Hello Friends 👋
In this latest episode of Neo News, Eli, Ben, and Daphna bring you the mainstream media stories shaping conversations about neonatology. These are the headlines your patients and their families are reading—so we’re here to break them down with insight and clinical perspective.
This month, the team takes a deep dive into Dr. Rachel Fleishman’s provocative New England Journal of Medicine piece, What is the Relative Value of a Baby?, tackling the financial and ethical disparities in neonatal care reimbursement. Dr. Fleishman joins the discussion to offer firsthand insights.
The hosts also explore a fascinating New York Times piece comparing medical training to professional sports and performance coaching, highlighting the power of pre-procedure practice. Plus, they examine a study on breastfeeding trends before and after the formula shortage, an Atlantic feature on a potential new emergency contraceptive, and even a Science article uncovering ancient Roman breastfeeding habits!
With expert analysis and lively debate, Neo News helps clinicians stay informed on the neonatal stories influencing public discourse. Have an article we should cover? Send it our way! Tune in and stay ahead of the conversation.
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The articles covered on today’s episode of the podcast can be found here 👇
NEJM: What is the relative value of a baby?
NYT: Coaching intubations
Atlantic: Ella (ulipristal) as new contraceptive on the block
NYT: Aluminum in vax
Science: Ancient Roman babies weaned earlier in city vs suburbs
NeoReviews on umbilical line placement
J Perinat on CPAP discontinuation
Pediatrics: Increased breastfeeding after formula shortage
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The transcript of today's episode can be found below 👇
Eli Cahan (00:03.586)
Hello everybody and welcome to our third episode, our February episode of Neo News. Thank you for tuning in. As a reminder to our listeners, this is our segment devoted to promoting the doctor-patient relationship by keeping you up to date with what's buzzing in the news today. And boy, Daphna, Ben, the news is buzzing. We're bumping.
Daphna Yasova Barbeau (00:27.93)
You know, when we started this, we were like, are we going to have enough content? But apparently, people love talking about babies and baby things and what we do in the NICU. So it's been great.
Eli Cahan (00:46.264)
Yes. For listeners who couldn't tell, Ben was literally doing a buzzing head nod. It is Friday, January 31st. It's raining, it's not quite freezing in Boston, but it's raining. How's it down by you guys?
Ben Courchia (01:10.23)
The sun is back, but we have a cold front, so it's pretty awesome weather right now.
Daphna Yasova Barbeau (01:10.23)
It's beautiful. We get to wear our sweaters and maybe a scarf, maybe. So we can't complain. Sorry, buddy. You should come record down here for the March episode.
Eli Cahan (01:10.23)
You give the word, I am booking my flight, but I like accessories. I like winter accessories, you know? You get to wear some stuff, it's nice. Anyway, we have lots to talk about, so let's just get into it.
Our first piece of the day is a really interesting one, really timely at a time when the federal government is rethinking some of how it's traditionally paid for things. This piece is called, “What is the Relative Value of a Baby?” by Dr. Rachel Fleishman. It is about a single resuscitation, but really it's about everything else. The context for this resuscitation, namely the fact that this resuscitation was happening at where Dr. Fleishman currently works. The place she previously worked closed in part because of funding shortfalls related to care, and payment for care of, children in the perinatal window, and of mothers and birthing people during the birthing windows. It is also about how we pay for things more broadly, through the infamous relative value unit. So there's a lot in this piece. Ben, Daphna, what did you guys make of this one?
Daphna Yasova Barbeau (02:59.514)
First of all, I thought the title was quite provocative. What is the relative value of a baby? Obviously she does this on purpose, because that's exactly the point. She talks about this resuscitation that she does where most people would think, the neo didn't even do that much, right? But had the neo not been there, that story could have ended very differently for that baby. And instead, it ended up with a happy, healthy baby and family. And people don't recognize the expertise and the finesse that was required to make that go well.
Then she goes on to talk about, what does the reimbursement look like? It really shows how our community and our society has not valued pediatrics in general, and especially baby care. I know we're preaching to the choir here, but it's important for us to be advocates. For families and for parents, their children are the most important things in their lives, but our system is not commensurate with the value that society places on children. I think she did a tremendous job. It's been circling on social media, so I hope everybody takes a look at it. Ben?
Ben Courchia (04:33.794)
I think it resonates with a lot of things that we agree with. We often talk about this general concept, that the value of pediatrics, of caring for children, is not there. The value that we place on the care being delivered to children is absolutely proportional to the size of the human being. So because they're smaller, everything is smaller. It does not take into account the fact of their complexity and the fact that babies are the thing that we cherish the most. So it is absolutely staggering that our children, who we value more than anything else, are probably the lowest ranked in terms of when they need medical attention. How do we value the medical expertise of the people who come to the table? She does a beautiful job describing it. It is published in the New England Journal of Medicine, and it's meant to be read by people in and outside of pediatrics. There's a beautiful description of what it entails to actually be at a resuscitation. And then she goes into the inner workings of the RVUs. And I love the play on words about the relative value unit and then the relative value of a baby. I think it puts everything in perspective. I think it was a beautifully written piece.
