Highlights

• Krisa Van Meurs, MD, Sonia Bonifacio, MD, neonatal nurse practitioner Kathi Salley Randall, and Courtney Wusthoff, MD, were invited speakers at the Neo Brain Brazil 2019 conference held in São Paolo, November 8-10. All spoke at a pre-conference workshop as well as the main conference attended by 900 medical professional from all 26 states in Brazil. The topic of the conference was HIE and therapeutic hypothermia with a focus on improving identification of HIE and decreasing variation in practice. 
• Can Liu, PhD, joins our neonatology family as a new postdoctoral scholar with Suzan Carmichael, PhD, as her mentor. Liu received her PhD from the Karolinska Institutet in Solna, Sweden, where she studied the psychosocial risk factors of preterm birth.
• Susan Hintz, MD, MS Epi, was the keynote speaker for the NICU Family Alliance Symposium in Roseville, CA on November 16. She spoke about the challenges that families face in transition from the NICU to home and community, and potential opportunities for improvement in California.
• Dr. Hintz was a guest speaker at the 95^th Perinatal & Developmental Medicine Symposium in Bonita Springs, FL, November 20-23. The Symposium offers a highly select group of fellows an opportunity to present their research and engage in focused mentorship with invited faculty. Neonatal-perinatal medicine fellow Eman Haidari, MD (class of 2021) was an invited fellow, and Dr. Hintz presented on the CPQCC CCS High-Risk Infant Follow-up Initiative.

Highlights

• Alexis Davis, MD, MS Epi, Sonia Bonifacio, MD, Jochen Profit, MD, MPH, and Henry C. Lee, MD, MS Epi, participated in the first Section on Neonatal Perinatal Medicine Quality Measures summit at the AAP headquarters in Itasca, IL, October 7 & 8.  
• Susan Hintz, MD, MS Epi, was one of the CPQCC leaders who spoke in Southern California (Anaheim and Glendale) and Northern California (San Jose) at data training events. These events give member hospitals an opportunity to learn about changes to the NICU, CPeTs, and HRIF data sets in the upcoming year, network with other hospital teams, and learn about available quality improvement and research activities.
• At the West Coast Pediatric Palliative Care Summit in Oakland, CA on October 29, Dr. Hintz was an invited speaker along with neonatal nurse practitioner Diana Kobayashi. They spoke on the topic of perinatal counseling and palliative care.

Highlights

• The British Medical Association Medical Book Awards for 2019 recognized a book co-edited by William Benitz, MD, and P. Brian Smith, MD, of Duke University. Neonataology Questions and Controversies: Infectious Diseases and Pharmacology (Philadelphia: Elsevier, 2018) was named Highly Commended. The award was presented at the BMA House in London, England on September 3. 
• Earlier this year, the American Pediatric Society (APS) awarded David Stevenson, MD, with the prestigious John Howland Award. The APS recently established the John Howland Visiting Professor Program as an extension of the award, and Dr. Stevenson will be the inaugural visiting professor. On September 10, the APS announced its selection of the first host institutions: University of Texas Health Science Center and the University of North Carolina at Chapel Hill with Duke University. Dr. Stevenson will visit these institutions to share his experience and knowledge, exchange ideas, and engage in discussions about critical issues affecting academic pediatrics. 
• Stanford faculty participated in the 7th Annual Pediatric Device Innovation Symposium in Boston, MA on September 22.
  • Anoop Rao, MD, MS,  Fatima Eskandar-Afshari, DO, and Bill Rhine, MD, have been working on a wearable continuous non-invasive blood pressure (BP) monitor along with Stanford spin-off PyrAmes Health. This device was selected as a winner in the "Make Your Medical Device Pitch for Kids!" competition during the Symposium. The competition focused on NICU innovations and was organized by the Children's National Hospital and the National Capital Consortium for Pediatric Device Innovation (NCC-PDI). Looking forward, the non-invasive BP monitor will be part of the Pediatric Device Innovator Accelerator Program and also a finalist in the Ignite Fire Accelerator Program.
  • Janene Fuerch, MD, was invited to judge the pediatric device competition. Additionally, she was invited to be an expert panelist on a panel called "Hope or Hype? Shining a Light on Digital Health and Software as a Medical Device for Kids."
• Dr. Fuerch was also invited to speak on a panel about innovative methods of education in neonatal resuscitation at the University of Oklahoma for the 3rd Annual Neonatal Resuscitation Symposium on September 27. Many of the members of the Neonatal Resuscitation Program steering committee are involved in this symposium.
• Neonatal-perinatal medicine fellow Megan Ringle, MD (class of 2020) presented preliminary research findings at the Neonatal Cardiopulmonary Biology Young Investigators Forum in Chicago, IL, and received a research grant award of $1500 for her work. Her presentation was on the use of functional echo and NIRS to characterize neonatal hemodynamics. 
• Dr. Stevenson gave a keynote presentation, entitled "Understanding Disparities in Preterm Birth," at the 50th Annual Perinatal Research Society meeting in Minneapolis, MN on September 28.

