Hello friends 👋
In this inaugural episode of our brand-new series, NeoNews, hosts Ben Courchia, Daphna Yasova Barbeau, and new team member Dr. Eli Cahan dive into articles from major news outlets like Rolling Stone, The Wall Street Journal, and The New York Times to unpack their relevance to neonatology, newborn care, and perinatology.
Dr. Cahan, a pediatrician and aspiring neonatologist with a background in journalism, leads discussions on critical topics, including prenatal cannabis use and its impact on families, disparities in treatment for 22-week preemies, the neuroscience of "mom brain," rising rates of sudden infant death syndrome (SIDS) post-COVID, and the concerning state of maternity care deserts in the U.S.
The episode concludes with quick updates on viral health concerns and a significant FDA meeting on probiotics for NEC prevention. Join us as we bring the latest news to the neonatal community in this exciting new format!
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The articles covered on today’s episode of the podcast can be found here 👇
Doctors Can Now Save Very Premature Babies. Most Hospitals Don’t Try.
First on CNN: US faces maternity care crisis, with 1 in 3 counties lacking obstetric doctors to provide care, report warns
These Moms Smoked Weed Legally. Then Their Kids Were Taken Away
How Does Pregnancy Change the Brain? Clues Are Emerging.
Fisher-Price Recalls More than 2 Million Snuga Infant Swings Due to Suffocation Hazard After 5 Deaths Reported
CDC details 21 Oropouche virus cases in U.S. residents, provides guidance for infants exposed in utero
Rates of sudden unexplained infant deaths increased during pandemic
Live Biotherapeutic Products to Prevent Necrotizing Enterocolitis in Very Low Birth Weight Infants
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Get to know our new host, Dr. Eli Cahan:
Eli Cahan, MD, MS is a pediatrics resident and aspiring neonatologist at Boston Children’s Hospital, Boston Medical Center, and Harvard Medical School. Eli is also an award-winning investigative journalist covering the intersection of child welfare and social justice. His written work has been featured in The Washington Post, LA Times, Rolling Stone, and USA Today, among other publications. His multimedia work has appeared on TV via ABC and radio via NPR. Eli’s reporting has won awards from the National Press Club, the News Leaders Association, and elsewhere. He has received reporting fellowships from the Pulitzer Center and the National Press Foundation, among others.
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The transcript of today's episode can be found below 👇
Ben Courchia MD (00:00.653)
Hello, everybody. Welcome back to the Incubator podcast. And we are back this Sunday with a special new series that we are launching called Neo News. Daphna, how are you? I'm doing well. You know, I always say, I'm so excited. we are like, we are jacked up about this. We are really pumped. I'm going to disclose at some point in time, my husband sent me an article, one of which we're reviewing today. And he's like, you guys got to talk about what people are saying about neonatologists.
And so this is something we'd had in mind for some time. Yeah, but we didn't really have the right partner. And so I'm very excited to introduce the newest member of the incubator team to our audience. And please welcome Dr. Eli Cahan from Boston. Eli, welcome to the show.
Eli (00:50.272)
Hey Ben, hey Daphna, thrilled to be here.
Ben Courchia MD (00:50.649)
Hey Ben, hey Daphna, thrilled to be here. Yeah, and so you're going to work with us on this series. You're going to be pretty much the PI of this new series. I'm going to give you the mic for a few minutes so you can introduce yourself and tell the audience a little bit about who you are and a little bit about your background.
Eli (01:13.708)
That sounds good and yeah, I guess this is all in the credit of ambushing people with email. I think I sent you guys a random email out of the blue and I don't know. This is how the magic happens.
Ben Courchia MD (01:14.093)
That sounds good. And yeah, I guess this is all in the credit of ambushing people with email. I think I sent you guys a random email out of the blue and that is how we work. don't know. That's right. We were kind of primed for it. It was something we were trying to do, interested in doing. And when your email came in, we were like, yep, this is this is it. So thank you for sending that email. And so you have you are currently in training and you have a background in journalism.
And you are an active writer for several news outlets. And so how did you get into that?
Eli (01:55.222)
Yeah, you know, I was out in California doing a master's degree in health policy and I had started that degree in September 2019, which at that point, I think nobody really cared about health policy. Well, maybe a couple of people did, but you know, it's a very small slice of the universe that cared about health policy. Like my grandma didn't get it. My mom didn't get it. They were like, you already have enough school. What are you doing?
Ben Courchia MD (01:55.511)
Yeah, you know, I was out in California doing a master's degree in health policy and I had started that degree in September 2019, which at that point, think nobody really cared about health policy. Well, maybe a couple of people did, but you know, it's a very small slice of the universe that cared about health policy. Like my grandma didn't get it. My mom didn't get it. You already have enough school. What are you doing?
Eli (02:21.366)
So I was, but I said, I'm changing the world. So I went out there and, you know, studied my R and was pretty bad at coding and pretty bad at some of this more rigorous, these more rigorous techniques for studying health policy, but was pushing through nonetheless. And then, you know, seven months into the degree, March, 2020, this little thing happened and the whole world all of a sudden cared about health policy. It went from, you couldn't convince a person to,
Ben Courchia MD (02:21.677)
So I was, but I said, I'm changing the world. So I went out there and, you know, studied my R and was pretty bad at coding and pretty bad at some of this more rigorous, these more rigorous techniques for studying health policy, but was pushing through nonetheless. And then, you know, seven months into the three, March, 2020, this little thing happened and the whole world all of sudden cared about health policy. It went from, you couldn't convince a person to,
Eli (02:50.754)
look up the ventilator stats in the state of Nebraska to like, someone was going to sue you if you didn't know the ventilator stats in the state of Nebraska. And I had a close friend who, had been a contributor at the LA times before he started school there. and long story short, he and I wrote an article together in April, 2020 and just totally fell down the rabbit hole. I mean, realized that, you know, we get asked.
