Behavioral Sciences

Connecting allied health professionals in pediatric nephrology

With the meeting in Washington this year, Children’s National Health System will be the local host, a distinct honor for an academic medical center that treats hundreds of nephrology patients each year, says pediatric Nephrologist Asha Moudgil, M.D., who directs Children’s kidney transplant service.

Pediatric nephrology is a relatively small specialty worldwide, encompassing just a few hundred doctors in the U.S. For each allied health field that provides collaborative care with these physicians – including nutrition, child-life, psychology and social work – the numbers of providers are even smaller. There are no national meetings for these individual subspecialty fields and no venues to meet new like-minded colleagues or learn about new research or protocols.

Six years ago, the American Society of Pediatric Nephrology (ASPN) aimed to help resolve this dilemma by launching a new multidisciplinary symposium that brings together allied health professionals of all kinds within pediatric nephrology.

Each year, the “ASPN Multidisciplinary Symposium” changes locations, allowing the meeting to target different regional groups of allied health professionals based on geography. With the meeting in Washington this year, Children’s National Health System will be the local host, a distinct honor for an academic medical center that treats hundreds of nephrology patients each year, says pediatric Nephrologist Asha Moudgil, M.D., who directs Children’s kidney transplant service.

There are multiple advantages to having the symposium in Washington, Dr. Moudgil explains. One is access to Children’s experts in this field, who have a wealth of experience in managing issues that affect patients who live in the greater Washington area. For example, the keynote address scheduled for the meeting’s opening night will be delivered by Jennifer Verbesey, M.D., Children’s surgical director of pediatric kidney transplantation, focusing on living donation in minority populations. Living kidney donors and recipients who are minorities have unique issues that can affect organ longevity, explains Dr. Moudgil, which may not be well known by all clinicians.

Children’s speakers also focus prominently in the main session on the second day, including:

  • Angela Boadu, RD, LDN/LD, a registered dietitian, and Kaushalendra Amatya, Ph.D., a psychologist, are giving a talk about nutrition and the psychosocial aspects of obesity
  • Surgeon Evan Nadler, M.D., director of Children’s Bariatric Surgery Program, is speaking about bariatric surgery before and after transplantation
  • Nurse Practitioner Christy Petyak, CPNP-PC, and Social Worker Heidi Colbert, LICSW, CCTSW, NSW-C, are leading breakout sessions about the practical aspects of immunosuppressive therapy and resources for uninsured patients
  • Amatya, the Children’s psychologist, also is leading a breakout session on internalizing psychological disorders in pediatric renal patients and
  • Registered Dietitian Kristen Sgambat, Ph.D., RD, and Dr. Moudgil are co-leading a breakout session on nutritional challenges and enteral supplementation in chronic kidney disease.

Another advantage to holding the meeting in the nation’s capital is its close proximity to government research and federal regulatory agencies, such as the Food and Drug Administration (FDA) and the National Institutes of Health (NIH). Speakers from both agencies will be present, talking about how the FDA approves medicines for pediatric patients and offering details about the NIH’s rare disease program.

Besides the abundance of more formal knowledge-sharing, Dr. Moudgil adds, there will be plenty of opportunities for attendees to network, making connections within and outside their own respective fields.

“This is a platform for making long-term professional relationships,” Dr. Moudgil says. “Even if you’re the sole clinician representing your specialty at your own institution, you’ll be able to connect with other specialists at institutions across the country. You’re not only acquiring new information, you’re acquiring a group of colleagues you can connect with this year and those professional relationships can extend far into the future.”

little girl with concussion at doctors

Predicting kids’ outcomes after concussion

little girl with concussion at doctors

A concussion symptom measurement tool, developed by investigators at Children’s National Health System, allows other researchers to collect valuable evidence about the natural progression of symptoms and recovery for children. The tool, Post-Concussion Symptom Inventory (PCSI), was a key tool in the recent large-scale multi-center prospective study of recovery trajectory for children, which was published online in JAMA Pediatrics Sept. 4, 2018.

That study included 2,716 children between the ages of 5 and 17, and identified major trends in symptom improvement post concussion, such as:

  • Children younger than 12 experience primary symptom improvement in the first two weeks
  • Pre-adolescents, male adolescents and teens experience primary symptom improvement in the first four weeks and
  • Female adolescents take longer to perceive primary symptom improvements than children, pre-adolescents and male counterparts.

“We’ve known for many years that different people experience concussion recovery very differently. This study is the first to provide significant evidence of what we should expect to see in terms of symptom improvement for children and teens,” says Gerard Gioia, Ph.D., chief of the Division of Neuropsychology at Children’s National and director of its Safe Concussion Outcome Recovery and Education Program, who co-authored the study and whose team developed the PCSI measurement tool. “Ultimately, these findings are an important step in predicting outcomes after a concussion and developing treatment plans that get kids back to school and sports safely, when they are ready.”

Dr. Gioia and his team also recently received a Centers for Disease Control and Prevention (CDC) grant to develop a new smartphone application, Online Treatment Recovery Assistant for Concussion in Kids (OnTRACK), that applies several concussion tools developed at Children’s National, including the same one applied in the JAMA Pediatrics study, to track individual symptoms over time.

The OnTRACK app will report concussion symptoms on a regular basis (daily or weekly) and map their trajectory, so doctors can see when recovery is proceeding along the expected pathway. Alternatively, clinicians will receive an alert when a child’s recovery misses targets and warrants further investigation and possible referral to a specialist.

Vittorio Gallo

Vittorio Gallo, Ph.D., honored with Senator Jacob Javits Award in the Neurosciences

Vittorio Gallo

Vittorio Gallo, Ph.D., Children’s Chief Research Officer, has been awarded a prestigious Senator Jacob Javits Award in the Neurosciences, which extends federal funding for Gallo’s lab for at least seven years. The long-term support is offered to “investigators with a history of exceptional talent, imagination and preeminent scientific achievement.”

Only National Institute of Neurological Disorders and Stroke (NINDS) staff members or NINDS Council members may nominate researchers for the coveted awards, named in honor of Sen. Jacob Javits, (R-New York). Before his death, Sen. Javits advocated for additional research in a wide variety of disorders of the brain and nervous system.

“It’s a great recognition from the neuroscience community and from NINDS for contributions to neuroscience and outstanding service to the neuroscience community,” Gallo says. “It’s also very exciting because it gives additional national visibility to our Center for Neuroscience Research and to Children’s National Health System, as one of the nation’s leading research institutions.”

Through the award, Gallo’s successful five-year Research Project Grant from the National Institutes of Health will be converted to a seven-year award. In the fourth year of federal funding, he can apply for a budgetary increase.

“Thanks to this funding, I predict we will be able to identify cellular and molecular mechanisms that underlie developmental delays in children who experienced neonatal brain injury,” Gallo says.

“We are really starting to understand this very complex problem: How does neonatal brain injury lead to developmental delays later in a child’s life? What are the mechanisms? We know there are cognitive and behavioral abnormalities that are common to children who have experienced hypoxia as newborns. But we don’t really know how these behavioral abnormalities arise at the physiological, cellular and molecular levels.”

Gallo says identifying these cellular targets will make it possible to tailor interventions that target distinct cell types at different times in the child’s life.

Recent work by Gallo’s lab includes a research paper published online Aug. 13, 2018, by Nature Communications that found chronic sublethal hypoxia is associated with locomotor miscoordination and long-term cerebellar learning deficits in a clinically relevant model of neonatal brain injury.

