#274 - Understanding the Role of Fatty Acids in Neonatal Nutrition ft. Dr. Camilia Martin

Hello friends 👋

In this episode of The Incubator Podcast, hosts Ben and Daphna welcome Dr. Cami Martin, a renowned expert in neonatal nutrition. Dr. Martin shares her insights on the evolving landscape of neonatal nutritional care, highlighting the critical role of early nutrition in shaping long-term outcomes for preterm infants. With a wealth of experience in clinical research and bedside practice, Dr. Martin delves into the latest evidence-based strategies to optimize growth and development in the NICU, addressing key challenges faced by neonatal care teams.

Throughout the conversation, Dr. Martin discusses practical approaches to individualized nutrition plans, the importance of fortification strategies, and the potential of emerging innovations in the field. She also provides valuable guidance on how clinicians can implement best practices to support the unique nutritional needs of vulnerable newborns.

Whether you’re a seasoned neonatal professional or new to the field, this episode offers invaluable perspectives on advancing neonatal care through tailored nutritional interventions. Tune in to gain practical takeaways and explore the future of neonatal nutrition with one of the leading voices in the field.

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Short Bio: Camilia (Cami) R. Martin M.D., M.S. is the Division Chief of Neonatology at Weill Cornell Medicine. She received her M.D. from Weill Cornell Medical College and completed her internship and residency at Lurie/Children’s Memorial Hospital-Northwestern School of Medicine where she also served as Chief Pediatric Resident. Dr. Martin completed her fellowship in Perinatal-NeonatalMedicine at the Harvard Combined Program in Neonatology. During her fellowship training, she completed a Masters in Epidemiology at Harvard School of Public Health.

Dr. Martin’s research program spans basic to clinical translational research to study neonatal nutrition and its impact on health and disease in the preterm infant establishing, through these efforts, the Infant Health Research Program at BIDMC. Her research program is supported by broad based funding from the NIH, foundation, industry, philanthropy, and state-level programs. She participates in multi-site cohort studies and clinical trials serving as the Principal Investigator evaluating nutrition, growth, and long-term neurodevelopmental outcomes in the extremely preterm infant. Dr. Martin's current research focus is on lipids and fatty acid metabolism, postnatal intestinal adaptation including the microbiome, and the nutritional impact on organogenesis, development of immune defenses, and regulation of the inflammation.

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

Ben Courchia MD (00:01.016)

Hello, everybody. Welcome back to the incubator podcast. We are back this week with a special interview. We have the pleasure of having in the studio, Dr. Cammy Martin. Cammy, welcome back to the show.

Cami Martin (00:11.803)

Thank you very much for having me.

Ben Courchia MD (00:13.794)

No, thank you for coming back. mean, we were talking frequently, but I think the last time we actually recorded something was probably for the board review. And so it's been some time. You have been you have taken a new position. You are now the division chief at the Vale Cornell College of Medicine in the Division of Neonatology. I'm sorry if I butchered that, but congratulations.

Cami Martin (00:40.785)

No, thank you very much. yes, I've been a fan, even though the last recording has been a while, and I still hear comments about that recording, so that's great. And that was, I remember that one, that was a fun one. Yeah, just continue to watch what you guys do, and just a true fan and supporter about disseminating information in a lot of different formats.

The Incubator (00:49.616)

That's great.

Ben Courchia MD (00:53.358)

Yeah.

Ben Courchia MD (01:02.564)

Appreciate that. I think it's funny that today we're sort of getting together. Daphna is also here, by the way. Sorry, Daphna. Good morning. How are you?

The Incubator (01:10.332)

here. No, mean, you know, we're starstruck when Dr. Martin's in the house. So I get it.

Ben Courchia MD (01:20.194)

I gave a talk yesterday, which is probably not the day that this is getting released, but basically talking about the inception of the podcast and mentioning how when you and Dr. Brodsky said, okay, to come on the show, this was our big get, we felt like we got the stars. I was like, crap, this is so good. So it's funny that...

The Incubator (01:30.31)

That was like, yeah, for sure. This is happening.

Cami Martin (01:34.955)

Two slides, and you guys have done wonderful things with the content. I view you as partners in our pursuit of medical education.