Ben Courchia MD (02:52.206)
look up the ventilator stats in the state of Nebraska to like someone was going to sue you if you didn't know the ventilator stats in state of Nebraska. And I had a close friend who had been a contributor at the LA Times before he started school there. And long story short, and I wrote an article
Eli (03:18.208)
hypothesis-driven questions in a rigorous way that was grounded not only in data, but also in humanity and in the human stories of these people. And that it could be a platform for advocacy instead of me saying, hey, this is what I believe. I could sort of curate, choreograph a story like a director on a movie to tell a story that I thought was important without needing to say it all in first person.
So that's where this all started, I think, for me. And as you point out, since then, I've had the good fortune of doing a lot of writing for a lot of different places.
Ben Courchia MD (03:49.657)
And as you point out, since then, I've had the good fortune of doing a lot of writing for a lot of different places. And so the point of this series is that we're going to review articles from the news, basically, from the Wall Street Journal, from the New York Times, from Rolling Stone today. Articles that are relevant somehow to the neonatal space. Some things that potentially the parents of the babies you care for in the NICU might be reading so that you could be
abreast of what is being said out there and what are parents and families reading. And so I guess we're going to let Eli give us the selection of articles that he has identified this month. But I think for this first article, I think I'm going to introduce it because it's an article, Eli, that you wrote that came out in Rolling Stone a couple of weeks ago called These Moms Smoked Weed Legally.
then their kids were taken away. Can you tell us a little bit about what is the story about and what prompted you to write this piece?
Eli (04:57.952)
Yeah, totally. So, you know, I think the origin of this story was with a mentor of mine who knew that I always have my ear to the ground on issues relating to mothers and babies and their health and especially equity issues and issues of populations that don't have their voice out in the main stage. And this mentor said to me, hey, I've cared for a number of kids recently who
it feels like we keep referring them to child protective services for really no other factors that I could tell than the fact that they had used cannabis prenatally. And that was interesting enough to me that I wanted to look up the evidence and see what we know about the effects of prenatal cannabis. And when I started to look into that, I realized
probably the most generous way to describe the evidence that's out there on prenatal cannabis use is that there's really nothing definitive. I mean, there's a lot of controversy and there are some studies out there on the impacts of prenatal cannabis use, but it's methodologically problematic. It is short-term, it is based on self-reporting, it is riddled with sampling bias, a whole lot of methodologic issues that raise
raise questions about the validity of claims or at least the generalizability of claims that were finding that prenatal cannabis had impact on early life and development of neurocognition. And there were lots of studies that also didn't even find an impact of cannabis on neurocognitive development. And so the genesis of the story started
really by putting two things next to each other. On the one hand, perceived adverse events associated with prenatal cannabis use, which were the very grounds for investigating these, referring and investigating and potentially separating these women from their children. And on the other hand, very well known and well described and robustly characterized adverse events of
Eli (07:19.456)
separating families and putting kids into the foster system and in the spiral that leads to. So that was the genesis of this story.
Ben Courchia MD (07:27.597)
Yeah, and I think in the piece you mentioned at some point that when we're talking about the separation of children from their parents on the pure grounds of parents using marijuana, in many cases with the assent or with the approval of their treating physician, to separation, leads to parents being listed on some lists from child services, leading to issues for these parents to get jobs and so on and so forth.
And like you said, the putting this in the balance between the grounds for the separation and the separation itself is quite dramatic. You write, comparison, separating children from their parents has long-term effects on nearly every aspect of their health. Rates of physical illness like heart disease and diabetes are higher. Rates of neurocognitive changes like developmental delay and regression are higher. Rates of mental illness like depression and suicidality are higher.
rates of truancy and incarceration are higher, rates of underemployment, unemployment and poverty are higher. And then you've you finished this paragraph by saying in a 2018 interview with the Washington Post, Charles Nelson, a neuroscientist specializing in pediatrics at Harvard Medical School, called the impact of family separation on childhood development catastrophic. And I think that that is being lost, I think, in this in this whole in this whole situation, something that obviously you bring to light in the in the piece.
Yeah, think in medicine we're always dealing with risks and benefits, right, of our choices, our treatments, but it seems like, I mean, the risk of separating a family for just one quote unquote infraction, marijuana use, seems much more harmful than potentially the marijuana use itself.
even if we were to buy in that marijuana use is dangerous, there's still a lot of problems with the way that we test families, a lot of inequities in that. And you highlight that in the article, if you could speak a little bit to that.
Eli (09:34.838)
Sure, yeah, and totally agree with what both of you said. think when you look at who is tested for drugs, is non-coincidental. is statistically significant. It is patterned who is tested for drug use. And disproportionately, kind of unsurprisingly for those who study health inequities, it is black and brown women who are disproportionately tested for drug use.
Ben Courchia MD (09:35.137)
Sure, yeah, and totally agree with what both of you said. think when you look at who is tested for drugs, is non-coincidental. is statistically significant. It is patterned who is tested for drug use. And disproportionately, kind of unsurprisingly for those who study health inequities, it is black and brown women who are disproportionately tested for drug use.
Eli (10:02.722)
and including, by the way, cannabis in states where it's legal. And we had examples of parents who had used cannabis or forms of cannabis in states where it's legal and they have been investigated because the child welfare system is not a system that is premised on like whether a substance is illegal or legal, it's premised on whether there's a perception of the terminology is typically imminent harm to child.
Ben Courchia MD (10:03.077)
and including, by the way, cannabis in states where it's legal. And we had examples of parents who had used cannabis or forms of cannabis in states where it's legal, and they have been investigated because the child welfare system is not a system that is premised on whether a substance is illegal or legal. It's premised on whether there's a perception of the terminology is typically imminent harm to child.