John Strang

Neuro- and gender-diverse teens find their voices

John Strang

“These autistic young people spoke a lot about their gender and gender needs and their descriptions of gender dysphoria were deeply emotional. One of the common characteristics of autism is reduced communication of feelings, yet many of these young people were very clear about the anguish that gender dysphoria caused for them and also their need for gender-related interventions,” says John Strang, Psy.D., director of the Gender and Autism Program at Children’s National Health System and study lead.

“They Thought It Was An Obsession” is the title of a qualitative study from the Journal of Autism and Developmental Disorders, that provides an unprecedented glimpse into the development, thoughts, perceptions, feelings and needs of this poorly understood but significant subgroup of transgender and gender minority teens.

The title is an accurate reflection of the study’s analysis, which finds that the accounts of gender dysphoria in autistic transgender youth parallel those of transgender young people without autism. These findings stand in contrast to previous studies asserting the idea that gender dysphoria in autistic youth is driven primarily by superficial autism-related interests.

“These autistic young people spoke a lot about their gender and gender needs and their descriptions of gender dysphoria were deeply emotional. One of the common characteristics of autism is reduced communication of feelings, yet many of these young people were very clear about the anguish that gender dysphoria caused for them and also their need for gender-related interventions,” says John Strang, Psy.D., director of the Gender and Autism Program at Children’s National Health System and study lead.

Additionally, the autistic characteristics of these young people – which may reduce their concern for social conventions – often lead them to express their gender in individual and sometimes surprising ways.

“A transgender autistic young woman may wear a full beard and understand her gender identity as something completely separate from her appearance,” says Dr. Strang. “The cooccurrence of gender identity-diversity and autism may reveal something of the deeper nature of gender when the overlay of social gender expectations is reduced.”

The study followed 22 autistic transgender teens over nearly two years. It is the first study of its kind to track and follow up with this many youth with the cooccurrence over a significant period of time. The authors believe the report can serve as a guide for how clinicians, peers and families can better support and understand teens who are both neurodiverse and gender diverse.

The study’s methodology is also novel, as it features the inclusion of a slate of autistic gender-diverse coanalysts and coauthors who partnered in the interpretation of the youth provided data.

The coauthor group also included a retransitioned (previously transgender) self-advocate coanalyst to help provide context regarding the experiences and trajectories of the few study participants who moved away from transgender identity during the study’s duration.

Reid Caplan of the Autistic Self-Advocacy Network, an autistic transgender self-advocate and one of the study’s coauthors noted, “Too often in medical literature, the overlap between autistic and transgender identities is described in a way that pathologizes both of these communities. As an autistic transgender young adult, I feel privileged to be a coauthor of research that puts the voices of autistic and gender-diverse youth at the forefront. By giving these youth control over their own narratives, this study exemplifies a key value of the self-advocate community: Nothing about us, without us!”

toddler on a playground

Perinatal hypoxia associated with long-term cerebellar learning deficits and Purkinje cell misfiring

toddler on a playground

The type of hypoxia that occurs with preterm birth is associated with locomotor miscoordination and long-term cerebellar learning deficits but can be partially alleviated with an off-the-shelf medicine, according to a study using a preclinical model.

Oxygen deprivation associated with preterm birth leaves telltale signs on the brains of newborns in the form of alterations to cerebellar white matter at the cellular and the physiological levels. Now, an experimental model of this chronic hypoxia reveals that those cellular alterations have behavioral consequences.

Chronic sublethal hypoxia is associated with locomotor miscoordination and long-term cerebellar learning deficits in a clinically relevant model of neonatal brain injury, according to a study led by Children’s National Health System researchers published online Aug. 13, 2018, by Nature Communications. Using high-tech optical and physiological methods that allow researchers to turn neurons on and off and an advanced behavioral tool, the research team finds that Purkinje cells fire significantly less often after injury due to perinatal hypoxia. However, an off-the-shelf medicine now used to treat epilepsy enables those specialized brain cells to regain their ability to fire, improving locomotor performance.

Step out of the car onto the pavement, hop up to the level of the curb, stride to the entrance, and climb a flight of stairs. Or, play a round of tennis. The cerebellum coordinates such locomotor performance and muscle memory, guiding people of all ages as they adapt to a changing environment.

“Most of us successfully coordinate our movements to navigate the three-dimensional spaces we encounter daily,” says Vittorio Gallo, Ph.D., Children’s Chief Research Officer and the study’s senior author. “After children start walking, they also have to learn how to navigate the environment and the spaces around them.”

These essential tasks, Gallo says, are coordinated by Purkinje cells, large neurons located in the cerebellum that are elaborately branched like interlocking tree limbs and represent the only source of output for the entire cerebellar cortex. The rate of development of the fetal cerebellum dramatically increases at a time during pregnancy that often coincides with preterm birth, which can delay or disrupt normal brain development.

“It’s almost like a short circuit. Purkinje cells play a very crucial role, and when the frequency of their firing is diminished by injury the whole output of this brain region is impaired,” Gallo says. “For a family of a child who has this type of impaired neural development, if we understand the nature of this disrupted circuitry and can better quantify it, in terms of locomotor performance, then we can develop new therapeutic approaches.”

Study authors Aaron Sathyanesan, Ph.D., Joseph Abbah, B.Pharm., Ph.D., Srikanya Kundu, Ph.D. and Vittorio Gallo, Ph.D.

The research team leveraged a fully automated, computerized apparatus that looks like a ladder placed on a flat surface, encased in glass, with a darkened box at either end. Both the hypoxic and control groups had training sessions during which they learned how to traverse the horizontal ladder, coaxed out of the darkened room by a gentle puff of air and a light cue. Challenge sessions tested their adaptive cerebellar locomotor learning skills. The pads they strode across were pressure-sensitive and analyzed individual stepping patterns to predict how long it should take each to complete the course.

During challenge sessions, obstacles were presented in the course, announced by an audible tone. If learning was normal, then the response to the tone paired with the obstacle would be a quick adjustment of movement, without breaking stride, says Aaron Sathyanesan, Ph.D., co-lead author. Experimental models exposed to perinatal hypoxia showed significant deficits in associating that tone with the obstacle.

“With the control group, we saw fewer missteps during any given trial,” Sathyanesan says. “And, when they got really comfortable, they took longer steps. With the hypoxic group, it took them longer to learn the course. They made a significantly higher number of missteps from day one. By the end of the training period, they could walk along all of the default rungs, but it took them longer to learn how to do so.”

Purkinje cells fire two different kinds of spikes. Simple spikes are a form of constant activity as rhythmic and automatic as a heartbeat. Complex spikes, by contrast, occur less frequently. Sathyanesan and co-authors say that some of the deficits that they observed were due to a reduction in the frequency of simple spiking.

Two weeks after experiencing hypoxia, the hypoxic group’s locomotor performance remained significantly worse than the control group, and delays in learning could still be seen five weeks after hypoxia.

Gamma-aminobutyric acid (GABA), a neurotransmitter, excites immature neurons before and shortly after birth but soon afterward switches to having an inhibitory effect within in the cerebellum, Sathyanesan says. The research team hypothesizes that reduced levels of excitatory GABA during early development leads to long-term motor problems. Using an off-the-shelf drug to increase GABA levels immediately after hypoxia dramatically improved locomotor performance.

“Treating experimental models with tiagabine after hypoxic injury elevates GABA levels, partially restoring Purkinje cells’ ability to fire,” Gallo says. “We now know that restoring GABA levels during this specific window of time has a beneficial effect. However, our approach was not specifically targeted to Purkinje cells. We elevated GABA everywhere in the brain. With more targeted and selective administration to Purkinje cells, we want to gauge whether tiagabine has a more powerful effect on normalizing firing frequency.”