Ben Courchia MD (01:40.931)

The Incubator (01:41.038)

of this.

Ben Courchia MD (01:45.388)

I appreciate that. So we're very excited today because we're recording this episode and we're happy to promote the work also that's being done at Neonatal Insider. We've been talking about Neonatal Insider on the show before. If people are not familiar, you can go at neonatalinsider.com. But basically, just to give a brief overview, the team at Neonatal Insider is doing something quite incredible where they have a course catalog and they have these sessions

The Incubator (01:45.788)

Appreciate that.

Ben Courchia MD (02:15.156)

where basically experts from the field are able to give conferences, lectures over a 90 minute period in topics that they're very well versed in, where they have done a lot of research. And this is happening virtually on Zoom. You can actually engage with the speaker, ask questions, and these sessions are obviously recorded. So if you signed up and you were working that night, you can actually rewatch these lectures. And so it's been...

It's been quite incredible. Dr. Martin, you're one of the featured speakers. Dr. Brodsky is there as well. Dr. Suresh Gotham is on there. mean, the list of faculty, Dr. Martin Kessler, I mean, it's a star-studded lineup of neonatologists and pediatricians that I think is quite exciting. I'm just curious to get your thoughts on what gets you excited about this particular project and the topics that are covered on Neonatal Insider.

Cami Martin (03:09.721)

Yeah, no, absolutely. And I recall reading something, it might have been on Twitter or X, Daphne, and I think it was one of your posts, and I hope I don't mess up the quote, but I like the whole thought about when you think about education and content, you bring the content to the learner.

The Incubator (03:28.092)

Hmm.

Cami Martin (03:29.041)

I think indefinitely over the span of my career, I've had to learn how to appreciate that because I'm old enough now where before you went to the lecture, you went to the location, you went to the meeting. And I think we're just understanding more and more that that's not always possible. So what are the different formats that allows that person to view content off hours during their commute, while they're cleaning the house or whatever it may be?

And I think what's really nice and maybe it's a post-COVID phenomenon is those efforts are successful now. I think before maybe they didn't get as much traction and folks have tried, but I see the traction now. so that's really exciting that there's many different ways now to disseminate medical education. Neonatal Insider is a terrific group to be a part of. It's a group.

The Incubator (04:04.956)

Mm-hmm.

Cami Martin (04:24.337)

and somewhat of an extension of the neonatal review course that was through pediatrics. And initially it was adopting a lot of those lectures and allowing folks again to listen to content that they couldn't go to that course. But since that it's really evolved to be more of a state of the art and more of an interactive format. I love the fact that it's a 90 minute lecture. It's not going to be entirely 90 minutes. Love to talk about

things I love and do, but it's just a much more relaxed atmosphere, a lot more time for interaction and questions and answers instead of feeling rushed in your 20 minute, 30 minute designated slot in other forums. So it's nice and it's offered in the evening and it'll be taped. But there's definitely a different dynamic between the speaker and those that are tuning in that I experience in other traditional formats.

The Incubator (05:21.796)

Yeah. And I went to the board review course when I, well, the first time I was planning to take the boards. if you know, people know my story, I deferred the board. So I went to all the board review courses. So I remember sitting there in this, you know, hundreds of people auditorium thinking, gosh, I wish I had done this before, right before the boards. And, you know, I wish I just, the lectures are so good. The faculty is so good. I wish I just had more time to.

Cami Martin (05:23.697)

Thank

The Incubator (05:52.592)

really kind of spend time with the material that was presented in the lectures, not just for the high yield board prep, but really to understand some of these concepts that I have been navigating, but I just didn't have the time to sit with. So, I mean, I love what you guys have done. I want to make sure you give us the kind of bird's eye view. So this is a longitudinal course, right? With the plan to get through all the concepts in about two years, is that right?

Cami Martin (06:17.553)

Okay.

