Neonatal Intensive Care

Innovative pediatrics


crawling babyFrom building on the promise of the latest medical breakthroughs to relying on the age-old formula of tender, loving care, the physicians and staff of Loma Linda University Children's Hospital make healing children their special mission.

That aim is inspired by the belief that children are society's most precious and yet most often endangered resource. Utilizing state-of-the-art facilities at the 250-bed Children's Hospital, the staff exemplifies the institution's commitment to preserving and caring for this population by providing the highest possible level of medical care.

Pediatric services at LLUCH range from plastic surgery to transplants, from neurology to oncology. Physicians not only use their experience and skills to offer their patients unparalleled care, but also take that commitment to countries around the world.

Today, Loma Linda University Children's Hospital is one of the largest providers of children's health care in California. Not content to rest on its achievements, Loma Linda is constantly creating new and more efficient ways to deliver health care to newborns, infants, and children.

This article provides a glimpse of the innovative work being conducted in several pediatric specialties every day at Loma Linda.

Neonatologists find new ways to help sick babies

Doctors at Loma Linda University Children's Hospital's neonatal intensive care unit are harnessing the capabilities of inhaled nitric oxide to help infants with respiratory problems breathe easier.

A variety of respiratory disorders in newborns are associated with a condition called pulmonary hypertension. This condition occurs when pulmonary blood vessels undergo persistent spasms that decrease the blood flow to the lungs, thus reducing the amount of oxygen absorbed by the blood. One or two babies out of 1,000 are affected by this disorder.

Researchers at Loma Linda University, Stanford University, and the University of California at Davis, have turned to a gas that occurs naturally in the human body to offer relief to these patients.

Nitric oxide is a gas produced by cells lining blood vessels in the human body. It is also a regulated pollutant--a byproduct of combustible reactions--that is toxic in high doses. But in low doses, inhaled nitric oxide is used to help newborns overcome their respiratory problems.

Before the discovery of inhaled nitric oxide, doctors had no treatment options for spasms of pulmonary blood vessels. Apart from reducing spasms of the blood vessels, nitric oxide also relaxes muscles around airways thus making it easier to breathe.

Gerald Nystrom, MD, associate professor of pediatrics in the School of Medicine, and chief of the division of neonatology in the Children's Hospital, says that one of the advantages of using inhaled nitric oxide is that it specifically acts on pulmonary vessels without affecting blood pressure.

Dr. Nystrom points out that the new treatment offers a ray of hope for premature and full-term infants battling breathing disorders.

"This natural treatment is a promising therapy that may help infants with respiratory disorders be managed more safely, more comfortably, and with shorter hospital stays," Dr. Nystrom reports.

Bringing smiles to faces: plastic surgeons at work

Plastic surgeons at LLUCH are not only bringing smiles to the faces of their youngest patients but to the faces of their patients' family and friends as well.

Reconstructive surgery on cleft lips and palates is one of the most gratifying aspects of the work that the plastic surgery division does in the Children's Hospital and on frequent missions abroad, reports Robert Hardesty, MD, chief of the department of plastic and reconstructive surgery.

About one child in 750 live births is born with cleft lip and palate, which is the second most frequently occurring congenital deformity. Since LLUCH is one of the largest providers of children's health care in the state, physicians see a large volume of patients with these deformities. Plastic surgeons at Loma Linda routinely operate on more than 100 children per year with the diagnosis of cleft lip and palate.

The Children's Hospital kept pace with the demand for quality care of patients with cleft lips and palates by forming a craniofacial team more than 20 years ago. A team of specialists including audiologists, dentists, geneticists, nurses, oral surgeons, otolaryngologists, pediatricians, plastic surgeons, social workers, and speech physiologists, work together to provide comprehensive care for the child with cleft lip and palate.

This team is the only one of its kind in the Inland Empire and one of only four in Southern California.

The plastic surgery division is also involved in research that has opened the possibility of intrauterine cleft lip repair. With the increased use of ultrasound technology, more fetuses with clefts are being considered for surgery. Intrauterine wounds can heal without evidence of scar formation so the child is born without signs of the deformity.

Plastic surgeons have also taken their ability to restore smiles to the faces of their patients to various foreign countries. Since a plastic surgery outreach program was set up almost 17 years ago, surgeons have traveled to Argentina, India, Mexico, and Nepal to repair cleft lips and palates. The international missions are all volunteer efforts.

Taking care a step further

Involving parents in the healing processes of their sick babies is a task that often falls to the staff of the neonatal intensive care unit. At LLUCH, the neonatal team has developed a program that specifically teaches frightened parents and busy staff how to cope with children's illnesses in a loving and nurturing way.

"Parents and staff are taught the type of contacts with sick babies that reinforce comfort and support," comments Gerald Nystrom, MD, associate professor of pediatrics and chief of the division of neonatology in the Children's Hospital.

Studies have shown that children who are backed by a supportive network recover faster, fall prey to fewer complications, and spend fewer days in the hospital. Hospitalizations were cut, in some instances, from three weeks to a few days, Dr. Nystrom reports.