In addition to Gallo and Sathyanesan, Children’s co-authors include Co-Lead Author, Srikanya Kundu, Ph.D., and Joseph Abbah, B.Pharm., Ph.D., both of Children’s Center for Neuroscience Research.

Research covered in this story was supported by the Intellectual and Developmental Disability Research Center under award number U54HD090257.

Tessie October

Effectively expressing empathy to improve ICU care

Tessie October

“Families who feel we’re really listening and care about what they have to say are more likely to feel comfortable as they put their child’s life in our hands a second, third or fourth time,” says Tessie W. October, M.D., M.P.H.

In nearly every intensive care unit (ICU) at every pediatric hospital across the country, physicians hold numerous care conferences with patients’ family members daily. Due to the challenging nature of many these conversations – covering anything from unexpected changes to care plans for critically ill children to whether it’s time to consider withdrawing life support – these talks tend to be highly emotional.

That’s why physician empathy is especially important, says Tessie W. October, M.D., M.P.H., critical care specialist at Children’s National Health System.

Several studies have shown that when families believe that physicians hear, understand or share patients’ or their family’s emotions, patients can achieve better outcomes, Dr. October explains. When families feel like their physicians are truly empathetic, she adds, they’re more likely to share information that’s crucial to providing the best care.

“For the most part, our families do not make one-time visits. They return multiple times because their children are chronically ill,” Dr. October says. “Families who feel we’re really listening and care about what they have to say are more likely to feel comfortable as they put their child’s life in our hands a second, third or fourth time. They’re also less likely to regret decisions made in the hospital, which makes them less likely to experience long-term psychosocial outcomes like depression and anxiety.”

What’s the best way for physicians to show empathy? Dr. October and a multi-institutional research team set out to answer this question in a study published online in JAMA Network Open on July 6, 2018.

With families’ consent, the researchers recorded 68 care conferences that took place at Children’s pediatric ICU (PICU) between Jan. 3, 2013, to Jan. 5, 2017. These conversations were led by 30 physicians specializing in critical care, hematology/oncology and other areas and included 179 family members, including parents.

During these conferences, the most common decision discussed was tracheostomy placement – a surgical procedure that makes an opening in the neck to support breathing – followed by the family’s goals, other surgical procedures or medical treatment. Twenty-two percent of patients whose care was discussed during these conferences died during their hospitalization, highlighting the gravity of many of these talks.

Dr. October and colleagues analyzed each conversation, counting how often the physicians noticed opportunities for empathy and how they made empathetic statements. The researchers were particularly interested in whether empathetic statements were “buried,” which means they were:

  • Followed immediately by medical jargon
  • Followed by a statement beginning with the word “but” that included more factual information or
  • Followed by a second physician interrupting with more medical data.

That compares with “unburied” empathy, which was followed only by a pause that provided the family an opportunity to respond. The research team examined what happened after each type of empathetic comment.

The researchers found that physicians recognized families’ emotional cues 74 percent of the time and made 364 empathetic statements. About 39 percent of these statements were buried. In most of these instances, says Dr. October, the study’s lead author, the buried empathy either stopped the conversation or led to family members responding with a lack of emotion themselves.

After the nearly 62 percent of empathetic statements that were unburied, families tended to answer in ways that revealed their hopes and dreams for the patient, expressed gratitude, agreed with care advice or expressed mourning—information that deepened the conversation and often offered critical information for making shared decisions about a patient’s care.

Physicians missed about 26 percent of opportunities for empathy. This and striving to make more unburied empathetic statements are areas ripe for improvement, Dr. October says.

That’s why she and colleagues are leading efforts to help physicians learn to communicate better at Children’s National. To express empathy more effectively, Dr. October recommends:

  • Slow down and be in the moment. Pay close attention to what patients are saying so you don’t miss their emotional cues and opportunities for empathy.
  • Remember the “NURSE” mnemonic. Empathetic statements should Name the emotion, show Understanding, show Respect, give Support or Explore emotions.
  • Avoid using the word “but” as a transition. When you follow an empathetic statement with “but,” Dr. October says, it cancels out what you said earlier.
  • Don’t be afraid to invite strong emotions. Although it seems counterintuitive, Dr. October says helping patients express strong feelings can help process emotions that are important for decision-making.

In addition to Dr. October, study co-authors include Zoelle B. Dizon, BA, Children’s National; Robert M. Arnold, M.D., University of Pittsburgh Medical Center; and Senior Author, Abby R. Rosenberg, M.D., MS, University of Washington School of Medicine.

Research covered in this story was supported by the National Institutes of Health under grants 5K12HD047349-08 and 1K23HD080902 and the National Center for Advancing Translational Sciences under Clinical and Translational Science Institute at Children’s National Health System grant number UL1TR0001876.

Tory Peitz and Victoria Catalano

Making weight: Ensuring that micro preemies gain pounds and inches

Tory Peitz and Victoria Catalano

Tory Peitz, R.N., (left) and Victoria Catalano, RDN, LD, CNSC, CLC, (right) Pediatric Dietitian Specialist in the Neonatal Intensive Care Unit at Children’s National Health System, measure the length of a micro preemie who weighed 1.5 pounds at birth.

A quality-improvement project to standardize feeding practices for micro preemies – preterm infants born months before their due date –  helped to boost their weight and nearly quadrupled the frequency of lactation consultations ordered in the neonatal intensive care unit (NICU), a multidisciplinary team from Children’s National Health System finds.

According to the Centers for Disease Control and Prevention, about 1 in 10 infants in 2016 was preterm, born prior to completing 37 gestational weeks of pregnancy. Micro preemies are the tiniest infants in that group, weighing less than 1,500 grams and born well before their brain, lungs and organs like the liver are fully developed.

As staff reviewed charts for very low birth weight preterm infants admitted to Children’s NICU, they found dramatic variation in nutritional practices among clinicians and a mean decline in delta weight Z-scores, a more sensitive way to monitor infants’ weight gain along growth percentiles for their gestational age. A multidisciplinary team that included dietitians, nurses, neonatologists, a lactation consultant and a quality-improvement leader evaluated nutrition practices and determined key drivers for improving nutrition status.

“We tested a variety of strategies, including standardizing feeding practices; maximizing intended delivery of feeds; tracking adequacy of calorie, protein and micronutrient intake; and maximizing use of the mother’s own breast milk,” says Michelande Ridoré, MS, a Children’s NICU quality-improvement lead who will present the group’s findings during the Virginia Neonatal Nutrition Association conference this fall. “We took nothing for granted: We reeducated everyone in the NICU about the importance of the standardized feeding protocol. We shared information about whether infants were attaining growth targets during daily rounds. And we used an infographic to help nursing moms increase the available supply of breastmilk,” Ridoré says.

On top of other challenges, very low birth weight preterm infants are born very lean, with minimal muscle. During the third trimester, pregnant women pass on a host of essential nutrients and proteins to help satisfy the needs of the fetus’ developing muscles, bones and brain. “Because preterm infants miss out on that period in utero, we add fortification to provide preemies with extra protein, phosphorus, calcium and zinc they otherwise would have received from mom in the womb,” says Victoria Catalano, RDN, LD, CNSC, CLC, a pediatric clinical dietitian in Children’s NICU and study co-author. Babies’ linear growth is closely related to neurocognitive development, Catalano says. A dedicated R.N.  is assigned to length boards for Children’s highest-risk newborns to ensure consistency in measurements.

