Thermoregulation of the Neonate with Dr. Emma Dune

Ben Courchia, MD:  Hello, everybody. Welcome back to the incubator podcast. We are back with another episode of our special series on thermal regulation of the neonate. And today we are joined by none other than Dr. Emma Dunne. Emma, how are you?

Dr. Emma Dune:  I'm very good, thank you. I'm very happy to be here. Thank you for having me.

Ben Courchia, MD: Yeah, we're very excited to have you on. For people who are not familiar with your work, I just want to go through your bio quickly. You are a neonatal trainee born and trained and raised in Dublin, Ireland. You're a final year higher specialist trainee in neonatology at the Royal College of Physicians in Ireland. You're currently working in the NICU at the National Maternity Hospital in Dublin.

As part of your PhD with the University College Dublin, you undertook a series of observational and interventional studies on temperature control in babies born prematurely. And we will be talking about that today. You've recently been awarded the Young Investigator Award for 2023 by the Imperial College of London. Congratulations on that. And yeah, thank you and welcome to the show.

Dr. Emma Dune: As I said, thanks a million for having me. I really am very privileged to be here and I'm equal parts intimidated and nervous, I'd say.

Ben Courchia, MD:  Nah, this will be fine, don't worry. So I guess my first question is, what led you to neonatology? What is the aspect of neonatology that you've liked, that pushed you to pursue this as a specialty?

Dr. Emma Dune: I guess when I started medicine, I actually wanted to be a pediatric oncologist. I spent a few summers in Tanzania with an Irish doctor named Trish Scanlon, who has a unit out there in Dar es Salaam. And that was kind of in my head. That was the only path and the only thing for me. And as part of our training in Ireland, you have a mandatory rotation through neonatology when you're training in pediatrics. So.

Ben Courchia, MD: Hmm.

Dr. Emma Dune: when I started that job, I actually realized that I loved that a lot more than paediatric oncology. So I was easily turned. I think what I love about it is I absolutely love the delivery room. I love the adrenaline of it. I like the privilege of being there at someone's birth at such an important time in their life and being able to have a skill set that you can really help out and you can really make things better.

Ben Courchia, MD: Yeah.

Ben Courchia, MD: Yeah.

Dr. Emma Dune: And as I progressed through that job and worked in the NICU when I was further on in my training, I think I really appreciated the continuity of care, the relationships that you can form with parents and kind of the, I suppose, the multidisciplinary aspect in neonatology. And further to that, then I got involved in research. So I'm all in. I'm committed.

Ben Courchia, MD: Mm-hmm. Yeah, that's cool. And for us in the US, it's a six year process, right? You do three years of general pediatrics with a lot of different rotations and various subspecialties, and then you make a decision to follow that up with a three year fellowship in unitology. Is that the same in Ireland?

Dr. Emma Dune: So the pathway is a little bit different for us and we don't have to decide immediately when we finish university which direction we're going. We do a year of kind of a mix of medicine and surgery. So we do that initial year, we do two years of paediatrics and basic training. And then for neonatology, it's a further two years of paediatrics as I suppose it would be an attending and then three further years as a neonatology attending and usually some research in between.

Ben Courchia, MD:  Wow, that's quite long.

Dr. Emma Dune: and it is, but I mean, I'm near the end of my training now and I feel like I have gained something from every part, but I don't think it's the journey, I suppose, as opposed to the destination. I've been very lucky to have great training and great mentors, and I'm gonna go on fellowship next July when I finish for a couple of years.

Ben Courchia, MD: Absolutely.

Ben Courchia, MD: Very nice, very nice. What kind of fellowship are you thinking of?

Dr. Emma Dune: I'm going to go to Melbourne to work in the Royal Children's and then the Royal Women's as well.

Ben Courchia, MD: Very nice. And so you said you got involved in research. And one of the subjects of this, the subject of this series is thermal regulation. What about thermal regulation attracted you to pick your interest? Was it like a mentor that was working on this that you just followed in their footsteps? Or was it something that piqued your curiosity?

Dr. Emma Dune: I would love to say it was the latter. I would love to say that I had kind of like an innate sense that temperature was important and I was really interested in it. But the truth is that I had a lot of respect and admiration for the two of my two mentors who are Lisa McCarthy and Colin McDonnell. They've done plenty of research in the delivery room and they do really pragmatic trials where they ask simple questions that give simple answers. I really liked the work.

