Inside Pediatrics

A statewide network for parent-child interaction therapy

Arista Rayfield, Ph.D., (middle) and the Children’s behavioral health team hosted a PCIT conference in March 2026.

When Ashley Pittman, LPC, signed up for parent-child interaction therapy (PCIT) training at Children’s of Alabama in 2023, she had no idea what to expect. Even after earning her certification, she realized it was like no other therapy she had offered. But an experience with one of her first PCIT clients was a revelation.

“At first, I was… a little bit out of my comfort zone,” she said. “But then I started to see results, and I started to recognize just how beautiful it was.”

Pittman is a licensed professional counselor in Enterprise, a small, rural city in south Alabama. Since her training, she’s seen many PCIT clients, including one who had a profound impact on her view of the therapy, which helps to correct moderate-to-severe behavioral problems in young children by teaching the parent and child how to interact effectively. During one of the sessions, the mom began to cry. “It was a very beautiful moment where she was truly connecting with her kid,” Pittman recalled. “And she told me that she felt that she had never been able to do that, did not know how to do that, and that she herself probably never felt connection with her own parents.” For Pittman, the moment was eye-opening.

“It came alive within me that there was beauty in what was happening with PCIT that I just fell in love with and became very passionate about,” she said.

Pittman says moments like this happen frequently with her PCIT clients, who make up about two-thirds of her business. And they’re likely happening with other counselors and clients across Alabama thanks to Children’s of Alabama’s commitment to training providers like Pittman.

How PCIT works

Shelia Eyberg, Ph.D., developed PCIT at the Oregon Health Sciences Center and later refined and researched it at the University of Florida. She designed it as a way to treat disruptive behavior disorders in young children. These behaviors can include tantrums, refusal to follow directions, aggression, and problems in school. For families experiencing these problems, a therapist trained in PCIT can determine if it is the right fit.

PCIT works by allowing the therapist to monitor and coach a series of playtime interactions between the parent and child. It is conducted in the play setting because that is how young children learn best. This happens in two phases: Child Directed Interaction (CDI) and Parent Directed Interaction (PDI). In CDI, the therapist teaches the family skills that a play therapist would use. In PDI, the therapist teaches parents how to be consistent and predictable to improve how children follow their directions. Then, during the interactions, the therapist watches from another room, usually behind a one-way mirror, and coaches the parent using a wireless earphone. Families typically complete PCIT in 12 to 16 weeks, and the results can be transformative.

“It has a huge impact,” said Arista Rayfield, Ph.D, who learned the therapy under Eyberg and serves as the PCIT service line leader at Children’s. “Behavioral problems are decreased. Parent-child relationships are improved and are very warm, supportive relationships. Parents quit getting calls from teachers. That is a big improvement.”

Coaching is what makes PCIT uniquely effective. “We are teaching [parents] the skills, and so we try to focus on when they’re getting it right: ‘We want to see more of this. You’re doing a great job following their lead,’” Rayfield said. “So, we’re really trying to focus on what the parent is doing well and help them make the changes sometimes that are pretty small and you’re not aware of unless someone is observing you and helping give you feedback on your interactions.”

This observation gives the therapist an up-close view of the child’s progress. “It’s wonderful working with young children because you see the changes happening in the moment,” Rayfield said. “I see the techniques working within the very session that we are in. I see children making changes based on how the parent is interacting with them.”

Training Other Therapists

Rayfield has been training parents on how to interact with their children for 35 years, but in 2022, she, her Children’s colleagues, and two other University of Florida graduates—Elizabeth Brestan-Knight, Ph.D., and John Paul Abner, Ph.D.—began training other therapists in Alabama on how to perform PCIT. The trainings are possible through a partnership with the Alabama Department of Mental Health (ADMH) and are supported by two grants, the Pediatric Access to Telemental Health Services (PATHS) grant and the Promoting Positive Early Experiences and Relationships (PPEERS) grant. So far, the group has trained 69 therapists across 21 Alabama counties to provide PCIT.

“That has made a huge difference in access for children across our state. Everybody can’t drive to Birmingham to get treatment,” Rayfield said. “That means that families can get access to treatment without a long wait list and closer to their home.”

Rayfield and her team have also trained several providers across the state to become within-agency trainers, meaning they can train others within their own agency on how to perform PCIT. This multiplies the number of PCIT-certified therapists statewide.

In March, Children’s and ADMH hosted a PCIT continuing education conference for the therapists they have trained, those in the process of training, and others who might be interested. “There’s a wonderful community internationally with PCIT, and we’re trying to build that in our state to help people feel supported and to be able to continue to provide this therapy for young children,” Rayfield said.

But Rayfield’s influence doesn’t end at the state line. In 2025, she became a regional trainer through PCIT International. She’s one of only about 50 such trainers nationwide.

Children’s investment in PCIT

In the last five years, Children’s has ramped up its investment in PCIT. In addition to the training the behavioral health team has provided across the state, they’ve also added more PCIT-certified providers within their department and built a space specifically designed for PCIT. The goal is to increase access for children across the state. Simply offering PCIT can help achieve that. Rayfield says the therapy is designed to help the child graduate the program so they no longer need therapy, which frees up space for more children who need help—more children who can be served by the growing network of PCIT providers Children’s is developing throughout the state.

