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Neonatology

BRAIN Protocol Reduces Brain Bleeds in Very Preterm Babies

Dr. Vivek Shukla is a neonatologist at Children’s of Alabama.

After implementing new measures to protect the brain health of preterm babies, a multidisciplinary team at Children’s of Alabama at the University of Alabama at Birmingham (UAB) saw promising results that suggest a new protocol could prevent brain bleeds in preterm neonates.

More and more infants born before 29 weeks, 6 days are surviving, bringing greater attention to their long-term outcomes, particularly their neurological health. In their first few weeks of life outside the womb, these babies have a high risk of intraventricular hemorrhage (IVH), a type of bleeding in the brain. To reduce the risk of IVH and other brain bleeds, Children’s of Alabama neonatologists Vivek Shukla, M.D., and Maran Ramani, M.D., led a multidisciplinary team from the level IV regional neonatal intensive care unit (NICU) at the University of Alabama at Birmingham (UAB) in the development of a quality-improvement and management program for infants at high risk of IVH or other neurological complications. The team implemented the program, called BRAIN, in April 2018 with the goal of improving long-term neurological outcomes for these babies.

The interventions begin at birth and continue through the first week of life, which is considered the highest-risk period for IVH and other brain bleeds. Components of BRAIN include:

Using more sophisticated monitoring such as near-infrared spectroscopy
Protocolizing routine medication use within six hours of birth for most of babies—such as initiating IV indomethacin prophylaxis, which can reduce the risk of IVH—and limiting the use of saline boluses and bicarbonate
Reducing noise levels by carefully handling equipment and the incubator, minimizing incubator

door opening, reducing the intensity of alarms and promptly responding to them, avoiding conversations at the bedside as much as possible and using a soft voice if needed.

Standardizing infant positioning with an elevated head of the bed, avoiding putting the baby flat on the bed and getting help when turning the baby to ensure a neutral head position.

Of 127 babies tracked after implementing the neuroprotective protocol, none experienced a brain bleed or early death in the first week of life compared to 11 out of 99 (11%) prior to the intervention. The results were published in the Journal of Perinatology in July 2022. The work isn’t finished, however, with several additional approaches planned, including using machine learning and artificial intelligence to identify features that predict worse outcomes.

“All the congratulations go to my wonderful team, my wonderful mentors and my excellent colleagues here,” Shukla said. “This is not a single-person show. A lot needs to be done to ensure that preterm infants reach their best potential development.”

January 16, 2023 by childrensal

Neonatology

Study Identifies Noninvasive Marker for Risk of Acute Kidney Injury

Dr. Christine Stoops is a neonatologist and the leader of the Baby NINJA team at Children’s of Alabama.

The leaders of an innovative project at Children’s of Alabama are looking to add a strategy that could help them identify an acute kidney injury (AKI) earlier.

The Baby Nephrotoxic Injury Negated by Just-in-Time Action, or Baby NINJA, project at Children’s of Alabama was established in 2015 to reduce the use of nephrotoxic medications and monitor neonates for early signs of AKI, which is a common complication in the Neonatal Intensive Care Unit (NICU) because very low birthweight infants are typically exposed to nephrotoxic medications during their stay. In Baby NINJA’s first 18 months, this first-of-its-kind program—which has now been validated at other major children’s hospitals—led to a 42% drop in nephrotoxic medication exposure and a 78% drop in AKI prevalence, according to Baby NINJA team leader Christine Stoops, D.O., M.P.H. The improvements have continued through 2022.

Stoops, a neonatologist at Children’s, hopes recent research will lead to even better outcomes for Children’s patients. In 2019 and 2020, Stoops worked with investigators at Cincinnati Children’s Hospital to see if a noninvasive urinary marker, neutrophil gelatinase-associated lipocalin (NGAL), could provide an earlier warning sign of AKI. The results of the study, which was funded by the National Institutes of Health, were strong, and Stoops hopes Children’s will ultimately be able to incorporate NGAL into its Baby NINJA program.