Cami Martin (06:22.309)

That is correct. That is correct. And so plenty of time to tune in and have access to prior and future lectures. But yes, having sort of this curriculum of content over those couple of years. I think you're right. Maybe the most optimal time is to do it even before your fellowship and definitely before your boards. What I think I love about the board review

content and the fact that it's a derivation of that is physiology. A lot of us go into neonatology because of the love of physiology. And if you keep that sort of front and foremost, I think it does explain a lot of treatment rationale or how you should approach certain situations. We continue to learn the physiology and hemodynamics has exploded with that concept of let's understand what's happening.

with this disease process or at this developmental stage. And I think we need to really carry that through. And so my lecture on lipids is really about that. I try to be less prescriptive of what you should be doing at what very specific point, but happy to answer those questions. But instead it's like, let's learn the physiology and then based on the physiology and the understanding and composition, then make your decisions. I just want people to make informed decisions based on physiology.

The Incubator (07:45.628)

I love that. And we're going to dive into your lecture in just a minute. I wonder for you as like a faculty member, how has it been different engaging with students, with learners in this way?

Cami Martin (07:59.323)

I think the time, just the time that's set aside for it, it's, I remember the previous lectures I had given in one of them being around GI physiology and anatomy, and I partnered with Jim Warner on that. And again, a little bit of an extension from what was happening in the board review course. And it's just fun, again, the engagement and the comments and, you know, the nice rapport with your co-lecturers and the group that's involved.

And I want it to feel accessible and ask me anything. And this is the time to do it. And no rush in time limitations around it as far as, you know, 90 minutes is usually a pretty good time to really delve deep into a topic. So it does have just a very different relaxed feel, but a nice, really informative feel as well.

Ben Courchia MD (08:56.482)

Dr. Martin, your talk on neonatal oocyte is going to be called fatty acids in development, injury and recovery, which ones, when and why? I guess what I really wanted to start by asking this question, I've been thinking about it for some time. For many neonatologists, fatty acids, it's basically lipids. It's 10 kcals per gram and that gives fat and it's good. So why are you making it complicated?

Cami Martin (09:22.417)

I love it. I love it. You know, and honestly, I don't know, I might be okay with that. that's what people walk away with. I think before we go into the nuances, because I can get nuanced around the physiology, I want to make it clear that all the lipid emulsions in our understanding of physiology and where babies should be for lipid replacement and specifically fatty acid replacement, we still have a long way to go.

Ben Courchia MD (09:28.408)

Hahaha

The Incubator (09:28.927)

Hahaha!

Cami Martin (09:52.215)

And so I don't want to, there's not one perfect composition, but let's understand why, what are the imperfections are as we move forward. And again, making the best choice, you the risk benefit analysis and the best choice for what you have, for what you need to do. I think underlying all of this too, is just the understanding that, you know, let's feed the baby. And I think we've come a long way, Emma.

let's feed the baby early and let's progress those feedings and let's get them off the PN and the intralipids. And then we'll probably have less concern of all the potential complications of what we're doing wrong with a very artificial means of providing calories and energy. So with those two basis in mind, why am I making it complicated? I think, know, when I, I was always involved in nutrition as part of my research and first,

with an epidemiology perspective and kept describing how we still don't do it well. Growth matters and we still don't know how to really grow babies. And then when you look at the classic studies by Richard Erich Kranz, you see that even well-grown babies still have a high chance of morbidity and long-term neurodevelopment, up to 30%, even well-grown in the NICU. So it's not the complete story.

So it's like, what are we leaving on the table? Well, going beyond the macronutrients and going beyond energy, I think what we're leaving on the table now is those compositional elements. And we're learning more and more about that with human milk biology, what those compositional elements may be. And I think we need to reflect back and say, okay, what are the compositional elements of our PNs and our intralipids? So I started to study in a more mechanistic way, the fatty acids specifically.

Ben Courchia MD (11:30.104)

Mm-hmm.

Cami Martin (11:45.775)

And I'll tell you, I was astonished. I went through the same kind of learning curve. I started exactly what Ben was saying. It's like, hey, it's high energy. Give it to him, From to, wow, look what we're actually doing. And I was impressed when I started looking at the translational work, both in the infants and the animals, how swiftly we changed the lipidome by our nutritional practices. And then through those translational studies and animal studies,

changing that lipidome matters in their host response to secondary stressors, whether it's a bacteria or hypoxia or whatever it may be. And so started to think about, if we're developing this nutritional armor so that they can react appropriately to these secondary stressors, what do we want that armor to look like?