Infants who were admitted within the first seven days of life and weighed less than 1,500 grams were included in the study. At the beginning of the quality-improvement project, the infants’ mean delta Z-score for weight was -1.8. By December 2018, that had improved to -1.3. And the number of lactation consultation ordered weekly increased from 1.1 to four.

“We saw marked improvement in micro preemies’ nutritional status as we reduced the degree of variation in nutrition practices,” says Mary Revenis, M.D., NICU medical lead on nutrition and senior author for the research. “Our goal was to increase mean delta Z-scores even more. To that end, we will continue to test other key drivers for improved weight gain, including zinc supplementation, updating infants’ growth trajectories in the electronic medical record and advocating for expanded use of birth mothers’ breast milk,” Dr. Revenis says.

In addition to Ridoré, Catalano and Dr. Revenis, study co-authors include Caitlin Forsythe MS, BSN, RNC-NIC, lead author; Rebecca Vander Veer RD, LD, CNSC, CLC, pediatric dietitian specialist; Erin Fauer RDN, LD, CNSC, CLC, pediatric dietitian specialist; Judith Campbell, RN, IBCLC, NICU lactation consultant; Eresha Bluth MHA; Anna Penn M.D., Ph.D., neonatalogist; and Lamia Soghier M.D., Med., NICU medical unit director.

Pregnant-Mom

Safeguarding fetal brain health in pregnancies complicated by CHD

Pregnant-Mom

During the last few weeks of pregnancy, certain regions of the fetal brain experience exponential growth but also are more vulnerable to injury during that high-growth period.

Yao Wu, Ph.D., a research postdoctoral fellow in the Developing Brain Research Laboratory at Children’s National Health System, has received a Thrasher Research Fund early career award to expand knowledge about regions of the fetal brain that are vulnerable to injury from congenital heart disease (CHD) during pregnancy.

CHD, the most common birth defect, can have lasting effects, including overall health issues; difficulty achieving milestones such as crawling, walking or running; and missed days at daycare or school, according to the Centers for Disease Control and Prevention. Brain injury is a major complication for infants born with CHD. Catherine Limperopoulos, Ph.D., director of Children’s brain imaging lab, was the first to provide in vivo evidence that fetal brain growth and metabolism in the third trimester of pregnancy is impaired within the womb.

“It remains unclear which specific regions of the fetal brain are more vulnerable to these insults in utero,” Limperopoulos says. “We first need to identify early brain abnormalities attributed to CHD and understand their impact on infants’ later behavioral and cognitive development in order to better counsel parents and effectively intervene during the prenatal period to safeguard brain health.”

During the last few weeks of pregnancy, certain regions of the fetal brain experience exponential growth but also are more vulnerable to injury during that high-growth period. The grant, $26,749 over two years, will underwrite “Brain Development in Fetuses With Congenital Heart Disease,” research that enables Wu to utilize quantitative, non-invasive magnetic resonance imaging (MRI) to compare fetal brain development in pregnancies complicated by CHD with brain development in healthy fetuses of the same gestational age.Wu will leverage quantitative, in vivo 3-D volumetric MRI to compare overall fetal and neonatal brain growth as well as growth in key regions including cortical grey matter, white matter, deep grey matter, lateral ventricles, external cerebrospinal fluid, cerebellum, brain stem, amygdala and the hippocampus.

The research is an offshoot of a prospective study funded by the National Institutes of Health that uses advanced imaging techniques to record brain growth in 50 fetuses in pregnancies complicated by CHD who need open heart surgery and 50 healthy fetuses. MRI studies are conducted during the second trimester (24 to 28 weeks gestational age), third trimester (33 to 37 weeks gestational age) and shortly after birth but before surgery. In addition, fetal and neonatal MRI measurements will be correlated with validated scales that measure infants’ and toddlers’ overall development, behavior and social/emotional maturity.

“I am humbled to be selected for this prestigious award,” Wu says. “The findings from our ongoing work could be instrumental in identifying strategies for clinicians and care teams managing high-risk pregnancies to optimize fetal brain development and infants’ overall quality of life.”

Lenore Jarvis

Screening for postpartum depression in the emergency department

Lenore Jarvis

“Some of these women had no idea how common postpartum depression was,” says Lenore Jarvis, M.D., M.Ed. “They thought they were crazy and felt alone and were bad moms.”

It’s a scenario that Children’s emergency medicine specialist Lenore Jarvis, M.D., M.Ed., has seen countless times: A mother brings her infant to the emergency department (ED) in the middle of the night with a chief complaint of the baby being fussy. Nothing she does can stop the incessant crying, she tells the triage nurse. When doctors examine the baby, they don’t see anything wrong. Often, this finding is reassuring. But, despite their best efforts to comfort her, the mother isn’t reassured and leaves the hospital feeling anxious and overwhelmed.

After these encounters, Dr. Jarvis wondered: Might the mother be the actual patient?

Postpartum depression (PPD) is the most common complication of childbirth, Dr. Jarvis explains, occurring in up to 20 percent of all mothers, and may be higher (up to 50 percent) in low-income and immigrant women. Far beyond simple “baby blues,” the mood disorder can have significant implications for the mother, her baby and the entire family. It can hinder mother-child bonding and lead to early discontinuation of breastfeeding, delayed immunizations, and child abuse and neglect. The associated effects on early brain development might cause cognitive and developmental delays for the infant and, later in life, can manifest as emotional and behavioral problems. PPD can disrupt relationships between parents. And suicide is the top cause of postpartum death.

Mothers are supposed to be screened routinely for PPD at postpartum visits with their maternal or pediatric health care providers. In addition, several medical professional societies – including the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists – now recommend screening for PPD in the prenatal and postnatal periods and during routine well-child visits in the outpatient setting. But these screenings often don’t happen, Dr. Jarvis says, either because doctors aren’t following the recommendations or parents aren’t attending these visits due to barriers to health care access or other problems.

One way to sidestep these challenges, she says, is to provide PPD screening in the emergency setting.

“The ED becomes the safety net for people who are not routinely accessing regular checkups for themselves and their children,” Dr. Jarvis says. “If a mother is having an acute crisis in the middle of the night and feeling anxious and depressed, they often come to the emergency department for help.”

Dr. Jarvis and colleagues launched a pilot study in the Children’s ED to screen for PPD. For eight months beginning June 2015, the researchers invited English- and Spanish-speaking mothers who arrived at the ED with infants 6 months old or younger with complaints that didn’t necessitate immediate emergency care to take a short questionnaire on a computer tablet. This questionnaire included the Edinburgh Postnatal Depression Scale, a well-validated tool to screen for PPD, along with basic sociodemographic questions and queries about risk factors that other studies previously identified for PPD.

Just over half agreed to participate. When Dr. Jarvis and colleagues analyzed the results from these 209 mothers, they found that 27 percent scored positive for PPD, more than the average from previous estimates. Fourteen of those mothers reported having suicidal thoughts. Surprisingly, nearly half of participants reported that they’d never been screened previously for PPD, despite standing recommendations for routine screenings at mother and baby care visits, the research team writes in findings published online May 5, 2018, in Pediatric Emergency Care.

Based on the screening results, the researchers implemented a range of interventions. All mothers who participated in the study received an informational booklet from the March of Dimes on PPD. If mothers scored positive, they also received a local PPD resource handout and were offered a consultation with a social worker. Those with a strongly positive score were required to receive a social worker consultation and were given the option of “warm-line” support to PPD community partners, a facilitated connection to providers who offer individual or group therapy or home visits, or to a psychiatrist who might prescribe medication. Mothers with suicidal thoughts were assessed by a physician and assisted by crisis intervention services, if needed.