Daphna Yasova Barbeau (05:58.062)
I know you guys got to chat with Dr. Fleishman and you'll tell us about that in a second, but did you go over this little quote that you liked, Ben?
Ben Courchia (06:07.106)
That quote is all we are going to talk about with Rachel. Without further ado, we can actually have the pleasure of having Dr. Fleishmann joining us on this episode of Neo News.
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Eli Cahan
Now to give us the real lowdown on the story behind the story, we have the author, Dr. Rachel Fleishman, Dr. Fleishman. Thank you so much for being here on Neo News.
Rachel Fleishman
Thank you for having me. I have loved the incubator, I've loved listening to the new Neo news section - Ben, Daphna, Rune, Eli, everything you guys are doing is amazing. So it's amazing to be returning as a guest.
Ben Courchia
Thank you.
Eli Cahan
We are delighted to have you, and we brought you on because we want the tea! We want the story behind the story. What motivated this essay? On its face, it is an essay about a resuscitation, but really is about so much more.
Rachel Fleishman
There's always the story behind the story, right? I've had several jobs as a faculty member since graduating fellowship in 2013 and I’ve ended up in these meetings where they're like, “Here are your RVUs, doctor, your individual RVUs as a neonatologist. And we would like them to go up.” The response is always, I will take care of two babies or I will take care of 28 (we have 28 beds in our NICU). Whatever you give me is what I will take care of. I will go to all the deliveries or none of the deliveries, but I cannot control where or how I am needed. I work shifts, and like all of you who are neonatologists know, we bill once a day. So it's not like I could then invent procedures and do more billing. I do what I do. But there's a disconnect between the impetus to improve individual productivity and the reality of how that is feasible.
I've had other things go on in my career that make no sense in terms of the devaluation of human beings. One of the most traumatic things that I ever experienced was the closure of Hahnemann University Hospital (Philadelphia, PA). We all worked there because we wanted to be there. We were a great team of good people. I'm still quite close with many of the nurses and physicians that I worked with there, many of whom were there longer than I was. To have the hospital shut down because there was no money to run it while human beings were in it and being taken care of, is just the most perverse and absurd thing that I've ever seen. It's not like the patients weren't real. But you need someone to pay the bills. If nobody pays the TPN maker, then you can't get TPN. If nobody is paying to clean the surgical instruments, then you can't do C-sections. If there are no trays, then you can't do deliveries.
I was thinking about this one day after the aforementioned meeting about RVUs while I was driving home down Broad Street in Philadelphia, and I stopped at a light. I looked over and there was a city bus with an ad that was like, if your child has suffered a birth injury and has cerebral palsy, please call us and we will get you piles of money. Sincerely, med-mal lawyers. I was like, okay…what?! And yet that is the state of affairs. The question becomes, how do we put them together in a way that is cogent? I think there's a lot of yelling and a temptation to make point after point – for example, “this is how medical billing works, why it's bad, how we could change it.” The issue is that a lot of times people either know and don't care, or they don't know and don't want to understand it. I don't know that I fully understand it. I went to talk to my CMO to ask him questions. He was like, “Well, there's this physician billing, and it's multiplicative, and there are these factors...” And I was like, I can't explain all of that, but I really want to write about this.
Ben Courchia
Since the piece has been published, I'm wondering what kind of reaction you've been receiving and what kind of feedback has been coming your way. You do not spare any words in that piece. I think at some point you quote, I think, a Forbes article that mentions how RVUs are allocated by a small group of physicians that some commentators have equated to a cartel. And you compare the RVUs and you do so in a very striking manner. You show how helping a baby survive is less than two RVUs, and if a physician performs a 30-minute hair removal, it's somehow 265 RVUs. You're really shining a light on the disparities in how the work that is being done for these small infants is being viewed. What kind of feedback have you been receiving since the piece came out?
Rachel Fleishman
I’ve gotten different kinds of feedback. I have a correspondence with one of the people whose books are on the shelf behind me. She said to me early on, when I was being attacked on the internet in response to something I had written, “When you write the thing, it goes out into the world, and it has its own adventures.” There is an amount of dissociation that I have tried, not always successfully, to cultivate between me and the writing. The writing is done intentionally. What I want is to make people feel what we feel when we are in the delivery room. And that is a skill with words which I have worked hard to cultivate in terms of creating as little narrative distance or psychic distance between the scene and the reader. There are tools to do that when you write. Most of the time people don't believe that children are sick, or don't believe that babies are born sick, until it's their kid. I want people to feel what it feels like to see a [sick] baby. I want them to feel the tension in the hopes that the emotional plea might make them more empathic to the misogyny and greed that devalue the care of women and infants.
Ben Courchia
It reminds me of what Daniel Kahneman in Thinking Fast and Slow talks about – there is really no credit or reward for the people who are preventing the next catastrophe. We believe all the kids are going to be fine. But truly, without the care of the pediatricians and the neonatologist, they have the real chance of not being fine. Somehow that gets lost in the shuffle.