Eli (10:31.798)
So even in a state where cannabis is legal, that doesn't exclude a person from being investigated by Child Protective Services. Along those lines, I just want to point out what you said then about doctors recommending or at the very least kind of saying, I have other patients who do this and it doesn't seem to be harmful with regards to cannabis use. The women that I had spoken to, and I think it's important to name names, because I think putting
Ben Courchia MD (10:32.131)
So even in a state where cannabis is legal, that doesn't exclude a person from being investigated by Child Protection Services. Along those lines, I just want to point out what you said then about doctors recommending or at the very least kind of saying, I have other patients who do this and it doesn't seem to be harmful with regards to cannabis use. The women that I had spoken to, and I think it's important to name names because I think putting
Eli (11:00.706)
people at the center of this is important. the people that I spoke to, Raneisha Hubbard, Doshia Givens, and Lindsay Ritchell, all three of them suffered from debilitating hyperemesis gravidarum, which we know is a quite undertreated, remarkably debilitating condition for people who deal with
Ben Courchia MD (11:01.049)
people at the center of this is important. Absolutely. The people that I spoke to, Raneisha Hubbard, Doshia Givens, and Lindsay Ritchell, all three of them suffer from debilitating hyperemesis gravidarum, which we know is a quite undertreated, remarkably debilitating condition. Yeah, and it's a morbidity that has a tremendous impact on quality of life for individuals who are pregnant.
Eli (11:30.966)
Yeah, huge quality of life implications. There's also evidence that it has like sort of morbidity implications on infancy. And we also know that this is an extremely under treated condition, especially in women of color. So exactly the same people who sort of later on are getting tested and potentially investigated for their cannabis use are the same people who are suffering from a condition that we know is debilitating and for whom cannabis
Ben Courchia MD (11:31.309)
Yeah, huge quality of life implications. There's also evidence that it has like sort of morbidity. Yeah, absolutely. On infancy. And we also know that this is an extremely under treated condition, especially in women of color. So exactly the same people who sort of later on are getting tested and potentially investigated for their cannabis use are the same people who are suffering from a condition that we know is debilitating and for whom cannabis
Eli (11:58.536)
is one of the few things that provides relief. And so I think we need to center the story around not these people using a substance recreationally in a vacuum. I think we think about this as a drug that you use and you watch a psychedelic movie and you have like a big bowl of cereal afterwards. That is not the context in which the women that I was speaking to were using this. And that is not the context in which research shows women are relying on cannabis.
Ben Courchia MD (11:58.837)
is one of the few things that provides relief. And so I think we need to center the story around not these people using a substance recreationally in a vacuum. think we think about this as a drug that you use and you watch a psychedelic movie and you have a big bowl of cereal afterwards. That is not the context in which the women that I was speaking to were using this. And that is not the context in which research shows women are relying on cannabis.
Eli (12:27.266)
as a form of palliation for a condition that is debilitating.
Ben Courchia MD (12:28.224)
as a form of allegation for a condition that is debilitating. And we will link the piece in the show notes. We have other articles that we want to discuss. I think some of the things that you do mention in the articles that I wanted to make sure were discussed before we moved on was that, like Daphne was referencing earlier, testing. think something that we didn't tend to think about, but how many people...
and children are tested without parental consent. And I think this really made me think about our practice and the fact that we've not been, I'm including myself in it, we've not been very good at talking to families about obtaining urine toxicology or meconium toxicology samples and these infants and sometimes the parents are tested without consent. And I think that's a huge ethical issue.
that the piece underscores quite well. Yeah, and before we move on, I wanted to say the other thing about testing is we kind of make a gut decision about, at least in most institutions, it's not standardized, who we test or what types of cases are tested for. If we had a policy that said everybody who comes to the NICU gets tested, that would at least be more equitable. I did want to highlight a Neo Reviews publication in 2022, the equity and policies regarding urine drug testing in infants.
And I think it gives a really nice historical perspective and some potential guidelines to help us mitigate some of the inequity in our units. And in the piece in Rolling Stone, you mentioned that the American College of Obstetricians and Guiding Colleges, for its part, recommends against routine drug screening around the time of pregnancy, especially in cases where parents did not consent. What it calls, and I quote, covert testing,
In 2001, the Supreme Court ruled that drug screening without consent was a violation of the Fourth Amendment, which protects against unreasonable search and seizure. Nonetheless, ACOG calls test and report practices still continue. Crazy. Crazy. Yeah. And I also want to point out one other thing that, Daphna, you said earlier, which is we think about risks and benefits for everything we do.
Eli (14:32.194)
Yeah, yeah. And I also want to point out one other thing that, Daphna, you said earlier, which is we think about risks and benefits for everything we do in the NICU and in other realms of medicine. mean, every medical decision that we make is premised on risks and benefits. And yet, for some reason, when it comes to mandating reporting or other situations where we're thinking about engaging child welfare, it
Ben Courchia MD (14:44.127)
in the NICU and in other realms of medicine. mean, every medical decision that we make is premised on risks and benefits. And yet for some reason, when it comes to mandating reporting or other situations where we're thinking about engaging child welfare, it seems like sometimes we don't use the same framework of risks and benefits in terms of thinking about it. We think about what's the worst case? And of course, the worst case is something
Eli (14:59.892)
It seems like sometimes we don't use the same framework of risks and benefits in terms of thinking about that. We think about what's the worst case? And of course, the worst case is something horrific happening, which is why child welfare systems exist is to prevent the worst case outcome. But it does feel like, and there's plenty of research to support the fact that, you know, there are lots of reports that go in and aren't.
Ben Courchia MD (15:09.689)
horrific happening, which is why child welfare systems exist is to prevent the worst-case outcome. But it does feel like there's plenty of research to support the fact that, you know, there are lots of reports that go in and aren't particularly founded on anything that is true medical concern. And there are a lot of reports that are initiated on hearsay and angry ex-partner. And those, I think,
Eli (15:25.932)
particularly founded on anything that is a true medical concern. There are a lot of reports that are initiated on hearsay and angry ex-partner. those, I think the processes that those reports trigger are traumatic and have profound effects on parents and children. So I do want to say we have to be thoughtful about how we're utilizing the intervention that is child welfare engagement.
