Inside Pediatrics Winter 2017

P E D I A T R I C S

Fall/Winter 2017

Laser Surgery Proves Effective for Some Epilepsy Patients

Children’s, UAB at Epicenter of CMV Research

Intensive Feeding Program Requires Patience, Persistence

Healthcare as amazing as their potential. O ur tagline here at Children’s of Alabama is a call to action of sorts – a powerful charge to our expert staff to provide nothing but high quality, safe and efficient patient care. It’s a tremendous task, no doubt about it, but we rise to the challenge every day.

and research, as evidenced by our partnership with the University of Alabama at Birmingham (UAB) and the Division of Pediatric Infectious Diseases (Page 4). For more than half a century, UAB has been the leader in congenital cytomegalovirus (CMV) research, and in the early 1980s, Children’s provided laboratory space to UAB researchers, fostering a multidisciplinary environment

On the Cover: Children’s of Alabama neurosurgeon Curtis Rozzelle, M.D., assists in preparing a patient for MRI-guided laser surgery using the ClearPoint targeting system in August 2017. (Photo by Denise McGill)

Our children’s futures are tied to the goings-on inside our walls. From our Intensive Feeding Program that treats patients with intractable feeding challenges (Page 14) to acquiring the latest technology in treating patients

of professional exchange and study. Looking forward to 2019, Birmingham will host the seventh International Congenital CMV Conference – a gathering of science and clinical expertise working to prevent and cure the disease. Healthcare as amazing as their potential.

who suffer epileptic events (Page 10), Children’s is at the forefront of innovative, family- centered pediatric care. We recently introduced testing equipment that helps our staff find better solutions for patients with vestibular disorders (Page 7). Our audiology, physical therapy, occupational therapy, sports medicine, rehabilitation medicine and otolaryngology departments work in collaboration to pinpoint the best treatment for patients with persistent dizziness or balance problems.

The charge isn’t easy, but nothing worth doing ever is. I invite you to read on about our news and services as we hold up our end of the deal – providing amazing healthcare with a compassionate team so our children can thrive.

Enjoy,

We also continue to build on our commitment to merging patient care

Children’s of Alabama 1600 7th Avenue South Birmingham, Alabama 35233 (205) 638-9100 www.childrensal.org

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04 07 10

Children’s, UAB at epicenter of CMV research

ADMINISTRATION Mike Warren, President and CEO Coke Matthews, Executive Vice President Garland Stansell, Chief Communications Officer EDITORIAL Cassandra Mickens, Editor Trent Graves, Design

Children’s introduces new equipment for vestibular, balance disorders

Laser Surgery proves effective for some epilepsy patients

Amy Dabbs, Digital Content CONTRIBUTORS

Andre Green Adam Kelley

John Tracy Tina Wilson Marti Webb Slay L. Amanda Owens PHYSICIAN MARKETING Tiffany Kaczorowski MEDICAL LEADERSHIP Mitchell Cohen, M.D. Katherine Reynolds Ireland Chair of Pediatrics, University of Alabama at Birmingham Physician-in-Chief, Children’s of Alabama Mike Chen, M.D. Joseph M. Farley Chair in Pediatric Surgery, University of Alabama at Birmingham Chief of Pediatric Surgery and Surgeon-in-Chief, Children’s of Alabama Lee I. Ascherman, M.D., M.P.H. Chief of Service, Child and Adolescent Psychiatry, University of Alabama at Birmingham For questions or additional information or to share feedback, please contact us at insidepediatrics@childrensal.org An online version of the magazine is available at www.childrensal.org/insidepediatrics

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Intensive Feeding Programoffers hope for children who refuse to eat

News, Honors and Awards

CONT E N T

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Children’s,UAB at epicenter of CMV research

By Cassandra Mickens Photos by Denise McGill

N early 35 years since inviting University of Alabama at Birmingham (UAB) researchers to study pediatric infectious diseases within its walls, Children’s of Alabama continues its mission of merging patient care and research under one roof. In 1983, when Children’s provided laboratory space to the UAB Division of Pediatric Infectious Diseases, it provided an ideal opportunity to leverage an established program in a National Institutes of Health (NIH)-funded infectious diseases research clinic into a collaborative, multidisciplinary patient care and management clinic. “When Children’s provided laboratory space for the investigators in our division, it allowed us to integrate research, patient care and interactions with other faculty because we weren’t isolated,” said Bill Britt, M.D.,

