, you know, sometimes it does.

[00:53:30] Afif: And again, Capturing, I don't know how you capture this in an RCT, you know, how, how, how can you design a study to capture all the nuances of the different pathophysiological underpinnings of what you see clinically? That's the challenge I sometimes have with large scale RCTs.

[00:53:51] Daphna: Well, I opened up Pandora's box and I think each of those can be their own episode, but we, we have to, we have to move on so that we can get to some [00:54:00] of our other topics. Do you have one

[00:54:01] Ben: Yeah. And the article, no, no, the article that you mentioned about visual press that we recently reviewed, I think Priya reviewed it. It was from Tennessee and it's in the American journal of perinatology. I think if you guys are looking for it, it's an episode 128. That's it. Um, definitely go ahead.

[00:54:13] Daphna: Thank you, Ben. Um, well, I wanted to talk about some of the other facets of your career. Um, so you are actually, um, an IBCLC and, um, I, my question,

[00:54:28] Ben: tell us what that is?

[00:54:29] Daphna: oh, I'm sorry, uh, uh, uh, board certified lactation consultant. Um, International Board Certified Lactation Consultant, IBCLC. Um, but my question, I was going to use the word role.

[00:54:41] Daphna: What is our role as neonatologists, but that makes it seem optional. Um, what is our responsibility as individual neonatologists in the procurement of human milk?

[00:54:52] Afif: Yeah, it's very interesting. And you know, at, um, at 5 p. m. my time, so in about three hours time, two hours time, I am giving a talk, [00:55:00] um, on human milk versus donor milk in the neonatal intensive care unit. So I don't think we have time for me to give you that talk now, but

[00:55:08] Daphna: log into that lecture.

[00:55:10] Afif: You can, yeah. So we were talking, we were talking off air about the sort of extended role we have here in Ireland as neonatologists in that we not only work in the neonatal intensive care unit, but we also work on the postnatal ward as well.

[00:55:24] Afif: So one week I could be in the NICU, knee deep in 23 weekers, and the second week I could be dealing with healthy, big fat term babies with kind of. No, no problems at all. One thing that struck me is that the reason I decided to become a lactation consultant is that the rates of breastfeeding in Ireland are horrendously low.

[00:55:47] Afif: Um, just to kind of give you a rough outline, although about 80% of mothers during pregnancy intend to breastfeed, only half of those, so 40%, leave the hospital [00:56:00] exclusively breastfeeding. So there's a massive drop off

[00:56:03] Daphna: And that's not NICU parents. That's all

[00:56:05] Afif: That's, no, that's not NICU parents. I'm talking all parents. And by six months, only 10% of mothers are exclusively breastfeeding.

[00:56:12] Afif: So, our supports here, unfortunately, aren't great, especially in the first few days following delivery. That was a big contrast to my time in Toronto, whereby the vast majority of mothers breastfed, and there was really good support. Um, you know, we had my daughter here in Ireland, and my son in, in Toronto, Canada, and we've had...

[00:56:32] Afif: Very different experiences in terms of the breastfeeding support that we had. Um, so I found myself not being able to help mothers, especially on the postnatal ward and in giving them the advice that they were looking for. A lot of mothers intend to breastfeed, but I did not have that skill. Again, like critical appraisal, lactation medicine is not very well taught in med schools.

[00:56:56] Afif: It's not on anybody's radar. Even in pediatrics there was It's almost [00:57:00] no training, yet we're expected to advise mums on breastfeeding. I don't think it's enough to tell them breastfeeding is good. You need to do it. We need to actually be able to provide the support if it is asked of us. It may not be as relevant in the NICU at some level, but on the postnatal floor, I think it's important.

[00:57:20] Afif: Having said that. I think it really opened my eyes up on the benefits of breast milk to our preterm population and in particular, the benefits of mother's own milk. Um, on, on the development of, of, of these babies. So, and actually realizing the different, the different levels of benefit that you get. And it's becoming increasingly obvious that fresh milk is really good, but practically that's not very easy to give to babies in the, in the NICU because a lot of moms express at home, freeze it and bring it in.

