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neonatology

Neonatology

Risk factors for BPD-PH in preterm infants

Studies led by Children’s neonatologists show early indicators of bronchopulmonary dysplasia with pulmonary hypertension.

It’s well-known that preterm infants are prone to breathing difficulties due to their underdeveloped lungs. But the most common lung disease in these babies, bronchopulmonary dysplasia (BPD), is only recently becoming better understood more than a half-century after it was first described.

Now, Children’s of Alabama neonatologist Samuel Gentle, M.D. is expanding that knowledge by focusing on the most severe type of BPD—the form associated with pulmonary hypertension (PH)—in research that teases out contributing factors to this deadly disease.

It’s a major threat: nearly half of preterm infants develop BPD, which can lead to long-term breathing and health problems. About 20% of these babies also develop PH, and an estimated 40% of them will die of BPD-PH before turning 2 years old.

Samuel Gentle, M.D.

“This is a disease for which there’s growing research interest. It can be lethal, is not uncommon in extremely preterm infants, and we have little understanding of how to prevent or treat it,” said Gentle, who’s also an assistant professor of neonatology at the University of Alabama at Birmingham (UAB). “And children who do survive have long-term complications that persist into adulthood. It’s not a disease they just grow out of.”

“I’ve also had many interactions with families who lost a child to this,” he added. “Oftentimes, a child will be stable and doing well, and then collapse. I’ve seen how this can ravage a family.”

Since research has been scant about what causes the development of BPD-PH—as well as how to screen, treat and prevent it—Gentle wanted to fill the vacuum. Currently, a single ultrasound of the heart is the standard diagnostic method, though UAB performs this testing more frequently.

“We need to get better at identifying this disease in real time, rather than doing ultrasounds at arbitrary time intervals,” Gentle said. “Even with UAB’s testing approach, I believe it will become possible to diagnose it sooner, allowing earlier initiation of PH-targeted therapies.”

Along with UAB colleagues, Gentle published two studies that assessed factors that may contribute to BPD-PH in preterm babies. Published in the American Journal of Respiratory and Critical Care Medicine, they found two important associations: The duration of intermittent hypoxia events and the presence and persistence of a patent ductus arteriosus (PDA) after birth are both novel risk factors for BPD-PH.

In the first study, Gentle found that infants who experienced intermittent hypoxia events lasting longer than one minute were twice as likely to develop BPD-PH. “If an infant has longer intermittent hypoxia events, we might be more proactive in screening that infant for BPD-PH,” he said.

In the second study, preterm babies born with BPD-PH between 22 and 28 weeks’ gestation were more likely to have a PDA vessel that stayed open longer than 28 days. Babies with longer PDA duration were also more likely to die due to complications of BPD-PH than infants with only BPD. “The PDA could be interfering with the development of pulmonary vasculature resulting in PH,” Gentle said.

UAB will be participating a multicenter trial to determine whether closing PDAs with a catheter-closure device might lower the risk of this PH variant. But far more study is needed, Gentle pointed out.

“While this research focused on a specific phenotype of BPD, we need a comprehensive approach to identifying each infant’s specific type of lung disease from which we can decide on the best therapeutic course for every child,” he said.

August 6, 2024 by
Neonatology

Improving outcomes for babies with neonatal encephalopathy

Children’s of Alabama neonatologist Vivek Shukla, M.D. is leading an effort to better understand neonatal encephalopathy.

In neonatology, few conditions pose as complex a challenge as neonatal encephalopathy, a condition that encapsulates various disorders characterized by depressed mental or neurological states in newborns. That is why Vivek Shukla, M.D., and his team are taking a multipronged approach to improve outcomes for infants affected by this condition.

Cause and challenges

According to Shukla, director of the Neuro-NICU at Children’s of Alabama, neonatal encephalopathy stems from multiple factors, ranging from fetoplacental, infection, genetic and metabolic disorders. On many occasions, neonatal encephalopathy results from perinatal hypoxic-ischemic events, usually right before or as a baby is delivered.

Diagnosis presents a challenge, often relying on meticulous review of the history and thorough physical examinations. Shukla says it can be difficult to identify the cause quickly, prompting the need for specialized tests. Techniques such as MRI with newer imaging sequences and EEG play pivotal roles in better understanding the neurological intricacies contributing to this condition.