Ben Courchia MD (15:39.693)
the processes that those reports trigger are traumatic and have profound effects on parents and children. But I do want to say we have to be thoughtful about how we're utilizing the intervention that is child welfare engagement. Yeah, and I think that's what I'm going to conclude for myself. at some point it mentions that this physician who's advised attorneys and stuff mentions that he's
repeatedly seen agencies claim scientific expertise they don't have and in his opinion are weaponizing medical jargon. think this is something where we as physicians have to go back to being in control of these situations. And like the follow up sentences mentions, suddenly the case worker becomes the medical expert. And I think that is something that we should probably not let happen, especially in the context of a condition, a situation where separation is potentially the outcome and lifelong
potentially ramifications of this can destroy families.
Eli (16:40.574)
Absolutely. Couldn't agree more. And by the way, I mean, the point earlier, there are hospitals that are developing universal protocols to address substance use. And so I recommend that anyone interested in this look at some of the hospitals that are adopting sort of universal protocols for how to manage these cases as a way to design out some of that subjectivity and potential bias.
Ben Courchia MD (16:41.281)
Absolutely. I agree more. And by the way, mean to the point earlier, there are hospitals that are developing universal protocols to address the substance use. And so I recommend that anyone interested in this look at some of the hospitals that are adopting sort of universal protocols for how to manage these cases as a way to design out some of that subjectivity and potential bias. For sure. Okay.
I feel like we had plans for this series that we were going to really be timely and yet I see that we're chatting and this is very entertaining. let's try to keep this moving. And Eli, can you tell us which article are we going to look at next?
Eli (17:24.618)
Yeah, and by the way, we can cut this part probably later, but there is an echo when I'm talking. If you don't mind just muting when I'm talking, because it basically is echoing into my headphones. And so I'm going to go three, two, one. Yeah, Ben, so just to outline sort of the approach that we're taking in this series, I mean, I think we said it at the top, but this is really about promoting the doctor-patient relationship.
Ben Courchia MD (17:24.961)
Yeah, and by the way, we can cut this part probably later, but there is an echo when I'm talking. If you don't mind just muting when I'm talking, because it basically is echoing into my... You got it. ...into my head.
Eli (17:54.486)
by keeping the neonatologist up to date with what's buzzing in the media about babies because we know that our patients are reading that information and whether it's good information or whether it's bad information, it is incumbent on us to be aware of that information so that can be a part of the way that we're counseling families because we know they are thinking about it and if we don't talk about it with them, there's lots of evidence that they will use that misinformation. It's not that our being silent makes it disappear. So that's kind of the premise of this segment.
And I think each episode we're going to do what we just did, which is we're going to take a deep dive in one or two stories. We're going to then move into a section that we're going to call research in the news, which is going to address two to three research studies that are making headlines. We'll do a quick breakdown on these studies. We'll do some key points and then we'll do, you know, kind of ESPN style and segment that you're going to we're calling you may have heard, which is just really quick hitters.
of some headlines making the news and we'll just leave it with you. can read more into it if you want to, but we think it's important that you be aware of that for the last part. So the next story that we're going to look at is a story that ran in the Wall Street Journal about the ways in which hospitals across country are providing differential treatment for infants born at 22 weeks.
Ben Courchia MD (18:54.413)
of some headlines.
Ben Courchia MD (19:10.071)
the ways.
Eli (19:21.734)
And I just want to start this segment by maybe reading a little bit the beginning of this story, just to set the stage. And the beginning of this story, the first line says, after her water broke early, doctors told Fatima Goins to prepare for her newborn's death. Goins was 22 weeks into her pregnancy, just past the halfway mark. Doctors at Methodist Hospital in suburban Minneapolis said they couldn't save such a premature baby.
Ben Courchia MD (19:21.973)
Yeah.
Eli (19:50.858)
and that no hospital could. They told her that once her baby girl was born, Goins could hold her until the infant died. What ended up happening was that Goins left that hospital AMA, and four years later, her daughter, Maloney, is doing great. In fact, if you read the article online, you'll see that a picture of Maloney in oversized heart-shaped glasses, a butterfly-adorned spaghetti strap, and two pink-ribboned ponytails that splash across the front of the story
She's a gorgeous kid as far as we know. Things are going great with Muller. The article goes on to say medical advances over the past several decades have given hospitals the ability to save younger and younger premature newborns. And yet most hospitals don't try and parents often aren't aware of what's possible or that other hospitals, even just a few miles away, might offer their newborns a fighting chance. Ben, Daphna, what did you think when...
Ben Courchia MD (20:45.645)
Daphne, what did you think when you like read this beginning of the story? I was furious.
Eli (20:47.606)
You like read this beginning of the story.
Ben Courchia MD (20:53.913)
I'll you go first. This is the article my husband sent to me and he's like, just so you know, this is what the lay public thinks about the work that you do. Yeah, I was very frustrated with this piece specifically because I think that it, especially in the beginning of the piece as you Eli, really it paints a picture of 22 weekers can be saved and they do great. Right? mean, sort of the gist of the beginning of the story is that. And it is quite buried into the piece.
So you have to read quite a lot of the piece to then reach the point where you get some statistics, which even then are quite optimistic with where they mentioned survival rates, where they mentioned survival rates in the above 60 % for certain centers, which again, we know that survival rates above 60 % are probably from the best centers. So I think that if you're not living in the vicinity of one of these centers of excellence, these may not be a reality.
And I think the piece did not do a good job at explaining the consequences of survival for this particular gestational age, especially when it comes to neurodevelopmental outcomes. think they, at one point, there is one line where they talk about the neurodevelopmental impairment for moderate or severe, and then recategorizes normal and mild, but really fails to mention that most of these infants have some form of neurodevelopmental impairment and completely omits the ethical
consideration of whether it is the right thing to do to offer resuscitation considering all these other factors. So I think it was a very much a very one-sided piece and yeah, so I had lots of issues with it. Yeah, I mean, I feel mostly the same way. I mean, are there some are there some nuggets of truth in here? Yes, not all hospitals are resuscitating 22 acres. That's true. But there are reasons for that. I mean, the this is a
a rapidly moving, changing, dynamic thing, this changing limit of viability. And I think it missed the opportunity to have a more open discussion with the lay public and bring us closer together, not farther apart with families and saying, I mean, these are why these discussions are happening. These are why not all hospitals are equipped to even do this.