NGAL can provide a timely way to predict which babies are at risk of AKI because it accumulates in the kidney tubules and urine after an injury, such as those caused by nephrotoxic medications. Studies in other settings show that NGAL elevations occur a couple of days before changes in serum creatinine, which is the traditional method of screening for AKI. But serum creatinine involves a needle stick and waiting for lab results. By the time babies show high levels of creatinine, they are already far along in the AKI. NGAL, in addition to being an earlier marker of AKI, is noninvasive, requiring just a few drops of urine. “The benefits of a noninvasive marker for kidney injury are a win all around for our babies, their families and the caregivers,” Stoops said.

In the NGAL study, researchers obtained daily creatinine and urine samples from 148 NICU babies for up to seven days after they were exposed to nephrotoxic medication, plus two days after they stopped the medication and/or when their AKI resolved. They identified the positive and negative predictive values of NGAL for AKI, confirming the results with the creatinine test. Stoops hopes the study and others like it will lead to FDA approval of NGAL as a test for AKI so Children’s of Alabama can incorporate its use into their Baby NINJA program and the very tiny babies in the NICU will receive far fewer blood draws.

January 16, 2023 by childrensal

Neonatology

New Research May Lead to Changes in the Care of Nano-preterm Infants

Researchers at Children’s of Alabama are studying the best ways to care for some of the smallest neonates.

Preliminary research conducted by neonatologists at Children’s of Alabama and the University of Alabama at Birmingham (UAB) could pave the way for new standards of care for extremely preterm babies.

Today, some babies with a gestational age between 22 weeks and 23 weeks, 6 days (previously considered inviable) may survive. However, very little is known about what increases the likelihood of survival and reduces the risk of long-term complications in these babies. In fact, until Children’s of Alabama and UAB neonatologists published a large series showing feasibility and outcome differences in infants who receive invasive and non-invasive respiratory support at birth, there wasn’t even a formal nomenclature for them.

“We coined the term ‘nano-preterm,’” Children’s of Alabama neonatologist Vivek Shukla, M.D., said. He is the lead author of a paper published in the journal JAMA Network that provides some of the first data on the best way to manage these neonates just after birth. UAB neonatologist Charitharth Vivek Lal, M.D., is also the senior author of the paper.

Non-invasive respiratory support at birth—rather than immediate intubation and delivery of lung surfactant—has been shown to improve short-term respiratory outcomes in extremely premature infants, defined as those born at gestational age 24 weeks to 27 weeks, 6 days. But it was assumed that non-invasive respiratory support was not feasible in those born between 22 weeks and 23 weeks, 6 days (now known as nano-preterm infants). The problem was that it had not been studied.

Shukla, Lal and their co-authors reviewed data on 230 nano-preterm infants treated at UAB’s level IV neonatal intensive care unit (NICU) between January 2014 and June 2021 to see if non-invasive respiratory support was best for these babies. Eighty-eight of the infants (whose average weight was 1 pound, 4.4 ounces) received non-invasive respiratory support in the first 10 minutes after birth; the rest (whose average weight was 1 pound, 2.4 ounces) received invasive respiratory support.

There was no difference in the combined primary outcomes of death or the complication of bronchopulmonary dysplasia at 36 weeks postmenstrual age between the two groups, but there was a higher risk of severe brain hemorrhageand deathin those who received non-invasive respiratory support. Shukla and Lal are planning a large, multicenter study to confirm the findings and provide data needed for professional societies to develop guidelines of care for nano-preterm infants.

“This could be practice-changing,” Shukla said. “It is also particularly important data given the increasing number of nano-premature babies who are surviving today.”

January 16, 2023 by childrensal

Neonatology

Initiative Aims to Send Low Birthweight Babies Home on Human Milk

Dr. Allison Black is a neonatologist at Children’s of Alabama.

Children’s of Alabama neonatologist Allison Black, M.D., is spearheading a project with the Children’s Hospital Neonatal Consortium to improve the percentage of babies in the neonatal intensive care unit (NICU) receiving human milk at 120 days of life or at discharge. More than 30 of the best level IV NICUs throughout the country are participating in the Project HOME (Home On Milk Every time) quality improvement project and sharing best practices to increase their success rates.

