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Pediatric and Infant Center for Acute Nephrology

Dr. David J. Askenazi is medical director of the Pediatric and Infant Center for Acute Nephrology (PICAN) at Children’s of David AskenaziAlabama and Associate Professor of Pediatrics at the University of Alabama at Birmingham (UAB). The PICAN Center works to improve the health and care of infants and children who are at risk for acute kidney disease.

Hospitalized children are at great risk to develop abrupt loss of kidney function. The risk factors for acute kidney injury include toxic side effects from drugs administered to treat a critical illnesses, shock from sepsis, decreased blood flow around the time of surgery and congenital conditions. Reducing those risks, and supporting the failed kidney during this time is the job of the Pediatric and Infant Center for Acute Nephrology (PICAN Center) established a year ago at Children’s of Alabama.

We take a three-pronged approach:

  • Clinical services, which strive to provide the best of care
  • Educational outreach here and throughout the country, which trains physicians and nurses to diagnose and support those with acute kidney damage
  • Research, which leads to a better understanding of the diagnosis, risk factors and outcomes and develops new strategies for prevention and treatment

This all requires coordination and cooperation not only within Children’s but throughout other pediatric care centers at home and abroad.

We are now leading the Neonatal Kidney Collaborative, an international group of more than 20 centers that are interested in the topic of neonatal kidney problems. This collaborative has emerged from observations and studies showing that babies in neonatal intensive care units frequently develop acute kidney injury. It’s not surprising. Normally, babies develop a full complement of nephrons—functional units that make up our kidneys—during the first eight months in the womb. After that, we no longer produce nephrons. However, when born prematurely, nephron production cycle is cut short and babies can end up with fewer nephrons than normal. That can make them more susceptible to short and longterm problems including chronic kidney disease and high blood pressure. By collaborating with other centers, we can look at much broader demographics and much larger numbers of patients, which will allow us to make stronger inferences. Our first study launches in March and will be titled AWAKEN (Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates. This study will improve our ability to diagnose acute kidney injury, understand risk factors, and determine how fluid provision affects kidney and other outcomes.

Meanwhile, Children’s has joined eight other hospitals nationwide to implement a program called NINJA (Nephrotoxic Injury Negated by Just-in-Time Action). This quality improvement project screens every patient admitted to the hospital for medications known to have toxic side effects to the kidney. Historically there has been a tendency to accept this damage as necessary, but we are showing that with risk assessment and daily evaluation of the medications we give our patients, we can reduce the incidence and severity of acute kidney injury. The pharmacy “NINJA’s” look through the hospital census daily and find those who with high risk of toxicity, then they work with care teams to minimize use of these medications, monitor levels of kidney function and to ask the question: “Is it in the best interest of this patient to be on this medicine?” By paying close attention to these risks, we can make a difference in the occurrence or severity of an acute kidney injury.

There are many other initiatives involving our center but one in particular is worth mentioning. It involves a dialysis machine that we are employing for babies. In the past we have relied upon adult dialysis machines for dialyzing babies with kidney failure. Because these machines are not designed for babies, they carry added risk of bleeding and low blood pressure. So we found an opportunity to work with an FDA-approved machine called the Aquadex FlexFlow. It was designed to remove fluids from patients with heart failure but it also happens to be the right size to use on babies. We’ve adapted the machine in the intensive care units of Children’s of Alabama to clean a baby’s blood, remove extra fluid and balance electrolytes. We have been able to do this while avoiding the risks inherent to adult-sized dialysis machine.

Visit our website at www.childrensal.org/pican for more information.

Preventing Dog Bites

Most children don’t think a cuddly dog would ever hurt them, but the fact is about 4.7 million dog bites happen every year in the United States, and more than half occur in children under the age of 14. Sometimes it may be just an innocent nip, but often these dog bites result in a child going to the hospital and even having surgery. Experts at Children’s of Alabama want parents to know that teaching kids about dog safety early on can help prevent the majority of these incidents.

Any Dog Can Bite

Dr. Bert Gaddis of Indian Springs Animal Clinic offers a better understanding of what may cause a dog to bite. Gaddis says first and foremost, it’s important to realize that any dog has the potential to bite. “Any dog no matter the breed or how sweet them seem can be pushed to that point unknowingly”, Gaddis says, “I tell pet owners with children, who probably feel very good around your pet, teach them not to approach strange animals. If it’s a dog with an owner, ask permission to pet that dog.”

Gaddis also says sometimes aggression in animals may be breed related, or even how the dog is raised. If the animal is raised to be defensive, or is often engaged in rough play, the dog may perceive a stranger as a threat even when that stranger is a child. Sometimes dog bites occur when the dog is feeding, and is very territorial around food.  But even the nicest, most well-trained family dog may snap if it’s startled, scared, threatened, agitated, angry or hungry.  And remember, even a small dog can have a dangerous bite.

