Neurology & Neurosurgery

Time is brain: A pediatric code stroke program

Code Stroke at UAB and Children’s of Alabama is designed to improve recognition, response and outcomes. (Stock photo)

By Heather Watts

A stroke is often thought of as a condition of adulthood, yet it remains a significant and underrecognized cause of morbidity and mortality in the pediatric population. Despite being cited among the leading causes of death in children, pediatric stroke is frequently missed or diagnosed late, in part due to its relative rarity, diverse clinical presentations and the unique risk factors that distinguish it from adult stroke. As a result, many children with stroke present outside the narrow window during which acute interventions may be considered, limiting opportunities for therapies that can meaningfully alter neurologic outcomes. In pediatric stroke, as in adult stroke, the principle remains the same: Time is brain.

Improving pediatric stroke education

During her training in child neurology at the University of Alabama at Birmingham (UAB), Sarah Novara, M.D., MSQHS, FCNS, associate professor in the Division of Pediatric Neurology, had several patient encounters that highlighted both the devastating potential of delayed stroke recognition in children and the extraordinary opportunity that exists when stroke is identified and treated promptly.

“When we were able to quickly evaluate and treat stroke symptoms in our pediatric patients, we saw amazing neurologic recovery,” Novara explained. “Seeing the importance of early stroke recognition firsthand inspired me to improve our pediatric stroke education and standardization processes at Children’s of Alabama and UAB.”

As a senior resident, Novara developed pediatric stroke education and streamlined order sets and processes for residents, fellows and faculty. Novara worked with Tony McGrath, M.D., associate professor in the Division of Pediatric Neurology and Nancy Tofil, M.D., M.Ed., professor in the Division of Pediatric Critical Care, to develop a pediatric stroke simulation as part of pediatric stroke education for trainees and faculty. “The simulation has been highly efficacious in advancing pediatric stroke evaluation and management knowledge in a variety of learner settings since its creation,” Novara explained.

From education to systems change: Creating a Pediatric Code Stroke

Once on faculty at UAB, Novara continued her work with pediatric stroke education and began working on improving early stroke recognition among providers at Children’s and UAB by establishing a Code Stroke for pediatrics.

“We decided to model a Code Stroke process after our adult neurology colleagues and other select children’s hospitals across the U.S.,” Novara said. The pediatric Code Stroke initiative aims to offer necessary, efficient evaluation and management of patients presenting with signs of possible stroke, and if inevitably they have not had a stroke, the Code Stroke process assists in evaluating and managing conditions that mimic stroke and deserve appropriate treatment. 

In the summer of 2024, the Code Stroke working group met to create the Children’s of Alabama Code Stroke protocol for patients greater than one month of age with acute neurologic deficits and who were last known at their neurologic baseline less than 24 hours prior to presentation at the hospital. This is the window in which options of acute stroke intervention may be offered, if there are no contraindications. In addition to the protocol, order sets within EPIC were streamlined for the evaluation of Code Stroke patients in the emergency department (ED) or on the hospital floors, and stroke patient admission order sets were provided as well.

This Code Stroke effort was spearheaded by Novara, Tofil and Jeffrey Blount, M.D., MPH, professor in the Division of Pediatric Neurosurgery. It also included colleagues from pediatric emergency medicine, neuro-interventionalists, radiology, nursing, and operators.

After the Code Stroke protocol was established and education was provided across the pediatric divisions, the Children’s of Alabama Code Stroke went live in September 2024. As of July 2026, a Code Stroke had been called 131 times (either in the ED or on a hospital floor). Approximately 12% of these Code Strokes have identified ischemic or hemorrhagic strokes, allowing for efficient evaluation and management. Several of the pediatric acute ischemic stroke patients have even benefited from an acute thrombectomy performed by the on-call neuro-interventionalists. Code Stroke patients with hemorrhagic stroke have benefited from the expedited care of the pediatric neurosurgery team. Many of the Code Stroke patients have made remarkable recoveries.

“We have been very excited about the success of multidisciplinary care within the Code Stroke process, as many patients—even those without strokes—have received expedited treatment for life-altering conditions,” Novara said.

“The Code Stroke working group meets quarterly to continuously discuss ways in which to improve our Code Stroke protocol and to collaborate together as we try to provide the best care for our patients,” Tofil added.

Expanding care beyond the acute phase: Pediatric Stroke Clinic

In early 2025, a monthly Stroke Clinic was established by Novara and McGrath to provide a unique pediatric stroke follow-up clinic that offers ongoing patient support, education and follow-up care, including best efforts at secondary stroke prevention. 