[00:57:54] Afif: We're now learning from some preliminary data that if you actually give babies fresh milk, That [00:58:00] hasn't been frozen where you didn't decimate the stem cells, the active, um, the bioactive components that these babies have lower BPD, lower neck and a trend towards lower mortality. And we know at another level that pasteurization of donor milk that is predominantly, um, gathered from mums of term babies, yet we use on preterm babies, is not as ideal as, um, breast milk, but it's better than formula.

[00:58:29] Afif: So, but we know that if you inoculate, Donor milk with a bit of mom's own milk that you could, um, what's the word I'm looking for? Salvage some of the immune properties back and improve the biodiversity of that milk. So there's so much to learn there It's a minefield and I actually firmly believe that that's one of the biggest areas that we can do real good.

[00:58:54] Afif: For babies in the, in the NICU, improving their exposure to mother's own milk [00:59:00] and improving our, um, I suppose ability to tailor donor milk, um, to become specific for the baby, you know?

[00:59:12] Ben: And so we're running short on time, so I'm going to jump on the next, the next item that we wanted to talk to you about is that you are, uh, you're an accomplished artist and for people who haven't seen your art, um, they can do so at a thief's. Art. net and while the, the process is, is something that's very personal, I'm wondering what does the artistic journey you're on mean to you in the context of your professional career?

[00:59:41] Afif: Yeah, thank you. Thanks for bringing that up. It's, uh, I look at it as a sort of creative outlet. You all know the, the stress that we endure doing, uh, the job that we do high stakes a lot of the time. And... I've always done art, but I've done it privately and, you know, when [01:00:00] COVID happens, a lot of aspects of life sort of slowed down for a lot of us and, you know, but work continued.

[01:00:07] Afif: So, I found that, you know what, I'm gonna maybe share some of the pieces I do on social media and a lot of it was, was influenced by, My role as a lactation consultant, right? Because a lot of my images are to promote breastfeeding and to mark the bond between mother and baby. And, you know, I got a couple of direct messages via Twitter and Instagram saying, Oh, that's lovely.

[01:00:30] Afif: Can I buy it? And I said, Well, we actually want to buy some of this stuff. You know, and I figured out, you know, why not, I'm just gonna try and commercialize it a little bit and see how it goes. And it has been, it's been a really, really nice creative outlet for me over the last three years. And it's something that's, um, trickling along in parallel and I've got great help at home.

[01:00:53] Afif: It's something that me and my son do together. Helps me frame and package a lot of the stuff, um, that comes through. [01:01:00] So it's a lovely thing that me and him do together as well. So it's a lovely, it's lovely being able to sit down and, and kind of paint at night and, um, come up with different ideas. It's lovely to do exhibitions.

[01:01:15] Afif: You know, it's really nice to meet people outside the field of medicine. I sometimes find that we're surrounded by medics. I know they're a great bunch, but you know, it's nice to actually Be involved in something completely different and look at how people. Do things differently. I have the utmost respect for artists that do this as a living.

[01:01:36] Afif: I do not know how they do it. It is tough. And I remember when I held my first exhibition, people used to come up to me and say, This must be really easy for you because you work in intensive care. And I tell them, you know what? I've never been so stressed in my life. Get, get me a 24 weeker. Any day. This is 10 times as stressful because you're sort of, [01:02:00] you're sort of opening up to the world and look, and exactly, you know, if nobody buys anything that that's a clear statement that what you're doing is garbage or doesn't, doesn't inspire anyone.

[01:02:09] Afif: But luckily that hasn't been

[01:02:11] Daphna: Or you picked the wrong audience, yeah?

[01:02:13] Afif: Well, yeah, exactly, exactly.

[01:02:15] Ben: But I, I don't think that's true. I think the, the history of art is, is, uh, plentiful of cases where art was completely dismissed the impressionist movement was thought to be a poor man's art and, and it's just sometimes it's, uh, it's, uh, yeah, so I think, uh, but it is stressful to put a work product out into the world and be subjected to.

[01:02:37] Ben: to, uh, to other people's views and criticism. And that's, that's very challenging. Now, my question is then circling back to the NICU, how has your art changed you as a clinician?

