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Dr. Shalini Ojha, Professor of Neonatal Medicine at University of Nottingham, presents the Feed One trial examining full enteral feeding (60 mL/kg/day) from day one versus gradual advancement in 30-32 week infants. While the primary outcome of hospital length of stay showed no difference (median 32 days), full feeding significantly reduced parenteral nutrition use, IV cannulations, and associated interventions without increasing necrotizing enterocolitis risk (4 versus 6 cases). This pragmatic trial challenges the unfounded fear that early full feeding causes NEC—demonstrating that moderate preterm infants can safely receive complete enteral nutrition from birth, simplifying care particularly in resource-limited settings while avoiding complications from IV access and parenteral nutrition.

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Dr. Pankaj Agrawal, Division Chief of Neonatology at University of Miami, discusses rapid genomic advances—from six-month diagnostic timelines in 2000 to same-day sequencing today. While current practice targets phenotype-based testing for unexplained conditions or dysmorphic features, Agrawal advocates moving toward universal NICU sequencing to identify previously unrecognized conditions. Key barriers include administrative buy-in, cost concerns, consent processes, and result disclosure challenges. Even negative results provide value—offering families reassurance and contributing to research databases. With only 5,000 of 20,000 genes linked to human disease, ongoing gene discovery work continues. Agrawal emphasizes the NICU as ideal for genomic implementation given high genetic disease prevalence and intervention opportunities.

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Three first-year fellows from University of Virginia—Jamie, Megan, and Brianne—share their Hot Topics conference experience. Despite being early in training, they engage deeply with cutting-edge research across diverse interests: POCUS and hemodynamics (Jamie), ENT non-surgical interventions (Brianne), and neurodevelopmental outcomes with Tiny Baby projects (Megan). They value learning from practice variation across institutions, particularly regarding fluid management and humidity protocols. Rather than finding evidence gaps discouraging, they're inspired by opportunities for future research. They plan to share conference insights through journal club upon returning to UVA. The fellows emphasize how accessible and collaborative neonatology speakers are, encouraging early-career engagement with research leaders.

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Julie Raskin, representing Congenital Hyperinsulinism International (CHI), advocates for universal newborn glucose screening following her son's brain injury from undiagnosed hyperinsulinism in 1996. Registry data reveals 28% of affected infants lack traditional risk factors (abnormal birth weight), and even high-risk babies are often discharged inappropriately. CHI's "Glucose is a Vital Sign" campaign promotes screening protocols currently under research, examining glucose plus ketone monitoring during initial days to identify affected infants without over-medicalizing healthy newborns. The organization maintains eight centers of excellence globally and provides international treatment guidelines at congenitalhi.org. Over 30 genes cause this diagnosable, treatable condition requiring immediate intervention to prevent preventable brain damage from prolonged hypoglycemia.

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Dr. Ariel Salas, recent R01 recipient, discusses challenging traditional feeding volume targets in preterm infants. His multi-center trial compares 180-200 versus 140-160 mL/kg/day volumes, examining body composition changes rather than weight alone. Salas emphasizes targeting fat-free mass gains over simple weight gain, as this component associates with better long-term neurodevelopmental outcomes. Body composition analysis reveals compartmental changes invisible to daily weights—distinguishing extracellular versus intracellular water shifts. This outcome provides reasonable compromise between immediate intervention effects and long-term results. Salas advocates acknowledging practice variation as opportunity for equipoise and fair testing, challenging arbitrary standards that persist despite limited evidence supporting them.

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Dr. Kavya Rao from University of Buffalo discusses quality improvement initiatives following completion of her master's in QI. Her team successfully implemented antibiotic stewardship by safely discontinuing antibiotics at 24 hours for early onset sepsis in clinically well infants with negative blood cultures, initially studying all gestational ages with plans for subset analysis. Additional projects include reducing PRBC and platelet transfusions using lower thresholds based on updated guidelines. Rao emphasizes finding QI topics through clinical passion and data-driven identification of performance gaps, using benchmarking with Vermont Oxford Network data. She co-mentors fellows in QI with Dr. Valerie Albertson and expresses enthusiasm for the Tiny Baby Collaborative, recognizing 22-weekers require distinct physiologic approaches.

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Dr. Ravi Patel, Professor at Emory University and Chair of the Georgia Perinatal Quality Collaborative, examines the tension between quality improvement and evidence-based medicine. He argues NICUs should prioritize high-certainty interventions (antenatal steroids, delayed cord clamping) rather than standardizing practices based on low-certainty evidence. Using tools like GRADE to assess evidence certainty helps determine when standardization is appropriate versus when practice variation allows for shared decision-making. Patel advocates re-energizing evidence generation as improvement in common morbidities has stalled. Examples like Eat Sleep Console demonstrate the value of prospective evaluation when adopting new practices. When evidence is uncertain, integrating family values and preferences becomes essential for individualized care decisions.

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Dr. Edgardo Szyld from Indiana University presents the PLANT study evaluating 20 minutes of prophylactic CPAP for late preterm infants (34-36+6 weeks) born via cesarean section. This population represents 70% of US preterm births and experiences five times higher respiratory distress rates with cesarean delivery. The pragmatic pilot enrolled 100 patients, demonstrating reduced NICU admissions without pneumothorax cases—addressing previous safety concerns from observational data. Szyld's team is planning PLANT 2, targeting 35-36 weekers across 11 international centers, which will compare outcomes with and without antenatal steroids. This pragmatic approach addresses a high-volume but understudied population significantly impacting NICU resources.

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Dr. Clara Song, Chair of the AAP Section on Neonatal-Perinatal Medicine, discusses urgent workforce challenges facing neonatology. With average neonatologist age around 50-55 and stable fellowship applications despite growing positions, the field faces potential shortages. The section launched initiatives addressing fair compensation, including a new website comparing negotiated commercial payer rates across states and engaging state chapters for payer advocacy. Song highlights concerning trends where neonatologist productivity increased while compensation decreased as the field became female-dominated. She discusses the section's comprehensive staffing toolkit and proposes restructured training pathways—potentially shortened residency with targeted 2-5 year fellowships—to attract trainees while ensuring adequate clinical preparation for increasingly complex neonatal care.

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Dr. Louise Owen from Royal Women's Hospital Melbourne presents the AEROPLANE trial comparing 21% versus 30% oxygen for 32-35 week infants at birth. This understudied cohort represents 80% of preterm births globally. Using cluster randomization with waived consent, the trial captured real-world practice across centers. Infants receiving 30% oxygen required less delivery room intervention including assisted ventilation, intubation, and chest compressions. Three-quarters of infants needing initial support continued requiring respiratory support beyond delivery. Both groups ultimately received average oxygen in the 50s, suggesting moderate preterm infants may behave more like very preterm rather than term babies regarding oxygen needs.

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As always, feel free to send us questions, comments, or suggestions to our email: [email protected]. You can also contact the show through Instagram or Twitter, @nicupodcast. Or contact Ben and Daphna directly via their Twitter profiles: @drnicu and @doctordaphnamd. The papers discussed in today's episode are listed and timestamped on the webpage linked below.

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