Eli Cahan
It seems like one of the most important concepts in this piece is the idea of structural violence. This idea that we make choices about where to allocate funding, and we have systematically deprioritized birthing people and deprioritized the care of the sickest infants. I wonder if that's been a concept that has resonated with people and if so, what have you heard?
Rachel Fleishman
I have read a bunch of Paul Farmer's books, including one called Pathologies of Power, which I highly recommend. He unfortunately passed away. He was an infectious disease physician who would bounce back and forth between Harvard and, early in his career, Haiti. He then did other global health work and founded an organization called Partners in Health. He is very interested in structural violence. I have learned a lot from both real-life mentors, both in Seattle (where I trained) and Dr. Unique Favaro, who does global health work in his faculty at St. Chris and formerly Hahnemann, about global health structures that place people's lives at risk. That was my point, Eli, and yet I have gotten no commentary or email response. I think it hasn't landed quite like that. People are much more interested in yelling about electrolysis than they are about the system or the bigger message, which is unfortunate.
Eli Cahan
Well, I think we all have so much we can learn from you. Sometimes it starts with electrolysis, and it percolates into an understanding of structural violence. I certainly hope it will. I hope everybody will read this piece and see the bigger picture behind the electrolysis example. You will also have to tell us the next time we have you on, and we insist that you come back. You'll have to tell us how you convinced the New England Journal to let you keep the word cartel in your perspective piece in reference to hospital administrators. But that will be a conversation for another day, or for beers at a conference.
Rachel Fleishman
There was actually no debate of all the editing. That was not a question. It just, was, I referenced it and there was no discussion about that word. It just remained there.
Ben Courchia
Rachel, thank you so much. We'll see you next time.
Rachel Fleishman
Thank you all so much. Happy whatever day it is when you're listening. See you later.
Ben Courchia
See you later.
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Eli Cahan
Well, I love that conversation. Ben, what did you think of our conversation with Dr. Fleishman?
Ben Courchia
What I'm taking away from this conversation is that you do not need to have some terrible thing happen to actually put pen to paper and write something that has a meaningful impact. I think that the fact that this piece came after what seems to be a pretty mundane meeting at the hospital, is a good reminder that there's a lot of things that sometimes don't sit well with us as we are thrown into the administrative realms of the hospital. If something is not right, then we probably should talk about it. I tend to just bottle things up and just move on with my day. Rachel inspires me to use my voice to advocate for babies.
Daphna Yasova Barbeau
I wanted to mention she also had another article released this month in The Lancet called “A Doctor's Lineage.” It's about her own family's health care needs and taking care of sick people. People should take a look at that one as well.
Eli Cahan
There's always something to learn. You could see lots of different people, and maybe even Dr. Fleishman on a given day, walking out of that delivery, and a colleague saying, “How did it go?” She says, “We held CPAP for 10 minutes, no biggie.” It all ended well, but I think it's a reminder that in every moment of our interaction with patients and families, there's something that we can learn and maybe it can teach us something bigger about the healthcare system.
I would love to highlight just one thing we touch on in the conversation about structural violence. As someone who, in my previous life, studied health policy and certainly think about it a lot now, it resonated very deeply with me. There's a quote in this piece that says, “These parents are probably not considering the structural violence waged against pregnant people and their babies in the United States by the systemic devaluation of their healthcare.” You guys were talking earlier about how we pay for pediatric and baby care proportionate to the body volume of the person. I remember, there was this saying when I was on my pediatric rotation, that kids are not little adults. And yet when we think about healthcare reimbursement, that is almost exactly how we decide to pay. It’s proportional to the meters cubed of the body.
The other thing that I just wanted to highlight about this piece before we move on is when we think about structural violence, it's such an abstract concept. Maybe we think, I was paying attention during conversations around more general systemic inequalities in society, and so I kind of understand what structural violence means. But I think Dr. Fleishman does such a good job of pointing out exactly what this means. There's another quote that says, “In the United States, we tolerate hospitals shuttering their labor and delivery services because of restrictive abortion laws, staffing shortages, and low Medicaid reimbursement rates for hospital birthing services that make intrapartum care for us mothers and babies unprofitable.” That is something that is sweeping the country. If you look at labor and delivery deserts, the implications of those are far-reaching. You see there are some options, but you also see this whole suite of politically- and religiously-informed facilities that seem to be offering potential options around the perinatal period, but come with an agenda filling the vacuum where these facilities used to be. I think the ripples of this structural violence are far-reaching, to say nothing of the match rates in pediatrics, which are decreasing. This is not just a story about how we pay hospitals, it's also a story about how we pay clinicians. Anyway, I will get off my soapbox, but a lot of this resonated with me.
So we've got lots more to talk about. There was another piece that I loved that was based on research, but also written up in the New York Times. This piece was called “The Hack That Doctors Should Take From Pop Stars and Quarterbacks.” Ben, you chose this one. What stood out to you about this op-ed and the research underlying it?
