Hello Friends 👋
In this episode of The Incubator Podcast, renowned neonatologist and researcher Dr. Keith Barrington discusses his career, his influential blog (Neonatal Research), and his contributions to evidence-based neonatology. Dr. Barrington explains how his blog originated from sharing recent research insights with trainees and grew into a platform that educates professionals and promotes consistent, evidence-based practices in neonatology. He emphasizes the importance of critically evaluating new studies and their potential impact on clinical care.The conversation also explores his personal journey as the father of a 24-week premature baby, Violette. This experience shaped his understanding of parental perspectives and the challenges families face in the NICU. He highlights the need for healthcare providers to align clinical decisions with what parents deem acceptable outcomes, emphasizing compassion and humility in predicting long-term results. Dr. Barrington reflects on the future of neonatology, stressing the importance of reducing variations in care across centers and leveraging multi-center networks to optimize outcomes. He advocates for innovative research approaches, such as registry-based trials, to address challenges in studying rare neonatal conditions. Throughout the episode, his passion for improving neonatal care through science and empathy shines through.
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Short Bio: Keith J. Barrington is a neonatologist and clinical researcher at Sainte Justine University Health Center in Montréal. He is Professor of Paediatrics at the University of Montréal. He was formerly chair of the Society of Neonatologists of Québec. His particular research interests are in cardiovascular support, in apnea and its treatment, in the ethics of decision making for high-risk newborns, and in anything in clinical care that might affect outcomes. The 22 of May 2005 he had a very preterm baby girl at 24 weeks gestation, her hand is in the banner photograph on this blog, with his ring around her wrist.
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The transcript of today's episode can be found below 👇
Ben Courchia MD (00:00.652)
Hello, everybody. Welcome back to the Incubator podcast. We are here today for another special interview, would say, Daphna, with much anticipated with a guest that we've been really excited to have on the podcast. Today, we are joined by none other than Professor Keith Barrington. Dr. Barrington, thank you so much for making the time to come chat with us this morning.
Daphna Yasova Barbeau, MD (00:08.135)
Mm -hmm, much anticipated. That's right.
Keith (00:25.248)
I'm very happy to be here. Thank you for inviting me.
Ben Courchia MD (00:28.544)
No, the pleasure is all ours. For people who may not, I feel like this is one of these cases where everybody knows you, but people may not have connected the name with the work you're famous for. You are obviously a neonatologist, you're a clinical researcher at Saint -Justine University Health Center in Montreal, and you are a professor of pediatrics at the University of Montreal, and you're formerly the chair of the Society of Neonatologists of Quebec.
Daphna Yasova Barbeau, MD (00:33.396)
Mm -hmm, that's right.
Ben Courchia MD (00:59.134)
You have had an incredible career and you are very famous for your neonatology blog called Neonatal Research that can be freely accessible on the web at neonatalresearch.org. We will link the blog in the show notes. You have been involved in research, education, and you are truly a giant of our field. Keith, thank you so much.
again for joining us today.
Keith (01:30.874)
Thanks, that's very kind of you.
Ben Courchia MD (01:32.876)
Of course. So since we're talking about neonatal research and we're talking about the blog, I would love to ask you a little bit. When did you first post on when did the blog get released, which year and what really was the incentive for you to really start this important blog on evidence based research?
Keith (01:56.688)
Yeah, it was actually just over 10 years ago when I started the blog.
What started it, was in fact, prior to the blog, every week or so I would send an email to my fellows describing recent published research and giving them a little bit of a usually just a few lines of introduction to the recent stuff that I thought was important for impact in practice. Then I thought, well, if I'm doing this for the fellows, why don't I just sort of set up a blog and do it more widely and
In the process of doing that my comments on the papers became much longer. that now usually they're all focused on single blog post. It's usually focused around just one or two publications. Sometimes there's a couple of things that come out fairly sort of simultaneously and very often I will go back and
With a new publication, will refer to other recent publications in the same field. The whole point is to try and educate trainees in particular, but also it became obvious to me over the years that there's an awful lot of variation in practice.
from one center to another. And I think, well, if we're all practicing evidence -based neonatology, shouldn't we all be doing very similar things? So to try and ensure that, you know, to have a very tiny role in making sure that people know what the important research is and how we should interpret it and how we should apply it to practice.
Daphna Yasova Barbeau, MD (03:23.316)
Hmm.
Ben Courchia MD (03:37.812)
And I mean, we have a lot of empathy for the work you're doing because we do something similar with our audio journal clubs. People may not understand, but the commentary you write up are so detailed, so well structured. It must take you a lot of time. How much time do you dedicate to the blog on a week to week basis?