Highlight

Ritu Chitkara, MD, was promoted to Clinical Associate Professor on August 1.

Highlights

• A Hospital Pediatrics article reporting on a clinical exam-based approach for the management of chorioamnionitis-exposed infants in the newborn nursery was honored by the journal's editorial board with the Jennifer Daru Memorial Award at the annual Pediatric Hospital Medicine Conference. Co-authors of the article (published in March -- see Notable Publications) include lead author Neha Joshi, MD, Arun Gupta, MD, Ronald Cohen, MD, Bill Benitz, MD, and senior author Adam Frymoyer, MD. The Daru Award is intended to honor the manuscript the editorial board feels has the most potential to impact clinical care. Already, the local impact at Lucile Packard Children's Hospital is evident. We have significantly reduced our antibiotic usage and decreased separation of mothers and infants in the Johnson Center. The work has involved collaboration between our Neonatal Hospitalist team, who has been on the front lines of this initiative, and the Johnson Center nursing staff as well as Well Baby Nursery and Palo Alto Medical Foundation colleagues. 

• Our faculty were busy at this year’s annual Pediatric Hospital Medicine (PHM) Conference in Seattle, WA, July 25-28. Multiple members of the division (including Drs. Gupta, Joshi, Frymoyer, Benitz, Elizabeth Blecharczyk, MD, and Jadene Wong, MD) helped lead and facilitate a variety of mini-plenary sessions, workshops, and subcommittee meetings throughout the conference. Members of our Neonatal Hospitalist team also planned and led a Newborn Medicine pre-conference focused on Neonatal Resuscitation skills. Our faculty collaborated with others from across Stanford and from across the country in presenting sessions on a wide range of topics, including the care of late preterm infants, managing infants at risk for early onset sepsis, neonatal resuscitation, value based newborn care, and gender bias.

The annual PHM Conference offers a platform for us to share our knowledge in newborn care with the pediatric hospitalist community with the goal of improving the health and well-being of hospitalized infants and children nationwide. The PHM Conference (co-sponsored by the American Academy of Pediatrics, Academic Pediatric Association, and Society of Hospital Medicine) is the largest annual gathering each year for pediatric hospitalists and attracted over 1,600 attendees this year.

• Dr. Frymoyer was promoted on July 1 to Clinical Associate Professor, Pediatrics - Neonatal and Developmental Medicine. 
• Anoop Rao, MD, MS, presented work titled "Feasibility of a wearable device that continuous non-invasive BP monitor" at the Current Applications for Artificial Intelligence in Cardiology conference in San Francisco, CA, organized by the Mayo clinic. For this oral poster presentation Dr. Rao and co-authors Bill Rhine, MD, Fatima Eskandar-Afshari, DO, and neonatal-perinatal medicine fellow Caroline Yeon-Kyeong Noh, MD, won the Dr. Moskowitz Scholar award.
• Krisa Van Meurs, MD, and William Benitz, MD, were invited speakers at the 5th International Neonatology Association Conference in Tijuana, Mexico, July 12-14. Dr. Van Meurs’ presentations were on the use of NIRS to provide neuroprotection in extremely low birthweight infants and the use of erythropoietin and other new drugs for hypoxic-ischemic encephalopathy. Dr. Benitz spoke on new approaches for sepsis and management of the patent ductus arteriosus.

