Browsing Tag

NICU

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. 

Inside Pediatrics, Neonatology

Using Quality Improvement to Improve Maternal/Child Health

Dr-Sam-Gentle-Neonatology-Resized

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.  

Inside Pediatrics, Neonatology

Generous Donation to NeuroNICU B.R.A.I.N. Program Helps Reduce Risk of Brain Injury in Premature Infants

NICU_WEB

Through a generous donation by Robert and Kathleen Israel, Children’s of Alabama is now home to new technology that helps dramatically prevent brain injury and improve brain development and function in its sickest patients.

Children’s of Alabama is thrilled to announce a very generous gift of a cutting-edge technology designed to help reduce the risk of brain injury in preterm infants. The gift was donated by Robert and Kathleen Israel in honor of the care their daughter, Ivy, received in the Neonatal Intensive Care Unit (NICU) in 2018. Ivy is home and doing very well. “The NICU team at Children’s of Alabama saved our daughter’s life,” said Robert Israel, “and we are forever grateful.”

“This new technology made possible by the Israel family is helping us  dramatically prevent brain injury and improve brain development and function in our sickest patients,” said Manimaran Ramani, M.D., director of the NeuroNICU program.

Preterm infants born at 30 weeks or earlier are at higher risk for developing intraventricular hemorrhage (IVH), which is associated with long-term neurocognitive and motor deficits. The risk for neurocognitive and motor deficits is also higher for term infants with hypoxic-ischemic encephalopathy (HIE), seizures, metabolic disorders, or stroke, and those undergoing ECMO therapy.

However, a multidisciplinary initiative in the NICU at Children’s of Alabama and the University of Alabama at Birmingham (UAB) called NeuroNICU B.R.A.I.N. (Brain Rescue and Avoidance of Injury in Neonates) aims to prevent and reduce neurocognitive and motor deficits in high-risk neonates.  

The objective of the B.R.A.I.N. program is to identify and prevent brain injury early in high-risk neonates through state-of-the-art diagnostic techniques and neuroprotective care. An interdisciplinary team of medical professionals meets every week to strategize individualized comprehensive neuroprotective plans for infants enrolled in B.R.A.I.N.

Though standard vital monitoring techniques used in NICUs such as blood pressure, heart rate and pulse oximetry provide valuable information about the infant’s hemodynamic status, such standard monitoring techniques don’t provide real-time information regarding the brain’s oxygenation saturation, oxygenation extraction and perfusion status of a sick neonate.

This is where infrared spectroscopy (NIRS) monitoring comes in. “This technology allows us to monitor cerebral oxygenation in very sick infants,” Ramani said. It is a non-invasive method that can be used continually at the bedside as well as during surgery to monitor the health of the brain. It can also be combined with amplitude-integrated electroencephalography (aEEG) to monitor cerebral electrical activity and to diagnose seizures in sick neonates in real-time.

“With the two NIRS devices donated by the Israel family, we are now able to monitor the brain health and adjust our therapies and strategies in real-time on our patients,” Ramani said.

 

 

Inside Pediatrics, Neonatology

Debriefing after Resuscitation: A Quality Improvement Initiative

Resuscitation_WEB

In October 2018, the Children’s of Alabama Neonatal Intensive Care Unit embarked on a quality improvement project, Debriefing Following Resuscitation/Code Events in the NICU, to identify opportunities to improve the resuscitation process, including staff satisfaction. It is one of several quality initiatives led by the Children’s Hospitals Neonatal Consortium.

The Neonatal Intensive Care Unit (NICU) can be an intimidating and stressful place to work.  One of the most stressful events in the NICU is a neonatal code or resuscitation, which may require intubation, chest compressions and special medications, all delivered under the pressure of knowing that seconds count. This requires that the team of doctors, nurses, respiratory therapists, pharmacists and other practitioners work together like a well-oiled machine.

Resuscitation codes are, by definition, rare events, said Children’s of Alabama neonatologist Hannah Hightower, M.D. Weeks may go by without any and then they might have several in one month. But they are definitely disruptive and stressful.