Breast milk has a host of benefits for babies, but for very low birthweight (VLBW) babies in the NICU, it can be lifesaving. The unique composition of human milk can reduce morbidity and mortality while conveying long-term cognitive and behavioral benefits.[1] Human milk that comes from an infant’s own mother is ideal because it includes antibodies to fight infection and a composition specific for each baby. But even donated breast milk can be beneficial. Despite these benefits, only about half of VLBW infants throughout the U.S. are discharged home on human milk. That rate is even lower among babies born in the South.[2]

The Project HOME initiative is built on research showing that a multidisciplinary approach is the most successful way to increase rates of human-milk feeding. “It’s not just one team member who makes a difference,” Black said. “Every caretaker who encounters patients and their families should provide the same messaging and education about the importance of human-milk feeding. We need to ensure that every staff member has the resources and knowledge to give this support to our families.” To that end, Black is assembling a team of NICU providers including bedside nurses, lactation consultants, speech and occupational therapists, nursing educators and even a mother of a NICU baby to identify and address barriers to providing the support needed for human-milk feeding.

The message is that human milk is a medicine that only you can provide for your baby.

One major barrier to getting mothers’ milk to babies at Children’s of Alabama is that the babies are born at hospitals throughout the state, some more than 100 miles away, then moved to Children’s via critical care transport teams. “We don’t see the mother until she’s discharged,” Black said, “and many times she’s too ill to speak by phone.” Yet studies find that expressing milk within the first six to 12 hours after delivery is associated with the highest success rates for initiating human-milk feedings.

Black says the transfer challenge requires them to think outside the box, such as including referring centers and the transport team in efforts to provide education about human-milk feeding before mothers arrive at Children’s.

“Another huge barrier is the physical and emotional distance a mother feels when her child has to be transferred to another facility,” Black said. This separation combined with the fact that many mothers are ill themselves can make it quite challenging for mothers to provide milk. Other barriers include access to electric pumps, support from someone who is knowledgeable about the benefits of human milk and a family and community support system. “These challenges continue as mothers have huge amounts of physical and emotional stress when their babies have prolonged hospitalizations, not to mention the different logistical challenges for mothers providing milk when they are back in the workplace and dealing with life outside of the NICU,” she said.

But Black sees numerous opportunities to overcome these obstacles, including educating mothers while they’re still in the hospital; outreach to high-referral centers to begin the education pre-delivery; giving brochures to families as early as possible; and forming a community support system.

While Black says the percentage of pre-term babies at Children’s who are still on human milk at 120 days or discharge is higher than the national average, she believes there is still room for improvement. She’d like to see the rate increased by at least 10 percent and is confident they’ll meet that goal. “All members of our team are passionate about working together to improve the care of our patients.”

[1] Vohr BR, Poindexter BB, Dusick AM, et al. Beneficial effects of breast milk in the neonatal intensive care unit on the developmental outcome of extremely low birth weight infants at 18 months of age. Pediatrics. 2006;118(1):e115-e123. doi:10.1542/peds.2005-2382

[2] Parker MG, Greenberg LT, Edwards EM, Ehret D, Belfort MB, Horbar JD. National Trends in the Provision of Human Milk at Hospital Discharge Among Very Low-Birth-Weight Infants. JAMA Pediatr. 2019;173(10):961–968. doi:10.1001/jamapediatrics.2019.2645

January 16, 2023 by childrensal

Inside Pediatrics, Neonatology

Neonatal Consortium Advances Care for Patients with Rare Diagnoses

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If you’re trying to make quality improvements, a good place to start is in the past. Historical data can hold the key to understanding what works, what doesn’t and what holds promise. But searching for answers in a small sample can be like panning for gold in a puddle. You need a stream of data to draw out the nuggets.

Prior to 2006, Children’s of Alabama was similar to most freestanding Children’s Hospitals: treating some of the sickest patients with unique conditions that didn’t always have textbook answers. Children’s neonatologist Tim Coghill, MD, was in the same position as his peers across North America; they knew there could be knowledge in numbers. With colleagues at 16 other Children’s Hospitals, he co-founded the Children’s Hospitals Neonatal Consortium (CHNC), an international group of level IV neonatal intensive care units (NICUs) that work together to improve patient outcomes.

Now in its 16th year, the group consists of more than 40 top-rated Children’s Hospitals in the U.S. and Canada. All contribute to the Children’s Hospitals Neonatal Database, which allows them to compare a larger number of outcomes for complex patients and rare diagnoses and find the “gold” in their shared data.

