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Inside Pediatrics, Neonatology

Using Quality Improvement to Improve Maternal/Child Health

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Children’s of Alabama neonatologist Samuel Gentle, M.D.

Children’s of Alabama neonatologist Samuel Gentle, M.D., is passionate about the tiny babies he treats—and passionate in his belief that healthcare professionals like him can always do better. That’s why he helped start the Alabama Perinatal Quality Collaborative (ALPQC), a statewide initiative devoted to improving the quality of care for women and children. “Quality improvement is something I’ve been intrinsically drawn to,” he said. “I love the application of data science to a healthcare setting, allowing a confluence of providers to demonstrably show their efforts have impacted a patient population.”  

The collaborative’s first project in 2018 was improving birth certificate accuracy. This might sound small, but accurate vital statistics and birth data are critical ingredients to monitor population health—particularly that of women and children—solve public health problems at the local, state and federal levels; and make wise decisions about where to spend limited dollars.  

When the initiative started, just 70 percent of the 25 participating hospitals were submitting accurate birth certificates based on 11 key variables, with low reporting accuracy for individual variables such as antenatal corticosteroids, birth weight and maternal hypertension. After this quality improvement initiative, 95 percent of enrolled hospitals were submitting accurate birth certificates.  

The pandemic hit before the collaborative could launch its next project. Instead of shutting down, however, “we pivoted,” Dr. Gentle said, hosting webinars about COVID-19 and maternal and child health to share best practices from other hospitals and to “continue to evolve and learn from each other.” 

Finally, with the country returning to some version of normal, the ALPQC was ready to move on to one of its next projects: neonatal opioid withdrawal syndrome (NOWS).  “Alabama saw a 20 percent increase in overdose deaths in 2020 compared to 2019,” Dr. Gentle said. “This is a critical time to address many of the aims set forth by this initiative.” In 2016, NOWS affected 6.7 per 1,000 in-hospital births with overall hospitalization costs of $572.7 million.1 In Alabama that year, nearly 600 infants covered by Medicaid were diagnosed with NOWS, an increase of nearly 100 percent from 2010. 

Using the Institute of Health Improvement’s model for improving quality, the initiative focuses on developing and instituting standardized practices around NOWS, including reducing stigma, increasing the use of non-pharmacologic care, and providing structural support for mothers, including addiction services and medication for opioid use disorder.   

“The global aim is to optimize care for mothers and their newborns with NOWS,” Dr. Gentle said. More specifically, the ALPQC hopes to reduce length of stay and exposure to pharmacologic treatments by 20 percent; and ensure that 95 percent of families are discharged with a collaborative plan linking them to community services. The project will run in conjunction with a third ALPQC initiative to decrease rates of severe maternal morbidity associated with hypertensive disorders of pregnancy. The collaborative hopes to have results by the end of the year. 

Although the ALPQC is still gathering data, at least one hospital cut the length of stay in half for infants with NOWS, Dr. Gentle said. 

The success of such statewide improvement requires a broad group of stakeholders, he said. “This work would not be possible without our partnerships,” he added, which include the Alabama Hospital Association, the Alabama Department of Public Health and payers. He also highlighted ALPQC Program Director Evelyn Coronado-Guillaumet’s leadership, as well as the consortium of hospitals’ continued engagement. “The hospitals’ shared experience certainly accelerates the work,” he said.  

Asked what’s next on the agenda, Dr. Gentle said telecommunication-based training for neonatal resuscitation. 


1 Strahan AE, Guy GP, Bohm M, Frey M, Ko JY. Neonatal Abstinence Syndrome Incidence and Health Care Costs in the United States, 2016. JAMA Pediatr. 2020;174(2):200–202.

Inside Pediatrics, Neonatology

Focus on Feeding in the NICU

Infants in the neonatal intensive care unit (NICU) are at huge risk of problems with oral feeding, potentially requiring surgical intervention if they can’t take in the nutrition required for growth and healing.  

Historically, specialized occupational therapists evaluated and treated babies who had feeding issues at Children’s of Alabama. But today, they are joined by specialized speech therapists. 

“The addition of speech therapists with special interest in NICU patients gave us an additional caretaker with a different background and skill set,” said neonatologist Allison Black, M.D. “We took advantage of both disciplines and their specialized, yet different, training and teamed them to create the infant feeding team.” 