In October 2018, the Children’s of Alabama NICU embarked on a quality improvement project, Debriefing Following Resuscitation/Code Events in the NICU, to identify opportunities to improve the resuscitation process, including staff satisfaction. It is one of several quality initiatives led by the Children’s Hospitals Neonatal Consortium (CHNC), a group of more than 30 children’s hospitals around the country dedicated to using performance improvement methods to improve the delivery and quality of care in Level IV NICUs, which care for high acuity and medically complicated neonates.

The premise is simple. As soon as possible after the code, everyone gathers for a few minutes to discuss what went well, any equipment or medication problems, communication quality, and, of course, highlighting what could go better next time. They also complete a short form documenting the discussion. In just three months, the team at Children’s exceeded its goal of holding post-resuscitation debriefings after 80 percent of codes.

Such approaches can lead to improved resuscitation quality and reduced mortality, research finds. [1]

“The goal is to help everyone involved in the process improve skills, cope with the stress, and ultimately and most importantly, improve the process and patient outcomes by identifying potential latent safety threats,” Hightower said. “We want everyone on the team to feel free to express any concerns as well as provide support. Even the caregivers need a chance to decompress.”  “Not only does it provide a venue for raising issues related to caring for the patient, she said, “but it also lets us show appreciation for the things that went well.”

“It wasn’t a surprise to hear that one of the biggest issues is communication in a stressful period,” Hightower said. “We can always improve communication, whether that means discussing who is leading the code or controlling the volume so everyone can hear and understand what’s going on.” Discussing communication issues shortly after the code is important, she said, “because it’s at the front of your mind. By doing this immediately, you remember things you may not later and can articulate issues that might not be apparent in a week or two.”

Since implementing the initiative, the team has begun a proposal to further improve communication by emphasizing who is leading the code. Future projects include providing each member a way to give real time feedback not just to the code event, but also to the quality and effectiveness of the debrief. “We want to quickly identify systemic matters that can be improved for the next event. This is to develop a culture of freely expressing ideas and working through issues together as a team,” Hightower said.

The team is still collecting data on the primary outcome of latent safety events, a key component of any quality improvement initiative. Secondary outcomes include quality of the debriefs and composition of the responding code team.

“I credit our success to our strong nursing leadership and the willingness of the staff to be actively involved in quality improvement and do the extra work required to accomplish that goal,” Hightower said. “They have to step away from the patient and cover for each other during the debrief and even though it may take just a few minutes, to ask a nurse to step away from the patient is a big task.”

Although the team is still collecting data on the impact on staff satisfaction, she said, “anecdotally we have heard from nurses and other staff who feel they had a chance to say what they needed during the code or might need in the future. That’s gotten positive feedback.”

“It’s important to highlight the goal of this project is improved patient care, patient outcomes and staff satisfaction,” Hightower said. It’s also important that Children’s of Alabama is a part of a national collaborative with other major children’s hospitals, she said, and has been one of the most successful programs in the CHNC in terms of demonstrated outcomes. Other performance improvement initiatives with the CHNC include improving pain management and reducing nephrotoxic injury.

Resuscitation_CHART

In just three months after embarking on its quality improvement project, the NICU team at Children’s of Alabama exceeded its goal of holding post-resuscitation debriefings after 80 percent of codes.


[1] Wolfe H, Zebuhr C, Topjian AA, et al. Interdisciplinary ICU Cardiac Arrest Debriefing Improves Survival Outcomes Crit Care Med. 2014 Jul; 42(7): 1688–1695.

 

Neonatology

Initiative Targets Pain Management in NICU Babies

neonatology_pain

Adults and children can tell you when they’re in pain. Infants can’t. Which is why Children’s of Alabama is participating in a national quality improvement initiative called Erase Post-Op Pain designed to reduce pain after invasive procedures. The initiative is part of the Children’s Hospital Neonatal Consortium (CHNC), an international group of children’s hospitals dedicated to improving care in the neonatal intensive care unit (NICU).

