The Incubator

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This week on The Incubator Podcast, Ben and Daphna dig into four studies reshaping bedside decisions. They open questioning whether routine DAT screening for ABO and RhD incompatibility still earns its place, finding transcutaneous bilirubin alone predicts phototherapy need just as well. Next, a Swedish national registry of over two million births links missed intramuscular vitamin K, and rising oral substitution, to a near-doubling of bleeding and intracranial hemorrhage risk. Ben then presents the PHILODENDRON pilot trial out of Milan, testing initial delivery-room CPAP of 5 versus 8 cmH2O in infants under 30 weeks, feasible...

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Ben and Eli dig into a Journal of Perinatology study that asks a deceptively simple question: can we trust birth certificate data to tell us how many babies actually need NICU care? The answer, it turns out, is no. Nearly 40% of NICU admissions are missing from birth certificates, with the biggest gaps among full-term and late-preterm infants, and troubling racial disparities in which admissions get missed. Ben and Eli unpack what this means for how states and hospitals allocate resources, why underreporting could be quietly starving NICUs of funding and attention, and why...

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Ben and Daphna  dig into a large, population-based study linking IVF conception to VACTERL association, a rare but serious pattern of congenital anomalies spanning the vertebral, anal, cardiac, tracheoesophageal, renal, and limb systems. Drawing on over 1.5 million births across four US states and linked SART registry data, the study finds IVF-conceived infants face significantly higher odds of VACTERL and related multiple anomaly syndromes compared to naturally conceived infants. Daphna and Ben unpack what this means for clinical suspicion at the bedside, why some VACTERL phenotypes may be easy to miss, and how better t...

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Ben and Daphna dig into a pilot RCT that asks a deceptively simple delivery-room question: should very preterm infants start on CPAP of 5 or CPAP of 8 cmH2O? The PHILODENDRON trial, out of Milan's Buzzi Children's Hospital, randomized 56 babies born between 26 and 29 weeks to find out — testing feasibility, safety, and early physiological adaptation before committing to a larger multicenter trial. No major safety signals emerged, but babies on lower CPAP reached surfactant thresholds faster, while higher CPAP trended toward fewer air leaks and shorter ventilation. Ben and Daphna weigh the physiology against the da...

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Is the newborn vitamin K shot really being skipped more often these days, and does that actually matter clinically? This week on Journal Club, Ben and Daphna review a nationwide Swedish cohort study of over two million births, published in JAMA Pediatrics, examining trends in non-receipt of intramuscular vitamin K and its link to bleeding in infancy. Non-receipt nearly doubled between 2006 and 2021, and infants without intramuscular vitamin K had significantly higher odds of bleeding, including intracranial bleeding, than those who received it — oral vitamin K carried an even higher bleeding risk still. Ben an...

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Do we really need a DAT on every baby born to a group O or Rh-negative mother? This week on Journal Club, Ben and Daphna dig into a new Pediatrics study questioning routine Direct Antiglobulin Testing (DAT) in low-risk neonates with ABO or RhD incompatibility. Using data from over 1,300 infants, the authors found that transcutaneous bilirubin alone predicted the need for phototherapy just as well as DAT in ABO-incompatible babies, and that passive anti-D from RhoGAM rarely caused significant hemolysis in RhD-incompatible infants. Ben and Daphna also discuss what this means for institutions...

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In this episode of From the Heart, Drs. Nim Goldshtrom and Adrianne Bischoff talk with Dr. Kristin Elgersma, a nurse-researcher whose path into neonatal nutrition began at her son's bedside in a cardiac ICU. A former concert pianist turned nurse-researcher, Kristin asked a question no one had: does human milk change outcomes for babies with congenital heart disease? Her multicenter PC4 study of day-by-day data from over 800 infants across 25 centers found no link between human milk and NEC, though bovine-derived formula or fortifier tripled NEC risk within five days, while higher human milk...

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In this episode of From the Heart, Dr. Nim Goldshtrom and Dr. Adrianne Bischoff dissect a hemodynamics consult that changes shape twice in 48 hours. A 30-week recipient twin from twin-to-twin transfusion syndrome presents with biventricular dysfunction and suprasystemic pulmonary hypertension, starts on epinephrine and milrinone, and stabilizes. Then overnight, everything falls apart: hypotension, rising lactate, falling urine output. Only on repeat echo does the real diagnosis emerge: hypertrophic obstructive cardiomyopathy (HOCM) with dynamic left ventricular outflow tract obstruction, where the "correct" initial therapy becomes dangerous. Nim and Adrianne unpack why milrinone can worsen...