July 29, 2026 by childrensal

Cardiology

A bridge to better outcomes

The bridges that connect UAB and Children’s of Alabama play a key role in the Bridging the Fetus collaboration.

Among the crucial features of Children’s of Alabama’s Benjamin Russell building, which was added to the hospital’s campus in 2012, is a set of bridges that connect Children’s to the University of Alabama at Birmingham (UAB) Hospital. The two institutions have worked in partnership for decades, and the building and adjoining bridges further enhanced the relationship. Specifically, they allowed for patients to be transported efficiently from one hospital to the other when necessary for care. A collaboration called Bridging the Fetus takes advantage of this arrangement to help patients with congenital heart disease. It’s helped save many lives, even in some of the most dire situations.

The collaboration involves the Children’s cardiovascular ICU team, cardiologists, cardiac surgeons, UAB’s Maternal-Fetal Medicine team, and neonatologists. And the bridge, of course, which is perhaps the program’s most unique feature.

“The setup we have with the bridge is a big deal for us because it allows us to best take care of moms but also best take care of babies by being so close,” said Laura Brasseale, MSN, CRNP, chair of the Children’s cardiac fetal team.

Proper care for both the mom and baby is vital in these cases because many of the congenital heart diseases the team handles are identified prior to birth. Thus, the team must have a detailed plan in place for delivering the baby at UAB, then getting it to Children’s for care while the mom remains at UAB. Thanks to the bridge that connects the UAB Women and Infants Center to the Children’s Heart Center, the transfer can happen in mere minutes. As a result, Children’s and UAB have taken referrals from other parts of the Southeast in these cases where, in another city, the delivering hospital might be 20 minutes or farther away from the Children’s hospital. “It is very unique to our situation that we have all these resources literally connected to each other,” Brasseale said. Few other hospitals in the Southeast offer this type of setup.

The collaborative effort of Bridging the Fetus begins as soon as a patient is diagnosed with a congenital heart disease. Brasseale follows each case and takes information from the mom’s clinic visits with obstetricians and cardiologists. She uses this info to compile a list with data to help the team plan for the delivery. Before the baby is born, the team provides advice and counseling for the parents. They also arrange logistical services, such as transportation assistance, long-term stay options and other resources. Lactation specialists meet with the mom to discuss feeding options and the importance of breast feeding. Palliative care assists with end-of-life decisions, if necessary.

From the time the diagnosis is made, members of the team meet regularly to discuss details of the case and form a plan of care for the child’s delivery. “It just makes us aware so that we save beds for these neonates,” Brasseale said. “We get them transferred over from [the UAB Regional Neonatal Intensive Care Unit] as soon as possible so that we can plan their next steps after birth.”

Typically, the next steps involve taking the child across the bridge to be seen immediately by the heart team and undergo and operation shortly thereafter. The mother, meanwhile, remains at UAB to be cared for at the Women’s and Infants Center.

Cases like these are highly complex, Brasseale said. And the biggest challenge is the simple fact that no one knows when the baby will arrive. But Bridging the Fetus streamlines that for everyone. “We plan according to your due date, according to whether mom has any pre-existing conditions, whether she’s had other children before, where they live. All of that plays a factor in terms of how we plan for delivery on these babies.”

Because of the planning, the team will know if the baby needs immediate care or if they can stay in the NICU for a few hours until a bed opens up. “It’s definitely a good heads up and provides a multidisciplinary approach for the family,” Brasseale said, “because Maternal-Fetal Medicine can refer them to genetic counseling and the neonatologist so the family can meet a wide variety of people before having the baby. So it can kind of calm nerves as far as that goes.”

The team also prepares the family by giving them hospital tours beforehand so they’ll get “an up-close look of who is going to be taking care of their baby and what their baby’s future looks like,” Brasseale added.

The most notable success stories owed to Bridging the Fetus involve babies with hypoplastic left heart syndrome with intact atrial septum. Babies with this condition lack intracardiac shunting, so oxygenated blood can’t reach the body. Most require immediate extracorporeal membrane oxygenation (ECMO) cannulation after birth to increase the chance of survival to palliative surgery.

Children’s and UAB have seen four such cases since they started Bridging the Fetus in 2016. Three of the babies were cannulated onto ECMO within 15 minutes of birth. Two had successful heart transplants. The results far exceed those at other centers, Brasseale says, and it’s due to the team’s coordinating and multidisciplinary approach. Just getting everyone on the same page has a complexity of its own, with multiple service lines involved and each one featuring 10-20 people with rotating on-call schedules. “There are so many players. I think that’s the biggest part,” Brasseale said. “So it’s just nice for the information to all be in one place considering there’s so many different people who need to be involved.”

The team also is participating in research related to its work with Bridging the Fetus. One study is taking a look at how delayed cord clamping among neonates with congenital heart disease can effect neurodevelopmental outcomes. Another is a collaboration with the Pediatric Cardiac Critical Care Consortium (PC4) and aims to advance understanding of the maternal-fetal environment and its influence on postoperative outcomes in children with congenital heart disease. “The role of maternal characteristics in postnatal outcomes is a major knowledge gap in the treatment of congenital heart disease,” Brasseale said. “Identifying these prenatal risk factors is the first step toward developing therapeutics to modify them.”