“There is really no ‘gold standard’ for pain assessment in preverbal children,” said NICU Associate Medical Director Allison Black, M.D. “Nor is there much data on the best way to treat pain in neonates.” However, there is data showing that preterm  babies who experience repeated pain can develop physiologic instability, altered brain development and abnormal stress response systems that persists into childhood. “The immature brain can potentially have a more diffuse and exaggerated response to pain,” she said.

The Erase initiative is designed to apply a multidisciplinary approach, including physicians, bedside nurses, pharmacologists, and even parents, to implement a standardized method to assess, document and manage postoperative pain.

The first action the team took was to adopt a single objective pain assessment tool, the N-PASS score, which measures sedation and pain based on vital signs such as heart rate and breathing, as well as behavior such as agitation, crying, facial expressions and neurologic resting tone. “These are things parents can help us assess as well,” Black said. Parents will also complete a survey after each procedure about how well they thought their baby’s pain was assessed and controlled.

The NICU pharmacist worked closely with other team members to develop different guidelines and different algorithms of what medications to use for each specific patient. Each guideline is unique, and the algorithm used depends upon the invasiveness of the procedure, whether the patient has had similar drugs in the past and if they are breathing spontaneously or with the help of assisted ventilation.

“By considering the history of the patient, the type of procedure performed. and looking closely at each drug’s  time to onset and duration of action, the treatment should be more effective,” Black said.

The initiative dovetails nicely with another CHNC performance improvement project, the STEPP-IN initiative. STEPP-IN works to reduce perioperative stress and instability  in NICU patients through improved handoffs and communication. “I think the projects will compliment each another and help improve our overall care of these small infants during the high-risk perioperative period,” Black said.

Babies in Need

Learn more about the Neonatal Intensive Care Unit at Children’s of Alabama.

Nephrology

Children’s of Alabama Becomes First to Safely Provide Dialysis to Tiny Babies

Didactic and hands-on teaching on the use of CRRT using the Aquadex Pureflow.

Despite the frequent use of dialysis for critically ill children and adults, the procedure has historically been used sparingly in neonatal intensive care units (NICU) because dialysis  machines designed for adults can cause severe complications in babies. That’s no longer the case at Children’s of Alabama.

The problem is that continuous renal replacement therapy in these tiny patients requires at least 100 ml of blood to initiate the therapy. This can be half or even more of the baby’s entire blood volume, said David Askenazi, M.D., MSPH, who directs the Pediatric and Infant Center for Acute Care Nephrology. “Many times, when we started the machine, we had to open the crash cart to resuscitate infants who were coding,” he said.

That changed in 2013, when Askenazi realized that a machine designed to remove fluid and sodium from blood in adults with heart failure — the Aquadex FlexFlow® System — could be repurposed for neonate dialysis.

“If we could adapt a machine that requires one-third of the blood of the traditional machine volume to do what we needed, we knew we could improve our ability to support these babies,” he said. So the team learned as much as they could about the device, developed a safety net of processes to maximize the likelihood of success and convinced the hospital to buy its first machine.

Today, the hospital has fiveAquadex machines and two or three babies are typically receiving dialysis at any one time. “Now we have complete control over their fluids, electrolytes and waste products,” Askenazi said, “while the nurses feel comfortable doing the therapy and the babies don’t even know they’re on it.” Last year, babies in the NICU spent a total of 800 days on dialysis compared to just 30 days in 2013.

“For our babies born with diseased or absent kidneys, Aquadex has given them a chance at life,” said NICU nurse practitioner Kara Short, MSN, CRNP, “because in the past, there were no options to treat these patients.”

The team published the results of its first 12 patients in the journal Pediatric Nephrology in 2016. Since then, they have treated more than 90 patients, the smallest just 1.2 kg (2 pounds, 7 ounces) and taught nephrologists at several other children’s hospitals around the country to use the Aquadex. However, there are still only a handful of hospitals offering the procedure.