UAB professor of pediatrics and inaugural holder of the Charles A. Alford, Endowed Chair in Pediatric Infectious Diseases. “Children’s provided an environment that enabled findings from research studies to be translated into patient care and, as a result, moved patient care forward. Merging research and clinical care into a single mission has been the pathway of success for the most well-recognized children’s hospitals in North America.” The Division of Pediatric Infectious Diseases, with major research interests in HIV infection, herpes simplex virus, cytomegalovirus (CMV), antiviral research and general infectious diseases, boasts a rich history that dates back to the division’s founder and first director, the late Charles A. Alford, M.D. After training in pediatrics at Children’s, Alford trained at Harvard University under Thomas

Weller, M.D., a recipient of the 1954 Nobel Prize in Physiology or Medicine who paved the way for the polio vaccine. Alford returned to UAB, where he and his colleagues defined the natural history and pathogenesis of congenital CMV, the leading nongenetic cause of sensorineural hearing loss and the most frequent known viral cause of neurodevelopmental delay. “UAB and Children’s have been the epicenter of congenital CMV research from the 1960s on, so we’re talking 50 years of world leadership in research,” said David Kimberlin, M.D., division co-director and the Sergio B. Stagno, M.D. Endowed Chair in Pediatric Infectious Diseases. “Charlie was just an amazing man. He had a vision, and he could spot talent. He recruited these incredibly smart people who were quite competitive, and together they did amazing things.” Over the span of his career, Alford trained individuals from around the world, including Rich Whitley, M.D., current division co-director; Sergio Stagno, M.D., distinguished professor and chair emeritus of the UAB Department of Pediatrics; Bob Pass, M.D., professor, director of Pediatric Hospital Medicine; and the Beth Gordy Dubina Endowed Chair in Pediatric Hospital Medicine and Britt. Continuing the work of their teachers and predecessors, Stagno and Pass established the extent of disease and sequelae caused by congenital CMV, studies which led to a phase 2 trial of a CMV vaccine headed by Pass; Karen Fowler, PhD, defined risk factors associated with maternal and congenital CMV; Britt examined the structure of the virus and the assembly of infectious particles, and with Suresh Boppana, M.D., and Shannon Ross, M.D., studied the question of infection with different strains of CMV, which could

4 Charles Alford, M.D., founder and first director of the UAB Division of Pediatric Infectious Diseases, right, pictured with Rich Whitley, M.D., in the research lab in 1977. (UAB Archives, University of Alabama at Birmingham)

The UAB Division of Pediatric Infectious Diseases includes, standing, from left: Division Co-Director David Kimberlin, M.D.; Division Co-Director Rich Whitley, M.D.; Suresh Boppana, M.D.; Bob Pass, M.D.; and Scott James, M.D.; Sitting, from left: Shannon Ross, M.D.; Sergio Stagno, M.D.; and Karen Fowler, PhD.

impact the likelihood of developing a CMV vaccine in the future. These studies include ongoing natural history studies in Brazil with more than 15,000 mothers and infants enrolled. Boppana and Fowler completed the CMV & Hearing Multicenter Screening (CHIMES) Study, a multimillion dollar, seven-year project funded by the NIH that enrolled more than 100,000 infants. CHIMES not only defined the importance of congenital CMV as a cause of hearing loss, but also developed a scalable molecular diagnostic test that could be used for universal screening of CMV, which provides the foundation for intervention studies such as treatment with antiviral drugs and evaluation of vaccines. The division today includes eight physician-scientists and six PhDs. For researchers tasked with peeling back the layers of congenital CMV, the past is a prologue to the present and future.

Currently, nine active NIH grants have been awarded to division members to conduct studies of CMV. In 2016, the National Institute of Allergy and Infectious Diseases awarded $11.5 million to support two studies, one of which will assess the treatment of babies born with congenital CMV but show no symptoms. About one out of every 200 babies in the U.S. is born with congenital CMV. However, only about one in five babies with congenital CMV will be sick from the virus, according to the Centers for Disease Control and Prevention, which has used division research results for its publications and recommendations. The study will explore whether treating asymptomatic babies with four months of an oral drug – valganciclovir – will improve outcomes. The availability of reliable data about the natural history of congenital CMV suggested that a clinical trial with antiviral agents was feasible

Merging research and clinical care into a single mission has been the pathway of success…