Ben Courchia, MD: Ha ha ha!

Dr. Emma Dune: they did and I really wanted to work with them. So luckily an opportunity came up to do some work on thermoregulation. Lisa had, about a decade ago now, she had published a randomised trial of exothermic mattresses and polyethylene bags in the delivery room and she had a lot of unanswered questions that I think had been churning around in her mind. So I was more than happy to participate and to kind of pick up the slack from that and look into thermoregulation.

Ben Courchia, MD: Mm-hmm. Yeah, that's a great segue into our first topic of conversation because one of the subjects and the questions you've tackled are just trying to compare thermometers and see how they fare in their use in newborn infants. I mean, that's something that we have never even considered. I mean, how do we actually put back on trial the tool itself? Well, like the tool measures and we use the output of the tool to make a decision. But rarely do we think, well, how well is that?

How well is that tool doing its job? So can you tell us a little bit what you found about, was that a productive endeavor to check how thermometers compare with one another?

Dr. Emma Dune:  Yeah, I like this was the first thing that I did on my very first day as a research fellow. And we went down to the engineering department, we got a water bath, and we tested out various thermometers at different temperatures and compared them to a control. And I think that I don't think I realized it at the time, but sometimes I think that actually the findings of these two studies are the most important findings of all of my research over the last couple of years. So what we did find was that the thermometer that we really, it's really commonly used in Ireland, the Welch-Allen thermometer. It's designed, or as most clinical thermometers are, to detect pyrexia or to detect fever in patients, not specifically to detect hypothermia in preterm neonates. So preterm neonates in themselves are, they're a different physiological animal to children or adults, and they're more prone to fluctuations in temperature. 

And I think the prevailing problem in this population is low temperature, we needed to make sure that the device we were using could accurately pick up low temperature. What we did find that day in the water bath was that the commonly used thermometer, it constantly overestimated the temperature and it didn't actually give low temperatures. It more likely gave you a temperature within the normal range when the bath was cold. So we went on to test a couple of thermometers in a cohort of very preterm infants on admission to the NICU.

And what we found then was the commonly used thermometer, the Wellchallan, it wasn't sensitive at detecting hypothermia. And if we use those readings or those rates of abnormal temperature, we would have been reporting a rate of 90 percent normal temperature in our unit when actually it was only 40 percent. So we actually we thought we had no problem. But in fact, we had a massive problem. So I think, you know, in any centre, if you think that you have no problem with abnormal temperature in your preterm infants, just have a look at your device and make sure that it's validated for use or that it's been studied in this population.

Ben Courchia, MD:  How did you guys, I mean, it sounds like just the ground falling under our feet. So how did you guys address this to make sure that you could, first of all, it is such, I have so many feelings hearing this because you're like, man, if there's, we thought we were doing something good and now we're going to find out that actually maybe not. That's so frightening. But then how did you guys correct for that? What is the approach then? Just swap the thermometer for another one, or was there a correction factor that you guys applied? How did that end up fixing this?

Dr. Emma Dune: So what we did was we found that a kind of a standard digital thermometer that we tested, it accurately measured the temperature in these babies and it was very well correlated with the control thermometer in the water bath. So we decided that for all of our studies we would use that. We stopped using that thermometer in our unit and we've published the results of the studies. So what we really need to do is disseminate that information and just get people to check out the thermometers that they're using. You know, you could even very simply in your own unit, when you get a newborn pre-term infant, you measure their temperature with the Welch Allen thermometer and then measure it with a digital one. And if that baby is cold you'll more than likely see a difference.

Ben Courchia, MD:  Right, right, very interesting, very interesting. And so then from that, I think one of the things that you're working on right now, which is very interesting, is looking at how our care in the delivery room does impact thermal regulation. One specific aspect that you're investigating is the implementation, thankfully, of delayed chord clamping and how trying to abide by the tenets of delayed chord clamping may actually lead us to a place where we're going to see more hypothermia. Can you tell us a little bit about your observations and how is that leading you to your next project?