Shukla emphasizes that while strides have been made, adverse outcomes in neonatal encephalopathy—especially from suspected perinatal hypoxic-ischemic events—remain the most common contributor to long-term impairment in children. Around one in three babies with moderate or severe encephalopathy faces severe disability or succumbs to the condition, signifying a need for continued improvement.

The team approach

Multidisciplinary teams together with engaged families are crucial in providing holistic care while infants receive treatment, Shukla says. This collaborative approach extends beyond NICU discharge, ensuring continuous support and intervention to enhance a baby’s developmental journey.

In the Children’s Neuro-NICU, Shukla leads just such a team. This multidisciplinary team includes neonatologists (Hope Arnold, M.D., neonatology fellows and pediatric residents), pediatric neurologists specializing in neonatal neurology (Stephen Walker, M.D., Salman Rashid, M.D., and pediatric neurology residents), pediatric developmental-behavioral specialists focusing on child development (Myriam Peralta-Carcelen, M.D.), a pediatric rehabilitation medicine specialist (Erin Swanson-Kimani, M.D.), interdisciplinary therapists, and dedicated nursing staff. “We collaborate closely to provide comprehensive care for newborn infants, integrating expertise across multiple disciplines to enhance neurological outcomes and support developmental milestones from infancy through early childhood,” Shukla said.

To address neonatal encephalopathy, the team has implemented several strategies:

  • Involvement in several clinically important studies to improve the outcomes of infants suffering from neonatal encephalopathy
  • Working to develop an early and individualized risk-prediction model for infants with neonatal encephalopathy using advanced machine learning and brain MRI images
  • Collaborating with researchers from other institutes to investigate novel biomarkers and utilize machine learning to enhance the understanding and prediction of therapeutic hypothermia responses
  • Working to develop and validate machine learning models to predict the risk of seizures in newborn infants using EEG data, video recordings and clinical information
  • Conducting clinical trials to study interventions including pharmacologic and developmental interventions aimed at improving survival and neurological outcomes

History of treatment

Over the years, advancements have transformed treatment strategies, particularly in babies with suspected perinatal hypoxic-ischemic encephalopathy. Therapeutic hypothermia—cooling newborns to reduce metabolic demand for up to 72 hours—curbed brain injury post-insult in NIH-funded randomized controlled trials, including in babies treated by the team at Children’s. “For babies with moderate to severe encephalopathy, adverse outcomes are much more likely. Therapeutic hypothermia certainly reduces longer-term complications, but there are still opportunities to serve these infants better. That is why we’re continuing research on other options, including treatments that improve the overall outcomes in these children,” Shukla said.

Newer research avenues explore stem cell therapies, medications and interventions beyond therapeutic hypothermia. Additionally, vigilance in monitoring and managing seizures, which are more likely to affect these infants, has become integral to care protocols. Shukla’s team is actively engaged in clinical trials, paving the way for more effective treatments to enhance outcomes beyond the existing therapeutic approaches.

The future

Shukla says urgency and passion continue to drive ongoing research efforts. Neonatal encephalopathy continues to challenge neonatal care, but ongoing research and innovative therapies offer hope for better outcomes. The dedication of the Children’s of Alabama and University of Alabama at Birmingham (UAB) health care teams and the integration of pioneering treatments are pivotal in reshaping the journey for these vulnerable newborns.

August 2, 2024 by
Neonatology

Link Between Infant Mortality and Insurance Type

A study shows that the the infant mortality rate is higher for pregnant people insured by Medicaid compared to private insurance.

A new study published in JAMA Network Open suggests that the type of health insurance pregnant people have may impact infant mortality rates. The research, led by Children’s of Alabama neonatologist Colm P. Travers, M.D., found that pregnant people with private health insurance had lower rates of infant deaths compared to those insured by Medicaid.

“The type of health insurance you have has been associated with adverse outcomes in adults and pediatric populations and differences in access to care, including prenatal care,” Travers said. “But few studies showed a difference in infant outcomes, particularly infant mortality rates, when comparing private health insurance to Medicaid public health insurance.”

The study analyzed data on more than 13 million births that occurred in the U.S. from 2017 to 2020. Overall, 46% of the pregnant people in the study had Medicaid insurance, while 54% had private insurance.