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Disclosure: Dr. Wanda Barfield appeared on this episode in her personal capacity. The views she expresses are her own and do not represent the official positions of the Centers for Disease Control and Prevention, the Department of Health and Human Services, or the United States government.

The American Academy of Pediatrics has never had a neonatologist as president. This September, that could change. In this special episode, Ben sits down with Dr. Wanda Barfield, neonatologist, retired Rear Admiral and Assistant Surgeon General in the US Public Health Service, and...

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This week's Journal Club. Monday, nasal CPAP versus NIPPV as the bridge to minimally invasive surfactant in infants born before 30 weeks, first author Dr. Hui Zhang. Tuesday, the PAEAN trial on high-dose erythropoietin for neonatal HIE, led by Dr. Helen Liley. Wednesday, extended infusion versus bolus feeding for weight gain in extremely-low-birth-weight infants, from Dr. Haribalakrishna Balasubramanian's team in India. Thursday, the DROP-ROP trial, testing dexamethasone eye drops against treatment-requiring ROP, led by Dr. Ann Hellström. Friday, Neo News: Eli and Ben on The Pitt's viral boundary-setting scene and what it says a...

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A medical student on The Pitt finishes her shift, is asked to stay, and tells her supervisor to learn some boundaries. The internet did not let it go. Ben and Eli use that moment to work through what boundary setting actually looks like in a NICU, why a tired clinician makes different decisions at three in the morning than at three in the afternoon, and where duty hours collide with the fact that patients do not arrive on a curriculum. Also, why handing a resident your pager at two PM may be the...

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Steroids again? This time in the eye. Daphna brings the DROP-ROP trial from JAMA Pediatrics, a double-masked randomized study across fourteen Swedish centers asking whether topical dexamethasone can stop pre-threshold ROP from progressing to type one disease. One hundred infants, born under 30 weeks, dosed for up to twelve weeks, some still getting drops at home. Twenty percent needed laser or anti-VEGF in the dexamethasone arm versus thirty-eight percent on placebo, a relative risk reduction that did not reach significance. Ben and Daphna talk through the safety signals, the intraocular pressure question, and how...

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Every unit has a bolus camp and a continuous camp, and both are usually dug in. Ben brings a single center non-inferiority trial from India, published in the Journal of Pediatrics, randomizing 132 infants born before 29 weeks and under a thousand grams to extended infusion feeding or two hourly bolus feeds. Weight gain at discharge was essentially identical at 15.3 versus 15.7 grams per kilo per day, but the infusion group lost two fewer days to interrupted feeds. Ben and Daphna talk through the five on one off infusion cycle, two hourly bolus feeding, and why...

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We already had HEAL, so why run this trial at all? Daphna brings PAEAN from JAMA Pediatrics, a phase three trial across 24 units in Australia, New Zealand, and Singapore that gave high dose erythropoietin to 313 late preterm and term infants already receiving therapeutic hypothermia for HIE. Same drug, same dosing, nearly the same eligibility criteria as HEAL, by design. Death or moderate to severe developmental deficit at two years was 34 percent with EPO versus 29 percent with placebo. Ben and Daphna talk through the thrombosis signal, why replication feels so foreign in neonatology, and...

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Most trials comparing CPAP and NIMV leave a lingering doubt about whether surfactant explained the difference. This one does not. Ben brings a multicenter noninferiority trial from JAMA Network Open in infants born between 24 and 29 weeks, randomized to nasal CPAP or NIMV with every baby receiving less invasive surfactant administration. The trial stopped early for futility after 312 infants. Noninvasive ventilation failure within 72 hours was 26 percent on CPAP versus 13 percent on NIMV. Ben and Daphna talk through what happens when surfactant is off the table, the unexpected NEC signal, and where the guidelines may...

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A term newborn looks fine on mom's chest, then crashes within minutes. By the time transport arrives, there's a pH of 6.9, a lactate over 10, and a baby already intubated and on surfactant. Is this pulmonary hypertension, congenital heart disease, or something else entirely? In this episode of From the Heart, It's Complicated, Dr. Adrianne Bischoff and Dr. Nim Goldshtrom work through a real, complex neonatal cardiac case in real time — the kind of case that keeps neonatologists up at night. They break down how to clinically differentiate PPHN from congenital heart disease with li...