“The teamwork begins during the evaluation process, even performing some of the tests such as swallowing studies and fiberoptic endoscopic evaluations of swallowing together,” Dr. Black said. Having two therapists work together for these studies is a bonus, said Christy Moran, an occupational therapist who works on the feeding team.  

For instance, she said, it is quite challenging to perform a modified barium swallow on an infant. With two therapists, however, one positions the infant and serves as feeder, incorporating the techniques used to support oral feeding. The other therapist prepares the barium and watches the screen. “It is a much better study with two therapists working together, so each can focus completely on their part instead of splitting their attention between one or the other,” Moran said.  

The therapists then collaborate to form a feeding and therapy plan, which they share with the rest of the NICU team. The approach continues until the patient is discharged home. 

“The patient benefits because they get evaluated by different people at different times, both of whom are experts at feeding infants,” Dr. Black said. “This helps us get a clearer overall picture of what the infant is truly capable of since a baby’s interest in feeding can depend on the time of day and multiple other factors, all of which are constantly changing in the NICU.”  

Working as a team also enables greater support for families and caretakers, said speech-language pathologist Allie Gilbert. “Since we work so closely together, there is a rhythm to our discharge sessions,” she said, “and parents seem to appreciate having both disciplines reinforcing the same recommendations.” 

Dr. Black is now collecting data on the impact the team has on infant feeding. Anecdotally, however, she said she’s seen greater success at getting babies to take oral feeds more quickly since implementing the team concept.  

Hematology and Oncology, Inside Pediatrics

Bringing Groundbreaking Cancer Trials to Alabama Children

Left, Elizabeth Alva, M.D., and right, Katie Metrock, M.D.

Although there have been great strides in treating pediatric cancer, it remains the leading cause of death by disease among children. In addition, more than 95 percent of childhood cancer survivors have significant health-related issues because of the toxicity of current treatment options. Yet just 4 percent of government spending on cancer goes to pediatric cancer.1 

That’s why the Sunshine Project is so important. The project, part of the National Pediatric Cancer Foundation, brings together more than 20 children’s hospitals, including Children’s of Alabama, with the goal of streamlining the process required to bring new, less toxic, more effective pediatric oncology drugs to clinical practice. 

Children’s joined the consortium in 2020 and is already participating in several novel studies for some of the worst pediatric cancers. The ultimate goal is to “provide hope to families,” said Children’s oncologist Elizabeth Alva, M.D. 

One such trial is for patients newly diagnosed with metastatic fusion-positive rhabdomyosarcoma, which has a three-year, event-free survival rate of just 6 percent. “Traditionally, we inundate these patients with very intensive therapy,” said pediatric oncologist Katie Metrock, M.D., but outcomes are still dismal. Research has traditionally focused on intensifying that therapy, but sometimes that just leads to greater toxicity without improving outcomes, said Dr. Alva.  

This uniquely designed study, called the EVOLUTION trial, is based on evolutionary theories around adaptation and resistance. Patients will be enrolled into one of four arms based on shared decision-making between the family and clinicians—not randomization. The first arm is standard of care. The second arm is “first strike therapy,” which Dr. Alva compares to a “meteor hitting the Earth and killing all the dinosaurs.” This approach addresses the hypothesis that children relapse because once the chemo-sensitive cells are gone, a more resistant population emerges. “So the first-strike theory is to get rid of everything,” she said.  

A third arm focuses on maintenance, or a “second strike”: providing the standard of care until the patient is in remission and then switching to a less-intense maintenance therapy to keep those resistant cells at bay while restoring quality of life. 

The fourth arm provides adaptive therapy. This means starting with standard chemotherapy that starts and stops based on response and adaptive timing of therapy, with a goal of increased time to progression rather than complete remission.  

Children’sis also participating in a phase 2 study evaluating the use of digoxin, a decades-old drug typically used in patients with heart failure, for patients with recurrent/refractory medulloblastoma. The drug was identified as potentially beneficial in laboratory and animal studies. 