Ben Courchia
I'm going to give a shout-out to one of our Incubator team members, Leah Jayanetti, who is the host of Beyond the Beeps [podcast]. She's actually the one who passed on this article before I could even see it on the New York Times website. I thought this was a very interesting article. The piece opens up by stating that it is perfectly non-negotiable for athletes and artists to rehearse and warm up before an important game or an important concert. But when it comes to medicine, it is now perfectly accepted that we will go perform a procedure that has life-saving ramifications without any warmups, without any practice. The crux of this piece is to ask, should we learn, in medicine, from these other practices and do a little bit of coaching, a little bit of warming up, before performing a procedure? It references a study that was published, I believe it was in the BMJ, about coaching an experienced clinician before a high stakes medical procedure. They coached trainees in pediatrics before an intubation in a very clever study. One group of trainees went forward with the process of intubation as usual under the supervision of a senior staff member. But the other group took a few minutes - the article highlights this point multiple times, that it only took a few minutes - to practice the mechanics of intubation on a mannequin before arriving at the bedside and performing the procedure. Their primary outcome was first-attempt success. The people who had the opportunity to practice for a few minutes before performing the procedure had a first-attempt success of about 91% versus 81% in the control group. There were some other secondary outcomes, including how the trainees felt during the procedure, showing that the level of comfort was higher after a bit of coaching.
This was a very interesting study for several reasons. It absolutely makes sense that we should rehearse the mechanics of a procedure, especially procedures as important as an intubation, beforehand. There's a point mentioned in the article about how we often have not performed these procedures in some time. They reference some other study from surgeons that the time away from performing a specific procedure reduces your ability to perform this procedure successfully. For some of us, especially if you work in a busy institution, if you haven't intubated or put in a chest tube or put in a line in some time, you're more likely to struggle.
I think that for teaching institutions, there's a lot of issues with trainees because, number one, we get less procedures today than we did a few years back. So, the opportunity to maximize the level of success for these individual procedures is important. Number two, there's always some stigma between the parents and the staff when a trainee has to perform the procedure. I've been in many situations where the parents might say, I would rather have the experienced physician do this, and I don't want the resident or the fellow to do this procedure. When you're working in a teaching institution, this goes against everything the institution stands for. To me, any opportunity that we have to create a level of safety that is better and an opportunity for these trainees to be in a more successful position to perform this procedure is a win-win.
I also thought that this piece was so good because often when you have a paper about neonatology, it talks about babies or parents and you know right away it's about neonatology. But this is really aimed at the field of medicine, but the example of the case is neonatal intubation. So I thought that was really neat.
Daphna Yasova Barbeau
I totally agree. I'm going to say this was like a no-duh paper for me, but we're not doing it, right? We don't routinely do this for our learners, even though it makes perfect sense that this would be effective. I'll disclose one of my tags for Delphi 2026 as a sports psychologist to come talk to us about exactly these sorts of things we've had her on the board review podcast to talk about test anxiety. So this makes a lot of sense. I was a swimmer in high school, I had a coach who did a lot of guided imagery. I realized as I was reading this paper, I still do this. We're a number of years out of training, but when they call me from the call room, I'm walking myself visually through the procedure by the time I get to the bedside. I don't even think I recognized that I was doing it, until I read this paper and I really thought about it. I think it's an easy thing that we can incorporate into our practice. And I think we will even have higher yields when we tell our trainees, I'm doing this because by doing this, you will do better at your procedure. I think we'll even increase the yields higher.
Eli Cahan
Yeah. So much of that resonates with me. Some of this gets back to this pedagogy of “see one, do one, teach one.” But “see one, do one” is present tense. It shouldn't be “saw one last time when I was in the NICU eight months ago, and now I'm going to do my first one eight months later.”
I have had amazing coaches on the wards. I have such gratitude to Dr. Elizabeth Taglauer, if she's listening anywhere. She was such an amazing coach clinically, including through my first intubation. I don't know if I would have been successful without that pre-coaching and pre-visualizing. It also gets to this bigger point about the role of supervisors. This is something I'm thinking a lot about as I'm progressing to fellowship. How can I be a good supervisor? What are the responsibilities that supervision includes? To me, I was raised on this idea that there are really three responsibilities that a supervisor has. Or, as a trainee, you should think about three different kinds of supervisors in your life. There are mentors, which seem like the easiest to find, frankly; these are the people who give you advice. They make some recommendations. They're kind of like your uncle or aunt at the dinner table. They're somewhat invested and they give you some advice. Then there are sponsors. These are the people who go to bat for you when you're not there. The people who are really sticking their neck out behind the scenes. And then there are coaches. Coaches are the people who take the five seconds - as the article says, if Usain Bolt can do it, we sure as heck can do it too - who take five seconds before that intubation to just say, “walk me through what you're going to do.” They sort of look at your running form, so to speak. I'm training for the marathon right now, so I'm thinking a lot about running form. They look at your running form and they say, you’ve got to lift your knees higher, and you’ve got to land on your mid foot and not your heel. Daphna, you said this is no-duh. Aren't the best papers, the no-duh-but-we-don't-do-this? I think those are the best papers.
Daphna Yasova Barbeau
That’s right, the low-hanging fruit. Something that people can take to the bedside this afternoon.