When the researchers followed up with mothers who screened positive one month later, an overwhelming majority said that screening in the ED was important and that the resources they were given had been key for finding help. Many commented that even the screening process seemed like a helpful intervention.

“Some of these women had no idea how common PPD was. They thought they were crazy and felt alone and were bad moms,” Dr. Jarvis says. “For someone to even ask about PPD made these women aware that this exists, and it’s something people care about.”

Many thanked her and colleagues for the follow-up call, she adds, saying that it felt good to be cared for and checked on weeks later. “It goes to show that putting support systems in place for these new mothers is very important,” she says.

Dr. Jarvis and ED colleagues are currently collaborating with social workers, neonatology and other Children’s National Health System care partners to start screening mothers in the neonatal intensive care unit (NICU) and ED for PPD. They plan to compare results generated by this universal screening to those in their study. These findings will help researchers better understand the prevalence of PPD in mothers with higher triage acuity levels and how general rates of PPD for mothers in the ED and NICU compare with those generated in past studies based on well-child checks. Eventually, she says, they would like to study whether the interventions they prescribed affected the known consequences of PPD, such as breastfeeding,  timely immunization rates and behavior outcomes.

“With appropriate care and resources,” Dr. Jarvis adds, “we’re hoping to improve the lives of these women and their families.”

In addition to Dr. Jarvis, the lead study author, Children’s co-authors include Kristen A. Breslin, M.D., M.P.H.; Gia M. Badolato, M.P.H.; James M. Chamberlain, M.D.; and Monika K. Goyal, M.D., MSCE, the study’s senior author.

Making the grade: Children’s National is nation’s Top 5 children’s hospital

Children’s National rose in rankings to become the nation’s Top 5 children’s hospital according to the 2018-19 Best Children’s Hospitals Honor Roll released June 26, 2018, by U.S. News & World Report. Additionally, for the second straight year, Children’s Neonatology division led by Billie Lou Short, M.D., ranked No. 1 among 50 neonatal intensive care units ranked across the nation.

Children’s National also ranked in the Top 10 in six additional services:

For the eighth year running, Children’s National ranked in all 10 specialty services, which underscores its unwavering commitment to excellence, continuous quality improvement and unmatched pediatric expertise throughout the organization.

“It’s a distinct honor for Children’s physicians, nurses and employees to be recognized as the nation’s Top 5 pediatric hospital. Children’s National provides the nation’s best care for kids and our dedicated physicians, neonatologists, surgeons, neuroscientists and other specialists, nurses and other clinical support teams are the reason why,” says Kurt Newman, M.D., Children’s President and CEO. “All of the Children’s staff is committed to ensuring that our kids and families enjoy the very best health outcomes today and for the rest of their lives.”

The excellence of Children’s care is made possible by our research insights and clinical innovations. In addition to being named to the U.S. News Honor Roll, a distinction awarded to just 10 children’s centers around the nation, Children’s National is a two-time Magnet® designated hospital for excellence in nursing and is a Leapfrog Group Top Hospital. Children’s ranks seventh among pediatric hospitals in funding from the National Institutes of Health, with a combined $40 million in direct and indirect funding, and transfers the latest research insights from the bench to patients’ bedsides.

“The 10 pediatric centers on this year’s Best Children’s Hospitals Honor Roll deliver exceptional care across a range of specialties and deserve to be highlighted,” says Ben Harder, chief of health analysis at U.S. News. “Day after day, these hospitals provide state-of-the-art medical expertise to children with complex conditions. Their U.S. News’ rankings reflect their commitment to providing high-quality care.”

The 12th annual rankings recognize the top 50 pediatric facilities across the U.S. in 10 pediatric specialties: cancer, cardiology and heart surgery, diabetes and endocrinology, gastroenterology and gastrointestinal surgery, neonatology, nephrology, neurology and neurosurgery, orthopedics, pulmonology and urology. Hospitals received points for being ranked in a specialty, and higher-ranking hospitals receive more points. The Best Children’s Hospitals Honor Roll recognizes the 10 hospitals that received the most points overall.

This year’s rankings will be published in the U.S. News & World Report’s “Best Hospitals 2019” guidebook, available for purchase in late September.

distressed woman holding baby

When depression lingers after the NICU

distressed woman holding baby

Roughly half a million babies end up in the neonatal intensive care unit (NICU) each year in the U.S., often sending their parents on a wild emotional rollercoaster. Like other new parents, many parents feel symptoms of depression when their child leaves the NICU. For the majority, these depressive symptoms lift over time. But for others, depression can persist, affecting their well-being and relationships, including those with their new babies.

Thus far, it’s been unclear which parents are at a higher risk for this lasting depression. However, a new study led by Children’s researchers and presented at the Pediatric Academic Societies 2018 annual meeting suggests that parents whose depression lingers six months after their child’s NICU discharge tend to share certain demographic characteristics: They’re younger, have less education and care for more than one child.

“Using a validated screening tool, we found that 40 percent of parents in our analyses were positive for depression at the time their newborn was discharged from the NICU,” says Karen Fratantoni, M.D., M.P.H., a Children’s pediatrician and the lead study author. “It’s reassuring that, for many parents, these depressive symptoms ease over time. However for a select group of parents, depression symptoms persisted six months after discharge. Our findings help to ensure that we target mental health screening and services to these more vulnerable parents,” Dr. Fratantoni adds.

The study is an offshoot from “Giving Parents Support (GPS) after NICU discharge,” a large, randomized clinical trial exploring whether providing peer-to-peer parental support after NICU discharge improves babies’ overall health as well as their parents’ mental health.

Mothers of preterm and full-term infants who are hospitalized in NICUs are at risk for peripartum mood disorders, including postpartum depression. The Children’s research team sought to determine how many parents of NICU graduates experience depression and which characteristics are shared by parents with elevated depression scores.

They included 125 parents who had enrolled in the GPS clinical trial in their exploratory analyses and assessed depressive symptoms using a 10-item, validated screening tool, the Center for Epidemiological Studies Depression Scale (CES-D). Eighty-four percent of the parents were women. Nearly 61 percent of their infants were male and were born at a median gestational age of 37.7 weeks and mean birth weight of 2,565 grams. The median length of time these newborns remained in the NICU was 18 days.

When the newborns were discharged, 50 parents (40 percent) had elevated CES-D scores. By six months after discharge, that number dropped to 17 parents (14 percent).Their mean age ranged from 26.5 to 30.6 years old.

“Parents of NICU graduates who are young, have less education and are caring for other children are at higher risk for persistent symptoms of depression,” says Dr. Fratantoni. “We know that peripartum mood disorders can persist for one year or more after childbirth so these findings will help us to better match mental health care services to parents who are most in need.”

An American College of Obstetricians and Gynecologists’ committee opinion issued May 2018 calls for all women to have contact with a maternal care provider within the first three weeks postpartum and to undergo a comprehensive postpartum visit no later than 12 weeks after birth that includes screening for postpartum depression and anxiety using a validated instrument.

Study co-authors include Lisa Tuchman, M.D., chief, Children’s Adolescent and Young Adult Medicine Division; Randi Streisand, Ph.D., Children’s interim chief of Psychology and Behavioral Health; Nicole S. Herrera; Katherine Kritikos and Lamia Soghier, M.D., Children’s neonatologist.