In the monthly stroke clinic, the pediatric neurology team collaborates with pediatric hematology and neurosurgery colleagues in the care of unique pediatric patient populations seen in their clinics who are at risk for stroke. The stroke clinic also allows the pediatric neurology team to provide effective transition of care for patients from pediatric to adult stroke care at UAB as needed.  

The pediatric stroke clinic at Children’s of Alabama is a participating site within the International Pediatric Stroke Study, which is a research group working hard within the International Pediatric Stroke Organization to expand the knowledge about pediatric stroke and best practices for these unique patients.

The Code Stroke program has demonstrated that targeted educational initiatives, combined with the development of standardized, multidisciplinary response protocols, can meaningfully improve the evaluation and management of children presenting with possible pediatric strokes.

As awareness grows and standardized care pathways expand, there is an opportunity to reduce the burden of pediatric stroke and ensure that children receive timely, evidence-informed care when minutes matter most.

July 22, 2026 by
Neurology & Neurosurgery

Lalor appointed Director of Pediatric Neurology

Kathryn Lalor, M.D. was appointed director of the Division of Pediatric Neurology in May 2026.

By Angel Pine

As the new director of the Division of Pediatric Neurology, Kathryn Lalor, M.D., aims to build on the strong foundation already established within the division.

Lalor, who was appointed to the position in May, has been a valued member of the division as associate professor, contributing to its continued growth in both clinical care and academic excellence. In her new role, she will lead efforts to further strengthen the division’s mission across patient care, education, and research.

“Dr. Lalor joined the division in the midst of its recent growth,” said Leon Dure, M.D., professor and former division director of Pediatric Neurology. “She has the skills and temperament needed to ensure UAB Pediatric Neurology’s reputation of academic and clinical excellence.”

“This appointment represents an opportunity to grow into a new kind of leadership which I plan to approach with humility and intentionality,” Lalor said. “Leon Dure has left big shoes to fill, but I am thankful to continue growing the supportive culture he has fostered.”

Lalor also expressed enthusiasm about the division’s future, noting its significant growth over the past decade and the opportunity to build on that momentum. Lalor emphasized the importance of collaboration across the division, adding, “If you want to go fast, go alone. If you want to go far, go together,” as she looks forward to working alongside faculty, staff and trainees to continue advancing care for children across Alabama.

Her appointment reflects the department’s continued commitment to strong leadership and advancing pediatric neurological care.

July 22, 2026 by
Neonatology

Studying magnesium sulfate in very preterm babies

Research shows magnesium sulfate does not improve neurodevelopmental outcomes in very preterm babies. (Stock photo)

By Anna Jones

Research led by Children’s of Alabama and the University of Alabama at Birmingham (UAB) shows that magnesium sulfate does not improve neurodevelopmental outcomes in babies born very preterm between 22 and 24 weeks gestation.

Babies born during 22-24 weeks of gestation have a higher risk of neurodevelopmental impairment. While prior studies have found that magnesium sulfate helps prevent the development of cerebral palsy for babies born at later gestational ages between 24 and 32 weeks, this observational study led by Margaret Page, M.D., and Ashley Battarbee, M.D., in the UAB Department of Obstetrics and Gynecology, along with colleagues in the Department of Pediatrics, is one of the few studies of its kind to look at the use of magnesium sulfate for babies born at 22-24 weeks of gestation.

“This multicenter study led by Dr. Page and colleagues at UAB is important as it is the largest study designed to assess the two-year outcomes of infants born extremely preterm exposed to antenatal magnesium sulfate and/or steroids, two common treatments given before delivery,” said Wally Carlo, M.D., co-director of Neonatology at UAB and Children’s of Alabama and the Neonatal Research Network.

Battarbee says that OBGYNs cannot always stop a preterm birth, so they oftentimes need to shift their focus to how they can best prepare the baby to be born early.

“We consider interventions such as administering magnesium sulfate or antenatal corticosteroids to the pregnant patient to help improve outcomes for their baby after birth,” Battarbee said. “While the American College of Obstetricians and Gynecologists (ACOG) recently updated their guidance on corticosteroids for babies at 22 weeks, we did not have updated guidance on magnesium sulfate and wanted to explore this treatment further.”

The results of the recent study reinforce current national guidelines recommended by ACOG and the Society of Maternal-Fetal Medicine that do not recommend giving magnesium sulfate at 22 weeks and instead prioritizing antenatal corticosteroids to improve neurodevelopmental outcomes. Unlike magnesium, steroids have demonstrated benefit for infants born at very early gestational ages and remain the primary intervention when an early delivery is anticipated.