Eli Cahan
One thing I was curious about reading this paper is, I would have loved a little more detail on the coaching intervention itself. There's not a lot of detail on the actual meat and potatoes of the coaching intervention. God knows that's got to vary so much between supervisors. I would love a follow-up study on this that actually looks at what effective coaching looks like and gives a script to some of these coaches.
Ben Courchia
I did go down the rabbit hole of going through the BMJ to get the paper. That specific question is available in the, I think, first supplementary figure. If you get the paper and get the supplementary material, it should be there. They have a bit of a detail of what that coaching session looks like.
Eli Cahan
All the best stuff is always in the supplement. “E-table three” is like, if reviewer two is the world's biggest villain, “E-table three” is like the angel.
This next segment is called Research in the News. We're gonna touch on a couple articles that are featuring research a bit more prominently. And so one of the articles that I was really interested in is this article that the Atlantic magazine ran, though the New York Times also had a piece on it, about Ella or ulipristal as potentially the new contraceptive on the block. We are not going to get into politics. We can certainly talk offline about it. But I think it is important for us to at least acknowledge this study in the setting of what we understand about how the current administration may approach access to abortion care. This write up in the Atlantic highlighted that Ella, which is a form of emergency contraception, traditionally called a morning-after pill, was trialed in a really interesting cohort in Mexico City. That makes me want to know the sort of backstory of this article. It was trialed in this cohort for abortions, not just emergency contraception, at higher doses. They found that, in combination with misoprostol (which is the adjuvant that people use traditionally with Mifepristone), when ulipristal/Ella was used in combination with misoprostol, it demonstrated 97% effectiveness in producing a successful abortion. Daphna, Ben, any thoughts on this study and the write-up that accompanied it?
Daphna Yasova Barbeau
I'll go first. I think the write-up made the point, which is important in all research, that there was no control. They weren't testing it against the gold standard. It was just looking at the “efficacy” of this intervention, which appears to be pretty efficacious, but again, it wasn't compared to the gold standard. I think we should know what's going on for our obstetrics colleagues all the time, especially when they're talking about medications we don't know about. And we'll see what that means for women in the States.
Ben Courchia
Yeah, I think it's definitely something that we will indirectly be dealing with - the consequences of these policies and different agendas from the government. I think that the ability for people to have access to these medications and to abortions is paramount for us to be aware of, especially for people like Daphna and I who work in “restrictive states.”
Eli Cahan
The inability to access an abortion has consequences both on people's health and medical status. There are any number of high risk pregnancies that are terminated early because of the medical risk of carrying those pregnancies to term, to say nothing of the socioeconomic and life circumstances of folks.
Ben Courchia
Go listen to Neo News number two. That was a great article from ProPublica that we reviewed.
Eli Cahan
Just to highlight one other thing that caught my interest here - the reporter at the Atlantic interviewed the former chair and the founder of the drug manufacturer for Ella. When they initially developed ulipristal/Ella, they intentionally avoided marketing it as an abortive agent. They kept it in the realm of emergency contraception, because they were worried that it might implicate people's ability to get the drug for emergency contraception; they thought that might lead to a crackdown. There's a lot of really interesting conversation, both in the Atlantic piece and in the New York times piece, about now that it potentially is entering the fray of abortion, what does that mean in terms of access to emergency contraception? It's worth noting that this is the only pill-based emergency contraception that is effective for people of higher BMIs, and what that means in terms of access to that drug. For our listeners, what does that mean for people carrying to term or carrying later into the pregnancy cycle than they would intend, if they had complete access?
Ben Courchia
Something that the New York Times article mentions is that the FDA labels the mechanism of action as likely to stop or delay ovulation. They try to play with the wording, in order to make sure that access doesn't become an issue.
Eli Cahan
The next story is also politically infused. I don’t know about you guys, but I've been getting called to so many consults in the middle of the night, in advance of delivery, when somebody is reluctant to get their eyes and thighs, to say nothing of hepatitis B, or following delivery, reluctance to administer erythromycin, vitamin K, and hepatitis C in the postpartum window. This article is looking at the conversation around the presence of aluminum in vaccines, which has been a source of much curiosity, discussion, reluctance, interest, and fear around administering vaccines. This is one of dozens of adjuvants that we've discovered through time are important in terms of producing sufficient immunologic response. And yet, there's lots of conversation about whether these adjuvants, even in the fleetingly small quantities that they're contained in these vaccines, are a source of toxicity and danger for developing children. Daphna, Ben, what did you think of this one?