Preemie Baby

Brain food for preemies

Preemie Baby

Babies born prematurely – before 37 weeks of pregnancy – often have a lot of catching up to do. Not just in size. Preterm infants typically lag behind their term peers in a variety of areas as they grow up, including motor development, behavior and school performance.

New research suggests one way to combat this problem. The study, led by Children’s researchers and presented during the Pediatric Academic Societies 2018 annual meeting, suggests that the volume of carbohydrates, proteins, lipids and calories consumed by very vulnerable premature infants significantly contributes to increased brain volume and white matter development, even though additional research is needed to determine specific nutritional approaches that best support these infants’ developing brains.

During the final weeks of pregnancy, the fetal brain undergoes an unprecedented growth spurt, dramatically increasing in volume as well as structural complexity as the fetus approaches full term.

One in 10 infants born in the U.S. in 2016 was born before 37 weeks of gestation, according to the Centers for Disease Control and Prevention. Within this group, very low birthweight preemies are at significant risk for growth failure and neurocognitive impairment. Nutritional support in the neonatal intensive care unit (NICU) helps to encourage optimal brain development among preterm infants. However, their brain growth rates still lag behind those seen in full-term newborns.

“Few studies have investigated the impact of early macronutrient and caloric intake on microstructural brain development in vulnerable preterm infants,” says Katherine Ottolini, lead author of the Children’s-led study. “Advanced quantitative magnetic resonance imaging (MRI) techniques may help to fill that data gap in order to better direct targeted interventions to newborns who are most in need.”

The research team at Children’s National Health System enrolled 69 infants who were born younger than 32 gestational weeks and weighed less than 1,500 grams. The infants’ mean birth weight was 970 grams and their mean gestational age at birth was 27.6 weeks.

The newborns underwent MRI at their term-equivalent age, 40 weeks gestation. Parametric maps were generated for fractional anisotropy in regions of the cerebrum and cerebellum for diffusion tensor imaging analyses, which measures brain connectivity and white matter tract integrity. The research team also tracked nutritional data: Grams per kilogram of carbohydrates, proteins, lipids and overall caloric intake.

“We found a significantly negative association between fractional anisotropy and cumulative macronutrient/caloric intake,” says Catherine Limperopoulos, Ph.D., director of Children’s Developing Brain Research Laboratory and senior author of the research. “Curiously, we also find significantly negative association between macronutrient/caloric intake and regional brain volume in the cortical and deep gray matter, cerebellum and brainstem.”

Because the nutritional support does contribute to cerebral volumes and white matter microstructural development in very vulnerable newborns, Limperopoulos says the significant negative associations seen in this study may reflect the longer period of time these infants relied on nutritional support in the NICU.

In addition to Ottolini and Limperopoulos, study co-authors include Nickie Andescavage, M.D., Attending, Children’s Neonatal-Perinatal Medicine; and Kushal Kapse.

Dr. Jackson and colleagues with D.C. City Council

Shining a light on child abuse, how to prevent it and help kids recover

Dr. Jackson and colleagues with D.C. City Council

Dr. Jackson and colleagues from Children’s National Health System and the District’s Multidisciplinary Team join resolution sponsor Councilmember Vincent Gray and the D.C. City Council for the presentation of the Child Abuse Prevention Month Recognition Resolution of 2018.

In recognition of Child Abuse Prevention Month, Children’s National Health System joined the DC City Council on Tuesday, April 10, 2018, to present the Child Abuse Prevention Month Recognition Resolution of 2018. According to Councilmember Vincent Gray, who sponsored it, the unanimous resolution “recognizes all the community partners who work to prevent the tragedy of child abuse before it happens, and who keep the children of the District of Columbia as safe as we can.”

He mentioned the many years that the District of Columbia fell in the top five for child abuse victims per capita, and that, while the city still ranks highly, the number of victims per  1,000 children has declined significantly since 2009. He attributes this decline to the communities and agencies who work together to protect children and strengthen families.

Allison Jackson, M.D., MPH, chief of the Child and Adolescent Protection Center at Children’s National, expressed her sincere appreciation for all the people who care for and protect children.

“Every day we see the scores of children who have experienced maltreatment,” she says. “We are so thankful for the recognition of the small voices, and grateful to Councilman Gray and the other supportive councilmembers for helping us to remove the veil of secrecy that burdens so many children and families who have experienced child abuse.”

The Child and Adolescent Protection Center at Children’s National Health System was started in the mid-1970s to provide medical care, forensic medical evaluations by pediatric trained forensic professionals, and mental health treatment for children. Dr. Jackson notes that in the 1990s, the District established a multi-disciplinary team to implement the trauma-informed response framework across all agencies in the District addressing these issues.

She also cites that years of research into adverse childhood events have shown that childhood abuse, exploitation, and neglect has long term medical and brain health consequences that last throughout life and can shorten lives, as well.

However, that research also shows that trauma-informed care and interventions can reduce the exposure to maltreatment, and also reduce the long lasting impacts of maltreatment on a child.

“Child abuse can be prevented if we can all commit to promoting safe, stable and nurturing relationships for children and youth,” Dr. Jackson points out. “I encourage each of you to learn how to recognize child abuse and the appropriate response if you suspect it. Parenting is difficult, so support and encourage parents and caregivers.  Remember that ‘discipline’ means ‘to teach,’ so find constructive ways to teach children right from wrong. And SPEAK UP for children and families.”

The presentation occurs at 33:00 minutes of the 22nd Legislative Meeting of the D.C. City Council.

Vittorio Gallo

Perinatal brain injury headlines American Society for Neurochemistry

Vittorio Gallo

Dr. Gallo’s research could have major implications for overcoming the common behavioral and developmental challenges associated with premature birth.

Children’s National Chief Research Officer Vittorio Gallo, Ph.D., recently had the honor of presenting a presidential lecture at the 48th Annual Meeting of the American Society for Neurochemistry (ASN). The lecture focused on his lifelong investigations of the cellular and molecular mechanisms of white matter development and injury, including myelin and glial cells – which are involved in the brain’s response to injury.

Specifically, he outlined the underlying diffuse white matter injury observed in his lab’s pre-clinical model of perinatal hypoxia, and presented new, non-invasive interventions that promote functional recovery and attenuate developmental delay after perinatal injury in the model. Diffuse white matter injuries are the most frequently observed pattern of brain injury in contemporary cohorts of premature infants. Illuminating methods that might stimulate growth and repair of such injuries shows promise for potential noninvasive strategies that might mitigate the long-term behavioral abnormalities and developmental delay associated with premature birth.

Dr. Gallo’s work in developmental neuroscience has been seminal in deepening understanding of cerebral palsy and multiple sclerosis. During his tenure as center director, he transformed the Center for Neuroscience Research into one of the nation’s premier programs.

ASN gathers nearly 400 delegates from the neurochemistry sector each year, including bench and clinical scientists, principal investigators, graduate students and postdoctoral fellows all actively involved in research from North America and around the world.

Joseph Scafidi

Developing brains are impacted, but can recover, from molecularly targeted cancer drugs

Joseph Scafidi

“The plasticity of the developing brain does make it susceptible to treatments that alter its pathways,” says Joseph Scafidi, D. O., M.S. “Thankfully, that same plasticity means we have an opportunity to mitigate the damage from necessary and lifesaving treatments by providing the right support after the treatment is over.”

One of the latest developments in oncology treatments is the advancement of molecularly targeted therapeutic agents. These drugs can be used to specifically target and impact the signaling pathways that encourage tumor growth, and are also becoming a common go to for ophthalmologists to treat retinopathy of prematurity in neonates.