“It is exciting to think that there are well-known drugs that can be repurposed to help treat various cancers,” said Dr. Metrock. “Our hope is that the tumors will show response to digoxin, and it could potentially be added to other up-front regimens in the future.” While the drug is well tolerated in children,” she said, “we haven’t used it in this heavily pretreated population, so we need to see how our patients do with it.” 

Two other trials are exploring immunotherapy. One is testing the immunotherapy nivolumab in combination with azacitidine for children with recurrent, refractory osteosarcoma. The other is exploring a vaccine made from the patient’s own cancer cells designed to trigger the immune system to target the cancer for destruction in children with high-grade gliomas. Trials such as these are coordinated by the Clinical Trials Office at Children’s of Alabama, which was established in 2019 to increase access to new therapies for Alabama children, thanks to a lead gift from the Hugh Kaul Foundation.

Projects like the Sunshine Project are desperately needed, said Dr. Alva. “Unfortunately, pediatric cancer doesn’t get the same degree of funding as adult cancer. It’s rare, but when it strikes in a pediatric population, so many more years of life are lost.” 


1 National Pediatric Cancer Foundation. Facts about Childhood Cancer. Available at: https://nationalpcf.org/facts-about-childhood-cancer/

Hematology and Oncology, Inside Pediatrics

Asthma, Sickle Cell Disease and Trauma – Connecting the Dots

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Brandi M. Pernell, DNP, assistant professor of Pediatric Hematology and Oncology

Take a child with sickle cell disease who is already at a significantly higher risk for asthma, pain and acute chest syndrome—the leading cause of death in these children—and mix in adverse childhood experiences (ACEs) such as violence, racism, abuse, parental death or divorce. The result: sicker children who, due to toxic stress exposures, are more likely to experience poorer health outcomes. 

That’s what Brandi M. Pernell, DNP, an assistant professor of pediatric hematology and oncology who works at the Children’s of Alabama dedicated pediatric sickle cell clinic, found in her research. 

“The literature shows that those who experience ACEs early in life have a higher risk of chronic conditions like asthma, cardiovascular disease, and obesity”—even cancer, Dr. Pernell said. But until her work, there was limited documentation in the sickle cell literature about ACEs. What is known is that acute stress is a common trigger for pain episodes in children with sickle cell disease. Pernell is now connecting the dots to show that ACEs increase asthma risk in these children which, in turn, leads to an increased risk for pain and acute chest syndrome.  

Her findings highlight the need to screen children with sickle cell disease, particularly adolescents, for ACEs and, if found, implement protective factors and buffering mechanisms to address the physiologic sequelae from these toxic exposures. 

She’s already begun that process, teaming with the local chapter of the Sickle Cell Foundation to promote social and emotional competence and resilience among affected adolescents. That community-based approach is important, she said. “I believe we need to meet families and patients where they are,” she said. And the Foundation has a different relationship with patients and families than the clinic staff. “We address the medical side, but ACEs are things happening in the home and neighborhood,” said Dr. Pernell. 

For Dr. Pernell, the work is more than a scientific endeavor; it’s personal. She felt called to this research, she said, both as a Black woman (sickle cell primarily affects Black people) and as a healthcare provider, particularly given the events of 2020. “In the wake of COVID and the social and racial uprising prior to and throughout 2020, it just spoke to me,” she said. So when she joined the University of Alabama at Birmingham faculty in 2016, this is where she focused her research. “I can relate to my patients in a way that some others can’t,” she said. “I’ve experienced some of the same things they have.”  

“If not me, then who?” she asked, quoting the late congressman and civil rights leader John Lewis. “If not now, then when?”  

Hematology and Oncology, Inside Pediatrics

Oncolytic Herpes Virus Immunotherapy Shows Early Promise in Pediatric Patients with High-Grade Glioma

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Gregory Friedman, M.D., professor of pediatrics at the University of Alabama at Birmingham (UAB), director of developmental therapeutics for the Alabama Center for Childhood Cancer and Blood Disorders at UAB and Children’s of Alabama

It’s a pretty big deal when your research is published in the New England Journal of Medicine. But it’s just as rewarding when your research holds promise for treating one of the most deadly cancers seen in children: high-grade gliomas.  