Ben Courchia
I thought it was a very interesting piece. Like you, we're getting that question on a weekly basis - parents who are saying, “I'd like to know if whatever you're going to give my baby contains aluminum.” They're very specific about that, to the point that we actually have a bunch of printouts in our office of the labels of the eyes and thighs so that parents can review them. Even though the labels may not mention aluminum, sometimes aluminum is still present at such small quantities that it doesn't even make it to the label. This article mentions how aluminum is a great adjuvant because it allows for a better immune response, it allows for better stability of the product, and it's been shown to be very safe. This article compares different populations; it talks about the pediatric population. It also talks about people who are exposed through work to significant amounts of aluminum, and if you are exposed to these amounts, there may be some issue. But not at the levels at which we are seeing in vaccines and other medications. It's also highlighting the fact that when you go out into the world and you breathe the air outside, you are exposed to that level of aluminum, those very microscopic levels. Nobody really talks about that. The article mentions, “The amount of aluminum in childhood vaccines is trivial compared to what people are routinely exposed to via the environment and food,” says Dr. Tony Moody, director of the Duke CIVICs Vaccine Center. “We're exposed to aluminum constantly. If you inhale dust from the outside, you are coming in contact with aluminum.” I think that's something that is often going unnoticed. I think that we're okay with this prerogative of saying, yes I'm exposed to aluminum, but the trade-off is that I get to live my life. And so I don't always find that the argument of people who want to prevent exposure of their kids to the microscopic dose of aluminum in a vitamin K shot is warranted, when many people go eat at McDonald's. I'm going to leave it at that.
Daphna Yasova Barbeau
I'll be honest when this was really becoming an issue, I was like, I gotta read about it. I don't actually know much about how much aluminum is in vaccines. CHOP has a great vaccine education center, and they have a wonderful article on aluminum in vaccines. And they also have some great videos that you can literally play for families. Why is aluminum in vaccines? Isn't it dangerous? Is there a difference between aluminum that is injected versus ingested? Because to your point, they say exactly that. Our babies are getting exposed to way more aluminum. So for example, let's say the Hib vaccine is 0.225 milligrams per dose. The Hep B vaccine: 0.225 to 0.5 milligrams per dose. The combo DTaP-polio-Hep B: less than 0.85 milligrams per dose. Then they compare it to other things that babies get. So breast milk: 0.04 milligrams/liter of aluminum. Infant formula: 0.225 milligrams/liter, almost the same dose as the vaccine. If those parents are electing for soy-based formula, it's almost double to quadruple: 0.46 to 0.93 milligrams/liter of soy-based formula. That’s more than the babies are gonna get in the vaccine. Antacids have 104 milligrams per tablet. That's why they work! It's interesting when you can put that into perspective. I hope it will make people feel more comfortable with that part of getting the vaccine. Our goal here is to meet people where they are, and to bring people information that is safe and reliable. That's my favorite question: tell me what you're concerned about for this vaccine so we can talk about it and move on from there.
Eli Cahan
It's such a good approach: tell me why you're worried, rather than convincing someone not to be worried. This feels like something we can do every moment of every day, to meet families where they are. This article feels like the point of this segment to me, because families are thinking about this, and you have three choices. Your first choice is to tell them to think about it differently. The second choice is to understand how they're thinking about it, and provide information and counsel to try to move them towards a decision. The third is to ignore it completely, or don't be aware that patients are thinking about it. That one I worry about. There's so much information and misinformation out there, that if we're silent on issues, if we don't address the issue of aluminum in vaccines, I don't think people will just say, okay, I don't need to think about it either. I think they will retrieve information from other sources. And as we all know, that has tended to be a recipe for disaster when it comes to legitimate, useful medical information.
Ben Courchia
It's interesting to me that things that we were fairly certain about are now being placed in question. I think the basis of most misinformation is the false premise that, hey, you [doctors] don't know. My approach has always been with parents to say, actually we do know several things. You're right that we don't know everything, but it doesn't mean that because we don't know everything that we can negate the things that we've established. I usually approach this by saying, here's what we know. Here's what we know in terms of exposure to aluminum, but also lack of exposure to the medication, vitamin, or supplement that we're recommending. When I tell them now that you have this information, you are free to make your own decision. It usually puts the parents at the foot of the wall of their responsibilities, where they were given the information and now they cannot say, “we really don't know.” Now you were told, so now you have to live with the consequences if anything were to happen. I am very frustrated when we’re the ones feeling bad for the baby if something doesn't happen. I think it should be the other way around.
Daphna Yasova Barbeau
I also think a lot of people are like, I don't have the time for this in the nursery or in the NICU, I'll just let their pediatrician deal with it. But I wonder if we have a unique opportunity, especially in the NICU, for families that we have a relationship with, to really set them up for success by talking about their fears and really explaining it to them, instead of just passing on the note. If a mother declines two month vaccines, did somebody sit with her and talk to her about what she's worried about? I think we underestimate the value we provide to families by being a known, reliable source of information. We have a lot of power there. And sometimes we don't use it to help babies as they're going out into the world.
Eli Cahan
We’re going to move into our third segment, which is called “You May Have Heard.” Daphna, Ben, you may have heard that in ancient Rome, babies - cause this is the thing that everybody talks about at a cocktail party, I don't know how you wouldn't have heard about this - in ancient Rome, babies from the suburbs adhered and followed breastfeeding guidelines. The ancient Romans had clinical practice guidelines that said you should breastfeed your baby for two years. Researchers found a really interesting analysis that kind of boggled my mind. They found that babies in metropolitan centers, like Thessalonica and Pompeii, were weaned off of breastfeeding earlier than babies from rural regions like Ostia Via Del Mare. It gets into a really interesting conversation about why that may have happened related to healthcare access information, sociodemographic characteristics, etc. Ben, what'd you think of this one?