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and could provide evidence that the outcome of congenital CMV could be modified by antiviral drugs. Prior to valganciclovir, symptomatic babies were treated with the intravenous drug ganciclovir. As antiviral drugs became available in the 1980s, Alford and Whitley approached the company that made ganciclovir and convinced the company to allow the drug to be studied for treating congenital CMV. When Kimberlin joined the division in the 1990s, he began work on an ongoing study spearheaded by Whitley and completed a phase 3 controlled study that determined ganciclovir improved outcomes when administered to symptomatic babies for six weeks. With the arrival of oral valganciclovir, a later study found six months of oral drug therapy for symptomatic babies improved audiologic and neurodevelopmental outcomes. The results were published in the New England Journal of Medicine in 2015. “By showing long-term treatment in babies with symptomatic disease improves hearing and development, we definitively answered one question that had been raised three decades before – Does treating symptomatic congenital CMV work?” Kimberlin said. “In this new study of asymptomatic infants, we will treat for four months because our hypothesis is asymptomatic babies are not as sick, therefore, we can treat over a shorter time frame.” To identify asymptomatic babies for the new study, almost 50,000 babies will be screened at nine sites nationwide, including UAB/Children’s. Once those babies are identified and enrolled, researchers will compare their findings to past data to determine the likelihood of asymptomatic babies developing hearing loss. Screening for the new study is slated to begin late 2017. “If those incident rates overlap, then maybe treatment doesn’t help very much at all. But if the incidents don’t overlap, then it would suggest the treatment may be helping,” Kimberlin said. Universal Testing & Ongoing Work “A targeted CMV approach that tests newborns who fail their [newborn hearing screening (NHS)] identified the majority of infants with CMV-related [hearing loss] at birth,” the CHIMES Study concludes. “However, 43 percent of the infants with CMV-related [hearing loss] in the neonatal period and CMV infants who are at risk for late onset [hearing loss] were not identified by NHS.” All in the division believe the medical field is moving toward universal testing for CMV, and that will result in identifying more asymptomatic babies. “There’s going to be a real pressure on doctors to treat those babies,” said Kimberlin, who added data gathered from the new asymptomatic study might inform that pressure and whether it is appropriate to do so. New data could coincide with the adoption of universal testing or, at least, adoption on a state-by-state basis. “We have a window of time that’s probably pretty finite before people start feeling the pressure.” The CHIMES Study sample bank allows Ross and Scott James, M.D., to study CMV in various parts of the body. They use next generation sequencing or deep sequencing to identify viral subpopulations with diminished resistance to antiviral drugs. “My main interest is looking at predictors of outcome for the virus and the patient, and the constellation of symptoms to let us know which babies will have hearing loss,” Ross said. “Deep sequencing generates a lot of genetic

data on the virus, or mutations in the virus that may give us hints about hearing loss risk.” Boppana and Britt also document the impact of CMV in highly seropositive settings, including developing countries. Studies have been conducted in India and Brazil, and ongoing studies are under way in Brazil and South Africa. The division also evaluates new antiviral drug therapies for diseases other than CMV via the Collaborative Antiviral Study Group, an NIH multicenter clinical trials group Alford and Whitley established in the 1970s. Each niche of research moves the needle toward better understanding prevention, diagnosis, prognosis and management. “To see the knowledge generated within these walls and its impact on families is a very gratifying thing, but it also gets us a bit impatient sometimes because we know where it needs to be,” Kimberlin said. “We know where we need to go.” Raising Awareness In addition to the CHIMES Study, Fowler and Boppana are involved with the National CMV Foundation, whose mission is education on specific prevention measures to protect against the risk of infection. Statistics show about 30 to 50 percent of women of childbearing age in the U.S. have never been infected with CMV. Of these, about 1 to 4 percent will have their first CMV infection during a pregnancy, giving them approximately a 40 percent chance of passing the virus to their unborn child. According to the foundation, only 9 percent of women know about CMV. “Nobody mentions CMV until they have to. And when it is mentioned, parents say, ‘What is that?’” Fowler said. “We must simplify the message for mothers and for women.” Kimberlin agrees, adding patients and families who share their congenital CMV experience have an impactful message. “We feel like what we do contributes to the lives of children, and as these studies go on, bonds have developed between each of us as researchers and the families affected by this,” Kimberlin said. “Parent advocacy amplifies the power of what we do. A parent advocating for their own child is a magnitude different from researchers who are trying to raise awareness about a disease they feel strongly about.”

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Restoring Balance Newdevices improve treatment for vestibular disorders

By Marti Webb Slay Photos by Denise McGill

D iagnosing children may present challenges due to their lack of vocabulary and limited ability to articulate what is happening to them. Pinpointing vestibular and balance disorders is no exception, but Children’s of Alabama has introduced testing equipment as part of its multidisciplinary approach to diagnosing such disorders, improving the care team’s ability to develop a targeted treatment plan.