“Unfortunately, outcomes are very poor for children with progressive gliomas, and we have not seen a significant improvement in outcomes for this dreadful disease in the last 30 years,” said Gregory Friedman, M.D., professor of pediatrics at the University of Alabama at Birmingham (UAB), director of developmental therapeutics for the Alabama Center for Childhood Cancer and Blood Disorders at UAB and Children’s of Alabama and lead author of the paper, “Oncolytic HSV-1 G207 Immunovirotherapy for Pediatric High-Grade Gliomas.” Dr. Friedman also presented the findings from the phase 1 trial during the virtual American Association for Cancer Research Annual Meeting in April 2021. 

“The toxicities associated with the current standard therapies are unacceptably high,” Dr. Friedman said. “There is, therefore, a great need for effective and less toxic targeted therapies for these children.” 

Dr. Friedman’s team used a genetically engineered cold-sore virus, a herpes simplex virus type-1 (HSV-1), which naturally infects cells of the peripheral and central nervous system. While the modified virus, called “G207,” can’t infect and harm normal cells, it can target tumor cells by directly killing the cells and stimulating the child’s own immune system to attack the tumor.  

Twelve patients between 7 and 18 years old with high-grade gliomas that had progressed on prior treatments received an infusion of G207 through intratumor catheters. Within 24 hours, some also received a single, small radiation dose directed to their tumors, which was designed to enhance virus replication and spread throughout the tumor.  

Treatment response was assessed by imaging, tumor pathology and the patient’s performance status. Eleven of the 12 patients demonstrated a response, with a median overall survival of 12.2 months; a 120 percent increase over the typical overall survival of 5.6 months in this population. To date, 36 percent of patients have survived longer than 18 months, surpassing the median overall survival for newly diagnosed pediatric high-grade glioma.  

To date, immunotherapies have failed to improve outcomes in pediatric brain tumors because the tumors are “cold,” with very few immune cells needed to attack the tumor, Dr. Friedman said. “Importantly, when examining matched pre- and post-treatment tissue from patients, we showed something that has not been seen before with any other therapy: that G207 dramatically increased immune cell trafficking to the tumors and turned the ‘cold’ tumors to ‘hot’ ones. This is a critical step in the development of an effective immunotherapy for children with brain tumors,” he said.   

G207 alone or in combination with radiation therapy was well tolerated, with no dose-limiting toxicities, grade 3/4 treatment-related adverse events, or evidence of virus shedding into the bloodstream, saliva, or conjunctiva.  

“While further investigation in a phase 2 clinical trial is needed, our findings suggest that oncolytic immunovirotherapy using a modified cold-sore virus is a safe and potentially efficacious approach to target pediatric high-grade glioma,” Dr. Friedman said. 

Cardiology, Inside Pediatrics, Pulmonology

Saving Children with Pulmonary Hypertension – One Patient at a Time

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Children’s of Alabama cardiologist Frank Bennett Pearce, M.D.

When the cardiology team at Children’s of Alabama heard the family history of a 6-year-old boy who presented with an episode of syncope, they knew immediately what was wrong. His father had undergone a double lung transplant at the University of Alabama at Birmingham to cure his pulmonary hypertension (PH). Now his son had been diagnosed with the same thing.  

But that wasn’t the only problem. The boy had also developed a supraventricular tachycardia requiring radiofrequency ablation, which was successful. 

“So we cured that,” said Children’s cardiologist Frank Bennett Pearce, M.D., the boy’s cardiologist. But then the patient continued having episodes of syncope, particularly during exertion. “When that happens in patients with PH, it’s because the blood can’t get through the lungs to the left side of the heart, limiting cardiac output,” said Dr. Pearce. To address that problem, Dr. Pearce and his team performed an atrial septostomy, creating a tiny hole between the atria in the atrial septum. Second problem fixed. 

Discharged on oral medications, the child did well with close follow up for several years, said Dr. Pearce, although he was vulnerable to pneumonia and other infections.  

Then in 2020, at age 13, he took a turn for the worse. “There are three principal metabolic pathways involved in treatment of PH,” said Dr. Pearce. Two—endothelin and phosphodiesterase—have effective oral drugs for treatment. The third, the prostaglandin pathway, is more difficult to address, he said. In the past, it required a central line for IV infusions of treprostinil, a prostaglandin pathway medication. “Most families are very reluctant to go to the central line because it creates major problems in their lifestyle and is a quantum leap in terms of the negative effects on these children,” he said. 