Children’s neonatologist Allison Black, MD observes that, “We receive patients with rare diagnoses that you may only take care of once every 10 years. When you can pool the data on these patients with other centers, you can see if certain treatments and characteristics are associated with better outcomes and help formulate the best practices.”

One of the primary ways the CHNC establishes those best practices is through Collaborative Initiatives for Quality Improvement (CIQI) projects, such as STEPP-IN, a program aimed at improving neonatal surgical outcomes. The STEPP-IN initiative developed a standardized handoff and workflow process for patients being transported to and from the operating room. Through this process, the stability of infants during the time surrounding surgical procedures was greatly improved. Another quality improvement initiative, Erase Post-Op Pain, included an algorithm for managing and preventing pain after surgery in neonates. After initiation of these algorithms, the frequence of uncontrolled post-operative pain episodes following procedures decreased to less than 6% at Children’s of Alabama, a best in class outcome. The CIQI projects often include clinicians, caregivers and specialists from various departments and disciplines throughout the hospital. Through the collaborations in these initiatives, there have been other permanent interdisciplinary teams established, such as the neurodevelopment care team, palliative care and infant feeding teams at Children’s. “Our involvement with the CHNC has helped foster a culture of collaboration, and this has helped us strive for a more well-rounded, multidisciplinary model when caring for our patients and supporting their families,” Black said.

Children’s involvement in the CHNC has provided the opportunity to help others seeking to improve care and create a collaborative environment in their units, as well. Hannah Hightower, M.D., presented at a national seminar highlighting her success with improving communications during high-stakes situations through a project involving debriefing after code events. In the past year and a half, Coghill and Black participated in two national workshops providing education to pediatric providers on difficult discussions and end-of-life decision making with families in the NICU. All three of these physicians have contributed to published manuscripts in the past year and have more in production through their involvement and collaborations in the CHNC.

Outside of the QI projects, CHNC members also participate in an ever-expanding list of focus groups. Focus groups Children’s of Alabama participates in include:

Resuscitation
Discharge planning
Gastroschisis
Palliative Care and Ethics (PACE)
Neurosurgery
Micrognathia
Kidney and Urology
Necrotizing Enterocolitis
Genomics

These focus groups, said Black, “allow us to work together to develop the best practices for specific diseases.” The greatest benefit of the CHNC is that patients get access to care that is constantly improving. “Through our involvement with the CHNC, we are lucky to be on the forefront of deciding how to best care for complex patients,” said Black. “We are constantly striving to gain knowledge and improve the care of our unique patient population, and in turn, our patients all benefit from this collective knowledge.”

September 5, 2022 by childrensal

Inside Pediatrics, Neonatology

Quality Improvement Significantly Improves Outcomes for the Tiniest Babies

Left, Colm Travers, M.D., and right, C. Vivek Lal, M.D., are neonatologists at Children’s of Alabama and faculty in the Division of Neonatology in the University of Alabama at Birmingham Department of Pediatrics.

In 2014, when neonatologists C. Vivek Lal, M.D., and Colm Travers, M.D., began digging into the data on extremely preterm infants (those born before 28 weeks), they found that Children’s of Alabama and the University of Alabama at Birmingham had some of the best outcomes in the country. But there was still room for improvement.

Infants born so early are at high risk of death and intracranial hemorrhage, or brain bleeds, the most devastating outcomes in the first week after birth.

“We saw a tremendous opportunity to improve mortality and other outcomes,” said Dr. Lal. “We saw this as a chance to fine-tune our practices, and not only be the best in outcomes, but also create a narrative for others to follow.”

“Our goal was to reduce the rates of brain bleeds or deaths in the first week,” said Dr. Travers. “There’s some evidence that non-adherence to certain practices and a lack of standardization can lead to worse outcomes in the smallest babies. We felt that by standardizing care to the best available evidence we could improve those outcomes.”

That’s exactly what they did with the Golden Week™ program, a multidisciplinary, evidence-based, standardized quality-improvement plan to improve the care and outcomes of the micro-preemies. It incorporates a variety of changes in how care is provided, with detailed protocols for the first hour of life, the first 72 hours, and days four to seven.