The infant mortality rate—defined as the number of deaths in the first year of life per 1,000 live births—was 2.75 deaths per 1,000 live births for those with private insurance compared to 5.30 deaths per 1,000 live births for those covered by Medicaid.

Those with private insurance also had a 43% lower risk of postneonatal mortality (from 28 days to one year after birth); a 10% lower risk of a low-birthweight infant; a 20% lower risk of vaginal breech delivery; and an 8% lower risk of preterm birth. They were 24% more likely to have received first-trimester prenatal care than those with Medicaid.

Travers said the difference may result from the onerous application process for Medicaid, which delays access to early prenatal care. Previous research shows such delays are associated with worse infant health outcomes.[1],[2]

To address this issue, Travers suggested exploring policies around presumed eligibility for pregnant Medicaid beneficiaries. “The idea there would be that once you’re pregnant, you would automatically have access to prenatal care appointments while waiting on Medicaid approval,” he said.

Travers also suggested more help for Medicaid beneficiaries with navigating the healthcare system and scheduling essential prenatal appointments. “Community health workers or healthcare navigators could have a role,” he said. Peer coaches, known as doulas, could also provide valuable emotional and informational support throughout pregnancy and childbirth.

“From a holistic perspective, infants should have good health outcomes, irrespective of their parents’ socioeconomic status,” he said. “Babies shouldn’t die because of the kind of health insurance their mother has.”

[1] Swartz JJ, Hainmueller J, Lawrence D, Rodriguez MI. Expanding prenatal care to unauthorized immigrant women and the effects on infant health. Obstet Gynecol. 2017;130(5):938-945.

[2] 22. Taylor YJ, Liu TL, Howell EA. Insurance differences in preventive care use and adverse birth outcomes among pregnant women in a Medicaid nonexpansion state: a retrospective cohort study. JWomens Health (Larchmt). 2020;29(1):29-37.

January 29, 2024 by
Neonatology

The Benefits of Early Breast Milk Fortification

A study led by Ariel Salas, M.D., suggests that early breast milk fortification may boost growth in extremely preterm infants.

A new study led by Children’s of Alabama neonatologist Ariel A. Salas, M.D., suggests that feeding extremely premature infants—those born at 28 weeks of gestation or less—with breast milk fortified with human-derived nutrients shortly after birth could help boost growth and, possibly, cognitive and neurological development.

The first two weeks of life are critical for the growth and development of these neonates. While older infants are fed bovine-fortified breast milk soon after birth, there has long been a reluctance to feed it to these fragile neonates, Salas said.

“Starting fortification early has always been a challenge for clinicians because we always get worried about introducing bovine-derived nutrients too early in infants’ diet,” given the risk of necrotizing enterocolitis, he said. “So, there was a lot of pushback about doing this study.” Using a human-derived product, however, provided reassurance, and the study was approved.

The study randomized 150 extremely preterm infants with a mean birth weight of 795±250 grams and a median gestational age of 26 weeks to receive either fortified breast milk starting on day two after birth or unfortified breast milk. After two weeks, all babies transitioned to standard breast milk with bovine fortification. Eleven infants died during the observation period. The outcome was assessed in 105.

Those receiving the human-derived, fortified breast milk early on gained weight faster from birth to 36 weeks and had lower head circumference-for-age declines than the control group. Head circumference correlates with brain size, which is vital for cognitive and motor development.

Although there was no overall change in fat-free mass, Salas attributes that to the fact that the team could not measure fat mass in the sickest babies, given the invasive method used for measurement.

“The ones that would benefit the most from this early intervention were not being scanned for that outcome,” he said. However, they still showed benefits in terms of body length and head circumference. His team is now testing a non-invasive urine analysis technique to measure body fat.

The study also found no difference in outcomes in babies fed donor milk versus milk from their own mothers, but Salas hypothesizes that less fortification might be needed in maternal milk, which is already higher in protein than donor milk.

Salas said that few feeding interventions have been shown to improve head growth in preemies.
“We might be one of the few studies that show that effect,” he said. His team plans to follow the babies to see if the head circumference growth correlates with cognitive and neurological outcomes at two years of age.