The team hopes these studies will pave the way to a better understanding of these highly complex neonates, which can only help further streamline their care and produce more positive outcomes.

“It’s really cool to see the team come together to provide the best care for the patient, because it’s a lot of different people from a lot of different disciplines and even hospitals,” Brasseale said. “But it’s very exciting to see a baby thrive that was really not destined to have a good outcome. So it’s very exciting to be a part of such a big team.”

July 29, 2026 by childrensal

Pulmonology

Teaching youth about the dangers of vaping

More than 5% of all middle- and high-school students say they use vaping devices. (Stock photo)

When Children’s of Alabama pediatric pulmonologists Isabel Lowell, M.D. and Brett Turner, M.D. speak to kids or their parents about vaping—which remains prevalent in middle- and high-school students despite a simultaneous decline in cigarette smoking—they continually find themselves battling the misconception that vaping is somehow safer.

Social media and advertisements for vapes, which are marketed in hundreds of teen-tempting flavors, have convinced kids that vaping isn’t the major health threat it is. But Lowell and Turner vigorously dispel such myths as part of a Youth Tobacco Prevention Program run in partnership with the Children’s of Alabama Tobacco-Free Task Force.

According to the U.S. Food and Drug Administration’s National Youth Tobacco Survey, about 5.2% of all middle- and high-school students say they use vaping devices, and 27.5% of those say they use these products every day.

“We’re uniquely positioned to take this on, since it’s an issue that affects both patients and families,” said Turner, who’s also the medical director of Children’s Respiratory Care Services and an associate professor of pulmonology at University of Alabama at Birmingham (UAB).

“This has been a very important part of how we provide education about vaping not only to kids in the community, but the Department of Pediatrics and the Division of Pulmonary Medicine,” added Lowell, who’s the medical director of Children’s Pediatric Pulmonary Care Unit and a professor of pulmonology and sleep medicine at UAB.

Lowell and Turner took over the program two years ago. Funded by a grant from the Alabama Department of Public Health, it involves several goals, including:

Teaching about the dangers of vaping to at least 1,000 students in grades 5 through 12 in Birmingham and the surrounding areas.
Providing anti-tobacco and vaping information at four or more community events.
Working with students at local middle schools and high schools to train them on vaping and facilitate their ability to lead peer-to-peer presentations.
Conducting 10 community adult presentations on the dangers of smoking and vaping.
Creating social media content on vaping to post on Alabama Department of Public Health social media sites.
Providing material and resources on vaping to school nurses and counselors, as well as answering questions.
Conducting assessments of vape and cigarette advertising at local gas stations and other retailers who sell vapes.

Independently of the grant, Lowell and the Pulmonary Asthma Team are surveying adolescents at Children’s severe asthma clinics on the use of vapes and cigarettes, as well as second-hand exposure. While anyone who vapes is exposed to many toxic chemicals that can damage and inflame airways and compromise the immune and cardiovascular systems, “in kids, there are harmful effects on the brain, affecting learning, impulse control, and mood,” Lowell said. “Vaping can also be especially dangerous for children with underlying lung disease.”

“We often see adolescent patients struggling to compete at the same level sports-wise as they had, feeling like they can’t take a deep breath,” Turner explained. “As we dig deeper into their social habits, we discover they’re vaping and that the timing of their respiratory symptoms aligned with when they developed chronic vape use.”

During their school presentations, Lowell and Turner also dispel the popular misconception that using nicotine boosts mood. In contrast, it “becomes something that drives more worry and fear and mood swings,” Turner said.

Students seem very open to the program’s message, Lowell and Turner say, and they plan to continue the program as long as funding remains. “We also provide them with resources to quit,” Lowell added. “If they’re vaping, they know there’s help out there, and people and programs they can go to that will help them without punishment.”

July 29, 2026 by childrensal

Neonatology

Research reveals optimal approach for patent ductus arteriosus

An X-ray shows a patent ductus arteriosus (File photo)

Doctors have long debated whether very premature babies with patent ductus arteriosus (PDA)—a cardiac condition where a blood vessel that normally closes shortly after birth remains open, stressing the heart and lungs—should be immediately treated with medication to close the vessel, or whether it’s better to wait and see if the vessel closes on its own.

Compelling new research by Children’s of Alabama neonatologist Waldemar A. Carlo, M.D., reveals important answers. Along with researchers from 32 other hospitals across the United States, Carlo sought to learn whether simply monitoring infants and intervening only if needed, compared with actively treating PDA, improves survival or reduces serious lung problems.

Results of the study, published last December in JAMA, surprised even Carlo. Monitoring infants and intervening only if needed, rather than treating the PDA up front, improved survival or serious lung problems—the main outcome—with the rate of developing bronchopulmonary dysplasia (a serious chronic lung disease) essentially the same in both groups. Notably, however, babies in the watch-and-wait group were significantly more likely to survive: 4.1% of infants in the expectant management group died, compared to 9.6% of those in the medication treatment group.

“I don’t think anyone was expecting to see such a large difference in mortality,” said Carlo, who’s also the Edwin M. Dixon Professor of Pediatrics and director of the Division of Neonatology at the University of Alabama at Birmingham (UAB).