Ben Courchia MD (23:19.405)
Can we get you to a center that is equipped to do it? I think And so that was a big issue that I had where at some point in the piece it says some US hospitals aren't sufficiently equipped or capable of pulling off new advances, which started making this separation of like you have the competent hospitals and the incompetent hospitals. And I think that then for a hospital to say hey. true. It felt very punitive. Very punitive. And then if you're a hospital that potentially did not offer a station, you could say, we could offer it if that puts us in the right basket.
even though our outcomes may not be the best, even though the interventions we deliver may not be the best, but at least we can say we're doing it. And so I think it may even be triggering the wrong response from institutions to avoid being labeled as the ones who are not going to give these babies a fighting chance. Yeah. And I'm sure that there will be some fallout, that there are some hospitals saying like, well, we're going to do it no matter what. that's...
That's not what happens in any of the NICUs where we go and we spend time counseling families about what's important to them. What is their individual case, right? Is this a baby who's maybe older than we think, a big baby, or is this a growth-restricted, is this a baby with an anomaly at 22 weeks? It really takes away some of the nuance, all of the nuance, some of the intimacy of those discussions. Unfortunately, this is
a pattern, especially in our space, about people making inferences about what happens in these rooms in the middle of the night. To me, the epitome of recklessness in this piece was somewhere in the piece it says, and I quote, out of those it tries to keep alive, 62 % end up going home. And that's the sentence that really ticked me off. The hospital has even graduated several 21-weekers from its NICU. And now you start seeing this sort of
game that is being played about like what about the 21 which then leads to what about the 20-weeker and the 18-weeker and it fails to completely discuss the pathophysiology and the implications. anyway. Yeah, I'll say one last thing. It's not just about us, parents have always moved forward pediatric care and neonatology specifically. you know, there are definite cases where we have been challenged and we have been successful.
Ben Courchia MD (25:36.741)
and maybe the outcomes were quote unquote good or maybe the outcomes that we are unacceptable to us are acceptable to parents, but I think this diminishes parent empowerment actually because I think it doesn't allow for that nuanced discussion for parents to feel empowered to make a decision that's right for their families and I think it confuses the public about what is viability.
Mean. You know, like, what is the problem with viability? The problem is that the lungs literally cannot any lower really than this. They just can't do the work of breathing. Maybe we'll figure it out, but we haven't yet. And so I think, unfortunately, I think it missed the mark. I think it was trying to empower parents, but I think it potentially does the opposite. I think it really confuses parents about some of those technical issues. And this beginning of the piece, to go back to give...
to give back the mic to you, Eli. I think the beginning of the piece that you read felt a bit like Mr. Smith played the lottery, one of four million dollars, and many other Americans are not following in his footsteps of playing the lottery. It's such an unrealistic outcome that it's unfair to promote this as a consistent one for parents who are really hopeful and are really stressed out about the situation they're in. I'm curious to hear what you thought. We've rambled.
Eli (27:02.826)
No, no, listen, pretty evocative story. And obviously, I also felt on the defensive, frankly, when I read it. I'm not even doing this full, you know, I'm applying to fellowship now. Like I'm not even doing this full time. Yet I hope I will very soon. Fellowship directors hire me. I make great baked goods. That is my one asset I can offer. And I can put in simethicone orders with the best of them. But anyway, I think.
Ben Courchia MD (27:21.593)
baked goods. That is my one asset.
Ben Courchia MD (27:29.177)
Anyway, I think.
Eli (27:30.882)
This is a story that is challenging, I think, for all of us. I want to give credit, obviously, to the reporters, because you know that I am a reporter, and I feel kinship with these folks. What is true is the JAMA Network Open Study that they cited at the bottom of, that really forms the foundation of the story. And the JAMA Network Open Study says that 45 % of NICUs are resuscitating babies at 22 weeks. Now,
I think what for me is lost in that statistic is that is the way the system is set up. That is the basis of regionalized care, which is what we do for intensive care and what we do in pediatrics is we regionalize care so that centers of excellence manage complexity for everything. And so I think that's for me a big piece of this conversation that got lost, which is that it was non-accidental that
Ben Courchia MD (28:11.009)
of other conditions, For everything.
Eli (28:24.226)
45 % of these NICUs for such-to-day babies. Ben, the other piece that you said about discussing survival rates in lieu of morbidity, I mean, I don't know how you could have a conversation about premature infants without having a conversation about what life looks like post-NICU with those babies. And I want to read the paragraph that highlighted, that was really the only language to speak to morbidity. And that paragraph said,
Those who survive can develop vision problems or blindness from their retinas developing abnormally. They may need extra oxygen or fiend tubes at home. Longer term, they might have developmental delays and fall behind their peers in crawling, walking and talking. Some might never catch up. And I don't know guys, I wonder how you felt about that. That was felt to me minimizing, I think a lot of the morbidity that we know in these.
Ben Courchia MD (29:15.853)
Felt to me minimizing the morbidity. Very vanilla for, I think it felt to me like a very vanilla description of what severe neurodevelopmental impairment could look like. And I think that I would have hoped that the piece with in all humility, I would have hoped the piece presents this like I presented to patients. But saying that it's a very complicated decision to make. is a trial of life.