And then that's when I started getting into the nuances of the balance of these fatty acids and how we were driving them even in that short period of emulsion use during the first week or two of postnatal life.

Ben Courchia MD (12:52.484)

Yeah, mean, it's such an eye-opening experience to look at some of the data you're presenting, especially in these first few slides. I I'm not going to even pretend to try to... I've never been able to pronounce DHA and AA, so I'm going to let you do that. But when we're looking at what's happening in the first postnatal weeks and you see this drop in DHA and you see this drop in AA and you see the linoleic acid rising and then...

The Incubator (13:04.61)

You

Ben Courchia MD (13:20.47)

you're informing us of the different effects this could have on pathologies that we're trying to control from every possible manner, but you're looking at these numbers that every single unit decrease in DHA leads to a 2.5 times increase in chronic lung disease. Every one unit increase in the LA to DHA ratio leads to an 8.6 time increase in chronic lung disease.

talking about late onset sepsis, every one unit increase in AA leads to a 40 % increase in late onset sepsis. Every one unit increase in LA, 25 % increase in late onset sepsis. So, I mean, these are staggering numbers. And like you said, as you start teasing apart a little bit the elements of that nutritional package and bundle that we're giving our children, I think it's quite staggering the effects it could have on important comorbidities.

Cami Martin (14:12.505)

Yeah, absolutely. And that's clinical data, the data that you were just saying not just the animal data, the animal data gives us a little bit of that mechanistic insight, but that's clinical data. And what's just completely fascinating or interesting is that when you look at what was supposed to be done during ongoing fetal development in utero, within that first week, we are flipping upside down.

what absolute levels are and the relative ratios to each other. So within a week, they are in an opposite fatty acid milieu environment, yet they still have 12 weeks of development left to go where they should have been in a completely different space. And so for me, it's what can we do, not just practices, but hopefully in future innovations of products, how do we start to...

right that balance? How do we start to kind of get it back to where it should have been and let those development trajectories of the brain and the lung and the gut sort of continue along a little closer to where they should have been?

The Incubator (15:18.236)

I love how you call it the lipidome, you know, because I think so much, when we think about nutrition, we think like, okay, the baby is needing energy, just like Ben said at the beginning. But I think we forget, and the clinical data I think highlights that the lipids are part of like every single cell and are absolutely critical to the functioning of the body. We're asking this body to do like a lot of extraordinary things. And so it's not just about energy, it's really truly about like...

cellular function and how can we remind ourselves of that when we're, you know, mostly in the clinical sphere.

Cami Martin (15:53.423)

You know, that is so spot on, is that everything about our cell membranes and our brain and, you know, and what I think sometimes is happening is that we have these perceptions of the impact of nutrition at sort of the adult phase or for us, like, you know, we don't want to have a lot of arachidonic acid or omega-6 hanging around.

We don't want high triglycerides. We don't want high cholesterol, because they all sort of... So I think we take these notions of generally bad sort of lipid states, but for the older individual, the adult, and we somewhat apply them still, even though we've all been taught babies are not little adults, premature infants are not little babies. We're always taught that, but sometimes I think it's really hard to disentangle that in our minds without like a specific education around that.

And so what brought that up to me or what reminded me about that comment is I'll hear sometimes comparisons that, well, when given a SMOF lipid emulsion, you have less elevation of the triglycerides or you bring down phospholipids and cholesterol. And it's like, do you really want that? Do you really want to inhibit lipogenesis during a period of massive growth? And where the brain and, you know,

The Incubator (17:11.217)

Mm-hmm.

Cami Martin (17:18.543)

like the cell membranes and lung and gut, like we all depend on those signaling molecules and cell membranes. And I think the animal data, someone supports it. No, we don't want to shift our relationships in that direction. Let's think back about where we are in development and what we're trying to do for this preterm infant.