Dr. Emma Dune: Yeah, sure. So we, I think hypothesize that potentially with the implementation of delayed cord clamping and not having any guidelines for thermal care before the cord is clamped and potentially not doing anything before the cord is clamped, it's like it's biologically plausible. It's simple to think about it that babies can potentially lose heat loss, heat during that time. You know, they're wet, they're naked, they've gone from a warm environment to a cold, small preterm thin skin. The list goes on. There isn't that much research specifically about thermoregulation before the cord is clamped or thermal care before the cord is clamped and as a result there aren't any changes to the guidelines or any advice in the guidelines. So I think what we wanted to do first off was do some preliminary studies. We wanted to see, we looked at over 100 videos of preterm infants that were born in our delivery room since we introduced delayed cord clamping. And at our centre we do 60 seconds and what we looked at was the timing of thermal care.

So what was actually happening was the time to place the baby under radiant heat, the time to place them in a polyethylene bag and the time to place a hat was greater than the one minute that was recommended, that is recommended by the neonatal resuscitation guidelines. And that seems, you know, people would say, well, of course, if you're delaying cord clamping for a minute, it's going to take longer. But we just want to, I suppose, to highlight that and to actually document it in the literature. We then looked at babies admission temperature since the introduction of delayed cord clamping. And we found that 54% of our babies were cold. So over half of them were cold on admission. And the only comparator that we had that was a similar cohort of babies in 2013 before we introduced delayed cord clamping, where our admission hypothermia rate was 6%. So quite a dramatic increase. 

And all the only change that we could identify in our practice was the introduction of delayed cord clamping. So those preliminary studies, I suppose, formed the hypothesis for a randomized trial that we completed the Apollo OPB trial, where we looked at, in very preterm infants, we compared placing a polyethylene bag before or after the cord was clamped and what we wanted to see was did that result in more babies with a normal admission temperature. We recruited nearly 200 babies over a couple of years but we actually found that it made absolutely no difference whatsoever.

Ben Courchia, MD: Hmm. And so for those of us who are not familiar with the protocol, that means that basically the OB most cases who's at the surgical field will be the one putting the baby in the polyethylene bag while waiting for delayed cord clamping, clamp, and then pass the baby in the bag to the resuscitation team.

Dr. Emma Dune: Yeah, pretty much. What we do at our centre is a member of the paediatric team would scrub and they would enter the field with a sterile bag and we have some really nice videos. It's actually the OB and the neonatologist do it together. And I suppose it's a nice activity to do during that minute where people are kind of looking around and wondering and counting time and whatever. So it was really well received at our centre and our of the other specialties were very welcoming and very kind of facilitating of the research and support of it. So it worked it worked out well but unfortunately didn't make a difference in temperature.

Ben Courchia, MD: I'm floored by that. I mean, theoretically that makes so much sense. How do you guys, do you guys have any ideas to why it didn't work? Is that not, do you think that the polyethylene bag is not sufficient? Like you're again, I'm just speculating, but like is your OR room so cold that the polyethylene bag is not going to make that much of a difference? I mean, did you guys figure out what was, what was going on?

Dr. Emma Dune: I was floored too. I really thought that it would work and I suppose we can only speculate as to why we think it didn't work. I think that when you look at all of the trials that examine interventions to prevent hypothermia in the delivery room, all of them, bar one or two, use radiant heat in both arms. So you have an external heat source. These babies have very little ability to generate heat so you have to give them something from the outside.

Ben Courchia, MD:  Yeah. Mm-hmm.

Dr. Emma Dune:  In this trial, I guess, we only had the bag. So you're preventing heat loss. You're not providing any external heat. I think that may have been a factor. And I also think that maybe the 60 seconds is actually probably was not enough time to see a difference between the two interventions. I suspect that with a trend in some sectors, certainly across Europe, towards physiological base-cord clamping or prolonging the time to cord clamping that maybe an intervention like that might actually make a difference when you're going to have a longer time where the baby's on the cord.

Ben Courchia, MD: Right. What was the response from the community to both your hype? I mean, is the Apollo trial findings published or not yet?

Dr. Emma Dune: They're in peer review at the minute.

Ben Courchia, MD: And so what has been the response? Because I mean, so many institutions are using, so many institutions are using delayed cord clamping. Did you get like a wave of support, people trying to figure this out with you, or did you receive, I don't know, people saying, well, we're not seeing this. Like, we don't know what you're talking about.