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The team includes audiology, physical therapy, occupational therapy, sports medicine, rehabilitation medicine and otolaryngology. “Children don’t have all the words, so we have to be detectives. And now we are detectives together,” said occupational therapist Karen McCormack. “Instead of patients seeing us all separately, we come together from all our points of view to give the patient what they need in a timely fashion so they can keep growing, developing and maintaining an active lifestyle.” “I’m proud to offer this service with a team of professionals investigating solutions and treatment for children with persistent dizziness or balance problems, said audiology supervisor Jennifer Shelor. “This is just another example of Children’s commitment to technology.” Children’s now assesses the vestibular system through a series of tests, including rotary chair testing, video head impulse testing (vHIT), vestibular evoked myogenic potentials (VEMP) and videonystagmography (VNG). The equipment was purchased in part by monies received from Wells Fargo via its annual Picks for Kids campaign, which donates $1,000 to Children’s Hearing and Speech Department every time a University of Alabama or Auburn University football player makes an interception. In April 2016, the National Institute on Deafness and Other Communication Disorders (NIDCD) funded a study that suggests that more than one in 20 (5 percent) U.S. children may have vestibular and balance impairment. Children with hearing impairment are two times more likely to have vestibular and/or balance impairment compared with children with normal hearing. “With this new equipment, we can target our treatment better,” said physical therapist Tiffany DeLeonard. “This allows us to streamline the process.” Patients with vestibular issues include athletes who suffer concussions, as it is fairly common to experience balance problems following a head injury. Others, such as patients with cerebral palsy, may have balance concerns from birth. It is sometimes more difficult to identify the need for vestibular services in young children who have problems unrelated to an accident. Audiologists advise close monitoring of gross motor milestones

Page 7: Children’s of Alabama now assesses the vestibular system through a series of tests, including rotary chair testing. Above: The vestibular evoked myogenic potential (VEMP) test is primarily used to evaluate the function of the saccule, an otolith sensor in the inner ear. Neck muscle activities are recorded by electrodes placed on the head and neck.

unexplained falls? Does he or she seem clumsy as compared to their peers?” “Maybe they always run into the wall on the left side, or walk into you when you are on their right side. They may lean over to touch their toes and come up looking scared. If they don’t like elevators or escalators, or complain

as a means of discovering children who may be at risk for vestibular deficits. “It may be hard for a child to tell you if and when they are dizzy,” said audiologist Kaitlin Sipos. Added audiologist Alecia Cleveland, “Parents and pediatricians should watch for patterns. Does the child have trouble walking and have frequent

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elevators or escalators make them sick to their stomach, that could be a concern,” McCormack said. “One red flag for me is if a child can walk up the stairs, but not down. If the child exhibits several of these things together, it might be worth checking them. This technology, paired with the knowledge and expertise of our multidisciplinary team, helps us paint a complete picture.”

CHILDREN AT RISK FOR VESTIBULAR DEFICITS

• Cochlear Malformations

Enlarged Vestibular Aqueduct Syndrome (EVA)

Partitioning Defects

Common Cavity

Mondini Malformation

Cochlear Implant Patients

Pre & Post

More than one in 20 (5 percent) U.S. children may have vestibular and balance impairment.

• Syndromes

Waardenburg

Usher

Pendred

• VIII Nerve Defects

Wispy Nerve

Absent Nerve

ANSD

• Ototoxicity

Vestibulototoxicity

• Head Trauma

Balance testing with visual and vestibular coordination task helps to pinpoint diagnoses.

Sports

Concussion

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Laser surgery proves effective for some epilepsy patients

By Cassandra Mickens Photos by Denise McGill

It is a wise father who knows his own child.

– William Shakespeare

I t was a shift gone unnoticed by everyone but Robert Struble. His then- 12-year-old daughter, Robin, would stare into space and cease to speak. The episodes would end as soon as they began, each one fleeting, over in a flash. “As time went by, it became more noticeable,” said Struble, who booked Robin an appointment with a neurologist to find answers. “He kept saying she didn’t have epilepsy and I never said she did, but I knew there was something wrong with her and I needed to find out what it was.” Robin’s symptoms worsened despite her initial electroencephalogram (EEG) coming back clear. Struble recalled

trademarked as Visualase. It’s touted as less invasive than an open brain surgery or craniotomy, and boasts a quicker recovery time. Visualase uses a flexible laser fiber that is guided through a “nick” scalp incision and small hole in the skull – 3.2 millimeters to be exact or about the width of a coffee stir stick. The laser heats and destroys abnormal brain tissue, leaving the surrounding healthy tissue unharmed. The entire procedure is viewed in real time on magnetic resonance imaging (MRI) to ensure safe and successful target treatment. Thermal maps show the extent of the tissue being destroyed. Finally, the laser is removed and the incision is closed with minimal sutures, typically one stitch. Robin was deemed an eligible candidate for Visualase, and on Valentine’s Day 2017, she became the first patient