Ben Courchia MD (17:39.81)

Yeah, I mean, you divide this into three phases, basically, the things we've been talking about until now, where you have phase A, phase B, phase C. And it's interesting how you present this graphic where phase A is this, you say it's this early critical fatty acid alteration that we see in the first week, then phase B is this alteration that persists during this period of organogenesis, where there's huge immune and organ development.

And then phase C is the early fatty acid alterations that are now linked to the diseases that we're seeing as neonatal morbidity. But what's interesting is that on the X axis, you have the separations between the parenteral phase and the enteral phase. I know you've been a big advocate about trying to be more mindful about what do we do at the transition phase between these two periods about

Yes, we want to feed the babies. Yes, we want to get them off parenteral nutrition. However, we need to do this in a safe way and not just try to say, we're almost there. Let's just cut them off and then just try to transition over. Can you tell us a little bit more about why that matters so much?

Cami Martin (18:42.565)

Yeah, I think what is still so fundamental is that total energy delivery is linked to so many outcomes, not in growth, but reduced neurodevelopment, reduced bronchopulmonary disease, reduced necrotizing enterocolitis. And so this total energy repletion in delivery matters and it matters early. There's plenty of studies to suggest that

that first two weeks and that postnatal period may be the most critical period in setting them up longitudinally what happens for their nutritional status throughout their NICU period. But again, in partaking sort of what that risk is in energy delivery and later outcomes. And so we have to be mindful, just as you said, that as we bring in newer concepts like...

maybe start to feed earlier, or what do we do with the fortification, or how do we transition off? Don't forget that fundamental principle and doing the math. And doing the math and making sure that those switch points don't compromise that total energy delivery. And so that is absolutely critical in all discussions as we think about evolving our nutritional practices.

Ben Courchia MD (20:02.466)

And what's interesting about that and something you've mentioned in the past is that, so we should be mindful of specific elements like DHA, for example. And as we're trying to transition more babies to a completely human milk diet, we know that the DHA content of breast milk can be very variable based on the individual. What is your insight into what the future will look like in terms of us trying to have better control over understanding what are we giving each of our babies based on

maybe maternal diet and breast milk content.

Cami Martin (20:35.503)

No, you're absolutely right. I think where we want these levels to be may be very hard to achieve through enteral nutrition and breast milk delivery alone early on. If we again think that the first sort of period of that deficit building, the first couple of weeks is critical because of the content of milk and our delivery of practices, it's a slow increment of time.

But longitudinally, that deficit occurs early and is persistent because we weren't able to sort of match those needs early on. And so what does the future look like? Well, hopefully my ideal future would be less reliance on PN and intralipid in some day. So can we come up with an enteral version that's nicely hydrolyzed, emulsified?

well tolerated, allowing that safety of early delivery and faster advancement. But I don't think we can do it with breast milk alone. I think it will have to be a supplement. And so you start to think about these strategies more as a therapy or as a supplement rather than what we can maybe optimize in human delivery, human milk delivery alone, whether it's added to human milk, perhaps, whether it's separate, perhaps I think

All of those are options, but I hope the future is having the ability to compensate for the lack of this content in our standard nutritional sources and offer that as an additional therapy or supplement. And I think it'll have to be the combination of that. And in fact, as we move to that, it may also mean that, you know what, maybe getting that perfect lipid emulsion is our efforts better at

Ben Courchia MD (22:09.124)

Mm-hmm.

Cami Martin (22:26.797)

limiting time, using one that's just less perturbative, and then supplementing using the internal strategies to supplement where it's missing. And it may be a combination of those two.

The Incubator (22:31.931)

Hmm.

Ben Courchia MD (22:41.976)

What do you say to the lazy individuals who are saying, well, but the evidence hasn't really been so overwhelming that I want to do the math.

Cami Martin (22:50.225)

Yeah, you know, I get asked a lot that question a lot in various ways like Or they'll say, okay, we understand we see what you're saying with the animal data and the mechanistic data But if you look at you know, the conch or meta-analyses there's no major difference between whatever you use and the lung injury and the sepsis and things like that and I think my answer to that is

Ben Courchia MD (22:56.856)

Hahaha!

Cami Martin (23:19.633)

When we look at these developmental trajectories in physiology, I want to again, write that trajectory a little closer to where it should be. I'm not sure we're looking at the right biomarkers and the right outcomes to understand those processes in that kind of detail. yeah, so I we need to shift it.