Dr. Emma Dune: I suppose a mixer, you'll get a really mixed bag. I think there are some people who don't believe that babies are susceptible to heat loss during delayed core clamping. And they would cite things like the transfusion from the placenta before the mom's warmed blood will keep the baby warm.

Ben Courchia, MD: Mm-hmm. Mmm.

Dr. Emma Dune:  I think you're going to talk to Steve Falk at another time, who is one of the engineers with GE Healthcare. He does some amazing explanations of the biological, the physiological reasons that babies will lose heat during cord clamping. So I'll leave that to him. But I kind of think of it of in Ireland, over Covid, a lot of people got really into sea swimming. People had nothing to do, so they just went out and got into the really cold sea for a dip and found it very refreshing, but it's really, really cold. And I equate, I suppose, that statement that the blood keeps you warm to getting into the sea, then getting out of it and having a cup of tea with no clothes on and thinking that the cup of tea is going to keep you warm when you're wet and you're exposed to, I suppose, the ambient temperature. There's lots of other ways to lose heat, even if you're providing some heat to yourself internally.

Ben Courchia, MD: Yeah. Finish. No, no, please.

Dr. Emma Dune: Go ahead. Other than that, I think people have very different experiences at their centers. And I think one of the things is that Ilcor recommend a combination of interventions to prevent heat loss. And we don't know what combination is best. And there was a really good survey recently published by a group in Italy. They surveyed over 400 units in Europe and found that there's just a huge heterogeneity of the practice in the delivery room when it comes to thermal care. So most people will use polyethylene bags and they'll use radiant heaters. But amongst the other interventions like heated and humidified gasses and exothermic mattresses, there's like different variable uptake. So a lot of people will say when I present the results of this trial, we do this or we do this and or we don't have a problem with temperature or that our temperature or our center is reporting very high rates of hypothermia.

So I think in some instances people think that they don't have a problem and maybe they don't. Maybe they do, we'll see.

Ben Courchia, MD: Or maybe they do. Are you thinking about next steps for this project? Are you going to leave it there, or are you going to start looking at other parameters in your process of managing the baby right after delivery to see if you can maybe identify the possible cause for this?

Dr. Emma Dune: I'm certainly not going to leave it there. I think we have, you know, really, really only scratched the surface. And I think we've probably in some of the other studies that I'll talk about later on, we've kind of opened a can of worms, I guess. I think when it comes to the delivery room, there are lots, lots of potential options and ways that we could look at it. And it's about, I suppose, picking the best one or the one that you think is most likely to work.

And I, personally, I think, and I feel very strongly about how we monitor babies in the delivery room and why we don't monitor their temperature continuously and adjust their thermal care according to the individual. So if you compare that to, for example, respiratory support in the delivery room, we provide oxygen to babies and we titrate the oxygen according to their oxygen saturations at the time. We don't just say, let's give every baby 40% oxygen and then when they get to the unit we'll see what their saturations are and we'll be surprised when some of them are outside the normal range. I think that it's more appropriate to take a baby as an individual and to apply you know whatever a standard set of interventions and add or subtract according to the baby's response in terms of temperature. I think what that requires is it requires an accurate continuous temperature monitor and one that will stay on the baby. It will stay on their skin and that we can use accurately. I think that's probably, that would be my ideal and that would be my ideal to test out.

Ben Courchia, MD: Absolutely. As a trainee, the Apollo study is something you've been... This is what got you, I think, one of these investigator awards, if I'm not mistaken. And so what is the feeling as a trainee to get negative results? I know that we all believe negative result is okay because it tells you where the path ends and it directs you to a new path. And we all believe in this. But when it happens to you, you're like, damn.

So I'm just curious, how did you deal with these outcomes?

Dr. Emma Dune: I've actually never been asked that before, how it made me feel. I've been asked was I surprised, but never how it made me feel. I think that when you set out, you really think that your intervention has the potential to make a difference. So I'd say there is a feeling of disappointment. But also, I'm very satisfied. Like the results were almost identical between the groups. So the question is answered without shadow of a doubt. The sample size or the trial was adequately powered to detect a difference. I think that I will still stand by and I'm very proud of the fact that we wanted to test a really simple intervention that can be used by anyone in high income settings, in low middle income settings. It requires very little training.