However, treprostinil can also be administered subcutaneously through a small catheter and external pump, much like an insulin pump. Unfortunately, the day the teen was scheduled for cardiac cath and initiation of subcutaneous treprostinil, he became very cyanotic. “We didn’t think it was safe,” Dr. Pearce said. Instead, the boy was admitted to the CVICU on inhaled and oral prostacyclin inhibitors. Despite increasing the dosage, his disease progressed. Finally, the team put him on the intravenous form of treprostinil, and he improved. Eventually, they were able to transition him to the subcutaneous form of the drug via the pump, and he became the first patient at Children’s to be initiated onto subcutaneous treprostinil. 

He’s now home and undergoing evaluation for a lung transplant. “He’s a typical teenage kid but able to deal with all these challenges and keep a pretty good attitude, thanks to support from his family,” said Dr. Pearce. “He just hangs in there.” 

Cardiology, Inside Pediatrics

T3: Clinical Decision Support Platform in the CVICU Improves Monitoring; Reduces Problems

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Right, Santiago Borasino, M.D., and left, Hayden J. Zaccagni, M.D.

An enduring issue in pediatrics is that so much of the technology used was developed for adults and must be retrofitted for children. That’s why the new software the cardiovascular ICU (CVICU) at Children’s of Alabama received for its monitoring devices is such a big deal. “It’s unique to the pediatric cardiovascular ICU population because it was developed initially for that population,” said cardiac intensivist Hayden J. Zaccagni, M.D.  

The software, called T3 (trajectory, target and trigger), was developed by ICU software development company Etiometry with input from some of the top children’s hospitals in the country. Dr. Zaccagni calls it a “situational awareness tool,” one that pulls information from the telemetry unit, ventilator and other machines and displays all the data on one screen. It also provides past data and trends and uses algorithms to warn staff of the probability of low oxygen levels in the venous blood (a surrogate of a lower-functioning cardiac pump). 

With 20 beds in the CVICU that are nearly always filled, anything that makes it easier for the team to track potential problems and potentially improve outcomes is a boon. 

The software’s greatest value comes from the historical information it provides, said Dr. Zaccagni. Physicians and nurses can then use objective data to review events and improve their knowledge about what happened and why, he said. For instance, they use the data during extensive reviews of all cardiac arrest occurrences. “It shows the baseline, what happened before the arrest and what happened that led to the physiology failure,” he said. And that can identify opportunities for improvement. 

“It provides two things we didn’t have before,” said cardiac intensivist Santiago Borasino, M.D. “The ability to see multiple vital signs trend at the same time on the same screen and the ability to see trends over time right at the bedside without running a report on a different computer.” 

“Sometimes the vital signs might look normal, but that might be very abnormal compared to what the patient was experiencing six hours ago,” Dr. Borasino said.  

It also improves rounding communication and efficiency, enabling the entire team, including the attending physician, fellow, bedside nurse, dietician, respiratory therapist and pharmacist, to view the patient’s history for the past 12-24 hours at the same time. “We want everyone on the same page,” Dr. Zaccagni said. “The goal is that everyone is aware of patients at risk for having an untoward event.” 

The other advantage is the software’s ability to continually recalculate the algorithm based on the changes in vital signs. “As intensivists, we’ve been trained to put together information from different sources to create a picture of whether the patient is fine or not fine,” Dr. Borasino said. But those mental algorithms are fraught by memory and sometimes wrong. The software, however, provides robust data analyses and assigns a probability of a problem. 

“The ability to view the history, see multiple vital signs at the same time and see data trends, I think, provides better monitoring and helps us find problems when they’re small rather than when they’re big,” said Dr. Borasino. “Everyone knows when the patient is crashing; the algorithm and the way the information is laid out in front of us might help us act before the patient is crashing.” 

Inside Pediatrics, Neonatology

Marking a Milestone: RNICU Goes More Than One Year Without Central Line Associated Bloodstream Infections

Three hundred and ninety days.That’s how long the Regional Neonatal Intensive Care Unit (RNICU) at the University of Alabama at Birmingham (UAB) has gone without a central line associated bloodstream infection (CLABSI). And that, in the world of tiny, sick babies, is huge.