[01:02:50] Afif: I think it, it, it sort of encouraged me to think outside the box and look at things from other people's point of view. Um, [01:03:00] because as you said, when, when I, when, whenever I held kind of exhibitions, I used to get a lot of. opinions and comments, um, on how the art make them feel, but suggestions on how to kind of improve things, or, you know, this is what I get from this painting.

[01:03:18] Afif: And I look at it and say, how are you getting this from something that, you know, and it made me think. You know, maybe my point of view isn't the only correct point of view, and especially when you may come to disagreement with a colleague about a way of approaching a difficult case, you always have to respect other points of view and recognize that your point of view isn't the only correct one, and it sort of opened my mind a little bit better into, um, working together with people in a better way.

[01:03:50] Afif: Not that I was, um, difficult to work with. I'd like to think I wasn't, but I think it just, um, it just opened my eyes up a little bit more into accepting other points of view on how to approach [01:04:00] things.

[01:04:01] Daphna: That's beautiful. And I think it's just, we talk all the time on the podcast about the importance of maintaining the humanities, even in a life in medicine. Um, we would be remiss if we didn't mention that you are also a fellow podcaster, um, of the Baby Tribe Podcast. Um, and not only that, very active, especially it looks like on Instagram in terms of kind of family centered content.

[01:04:27] Daphna: If you could tell us a little bit more about that, what, what, what made you put that out there?

[01:04:32] Afif: well, um, I'm not just saying this because I'm on this, but you guys were an inspiration for me to start it. Um, I, I, um, I've always had it in the back of my mind that there is no freely publicly available, easily accessible resource for parents, um, about the common day to day things that go with raising a child from.

[01:04:55] Afif: First coming home, all the way to the first year of age. Yes, if you really [01:05:00] dig deep, you will find information online, but having it packaged for you in an easily accessible way, where you're not sitting in front of a computer and reading it, in a similar way as you guys are doing for papers for, you know, trainees and neonatologists and whatnot.

[01:05:15] Afif: So I decided that it was time to actually do the Baby Tribe podcast, which is dedicated to parents, um, and giving them evidence based, unbiased information on all things to do with baby health and baby nutrition going from the antenatal period. all the way to the first year of age. So we're just about finishing the first season and we're going to break for the summer and hopefully coming back in a couple of months time for season two.

[01:05:40] Afif: It's been great. And you know, interestingly enough, a lot of residents and fellows are coming to me saying they are also learning a lot because I think in pediatrics, we're great at teaching what can go wrong, but we're not very good at teaching what should happen. You know, what are the normal, you know, what are the, what should a [01:06:00] baby do normally?

[01:06:01] Afif: And one of our most popular episodes is episode two, which is normal baby behaviors. What to expect from your baby over the first, um, you know, 24, 48 hours of age. And the number of public health nurses and residents that have come to me saying, I did not realize that a baby. Can't take more than 10 to 15 mils per feed over the first day, you know, I thought they needed to take 60 or 70 mils and, you know, we tell mothers then you're not feeding your baby.

[01:06:29] Afif: Um, and, you know, things like the baby's nursing all the time. We interpret as. A hungry baby and the terms that we use can have so many different connotations. So we're getting great feedback from parents. Our listenership is predominantly from Ireland and the UK. So we'd love for some US parents to actually start listening to this.

[01:06:49] Afif: So, um, uh, we have some listeners in the, in the US, but not that many, but this is a kind of global thing that is relevant to parents anywhere. And we don't exclude anyone. We talk about [01:07:00] breastfeeding, formula feeding. And we're trying to make each episode as inclusive as possible, so that parents, regardless of their method of feeding, can benefit from it as well.

[01:07:09] Ben: We're going to definitely, I was going to say, we're going to definitely link the podcast is available on pretty much all podcasting platforms, Spotify, Apple podcast, so we'll definitely link it, link it in our, on our webpage and, uh, yeah, so baby tribe and you, and you're co hosting that with, uh, Katie Muggin.

[01:07:26] Afif: Kate, Katie Mugen.

[01:07:28] Ben: Dang it.

[01:07:29] Afif: Well, I know, I know you're doing, you're doing, you're doing great work towards pronunciations. Um, I always,

[01:07:34] Ben: I got Satyen, I got Satyen's name correct. So that's it. I'm done for the year.