And that we are very uncertain about what we're doing to these infants. it failed to showcase the uncertainty that our field is feeling about what we're offering these families. And that when we are offering resuscitation, we're very afraid of, are we making the right decision for this family? Because the outcomes can be quite catastrophic and it could be very devastating for a family to even go through a NICU hospitalization.
for six, seven months and going on this roller coaster. Yeah, and I think most families, no matter how we are counseling them, are still choosing active resuscitation. And that's fine. However, they deserve to have all the information. I think that's where this really missed the mark. It infantilizes.
families as if they couldn't handle the information or they're not worthy of receiving the information and that really makes me mad. And what's interesting to me is that there was an opportunity I think from the paper to maybe jump into an issue which is if you are in a lower level hospital like a level two, the hospital that has a level two NICU where they cannot resuscitate a 22-weeker, how does the counseling evolve to offer potentially transfer for these mothers?
and also maybe highlighting the difficulties of transferring these babies after birth, like transferring a 22-week-old born at a level two is a disaster. And so I think that's where there was an opportunity to go deeper into that. There were some conflicting reports from the hospitals who claimed at least that they provided adequate counseling. So it's unclear exactly what was actually said.
Ben Courchia MD (31:32.409)
But it's a very evocative piece, as you said, and I recommend everybody read it because, this has made the rounds. It's in a major publication, and it raises an important issue. Yeah, I think the one thing I'll say, I'll play the advocate, the devil's advocate, but I think we can no longer counsel parents and say, universally, the outcomes are catastrophic. That's just not true, right, in the 22 weeks, in the 21 and 6.
weeks, you know, we have babies that are for all practical whatever, typically developing. And even for those babies that aren't typically developing, they play a crucial role in their families. And so certainly I think that we need to be careful about the words that we use. I mean, we've all had shadowed, you know,
mentors that went in and said, there's no hope, this is catastrophic, there's nothing we can do. And I mean, that's not true. And so I think as a community, we have to be careful about the language that we use. And maybe this is not the right facility, but how can we get families to the right facility? And we know that there's huge disparities, speaking of disparities, in being able to transfer families to those higher levels of care.
And that's really a missed opportunity, I think, where we say, like, we should rethink our system. One of our papers coming up is about maternity deserts, and they are getting worse, not better. And so I think if the authors of this paper really cared about this issue, then they would be reporting about the problem with maternity deserts.
Eli (33:11.564)
Couldn't agree more. just lots of, I think, material for conversation. And I think that that's what this segment is aimed at. knowing that for some people, viability is just a number that you have to get past on your weeks of gestation is important to know when you're discussing.
how to manage the situation, what the options are, what the future can look like, and all the routes that are available, each with their own nuances. Why don't we move on to that next paper? I think before we get to the maternal desert paper, there is a piece of research that's making the rounds. In fact, it hit my Science Friday podcast feed just today, which is about mom brain.
Let's talk about mom brain for a second. guys, this article in the New York Times, which ran on September 16th, covered a article in Nature Neuroscience that was titled, Neuroanatomical Changes Observed in the Course of a Human Pregnancy. The article, which did serial MRIs of one patient, found, quote, pronounced decreases in gray matter volume and cortical thickness during pregnancy in contrast to increases in white matter
microstructural integrity, ventricular volume, and cerebral spinal fluid. And the study adds few regions were untouched by the transition to motherhood. What did you guys think of the New York Times coverage of this article and the article itself?
Ben Courchia MD (34:51.801)
Go ahead. Well, I think that if you've been had a pregnancy, then this is no surprise to you. I mean, this sense of, you know, pregnancy brain, I mean, is very real. You know, they go into the neuroscience about it how this is potentially very adaptive for moms and focusing on new parents and focusing on the needs of their baby, but letting go some of that other stuff.
And I think it speaks to why things like paid parental leave is so important because we need this time evolutionarily, biologically to catch back up. And if I remember correctly, I don't have it right in front of me, but it persisted up until two years. Two years, that's correct. And this makes sense. This feels right. So.
Yeah, I mean, mean, the article is interesting. mean, just to some of the things I've highlighted by the ninth week of gestation, 80 % of 400 brain areas analyzed showed decrease in gray matter volume and cortical thickness that continued through pregnancies with areas shrinking by 4 % on average. There was also one of the subjects, I think that was a neuroscientist that basically went through IVF. So they had pretty good control over her conception and so on.
and basically ended up going through 26 MRIs. Yeah. Somehow this stuck with me. I like, that's a lot of MRIs. was really committed to the project. That's true. But it's a very interesting paper. again, showing how things are not just independent or in a vacuum and that a pregnancy, the birth of a child does have profound implications for the parents and for the mother as well. So I thought it was a very interesting article.
And I think it did a good job in simplifying a little bit the article because the article in nature is quite extensive. I peeked at it and it was a little bit, I didn't finish reading it. I must admit. The only thing it highlighted for me is that this opens up more questions than answers. I'll say, say for our parents of preterm infants, I mean, it wasn't just, it wasn't just,
Ben Courchia MD (37:07.767)
loss, it wasn't just atrophy, right? Some structures were atrophying, but other structures were becoming more developed. And so I wonder for these families where the pregnancy is disrupted halfway through, and this hasn't totally happened. I mean, the parent's brain is just not totally fully prepared for this preterm infant. I think that is just fascinating, and again, highlights the need for ongoing parent support, both in the NICU and society.
Eli (37:38.902)
Yeah, I love that. We talk about maternal infant dyads all the time for all sorts of different outcomes. I don't think we thought about it neuroscientifically in the sense of both are going undergoing profound evolutionary anatomical and physiologic changes. And I think one quote that that stood out to me in the article was really speaking to how what we're discussing is not good or bad changes in
brain matter, but really pruning and a process of pruning. as we know, pruning is good, pruning is bad, pruning at the end of the day is just different. So my read on the article was, hey, this mom brain thing is a thing and we need to know more about it. And certainly we need to try to protect both the mom and the infant during that period of time to...
let evolution or let these anatomical physiologic changes play their course because perhaps the study suggests that this is something that is by design, it's non-accidental. This wasn't one rogue neuroscientist morphing her brain intentionally for the purposes of getting a nature paper.