“There is not a lot of guidance on the use of magnesium sulfate in babies at this gestational age,” said Page, the lead investigator of the study. “Through this research, we were able to find that there was no benefit to using magnesium sulfate in addition to antenatal corticosteroids. This shows us that more treatment does not always equal better outcomes.”

Both Page and Battarbee emphasize that administering magnesium sulfate at that gestational age did not lead to any measurable increase in maternal or fetal harm in this study, but magnesium does carry known maternal risks, making it important not to use it without proven benefit. Additionally, using magnesium for neuroprotection in babies at these very early gestational ages when it is not effective may hinder future research in identifying interventions that truly make a difference.

This analysis was conducted using data from and in collaboration with the Neonatal Research Network, a large research network encompassing academic institutions across the United States funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

July 22, 2026 by
Endocrinology

Ashraf co-edits textbook on pediatric diabetes

Ambika Ashraf, M.D. is the director of the Division of Pediatric Endocrinology and Diabetes at Children’s of Alabama and UAB.

By Amy Richardson

A new textbook, co-edited by Children’s of Alabama pediatric endocrinologist Ambika Ashraf, M.D., offers a comprehensive look at pediatric diabetes, highlighting the latest research findings and clinical guidance for managing diabetes in children and adolescents.

Written by international experts from leading diabetes care centers, “Pediatric Diabetes” covers major forms of the disease, including Type 1 diabetes (T1D), Type 2 diabetes (T2D), Wolfram syndrome and cystic fibrosis-related diabetes. It also provides up-to-date management strategies for evolving diabetes phenotypes and current clinical approaches to care.

Ashraf, who also serves as director of the UAB Division of Pediatric Endocrinology and Diabetes, says the book addresses a critical gap in clinical resources focused specifically on pediatric diabetes. “Most available information on pediatric and adolescent diabetes has historically been limited to chapters within larger pediatric endocrinology books, without the space to cover specific topics in depth,” she said. “That’s what makes this book valuable. It fills a genuine gap in the literature.”

Ashraf co-edited the 15-chapter volume with Benjamin Udoka Nwosu, M.D., professor of Pediatrics and Endocrinology at the Zucker School of Medicine at Hofstra/Northwell in New York. She also co-authored two of the book’s chapters: “Precision Medicine in Diabetes Phenotypes” and “Neonatal Diabetes.” Mary Margaret Barr, M.D., a fellow in the Joseph S. Bruno Pediatric Endocrinology Training Program at UAB, co-authored Neonatal Diabetes with Ashraf. Barr will be joining the Division of Pediatric Endocrinology and Diabetes as a faculty member in July 2026.

Pediatric diabetes one of the most common chronic diseases among individuals under age 20 in the United States. In 2022, an estimated 21,732 youth under 18 were newly diagnosed with T1D, and 14,490 were diagnosed with T2D. Between 2001 and 2017, the prevalence of T1D in U.S. youth increased by 45%, with the largest increases among non-Hispanic white and non-Hispanic Black youth. Over the same period, T2D prevalence increased by 95%, with the largest increases among non-Hispanic Black and Hispanic youth. Based on increasing rates, by 2060, the number of youth with T1D is projected to reach 335,000, and the number of youth with T2D is expected to reach 220,000—increases of 65% and 673%, respectively.

“Pediatrics Diabetes” is published by Springer as part of the Contemporary Endocrinology series and is available in print (ISBN: 978-3-032-17035-4) and eBook (ISBN: 978-3-032-17036-1) formats at Springer.com and Amazon.

Ashraf also holds the Ralph Frohsin Endowed Chair in Pediatric Endocrinology at UAB and serves as associate director of the UAB Comprehensive Diabetes Center. Ashraf is also co-editor of “Pediatric Dyslipidemia,” published by Springer in 2023.

July 21, 2026 by
Pulmonology

New study explains ETI’s effectiveness on Cystic Fibrosis

A new study’s findings “moved the needle” on researchers’ understanding of how ETI works. (Stock illustration)

The 2019 approval of the transmembrane conductance regulator (CFTR) modulator elexacaftor, ivacaftor, and tezacaftor (ETI) for cystic fibrosis (CF) dramatically changed the landscape of the disease. For the first time, nearly 90% of those with CF had access to a disease-modifying drug. In the pivotal clinical trial, ETI significantly improved lung function and reduced pulmonary exacerbations while improving patient quality of life.

But exactly how the drug worked still needed explaining.