[01:07:38] Afif: I, I, I have never attempted to pronounce his surname, and I don't think I'm going to do that anytime soon. So, fair play. You have, you have my... Of most respect.

[01:07:47] Daphna: Well, I just wanted to add just a nod to the podcast. You know, I remember bringing home my daughter. I was a third year pediatric resident at the time and we got to the point where I had to give her her first bath and I was like, [01:08:00] nobody taught me how to, how to be the baby. And so, you know, I think the internet is such a, complicated place for parents who are just trying to do the right thing.

[01:08:10] Daphna: And I think as physicians, sometimes, um, we fall on the side of like a lot of judgment when how, how do parents know where the right information is if we can't give them a good, reputable easy to access source, right? Like, so, you know, we talk a lot about why being on social media is a value for the physician parent relationship.

[01:08:36] Daphna: And I think yours is a perfect example of that. Like if we don't, if we don't put out the right information in an easy to digest way, they're going to find it somewhere else. And it may not

[01:08:46] Afif: yeah, absolutely. And there's so much misinformation out there. The number of times I get mothers in clinic coming telling me that their mother in law have asked them to put baby rice in their three months old baby's bottle because [01:09:00] they're feeding too much. And you're kind of going. Oh my God. And it's so funny.

[01:09:04] Afif: My wife, um, but you know, when we had my first daughter, she's 15 now. So this was 15 years ago. I was a pediatric trainee. Um, people used to come up to my wife who's an anesthesiologist and they tell her, Oh, you're so lucky you're married to a pediatrician. You must know everything. And I don't know if you're allowed to swear on this podcast or not, but she said, No, he's fucking, he's fucking useless. You know,

[01:09:25] Daphna: That's

[01:09:25] Afif: no, no, no help, no help whatsoever. And it's funny. ever since I've become a lactation consultant, I've appreciated the trauma that she went through in her breastfeeding journey. And she's like, you know, you're, you're 13 years too late, but at least you got there eventually. Yeah. Where were, where was this, where was this lactation consultant 13 years ago?

[01:09:46] Afif: Um, but yeah, we know. Yeah, when I needed one, but that just shows you that even as a pediatrician or somebody training in pediatrics when you become a parent You are a parent and everything else goes out the window, and I don't think [01:10:00] that your pediatric knowledge comes in handy It may if your baby, you know, I don't know has a specific problem or something like that, but normal parenting stuff I was as clueless as the next guy, you know,

[01:10:12] Ben: And I think you're making such a good point because I think on the one hand, the podcast is fantastic. The, um, the episodes are about like 30 minutes each. I've listened to a few of them. I'm not completely caught up, but what I want to say is that for parents, it's, it's an obvious value add in terms of, um, really understanding the, what was the, um, um, there was this great PDF when I was a resident about like skin lesions and newborn called departures and minor variations.

[01:10:40] Ben: And I think it's exactly right. It's like, how do we know the little things that are like, It's not like, Oh, like check the temperature if your baby is blue and not breathing. It's like, that's not the point. The point is like all these little departures and minor variations where it's like, I don't know if that is that something is that not something and as a parent, it's very isolating because you don't want to sound like you don't know what you're doing and [01:11:00] you want to have this, this, at least this opportunity to improve.

[01:11:03] Ben: But what I would say is that for trainees. and young physicians. It's extremely valuable. I was fortunate enough to enter pediatric residency after my daughter was born. And I could, and when I spoke to colleagues of mine who were single, who didn't have kids, they were conveying to me how difficult it is to provide anticipatory guidance to parents taking a baby home when it's like, I haven't, I haven't, we, we, they didn't teach us this very well in med school.

[01:11:29] Ben: And I've never done this myself. Yeah, and it's like and I've never done this myself and I'm supposed to give them advice and and this and and I don't have any so I think as a trainee, I mean, I listened to a few parenting podcasts because it's always interesting to hear the experiences of people going home and and doing things that you may not have an experience with.

[01:11:48] Ben: I don't know taking twins home. How am I like? I'm giving advice to parents of taking twins home I've never taken twins home. I don't know what i'm talking about. I have one kid. I don't even have two so Um, I think from that standpoint as well. It's such a [01:12:00] great uh resource.