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Why does reading in the NICU still feel optional when the evidence says otherwise? Daphna sits down with Paige Pedroli, author of the Nic Zoo book and two-time NICU mom, and Dr. Raquel Garcia, a craniofacial and feeding specialist, to unpack why reading to preterm and critically ill infants belongs alongside kangaroo care as neuropromotive, not just neuroprotective. They cover the evidence behind auditory stimulation and language outcomes, why reading gives overwhelmed parents a real role in their baby's care, and how units can build low-cost reading programs with book libraries and student...

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Is your EMR actually built for neonatology, or just retrofitted to survive it? Ben sits down with Dr. Lindsey Knake, clinical assistant professor and associate chief health information officer at the University of Iowa, to talk AI in the NICU. They cover the real difference between Epic's homegrown tools and third-party options like Evidently and NABLA, why a six-month hospital stay breaks most chart summarization tools, and how ambient AI is starting to change documentation and family counseling. Lindsey also shares practical paths into clinical informatics for clinicians without a coding background. A...

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The full week of Journal Club in one place. Monday, the PLaNT trial of prophylactic CPAP for late preterm infants born by cesarean, with senior author Dr. Edgardo Szyld. Tuesday, whether parental holding during therapeutic hypothermia changes feeding and length of stay. Wednesday, the Connection Study, the first live biotherapeutic product tested under an IND, and what it means for probiotics returning to the NICU. Thursday, a handheld light probe that reads bowel through the skin to catch NEC before the X-ray does. Friday, Dr. Dinushan Kaluarachchi on the respiratory severity score and...

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The respiratory severity score is one multiplication most of us already do in our heads, mean airway pressure times FiO2. This week Dr. Dinushan Kaluarachchi joins Journal Club to walk through three papers built on it, RSS trajectories across gestational age in the PROP cohort, an RSS based grading of BPD at 36 weeks, and RSS after 40 weeks as a predictor of tracheostomy. He also talks about writing that last paper with his son, a high school junior, and why a brief communication is a realistic on-ramp for students. Plus a preview of two...

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NEC still tends to announce itself on an X-ray, usually later than we want. This week Daphna reviews the first-in-human study of broadband optical spectroscopy, a handheld transcutaneous probe out of Lurie Children's that reads reflected light from 350 to 2500 nanometers to look at bowel beneath the skin. Just under 100 preterm infants, more than 11,000 scans, and a machine learning model that separated NEC from non-NEC scans with 100% sensitivity and a 100% negative predictive value, though the positive predictive value sat at 24%. Ben and Daphna work through what the curves actually show and what would have...

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Probiotics left US NICUs after the FDA reclassified them, and NEC rates went up. This week Ben reviews the Connection Study, a 2,158 infant phase 3 trial of IBP-9414, a live biotherapeutic product containing Limosilactobacillus reuteri, run under an IND with the regulatory rigor probiotics never had. Neither primary endpoint reached significance, but all cause mortality fell 27%, and surgically confirmed NEC favored treatment after 14 days of dosing. The discussion may be the real story, including a kappa of 0.36 between radiologists reading the same NEC films. Ben and Daphna talk through what a regulated probiotic would...

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Parents of babies undergoing therapeutic hypothermia often wait days before they can hold their child, and many never get the chance during cooling at all. This week on Journal Club, Daphna reviews a new Journal of Perinatology retrospective cohort from two level IV NICUs, 379 infants with HIE, where 28% were held during cooling. Held infants reached full oral feeds sooner, were more likely to go home on breast milk, and had shorter stays, but they were also less sick to begin with. Ben pushes on confounding, on the exclusion of infants who died, and...

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Late preterm babies born by cesarean fill our NICUs, and most of them are there for respiratory distress that resolves in a day or two. Could 20 minutes of CPAP in the operating room keep them out? This week on Journal Club, Ben and Daphna break down the PLaNT trial, a five center randomized pilot of prophylactic CPAP at 5 to 6 cm of water in spontaneously breathing infants born at 34 to 36 weeks by cesarean. They then sit down with senior author Dr. Edgardo Szyld to talk pneumothorax risk, the 35 to 36 week subgroup, consenting families, and...