Now, a major new study, called PROMISE, involving pediatric pulmonologist Spencer Poore, M.D., and University of Alabama at Birmingham (UAB) pulmonologist George M. Solomon, M.D., clearly demonstrates that some of ETI’s effects are due to its ability to tamp down inflammation.

Inflammation is the background noise of CF: always present, always active, contributing to lung damage, infections, fatigue, weight loss and poor outcomes. Even when symptoms improve, some degree of inflammation continues unchecked.

But as PROMISE showed, ETI dramatically reduces that inflammation. The PROMISE trial is a prospective, multi-center, observational study following 487 people ages 12 and older with CF. A group of 223 participants agreed to participate in the inflammation substudy, in which their blood and sputum were collected prior to starting ETI and then five times over the next 30 months.

The team measured markers of inflammation in the lungs, including neutrophil elastase (NE), a powerful enzyme linked to tissue damage; calprotectin, a marker of neutrophilic inflammation; and pro-inflammatory cytokines such as IL-1β and IL-8. In the blood, they tracked levels of the inflammatory markers high-sensitivity C-reactive protein (hsCRP); calprotectin; and HMGB-1, another inflammatory mediator. All are tied to lung destruction, bronchiectasis, exacerbations and outcomes.

Within one month of starting ETI, airway inflammation markers fell sharply and remained low throughout the 30 months. At the same time, markers of system inflammation (hsCRP and calprotectin), also significantly declined.

As the authors wrote, “These changes represent a disease-modifying benefit of this transformative therapy.”

What made the findings even more powerful was how closely inflammation tracked with clinical outcomes. So, lower neutrophil elastase levels meant better lung function, while lower hsCRP led to improved respiratory symptoms. Interestingly, an increase in airway IL-6 also correlated with improved lung function, a puzzle since IL-6 is often thought of as inflammatory. However, the authors noted, it also plays a role in regulating inflammation. This suggests its increase may reflect a shift toward a more normal immune response rather than chronic destructive inflammation.

Although ETI quelled much of the inflammation, it was still there, especially in older patients and those with more advanced lung disease.

“We have not seen complete resolution,” Poore said. But, he noted, the set point has shifted. And this represents a shift in the disease itself, he said. “What I was taught versus what I see now is different.”

This includes fewer patient admissions; less dependence on feeding supplementation, advanced feeding support and feeding tubes; improved growth; and more stable disease.

One of the biggest questions lies with children who start therapy very early given that ETI is now approved for kids as young as 2.

If they never experience that chronic inflammatory engine, “what does their health and outcomes look like when they’re 25?” Poore asked. Does early treatment prevent the damage entirely? Or does it simply delay it? “We’ve moved the needle,” he said. “But how far?”

That uncertainty is fueling ongoing research. “This isn’t done,” he said. “This is a living, breathing assessment.”

February 17, 2026 by
Urology

Treating Bathroom Issues Virtually

Children’s is using telehealth to answer parents’ questions about bathroom habits. (Stock photo)

For families of children with bladder and bowel dysfunction, the journey to care at Children’s of Alabama can involve a long drive, a crowded waiting room, and the worry that the problem was serious—only to be told that what their child needs most is better bathroom habits.

“We have a really wide catchment area,” said Children’s chief of pediatric urology Stacy Tanaka, M.D. “Sometimes we were seeing families coming in from the coast. They had driven three-and-a-half, four hours.” By the time they arrived, parked and waited, an entire day was lost and the advice they received was, well, less than earth-shattering.

“They get here, and you tell them, ‘Hey, you just need to urinate and poop a little bit better,’” she said. “It doesn’t go over that well sometimes.” In fact, it could have been handled by a phone call.

Today, that’s essentially how they handle it. Tanaka and nurse practitioner Kelsey Boswell Moore, CRNP, see more than 20 patients each week via telehealth.

The program launched in early 2025, partly out of necessity. “We were transitioning and were a bit understaffed,” Tanaka said. “We started it just as a ‘let’s try to get as many patients seen as possible.’”

What began as a staffing solution quickly became a new model of care.

One reason it works so well is that most children with bladder and bowel dysfunction improve just from counseling and conservative management on better bladder habits and better bowel habits. They don’t even require prescription medication. If any red flags pop up, such as a child who had back surgery or is having urinary tract infections with fever, the team brings them in for a face-to-face consultation. “Those are signals we need to see you sooner,” Tanaka said.

For most families, all it takes is talking and instructions.

“A lot of times they’ve never really paid attention to how often they’re going to the bathroom,” said Moore, who conducts most of the telehealth visits. “They’ll say they have urgency, or that they can’t hold it, but then you realize they’re waiting until the last minute every time.”