Keith (03:59.184)
It's very variable as some of you will know that it's been very quiet the last couple of months because I've been on service and then on vacation and then back on service to pay for my vacation. But I think, there's a nod there, everyone sort of experienced the same thing. We're very lucky in my group, we've all decided that we like to have slightly longer holidays than the average, which means that we have slightly more work to pay back when we come back to work.
Ben Courchia MD (04:10.994)
I'm
Keith (04:28.156)
And but it varies sometimes it can be very quick and it'll just take me two or three hours and sometimes it will take me the whole day to actually construct what I want to say and to make sure that I'm saying things that are appropriate and I try not to be sort of gratuitously rude but sometimes there's some of the comments do I think come over a little bit rude sometimes but I think my
One of my basic principles is to realize that if you're doing research and publishing then you're already way ahead of the field of the large majority of people who just sit back and moan or don't actually take the effort to do that.
Ben Courchia MD (05:10.957)
And so that's a very interesting, because I think, I mean, I personally don't feel like you're coming off as rude, because I think you're always very much focused on the science. You're always discussing what was the question? What were they trying to answer? Was the question answered properly? Where are some of the holes in the methodology or in the design? And I think that stress testing or studies is really necessary.
Before I hand it off to Daphne, I wanted to ask you really, we were talking about this affair. There's a ton of publications coming out every day in the field of neonatology. How do you decide that, this is a paper I would like to write a commentary about, or this is a study I'm going to, I'm not going to. How do you pick the studies you really want to share your thoughts on?
Daphna Yasova Barbeau, MD (05:53.748)
Mm.
Keith (05:59.46)
Well, mean, first of all, it's actually the...
to try and sort of keep up with the whole range of, and so I've actually subscribed to a few services. There's a service called Amadeo that will email you every week a list of recent publications, which they filter. And then I've got some ongoing searches from the NCBI, the PubMed, which that emails me sort of four or five lists every week. And then there's sort of tables of contents of several journals that get emailed to me.
So then I have to sort of filter through those often it's just looking at the title and realizing it's not something that I'm interested in. But then the most important thing for me in terms of writing a blog post about something is whether I think it should have an impact on clinical practice.
you know, whether it should or should not have an impact on clinical practice. Sometimes there's sort of details of how the research was done, but more commonly, it's sort of the question that's being asked and whether or not the question has been appropriately answered and whether or not that I say it's something that we should integrate into our practice or something that we should stop doing. The whole point of that, say, being to try and promote evidence -based neonatology.
Daphna Yasova Barbeau, MD (07:19.784)
Ben alluded to this off air, but we are quite intrigued. You take obviously a very standardized approach, which is common in medicine and journal clubs all across the country, across the world, I should say. But what's your approach to a paper? When you open up the journal, what is your approach to reading a paper, flipping through the abstracts, and then again, forward, not with your selection, but then your evaluation of the paper?
Ben Courchia MD (07:49.78)
Yeah, I'm going to take notes, so go step by step, please.
Daphna Yasova Barbeau, MD (07:51.238)
That's right.
Keith (07:52.08)
Well, I don't have any sort of thing that's particularly different to other people who do this, but I say that the first thing is just to see whether or not it's something that I think might be of interest for clinical practice. the recent post that I've done about, you know...
things that I keep coming back to like probiotics and so on, whether or not they're what the best probiotics might be and who should be receiving them and for how long. So if I see a paper that's actually got something new to say about that or something important to say about that because of a good research or design or good sample size, then I will include that. I mean, there are certainly things that I'm more interested in than others, but in fact, just about.
anything to do with neonatology, it's to do with infectious diseases, respiratory care, cardiovascular support and so on. I've been involved in a lot of multi -center trials and in single center trials and I've been involved in one which failed, which is the HIP trial, which some of you all know about. So I know the difficulties of doing clinical research is really not something that you can...
you can just take on and expect to get a result very quickly. When I look back in the history of neonatology, that's one of my advantages. I've been doing this now for so long that I can very quickly sort of fit a new publication into the history of what's gone on in the past. So...
When I see something that's coming out, I've got a particular way that my mind works and I can quickly flip it into a sort of context with other things that have gone on in the past. I'm sort very lucky that way. It makes it easier for me than I think it would be for other people. Plus, as I say, I've been around a long time and I've been involved in very successful research, like the CAP trial, for example, and some of the
Keith (10:15.836)
the initial nitric oxide studies and so on. But then the HIP trial, which was our trial of hypertension in preterms, which was, I think, an extremely important potential study, but we had to stop early because we ran out of time and ran out of money. It was extremely difficult to enroll kids in that. In fact, in my own center, even though we were going for three and a half years, we didn't manage to enroll a single baby. And some of the other centers that
Daphna Yasova Barbeau, MD (10:44.361)
Wow.