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When is surfactant "early," and when is it too early, or too late? In this second installment of our two-part series with the Neonatal Resuscitation Symposium, Ben Courchia sits down with Dr. Roger Soll, a leading voice in surfactant research since the 1980s, to trace how our thinking on timing has evolved, from aggressive prophylactic dosing to selective rescue therapy to today's less invasive approaches like LISA and SALSA. Dr. Soll unpacks why head-to-head trials keep favoring less invasive administration over InSurE, and how the rise of "nanopreemies" is quietly pulling the pendulum...

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Which babies with critical congenital heart disease face the highest risk of brain injury, and does earlier surgery actually help? Why is infant CHD mortality climbing again after years of decline, and who's most affected? Can a mother's cardiovascular status in preeclampsia predict her newborn's circulatory transition? This week's Journal Club brings together five conversations on CHD, maternal-fetal physiology, and vaccine policy. Nim and Adrianne cover a meta-analysis on brain injury in critical CHD, a 25-year national mortality study, a pilot study on preeclampsia and neonatal cardiac output, and a look at RV...

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In this episode of Neo News, Ben and Eli break down a troubling story in vaccine policy: an unsolicited $1.6 million CDC grant funding a Danish research group's trial in Guinea-Bissau, one designed to withhold or delay the hepatitis B birth dose from thousands of newborns in a country where the disease is highly endemic. They trace the ethical parallels to Tuskegee, the funding irregularities, and the pushback from the Africa CDC that halted the study. They also cover the clinical stakes clinicians face daily, including age-dependent chronicity and the real risks of a "...

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In this prospective study, Adrianne and Nim dig into an area with almost no normative pediatric data: right ventricular diastolic function. Comparing 57 infants with RV pressure overload after intervention for pulmonic stenosis or tetralogy of Fallot to 134 healthy controls, the authors found a consistent pattern, reduced beat-to-beat variability, a higher atrial contribution to filling, and an E/A ratio inversion that was nearly universal in the CHD group versus about half of controls. It's one of the first real attempts to define what a right-sided diastolic pattern actually looks like in this population...

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In this small prospective pilot study, Adrianne and Nim explore a domain rarely discussed on rounds, how a mother's cardiovascular function in preeclampsia shapes her newborn's circulatory transition. Using maternal echo and neonatal electrical cardiometry across 13 mother-baby dyads, the authors found an inverse relationship: the worse the mother's cardiac function, the higher the neonate's cardiac output, though vascular tone barely budged. It's a compelling hypothesis about placental strain and fetal adaptation. But Nim pushes back hard on the methodology, pairing this paper with a companion study showing electrical cardiometry consistently overestimates cardiac output...

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In this retrospective national study, Adrianne and Nim look at 25 years of congenital heart disease mortality in the US using CDC WONDER data. Infant mortality remains staggeringly high (54 per 100,000), and after years of steady decline, it has been climbing again since 2014. Disparities run throughout: higher deaths among males, non-Hispanic Black and American Indian/Alaska Native populations, and in rural, Midwestern regions, pointing more to gaps in access and resources than to disease biology. The conversation also flags a growing, under-discussed problem, an aging adult congenital population outpacing the pediatric one for the first...

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In this systematic review and meta-analysis, Nim and Adrianne dig into just how common brain injury really is in neonates with critical congenital heart disease. Pooling 31 studies spanning two decades, the authors found that nearly 70% of these babies show some form of ischemic brain injury, split roughly between pre-operative and post-operative timing. Counter to what most clinicians would predict, kids who went to surgery earlier (days 4-6) had higher rates of white matter injury than those who waited longer. MRI remained the most sensitive tool for picking up these lesions, well ahead of...

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What if communication were treated as a procedure, something we train for and get feedback on, just like an intubation?  In this episode of Neo News, Eli Cahan talks with Dr. Jessica Fry of Northwestern University and Lurie Children's Hospital about her NeoReviews piece, "Recognizing Communication as a Procedural Skill in Neonatology." Dr. Fry shares the personal loss that shaped her career, the ethical stakes of getting family communication right, and how trauma-informed care can guide something as simple as how we address parents on rounds. They discuss the critical first 48 hours after a...