Telehealth makes it easier to explore those details.

“They’re sitting in their living room,” Tanaka said. “It’s a more relaxed environment. All the other distractions really go away. In that relaxed environment, it’s easier to talk about how often they’re going, when they’re going and what’s really happening,” she said.

“Sometimes they say they’ve done everything,” she said. “But the child is still drinking fluids late at night or didn’t actually go to the bathroom before bed.”

And for those who do need to be seen in person, the telehealth visit allows Moore and Tanaka to prepare for the appointment by ordering any necessary tests, which increases efficiency.

If families still want to be seen in the office or have the child undergo imaging, “We can absolutely do that,” Tanaka said. “We can rule out the scary things, and then it becomes easier to continue with telehealth knowing everything looks okay.”

“This only works if the patient and parent are engaged,” she added. “If they don’t feel right about the plan, it’s not going to work.”

And it does work. For instance, consider the 8-year-old boy with enuresis. The problem became obvious after a brief telehealth visit.

“When he woke up in the morning, he didn’t go to the restroom,” Tanaka said. “He would eat breakfast, get dressed, and the first time he went was at school.” The child had trained himself to ignore bladder signals.

The solution? A schedule. Go first thing in the morning and use the restroom at planned times during the day. Also, alert the teacher. Four weeks later, the problem was resolved.

“That family never had to step foot in the hospital,” Tanaka said.

Which, of course, is the goal.

February 17, 2026 by
Orthopedics

A New Approach for Patellar Instability in Children

An X-ray showing a displaced left kneecap

For Kevin Williams, M.D., and the Children’s of Alabama orthopedic team, patellar instability is a commonly seen problem. The condition—in which the kneecap repeatedly slips out of place—and all of its inherent challenges have been the subject of much discussion worldwide recently, Williams says. But he and his team have developed a solution—a modified procedure that combines existing, well-established methods and is already showing promise.

The procedure is called medial patellofemoral ligament (MPFL) reconstruction. Williams and his team began developing a modified version of it about two years ago and refined it in 2025. They’ve used it on approximately 15-25 patients, and the results have been encouraging. “Children and adolescents that are still growing and developing have been able to get back to doing activities they enjoy—such as dancing and gymnastics—faster compared with our previous, more invasive procedures,” he said. “Complications have been scarce so far in the early stages of this modified procedure.”

The Challenges of Patellar Instability

The procedure treats a problem that is challenging for several reasons, perhaps most notably the various ways patellar instability can present. In some cases, a child might have  been born with a kneecap problem or developed it early in childhood, which means the body is used to the anomaly. When treating children, orthopedic surgeons also have to manage challenges such as small bones and growth plates, “which we don’t want to impede or create any problems with, because it could be detrimental toward a kid’s growth,” Williams explained.

Williams and his team developed the modified procedure to address all of these challenges. It allows them to use small implants that are stitch-based or suture-based and don’t require a lot of drilling. It also allows surgeons to spare the growth plate and balance the soft tissues.

How it Works

MPFL reconstruction in young adolescents is performed in a limited fashion by surgeons in North America and abroad, Williams says. To perform the procedure, the surgery team creates holes in the bones to attach the kneecap to the inside of the femur bone via either an allograft or autograft tissue source. Williams and his team use smaller instrumentation and grafts for this procedure to spare the growth plate and account for the smaller anatomy. “The surgical procedure is designed to grow with the patient,” he said.

Though the team’s procedure is different from others that are available, it’s not experimental, Williams says, because it’s a combination of techniques that are already standard practice. The implants used in this procedure are approved by the U.S. Food and Drug Administration. 

Recovery

One of the biggest benefits of the new technique is recovery time. “Compared with the bigger anatomy-changing surgeries, it’s much improved,” Williams said. With modified MPFL reconstruction, the patient is typically on crutches for only a week or two before they’re able to walk around mostly normally. After that, they wear a brace for up to two months. In many cases, they’re back to playing sports within three or four months, although some may need six months depending on factors such as age and underlying conditions.

Risks Compared to Alternatives

Another benefit is decreased risk. Though every surgery comes with risks, Williams says the modified MPFL procedure seems to carry fewer risks compared to conventional techniques, especially when it comes to issues with the growth plate.

Wide Range of Uses

Part of what makes the procedure successful is its ability to treat patients whose kneecap issues stem from a variety of causes. For example, many children with Ehlers-Danlos syndrome, Down syndrome, Klinefelter syndrome and other congenital conditions are often predisposed to having kneecap problems. Williams and his team have successfully treated them with the modified MPFL procedure. It also works for patients with Nail-Patella syndrome and Genitopatellar syndrome. The Children’s orthopedic team sees many of these types of cases because they serve the entire state of Alabama.