PDA is the most common cardiovascular condition in preterm infants, and Children’s clinicians monitor or treat about 100 babies with the condition each year. Occurrence of PDA jumps to more than 50% for extremely premature infants such as the 482 included in the study, who were all born between 22 and 28 weeks of pregnancy.

“PDA tends to be present in the sickest premature babies with the worst outcomes, which is why there has been a lot of interest in closing the PDA,” Carlo says. “But the data have been controversial on whether these babies need treatment or not.”

A small PDA might cause no symptoms and resolve on its own. Larger ones can lead to a variety of dangerous complications, including rapid breathing or shortness of breath, poor feeding, failure to thrive, fatigue, and frequent respiratory infections. In the study, which was carried out as part of the National Institute of Child Health and Human Development Neonatal Research Network, expectant management proved superior to all medications or other approaches used in babies randomly assigned to active treatment, including acetaminophen, ibuprofen, or indomethacin as well as surgery.

“Treatment to close the patent occurred in both groups, which is mimicked in clinical practice,” Carlo said, “and none of the treatments really had a benefit. The study design was pragmatic and easy to implement. It can help clinicians in a practical way.”

The trial reinforced how neonatologists at Children’s have long managed PDA, Carlo noted, but participating in such a high-profile, comprehensive effort benefits everyone involved.

“Our patients can take advantage of state-of-the-art care through randomized, clinical trials and innovative inventions. The trial is funded by the government, and the government benefits because we find out what are the right treatments in these patients,” Carlo said. “It’s a win-win situation.”

July 29, 2026 by childrensal

Hematology and Oncology, Orthopedics

Combining two specialties, Hess plays unique role at Children’s

Matthew Hess, M.D. specializes in pediatric and adult orthopedic surgical oncology.

After witnessing his beloved drum teacher cope with sarcoma, Matthew Hess, M.D., knew starting in high school he wanted to someday work in oncology. That fraught life stage also brought a variety of orthopedic injuries that piqued Hess’s interest in orthopedics. Then he learned he could combine the two specialties by performing orthopedic surgery on children and adults with cancer.

The result has benefited patients at Children’s of Alabama. Hess, who came to Children’s in September 2024, is the only specialist in Alabama who’s trained in both pediatric and adult orthopedic surgical oncology.

The conditions Hess tackles are fairly uncommon, he notes, attracting only about 20 new fellows nationwide to his dual specialty each year. In children, he most often treats osteosarcoma, Ewing sarcoma, and non-cancerous tumors that are locally aggressive and threaten to destroy bone. In adults, Hess usually sees patients with metastatic cancer that has spread to bone and requires surgical stabilization or reconstruction.

Also an assistant professor of orthopedics at the University of Alabama at Birmingham (UAB), Hess—who earned his medical degree from the UAB Heersink School of Medicine and spent his residency at UAB Hospital—was thrilled to come back into the fold by joining Children’s.

“I had some faculty members who put teaching and mentorship at the forefront of practice and inspired me to want to do that for the residents around me,” he said. “The thing that stood out to me was that they were extremely collaborative.”

Hess is using that example well. His role requires extensive collaboration with a wide variety of other highly trained physicians, including medical oncologists, pathologists, and musculoskeletal radiologists. Children’s and UAB also boast a cross-institutional collaboration group designed for adolescent and young adult (AYA) patients—those ages 15 through 39—in which Hess features prominently because of his skillset.

“AYA patients exist right in the middle and can get a little lost in translation—do we treat them like an adult, or like a kid?” Hess said. “Osteosarcoma in particular is pediatric, but we see it a lot in teenagers and college students, who are trying to start to be adults. I tend to be the one who helps facilitate which team they end up seeing.”

While there’s some overlap between the way pediatric and adult orthopedic oncology patients are treated, children have certain unique considerations, Hess noted—“namely, a long life ahead. Sometimes you can make different decisions for someone who’s 70 years old versus someone who’s 7,” he said. “Mostly it comes down to how we choose to get rid of the cancer and keep their limb functional.”

What Hess enjoys most about his role is the continuity of care. Ideally, pediatric sarcoma patients who undergo successful surgeries—often living with metal implants in a limb—need a specialist to monitor and treat them through many decades. Hess is happy to oblige.

“I have patients who had surgery with another surgeon 20 years ago and are now 35, and we’re doing revision surgery together to keep them walking and fully ambulatory,” he said. “You’re the continuity person for these kids when they become adults, because the cancer is gone but they’re still dealing with the repercussions.”

“Every orthopedic oncologist goes into the specialty with the dream of seeing the kids they treated in their first years of practice come back someday having had their own kids,” Hess added. “I don’t think you get to do that in most medical specialties. It’s very exciting.”

July 28, 2026 by childrensal

Endocrinology

Helping Teens with Diabetes Move to Adult Care

Christy Foster, M.D., leads a new clinic that helps prepare adolescents for the transition to adult care.

For adolescents with diabetes, moving from pediatric to adult healthcare can be one of the most vulnerable periods in disease management. Studies have shown that gaps in care often occur during this transition, increasing the risk for complications such as worsening glycemic control and diabetic ketoacidosis.

To address this challenge, Children’s of Alabama recently launched the Bridge Clinic, a dedicated program designed to help adolescents and young adults with type 1 and type 2 diabetes gain the skills and confidence needed to successfully navigate healthcare independently.