Highlights

• Alexis Davis, MD, MS, was elected to the District IX Section on Neonatal-Perinatal Medicine's Executive Committee. Dr. Davis has been a member of District IX since 1999, when she began her residency training at Lucile Packard Children’s Hospital Stanford and continued here as a neonatal fellow. Dr. Davis has been involved in several regional collaborations, including the Bay Area Cooling Collaborative and the Northern California Summit on Periviability. She is a founding member of the SoNPM MidCaN interest group and an active member in the Women in Neonatology Task Force.
• Anoop Rao, MD, MS, Tavpritesh Sethi, MBBS, PhD, and Vinod Bhutani, MBBS, MD, presented their work titled "A Bayesian Decision Network Approach to Address Inequity in the Neonatal Intensive Care Units in California" at Stanford's Center for Advanced Study in the Behavioral Sciences. They utilized a validated graphical approach based on Bayesian networks to quantify the role of heterogenous covariates influencing adverse neonatal morbidity outcomes in a limited California Perinatal Quality Care Collaborative dataset.
• Jochen Profit, MD, MPH, along with Jure Leskovec, PhD, from the Computer Science department was awarded Transdisciplinary Initiatives Program grant from Stanford Maternal & Child Health Research Institute (MCHRI). Their project is titled "Quantifying regionalized care delivery and outcomes using network science." The proposal supports new research by bringing methods of network science, previously applied to large scale social and technical networks, to the field of neonatology; the aim is to quantify patterns of regionalization and care network structure for vulnerable preterm and sick infants in California and eventually other patients throughout the nation. 

Highlights

• Our team at the Center for Advanced Pediatric & Perinatal Education (CAPE), Nicole K. Yamada, MD, Louis P. Halamek, MD, and Janene H. Fuerch, MD, presented a workshop on advanced debriefing techniques at the International Pediatric Simulation Symposia and Workshops on May 22 in Toronto, Canada.
• William Benitz, MD, continued traveling during this sabbatical. He spoke at the IPOKRaTES Seminar entitled Bacterial Infections in the Newborn Infant, sponsored by the Azienda Ospedaliero Universitaria Policlinico, in Modena Italy. There, he lectured on (1) evidence-based approach to early onset sepsis, (2) culture negative sepsis, (3) criteria for stopping antibiotics, and (4) ancillary diagnostic testing for early onset sepsis. Also in May, Dr. Benitz was a visiting professor at Carmel Medical Center in Haifa, Israel. There, he repeated the presentations he did in Brazil, including (1) new approaches to early-onset neonatal sepsis, (2) update in management of bronchopulmoary dysplasia, and (3) management of patent ductus arteriosis in preterm infants. 
• Postdoctoral scholar Elizabeth Wall-Wieler, PhD, is one of 23 recipients of the 2018-2019 Banting Postdoctoral Fellowships awarded by the Canadian Institutes of Health Research. Her project is entitled “Psychotropic Medication Use and Ectopic Pregnancy.” The award funds 2 years of research at $70,000/year. 

Notable Publications

Gender norms contribute to creating an unequal gender system

The Lancet published a new Series on May 30, finding that restrictive gender norms impact the health of all people — women and girls, men and boys, and gender minorities — across multiple dimensions of health, all along the life course, around the world. The Lancet Series on Gender Equality, Norms, and Health has determined that health systems are structured in ways that perpetuate bias, and much health research and data are similarly biased. Additionally, the work aims to identity opportunities to improve health and strengthen health systems through programs and policies aimed at transforming gender norms and addressing inequalities. 