Looking Forward

Despite the success of the procedure, it’s not something the team pushes. Williams says they typically try conservative approaches first, such as braces—which don’t typically work well in these cases—or rehab. But he says it’s a good option if surgery is needed.

Williams anticipates that they’ll learn more as they perform more of these procedures. With the hospital’s move to a new electronic health record system, the team is working on strategies for better tracking outcomes. “That’s one of the goals for this year—we’re  planning on tracking patient-reported outcomes more effectively and becoming more involved in national registries to track procedural success and contribute to research more vastly in the U.S. and abroad,” he said.

So far, the team and their patients have been pleased with the impact of the modified MPFL procedure. “We’ve been happy with the breadth of underlying conditions our modified procedure treats, with decreased complications, and with increasing capacity for returning to sport,” Williams said.

February 17, 2026 by
Gastroenterology

Helping heart patients with swallowing and feeding problems

At Children’s, a multidisciplinary team cares for heart patients with swallowing and feeding problems. (Stock photo)

Within days of being born with hypoplastic left heart syndrome, or HLHS, in early 2025, “James” underwent life-saving surgery to reconfigure blood flow so the right ventricle of his underdeveloped heart could pump blood to his little body. Unsurprisingly, the newborn had trouble swallowing and building the endurance needed to feed by mouth. In swooped skilled clinicians from the Dysphagia Clinic at Children’s of Alabama, who worked with James and his parents to determine the safest, most optimal feeding strategy for him after discharge.

The baby—now heading toward his first birthday and doing well—exemplifies the value of the Dysphagia Clinic’s multidisciplinary approach. The clinic previously existed in other capacities at Children’s but coalesced in January 2025 after the arrival of physician assistant Alex Clifton, PA-C, who runs the once-weekly, full-day clinic, seeing about 10 patients each week. Clifton works closely with speech language pathologist Kristen Kirkland, MCD, CCC-SLP, along with several other speech clinicians who rotate to cover the clinic.

Leaders with the Children’s of Alabama Aerodigestive Program created the Dysphagia Clinic to address the feeding and nutrition needs of babies with congenital heart disease as well as babies followed within the Aerodigestive Program who need close support from the gastroenterology, nutrition and speech therapy teams. In the clinic, patients receive medical and speech therapy perspectives, along with nutrition support. Kelly Trumbull, a registered dietitian with the Children’s Clinical Nutrition team, is embedded in the clinic.

The cardiac portion of the program was designed to address the previous gap of multidisciplinary, outpatient feeding care for babies with congenital heart disease. The team cares for these patients using the pediatric feeding disorder framework, addressing medical, nutritional, skill and psychosocial needs. Cardiologists, pulmonologists, otolaryngologists and pediatric surgeons collaborate with the clinic on this effort.

“We long wanted to fill a local void in this type of care for these heart patients,” said Rachel Kassel, M.D., Ph.D., a pediatric gastroenterologist with the Aerodigestive Program. “Buy-in from the University of Alabama at Birmingham (UAB) Department of Pediatrics, the Children’s Hearing and Speech team and the Children’s Nutrition team—paired with having a team of passionate individuals in the Dysphagia Clinic—has improved outpatient feeding and nutrition care for babies with complex congenital heart disease.”

Congenital heart disease encompasses a set of conditions that greatly predispose a baby to feeding and swallowing difficulties. These problems occur in pediatric heart patients in several ways: either by compressing the esophagus or vessels; through nerve damage; or from rapid breathing and fatigue in infants that can disrupt the coordination of sucking, swallowing and breathing. Their cases can also be complicated by vocal cord paralysis, ECMO treatment or the need for intubation.

Clifton and Kirkland estimate that perhaps 70% of pediatric cardiac surgery patients deal with some component of feeding difficulty or aspiration. “Many pediatric GI programs in outlying communities refer to us, so we’re often the last step in the region for these complex kids,” Clifton said.

Clifton also sees patients in the Children’s GI clinic, addressing challenges with formula tolerance, advancing diet, and any other feeding issues. Additionally, she refers patients to the aerodigestive team, which treats children with overlapping problems involving the airway, lungs and upper digestive tract. In the Dysphagia Clinic, Clifton and Kirkland are often joined by nutrition specialists and other speech clinicians, and they also consult with social work and lactation professionals as needed.

“It’s helpful to have multiple disciplines looking at a child with complex medical problems,” Clifton said. “Every kiddo is different.”