Ben Courchia MD (38:53.655)
I got one last thing that you said. The brain is preparing for some of the very important pieces of parenthood. Those are the parts that are building up. And so it's not that parents are helpless, right? It's just that the brain is saying, let's focus on these areas instead of these areas. Sometimes, like, where I left my keys and things like that. So I think it's one really cool.
to I hope will serve as more fodder for parental support. Yeah, yeah, totally. I love that. Yeah, the sections of the brain that it said were changing were the ones related to attachment. And so perhaps there's lots more to learn about the ways in which moms and infants bond and whether there's a neuroscience to that. Let's move on the next article. The next article was looking at
Eli (39:28.246)
Yeah, yeah, totally. I love that. Yeah, the sections of the brain that it said were changing were the ones related to attachment. And so perhaps there's lots more to learn about the ways in which moms and infants bond and whether there's a neuroscience to that. Let's move on to the next article. The next article was looking at sudden infant death syndrome, SIDS, before and after COVID.
Ben Courchia MD (39:50.243)
sudden infant death syndrome sits before and after COVID. And on October 6th, Washington Post reported on
Eli (39:53.768)
And on October 6th, Washington Post reported on a JAMA Network open study that cited that the rates of sudden infant deaths began rising starting in July 2020 and that researchers noted what they call quote a pronounced epidemiologic shift of an increase of SIDS rates between 10 and 14 percent, which is quite profound. Guys, how did you respond to this one? What did?
What were your takeaways?
Ben Courchia MD (40:26.049)
I thought there was an interesting thesis, I think, trying to look at these trends and seeing if this could be a connection. think at some point there's a good quote that summarizes a little bit the state of affairs where they say, don't know what makes babies who die from sudden unexpected infant death syndrome or SIDS more vulnerable, whether it's genetics or something else. It could be that infections like RSV amplify those factors and make them more vulnerable.
And so it's interesting to see that if the conditions that were set by the COVID pandemic led to a shift in the prevalence of RSV that then had an impact on SIDS or SUID. I think that's an interesting idea. I don't know what you thought, Daphne. It seems like there's not enough data to make that connection very, very clear and especially the causation piece of it. But I thought it was an interesting data points that were linked.
in the telling of this story. Yeah, I would have liked more factors, right, of the babies themselves. They do highlight, I think this is important, seasonal shift in RSV. So there was a correlation with the peak in RSV after the first year of the pandemic as things were opening back up.
we were seeing surges of viral illness and there has been association with SIDS in the past. So I think that's interesting. think we cannot ignore that. Maybe this would have been a good public health opportunity to talk about cocooning infants as a protective measure. I didn't think there was, there were so many things happening for families during the pandemic. I can't even begin to extrapolate.
I think what the cause is, but it's an interesting finding.
Eli (42:21.92)
Yeah, for what it's worth, think the authors also struggled to explain it. I mean, they superimposed a couple of viral curves. If there was a correlation with RSV, it was pretty rough. It wasn't really statistical. I think to the extent the authors make a conclusion, it's really about these other factors. Like, what were we missing during the pandemic that may have prompted this? And probably the hypothesis that makes the most sense to me is you have lots of families who just hadn't seen their doctors for a while.
And it highlights the importance of doing the things that often may not be at the top of your list or even in the middle of your list in your clinic visits and in your follow-up care and even in your discharge planning, which is saying, hey, remember, these are safe sleeping practices. These different strategies that you've heard about or the fact that, sure, you can put this kind of blanket that Amazon sells now or you can put this.
kind of toy in there and without any effect, that those conversations are important and maybe play more of a role than we thought they do. Because when they're not happening, maybe this is related, but certainly more research is needed. So, okay, we're sort of on the home stretch here. Let's move into our segment, which is called You May Have Heard. So the first thing you may have heard is that there was a big fat recall of
Fisher Price baby swings after five babies died sleeping in these swings at the time of death. The swings were called snuga swings. And according to a commissioner at the US Product Safety Commission, the snuga swings were doomed to fail because babies were falling asleep in these things. And unfortunately, they think that may have been related to these deaths. Guys, any other takeaways on this recall?
Ben Courchia MD (44:19.129)
I mean, that's our counseling, right? The baby shouldn't fall asleep on the swings. But it's also exactly why parents buy swings, so that they can put their babies to sleep. So I think it's important for us to keep with the counseling. Yeah. Yeah. And sometimes make sure that we're not promoting the use sometimes that we have. our Yeah. I've seen some similar products in units. So let's just be careful. Yeah. I'm glad you brought that up. We have to role model this in a positive way.
Eli (44:44.866)
Yeah, I'm glad you brought that up. We have to role model this in a positive way and also make patients aware that there's a recall of not only the single product, but this whole class of products. And let's move on to the next article here, which is the March of Dines Report, which gets into maternal care deserts. Daphna, you sort of brought this up earlier. What were your key takeaways from this one?
Ben Courchia MD (44:48.887)
also make patients aware that there's a recall of not only the single product, but this whole class of product. And let's move on to the next article here, which is the March of Dimes Report, which gets into maternal care desert. Daphna, you sort of brought this up earlier. What were your key takeaways from this one? Well, just to remind people, I had to pull up the definition. But a maternity care desert is a county in the US where access to maternity care is limited or absent. The March of Dimes defines a maternity care desert as a county that
has no hospital or birth center that offers obstetric care, or has no obstetric providers. I mean, this is dismal. And I mean, the takeaway for the report is it is getting worse and not better. And obviously, it affects both maternal and neonatal outcomes dramatically. And it is still worsening racial and ethnic disparities in our country. Yeah.
Some quotes from the paper that I thought were quite interesting. I quote, overall more than 35 % of US counties are considered, quote, maternity care deserts, which means there is limited or no access to maternity care there, according to the March of Dimes. In about 1,104 counties, there is no birthing facility or obstetric clinicians available to provide care. And these counties are home to more than 2.3 million women of reproductive age.