The clinic, which officially began seeing patients this spring, provides a structured, multidisciplinary approach to transition planning for patients beginning at age 16 and continuing through their move to adult endocrinology providers.

“We really want to help patients build confidence over a couple of years before they leave pediatric care,” Christy Foster, M.D., assistant professor in the Division of Pediatric Endocrinology and physician in the Bridge Clinic, said. “Our goal is to partner with them so that transitioning into adult healthcare doesn’t feel abrupt or overwhelming.”

The idea for the clinic grew out of a healthcare transition workgroup that has spent several years refining educational tools and identifying ways to improve continuity of care for adolescents with diabetes. Although transition topics are already incorporated into routine endocrinology visits, Foster says the Bridge Clinic offers an opportunity to explore those issues more intentionally and in greater depth.

Patients in the Bridge Clinic continue seeing their primary endocrinologist every three months, while alternating visits with the clinic approximately every six months. During those visits, they work with a multidisciplinary team that includes physicians, diabetes educators, dietitians, and social workers.

One of the clinic’s distinguishing features is its encouragement of adolescents to take a more active role in their own healthcare. Patients are asked to spend at least part of their visits independently with providers, allowing them to practice discussing concerns, asking questions, and making decisions about their diabetes management in a familiar and supportive environment.

“We’re trying to create a safe place where patients can gain skills for navigating the healthcare system while still having the security of their family being involved if needed,” Foster said.

For many patients diagnosed in early childhood, this may be the first time they are expected to discuss concerns directly with their provider, describe their medications, or discuss adjustments to insulin doses without relying on a parent.

The clinic also focuses heavily on practical life skills that become increasingly important as teenagers gain independence. Topics include learning how health insurance works, understanding prescription costs, requesting medication refills, navigating college life, driving safely with diabetes, and managing alcohol use.

Rather than simply providing information, the Bridge Clinic emphasizes hands-on learning.

Patients may be asked to complete “scavenger hunts” between visits to determine the out-of-pocket costs of medications, practice refilling prescriptions, or explore insurance options available through college, employment, or other coverage plans. The team then reviews those experiences during follow-up visits and helps troubleshoot any challenges.

Social workers collaborate closely with families to discuss changes that often accompany young adulthood, including moving into dormitories, entering the workforce, or transitioning to a different insurance plan. Dietitians address healthy habits and nutrition concerns that become more relevant as adolescents begin making more independent choices.

Another key objective of the clinic is to reduce the number of patients who lose care during the transition from pediatric to adult endocrinology.

“We know from the literature that this is a high-risk period for gaps in care,” Foster said. “Anything we can do to help prevent that gap and maintain continuity has the potential to make a meaningful difference.”

As patients approach adulthood, the Bridge Clinic team helps identify an adult endocrinologist, prepares a transition summary letter, and guides patients through establishing care with a new provider.

The clinic currently has the capacity to see approximately 30 patients per session and serves a population of more than 800 patients aged 16 and older with type 1 or type 2 diabetes.

Although the program is still in its early stages, Foster hopes it will become an important resource for families seeking additional support during a period that can feel daunting for both patients and parents.

“This is really about giving young people the opportunity to practice being successful adults with diabetes,” Foster said. “If we can help them gain knowledge, confidence, and independence before they leave pediatric care, we’ve given them a stronger foundation for lifelong health.”

July 28, 2026 by childrensal

Urology

Boswell leads effort to adopt minimally invasive approach for primary obstructive megaureter

Timothy Boswell, M.D., is one of the nation’s experts on primary obstructive megaureter treatment.

For about 80% of infants with primary obstructive megaureter (POM)—a relatively rare congenital condition in which the ureter is abnormally narrow where it enters the bladder, hindering urine flow—the problem resolves without treatment as the baby grows. For the rest, open surgery has long been the standard approach.

Children’s of Alabama pediatric urologist Timothy Boswell, M.D., is trying to change that. Inspired by European research on, and relatively widespread use of, a minimally invasive technique called high-pressure balloon dilation (HPBD) on children with POM, Boswell is leading the charge to make the option more common in the United States. By doing so, he hopes to minimize pain and other surgical complications for these children.

He and Children’s colleagues have been offering this minimally invasive treatment to the small number of patients needing intervention for POM. HPBD is an endoscopic technique that uses a high-pressure balloon to stretch the narrowed section of the ureter, and it can be a highly successful first-line intervention.

Open reconstructive surgery, called ureteral reimplantation, involves removing the narrow segment of the ureter and reattaching it to the bladder so urine can flow freely. An interim procedure called a ureterostomy can redirect the ureter to a stoma in the abdomen, allowing urine to bypass the bladder and drain directly into a child’s diaper. A ureterostomy eventually has to be reversed, and the ureter reimplanted.

Some type of intervention becomes necessary when children with POM experience recurrent urinary tract infections, kidney or ureteral stones, pain due to the obstruction, or worsening dilation with decreasing renal function.

“Open surgery involves a several-centimeter incision, pain, and staying in the hospital at least one night, and it’s challenging to do in babies under 1 year old,” said Boswell, who’s also an assistant professor of pediatric urology at University of Alabama at Birmingham (UAB). “But it has a greater than 95% success rate.”