immediately got off the bus and returned home. She lost track of time and assumed it was afternoon. “Over time, the seizures became longer and occurred more often,” Struble said. “It began to affect her schooling. The children made such bad fun of her, and the teachers didn’t want to deal with her.” Robin did indeed have epilepsy, which led Struble to contact Children’s of Alabama. Robin underwent a series of EEGs to monitor the electrical activity in her brain. She also underwent surgery to implant a vagal nerve stimulation (VNS) device that, paired with medication, may help lessen the number and intensity of seizures. Robin’s seizures persisted. Now at 18 years old, Robin turned her attention to a new procedure at Children’s called thermal laser ablation,

an episode when Robin boarded the school bus one morning, then

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Page 10: Children’s of Alabama neurosurgeon Curtis Rozzelle, M.D., prepares a flexible laser fiber that is inserted into the skull for MRI-guided laser surgery, trademarked as Visualase. Visualase is touted as less invasive than a craniotomy and boasts a quicker recovery time. Above: Rozzelle as well as members of the Children’s neurosurgery and imaging teams view a Visualase surgery using the ClearPoint targeting system in the MRI suite. Thermal maps show the extent of abnormal brain tissue being destroyed.

to have the procedure at Children’s. Eligible candidates include patients whose epilepsy doesn’t respond well, or at all, to medicine or those who have MRI-visible lesions that have been confirmed as the source of the epilepsy. A key part of determining Robin’s suitability was an intracranial EEG investigation using an array of depth electrodes that were implanted using the ROSA Surgical Robot, which acts as a sort of GPS for the skull and may be used for all types of cranial intervention. Only when the depth electrodes confirmed Robin’s seizures originated from her MRI-visible lesion did Visualase become a treatment option. The target does not have to be visible on MRI to use laser ablation, although targeting is easier in those cases.

“She’s the one who constantly said I want to do it and move forward. She wanted some type of normalcy,” Struble said. “I was the one who was more concerned, but she said, ‘Daddy, it’s going to be OK.’ She is a trouper and she has handled so much going through this.” Children’s neurosurgeons Jeffrey Blount, M.D., and Curtis Rozzelle, M.D., underwent training to perform Visualase therapy, first approved by the U.S. Food & Drug Administration in 2010. In addition, the Children’s neurosurgery team and imaging department worked closely to implement the new system. While long-term outcomes are not fully known, preliminary results show a large portion of patients experience immediate improvement or control,

and these results have lasted several months to one year. Additional studies are ongoing to measure long-term outcomes. “[Visualase] puts us on the cutting edge in offering the latest treatment options and modalities in neurosurgery,” Rozzelle said. “It gives us another tool for epilepsy patients and perhaps going forward for tumor patients as well.” Rozzelle explained the neurosurgery team delivers the therapy one of two ways – via the ROSA Surgical Robot or the ClearPoint system. ClearPoint provides stereotactic guidance for accurate placement and operation of instruments in a hospital’s existing MRI suite. When ROSA is used, however, the laser fiber is inserted in the operating

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room, then the patient is transferred to imaging. While treatment time is a matter of minutes, setup and laser placement can take on average three to four hours. Once again, careful and accurate placement is key. Robin was discharged the day after the procedure and has not experienced a seizure since. “It makes me feel good,” Robin said of living seizure free. “I can work now!”

Struble is doubly relieved – for the results and for his daughter’s quality of life moving forward. “We’re truly blessed and thankful to the surgeons and staff at Children’s, everybody who took care of her,” Struble said. “She wants to work, she wants to drive, she wants to finish school. She can have a normal life.”

POTENTIAL ADVANTAGES OF THERMAL LASER ABLATION • Most patients have little or no hair removed • Can be performed with patient wide awake • Minimally invasive: Small laser size allows safe access to deep-seated and surgically inaccessible lesions • Destroys only the target, leaving surrounding tissue unharmed • Causes little or no pain during or after procedure • Reduced recovery times, hospital stays and complications • Minimal sutures required, typically a one-stitch suture • Entry site heals quickly with minimal scarring • Because the procedure delivers no (ionizing) radiation, the procedure can be repeated multiple times; there are no dose limitations • Does not limit use of other treatment options

Robin Struble with father, Robert. On Valentine’s Day 2017, Robin became the first patient to undergo MRI-guided laser surgery at Children’s of Alabama. Robin has not experienced an epileptic seizure since the surgery.

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Unique program offers support for parents, picky eaters

By Marti Webb Slay Photos by Denise McGill

M any parents struggle with a child who is a picky eater or exhibits concerning eating and drinking habits. Once the issue is brought to a pediatrician’s attention, subsequent evaluation and treatment by medical subspecialists and outpatient feeding therapy help many families. But when the eating challenge is not transient and persists despite intervention, a more targeted and intensive approach may be needed. Children’s of Alabama offers such an approach. One of a handful of programs of its kind in the U.S., the Intensive Feeding Program at Children’s offers a transdisciplinary approach to treating children with intractable feeding challenges that often impact their growth, nutrition and development.