Healthcare-acquired infections (HAI) are a major problem in all hospitals, said Lindy Winter, M.D., Medical Director, but particularly for premature babies. “They are more vulnerable to infections because their immune systems are immature,” she said, “and they can’t fight off bacteria in the same way that adults are able to.”

Ideally, the rate of CLABSIs in a NICU should be zero, she said. Buta few years ago UAB’s rate was higher than national benchmarks, a rate determined through a formula based on the number of days patients have an IV line and how often infections occur. It’s also a major quality indicator for hospitals, reported to the Centers for Disease Control and Prevention and required for US News & World Report’s Best Hospitals ranking.

Thus, in 2013, UAB NICU leadership launched a major initiative to bring down the rate of CLABSIs. It was not an easy task, Winter said. “It required a huge culture change,” she said, “because NICU clinicians around the country believed such infections were inevitable, a natural outcome because these infants were immunocompromised anyway and nothing could be done to prevent it.”

She and her team set out to prove them wrong. They started with operational changes in how the central line was inserted and accessed, working closely with materials management to try different products to improve sterility. They changed how the skin and devices were prepped, and moved from having a single nurse insert, access, and manage the line, including changing dressings, to a buddy system in which at least one nurse is PICC (peripherally inserted central catheter) certified.

They studied their data to see which babies were more likely to get an infection. They discovered it was those who had umbilical lines that had been inserted at birth and remained longer than five days. “We did a lot of education with providers about switching from the umbilical to a PICC line to move closer to that five-day goal,” Winter said.

They also added central lines to the list of 10 things clinicians discuss during their daily patient rounds. This, Winter said, reminds staff to think about central lines and if they were needed as part of their daily routine.

Their efforts paid off. By 2016, the NICU started seeing a steady reduction in CLABSIs. And then, starting in the summer of 2019, there were none for more than a year.  “We held our breath all year,” said Winter. When they reached the 365-day mark they celebrated, ordering in food from the staff’s favorite restaurants.

The streak eventually broke when a critically ill baby developed an infection. After the emergency was over, the team instituted a “swarm,” a rapid cycle debrief to figure out what happened. “He was very sick and we had to access the line frequently for medications,” said Winter. “We think that was the issue.”

 Since that one infection, there have been no others tied to central lines.

“It was such a team effort,” said Winter. It’s not just the doctors and nurses, but the respiratory therapists, housekeeping staff, even materials management, all working together to reach the goal of zero.

Editor’s Note: The UAB Department of Pediatrics Neonatology Division and its 23 board-certified neonatologists works in collaboration with the Regional Neonatal Intensive Care Unit (RNICU) at UAB and the Neonatology Intensive Care Unit (NICU) at Children’s of Alabama. The RNICU provides care for infants with varying diagnoses, including extreme prematurity and cardiac defects, in an environment equipped with the latest patient care technology. The RNICU is housed in UAB’s new Women and Infants Center. The NICU at Children’s of Alabama is a Level IV unit with 48 private rooms available for neonates and infants and provides care for patients similar to the RNICU in addition to surgical procedures, ECMO and specialized dialysis (Aquadex) for the neonatal population.

Inside Pediatrics, Neonatology

Addressing COVID-19 in the NICU

When you are responsible for the tiniest, sickest babies in the state and a global pandemic hits, there is no time to waste. That’s the approach Hannah Hightower, M.D., a neonatologist at Children’s of Alabama and the University of Alabama at Birmingham (UAB), and her team took in early March 2020, when normal life seemed to cease overnight. The state started shutting down March 13, and by March 19 she and her team released their first set of guidelines for COVID-19-related maternal and infant care.

“I realized this would have a great effect on how the Neonatal Intensive Care Unit (NICU) and infant nurseries operated,” Hightower said. “The virus was a great unknown and very little published guidance was available. There was also a lot of fear among the staff. I felt an urgency to provide our NICU staff a framework of how to safely handle patients and families in the midst of the emerging virus.”

So she took what little information was available from other regions and countries and sought guidance from her pediatric infectious disease colleagues to develop Guidelines of Care for COVID-19-exposed mothers and infants.

Those first guidelines would form the foundation of numerous iterations over the following year as the virus spread and more data on its effects in pregnant women and their babies emerged. “As time went by, the protocols changed pretty frequently because of the speed of the emerging data,” she said.