However, Boswell authored a February 2024 study in the Journal of Pediatric Urology that suggested that HPBD is a promising alternative. Evaluating the outcomes of using HPBD in 15 infants under 1 year old with progressive or symptomatic POM and tracking participants for an average of 2.9 years, he and his colleagues found the minimally invasive approach to be successful in 80% of cases, sparing most of the babies from subsequent invasive open surgeries.

Because no incisions are involved, HPBD is potentially safer than open surgery and can be done in younger babies, Boswell notes. “As of the 2010s, only a couple of centers in the United States were doing it,” he said. “We’ve been doing it at Children’s since 2023.”

Boswell, who spoke on the topic at the American Academy of Pediatrics Section on Urology in September 2025 and continues to publish papers, hopes more institutions will consider HPBD for children with POM. He also wants to spearhead research that would directly compare the open and minimally invasive approaches for a clearer picture of the pros and cons.

“We know we can do this procedure without needing an incision, but there have never actually been good comparative studies,” Boswell said. “I hope pediatric urologists across the country and world can band together to deliver well-designed studies to see what’s best for patients.”

July 28, 2026 by childrensal

Nephrology, Urology

A New Pathway for Prenatal Hydronephrosis

A model of the kidney (Stock photo)

A multidisciplinary team at Children’s of Alabama and the University of Alabama at Birmingham (UAB) has developed a standardized clinical pathway for newborns diagnosed prenatally with hydronephrosis, reducing variability in care, improving coordination among specialties, and helping families receive timely guidance without unnecessary testing or travel.

The pathway, developed by general pediatricians in the newborn nursery in collaboration with pediatric nephrology and pediatric urology, provides a risk-stratified approach to determining which infants require immediate evaluation, which can be safely monitored, and which need little to no intervention. The initiative has already prompted changes in workflow, increased access to telehealth services, and generated interest from providers outside Birmingham.

Prenatal hydronephrosis, or dilation of the kidney’s collecting system, is one of the most common abnormalities identified on prenatal ultrasound. While some cases resolve spontaneously, others may signal underlying conditions such as urinary tract obstruction, vesicoureteral reflux, urinary tract infection risk, or chronic kidney disease. Determining which infants need urgent intervention has historically been challenging.

“We found the existing guidelines confusing,” said Terry Wall, M.D., division director of the UAB Division of Academic General Pediatrics and attending physician in the newborn nursery. “Different specialties interpreted them differently, radiology reports varied in terminology, and there was a lot of inconsistency in how babies were evaluated and referred.”

Wall, who is also a medical informaticist, brought together leaders in pediatric nephrology and pediatric urology to create a single algorithm that could be used consistently by nursery physicians, specialists, radiologists, and obstetric providers.

The resulting pathway categorizes infants based on prenatal and postnatal imaging findings, including the degree of hydronephrosis, bladder abnormalities, and progression over time. Infants identified as high risk are evaluated by urology or nephrology before discharge, while lower-risk patients receive targeted education and follow-up recommendations.

David Askenazi, M.D., pediatric nephrologist and medical director of the Pediatric and Infant Center for Acute Nephrology at UAB, said the pathway was designed with two goals in mind: ensuring that babies with significant disease are identified early while avoiding unnecessary interventions for families whose infants are unlikely to require treatment.

“We don’t want to miss a child who needs to be seen right away, but we also don’t want to burden families when their baby has a mild finding that is likely to resolve,” Askenazi said.

For infants requiring specialty follow-up, the pathway introduced another innovation. Stacy Tanaka, M.D., chief of pediatric urology, established a telehealth model that allows families to meet with pediatric urologists approximately two weeks after discharge.

Previously, referrals often occurred through community pediatricians, and specialists frequently lacked access to postnatal imaging before the initial visit. Families would travel to Birmingham for an appointment, only to learn that additional studies were needed.

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Now, newborn ultrasounds are obtained before discharge when indicated, and specialists can review imaging in advance of the telehealth visit. During these appointments, providers discuss results, explain whether additional testing is needed, determine if antibiotic prophylaxis is appropriate, and establish a plan for ongoing surveillance.

“It has helped our workflow tremendously,” Tanaka said. “It also allows us to set expectations for families much earlier. If they need another study, they know why. If the hydronephrosis is likely to resolve, they understand what we’re watching and what to expect.”

This approach is particularly beneficial for families traveling from rural communities or other regions of Alabama. Parents of newborns can participate in appointments from home rather than making repeated trips for visits that may not require in-person evaluation.

The pathway also has strengthened communication among departments. Discussions with radiology and obstetrics have focused on standardizing prenatal ultrasound reporting so nursery providers can more easily place patients into the appropriate risk category.

Although the initiative was implemented only recently, providers say it already has reduced confusion, improved consistency, and enhanced education for both families and primary care physicians.

The work ultimately may extend beyond Children’s. Tanaka has shared the algorithm with pediatric urologists in Mobile, Ala., and Askenazi plans to discuss the model with colleagues in the Neonatal Kidney Collaborative, an international network focused on improving kidney care for newborns. “We’ve worked out many of the details,” Wall said. “If other centers can use what we’ve learned to standardize care and improve outcomes for families, that’s a win for everyone.”

July 24, 2026 by childrensal

Pulmonology

Finding Early Warning Signs of CF-Related Kidney Disease

William “Tom” Harris, M.D., is a pulmonologist at Children’s of Alabama and UAB.