“We have shown we can now support these babies safely,” Askenazi said. “The impetus now is on us to make sure the patients who can benefit from this therapy make it to Children’s so we can give them a chance for life.”

And the machine’s manufacturer? It is now pursuing a pediatric indication for Aquadex.

A Team Effort

Learn more about the neonatology program and team at Children’s of Alabama.

Neonatology

NeuroNICU B.R.A.I.N. Program Aims to Improve Outcomes in High-Risk Neonates

Neonatology_Care Protocols

Preterm infants born at 30 weeks or earlier are at higher risk for developing intraventricular hemorrhage (IVH), which is associated with long-term neurocognitive deficits. The risk is also higher for infants with hypoxic-ischemic encephalopathy (HIE), those undergoing ECMO therapy, or those with seizures, metabolic disorders or stroke. Now, a new initiative in the University of Alabama at Birmingham (UAB) Division of Neonatology called NeuroNICU B.R.A.I.N. (Brain Rescue and Avoidance of Injury in Neonates) aims to prevent or reduce that risk.

The core of the initiative is a multidisciplinary team of professionals who work to provide neurodevelopmental care for infants at risk for developing brain injury and cognitive deficits. The team includes a pediatric neurologist, pediatric rehabilitation medicine specialist, pediatric neuro-radiologist, neonatal nurse practitioners, nurse manager, physical therapist, occupational therapist, speech therapist, respiratory therapist and nurse champions. The program also makes parents an integral part of the team.

“We all come together every week and discuss every baby on the unit,” said Allison Black, M.D., NICU associate medical director at Children’s of Alabama. “Before the NeuroNICU program, we would consult individually on an as-needed basis.”

Even though an infant may not need every aspect of care, she said, “everyone working together to integrate the different expertise we have in our field will result in better care for the babies.” The program also uses a standardized bundle of care designed to stabilize the infant and carefully monitor for clinical signs that can increase the risk of IVH.

“The process for the brain injury prevention program starts at birth and continues throughout the entire hospital stay,” said Maran Ramani, M.D., who directs the NeuroNICU program. The protocols call for preventing hypothermia, hypoglycemia and extreme variations in the blood pressure and carbon dioxide levels, and for maintaining fluid intake, all with minimal stimulation. Once discharged, all infants are followed long-term and continually assessed for developmental milestones, he said.

In addition to multidisciplinary care, the program provides near infrared spectroscopy monitoring for preterm and term infants to assess the oxygen saturations in the brain. It also uses transcutaneous CO2 monitoring for preterm infants to assess variations in serum CO2 levels, which plays a critical role in the development of IVH. Term and preterm infants also receive a head ultrasound in to screen for IVH, while preterm infants with grade III and IV IVH undergo   conventional electroencephalogram to detect subclinical seizures. Finally, infants with HIE have an MRI with spectroscopy to assess any damage.

Despite the multifactorial etiology of IVH, Ramani said, standardizing the neuroprotective care is reducing the overall rate of IVH in preterm infants (Figure 1).

Figure 1           Rate of IVH Before and After NeuroNICU B.R.A.I.N. Program

Neonatology Care Protocols Chart

Arrow indicates NeuroNICU roll out

Managing Neurologic Disorders
Visit www.uab.edu/medicine/peds/patient-care/neuro-related-programs-centers to learn about the Division of Pediatric Neurology’s subspecialty clinics at the University of Alabama at Birmingham.

 

Nephrology

Baby NINJA Fights Back Against AKI

Nephrology_Baby_NINJA

The Pediatric and Infancy Center for Acute Nephrology (PICAN) at Children’s of Alabama, in partnership with the University of Alabama at Birmingham (UAB) Department of Pediatrics, has served children in Alabama and across the world since its 2013 inception. PICAN’s three-pronged model provides the best available comprehensive multidisciplinary clinical care, education, and research for children with acute kidney injury (AKI) and neonates with kidney disease.

“We believe that if we provide the best care, make important discoveries and educate our staff and those beyond our institution, we can make a huge impact in this field,” said David Askenazi, M.D., MSPH, PICAN director and UAB professor of pediatrics.