[01:12:01] Ben: So,

[01:12:01] Afif: have two kids. I have two kids and I tell parents to stop at two because I can't advise them on three, you know, I have no idea.

[01:12:07] Daphna: Can't help with that. I also think, um, I also think it's a good reminder for, really, our neonatology colleagues that we often, often babies end up in the NICU that need to be in the NICU, but are otherwise pretty well. And we run the risk really of over medicalizing a lot of these babies. And, um, you know, not focusing on, like you said, uh, feeding volume, normal feeding volumes in the first few days of life.

[01:12:38] Daphna: This just came up in our unit. Um, things, uh, like normal baby behaviors. It's in a baby who's being worked up for other things, you know, um, and so we can sometimes create a much more stressful NICU stay, a much more long NICU stay, um, by not focusing on the like basic pediatric [01:13:00] principles.

[01:13:01] Ben: Yeah, and and on top of that I think dafna the I mean when I was a resident We were a big transplant center. And so there was this perception from the residents that like liver transplants were awful because they all come back with problems and then it was completely selection bias because it's like no you're only seeing the ones that are coming back because you're a pediatric resident the one you're not seeing are doing fine and and and there's a large number of them i think it's the same the same thing that ER physicians benefit from as, as neonatologist, if you call somebody and say, Hey, my baby has puked twice.

[01:13:30] Ben: It's like, Oh, let's do a sepsis work. Like you think already the worst things when in truth, there is so many things that are within normal that you can actually reassure. And, and like Daphna said, you, you don't have to over medicalize everything. And I think it's where Um, the the the baby tribe podcast and and what you're doing and other podcasts in um in that sphere are so helpful So, um, I think that's also very very useful Um,

[01:13:53] Ben: yeah, that's it's not really a question.

[01:13:55] Ben: But yeah, I just wanted to say that

[01:13:58] Afif: Yeah, thank you very much. [01:14:00] Yeah, no, it's, it's been, it's been a great experience and I think, and I'm sure you guys will both agree, actually doing the podcast expands your knowledge

[01:14:09] Daphna: For sure.

[01:14:09] Afif: in multiples because you have to make sure that everything you say is evidence based. You have to research the topic because you need to sound like you know what you're talking about.

[01:14:18] Afif: And I've actually learned a lot. I've learned a lot in that process and my, um, my co host Katie Mugen is, is, is a fantastic. She's a pediatric nurse, a public health nurse and a lactation consultant. So the knowledge that she has is exceptional and she sees babies in the community on a daily basis. So she has huge expertise in the.

[01:14:39] Afif: Variety of ways that babies behave and I've learned a lot from her. I mean often I'm listening to her talking and I'm thinking God, I need to really ask a question to sound like I know what I'm talking about You know, and I often have to then edit it out because it sounded really stupid So, um, it's the yeah, that's why that's why I edit everything just to you know Just to make sure that that doesn't come [01:15:00] through but no, I mean I've I've learned a lot in the process as well So it's been fantastic, you know

[01:15:06] Ben: Yeah, I mean this is this is such a cliche but um There's, there's this famous saying of like, I've learned a lot from my teachers, but so much more from my students. And I think the process of teaching is where you learn the most. Um, so I, I could not agree with you more. Last question, because since we're over time and we do have to wrap this up at some point, we could talk to you for hours.

[01:15:28] Ben: Um, is. You're doing all these things and and I agree you mentioned you started touching on this that each endeavor really feeds into the bigger picture of you taking better care of Children, but it can sometimes feel like what you're doing is overwhelming. You are doing so many different things. The thing that's depressing almost that you're doing them so well.

[01:15:51] Ben: Um, but for people who, um, what is your advice? And you make it look easy and but you but but it you could do a hundred different things and do them poorly [01:16:00] You're doing everything at such a high level of excellence. I am just wondering what is your advice to people who are a bit afraid? Of of venturing and multitasking and and and how do you do this?

[01:16:11] Ben: Um without letting yourself down by by not maintaining your expectations

[01:16:16] Afif: Yeah, thanks. Thanks for asking that. And I get asked that a lot and there's no magic answer. First of all, you go through different stages in your life, right? I mean, when my kids were young, there was no way in hell I was going to be able to do any of this. Right, so I had to focus on my career, focus on finishing, finishing the fellowship.