The program treats children with oral aversion, total food refusal, feeding tube dependence and challenges transitioning to appropriate liquids and food textures. Children in the program often have histories of complex medical problems, developmental delays, sensory issues, oral motor deficits and/or behavioral challenges. The initial evaluation seeks to identify medical, nutritional, oral- motor and behavioral feeding problems, and provides recommendations for further evaluation and treatment. Recommendations may include participation in a day treatment program. Participation in the program is a big commitment for the patient’s family as well as the care team that specializes in children with feeding challenges. The day treatment program currently involves

four feedings a day, five days a week, for six to eight weeks. Caregivers can expect to participate in the meals during the first day of treatment and then observe each meal from an observation room for the next several weeks. As children approach their eating and drinking goals, caregivers are reintegrated into feeding sessions in order to learn and implement the same strategies used with therapists throughout treatment. The program uses a bug-in-the-ear technology so coaching can be offered to caregivers without the treatment staff physically in the feeding room. This offers an opportunity to begin the practice of mealtime at home without the day-to- day support of the program. “Incorporating the family is a key component to our treatment program”

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a G-tube. He would drink a little bit of water, but it wasn’t significant. When he graduated the program after seven-and-a- half weeks, he consumed 100 percent of his nutrition orally. Two years later, while his parents still monitor his eating and continue to work with him, he eats his bologna sandwich in the school cafeteria at lunchtime with other students. The transition to eating in a school cafeteria was a difficult one, and her son initially lost four pounds after starting kindergarten, but Watkins worked with school counselors, administration and teachers to put a plan in place. She called the clinic for advice during this time and was guided toward success. “I can’t say enough about the staff there,” Watkins said. “Even today, two years after we graduated from the program, I could call and get help.” Graduates of the Intensive Feeding Program are discharged upon reaching their identified goals. Once children complete the day treatment program, the team guides additional feeding goals at specified intervals for the next year post-discharge. Mastin said the success of the program is rooted in the partnership with caregivers, an integrated team approach and making treatment plans and changes based on measurable data and observation. The program uses a behavioral modification approach while integrating oral-motor skill development and the provision of optimum nutritional interventions. “We meet children where they are in terms of their eating and drinking and systematically build on their current skills while teaching them new skills,” Mastin said. The program currently cares for three children at a time in day treatment. The process for a child to participate in the day treatment program begins with a referral and subsequent comprehensive evaluation. During that evaluation, the team makes recommendations from a medical, nutritional, therapeutic, behavioral and psychosocial perspective. The team identifies whether a child is a candidate for the day treatment program, and if the family and team agree, the program will continue to follow up with the child until he or she is admitted into the day treatment program. During this time, the medical

Michelle Mastin, PhD, clinical psychologist and director of the Intensive Feeding Program at Children’s of Alabama, observes Hilyer Watkins with mother, Bridgit, during a treatment session.

said Michelle Mastin, PhD, clinical psychologist and director of the program. “While we understand the commitment and sacrifice that families make to participate in the feeding program, without active and engaged parent involvement, we would not be successful helping the child sustain progress and make additional gains following the day treatment admission.”

“Intense doesn’t even describe it,” said Bridgit Watkins, whose son, Hilyer, graduated from the program. “It’s in the name, and they try to warn you, but until it’s your child, you just don’t understand how different things are going to be and how it carries over into your homelife.” Like most children entering the program, Hilyer, who was 4 at the time, was 100 percent dependent on

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social worker serves as a liaison for the family to assist with coordination of care, including but not limited to potential lodging, school resources and family medical leave if appropriate. During the day treatment program, not only does the child have four therapeutic meals a day with an occupational therapist or speech and language pathologist, but also the psychologist co-treats throughout the week. The family meets with the team’s registered dietitian to review and discuss nutritional plans, and participates in a nutritional/educational curriculum throughout the program. Families have individual weekly sessions with the psychologist and have the opportunity to meet with the entire treatment team, including a gastroenterologist, in a structured weekly setting to discuss questions, concerns and/or to review progress. A social worker is available to the family throughout the program to ensure their extended needs are met. “Participation in the Intensive Feeding Program is certainly a commitment, hard work and requires significant familial motivation,” Mastin said. “We find, however, that the families that do so tell us the commitment and sacrifice were certainly worth the outcome.” For more information about the Intensive Feeding Program and referral forms for evaluation, visit the www.childrensal.org/intensivefeeding .