But in the developing brain of a child or adolescent, these pathways are also crucial to the growth and development of the brain and central nervous system.

“These drugs have been tested in vitro, or in tumor cells, or even in adult studies for efficacy, but there was no data on what happens when these pathways are inhibited during periods when their activation is also playing a key role in the development of cognitive and behavioral skills, as is the case in a growing child,” says Joseph Scafidi, D. O., M.S., a neuroscientist and pediatric neurologist who specializes in neonatology at Children’s National Health System.

As it turns out, when the drugs successfully inhibit tumor growth by suppressing receptors, they can also significantly impact the function of immature brains, specifically changing cognitive and behavioral functions that are associated with white matter and hippocampal development.

The results appeared in Cancer Research, and are the first to demonstrate the vulnerability of the developing brain when this class of drugs is administered. The pre-clinical study looked at the unique impacts of drugs including gefitinib (Iressa), sunitib malate (Sutent) and rapamycin (Sirolimus) that target specific pathways responsible for the rapid growth and development that occurs throughout childhood.

The agents alter signaling pathways in the developing brain, including decreasing the number of oligodendrocytes, which alters white matter growth. Additionally, the agents also impact the function of specific cells within the hippocampus related to learning and memory. When younger preclinical subjects were treated, impacts of exposure were more significant. Tests on the youngest pre-clinical subjects showed significantly diminished capacity to complete cognitive and behavioral tasks and somewhat older, e.g. adolescent, subjects showed somewhat fewer deficits. Adult subjects saw little or no deficit.

“The impacts on cognitive and behavioral function for the developing brain, though significant, are still less detrimental than the widespread impacts of chemotherapy on that young brain,” Dr. Scafidi notes. “Pediatric oncologists, neuro-oncologists and ophthalmologists should be aware of the potential impacts of using these molecularly targeted drugs in children, but should still consider them as a treatment option when necessary.”

The effects are reversible

Researchers also found measurable improvements in these impaired cognitive and behavioral functions when rehabilitation strategies such as environmental stimulation, cognitive therapy and physical activity were applied after drug exposure.

“The plasticity of the developing brain does make it susceptible to treatments that alter its pathways,” says Dr. Scafidi. “Thankfully, that same plasticity means we have an opportunity to mitigate the damage from necessary and lifesaving treatments by providing the right support after the treatment is over.”

Many major pediatric oncology centers, including the Center for Cancer and Blood Disorders at Children’s National, already incorporate rehabilitation strategies such as cognitive therapy and increased physical activity to help pediatric patients return to normal life following treatment. The results from this study suggest that these activities after treatment for pediatric brain tumors may play a vital role in improving recovery of brain cognitive and behavioral function in the pediatric population.

This research was funded by grants to Dr. Scafidi from the National Brain Tumor Society, Childhood Brain Tumor Foundation and the National Institutes of Health.

Millenial Panel at Population Strategies for Childrens Health Summit

Population health and value based care discussed at the Population Strategies for Children’s Health Summit

With sponsorship from Cerner Corporation, Children’s National held the first Population Strategies for Children’s Health (PSCH) event on February 19 – 20, 2018 at The Westin City Center in Washington, D.C. Speakers and attendees gathered from around the country to discuss pediatric population health and the transition to value based care.

PSCH opened with an insightful presentation from Ellen-Marie Whelan Ph.D., CRNP, FAAN, chief population health officer at the CMS Center for Medicaid and CHIP Services. Her presentation, “Medicaid Transformation to Value Based Care,” explored an incentivized health care delivery system reform that will result in better care, smarter spending and healthier people.

Sean Gleeson, M.D., M.B.A., president of Partners for Kids at Nationwide Children’s Hospital, spoke about the mechanics of Partners for Kids and the population health strategies they choose to implement. These strategies require an entire enterprise to be engaged and they must be an intentional component of each healthcare organization. Dr. Gleeson put it simply that population health turns healthcare “right side up” by tying financial incentives to positive value outcomes versus upside down when health organizations make more money when kids are sicker.

A presentation from William Feaster, M.D., M.B.A., chief medical information officer at CHOC Children’s Hospital, and Brian Jacobs, M.D., vice president, chief medical information officer and chief information officer at Children’s National Health System, delved into implementing condition-specific pediatric registries. They highlighted that it’s necessary to integrate registries and workflows into the daily work of clinicians and make them actionable to encourage engagement.

Another highlight of the conference was the millennial panel “The Current and Future State of Health Care from a Consumer’s Perspective.” The panel consisted of Janice Bitetti, a physician and mother of a 10-year-old with Type 1 diabetes; Jonathan Morris, a 15-year-old Type 1 Diabetes patient at Children’s National; and moderator Emily Webber, M.D., FAAP, chief medical information officer at Riley Children’s Hospital. Panel participants shared their take on the current state of Type 1 diabetes care, and the way millennials interact with healthcare. Both Jonathan and Janice agreed that the intensive nature of Type 1 diabetes care puts many families who don’t have the time, resources and initiative that they do in a very difficult place.

Other speakers throughout the two day event explored topics including population health strategies to reduce child health disparities, the role of telehealth in population health, care coordination and coaching to health, and technology in population health.

Millenial Panel at Population Strategies for Childrens Health Summit

Brian Jacobs, M.D. introduces the Millennial Panel at the Population Strategies for Children’s Health Summit.

Maureen Monaghan

Using text messages and telemedicine to improve diabetes self-management

Maureen Monaghan

Maureen Monaghan, Ph.D., C.D.E., clinical psychologist and certified diabetes educator in the Childhood and Adolescent Diabetes Program at Children’s National Health System, awarded nearly $1.6 million grant from American Diabetes Association.

Adolescents and young adults ages 17-22 with Type 1 diabetes are at high risk for negative health outcomes. If fact, some studies show that less than 20 percent of patients in this population meet targets for glycemic control, and visits to the Emergency Department for acute complications like diabetic ketoacidosis peak around the same age.

The American Diabetes Association (ADA) awarded Maureen Monaghan, Ph.D., C.D.E., clinical psychologist and certified diabetes educator in the Childhood and Adolescent Diabetes Program at Children’s National Health System, nearly $1.6 million to evaluate an innovative behavioral intervention to improve patient-provider communication, teach and help patients maintain self-care and self-advocacy skills and ultimately prepare young adults for transition into adult diabetes care, limiting the negative adverse outcomes that are commonly seen in adulthood.

Dr. Monaghan is the first psychologist funded through the ADA’s Pathway to Stop Diabetes program, which awards six annual research grants designed to spur breakthroughs in fundamental diabetes science, technology, diabetes care and potential cures. Dr. Monaghan received the Accelerator Award, given to diabetes researchers early in their careers, which will assist her in leading a behavioral science project titled, “Improving Health Communication During the Transition from Pediatric to Adult Diabetes Care.”

“Behavior is such a key component in diabetes care, and it’s wonderful that the American Diabetes Association is invested in promoting healthy behaviors,” says Dr. Monaghan. “I’m excited to address psychosocial complications of diabetes and take a closer look at how supporting positive health behavior during adolescence and young adulthood can lead to a reduction in medical complications down the road.”

During the five year study, Dr. Monaghan will recruit patients ages 17-22 and follow their care at Children’s National through their first visit with an adult endocrinologist. Her team will assess participants’ ability to communicate with providers, including their willingness to disclose diabetes-related concerns, share potentially risky behaviors like drinking alcohol and take proactive steps to monitor and regularly review glucose data.