We were testing something very basic and that question has been answered. So it is it's just on to the next thing. And I'm proud of my contribution to that.

Ben Courchia, MD: As you should be. But you know, I mean, I think I've been in your shoes where it's like, man, I was really hoping that we were going to stumble upon this gold mine. Like, oh, we figured it out. This is the intervention. You do this and it's fixed. And so now it's like back to more research. As a trainee, how did you manage navigating the, I guess, quote unquote, politics of the delivery room with OB and neonatology? I think it's always very difficult.

Dr. Emma Dune: Hehehe

Ben Courchia: I mean, either you're very lucky and your institution has a very homogeneous body of physicians that are collaborators, want to work together. But for many of us, sometimes it feels like we're quote unquote, almost bothering the OB with all the things that we're trying to do. We're trying to invade their space in the OR and so on. So I'm just curious if that's something that you ran into and if you have any advice on how to foster a good collaborative team in the operating room at the time of delivery.

Dr. Emma Dune: I think that I think I was like really fortunate in that the National Maternity Hospital between Colin McDonnell and Lisa McCarthy and then Madeleine Murphy who followed after there's a well-worn path of performing trials in the delivery room immediately after birth. So they've been kind of knocking around there and doing various different things and randomising babies in the delivery room. So the OBs and the anaesthetists and the theatre staff, they're used to that. I guess that prior to this trial there was the POPR trial, which was the prophylactic oropharyngeal surfactant after birth, where babies were receiving surfactant the moment they were born. So that involved also going into the sterile field. So again, the path was worn to the delivery room, but it was also worn into the sterile field.

And I think in terms of of acceptability of the intervention. It's about, I suppose, talking to all the relevant stakeholders beforehand, getting their opinion, seeing if they think that it's OK, and then just going through the various processes to ensure the theatre staff are happy with your sterile bag and your equipment and how you're going to lay it out exactly where you're going to go in. But I have to say it was a pretty, pretty smooth process. And I think that goes down to the culture in the National Maternity Hospital. So I was very lucky.

Ben Courchia, MD:  That's really good. I know you wanted to talk about some more studies, but you said something, Afair, that I wanted to maybe bring up because you mentioned how you are, we talked about the initial steps after resuscitation. We were talking about golden hour. And you said that for you, it's more like the golden two hours. Can you tell us a little bit about that and why are you changing everything?

Dr. Emma Dune: That was actually off the record.

Ben Courchia, MD:  But even if you can't share too much, but I'm just curious about the thought process. What is prompting you guys to think about this in a bit of a longer timeframe?

Dr. Emma Dune:  So actually what I meant by that was that we generally don't complete the allocated tasks within the golden hour. Not that we're extending the golden hour, it just tends to take a little bit longer. So that's what I meant by that. What we did do following on from the delivery room was we started to look at babies' temperatures immediately after admission. So kind of just continuing on from the delivery room, I guess. The very preterm infants, they're really at risk of heat loss by the exact same mechanisms that they've lost heat in the delivery room. You know they're going to be exposed for procedures, they'll be under radiant heat, then their incubator will be closed, so there's lots of times that they can potentially get cold. And what we did was another randomised trial after admission where we randomised babies to peripheral cannula. I don't know, is that what you would call it in the States? Where you just place a simple cannula in the babies.

Ben Courchia, MD:  We would say, I know what you mean by cannula. We usually call these peripheral IVs, versus the central catheter, the umbilical catheter.

Dr. Emma Dune:  Yes, yeah, so we compared the two of them with the thinking that a peripheral IV would take a much shorter time and a baby could kind of be in their closed incubator, humidified, all packaged up much quicker than if you put in a number like LeCaster. We thought that would improve temperature two hours of life, but what we actually found in that trial was that there was absolutely no difference, once again.

Ben Courchia, MD:  Mm-hmm.

Dr. Emma Dune:  That, I suppose, whether that came as a surprise or not, is not important. But what we did find was that we continuously measured the temperature of a very small cohort of babies in that study. So 25 of them from the minute they were admitted until two hours of life. And what we saw was that their temperature was actually really well controlled during procedures. But when we closed the incubator down and we transitioned from radiant to convective heat, their temperature dropped and it actually stayed low for quite a long time.