Who is a candidate for the Intensive Feeding Program? Typically, children should be at least 12 months old developmentally, chronologically and cognitively. If they have a feeding tube, they should be nutritionally stable. Children often have the following feeding difficulties:

• Total food refusal

• Oral aversion

• Feeding tube dependence

• Reliance on supplement for nutrition • Challenges transitioning to appropriate textures, consistencies or utensils • Recurrent vomiting with eating Common medical conditions experienced by children treated in the program: • Gastric esophageal reflux disease • Restrictive eating patterns

While his parents continue to monitor his eating, Hilyer has made good progress since graduating from the Intensive Feeding Program. “Even today, two years after we graduated from the program, I could call and get help,” said Hilyer’s mother, Bridgit.

• Dysphagia

• Eosinophilic esophagitis

• Gastrointestinal disorders, including dysmotility, constipation and abdominal malformations

• Neurodevelopmental challenges, including genetic disorders • Developmental delays, including autism

• Behavioral challenges

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News, Honors and Awards

DR. ASHRAF INVITED TO CO-CHAIR PES EDUCATION COMMITTEE Ambika Ashraf, M.D., Pediatric Endocrinology, has been invited to co-chair the Pediatric Endocrine Society (PES) Education Committee. The PES has over 1,300 members representing the multiple disciplines of Pediatric Endocrinology. The members are dedicated to research and the treatment of children with endocrine disorders; reproductive, bone, thyroid, diabetes, obesity, growth, pituitary and adrenal. DR. BARBER HONORED FOR SPS SERVICE Judson Barber, M.D., Pediatric Emergency Medicine (PEM) physician and Medical Director of the PEM Sedation Service, was recognized at the 2017 Society for Pediatric Sedation (SPS) Conference for his six years of service on the Board of Directors for the society. Barber is also a founding member of the SPS and serves as the chairman of the communications subcommittee. The SPS was founded in 2007 to promote safe, high-quality care, innovative research and quality professional education in pediatric sedation. DR. BOPPANA SELECTED FOR THE PREP INFECTIOUS DISEASES EDITORIAL BOARD Suresh Boppana, M.D., Pediatric Infectious Diseases, has been appointed to the Pediatrics Review and Education Program (PREP) Infectious Diseases Editorial Board. PREP is a program of the American Academy of Pediatrics. As a member of the PREP Infectious Diseases Editorial Board, Dr. Boppana will play an important role in the development and success of the PREP Infectious Diseases Self Assessment. DR. CHEN TO SERVE AS TREASURER ON APSA BOARD OF GOVERNORS The American Pediatric Surgical Association (APSA) has selected Mike Chen, M.D., Pediatric Surgery, to be on the APSA Board of Governors. Dr. Chen will serve as the APSA treasurer for a three-year term. DR. COHEN ELECTED TO AAP SECTION ON GASTROENTEROLOGY, HEPATOLOGY AND NUTRITION EXECUTIVE COMMITTEE, AMSPDC COMMITTEES AND IMPROVECARENOW BOARD OF DIRECTORS Mitchell Cohen, M.D., Pediatric Gastroenterology, Hepatology, & Nutrition, has been elected to serve as a member of the American Academy of Pediatrics (AAP) Section on Gastroenterology, Hepatology and Nutrition Executive Committee. Dr. Cohen was also appointed to the Association of Medical School Pediatric Department Chairs (AMSPDC) Education Committee and New Chairs Program Committee. He has also been elected to the Board of Directors of ImproveCareNow. DR. DIMMITT NAMED AS DAVID E. DIXON ENDOWED CHAIR IN PEDIATRIC GASTROENTEROLOGY Reed Allen Dimmitt, M.D., is the first holder of the David E. Dixon Endowed Chair in Pediatric Gastroenterology. Dr. Dimmitt is a professor in the UAB Department of Pediatrics, the director of the Division of Gastroenterology, Hepatology, and Nutrition, and the medical director of Children’s Intensive Feeding Program.