“If the positive effects on length and head circumference translate into potential benefits for neurodevelopment at two years of age, early human milk fortification could be justified” despite its higher cost, he said.

The results were so significant that “we decided to change our practice,” Salas said. Now, all extremely preterm infants at Children’s receive human-derived, protein-fortified donor milk for the first two weeks of life.

“I’ve been doing clinical trials for almost eight years and always wondered how impactful they will be in common practice. And this one, I think, will be very impactful,” Salas said.

January 29, 2024 by
Neonatology

Developmental Research Program Making a Difference for Multiple Specialties

Dr. Namasivayam Ambalavanan looks through a microscope in a lab at UAB. Ambalavanan leads the TReNDD research program at Children’s.

Much research in pediatrics focuses on disorders related to specific organ systems such as the brain, liver or kidneys, without an emphasis on the developmental time period that influences how those disorders may unfold in babies and young children. But a 15-year-old program at Children’s of Alabama bridges that gap, connecting investigators from a bevy of disciplines and supporting basic and translational research efforts that have paid off in better outcomes for patients.

Established in 2008, the Translational Research in Normal and Disordered Development (TReNDD) program is run by the Division of Neonatal Research. Namasivayam Ambalavanan, M.D., has been at the helm since its inception, directing TReNDD and neonatal research as well as co-directing the Division of Neonatology at Children’s.

“Our focus is on normal and abnormal development from late fetal life through early childhood—not so much on one disease or organ system, but the entire time period,” Ambalavanan said. “Ours is a highly collaborative network, bringing together people interested in disorders that occur during this time period. It’s relevant to all pediatrics, rather than one subspecialty.”

Faculty members from pediatric specialties such as neonatology, nephrology, pulmonology and critical care participate in TReNDD and typically approach the program with a certain research priority in mind, Ambalavanan explained. Ongoing basic science and clinical research projects, for example, are examining a wide variety of problems affecting neonates and other infants, from ventilator-induced lung injury to acute kidney injury to vitamin D supplementation in preterm babies.

Investigators can also rely on TReNDD facilities to help advance these projects, including core facilities able to run a wide variety of assays and a repository of pediatric biospecimens and model systems.

“Investigators come in with an area of interest, and we help them develop an animal model or assay to meet that interest,” Ambalavanan said. “We also put them in touch with additional people who can help, whether here or off campus.”

Over its history, the TReNDD program has produced research breakthroughs that have benefited children far and wide. Evaluating multiple signaling pathways during lung development, for example, led to key insights about lung impairments in preterm infants and tests determining who’s most vulnerable to certain breathing problems from their first day of life. Other lung research on the microbiome of tracheal aspirates of preterm babies led to the development of probiotics that can benefit lung health.

“I think TReNDD has a vital role because there are many people who want to do pediatric research but don’t know how to get started,” said Ambalavanan. “We’re a way of enabling people to both get their research done and find mentorship in research in the Department of Pediatrics.”

August 25, 2023 by
Upcoming Events

Children’s and UAB to Host International Neonatal Nephrology Symposium

The inaugural International Neonatal Nephrology Symposium (INNS) takes place in Birmingham in September 2024.

The Pediatric and Infant Center for Acute Nephrology (PICAN) at Children’s of Alabama and the University of Alabama at Birmingham (UAB) will host the inaugural International Neonatal Nephrology Symposium (INNS) September 11-15, 2024, at the Hilton Birmingham Downtown at UAB.

This symposium will bring together experts, researchers and clinicians from across the globe to share knowledge, exchange ideas and collaborate on the latest advancements in neonatal kidney disease. The event will provide a unique platform for networking and foster scientific dialogue that will contribute to improving outcomes in the youngest patients.

Topics

  • Practical aspects of neonatal kidney care—the science and the art
  • From crib to bench and back to the crib
  • Kidney health metrics in neonates and young children
  • Fetal kidney disease—a new era
  • Neonatal organ cross talk
  • Neonatal nephrology potpourri

Featured Workshops

  • Clinical roundtables—caring for neonates with kidney disease and their families
  • Hands-on practical skills sessions—tools to optimize care of neonates with kidney disease

For more information, visit www.childrensal.org/inns.

August 24, 2023 by
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
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
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
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