Keith (10:45.602)
were involved had very, fact, none of the centers apart from I think one in Eastern Europe were able to enroll many babies at all. So, you know, we're from an initial sample size of something like 750 per group, we ended up with about 60 babies total. And part of that was because of some of the restrictions that were imposed on us by the European Medicines Agency, some of which were I think quite reasonable.
They didn't want us to enroll, for example, babies who didn't have an arterial line in place because they recognized, as many of us recognize, that non -invasive blood pressures are so unreliable that we really shouldn't be using them to base, certainly base evidence on the utility of inotropes and so on. And so that meant that there was immediately, dramatically restricted the number of babies that could be enrolled.
Ben Courchia MD (11:36.25)
This was a very...
Ben Courchia MD (11:46.464)
This was such an interesting paper since we're talking about the hip trial, right, where we were going to challenge this sort of preconceived notion that somehow the correct gestational age equals the mean arterial pressure. And I think it was such a disappointment that we were not able to get to the answer to that question regarding the approach to these babies and see if truly we needed to start vasopressors early on.
But then it begs the question of how do you feel about certain areas of neonatology that may not, based on logistical and the clinical setting, be appropriately studied? Like, what are we supposed to do in those cases? And I'm curious to hear your takeaways from, I hate to say the failure, because it was, we learned so much about what kind of studies we can design based on the HIP trial. what are your thoughts on that, about how can we study things that are hard to study?
Keith (12:41.583)
Yeah.
Keith (12:45.646)
Well, I think there's a number of things that we can do. think for...
For one thing, the hip trial isn't the only failed similar study. There was another study that also tried to look at cardiovascular support in extremely preterm babies and also had to terminate early. So I think in order to be able to answer some of these questions, we need to think of different ways of doing research. the two things that I think we need to really focus on, one of them is to do registry trials. And there are registries like Vermont Oxford Network, like the UK Network, like the German Neonatal Network, and like the Canadian Neonatal Network, which are already collecting a lot of the outcome variables that you need to be able to determine whether a treatment is effective and or safe. And if we can, as there have been in other fields,
Ben Courchia MD (13:42.241)
Mm.
Keith (13:53.483)
utilize that sort of data collection as a way of analyzing the response to interventions. And then to actually do that, you actually need to have some sort of slight adjustment to the way you collect the data. You need to have some safeguards built in for serious adverse events. And you probably need to limit it to
comparative effectiveness research. If you're comparing two approaches which are currently being used to then randomize kids within all randomized units, so either cluster randomization or individual randomization, obviously you lose power with cluster randomization but it becomes logistically an easier thing to do, a cluster randomized trial in some way.
and then to have the data collection be based on the data collection that's already ongoing. Now that's actually been leveraged in, there's one fascinating study in Scandinavia where they already had a data collection for all of these adults who were going through coronary revascularization. And so they decided to do a study where they were already collecting all this data. They compared two ways of doing the coronary revascularization.
were able to get this study done in record time with huge numbers, several thousand patients in each group. And without with relatively low cost because they didn't actually have to have an extra research nurse in every center. They actually also had a two stage consent process, which is something else that we need to think about in some more detail, I think that several people already
looking at this where they actually had a very brief consent before the procedure because it was something that needed to be done very urgently, this colon revascularization. And then after the procedure, if the patient had said, yes, I'd be open to looking at two different ways of doing this when both of them are ways that are currently being used. And then afterwards they were asked to give consent to retain their data within the study.
Keith (16:21.01)
sort of about 98 % of people at that point said yes you can keep my data and analyze it.
We could do some similar things and there's something similar to that, but not quite the same going on right now in Canada. In the CNN, we're doing some comparative effectiveness research, but they're not randomized. which is one of my concerns about trying to make this as reliable and as replicable as possible. So there's a study, for example, going on right now where we're comparing the outcomes of centers who use dopamine for treatment of septic shock to the centers who use
Ben Courchia MD (16:28.31)
So interesting.
Keith (16:57.02)
norepinephrine for treatment of septic shock.
Ben Courchia MD (16:58.209)
Mm.