In the event your child is around an unfamiliar dog, here are some tips to follow:

Interacting with an Unknown Dog:

  • Teach your child to ask the dog’s owner for permission to pet their dog
  • If the owner says yes, move slowly
  • Allow the dog to see and sniff before petting
  • Keep fingers together
  • Avoid sudden, jerky motions

The state of Alabama has had a leash law in place since 1915, but local municipalities have the authority to have their own ordinances to better reflect the needs of the community.

Still, keep in mind, just because there may be a leash law, that doesn’t mean your child won’t encounter a roaming dog without a leash.   It’s important to teach your child to know how to respond when they are approached by a strange dog.

When Approached by a Strange Dog:

Dr. Gaddis offers these important tips if you or your child has an encounter with a strange dog:

  • Don’t Run
  • Don’t Scream
  • Don’t Make Eye Contact
  • Don’t Turn Your Back
  • Back Away Slowlu
  • If a dog does try to bite, put anything you can between you and the dog.
  • If knocked over by a dog, roll into a ball, cover your face and lie still.

Always Supervise

A lot of dog bites can be avoided with parental supervision.  Never leave a child alone with a dog.  And teach children to never tease an animal. Being safe and responsible around dogs is the first step in preventing a dog bite.

New Intensive Feeding Program at Children’s

Dr. Michelle Mastin

Dr. Michelle Mastin

Dr. Michelle Mastin is a clinical psychologist and head of the new Intensive Feeding Program at Children’s of Alabama.

A new Intensive Feeding Program at Children’s of Alabama helps infants, toddlers and adolescents overcome problems feeding and drinking often associated with developmental delays or serious illness. It is the first and only program of its kind in Alabama and one of only a handful of similar programs in the U.S.

The program incorporates pediatric subspecialists, technologies and behavioral psychology into a unique and effective system for teaching both parents and children how to deal with these difficult issues. The program at Children’s is designed in a similar fashion to the one developed at Helen DeVos Children’s Hospital in Grand Rapids, Mich.

The program at Children’s of Alabama is the behavioral psychology component of the new Aerodigestive Program, which encompasses a larger mission of managing complex airway, feeding or nutritional issues. Program specialists evaluate children, develop treatment plans and provide care for a wide variety of conditions using proven, behavior modification techniques coupled with the insight and interventions of speech and language pathologists and occupational therapists.

About half of the program’s patients are expected to be feeding-tube dependent, and in many cases the team will work to normalize the child’s eating and drinking abilities. The Intensive Feeding Program is also capable of dealing with:

  • Food refusal
  • Oral aversion
  • Inability to consume adequate volumes of food and liquid
  • Transitioning to age-appropriate textures, consistencies or utensils
  • Recurrent vomiting
  • Restricted eating patterns

Patients should be referred to the program at Children’s after going through previous attempts to improve their feeding and drinking behaviors. The program is set up to handle tougher, more persistent cases that require multi-disciplined interventions and are often associated with conditions such as gastric esophageal reflux disease, failure to thrive, dysphagia, gastrointestinal problems, developmental disorders, including those on the autism spectrum and behavioral difficulties.

This is an intensive, outpatient program lasting six to eight weeks, five days a week, from 8 a.m. until 5 p.m. Generally, experts will spend about four weeks feeding a child all meals during the week in order to approach identified goals. Care is provided in a room equipped for unobtrusive observation by parents, other caregivers or health professionals.

After that, parents or caregivers will be provided with a small earphone and sent into the treatment room to take over the feeding and drinking interventions. Initially they will be working with their child with the help of therapists. As the caregivers progress and the child demonstrates consistent success, therapists will transition to the observation rooms where they can continue to coach caregivers. It is an effective way to improve the interaction between parents and children at mealtimes.

The results are often impressive. For example, the program at Children’s had its first graduate of the day treatment program in November 2014. This patient was born with significant complex medical challenges, including significant prematurity (born at 22 weeks gestation). The patient came into the program 100 percent dependent upon a feeding tube for nutrition, but was discharged 8 weeks later without the need for G-tube feedings.

Similar programs have been studied and found to be effective. This is a precisely targeted therapy that often succeeds in improving the quality of life for both the child and family. Children’s program is currently evaluating patients weekly and is currently admitting two patients at a time into day treatment. The goal is to expand the program to be able to treat three patients at a time in the second year of the program and four patients at a time in the third year. Referrals forms for evaluation can be found on the Children’s website at http://www.childrensal.org or by calling 205-638-7590.