[01:16:35] Afif: My kids now are 15 and 12, so we have to beg them to actually spend any time with us, you know. Um, so you find that once your kids kind of approach teenagers, you have a lot of time. What I... The way I approach things is that do one thing at a time, get really good at it, let it run itself by itself, by having good people around you, and then you move on to the next thing.

[01:16:57] Afif: So, for example, since [01:17:00] I came back from Toronto in 2012, and my aim was to develop a research program in hemodynamics here in Ireland, and that was my focus pretty much up until 2021. So, uh, you know, a nine year period where I just focused on building what we were doing and now we have. A sort of program that, you know, yes, I oversee it and I can, uh, contribute to it, but you know, I have a lot of great people around me that are continuing this work.

[01:17:30] Afif: And in terms of the artwork, again, I've spent about two or three years building up a portfolio of artwork and I now have a great assistant and enough sort of source material, if you like, to keep putting it out bit by bit, um, that is now I don't need to actually. With it, with the exception of commissions that I asked to do every now and again, I'm not sitting there painting every evening because I have a lot of work sort of saved up.

[01:17:57] Afif: And I did that during COVID when there was very little else. [01:18:00] To do. And now the podcast is my main focus and the social media presence. So, you know, I do things in stages. I think if I decided to take all three up at the same time, they all would have failed, right? So pick one thing at a time, get really good at it.

[01:18:15] Afif: Make sure that it becomes second nature and then you move on to the next thing and then you slowly build yourself up like that. That's how I've always approached things and that would be my advice to people is that Don't look at somebody 10 years ahead of you in their career and say, gosh, I need to do all of these things now.

[01:18:32] Afif: No, you know, pick one thing and say, what is your main objective now? What would you like to achieve and work on that? And then the things will follow in time. Look at the stage, um, look at, you know, the stage in your career, you know, I've asked the same question to really kind of high profile moms that, um, have had four children, yet they're excelling in their business.

[01:18:55] Afif: And I asked them, how do you do it all? You know, how can you manage having four kids [01:19:00] and having such an amazing business and such an amazing social, social media presence? And their answer was the same, you know, it's different stages in life. I couldn't do any of this when my kids were young. So that's what I focused on.

[01:19:12] Afif: And now, you know, you change your focus bit by bit as you get good at something or Your phase in life changes,

[01:19:19] Daphna: That's a good lesson for us. Were you listening then? Okay.

[01:19:23] Ben: Of course, of course I was listening.

[01:19:26] Afif: but I mean, you know yourself how much time it takes to maintain a weekly podcast. It's, um, it takes a lot of time, doesn't it? And,

[01:19:34] Afif: um, but you also try and be

[01:19:36] Ben: and you are, yeah. And, and, and what you described is sort of the phases we did go through, which is you sort of build it in stepwise fashion. And then once you reach the point where the task at hand becomes very easy, almost subconscious, you can, you can edit a podcast pretty quickly.

[01:19:51] Ben: Then you say, okay, now I've, I've, I've relieved. Some of the bandwidth that's going to allow me maybe to take on something else. Um, and, and like you said, um, I think one of the [01:20:00] things about the podcast that people don't see is that we have a team behind us that is doing phenomenal work and that's allowing us to continue moving forward.

[01:20:07] Ben: So no, everything you said resonated. I was listening tough now. How dare you in any case that uh, Afif, thank you. Thank you so much for making the time. It's um, it was it was a great interview and and we can't thank you enough for all the pearls you've shared with us and um, we will put all the information about how to get in touch with you your twitter account and and and the um and the podcast and everything else on the episode page and uh, Yeah, let us know how we can help uh promoting the podcast and uh, we're looking forward to uh any

[01:20:40] Afif: I know. Thank you. Thank you so much for having me. And it was honestly a great pleasure and a great honor. I'm a huge fan and thank you so much and keep doing what you're doing. It's amazing.

[01:20:49] Ben: Thank you. Thank you, Afish.

[01:20:51] Afif: Thank you. Take care.

[01:20:52] [01:21:00]