Kirkland works closely with patients’ parents and caregivers to help them look for feeding stress cues in infants as well as signs of aspiration. She helps align the child’s individual challenges—which can also include aversion to oral feeding—with the needs of the family, often employing feeding tubes to fill the gap in nourishment. Other interventions can involve thickening formula, adjusting feeding utensils or bottles, and prescribing medications to help with reflux, nausea or appetite.

“Some babies associate eating with negative past experiences such as frequent emesis or overall GI discomfort or intolerance,” Kirkland explained. “And malnutrition alone makes them less likely to eat, because they tend to fatigue earlier.”     

All of these issues can affect a patient’s ability to lead a normal life, even down the road. But Kirkland and Clifton are doing their best to smooth the path forward.

“Feeding is a very emotional experience for a lot of families. It’s also something that families just expect to occur—that everyone can eat and swallow and enjoy those experiences,” Kirkland said. “While they’re inpatient, we’re trying to get them home, and in clinic, we’re focused on the long-term goals of how this will shape their future.”

The Dysphagia Clinic strongly complements and reinforces the care these cardiac patients are getting at Children’s, Clifton said. “We’re looking at the big picture,” she said, “and making sure they get all the resources they need—the individual parts that might otherwise get forgotten or overlooked.”

February 17, 2026 by
Neurology & Neurosurgery

McRae Addressing PTSD in Kids With Hydrocephalus

Elizabeth McRae, Ph.D., is a psychologist embedded within the Children’s of Alabama Neurosurgery team.

The young child was beyond terrified of the hospital. Born with hydrocephalus, he’d had numerous surgeries, and his anxiety was so high that just getting him to the car for doctors’ appointments was a struggle. It could take an hour to get from the parking garage to the hospital entrance given his tantrums and refusal to walk. The behavior continued at home every time someone opened the front door. “The parents really couldn’t live their life because it was so intense,” said Elizabeth McRae, Ph.D., a pediatric clinical child psychologist at Children’s of Alabama.

Here was a clear case of post-traumatic stress disorder (PTSD) related to the boy’s illness. Resolving it is exactly what McRae, who joined the neurosurgery team in January 2024, was hired to do.

For years, neurosurgeons and families caring for children with hydrocephalus understood the physical stakes: shunts that could fail without warning, repeated surgeries, emergency trips to the hospital. What was less visible—and often unaddressed—was the psychological toll of living in constant vigilance both for the patient and the family.

Earlier work at Children’s helped bring that reality into focus, documenting high rates of medical post-traumatic stress among families coping with hydrocephalus. But identifying the problem was only the beginning.

“Based on the results of that previous survey, we brought Dr. McRae on board and embedded her in our neurosurgery practice to provide psychological support for PTSD from screening and diagnosis through interventions to getting people plugged in to community resources,” pediatric neurosurgeon Brandon Rocque, M.D., said.

What’s emerged is an integrated, trauma-informed model of care that treats psychological health as part of standard neurosurgical practice.

From Measuring Stress to Building Resilience

Families of children with hydrocephalus face a unique kind of uncertainty, McRae said. Even when a child is medically stable, the possibility of sudden deterioration and a need for a new shunt never disappears. That’s why resilience, which she defines as strengthening the ability of families and patients to view difficulties as challenges rather than barriers, is so important.

Whether she’s meeting a family for the first time at diagnosis or after a child’s 10th surgery, she starts from the same place: helping them identify strengths they already have that can enable them to cope.

McRae also emphasizes connection. “One of the key predictors of potential traumatic stress is feeling like we’ve lost power and feeling isolated,” she said. “So if, right off the bat, we can empower them and encourage a connection, to me, those are two of the best things we can do up front.”

“There’s also a big piece of how do we prevent the trauma?” she continued. One approach, she said, is “taking a trauma-informed approach to our service so we mitigate the risk on the front end.” That includes explaining what’s going to happen to children; giving them options and a sense of control whenever possible; creating a sense of structure and predictability in the hospital setting as much as possible; and relying on other services such as Child Life to help children cope and adjust through play. 

McRae works closely with the surgeons, nurses and residents in both clinic and hospital settings, participating in the morning clinical discussions. Nurses refer families they see struggling, and surgeons seek her input about how to provide trauma-informed care in communication and interactions with patients.

The clinical model emphasizes brief, targeted interventions—an intentional choice in a population already burdened by multiple appointments. “I’m doing them a disservice if I can’t do something fairly efficiently,” McRae said.