As a part of its efforts, PICAN implemented Nephrotoxic Injury Negated by Just-in-Time Action (NINJA), a collaboration between Children’s and Cincinnati Children’s Hospital Medical Center. Via NINJA, hospitalized patients receiving medications that can cause kidney injury are automatically identified by using the electronic medical record system and scheduled for dose adjustments and increased renal function surveillance. The rate of acute renal injury in inpatients has been decreased by more than 60 percent, resulting in substantially decreased morbidity across the hospital and reduced hospitalization duration. The NINJA program is so successful that this year it became the first new program added to the Solutions For Patient Safety consortium and instituted at 147 children’s hospitals worldwide.

A recent application of NINJA in Children’s Neonatal Intensive Care Unit (NICU) referred to as Baby NINJA, a project exclusive to Children’s, has nearly eliminated medication associated acute kidney injury in the most vulnerable premature infants. In March 2018, Baby NINJA won the Best Abstract Award at the 23rd International Conference on Advances in Critical Care Nephrology in San Diego, California.

“What’s exciting about Baby NINJA is the simplicity of the approach,” said Christine Stoops, D.O., MPH, Baby NINJA co-investigator and UAB assistant professor in the Division of Neonatology. “It’s looking at all infants exposed to nephrotoxic medications for potential kidney injury with a daily lab level (serum creatinine), and paying careful attention to whether a baby still needs these medications or can benefit from a lower daily dose.”

“With that easy shift in our mindset, we have shown greater than an 80 percent reduction in kidney injury in high-risk patients,” Stoops said. “This has the potential to reduce chronic kidney disease in these already at-risk infants.”

In addition, PICAN has one of the most successful Continuous Renal Replacement Therapy (CRRT) programs to support critically ill patients who have lost kidney function. For example, PICAN in 2014 studied a new dialysis device called Aquadex FlexFlow ™ and adapted the device to treat neonates and premature infants with kidney failure who are too small for hemodialysis. As a result, children as small 1 kilogram can now receive this lifesaving therapy. Children’s is the first pediatric hospital in the country to successfully adapt Aquadex for use on infants, and the device is now being used at other major children’s hospitals, including Cincinnati Children’s, Boston Children’s Hospital and Seattle Children’s Hospital.

“We do more dialysis in newborns than other hospitals in the world,” Askenazi said. “We have cared for 70 babies with CRRT and have great success in initiating the machine without cardiovascular compromise, which was a problem before using Aquadex. Our survival rate in babies has increased from 30 percent to 55 percent over the last few years.”

PICAN is also the driving force behind the international Neonatal Kidney Collaborative (NKC). Under the direction of Askenazi, this network of neonatologists, pediatric nephrologists, epidemiologists and statisticians from the U.S., as well as India, Canada, and Australia, are committed better understanding AKI in neonates.

The inaugural project of NKC is the Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates (AWAKEN) study. The 24-center study captured data from over 2,000 neonates admitted to the NICU who were on intravenous fluids for at least 48 hours.

“We have learned a tremendous amount from the AWAKEN database. We can now show that AKI is very common in select groups of patients. Those patients with AKI were four times more likely to die, even after controlling other factors that are associated with neonatal death,” Askenazi said.

“We have recently reported that caffeine can be a protective agent against AKI, and we have 12 other manuscripts in preparation as well. Our plans are to submit a [National Institutes of Health] grant to continue our research and answer more questions on this topic in the future.”


Nephrology Fellowship Program

Learn more about the Pediatric Nephrology Fellowship Program at UAB at https://www.childrensal.org/FellowshipProgram.

Neonatology

Joined at the Hip

Neonatology_Hip

The sky bridges connecting the University of Alabama at Birmingham (UAB) Women & Infants Center and Children’s of Alabama provide more than a means of travel from point A to B. For the UAB/Children’s Division of Neonatology, the sky bridges not only facilitate seamless clinical care, but also seamless research collaborations.