Keith (16:59.856)
two approaches which are fairly commonly used across Canada. But the center chooses which group they're going to be in because, you know, in my center, for example, we use a lot of norepinephrine and I haven't personally prescribed dopamine for about 30 years. other centers which use dopamine in preference. And, you know, when you look at the adult data, you could
Ben Courchia MD (17:17.644)
We'll come back to that.
Daphna Yasova Barbeau, MD (17:21.778)
You are far ahead of the curve, far ahead of the curve.
Keith (17:29.802)
justify either of those approaches with some differences in the hemodynamics and little evidence that it makes any difference to survival in the adult studies.
But, and so right now we're doing that study across Canada. But again, it's not a randomized trial. It's more of an observational comparative of the diverse research, which I think will have some huge benefits. Won't necessarily give us the final answer, but should give us some very important information about, about treating to septic shock and cardiovascular support in septic shock. So that's the kind of thing that I think we need to progress further along in doing that.
Ben Courchia MD (17:48.278)
Mm -hmm.
Keith (18:13.296)
And I've mentioned in my blog a couple of times recently about the difficulty doing research, for example, in prevention of necrotizing enterocolitis. When you're trying to prevent something that has an incidence of 8 % or whatever group you're looking at, whatever risk group you're looking at, a reduction from 8 % to 4 % would be a huge benefit for babies. But it's extremely difficult to prove that. You need very large sample sizes. And to do that,
that without a registry -based trial, without cluster randomization is extremely difficult.
Ben Courchia MD (18:51.372)
And so for the audience that was just wondering if they heard correctly, you said you stopped using dopamine 20, 30 years ago.
Keith (18:58.318)
Me personally, I haven't used dopamine for a very long time. And that was basically, at first it was based on, I used to run an animal lab, both in Edmonton and in San Diego. I haven't had the opportunity to do that since coming back to Montreal and I've had plenty of other things to do. But in my animal lab, I think it was quite clear that dopamine is almost exclusively a vasoconstrictor.
that it doesn't improve the perfusion of any vital organs. It doesn't improve brain perfusion or kidney perfusion or anything. So I don't really see the point of giving vasoconstrictors to babies who already have poor perfusion. So, you know, depending on what the circumstances, I will use dobutamine or epinephrine or norepinephrine. And again, the evidence for any of those in terms of clinical outcomes in babies is very, very
in.
Ben Courchia MD (19:56.748)
I mean, I love the fact that you're not succumbing to peer pressure because I mean, right now, I mean, obviously, I think the conversation has seeped through and there's a lot of people questioning the use of dopamine. I don't know, 20 years ago, this was the first line. Everybody used this. so kudos for following the physiology and the evidence, because that must have been that must not have been easy. I wanted to. Yeah.
Daphna Yasova Barbeau, MD (20:15.443)
Mm -hmm.
Keith (20:20.686)
Yeah, I mean, I think I've always worked with groups of colleagues who are sort of fairly open to my quirks and to... And you know, when you talk about the fact, know, dopamine suppresses pituitary function, which the other catecholamines don't. And why do you want to do that? I mean, I think thyroxine is probably useful. So don't want to suppress that.
Daphna Yasova Barbeau, MD (20:29.256)
Ha!
Ben Courchia MD (20:29.706)
Hahaha!
Daphna Yasova Barbeau, MD (20:42.61)
Mm -hmm. Yeah.
Ben Courchia MD (20:45.1)
For sure, for sure. I think, interestingly enough, I mean, don't know if I can, I mean, think Audrey Hebert is one of your trainees, somebody that you worked with.
Keith (20:56.782)
Yeah, she's a colleague. She works in Quebec City, not far from here.
Ben Courchia MD (21:01.836)
Yeah, so and she's now, she was preaching that. That's right. I wanted to talk to you a little bit about, since we're talking about your assessment of the evidence, you're pretty open about the fact that in 2005, you had yourself a baby girl at 24 weeks gestation. And there's, mean, there's a beautiful picture.
Daphna Yasova Barbeau, MD (21:05.588)
taking on the charge.
Keith (21:07.204)
Hahaha
Keith (21:24.549)
Right.
Ben Courchia MD (21:29.444)
on the cover of the book written by Dr. Jean -Vier called Breathe Baby Breathe, where we see her hand and we see your ring around her wrist. think it's always I love these pictures to remind us of how small our patients and our babies are. I'm wondering if the birth of your child prematurely changed your perspective on the significance of some of the evidence you read. I know there's a lot of discussions
currently about the importance of parental preferences, parental values. Can you tell us a little bit about what your journey was like?