Ben Courchia
First of all, I want to thank you because I did miss that paper. Reading it was such a joy. If it was up to me, this is what Neo News would be always about, just going back into ancient history. I think this is so, so interesting. This was published in Science and it was fascinating on so many levels. Number one, I think the first question people might wonder is, how do scientists figure out exactly what the breastfeeding practices of people back in ancient Rome were? I went down the rabbit hole. I printed the study that this article is based on. It was published in PNAS Nexus. To make it concise, basically through the teeth record, they're able to analyze various isotopes, kind of like the rings on the tree. They're able to determine when the isotopes that are related to breastfeeding suddenly stop. So they can tell when along the path of their life, they stopped being exposed to breast milk. That in and of itself is just fascinating.
If you look at ancient Rome, you're looking at a population that potentially has access to wet nurses and may not reflect the overall Roman population, or the population in that area of Italy at the time. So, they went into the suburbs. In the city where people were probably wealthy, it seems pretty clear that after two years they stopped using breast milk. However, that timeline in the rural areas was much more variable, going from 1.5 years to sometimes up to five years. It gets into a very interesting discussion about following the recommendations at the time, which seems to be very much in line with our current recommendations of trying to promote breastfeeding up until two years. For people who need a reminder, the recommendations are exclusive breastfeeding for the first six months, and then supporting breastfeeding through two years. In the rural areas [of ancient Rome], resources were more scarce, and so if a baby could be fed using breast milk for a bit longer, and it didn't mean that we would have to split the potatoes with another person, it might be beneficial. All of this is absolutely fascinating. It's interesting to see that even in ancient Rome, they were thinking about breastfeeding and wondering how long we should do this for. We tend to think of people from ancient history as people who didn't have the same concerns or the same issues that we do, but it's interesting to see that they actually did. And they were practicing not far off from what we're doing today. Fascinating, fascinating paper.
If you are rusty on your geography, the paper has a great map of the Roman Empire. And if you don't know, they conquered a lot of territory.
Eli Cahan
I'm sure that map came in because Reviewer Two was like, you guys don't even know geography. then the authors one-up the reviewers with a map. I love what you brought up. I also think it brings a couple of questions to mind. Have we made no progress on breastfeeding in centuries? I don't think that's the right question, maybe breast has been best for centuries. The other question it brings to mind is, have patients been nonadherent for centuries? So maybe we're not doing so bad. I think if I had one takeaway from this piece, it's that language of nonadherence is so inconsiderate of people's social context. The authors go very deep into descriptions of the way in which society was constructed in terms of what they call settlement complexities, relationship to socioeconomic equality, degrees of human spatial mobility, and accessibility to medical knowledge and infrastructures. Basically all of that to say, these cities have immense inequality. In the suburbs, you may have less access to some facilities as a matter of distance, but actually the construction of these areas was more equal socioeconomically. And maybe we can learn something about the fact that inequality relates to people's tendency to be able to provide breastfeeding for this long, or whether there were pressures on folks that made it difficult to adhere to these recommendations way back then, including into the present.
It's actually a nice transition into our next story. Pediatrics had a really nice analysis on changes in breastfeeding before and after the formula shortage. So just to remind people of the timeline, in late 2021, long after toilet paper was nowhere to be found, formula was nowhere to be found. In late that year, there were all these pandemic-related supply chain issues that led to problems with formula access. These were exacerbated in February 2022 when Abbott shut down one of its facilities due to a huge recall and then an investigation into that facility. The formula shortage became so severe that there were states that had shortages of up to 30%. Those shortages persisted through the summer of 2023, a time when even 20% of parents were still reporting facing challenges obtaining formula. All of this added up to increased breastfeeding in lots of different groups, but most market increases were in folks who faced more challenges socioeconomically. The authors had a really interesting commentary about how we might think about breastfeeding in a new light when it comes to socioeconomic opportunity versus the burdens imposed on people, and how an overnight shortage forces people into positions they might not otherwise take. Daphna, Ben, what did you guys think of this one?
Ben Courchia
Interestingly enough, this article made me very upset. As you mentioned, the formula shortage happens and what this article shows is that it is people from lower socioeconomic status that are going to suffer the most. So the byproduct of this issue is that it's a positive byproduct - that they did end up relying more on breastfeeding, which is good.
But it highlights several things to me that are not good. Number one, it's a good way to circle back to our original discussion of the first paper where we're talking about structural violence on people. We see this in the NICU very often, where people from a lower socioeconomic status have difficulties taking time off from work, difficulties traveling to and from the hospital, and then subsequently difficulties to be at the bedside. This has been very well-established from multiple studies that this translates into decreased levels of breastfeeding, and so they are more likely to go home with a WIC form to get some formula. If they had been at the bedside, this paper shows you that when push comes to shove, these individuals can breastfeed their babies successfully.