Ben Courchia, MD: Mmm.

Dr. Emma Dune: And we think that potentially the transition from radiant to convective heat actually may be a time where babies are at real risk of hypothermia. So that's something that's a can of worms that we've opened that we need to explore further down the line.

Ben Courchia, MD: Is that finding part of this report that you guys published in Acta Pediatrica? Is that the correct reference? 

Dr. Emma Dune:  Er, nope, nope. We haven't published that yet.

Ben Courchia, MD: Oh, you haven't published that. I'm so sorry. Okay. Cause I was, I was trying to like go back. I was like, man, I missed that.

Dr. Emma Dune: No, that's a new finding and something we were really surprised by. I suppose that goes back to my banging on about continuous temperature monitoring, but if we measure the temperature, for example, at two hours, that's a single point in time and you're actually missing out on so many other times where babies' temperature may be fluctuating going up and down or times where they're vulnerable to heat loss. So I think if I were to...

If I had loads of money and loads of resources and I could start something now, I would continuously monitor a baby's temperature from birth, you know, for the first, whatever, four or five hours, and really pick out the times where they're vulnerable to heat loss and then target them for, for randomised trials and for interventions.

Ben Courchia, MD:  Mm-hmm. Like in a two-step process, trying to identify these windows of time and then trying to find the intervention. That's very interesting. Do you feel like thermal regulation is a topic that, as we've discussed, you've mentioned a few more ideas. As you are embarking on your career, I think as trainees, sometimes we always have this anxiety of like, am I going to be typecast as the thermal regulation person? And your worry is that, is that aspect of neonatology going to be fruitful enough to give me enough material to feed some of my research interests? Is that something you're feeling like you could spend your career looking at or do you feel like this is a well that might run dry in the near term? Or are you even thinking about that?

Dr. Emma Dune: I'm very happy to pursue thermoregulation for the rest of my career. I think there's more than enough there. I think there's plenty to look at in the delivery room. There's loads to look at after the babies are born. Despite all of the decades of research and the fact that we've known for hundreds of years that babies getting cold or having abnormal temperatures is bad for them and puts them at risk of death, we're actually still really bad at it. So...

Ben Courchia, MD:  Mm-hmm.

Dr. Emma Dune: I can commit the rest of my life to that and I'm sure we still won't be very good at it. So any small improvements are good for me. I think I've been typecast already. Some people call me the bag lady.

Ben Courchia, MD: That's not nice. They could have find a better, a better, a cuter name for that. I mean, the bag lady sounds very morbid somehow. But yeah.

Dr. Emma Dune: Yeah.

Yeah, I mean, I'm OK with that. I don't mind. And I thought as well, listening to one of your previous episodes with Anne Hanson from Boston Children's, I was absolutely fascinated to hear about the dream warmer in terms of, like, I suppose, thinking of thermoregulation in low and middle income countries. But she also spoke about, you know, the version 2.0 that may actually that would have potentially can be plugged in. So you're eliminating the need for the thermos. And I think there are lots of kind of ideas and modifications you could make to that. And that could actually be really, really important in thermoregulation in the kind of the years and to come down the line. I think she's on to something really good.

Ben Courchia, MD:  Mm-hmm. I think so. I think she's a very innovative person and yeah, very excited to see what she comes up with. She's a perfectionist and so I think it's very cool to see what she comes up with. We asked this question to every guest this week and I think it's an interesting one. As you're taking a 35,000 foot view of newborn care thermal regulation, it's something we've known about forever, right?

Dr. Emma Dune: Mm-hmm.

Ben Courchia, MD: People have been putting babies in shoe boxes and in ovens to try to keep them warm since the dawn of time. And we're now in 2023. We're about to go into 2024. And we're still, like you said, we're still not very good at it. And this is probably one of the first few aspects of neonatal care that we've known of. Why do you think, what has been the problem in us not attaining a level of excellence when it comes to thermal regulation that would have been expected of our field, considering how much time we've had to address it?