Keith (22:09.006)
Yeah, was and for anyone who doesn't know the author of that book Annie Janvier, is Annie Janvier, Dr. Janvier who's herself now becoming more famous than me.
Daphna Yasova Barbeau, MD (22:25.074)
You're a dynamic duo, the two of you, yeah.
Keith (22:26.594)
So in the past she used to come round to conferences sort of accompanying me. Now I go to conferences accompanying her. So I'm now the trailer spouse as Annie puts it. And yeah, it's sort of, obviously it's a very different being on the other side and incredibly stressful. And some of the things that parents say that you understand.
They actually, when it really becomes real in a different way, you talk about the ups and downs that parents go through. We know parents go through ups and downs, but really it's so incredibly.
destabilizing to have a kid who's doing a little bit better one day and to the medical staff a little bit worse the next day and a little bit better the day after. To a parent it's not a little bit better a little bit worse it's the huge ups and these enormous terrible downs where you start to worry about whether or not she's going to make it. And we went through a phase when she was two to three weeks old where she had an episode of septic shock and we got very close to withdrawing active care.
for Violette and in fact I'll always be grateful to Neil Fine and my mentor and someone who's I don't know if he's been on the blog but he I don't know if he's been on the podcast but he was enormously important to me in my training and in supporting me.
It was his counsel to me when Violette was very sick that he told me to take a step back and to wait and to continue to hope and that from what he heard, from what I told him, she still had a good chance of doing well. And because of that, when I went back into the NICU that day, when Violette had been in septic shock, she was comatose, she was anuric, she was on a high frequency ventral
Daphna Yasova Barbeau, MD (24:14.75)
Hmm.
Keith (24:32.498)
later, she was on an epinephrine infusion and one of my colleagues who'd come in to look after her had just started her on steroids, which we weren't using early for septic shock in those days, we were using it relatively late. At that point, I saw Violette and with Neil Finer's counsel in my mind, I saw that she started sucking on her soothe, which was the first movement that she'd
Daphna Yasova Barbeau, MD (24:45.395)
Hmm.
Keith (25:02.4)
made for two days. And I went back to Annie and I told her I thought we should that I wasn't ready to pull the plug to say crudely. And she said to me, you know, that's just the brain stem, don't you? And I said, yeah, I know. I know it's just the brain stem, but I think there's still a chance that the rest of the brain might recover. And my and that was
Daphna Yasova Barbeau, MD (25:28.904)
Hmm.
Keith (25:32.432)
19 years ago and she's going into nursing in the fall. She's starting a course of Bachelor of Nursing at the University of Montreal starting in the next couple of weeks. I'm grateful for what neonatology can do and I'm grateful for what my mentor said to me and the support of all the people around me.
Daphna Yasova Barbeau, MD (25:37.502)
Bye.
Keith (26:02.01)
but also the extremely good care that we give to babies and that we gave and that was given to Violette.
Ben Courchia MD (26:02.422)
and
Ben Courchia MD (26:09.002)
And has this experience changed your interpretation of evidence?
Keith (26:14.478)
I don't know if it changed my interpretation of evidence. think everything that we did for Violette was evidence based as far as it can be. You know, as say, there isn't a lot of evidence for the use of steroids in septic shock in babies. But I know that that's when she started to turn around, was when Dr. Sophie Nadeau, who's still a colleague and a close friend, started on the steroids. That's when she started to turn around.
and we were able then gradually to wean her off all the support over the next couple of days. So I'm not sure that it's changed my interpretation of the evidence, but I think we still always have to recognize there's a lot of things we still do for which there isn't very good evidence. So there's still, even though it's now 19 years later, no good evidence for when you should use, if you should use steroids and septic shock in babies.
Daphna Yasova Barbeau, MD (27:09.298)
Yeah. Why we so appreciate your candor and you sharing Violette and your story with us. you there's, you've had a very varied research career, but since we're talking about parents, I'd love to ask you a few more questions. Certainly a lot of your more research has focused on perspectives of parents, ethical decisions.
and in particular, I've heard you speak many times. One of my favorite talks I think is so powerful that everybody in our community should listen to, you've spoken at the grievance conference, obviously a number of times and, about how our perceptions potentially as healthcare professionals about what is an acceptable outcome, quote unquote, acceptable outcome can be so different than what families view is an acceptable.
outcome for them and their lives. And I hope you can speak a little bit to the work you've done in this area specifically.
Keith (28:13.166)
Yeah,
I'm happy to. There's actually a whole project across Canada called the Parents Voices Project, which I'm only sort of peripherally involved in. It's really more three people who are driving that tiny Janvier. Mai Lu, who's the pediatrician who runs our neonatal follow -up in and is now the chair of the Canadian Neonatal Follow -up Network, or CNFUN as we call it, because follow -up is so much fun.