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How far has delivery room ventilation really come? In this special episode, recorded in collaboration with the Neonatal Resuscitation Symposium, Ben sits down with Dr. Charles Roehr, professor of neonatology and perinatal medicine at the University of Bristol, clinical trialist at the University of Oxford, and member of ILCOR. Together they trace the evolution of respiratory support at birth, from the era of fixed inflation breaths to today's focus on physiologic stability and gentle cardiopulmonary transition. Dr. Roehr reflects on a quarter century of resuscitation science, the enduring challenge of human factors in...

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Which PDAs actually need treatment? Can maternal voice and scent shape language outcomes? Should we cool at 35 weeks? And did stepping away from probiotics come at a cost? This week’s Journal Club takes on five papers that push back on standard practice. Ben reviews the SMART-PDA trial and a comparative study of PDA pharmacotherapy, Daphna covers the MIND trial on multisensory maternal interventions and a Pediatrix database study on NEC after the FDA probiotic warning, and Ben rounds out the main segment with a national look at hypothermia in 35-week infants with HI...

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Vitamin K refusal has crossed 5%. That's one in twenty babies, and the curve is bending the wrong way. Ben and Eli work through a new Pediatrics case review that opens with a warning shot, that hemorrhagic presentation in an infant should no longer be a diagnostic mystery, alongside a JAMA letter tracking refusal from 2.9% in 2017 to 5.2% in 2024. Eighty-one times the risk. Intracranial hemorrhage in most late-onset cases. Twenty percent mortality. They talk about the halo effect on other refusals, the ICD code you should be using, and why this conversation belongs in the...

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When the FDA warning landed in late 2023, probiotic use in high-use NICUs collapsed from 86% to under 7% almost overnight. What happened to NEC? This week Daphna brings Tolia and Patel's new Journal of Perinatology analysis of the Pediatrix Clinical Data Warehouse, a natural experiment across 347 NICUs and more than 10,000 extremely preterm infants. Centers that stopped saw NEC climb from 2.7% to 4.4%. Centers that never used probiotics saw nothing change. Ben and Daphna work through the difference-in-differences model, the demographic imbalances, and the uncomfortable question underneath it all. When does data stop and advocacy begin?

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Cooling works at 36 weeks. At 35 weeks, nobody is sure. Ben brings a new Journal of Perinatology analysis of the National Inpatient Sample, covering 1.4 million infants from 2016 to 2022, asking what happens when therapeutic hypothermia is offered just below the evidence line. Cooled 35-weekers died at higher rates than cooled 36-weekers, but within the 35-week group, cooling changed nothing either way. Coagulopathy rose with cooling. Mediation analysis says it wasn't the cause. Ben and Daphna work through what that leaves us, and why shared decision making and careful documentation carry the weight here

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In this Journal Club, Daphna takes the reins with the MIND randomized controlled trial from Nathalie Maitre and colleagues in The Journal of Pediatrics. Can a multisensory bundle, combining infant-directed voice, a parent's scent, holding, and gentle containment, do more for a preterm baby's developing brain than recorded voice alone? Using event-related potentials to track how infants tell speech sounds apart, the team followed language outcomes all the way to age two. Daphna and Ben unpack the design, the Bayley and PLS-5 findings, and a takeaway every clinician can act on tomorrow. Talk...

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In this Journal Club, Ben and Daphna dig into two new papers on PDA management in our smallest patients. First, the SMART-PDA pilot RCT from Souvik Mitra and colleagues, which uses comprehensive hemodynamic screening to selectively treat high-volume shunts in infants born before 26 weeks, and whose striking Bayesian signal for reduced pulmonary hemorrhage and NEC stopped the trial early. Then a companion JAMA Network Open comparative effectiveness study across four pharmacotherapy regimens. Along the way, Ben shares hemodynamics pearls from his Montreal training: why left ventricular output, LA:Ao ratio, and transductal velocity...

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In this episode, Ben and Daphna sit down with Dr. Scott, pediatrician, neonatologist, and inventor of the Tortle. She shares how a simple observation in her Idaho practice, babies developing flat heads despite diligent parents, sparked a second career in medical device innovation. The conversation covers the evolution from the original corrective beanie to the Midliner and Transportal, the physiologic rationale for midline positioning in IVH prevention, and real-world data from a Tennessee children's hospital that cut its IVH rate from 28% to under 6%. She also offers candid advice for clinicians looking to turn...