When the initiative began in 2016, the rate of severe brain bleeds or death was 27.4 percent. Today it’s less than 10 percent and continuing to fall.

The team involves neonatologists and neonatal fellows, as well as respiratory therapists, nurses, residents, and other stakeholders who care for the tiny babies at the bedside.

The initiative began with a comprehensive literature search of every clinical trial or observational study related to mortality or brain bleeds in these babies, identifying successful interventions and then integrating them into the care pathway.

These include ensuring that the mother receives corticosteroids before delivery to help the fetus mature; delayed cord clamping after delivery; putting the baby into a certain position once they’re admitted; initiating evidence-based order sets; and limiting fluid and bicarbonate boluses and the use of inotrope drugs as well as blood transfusions.

Some of the changes were tiny, but with big payoffs, including how the nurses change the babies’ diapers. “We make sure they don’t move the head too much or lift the body too much. Anything that might cause a change in the blood flow going to the brain,” Dr. Travers said. Overall, the team made 24 changes in the care provided during the first week.

The key was not one change, but the changes as a whole, said Dr. Travers. “It was when we put all of these small changes together that we saw the impact,” he said.

The results are being published in the journal Pediatrics this spring.

February 15, 2022 by childrensal

Inside Pediatrics, Neonatology

Bringing Evidence to Bear in the Use of Perioperative Antibiotics

Ninety percent of patients in the neonatal intensive care unit (NICU) at Children’s of Alabama will undergo a surgical procedure during their admission, putting them at risk of infections and other complications. Thus, the NICU team has been implementing performance improvement initiatives to improve outcomes, including focusing on pain control and standardizing handoffs before and after surgery.

The most recent initiative targets perioperative antibiotic use. “The vast majority of surgical patients will require some type of antibiotic during the perioperative period,” said neonatologist Allison Black, M.D., “and we noticed there wasn’t any standard as to the dose or type of antibiotics used for each procedure.”

That’s a problem, she said, because prolonged use of broad-spectrum antibiotics may be harmful. “It changes the infant’s gut flora, increases the risk for antibiotic-resistant infections, and may have toxicities,” she said.

Thus, the NICU team, including physicians, nurse practitioners, and pharmacists, collaborated with the general surgeons and each surgical subspecialty to devise a solution. The surgeons collected evidence and then recommended an antibiotic as well as its dose and duration based on the specific procedure. The team used these recommendations and the evidence supporting them to create the NICU Perioperative Antibiotic Prophylaxis guidelines.

“Now, unless there is a specific reason, all perioperative antibiotics are ordered based on these guidelines, and surgeons follow the protocol,” Dr. Black said. “It’s like clockwork.” The result is less use of prolonged empiric antibiotics and less confusion over which to use. Another advantage is less exposure to nephrotoxic drugs that can lead to acute kidney injury, she said.

The unit’s two pharmacists ensure the protocol is followed. “Initially, it was difficult to break our decades-long habit of asking the surgeons which antibiotic they preferred and for how long after each surgical case,” said clinical pharmacist Sadie Stone, PharmD. “With the perioperative guidelines in place, we can initiate an evidence-based regimen quickly for our most common surgical procedures.”

Since instituting the guidelines, the pharmacists have been collecting data and tracking guideline compliance. “We discuss each surgical plan with the nurse practitioner based on the guidelines when the patient returns from surgery,” said clinical pharmacist Emily Evans, PharmD. Each case is then retrospectively reviewed to determine if the procedure has an antimicrobial course included in the guidelines. If so, the actual antimicrobial course is screened against the guidelines for adherence. “These guidelines have expanded our antimicrobial stewardship role in the NICU,” she said.

“The hope is that reduction in the use of antibiotics will decrease the need for central lines, which, in turn, also reduces the risk of infections and associated complications,” said Dr. Black. The team also tracks post-operative infection rates to ensure there is no increase.

“This initiative again shows the improvement possible with multidisciplinary collaboration,” she said.

August 27, 2021 by childrensal

Inside Pediatrics, Neonatology

Using Quality Improvement to Improve Maternal/Child Health

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.

August 27, 2021 by childrensal

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.

August 27, 2021 by childrensal

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.”

February 26, 2021 by childrensal

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