Daphna Yasova Barbeau, MD (28:18.356)
Mm -hmm. Mm -hmm.
Keith (28:45.23)
and sinners in Vancouver. The three of them have really been pushing this along with parent partners, both people who are involved in the Canadian Pre -Term Baby Foundation and the...
Keith (29:05.853)
and other people that have parents who've been through our unit. And that has been to try and ensure that the things that we measure in terms of outcomes are things which are relevant to parents. know, we've, and something I've talked about a lot in this, in my blog is this outcome, the NDI, right? NDI neurodevelopmental impairment, most of which is driven by the
neurodevelopmental impairment, whether you have it or not. First of all, it's a dichotomous outcome, You either have or you don't have NDI. Whereas parents don't think of their kids as being either good outcomes or bad outcomes, they're almost always good outcomes. And with the kids who have problems, some of them, some of them very big problems, and some of them big problems that we don't even measure. And some of them minor problems that we think are big problems. So,
The NDI is largely driven by Bailey scores which are below a certain arbitrary cutoff.
It's interesting because Violette as well went through neonatal follow -up and went through and had Bailey testing. And our nanny at the time, had a nanny who was with us much of the time, is actually the sister of the follow -up doc at McGill where Violette was being followed. so Marjolaine, our nanny, actually put Violette through Bailey boot camp to try.
Daphna Yasova Barbeau, MD (30:44.132)
I'm sure.
Keith (30:45.298)
to try and make sure that she knew all the things that she had to do and that she could actually come up with a good result.
Daphna Yasova Barbeau, MD (30:48.156)
Hmm?
Daphna Yasova Barbeau, MD (30:54.984)
Mm
Keith (30:55.51)
And Violette actually did have some substantial executive function problems, much of which is getting better with time, as is often the case. But it meant that in order to do well at school, and she's done super well at school, she had to put in two or three times the effort of any other kid because she really had to work very hard to be able to do as well as she's done. And then many of the things that we haven't measured in the past, which aren't in
included in NDI such as feeding problems, such as behavioral disorders, such as sleeping difficulties, things which really disrupt family life but are not measured in any of the outcomes. I'm not sure that we should choose which interventions to use in the neonatal period based on sleep disorders at three years of age. I don't necessarily think that at all, but
At least we should know if the things that we're doing actually have an impact on behavioral outcomes, which we really don't right now. I have no idea if changing the neonatal environment, for example, I think it could well have an impact on behavior, know, promoting sleep.
Wake cycling promoting diurnal rhythms promoting Skin to skincare does that have an impact on long -term behavioral outcomes of their babies? Who knows I certainly don't know I think it could well but on the event might be completely Without an impact on those things. Maybe it's all to do with organic brain injury and But as we aren't collecting
and analyzing those things, some things which are extremely important to parents, whereas we're very good at measuring cerebral palsy. cerebral palsy is something that parents in general cope with and the kids cope with. And they find ways to deal with the difficulties or the limitations that they have without necessarily having a major impact on their quality of life.
Keith (33:21.422)
Again, developmental delay for most kids is a delay. Most of them, if we look at the long term follow up that we did of the CAP trial, only 20 % of the kids who had developmental delay actually ended up with an IQ more than two standard deviations below the mean. So only 20 % of them, the other 80 % actually had an IQ which was better than that. So I know the developmental quotients in the IQ are measuring different things.
but we've often assumed that a poor developmental score means the kids are going to have difficulty and it's not necessarily the case at all. So I think we really need to continue pursuing that. I've been involved in some of these studies actually where we gave parents scenarios and asked them whether or not they thought the kid had a major problem or not. unless you got to children who had developmental
developmental delay, cerebral palsy and language delay, more than 50 % of the parents for every single one of the scenario for the kid did not have a major problem, even though there were large numbers of the babies that we would have classified as being a severe outcome.
Daphna Yasova Barbeau, MD (34:41.876)
Certainly, I think this work has been monumental, both in how we counsel families, how we understand families, but again, changing the research paradigm about what are we actually studying. And this is just a small part of your research repertoire. The breadth of your work is quite extensive from physiology to medication, like I said, to ethics and family and medical education.
I wonder, it's hard enough just to keep up on one area of expertise. And so how have you managed that all? And what are kind of your recommendations for, you know, new trainees who come into fellowship and they say, you know, you got to pick a lane, you just got to pick one thing to study. And that's how you build a career.