The Series is comprised of five papers, led by Gary Darmstadt, MD, and colleagues, many of whom are affiliated with Stanford University School of Medicine. Ann Weber, PhD, who was a postdoctoral scholar under Dr. Darmstadt and later an instructor before accepting an Assistant Professor position at the University of Nevada, Reno, is the lead author on the second paper entitled “Gender norms and health: insights from global survey data.” The paper uses six case studies to quantify the how gender norms — defined as social roles encompassing a range of behaviors and attitudes that are generally considered acceptable, appropriate, or desirable for people based on their actual or perceived sex  — contribute to creating an unequal gender system.

Human 3D cellular model of hypoxic brain injury of prematurity

Research from Anca Pasca, MD, was featured on the cover of the May issue of Nature Medicine. Dr. Pasca uses human pluripotent stem cells to develop three-dimensional organoids that model fetal and neonatal injury in the developing brain. In this specific research, Dr. Pasca and colleagues focused on studying cellular defects associated with low oxygen exposure.  Often infants who are born extremely preterm (<25 weeks) suffer from repeated hypoxic episodes and may develop encephalopathy of prematurity in addition to long-term neurodevelopmental impairments. Dr. Pasca and her team found specific defects in intermediate progenitors, which is a cortical cell type associated with the growth of the human cerebral cortex. Reduction of the intermediate progenitors following hypoxia impacts the unfolded protein response pathway; however, the team also demonstrated that a small molecule can restore aspects of this response, potentially opening the door for future pharmacologic intervention.

Highlights

• Our Division's faculty and trainees were busy at this year’s annual Pediatric Academic Societies (PAS) Meeting in Baltimore, MD, April 24 – May 1. In total, we had 2 Plenary Presentations, 1 Hot Topic/Topic Symposia, 8 Platform Presentations, and 25 Posters Presentations. Research presented covered a wide range of topics and included (but were not limited to) neurodevelopmental outcomes in school age children who were born extremely preterm, disparities in care delivery in NICUs, neonatal hematology and bilirubin metabolism, cerebral oxygenation and auto regulation in preterm infants, and drug treatment of the patent ductus arteriosus.

The annual PAS Meeting offers a platform for us to share our research with other child healthcare professionals with the goal of improving the health and wellbeing of children worldwide. Each year, our faculty, trainees, and staff present at the PAS Meeting, which attracts over 8,000 attendees including child health researchers, clinician-educators, public health professionals, and clinical care providers.

• David Stevenson, MD, was honored with the Howland Award on April 28 at the PAS Meeting. An introduction was given by Stanford Professor Philip Pizzo, MD, and speakers at the dinner included Stanford Professors Charles Prober, MD, and Philip Sunshine, MD, and Phyllis Dennery, MD, who is the Chair of the Department of Pediatrics at the Warren Alpert School of Medicine at Brown University. Pediatric Research has published the full transcript of the plenary presention Dr. Stevenson gave when he received his award. 
• Jonathan Palma, MD, MS, was elected Chair of the Epic Neonatology Steering Board. This group of clinical domain experts helps Epic optimize their system for neonatology, and helps set the direction for future development.
• Shazia Bhombal, MD, was an invited speaker at the PDA Symposium in Memphis, TN.
• William Benitz, MD, was on a speaking tour during his sabbatical. He spoke at the VI Encontro Internacional de Neonatologia conference in Gramado, Rio grande do Sul, Brazil. He lectured on the following topics: (1) new approaches to early-onset neonatal sepsis, (2) update in management of bronchopulmoary dysplasia, and (3) management of patent ductus arteriosis in preterm infants. On April 18, Dr. Benitz was a visiting professor at Universidade Federal do Rio Grande do Sul/Hospital de Clínicas de Porto Alegre.