By Charles Buchanan

Cystic fibrosis (CF) is often defined as a disease of the lungs. But as advanced therapies help today’s young patients breathe easier and live longer—many will reach their 60s, according to the 2024 Cystic Fibrosis Foundation Registry—attention is shifting to the disease’s impact on other organs that may be vulnerable to the consequences of aging. This evolving landscape of CF clinical care has prompted Tom Harris, M.D., a pulmonologist at Children’s of Alabama and the University of Alabama at Birmingham (UAB), to investigate the kidneys.

“Interestingly, there’s more CFTR [cystic fibrosis transmembrane conductance regulator], the protein that causes cystic fibrosis, in the kidneys than the lungs,” Harris said. That means that as people with CF grow older, they face a higher incidence of chronic kidney disease than the general population, where the risk is about one in seven, according to Harris. Acute kidney injury (AKI), is more prevalent among people living with CF due to frequent antibiotic exposure and previous hospitalizations, and recurrent AKI is a major risk factor for development of chronic kidney disease. Harris also suspects loss of CFTR function takes away some of the kidney’s reserve.

Protecting the kidneys and other organs that express CFTR is crucial as lung disease stabilizes and people with CF age to help prevent health complications that can consume the patients’ hard-earned longevity. “The priorities of CF are changing,” Harris said. “We are now very much prioritizing quality of life across the years.”

Not every person with cystic fibrosis will develop kidney disease, of course. The challenge for researchers like Harris is to find biomarkers that will identify the ones at risk—and sound the alarm early enough for therapeutic intervention to preserve kidney function. “Right now, we are trying to establish which biomarkers are important and how they might indicate the progression of chronic kidney disease over time,” Harris said. Joining him in this mission are a team of scientists across the country who are part of a landmark project funded by the Cystic Fibrosis Foundation (CFF). Together they will follow a group of inpatients and outpatients for three years to study promising new diagnostic tools for CF-related kidney disease. They also are looking at kidney disease in the CF animal model that was pioneered at UAB. “We are very grateful to the CFF for having such vision to allow us to lay such a firm foundation to study kidney disease, combining both human observational study with mechanistic analyses in gene-edited animal models,” Harris said. “We are hopeful this project will allow us to pioneer the field of CF kidney disease and health.”

The researchers are focusing on urine in their quest to find novel biomarkers because of its direct connection to kidney health. Urine is “like a liquid biopsy,” Harris said. “With every urinary output, you can measure how well the kidney is working.” Physicians traditionally have tested urine or blood for elevated levels of specific proteins, electrolytes, and waste products such as creatinine to find proof of disease. But organ damage has already occurred by the time those reveal a problem, Harris said. Instead, he and his colleagues are investigating more subtle, sensitive measures that could flash the earliest warning signs of trouble. Candidates include kidney injury molecule (KIM-1) and neutrophil gelatinase-associated lipocalin (NGAL), two urinary biomarkers indicating minute structural changes in the kidney that precede a deterioration in function.

“In addition to detecting which patients might have some evidence of disease, we also want to use those biomarkers to help us understand the pathways of disease,” Harris said. “Is it more fibrotic? Is it more inflammatory?” Exosomes, which are the molecular packages transmitted between cells, offer a prime example. Exosomes can be informative about the intercellular communication in health and disease, but they also often carry the mediators that affect change. For instance, neutrophil-derived exosomes may shed light on the inflammatory triggers of kidney disease.

Such detailed methods of diagnosis could hold promise for designing personalized treatments for patients. CF already is a precision medicine success story following breakthrough discoveries about the CFTR gene that causes the disease, including the distinct ways in which each CFTR mutation affects protein function. Some mutations impact how much CFTR is made; some affect how well CFTR gets to the cell surface; some impact how well CFTR transports electrolytes. Knowing each patient’s genetic mutation plays a role in the choice of CFTR-directed therapy.

Now, researchers are applying what they know about CFTR’s impact in the lungs to the kidneys, where they suspect it plays a different role. In the lungs, CFTR is needed to transport chloride ions, and a lack of it can cause airway secretions to thicken. But in the kidneys, CFTR is involved in acid-base metabolism, which may be disrupted in chronic kidney disease. “Part of the reason CF-related kidney disease has been overlooked previously is that, instead of being a disease of obstructed lumens from mucus plugging, the kidney disease is an organ of pH balance and fluid transport,” Harris said. Scientists want to pinpoint the specific cell types and regions of the kidney that are affected most by CFTR dysfunction. “CFTR expression is not the same across all cell types in either the lung or the kidney. In the lung, an ionocyte that is positioned near mucus glands is the highest CFTR-producing cell,” Harris said. “Investigators at UAB have recently discovered a similarly high CFTR-expressing cell in the kidney. Future steps will be to define how this high CFTR-expressing cell promotes renal health.” These findings could illuminate new targets for potential treatments to protect kidney function and help patients thrive as they age.

“The future’s bright,” Harris said. “CF has primarily been considered a pediatric disease. Now it’s very much an adult disease. And we as pediatricians have to think about the future . . . to transition our focus from disease to health—and to celebrate the wonderful, previously unimaginable question of how can we help our pediatric patients with CF age well into senior adulthood.”