“The period of transition from pediatric to adult diabetes care represents a particularly risky time. Patients are going through major life changes, such as starting new jobs, attending college, moving out of their parents’ homes and ultimately managing care more independently,” says Dr. Monaghan. “Behavioral intervention can be effective at any age, but we are hopeful that we can substantially help youth during this time of transition when they are losing many of their safety nets.”

Study leaders will help participants download glucose device management tools onto their smartphones and explain how to upload information from patients’ diabetes devices into the system. Participants will then learn how to review the data and quickly spot issues for intervention or follow-up with their health care provider.

Patients also will participate in behavioral telemedicine visits from the convenience of their own homes, and receive text messages giving them reminders about self-care and educational information, such as “Going out with your friends tonight? Make sure you check your glucose level before you drive.”

At the study’s conclusion, Dr. Monaghan anticipates seeing improvements in psychosocial indicators, mood and transition readiness, as well as improved diabetes self-management and engagement in adult medicine.

little girl holding a stuffed bear

Population Strategies for Children’s Health Summit

little girl holding a stuffed bear

Children’s National, with sponsorship from Cerner Corporation, is excited to announce the first Population Strategies for Children’s Health Summit on February 19 – 20, 2018 at The Westin in Washington, D.C. This is the first summit focused exclusively on comprehensive population health management approaches that can help children reach their highest levels of health and potential.

Join us in developing new ideas and best practices that engage millennial healthcare consumers and address challenges pediatric providers face in transitioning to value-based care. You’ll learn how population health management strategies can improve care quality for an entire pediatric population in a way that supports your health system’s bottom line.

Speakers at the summit will focus on topics such as:

  • Health policy
  • Care coordination
  • Physician engagement
  • Registries and risk stratification
  • Telehealth
  • Health disparities
  • Taking on risk

Get a sneak peek of the featured Millennial Panel discussion on February 20:

The current and future state of health care from a consumer’s perspective

Health care is a dynamic, constantly evolving entity. This three-person panel plus moderator takes on the consumer point of view to discuss what is and isn’t working in health care today. The panel consists of a pediatrician and mom of a child with Type 1 diabetes and a 15-year-old Type 1 diabetes patient. They’ll share their experiences and thoughts about how they believe health care will progress in the future.

For more information about the 2018 Population Strategies for Children’s Health Summit, please visit our website.

Lee Beers

Mental health screenings increase in practices with hands-on support

Lee Beers

A new study suggests many more pediatricians would make mental health screenings an integral part of a child’s annual checkup if they received training and support through a proven and powerful method used to improve health care processes and outcomes.

Results of the multidisciplinary study led by Children’s National Health System and published in Pediatrics, showed screening rates improved from one percent to 74 percent during the 15-month study. A total of 10 pediatric practices and 107 individual providers in the Washington, D.C., area voluntarily participated in the study.

“This study is an important first step towards early identification of children with mental health concerns,” says Lee S. Beers, M.D., the study’s lead author. “If you identify and treat children with mental health concerns earlier, you’re going to see better outcomes.”

In this country, approximately 13 percent of youth live with a serious mental illness, but only about 20 percent of them get the help they need, according to the D.C. Collaborative for Mental Health in Pediatric Primary Care. 

While many pediatricians agree that early mental health screenings are important, the researchers found that few providers were actually conducting them. In the past, primary care providers have cited a shortage of pediatric mental health providers, a lack of time, insufficient resources and lower reimbursements.

To address the lack of mental health screenings, researchers decided to test whether the Quality Improvement (QI) Learning Collaborative model, which was pioneered in the mid-1990s to scale and improve health care services, would help study participants integrate screenings into their practices.

The QI Learning Collaborative model takes a more hands-on approach than the typical “once and done” study, says Beers. Specifically, the participating primary care providers received periodic check-ins, ongoing support, monitoring and technical assistance. “We use rapid cycles of evaluation to see what’s working and what’s not working, and we keep going,” Beers says.

Dr. Beers is optimistic about how well the practices performed, adding the caveat that more information is needed about the burden it could place on already bustling pediatric practices. In addition, she says, “future research will be needed to determine whether identifying mental health issues also leads to improved access to care and outcomes for pediatric patients.”

Dr. Beers serves as medical director for Municipal and Regional Affairs at the Child Health Advocacy Institute (CHAI), part of Children’s National. CHAI is a founding member of the D.C. Healthy Communities Collaborative (DCHCC), which partnered on the study with the Georgetown University Medical Center and the Georgetown University Center for Child and Human Development.

Adolescent brain scan from obesity study

Imaging captures obesity’s impact on the adolescent brain

Adolescent brain scan from obesity study

For the first time, a team of researchers led by Chandan Vaidya, Ph.D., chair of the Department of Psychology at Georgetown University, has used functional magnetic resonance imaging (fMRI) to capture the brain function of a small population of adolescents with obesity, both before and after bariatric surgery.

Obesity affects the whole body, from more obvious physical impacts on bones and joints to more subtle, internal impacts on organs like the brain.

For the first time, a team of researchers has used functional magnetic resonance imaging (fMRI) to capture the brain function of a small population of adolescents with obesity, both before and after bariatric surgery. The goal is to better understand the neural changes that occur when an adolescent is obese, and determine the effectiveness of interventions, such as vertical sleeve gastrectomy, at improving brain function as weight is lost.

The study, published as the November Editors’ Choice in the journal Obesity, found that executive and reward-related brain functions of study participants with obesity improved following the surgical procedure and initial weight loss.

How bariatric surgery changes the teenage brain from Research Square on Vimeo.

“We’ve known for some time that severe obesity has negative consequences on some neurocognitive function areas for adults,” says Chandan Vaidya, Ph.D., chair of the Department of Psychology at Georgetown University and a senior author of the study. “But for the first time, we’ve captured fMRI evidence in young patients, and also shown that surgical intervention and the resulting weight loss can reverse some of those deficits.”

“For me, this early evidence makes a strong case that when kids are struggling with severe obesity, we need to consider surgical intervention as an option sooner in the process,” notes Evan Nadler, M.D., director of the Bariatric Surgery Program at Children’s National Health System, who also contributed to the study. “The question that remains is whether the neurocognitive function improves more if surgery, and thus weight loss, happens earlier – and is there a time factor that should help us determine when to perform a procedure that will maximize improvements?”

The preliminary study included 36 participants and was conducted using patients recruited from the Children’s National Bariatric Surgery program, one of the first children’s hospitals to achieve national accreditation by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program.

“We asked these questions because we know that in the kids we see, their behavioral, brain, and physical health are all very closely related to one another and have an impact on each other,” adds Eleanor Mackey, Ph.D., study senior author and co-principal investigator on the National Institute of Diabetes and Digestive and Kidney Diseases grant that funded the project. “We expected that as physical health improves, we might see corresponding improvements in brain and behavior such as cognitive and school performance.”

The study also pointed out some technical and practical challenges to studying this particular young population. Anyone with a BMI greater than 50 was not able to fit within the MR bore used in the study, preventing fMRI participation by those patients.

“In addition to future studies with a larger sample size, we’d like to see if there are neuroimaging markers of plasticity differences in a population with BMI greater than 50,” says Dr. Vaidya. “Does the severity of the obesity change how quickly the brain can adapt following surgery and weight loss?”

The abstract was selected by the journal’s editors as one that provides insights into preventing and treating obesity. It was featured at the Obesity Journal Symposium during Obesity Week 2017 in Washington, D.C., as part of the Obesity Week recognition, and a digital video abstract was also released about the findings.