Notable Publication

Haemodynamic effects of premedication for neonatal intubation: an observational study

Premedication for non-emergent neonatal intubation has been highly recommended since studies dating back to 1980-90s due to benefits and proven harm. In a small, prospective, observational study, researchers enrolled infants of all gestational ages and measured their hemodynamics (BPs, non-invasive electrocardiometry, and cerebral regional oxygen saturation [rScO2]) during premedication for neonatal intubation (prior to blade insertion) and during intubation. After premedication, there was a concerning decline in BP of at least 20% from baseline in ~30% of infants without significant impact on cardiac output or rScO2. Further declines were seen with intubation.  While this study is small, it calls to attention importance of closely monitoring hemodynamic changes with premedication and intubation.  Larger studies are needed to better delineate true significance of these premedication effects.  This paper was published on April 29 in Arch Dis Child Fetal Neonatal Ed with Linda Truong, DO, as lead author.

Highlights

• Anca Pasca, MD, was selected as a joint winner to receive the inaugural Bhatt-Ramanathan scholarship award. Pasca received her award during the 25th annual Cool Topics in Neonatology Conference on March 2 in Coronado, CA. She also gave a brief lecture to fellow attendees about her scholarly work in the field of human neurodevelopment and stem cell biology.
• Our NeuroNICU team, including Krisa Van Meurs, MD, Sonia Bonifacio, MD, and neonatal nurse practitioners Celia Glennon and Kathi Randall, traveled to Israel in March. They spoke at the 1st Annual Israeli NeuroNICU Symposium attended by neonatologists from all over Israel. Following this conference, they taught the basics of brain focused care to nurses and physicians at the largest children’s hospital in Tel Aviv—The Edmond and Lily Safra Children’s Hospital, which is part of Sheba Medical Center.  
• Janene H. Fuerch, MD, represented Stanford Children's Hospital as a judge for the SXSW Impact Pediatric Health Start-up Pitch Competition in Austin, TX, where finalists pitched digital health and medtech solutions to hospitals, investors, and healthcare stakeholders.
• Dr. Fuerch helped to organize the Pediatric Innovation Symposium held on March 29 at Stanford. She moderated the UCSF-Stanford Device Consortium Pitch Competition. Additionally, she was a panelist who discussed “Innovation from Small Markers to the Masses,” where she shared her comprehensive experience and advice as a medtech industry leader in pediatric and women's health.
• At the Neonatal-Perinatal Practice Strategies Workshop in Scottsdale, AZ in March, Jochen Profit, MD, MPH, spoke on outcome disparities and combating healthcare provider burnout. Shazia Bhombal, MD, serves on the Steering Committee of Women in Neonatology (WiN), who held their second annual meeting at the workshop.
• During the NeoHeart conference in Huntington Beach, CA in March, Dr. Bhombal led the pre-conference session on targeted neonatal echocardiography. Neonatal-perinatal medicine fellow, Megan Ringle, MD, MPH, presented a case and Dr. Van Meurs was an invited speaker.

Notable Publications

Racial segregation and inequality in the neonatal intensive care unit for very low-birth-weight and very preterm infants

A recent study published on March 25 in JAMA Pediatrics explores the extent of segregation and inequality in the care of black, Hispanic, and Asian infants as compared to white infants in the neonatal intensive care unit (NICU) setting. The findings reflect care for very low-birth-weight and very preterm infants born at Vermont Oxford Network NICUs across the United States. Results showed substantial segregation in NICU care for black, Hispanic, and Asian infants. Compared to white infants and after accounting for region of residence, black infants were concentrated in NICUs with lower quality scores, whereas Asian infants were concentrated at NICUs with higher quality scores. It is evident that NICU quality varies widely across regions, with the Pacific region scoring the highest based on a hospital-level composite score of NICU quality. This study also adds to the literature 2 new indices—the NICU segregation index and NICU inequality index—that may be of use to researchers in the future. Study co-authors include Jochen Profit, MD, MPH, Henry Lee, MD, MS Epi, Ciaran Phibbs, PhD, and Jeff Gould, MD.