For more information about Harris’ research, check out this episode of the Children’s of Alabama PedsCast.

July 24, 2026 by childrensal

Cardiology

Aortic Arch Surgery and Cognitive Development

A Children’s cardiac surgeon is researching the connecting between aortic arch surgery and brain development. (Stock image)

By Charles Buchanan

Parents naturally ask plenty of questions when their newborn needs aortic arch reconstruction, a life-saving surgery for congenital malformations restricting blood flow. Their major concerns involve the procedure’s complex logistics and potential complications, which Hampton Gray, M.D., a Children’s of Alabama cardiac surgeon, can explain in detail. But not every answer comes so easily. He says some of the simplest questions from parents are also the toughest: “How’s my kid going to be when he is 5 years old? Can he go to school, or is he going to be delayed? Is he going to be behind the other kids?”

Their worries arise from a critical component of aortic arch reconstruction—the temporary reduction or shutdown of blood circulation throughout the body and to the brain. And the reason those questions are difficult to answer is that little is known about the surgery’s long-term effects on brain development. “There is limited data currently for us to properly educate parents on how their kid will cognitively develop through infancy, toddler, and school-age years,” Gray said. Now he is spearheading a novel, multiyear research project to fill that knowledge gap. The findings could provide parents with the answers they need and help them understand what to expect as their children grow.

Cardiac Surgery Meets Psychology

The trial kicked off in July, funded by an $80,000 grant from the Kaul Pediatric Research Institute, a Children’s/University of Alabama at Birmingham (UAB) program supporting trailblazing work from rising investigators. During the next two years, Gray and his team will follow up with Children’s patients who had major open-heart surgery to repair a congenitally small native aorta in the last 15 years. That cohort includes up to 200 children, though Gray anticipates the study will attract approximately 80 participants ranging in age from infants to school-age children.

To measure the patients’ long-term progress, Gray has forged an innovative collaboration with the clinical psychologists at UAB and Children’s. “They are pros at testing kids about cognitive function, executive function, fine motor skills, and all the things that dictate how your brain is developing as a young child,” Gray explained. UAB already has an established Newborn Clinic, where the clinical psychologists gauge the growth and development of children who spent time in the neonatal intensive care unit (NICU). For the cardiac surgery study, they created a novel algorithm to tailor their tests for the varying age levels of patients following aortic arch surgery. They also will administer the tests to participants and interview parents about their child’s cognitive development.

“It will be very valuable to test these kids at different time points and different age groups,” Gray said. With the cognitive development data in hand, the researchers will evaluate the trajectories of aortic arch patients alongside children who have not experienced heart surgery.

A Tale of Two Strategies

The study also may shed new light on the two cerebral perfusion strategies used to manage blood circulation during aortic arch surgery. The researchers are eager to know if the techniques affect brain development differently, which leads to the inevitable question: Is one option better than the other?

The original cerebral perfusion strategy, deep hypothermic circulatory arrest (DHCA), involves cooling the body to a temperature between 18 and 20 degrees Celsius and turning off the heart-lung machine so that no blood circulates through the body. That gives cardiac surgeons approximately 40 minutes to complete the reconstruction without increasing the risk for brain injury, Gray said. Cardiac surgeons following the newer strategy, antegrade cerebral perfusion (ACP), cool the body to the same low temperatures but also sew a small graft to the innominate artery and keep the heart-lung machine running, selectively perfusing the brain. As a result, about 15 to 20% of the entire cardiac output continues flowing, according to Gray’s estimate. Today, at least 70 to 80% of cardiac surgery centers, including Children’s, have adopted ACP while the rest continue to rely on DHCA, he noted.

“It would make sense, theoretically, that giving the brain a little bit of blood flow would be better than giving it no blood flow,” Gray said. However, in a 2024 study comparing the two cerebral perfusion strategies, he and his research team found no significant differences in short-term hospital outcomes among 165 newborns and infants undergoing aortic arch surgery at Children’s between 2012 and 2023. Both types of patients also experienced a low rate of neurologic events such as stroke and seizure.

Gray’s current project, with its long-term, cognitive development focus, offers a logical next step in identifying any differences that emerge between DHCA and ACP patients as they grow up. The study’s participants will include the two groups, since both cerebral perfusion strategies were in use at Children’s as recently as 2022, giving the researchers ample opportunities to compare outcomes. The team also will gather information about nonsurgical factors that can influence brain development, including the children’s family structures and education, to round out the picture of each child’s growth.

Answers at Last

Gray hopes the research will serve as a stepping stone to a broader exploration of aortic arch patients and their progress. Ultimately, he would like for the findings to serve as pilot data for a larger initiative involving multiple cardiac surgery centers and extramural funding from sources such as the National Institutes of Health. The most useful information would come from a trial that pairs a DHCA-exclusive center with an ACP-exclusive center and follows patients from both over several years, he said.

No matter where his investigation leads, Gray says the goal remains the same: to provide parents with meaningful answers to their simple, yet tough, questions about their child’s future. And if the cardiac surgeons and clinical psychologists make pioneering discoveries about the impact of aortic arch surgery along the way, that’s a bonus. “Children’s supports pushing the envelope to make children’s lives and parents’ lives better,” Gray said.

July 24, 2026 by childrensal

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