Dr. Emma Dune: I think that's a really good question and I'm not sure if my answer will be adequate. I think that thermoregulation is not cool and it's not sexy, you know, it's not intubation, it's not echoes, it's not fancy tech and fancy machinery, it's very rudimentary and you actually you can't see it and I think that again that comes down to things like why do we monitor oxygen saturations continuously? Like why has that come about and why is that important? And why do we titrate and focus things on that? If we, I think if we had a continuous temperature monitor and people could see that the baby was cold or that the baby was hot and there were alarms, a lot more attention would be paid to it. And potentially we could be a lot better at it. I think you can't really be good or you can't improve on something that you can't see.

Ben Courchia, MD: Mm-hmm. That's a good, that's a good answer. It is.

Dr. Emma Dune:  And I think really important is, I suppose, raising awareness about the importance of it and then providing education. And a lot of it will come down to like simple, pragmatic things. I know you have you, Jessica Jones, on as well on a different podcast. She did a really interesting webinar, which I watched about thermal care and lots of the things were like really simple, practical things. Like if you're.

If you're raising the canopy of the incubator, you cover the baby in a plastic sheet. Like there are basic things that I think people don't think about a lot of the time or they're not thinking about temperature, particularly if it's an emergency situation. It's the last thing on someone's mind. So I think it's important to kind of to bring it to the forefront and raise awareness about it and hopefully attract more people to research it.

Ben Courchia, MD:  Very nice. As we're getting to the end of our time together, I'm just curious about, you've talked about continuous temperature monitoring. Any other aspect of thermal regulation that gets you excited or the future of thermal regulation that could get you excited? It doesn't really have to be grounded in anything, but I'm wondering, do you look at really the democratization of AI and stuff like that and think, oh, that's a cool tool I could potentially use in our arsenal to try to promote thermal regulation in our neonates. Anything like that, anything that anybody else is doing around the world that gets you excited for the future.

Dr. Emma Dune:  I think I've already mentioned, I think the Dream Warmer is, that's the most exciting thing I've heard about in a long time. I think it's amazing and I think future iterations of it or different versions of it for different settings and different socioeconomic settings will be really important. I think functions like, you know, if you had, do you know the tectotherm mattress that you use for neonates that are undergoing therapeutic hypothermia?

Ben Courchia, MD: Yep.

Dr. Emma Dune: Why can't we have something like that for a preterm neonate where you actually, you're using a servo control and providing, I suppose, the environment that they need to maintain their temperature.

Ben Courchia, MD: Going back to the first question that we talked about, I think some of the origin story of your career in pediatrics and neonatology starts with a concern and an appreciation for global health. Is that something today that when you're looking at thermal regulation, you're thinking of in terms of a solution that has to be found that would be accessible to everyone?

Or how do you think of low and middle income countries in the ongoing research for thermal regulation?

Dr. Emma Dune: Yeah, I think that was that was kind of central to our planning for the trial when we were sort of coming up with what we were going to what intervention we were going to test. We wanted to test something simple, something cheap, something that's readily available that anybody can use. And that's why we chose the timing of the polyethylene bag. And, you know, people were like, why don't you use a mobile resuscitation trolley or something like that? But they're not accessible to everyone. They're, you know, they're in specific centers, the results aren't widely applicable. So certainly with the group that I work with in the National Maternity Hospital we're always considering can our interventions be applied widely, as widely as possible across the world. So yeah for sure we're considering everyone when we design our research.

Ben Courchia, MD:  Love to hear that. Emma, thank you so much for making the time to be on with us. This was a super interesting conversation and I'm gonna be looking out for, you publish a lot in archives. So I'm gonna be looking in archives for an upcoming publication on continuous thermal regulation. And yeah, I mean, I think the way you're, I'm both, I'm ambivalent now because the way you presented, I'm like, yeah, for sure. Like that makes absolute sense. But as we've spoken on this podcast, sometimes even the things that make sense, you do the study and it comes out to be like, yeah, well, maybe not. So.

Dr. Emma Dune: Hehehe

Dr. Emma Dune: Mm-hmm.

Ben Courchia, MD: But I do think you're onto something when it comes to continuous temperature monitoring. So good luck with that and congratulations on already having a pretty impressive publication list as a neonatal trainee. Yeah, congratulations on that.

Dr. Emma Dune: Thanks so much for having me. It was a real pleasure.

Ben Courchia, MD: Same here, Emma. Thank you.

Dr. Emma Dune: Okay.