Keith (35:31.79)
Yeah, I think.
Well, again, I'm very lucky to have worked with Neil Finer when I was in Edmonton. He was my supervisor when I went to Edmonton to do my fellowship and he already had a very broad interest in both in particularly he was particularly interested in asphyxia and in respiratory control. those were sort of two areas that I've
continued to be interested in and then added cardiovascular support.
never a sort of a direct interest in infectious disease, but it's something that affects all of our babies. So anything that can affect clinical outcomes is really something that interests me. I'm just, I think I'm very lucky that I've got a particular kind of mind that I can, when I read a paper, I can sort of file it away and remember who did what and how many patients there were in the study and what the limitations were. But don't ask me when my kid's birthday
these are. Because that's... That's right. So it's just partly the way my brain works. And I think for a lot of people it's very important. there's certainly people who've done very important things and who've limited themselves to one particular area.
Daphna Yasova Barbeau, MD (36:44.348)
I guess we all only have so much capacity, right, to care?
Keith (37:09.648)
You know, hematology and oncology, for example, and have done amazingly important work that I could never have done because they've been able to focus on that and study it in great depth. My research career, has been more broad. And I'm, as I say, I'm very fortunate to have been in collaboration with a lot of people who actually study those things.
in great detail. think when it comes to the final clinical research studies there's actually
Whatever the subject is, there's some basic requirements for all research studies that are the same. Whether you're doing a study on caffeine or on dopamine or on erythropoietin, a lot of the features of the research projects in those regions have to be identical in order to have reliable research. So then it becomes actually easier.
the more basic preliminary studies for which you need to have a more detailed, in -depth understanding of a particular area.
Daphna Yasova Barbeau, MD (38:31.444)
love that. You've also kind of written a bit about the perspectives of neonatal healthcare professionals and some of the moral distress associated with working in the NICU. And so I'm hoping you can speak a little bit about how you feel like we should balance our own hopes and expectations kind of in today's modern healthcare system that is creating more and more obstacles for the modern day physician and healthcare team.
Keith (39:02.084)
Yeah, and I think...
It's clear that moral distress is a huge issue. think the term as it applies to neonatology was first developed by nursing researchers and nurses who felt that their distress was largely because there were conflicts between the nurses' vision and the doctor's approach. But I don't think that's really true anymore, if it ever really was true.
I think the most common ethical conflicts, and that's what usually leads to this moral distress, ethical conflicts, the most common by far ethical conflicts we come across nowadays is when we feel that that redirection of care and comfort care would be the best approach in the child's best interest and the parents aren't ready to reduce the intensity of care.
it's 95 % of the ethical conflicts that are occurring these days are due to, are because of that. that creates just as much moral distress among the physicians as it does among the nurses and the respiratory therapists and the pharmacists and everyone else who's involved in the care of these kids. And I think that the most important thing
there is to try and make sure that these disagreements don't become conflictual.
Keith (40:41.616)
that you can address the differences of opinion while at the same time recognizing that the parents really want the best for their kids. You don't come across parents who don't want the best for their kids, right? I how often has that ever happened? I used to work in the PICU as well. For 13 years, I did both PICU and NICU. And certainly in the PICU, you come across kids who've been beaten.
Daphna Yasova Barbeau, MD (40:58.292)
Hmm.
Keith (41:11.522)
You don't have that sort of horrible thing to deal with in the NICU. We've got 99 .9 % of our parents just want the best thing that they can, the best for their kids. And if that means for them sometimes, it means just never giving up. Even if everyone says it's hopeless.
First of all, I don't think we should ever say that. There's always some hope. You just have to change what you're hoping for. Even though everyone else thinks there's no chance of a good outcome, first we need to figure out what parents think is a good outcome. And again, we need to go back to what are we basing our understanding on? What do parents feel is a good or even an acceptable outcome? We know that parents are much more positive about the outcomes based on what we've just been
talk yet much more positive about the outcome of children with limitations than medical professionals. So we have to always keep that in the back of our mind that children who are fairly severely limited in terms of their capacities, both intellectual and physical, can still have a life which is of quality to them and to their families and which are considered
positively, that they actually have benefits for the family and for the child themselves. That's not to say that we never, you know, we can never have our own opinion about that, of course we will and we should have. And I think there are times when we have to be relatively directed with some parents. I think some parents actually appreciate the fact that, you know, the shared decision -making
has become this mantra and not all parents want to share those decisions. Sometimes their parents will actually prefer it when we say actually we've gone far enough. This is really there is no good no realistic possibility that your child's going to get through this.