Early policy changes limited visitors to the NICU to only the mother and one support person in order to reduce possible exposure of infants and staff in the NICU. They also followed national recommendations to briefly separate COVID-positive mothers from their babies after delivery in order to prevent transmission to the infant. That changed over the summer as evidence emerged that as long as the mother was not severely ill and used proper precautions, including wearing a mask and performing hand hygiene, the risk of transmission to her infant was low.

The more the NICU team learned, the more they reached out to share their knowledge, Hightower said. “I coordinated with nursing leadership and other neonatologists around the state to share our experiences with each other,” she said. “It was a big collaborative effort.” She also spent a lot of time on Zoom and national conference calls with other pediatric and neonatal physicians, as well as the hospital’s own infectious disease specialists. In addition, there was also ongoing education for the staff about how to protect themselves and others.

A big part of their effort was educating the families about safety protocols and helping them get COVID tested when necessary, and then explaining the need to quarantine or isolate. After a year of living with the pandemic, Hightower now says, “We are more comfortable handling infants and families dealing with COVID-19. Even though vaccines are becoming available, it will remain important to continue masking throughout the year. For now, limiting visitors is also going to continue,” she said, and they still encourage families to limit their interactions outside the hospital.

Inside Pediatrics, Neonatology

Helping the Tiniest Babies Grow

Ariel A. Salas, M.D., a neonatologist at Children’s of Alabama and the University of Alabama at Birmingham (UAB), was completing his master’s in public health when he first became interested in growth and nutrition in premature infants. “It’s a growing field,” he said. For years, neonatology was primarily focused on lung disease because most survival was linked to the degree of respiratory disease, he said, but with significant improvement in respiratory care and outcomes, “we’re now trying to optimize outcomes among the surviving infants.”

Premature infants, particularly those born at the limits of viability, typically don’t grow well during their hospital stay and have a higher risk of developing long-term nutritional complications related to extreme prematurity. Yet nutritional issues were traditionally an afterthought.

Now, thanks to a five-year, $777,384 Mentored Patient-Oriented Research Career Development Award (K23), Salas hopes to change that. The award provides him with the mentorship, training, and research experience to become an independent clinician scientist and leader in neonatal nutrition research. As he wrote in his grant application: “My long-term career goal is to reduce the burden of postnatal growth failure through novel translational studies and large scale, multi-center clinical trials of promising dietary interventions that optimize growth, reduce dysbiosis of the gut microbiome, and ultimately improve neurodevelopment.”

The grant will support a study to determine if giving preemies protein-enriched human milk during their first two weeks can promote lean body mass accretion, stimulate maturation of the gastrointestinal tract, and modify the gut microbiome.

One thing that makes this study unique is its focus on lean mass growth versus growth overall, Salas said. “Preemies are born so small they can grow really fast, but that could be because they’re getting too much fat in the diet,” he said, which could lead to later problems, including obesity. “There are a lot of unknowns in the implications of changing fat mass in preemies.” Still, he said, it will take two decades before the full implications of improved lean mass in premature infants is known.

“The advantage of protein is that it’s so important for structural growth.” Indeed, preliminary evidence from another study he participated in found that increased protein did improve the amount of lean mass growth in premature babies, he said. Those babies received the enhanced milk when they were older and their condition more stable; this study will start babies on the milk in the first two weeks.

The study uses a human-based protein fortifier added either to the mother’s breast milk or milk from the milk bank. It also uses a novel approach of measuring biomarkers in urine to see if they can predict the amount of lean mass seen in the body scans.

It’s not clear how lean mass affects development, Salas said, since the field is so new. “It’s only been in the past 10 years that we started measuring lean mass with non-invasive methods in extremely premature infants,” he said. Data over the past decade suggests, however, that overall lean mass is the safest approach to growth, leading to greater length and other outcomes.

The next step in this research, he said, is to see how the additional protein is digested and absorbed in the intestines and how it affects the gut microbiome. “Possibly some of those microbes can facilitate the digestion and absorption of the nutrients and if we can improve both, we may be able to improve growth overall.”

“This is a fascinating area,” said Salas, “and it probably has more serious implications in preterm infants because they have so much potential for growth.”