Women in those counties gave birth to more than 150,000 babies in 2022. But living in a maternity care desert is associated with a 13 % higher risk of preterm birth, according to the new report. And about six in 10 maternity care deserts are in rural areas. I think that it's a very interesting piece. I was talking to some obstetric colleagues about this, basically the state of affairs for obstetric colleagues is so dire that a lot of them are switching to gynecology pretty quickly that
The lifespan of an obstetrician right now these days is about four to five years before the transition away from obstetrics. And I think this report highlights that. It highlights also the lack of usage for ancillary providers like midwives and so on at the time of delivery. And it also highlights how the current political climate with the Supreme Court justice decisions have led to obstetricians feeling like, I don't want to...
Ben Courchia MD (47:06.241)
practice a profession where I might be criminalized if I do my job. And so there's a lot of people who are moving away or actually afraid of practicing in certain specific areas where they are afraid of the legal ramifications of practicing evidence-based medicine. it was a very interesting paper, very interesting piece.
Eli (47:26.818)
Yeah, yeah, yeah. I love everything you guys pointed out. The one other piece I'll point out is the study also highlights the rise in the number of birth centers. So this is really a new kind of facility that's popping up and now is becoming increasingly common across the country. Between 2017 and 2022, the number of births that occurred at birth centers rose 20%. There were only about 20,000 in 2017 and closer to 24,000 in 2022.
Ben Courchia MD (47:54.404)
24,000 in 2022, but maybe a trend that we should all keep our eyes on when we think about the places people are going to seek this care. Absolutely.
Eli (47:56.352)
Maybe a trend that we should all keep our eyes on when we think about the places people are going to seek this care.
Eli (48:05.218)
Let's move on to the next study, which is just sort of a PSA here about the rise of Oropouche virus. And the US authorities found that 21 travelers returning to the US from Cuba contracted Oropouche and that health officials were providing guidance on caring for newborns who were exposed in utero to this virus. I think the TLDR for me on this virus,
Ben Courchia MD (48:05.421)
Let's move on to the next.
Eli (48:35.074)
There's still a lot we don't know, but that it may very well be teratogenic and it may be one of those viruses that we add to our list that is playing a role in utero on neurodevelopment. Guys, any thoughts on this PSA that the authorities put out?
Ben Courchia MD (48:50.681)
Yeah, I mean, I think it's something that's quite relevant for us down in Florida. think the CDC in the article, they mentioned that CDC detailed cases in 20 Florida residents and one New York resident returning from Cuba. The symptoms that they mentioned for this particular virus are quite nonspecific. They include fever, muscle pain, headache, fatigue, joint stiffness, diarrhea, abdominal pain, nausea, vomiting. No one died. There's some hospitalization. There are some reports reminding us a little bit of the Zika sort of
episode where there's reports of stillbirth, congenital anomalies, including microcephaly. At the end of the day, in the article, it mentions that the CDC has released new guidance and that for us, at least in the NICU, it seems that the investigation should really be pretty standard involving a comprehensive newborn physical exam, standard newborn hearing screen, nothing that really should deviate from what we're currently doing.
So like you said, probably something to keep on our radar and just keep following the news as to how the statistics are trending. Yeah, I just wanted to highlight some of the other effects on infants. So that may trigger us to think about that instead of go on some other search for some other virus. But microcephaly, like you said, some of the infants had high drops, ventriculomegaly or hydrocephalus, anomalies of the corpus callosum, loose, redundant skin folds on the head, arthrogryposis and club foot.
and some of them presented in kind of viral meningoencephalitis type presentation. So those are the things we'd be looking for.
Eli (50:22.774)
Great. One more virus to add to our list for these poor med students to memorize when they think about congenital affection. All right, guys, last PSA here at the FDA just a couple of days ago on Friday, October 25th, hosted a big convening about the potential use of probiotics for management of neck. Guys, we don't have the findings from the meeting yet, but what are you looking forward to? What are you hoping?
Ben Courchia MD (50:31.437)
guy's last PSA here.
Eli (50:52.578)
we learn from the meeting.
Ben Courchia MD (50:53.353)
we learned from the meeting? Well, I think it's a great first step. think that's the step that we've been sort of clamoring for. And it's the meeting that we were hoping, the conversation that we were hoping to see begin between the FDA and the, I don't like this word, but the stakeholders involving the families, involving the providers. So I am hopeful that this becomes the first step in this conversation about what is the path in order to reintroduce probiotics in a way that is safe.
for our patients in the NICU. And so that makes me hopeful. Yeah, and the only thing I'll say, we've got lots of neonatologists, lots of family organizations that are working very hard to be a part of that discussion. And I think part of why we're even doing this segment is to say what we say and how we interact with legislators and
The community matters. And so I think this is an opportunity for people in this space to get involved, engaged, and to speak up.
Eli (51:59.18)
Totally. And in the spirit of doing the segment, it's an experiment. So certainly listeners, let us know what you thought of the segment. Let us know what you thought of the structure. If there are articles that you want us to cover or you hear your patients or colleagues talking about, let us know and we definitely want to hear your thoughts. Ben Daphna, any closing comments wrapping up today?
Ben Courchia MD (51:59.641)
Totally. And in the spirit of doing the segment, it's an experiment. certainly listeners, let us know what you thought of the
Ben Courchia MD (52:27.511)
No, thank you Eli for spearheading this project. Thank you for your input. Thank you for being willing to do this on the podcast. And I had a great time. looking forward to next month's edition. like you said, if anybody has any feedback or articles they want to suggest, please send them our way and we'll add them to the folder. I don't even know if we told people it's called Neo News. It's very exciting. I hope that people love it. So let us know.
Eli (52:57.28)
Neo News, we'll hit you with a jingle next time. Stay tuned and thanks for listening.
Ben Courchia MD (52:57.463)
Neo News, we'll hit you with a jingle next time. Stay tuned. Thanks for listening. Thank you,