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DR. DYE SELECTED TO ATTEND AAMC EARLY CAREER WOMEN FACULTY LEADERSHIP DEVELOPMENT SEMINAR Candice Dye, M.D., General Pediatrics, with support from the Pediatric Office of Faculty Development, was selected to attend the Association of American Medical Colleges (AAMC) Early Career Women Faculty Leadership Development Seminar in Stevenson, Washington. DR. EVERTS NAMED RECIPIENT OF THE INTERNATIONAL SOCIETY FOR ANTIVIRAL RESEARCH WILLIAM PRUSOFF YOUNG INVESTIGATOR LECTURE AWARD Maaike Everts, Ph.D., Pediatric Infectious Diseases, has been named as the recipient of the International Society for Antiviral Research William Prusoff Young Investigator Lecture Award. This award is given to outstanding young scientists who have demonstrated dedication and excellence in the field of antiviral research and have future potential for contribution to the field and the society. DR. HILLIARD ACCEPTED IN 2017 ASH ADVOCACY LEADERSHIP INSTITUTE Lee Hilliard, M.D., Pediatric Hematology and Oncology, has been invited to participate in the seventh annual American Society of Hematology (ASH) Advocacy Leadership Institute. The ASH Advocacy Leadership Institute is a unique opportunity for a select group of ASH members to learn about legislation and health policy that affects hematology. Participants will receive intensive training in the policy-making process and advocacy. DR. LAL RECEIVES PRS YOUNG INVESTIGATOR AWARD, SELECTED AS EARLY CAREER SPEAKER Vivek Lal, M.D., Neonatology, has been selected for an award under the PRS Young Investigator program to attend the Perinatal Research Society Annual Meeting and the NIH-Abbott Nutrition Pre-meeting. In addition, Dr. Lal has also been selected as an Early Career Speaker. DR. SALAS RECEIVES SSPR TRAVEL AWARD Ariel Salas, M.D., Neonatology, has been selected as the Southern Society for Pediatric Research Awardee of the SSPR Travel Awards to Enhance Diversity in the Research Workforce. Dr. Salas was nominated by the SSPR. DR. TIPPLE JOINS EDITORIAL BOARD OF LIFE SCIENCES Trent Tipple, M.D., Neonatology, has been asked to serve as an editorial board member of Life Sciences. Life Sciences is an international journal publishing articles that emphasize the molecular, cellular and functional basis of therapy. CATHY TURNER JOINS MOMENTUM, ALABAMA’S PREMIER WOMEN’S LEADERSHIP PROGRAM Thirty women have been selected to join Momentum, Alabama’s premier women’s leadership program. Among these is Cathy Turner, CPA, CGMA, Executive Administrator of UAB Pediatrics. DR. WALLACE SELECTED TO BE VICE PRESIDENT/ PRESIDENT ELECT FOR THE SOUTHEAST REGION OF THE SAHM Stephenie B. Wallace, M.D., FAAP, Adolescent Medicine, has been selected to serve as Vice President aka President Elect for the Southeast Regional Chapter of the Society for Adolescent Health and Medicine (SAHM). The Southeast Regional Chapter includes members from six states: Alabama, Louisiana, Mississippi, Tennessee, Georgia and Florida.

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DR. WALLEY SELECTED AS CME CHAIR AND BOARD MEMBER OF THE AL-AAP AND SELECTED FOR PEDIATRIC HOSPITAL MEDICINE ADVISORY BOARD Susan Walley, M.D., CTTS, FAAP, has been selected as Continuing Medical Education (CME) Chair and Board member of the Alabama Chapter-American Academy of Pediatrics (AL-AAP). In addition, Dr. Walley has been selected as a member of the Pediatric Hospital Medicine Advisory Board for the Inaugural edition of Pediatrics Review and Education Program (PREP) Hospital Medicine. PREP is a program of the AAP. DR. WU NAMED APA REGION VIII CO-CHAIR FOR 2017-2019 Chang L. Wu, M.D., Pediatric Hospital Medicine, has been selected for the Academic Pediatric Association (APA) Region VIII Co-Chair position. RETT SYNDROME ADVOCACY GROUP RECOGNIZES CHILDREN’S/UAB AS CENTER OF EXCELLENCE The University of Alabama at Birmingham (UAB) Civitan Rett Syndrome Clinic, under the leadership of Alan Percy, M.D., director of the UAB Civitan Rett Syndrome Clinic, has received the Center of Excellence Award from Rettsyndrome. org, a leading advocacy organization for patients and families affected by Rett syndrome. SEVEN CHILDREN’S OF ALABAMA SPECIALTIES RECOGNIZED AMONG NATION’S BEST BY U.S. NEWS & WORLD REPORT For the eighth consecutive year, Children’s of Alabama is ranked among the nation’s best children’s hospitals by U.S. News & World Report. Seven of Children’s pediatric specialty services – Cancer, Diabetes & Endocrinology, Gastroenterology & GI Surgery, Nephrology, Neurology & Neurosurgery, Orthopedics and Pulmonology – were placed among the top 50 in the U.S. in the magazine’s 2017- 18 Best Children’s Hospital rankings.

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Inside Pediatrics Podcast is a monthly series that will often complement stories appearing in Inside Pediatrics magazine. Episodes will feature Children’s of Alabama and University of Alabama at Birmingham (UAB) specialists, and cover topics related to child health and wellness, research and treatment. Inside Pediatrics Podcast COMING JANUARY 2018

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