Ben Courchia MD (23:38.198)

Absolutely. think we're doing a lot of work right now with Dr. Susan Hintz on this perspective of just a life course. And I feel like we're trying to measure very small changes in a... If you think about this in terms of geometry, you're trying to measure very tiny angles, differences at 18 months, 24 months, five years even. But I think this work that is being done on the nutritive side early on...

is things that will have ramification when these children are 30 years old and 40 years old. And we have no clue. And I think it's kind of shortchanging all these efforts by just saying, well, at 18 months, they have a couple of higher IQ points. Is that really worth the trouble? But I don't think I think we just are completely blind to the long term effects as of yet.

Cami Martin (24:25.177)

Right, right. And what that looks like, what that biomarker and what that measure looks like. So I think we're missing it. But I think it's the, you know, when you're doing, this is what I've really loved about my transition from sort of an epidemiologic to a basic science or translational is when you see in your models, just the profound ramification, these changes, depending on how you manipulate these fatty acids to understand the biology, the profound changes it makes, you're just,

The Incubator (24:39.484)

Hmm.

Cami Martin (24:54.789)

humbled by the whole process of how, especially for our babies, that they are just completely reliant on us and that nutritional delivery. And those changes happen swiftly. My mentor in a lot of this science is an adult GI, adult doctor, and he does some also lipids and fatty acid works and other vulnerable populations like cystic fibrosis. And when we started to first work together and we would see these swift changes clinically and then

The Incubator (24:55.91)

Yeah.

Cami Martin (25:24.623)

in these seven to 10 day models of immature pups and immature animal models, he was floored. He was like, I cannot believe the metabolism that you're seeing and the changes that you're seeing. His study takes weeks and weeks to see differences in movements and shifts in an adult. Whereas it is almost immediate in what we're doing.

The Incubator (25:31.974)

Hmm.

Ben Courchia MD (25:47.748)

Thanks

Cami Martin (25:48.869)

So we have to really be thoughtful and understand that physiology and science to do the best we can to get them where they should have.

The Incubator (25:57.478)

I love this concept of, I mean, it's really laying the scaffolding for everything else to come. And so I think people have this concept, okay, if they're missing it, we'll just give it to them in some formulation that I pulled off of the shelf, whatever my hospital has. But I love how you tackle some myths near the end of the talk about how the type and the concentration and the ratios matter.

What's your favorite myth to dispel?

Cami Martin (26:29.755)

Just that arachidonic acid is bad. And again, I think that comes from us understanding and other medical literature and other populations that you want an omega-3 DHA kind of rich environment versus this omega-6 inflammatory arachidonic acid environment. And that might be true when you're older. I probably would want to be there and in that space.

but we have to think about what the role is of that fatty acid along the time course in development. it's, I consider arachidonic acid the cool fatty acid, because it's not always bad. It's not always good. It's like the complex kind of character, misunderstood soul. And the rebel, it's kind of the rebel, you know, he'll stick up for you or she will stick up for you when you need it, but hey, don't mess with arachidonic acid. That's right. It's how I see it as the...

The Incubator (27:15.74)

The Rebel, The Rebel.

Ben Courchia MD (27:22.584)

What you say about my friend?

Cami Martin (27:26.961)

Cool dynamic. So yes, there are things that you may not want to see, older on and other disease problems. But during that preterm and developmental period, it is about growth. It is about laying down organ structure. It is about developing your immune system. It's about being the first one to attack when there is a bacterial invasion. It's the structure to later function of all these organs.

I think I don't know if the appreciation for that is as deep as I want it to be because we have

Ben Courchia MD (28:02.404)

But it's kind of like vitamin D and calcium, right? mean, it's just like, you kind of, seem to be like to get the most out of DHA, you need aerodynamic acid.