Clinical exam-based approach for the management of chorioamnionitis-exposed infants in the newborn nursery

Building on earlier work that was featured last year in Pediatrics, Phase II of a quality improvement initiative at Lucile Packard Children’s Hospital (LPCH) Stanford shows that managing well-appearing chorioamnionitis-exposed late preterm and term infants with a clinical exam-based approach can also be successfully implemented in the newborn nursery. The approach is the first in the United States to describe relying on clinical examination alone to determine the need for antibiotics in this specific subgroup of infants. The impact of the initiative has been remarkable. Antibiotic use has declined by >92 percent in chorioamnionitis-exposed infants born at LPCH, representing hundreds of infants saved from unnecessary antibiotic exposure. It addition, these infants now remain with their mother in couplet care during the birth hospitalization, which helps to foster bonding and breastfeeding. On a national level, the project’s leadership has helped move the needle on the management of late preterm and term infants at risk for suspected early-onset bacterial sepsis. The updated 2018 American Academy of Pediatrics (AAP) Guidelines now list serial clinical examination as one of the approaches that can be used to risk stratify infants for early-onset sepsis. Co-authors of a Hospital Pediatrics paper on the project findings include lead author Neha Joshi, MD, Arun Gupta, MD, Ronald Cohen, MD, William Benitz, MD, and senior author Adam Frymoyer, MD.

Additional coverage can be found in AAP News and the AAP Journals Blog.

Assessing the current practice of delayed cord clamping among infants in California neonatal intensive care units

New findings show that the practice of delayed cord clamping varies widely across hospitals in California. A total of 52 California Perinatal Quality Care Collaborative (CPQCC) member hospitals submitted data on delayed cord clamping (DCC) in 2016, and hospital rates of DCC were found to range from 0 to 74.5 percent. Overall, infants <32 weeks or with a birth weight of <1500 grams were more likely to receive DCC, though many hospitals reported significant gaps in data collection. A paper on the study’s findings was published on March 21 in the American Journal of Perinatology. Henry Lee, MD, MS Epi, is the senior author. CPQCC is now collecting delayed cord clamping data from all 140 member hospitals. 

For additional coverage, please see the CPQCC press release.

Highlight

Nilima Ragavan, MD, was invited as a distinguished speaker on a panel at the Vibrant Gujarat Global Summit on January 19; she spoke on the “1,000 days approach” in newborn care. The following day Dr. Ragavan addressed pediatricians at government medical centers in Gujarat via live satellite.

Accompanying Dr. Ragavan to India was a multidisciplinary team from Lucile Packard Children’s Hospital Stanford, including neonatal transport specialist Paul Cole, neonatal nurse practitioner Arlene Sheehan, neonatal occupational therapist Kelly Andrasik, and respiratory therapist Robert Gales. Pete Acker, MD, from the Department of Emergency Medicine also joined the team. In collaboration with the Srimad Rajchandra Hospital and the government of Gujarat, the team conducted a two-day neonatology conference at Dharampur in Gujarat that was attended by over 150 physicians and nurses. The team then spent 4 days at the Government Medical College in Yavatmal, where they were invited by the dean to provide training and education to the neonatal staff.

Notable Publication

Known risk factors may account for only part of the U.S. increase in life-threatening childbirth complications

In the U.S., severe maternal morbidity has more than doubled over the last 15 years. At the same time, pre-pregnancy maternal health factors like maternal age, obesity, and comorbidities have also increased, and so too have rates of cesarean deliveries. Could these upward trends be related? Surprising research findings show that pre-pregnancy maternal health factors and rates of cesarean deliveries do not explain the uptick in severe maternal morbidity in California from 2007 to 2014. During that time period, severe maternal morbidity increased by 65 percent and affected nearly 48,000 women who delivered in the state. Investigators found severe maternal morbidity was associated with advanced maternal age, pre-pregnancy comorbidity, and cesarean delivery, but not pre-pregnancy obesity. However, changes in these risk factors did not account for the increase in severe maternal morbidity over time. The open access study was published in BMC Pregnancy and Childbirth, with lead author and postdoctoral scholar Stephanie Leonard, PhD, senior author Suzan Carmichael, PhD, and co-author Elliott Main, MD.

The National Institutes of Health reported on the reseach.