So what it means is that up until then, the system was not putting them in a position to succeed, when it comes to offering exclusive breast milk to their infant. I feel like it's just a reminder that a baby who is living with their mother in the not-so-nice part of town and is going home on formula, there is a reality in which this mother could potentially breastfeed her child. It's not something that falls on the shoulders of the neonatologist or the nurse. It's both a societal issue and it is also partly the responsibility of the medical team, to try to reinforce how important this is. I think this article shows pretty neatly that for the people who are well off, they'll make do anyway.
Daphna Yasova Barbeau
It's interesting to have these two papers next to each other, because the problem has been the same for generations and generations, and we still haven't solved it. I thought the most important lines in the paper are what can you do with this article or information, and it says explore the types of feeding support that exist in your community. If you are not sure where to start, 2-1-1 is a nationwide number you can dial that will help connect you with agencies in your area. They're a good source of information for parents who need help feeding their babies. The next one is important to us as professionals, which is to become involved with efforts supporting better laws to protect parents in the workplace, things like family leave. Parents want the best for their babies, and they'll make it work if they have to. But wouldn't it be nice if parents could breastfeed because they wanted to and they were able to, and not because they had to?
Eli Cahan
Setting people up for success is really at the heart of this one. You look at this article and, at face value, you're like, my God, did we score a win from a really bad thing? Should we just have formula shortages more often? Let's just do these every once in a while, get the rates up.
Ben Courchia
You're going to receive some death threats, Eli!
Eli Cahan
Haha! I have no role, no authority. All I can do is write feeding orders. But maybe the point is that whether someone chooses to give formula or breastfeed is so much more than just the diet order in a chart. There is so much that goes into the ability to exclusively breastfeed or even partially breastfeed through time, and we have to be considerate of those things.
Why don't we move to the next piece, which is two back-to-back studies and commentaries about the potential for ultrasound and point of care ultrasound (POCUS) in the NICU. One, which was published in NeoReviews, has a really nice discussion and video of how to train yourself and your colleagues to use ultrasound to assist in umbilical line placement and confirmation of umbilical line placement. And the second, which was published in the Journal of Perinatology, was on the use of ultrasound for discontinuing CPAP and for looking at aeration in the lungs, and other factors related to the status of the lungs, as it relates to an infant's likelihood to tolerate extubation. Ben, Daphna, what did you think of these two?
Ben Courchia
I'm going to dismiss the one from the Journal of Perinatology. I didn't find it to be as useful as I would have hoped. It's not been an area where people have struggled so much. And I think people are comfortable just trying babies off CPAP, especially in infants less than 32 weeks, and see how the baby does. I think that there are some interesting tools that are going to surpass lung ultrasound very quickly. If you're looking at EIT [Electrical Impedance Tomography] and stuff like that, it will become much more useful and much more easily applicable at the bedside.
The NeoReviews article on the position of umbilical lines is a must. If you are anyone working in the NICU, print it. Watch that freaking video. The video is amazing. It basically shows you which probe you should use. It's sort of like a cookbook. You don't really need to know how it works. You just basically follow the steps. And you won't have to wait for 25 minutes for the extra machine to confirm positions on those lines. The paper itself has a bunch of figures where they have the diagrams. They can point at the various structures so everything is clear. This is something that you can read over the weekend and roll out in your NICU on Monday morning. Having done some POCUS myself, getting comfortable with ultrasound and finding catheters is not the hardest. It's actually one of the easiest things, because if you're just putting the probe in the right place and fanning the right way, [you’ll see] a piece of plastic that will shine. It's super easy to do. I'm excited about that particular paper and I cannot recommend it enough.
Daphna Yasova Barbeau
Shout out to Jenny Koo who put it together. In the video corner of NeoReviews, they have a lot of very high-yield videos.
Ben Courchia
Do you know Jenny Koo?
Daphna Yasova Barbeau
Yeah, she does a lot of things. One of the things she does is she's a medical illustrator. She does some really cool illustrations for lots of people in the community.
Eli Cahan
God bless NeoReviews. I don't know where I'd be without NeoReviews. What an amazing asset.
Ben Courchia
Well, let me just tell you something, my friend. You are going to study for the boards and you're going to print a lot of these articles. They are the key.
Eli Cahan
Yes, yes, I am going to study. I just got my ITE score back and boy, do I need to study for boards. But I'll take the far side on the use of POCUS for CPAP. I was intrigued. But then again, what do I know? I'm just sort of in the sandbox here.
Ben Courchia
Just to wrap up the discussion on POCUS, I think you have to look at the instances where POCUS can help you when you are in an area of indecisiveness. And there are many instances like that in the NICU. I think bladder ultrasound is amazing, but I found that there's a lot more difficulties applying it to lung ultrasound, even though people are trying.
Eli Cahan
We will see. That wraps up this month's episode of Neo News. Thank you everybody for listening. If you have feedback on the discussion today, article recommendations, things you want us to do in the future, things that you want us to do differently or do better, please let us know. Please email us and engage with us on Instagram, on X, whatever your preference is. In the meantime, stay warm to everybody who's not in Florida or in the South. Thanks for listening.
Ben Courchia
Thank you, Eli. See you next time.
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