Cami Martin (28:11.361)

Right, you do. And that's the other thing that is so, and again, I use the analogy in the talk about sort of a foundation in the house and then sort of all the extra trimmings. It's, you need to work on a scaffold, on a foundation. And if you don't have that there, it doesn't matter how much DHA we want to pour into the babies. It's acting on nothing because they have been deficient on another fatty acid.

that our body early on relies on to build those organs and those structures. And so that's where we need to understand those switch points longitudinally across development. Like once you're building and you're done building that scaffold, it probably is unnecessary to have a bunch more around. But then you need to focus on the other one. Now let's lay down the finishing touches and the function to those organs. And so we need to be smarter about

understanding those developmental switch points, the right nutrition at the right time sort of thing.

The Incubator (29:09.596)

Yeah, I think we forget sometimes in, you know, at the bedside that what's happening to this baby in this week is not the same as what's happening to the baby in the next week, even though we have our discharge goals, right? And then I think that babies are along this trajectory. Do you think the future will be that we have a different quote unquote supplement at the 26th week, the 27th week, the 30th week, the 32th week? Do you think we'll get there?

Cami Martin (29:36.273)

Yeah, I do and I don't think it'll be as finely structured. You when I look at the data that's out there about these switch points, what we do know and I have this in one of my talks is what we do know if you just look at the brain, you're right, the arachidonic acid is the dominant fatty acid till about late term, early term, 37 weeks and then it becomes more of a one-to-one. They start to meet each other a little bit.

And so maybe it is for the infant that's 22 to 37, most of the NICU period, it is more of maintaining that relationship where you're providing sufficient arachidonic acid. But then later after that period, then does it start to become, okay, what is my discharge plan for this? Because it's longitudinal. Maybe it's not as aggressive, so to speak, on the arachidonic acid. It's now...

making that ratio a little closer to a one-on-one and providing the DHA at near discharge and after discharge relative to ARA. But I hope to. I hope to through a couple of studies that are ongoing and my continued work is to understand what those developmental switch points are.

Ben Courchia MD (30:51.342)

So as we are getting close to the end of this conversation, Camille, I wanted to maybe advocate for the people who are working in maybe smaller groups and who are saying, well, I don't have the privilege of having a dedicated nutrition person. Some people may not even have dieticians in their unit. And so for some of them, it may just be they may not have all the opportunities to tailor their nutrition. They may have intralipids, SMOF, omega van maybe. What are your sort of

maybe tips and guidelines for people to try to do the best possible with limited resources wherever that may be.

Cami Martin (31:31.41)

Yeah, you know, that's a very good point. And sometimes after I speak, I'll have a few individuals come to me and say, I hear you, but I have no choice. I'm a smaller NICU and a bigger adult hospital. the pharmaceutical or the pharmacy committee just wants one lipid emulsion for everybody. And so I do think that...

Ben Courchia MD (31:42.2)

Right.

Cami Martin (31:56.303)

We should all keep trying to tell our hospitals and those who make those product decisions that our babies are unique with unique physiology and try to advocate for that. But in lieu of that, it goes back to maybe how we started. Then just limit the exposure the best you can. Make sure you have enteral nutrition protocols that you're getting them off these lipid emulsions and PN and really switching to an enteral nutrition, a dominant enteral nutrition.

that's always well, it's always better processed, utilized than parenteral nutrition. And so really just relooking at your dependence on PNNIL and where can you curtail it the best you can, knowing we don't have the best options for it and you may have limited options to even react to that.

Ben Courchia MD (32:44.898)

And so as a follow-up, based on the conversation we've had about LA and DHA, what would you say to someone who says, it might just be better off for me if I have only two choices, I might as well offer OmegaVen instead of SMOF because it seems to be checking all the boxes that can be talked about. What is your answer to that comment?

Cami Martin (33:05.627)

So it doesn't check all those boxes off. So both any fish oil containing lipid emulsion always brings along EPA. And it's really the EPA that I think is the problem in those fish oil-based lipid emulsions because those elevated EPA, we increase it by the use of fish oil lipid emulsions almost 10-fold. Our babies do not need to see elevated EPA levels. And when you're increasing it by almost 10-fold,

that's actually negatively regulating the arachidonic acid production. So you're exacerbating a potential deficit again in the fatty acid that I think we need to make sure we protect early on. So OmegaVen would be worse to have that as a maintenance because it is very far away from what we need to do. And plus the amounts that you give are somewhat limited. You'll never probably meet your energy goals. And so with what

you have, I think if you have those options, which one I'm not going to, you know, I don't want to get in trouble because I talk to everybody. I talk to all companies to nutrition. So I don't want to get in trouble by advocating, but the principles, I'll just talk in principles. Look at them, which one preserves the ARA or arachidonic acid the best, which one maintains that arachidonic acid to DHA ratio, which one sort of minimizes that LA rate rise that we get in all of them.