Daphna Yasova Barbeau, MD (43:09.172)
Hmm.
Keith (43:24.66)
And we have to be very careful about that because we can sometimes be wrong. I mean, I've been wronged more times than I really try very hard nowadays not to make predictions. I've I know I've seen kids who've had a pH less than less than seven point zero for four hours. And, you know, a kind of thing. think, no, there's no way this child's going to come through this and the child's pulled through it.
Daphna Yasova Barbeau, MD (43:29.384)
Mm -hmm.
Daphna Yasova Barbeau, MD (43:37.416)
Hehehe.
Keith (43:55.034)
and gone home. We have to be very humble about our capacity to predict either survival or long -term outcomes. There are other kids who I was fairly sure were going to do very poorly, who doing really pretty well. And other kids who I had actually no worries about them at all, who have very serious limitations. So our capacity
and our ability to predict is very limited, doesn't on the other hand mean that we should just throw up our hands and say, we can never predict anything so we'll just carry on till the bitter end for everybody. That's not appropriate either.
Daphna Yasova Barbeau, MD (44:38.772)
Well, I appreciate that. I think that's something we all struggle with clinically at the bedside, but to hear somebody like you, you know, be able to share that, know, that there are some things we can't know, I think is very powerful. So I appreciate that. I know we're getting to the end of our time together, but before we logged on, you had started to mention, you have already thought a little bit about
the challenges that are upcoming for neonatology. And like we've mentioned, you've had your hand in most of the major studies in the last handful of decades. So what do you think is next for the future of neonatology and what are some of those challenges we should be prepared for?
Keith (45:30.032)
I think one of the things that
that I appreciate with these multi -center networks is that it's sort of pointed out some of the variations in practice and the variations in outcomes. So we have within the Canadian Neural Network in our annual reports, you can see some centers that have much less bronchopulmonary dysplasia than others, for example. Now, whether that's because the way it's measured, which isn't necessarily the
best for the other centers do those centers that have lower BPD that is less oxygen at 36 weeks are they also sending fewer babies home in oxygen and if so how can we reduce those so that everyone can approach the centers that have the best outcomes some centers have much lower health care associated infection rates than others so what is it that they are doing and I think those are the things that we need to focus on because if we could all do as
well as the best centers, then that is just as important, I think, for the future as trying to come up with the next magic bullet. I'm not sure there's a magic bullet around the corner, but there's still a lot of variations in things that I don't understand some of the variations. So there's huge variation in feeding practices, for example. There are still centers that keep their babies, and I don't think there are any in Canada, but there's still centers in the USA that keep their babies nil by mouth for the first week.
Daphna Yasova Barbeau, MD (47:03.006)
Mm -hmm.
Keith (47:05.304)
Why? I mean, and you could actually improve everybody's nutrition by starting them on breast milk on day one. Or maybe on colostrum, who knows?
Daphna Yasova Barbeau, MD (47:05.854)
Mm -hmm.
Ben Courchia MD (47:14.742)
Mm
Keith (47:18.306)
If you've read my latest blog post, I'm not sure about colostrum, but I colostrum is wonderful stuff and we should be giving it enterally. I'm not sure we should be painting the baby's mouths with it because I'm not sure that really does anything, but maybe it does. And at least it's a way of involving, of ensuring that there's a colostrum supply that you can give to the babies and helping to support mothers in their vitally important role of producing milk for the babies. And then,
Ben Courchia MD (47:18.817)
So.
Keith (47:48.3)
Other things such as the duration of initial antibiotics, there's still centers that will have all sorts of obscure reasons for keeping the babies on antibiotics for the first week of life, even if the initial blood cultures are negative. And that's something that I think we can militate against and which I think will have benefits in terms of late onset infections and enterocolitis and so on.
Ben Courchia MD (48:15.734)
So if you're keeping babies and PO for seven days, you've been put on notice. Dr. Barrington, thank you so much for taking the time to answer some of our questions. And thank you for all the work you're doing on the Neonatal Research Blog. We will link all these resources in the episode show notes. And again, keep up the great work. Thank you for your time.
Keith (48:19.758)
Hahaha.
Keith (48:36.292)
Well, thank you very much for the invite and thank you very much for this podcast. think it's a great way of keeping the community together and hearing all sorts of interesting opinions from very interesting people other than me.
Daphna Yasova Barbeau, MD (48:52.02)
But we'll always keep an ear out for your interesting opinions, for sure, for sure. Thank you for your time.
Ben Courchia MD (48:52.458)
Hahaha.