These strategies were helpful with the aforementioned young child. McRae worked with him and his mother using developmentally appropriate coping strategies such as play-based breathing exercises, predictable reassurance and gradual exposure. She had him pretend to be a snake and breathe in slowly and deeply like a snake to quell his anxiety. A scavenger hunt throughout the hospital helped provide distraction so he could become comfortable in the medical setting. And Rocque met with him dressed in his blue scrubs for a meet-and-greet, no medicine involved, since the child was usually so frightened by anyone in blue scrubs. McRae also involved the boy’s mother in the interventions, providing a greater sense of control over the situation.

The result? The walk from the car to the hospital takes just a few minutes. The tantrums in the clinic are over. His parents have space to breathe. All this was achieved over the course of just six, one-hour sessions.

Research is also a big part of the program, McRae said. To that end, she and the team are collecting data on how the model functions, including who benefits most, how referrals happen, what interventions are feasible, and whether the approach is sustainable.

“This is the first time anybody has tried to integrate psychology into pediatric neurosurgery like this,” Rocque said. “So there are so many questions that we need to answer.”

That includes developing screening tools to identify which families need support most urgently and tracking service metrics to ensure the model can be replicated.

“We really want to show that this works,” Rocque said.

Early signs suggest it is. The model has already been adopted in other specialty clinics, including tuberous sclerosis.

“Ideally,” Rocque said, “I would love for this to become the standard of care in pediatric neurosurgery.”

February 17, 2026 by
Nephrology

NINJA: A decade of preventing acute kidney injury

Since it began, the NINJA initiative has prevented hundreds of AKI episodes at Children’s. (Stock photo)

Acute kidney injury (AKI) is a common but under-recognized complication in hospitalized children. In non-ICU patients, the most common cause is due to nephrotoxic medications such as aminoglycosides, NSAIDs and vancomycin. It’s hardly a benign condition; even a single episode of AKI can set a child on a trajectory toward hypertension and chronic kidney disease later in life.

Traditional care often detects AKI only after it occurs—when creatinine rises. That’s reactive, not preventive. The NINJA (Nephrotoxic Injury Negated by Just-in-Time Action) initiative flips the script by identifying children exposed to high nephrotoxic medication—defined as three or more in one day or prolonged aminoglycoside/vancomycin use—and then screening daily for signs of kidney harm to prevent AKI.

Children’s of Alabama has been one of more than 20 children’s hospitals that are part of the NINJA project. “NINJA is designed to help prevent AKI by educating providers that AKI is not a benign condition, helping them identify high-risk patients, and providing them with the knowledge they need to prevent and mitigate medication-associated AKI,” Children’s pediatric nephrologist David Askenazi, M.D., MSPH, said.

Multi-center studies on NINJA show that collectively, institutions can reduce the rate of AKI by as much as 62%. Those reductions are attributed to the core tenets of NINJA: screening and stewardship; early detection through daily creatine monitoring; and a cultural shift toward preventive renal care.

“What we do is simple. We systematically identify patients at high risk of AKI and put them on the NINJA list,” Askenazi said. “Then, the pharmacist lead from each team ensures the team monitors the child’s creatinine levels daily and discusses possible alternative drugs with them.”

“Our pharmacists are the real ninjas of this program, and they deserve the credit,” he added.

After 10 years participating in the NINJA program, Children’s continues to see the number of AKI events drop. “It’s a testament to the dedication from the top down at Children’s to provide the best quality care to our children,” Askenazi said. He and his team are currently parsing the data to determine how many AKI episodes have been prevented. The number appears to be close to 1,000.

Now, the department is working with the hospital’s IT experts to integrate the NINJA system into the EPIC electronic medical record (EMR). This will enhance the clinician’s ability to see what’s happening in real time since patients on the NINJA list will be flagged immediately and a dashboard with all their medications and labs listed, Askenazi said. “We’re building data sets and clinical decision support tools for providers so they can navigate through NINJA and care for their patients with up-to-date data and suggestions.”

Until now, because pharmacists are not there on nights and weekends, at-risk patients could have been missed. With an EMR-based system, clinicians have access to the data 24 hours a day, 365 days a year. The EMR integration should also significantly increase efficiency for pharmacists and quality improvement specialists who previously had to manage the data on Excel spreadsheets and create reports manually.

In addition, a new urine test that can detect AKI without the need to prick the child for blood is being implemented. “We’ll incorporate that within our NINJA initiative,” Askenazi said, “as we continue to optimize patient comfort and safety throughout the hospital.”

Overall, he said, “NINJA has been successful because we’ve been able to convince everyone that preventing harm from nephrotoxic drugs is important.”

February 17, 2026 by