“It’s a tremendous benefit,” said Trent Tipple, M.D., UAB associate professor of pediatrics, director of neonatology faculty development and co-director of the Neonatal-Perinatal Medicine Fellowship Training Program. “The integration is one that just makes sense. It eliminates a lot of barriers that can make research frustrating and allows one to focus on designing the best study with the necessary personnel; to really think about how to execute a study rather than whether a study can be done.”

“It’s one of the unique features here. UAB’s Regional Neonatal Intensive Care Unit and Children’s NICU are literally joined at the hip,” said Namasivayam Ambalavanan, M.D., UAB professor of pediatrics, neonatology division co-director, director of the Translational Research in Normal & Disordered Development (TReNDD) Program at UAB and principal investigator of the UAB Research Center. “This makes clinical care a lot better and research also improves.”

Carl “Tim” Coghill, M.D., UAB professor of pediatrics and medical director of Children’s NICU, said the physical proximity not only serves as a benefit to clinicians and researchers, but also patient families facing what can be a stressful experience.

“Many freestanding children’s hospitals are blocks away from their associated delivery units, making it difficult for consultants to see the infants without transfer away from the mother,” Coghill said. “Children’s of Alabama used to be two blocks from UAB with no connecting bridge. With the present bridge, the closest NICU bed at UAB is only 75 feet from the nearest NICU bed at Children’s, which is closer than some beds are to each other in other respective units.”

Coghill continued, “The ability to stay with a nursing staff that you know and a hospital that you are familiar with while continuing to get the best care is a confidence builder, and delivering great care is only good enough if it is perceived to be great care by the patients and families as well.”

As a founding member of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Neonatal Research Network (NRN), part of the National Institutes of Health (NIH), UAB/Children’s is consistently one of the top centers in developing, leading, enrolling and analyzing randomized controlled trials and clinical studies. For example, neonatology division members have led three major innovative NRN studies – the SAVE Factorial Trial, the Cytokine Study and the SUPPORT Factorial Trial. A fourth trial led by UAB/Children’s neonatologists testing the effects of caffeine late in the neonatal course and at home to shorten hospitalization and decrease apparent life threatening events began enrollment this year.

In its more than 30 years of existence, the NRN has defined the standards of multi-institutional collaborative research resulting in increased survival and decreased morbidity rates of extremely low birth weight infants and other critically ill infants in the U.S. Wally Carlo, M.D., Edwin M. Dixon Endowed Chair in Neonatology and neonatology division co-director, and Ambalavanan are principal investigators for the NRN and have led nationwide studies on ventilator care, antenatal steroids, chronic lung disease and neurodevelopment outcomes. A study in the NRN published in the New England Journal of Medicine reported that neonatal mortality has been decreased over the last 10 years, including decreases in almost all specific causes of neonatal mortality, because of improvements in care implemented in the NRN centers.

In addition, UAB/Children’s is the only facility in the U.S. to be awarded grants in all three perinatal networks from the NICHD – the NRN, the Maternal-Fetal Medicine Units Network and the Global Network for Women’s and Children’s Health Research. For more than two decades, these networks have awarded UAB/Children’s more than $20 million to fund research for pregnant women and babies. The most recent grants, awarded in 2016, will bring a total $1.1 million per year through 2021.

Under the Global Network, UAB/Children’s researchers have led seminal investigations of resuscitation and essential newborn care in 100 communities in six countries, which included almost 200,000 infants. These trials established the effectiveness of these interventions in reducing stillbirths and neonatal mortality, and led to worldwide implementation of training, including the globally-implemented Helping Babies Breathe Program and the Essential Care for Every Baby Program launched in 2014. The programs have been introduced in more than 75 countries to save babies’ lives at birth, with the potential to reduce infant deaths soon after birth by 1 million.

“It should save a million lives every single year at almost no cost,” Carlo said of the programs. “It will save the most lives in the world.”

Division of Neonatology
Learn more about the Division of Neonatology, including specialty clinics and faculty bios, at https://www.childrensal.org/neonatology.