Ben Courchia MD (34:12.665)

Yeah.

Cami Martin (34:34.009)

and kind of just think about that and say, okay, maybe this is the one we start with to minimize those postnatal perturbations and then come off as quickly as we can. And I'm not talking, again, I'm not talking about the high-risk neonate, the surgical neonate. Those are special considerations, happy to do on another talk, but I'm talking about the routine lipid delivery of nutrition for an otherwise.

you know, as expected preterm infant who requires PN and IELTS.

Ben Courchia MD (35:05.892)

For sure. For sure. And I wanted to just touch on that point because obviously, as you mentioned, the ratio of EPA, it's like seven times. So there's like sevenfold difference between the two. And so you have, like you said, to look at everything. You should not just look at DHA and be like, this one has more, better, let's go. And so I just wanted to quantify that a little bit. So thank you for doing that.

Cami Martin (35:12.002)

is extraordinary.

Cami Martin (35:20.41)

Yes.

Perfect.

The Incubator (35:25.18)

When we started this, we were talking about studying for the boards. And I feel like nutrition is one of those topics that when people go to sit down, they find very daunting, right? They may do it early to try to just figure it out. They may do it last to just try to cram it. Do you have any guiding principles for the high yield board prep in nutrition?

Cami Martin (35:52.421)

I think most of the questions, and it's been a while since I've had to sit down, and so the younger audience should weigh in. I think most of the questions that will be asked are going to go about it as far as targets, recommendations and targets, and understanding what you need to change to get to those targets. Still kind of at a macronutrient.

level because a lot of what we're talking about now is still right a lot of research understanding the bio balances and nuances and I'm not sure that would enter a board question just yet but the principles of energy delivery your protein and lipid goals

where the adjustments need to be made when you're not meeting those goals. I think those are a fair game and those are things that we do every day at the bedside and we do have a pretty good idea of what those targets are. So I would keep that approach in mind. And don't forget your calculations, even though we never do calculations, that might sneak up on you. So it's easy.

Ben Courchia MD (36:59.544)

That's always something that I do calculations all the time. And then you get to the boards and you're like, how am I not getting this? This is so frustrating. I'm doing them every day. And now here's the day that I need to get this done quickly and right. And I'm struggling. This is so frustrating. But I would say, like you said, Camille, I think for the boards, just know the differences between the tools that are available to you. I think they may not ask you for specific goals and so on. But then they might ask you, hey, what's the difference between this?

Cami Martin (37:19.077)

Yes.

Ben Courchia MD (37:26.446)

this formulation and that formulation. think, like you said, these are all very much fair game. Well, we're going to link in the episode show notes to the Neonatal Insider course. So for people who want to learn more. And Daphna, we have a promo code for people who are not members of Neonatal Insider. I think we mentioned it at the beginning of the podcast anyway, but do you happen to have it with you?

The Incubator (37:51.599)

Yes, it should be incubator 20.

Ben Courchia MD (37:54.85)

Yeah, so if you want to get a little discount, thank you to the Neonatal Insider team for providing that. And then they can sign up and listen to your talk and listen to the rest of the talks that have been already recorded. So.

The Incubator (38:08.796)

And then with that, people can sign up for the two full two year course, or if they wanted to do one year, they can do either.

Ben Courchia MD (38:14.84)

Yeah, yeah. So we'll link to all that in the show notes. Cami, thank you so much for this pleasant conversation. Congratulations again on this extensive body of work and on the new position.

Cami Martin (38:25.007)

Yeah, well, thank you very much and thank you for inviting me. Always a great time talking to you too.

Ben Courchia MD (38:29.518)

same.

The Incubator (38:29.85)

Is your...