A child's illness is not easy on the parents, either. Prolonged hospitalization has been found to be very stressful for young couples. The divorce rate climbs, and child abuse and neglect become common because infants and children are separated from their caregivers for long periods.

Loma Linda's program seeks to remedy the alienation felt by parents by improving the bonding process. Medical personnel encourage loving contact including talking, holding, and playing, so that the parents' relationship to the child is strengthened and the baby feels comforted and wanted.

Dr. Nystrom notes that the one-year-old program, called the individualized neonatal behavioral assessment and development program, is expensive to develop and doesn't have the glamour of high technology treatment. But, he concludes, it exemplifies Loma Linda's dedication to healing the whole individual and not just the illness.

Watching the tide turn: improvements in pediatric patients with AIDS virus

Breakthroughs in the fight against the AIDS virus are making headlines around the world. For the first time, researchers are learning what may be the most important fact about AIDS: it is not invincible.

At Loma Linda University Children's Hospital, Jane Bork, MD, chief of pediatric infectious diseases, has been watching an amazing development in her own pediatric AIDS patients. The tide seems to be turning.

Dr. Bork, who treats 20 to 30 children with AIDS and HIV exposure every year, used to lose two to four children a year to the terrifying disease. However, in the past two years, she has lost none of her pediatric AIDS patients.

"If there was any time to have AIDS, it is now," Dr. Bork reports. "There is good medicine and there is hope for better medicine."

The youngest pediatric patients are being treated with Epivar, while older children are being treated with protease inhibitors, which are still being studied in clinical trials. Dr. Bork says her patients, who range in age from newborn to 15 years, are involved in all the activities their peers enjoy.

"My kids used to get sicker and sicker," Dr. Bork remembers. "But now, with new medicines and treatments, they are staying healthy. If you saw them, you wouldn't know they have a chronic illness."

In her work with young AIDS patients, Dr. Bork tries to maximize their quality of life by being sensitive to their needs when scheduling appointments and planning other health-care requirements. Some treatments are done at home to minimize interruptions to the child's life. She still believes that much can be done to prevent children from acquiring the HIV virus. Educating young people about the dangers of promiscuity and unsafe sex can go a long way to prevent the spread of the disease, Dr. Bork emphasizes.

Bringing it all together: spina bifida clinic

Children with spina bifida could get lost in a maze of doctors' offices because they have to see so many different specialists. There are neurosurgeons, orthopaedists, pediatricians, social workers, speech therapists and urologists. But at Loma Linda University Faculty Medical Offices, the children visit one clinic and it's the physicians and hospital personnel who do the walking.

"We handle the care of these children in a multidisciplinary fashion so they don't have to travel from one office to another," explains Ravindra Rao, MD, associate professor of pediatrics, and chief, division of general pediatrics at LLUCH.

A coordinated team approach to spina bifida has been found to be the most successful method to treat the growing number of children with this illness. Frequent clinic visits based on need, where each of the specialists on the team evaluates the child, leads to a unified approach and early detection of problems.

On a typical Tuesday, the waiting room is full of children and their parents. The clinic physicians are waiting their turn.

Kim Rawson, RN, is the nurse case manager who helps run the show during spina bifida clinic. Clinic physicians treat more than 400 patients from throughout the Inland Empire, Ms. Rawson declares.

Doctors consult as a team on each case, thus cutting down on the time and paperwork needed to arrange consultations and schedule meetings. Children and their parents may spend from two to four hours at the clinic, but then they probably don't have to come back for another six months.

Spina bifida occurs in 2 out of 1,000 children born. It is a birth defect that results when the development of the spinal cord is altered early in pregnancy. Most children with spina bifida have some handicap: bladder and bowel dysfunction, paralysis of the legs, and lack of sensation are evident at birth. But with the help of medication and specialists, many children enjoy the same activities as their peers.

LLUCH continues to perfect the team approach to treating patients with spina bifida. A rehabilitation specialist has recently been added to the battery of doctors that sees each one of these patients when they visit the clinic.

Preparing for a dream: pediatric liver transplants

The Transplant Institute at Loma Linda University Medical Center is preparing for the realization of a dream--one not only held by dozens of sick children, but also by their surgeons.

The dream is to perform pediatric liver transplants. The Institute already performs pediatric kidney transplants and adult liver, kidney, and pancreas transplants. Waldo Conception, MD, associate professor of surgery and director of the Transplant Institute at LLUMC, joined the hospital's surgical staff in September.

"It is one of our dreams," Dr. Conception says of performing pediatric liver transplants. Currently, about 8 to 10 pediatric patients require transplants per year. Residents of San Bernardino and Riverside counties who require the pediatric liver transplants must go to hospitals in Los Angeles or San Diego.

Dr. Conception has been interested in beginning a pediatric liver transplant program at Loma Linda since he became part of the staff. There are several prerequisites before a liver transplant program can begin, he observes.

One of the most important prerequisites is to make people aware of the program. Patients and their parents should also be educated about the chronic nature of the disease.

"We have to develop channels of communication with the public and get referrals from other physicians," Dr. Conception observes.

In addition, the Institute must be staffed with specialists who can provide medical attention on the spot. Two pediatric hepatologists and a team of pediatric anesthesiologists are on the staff at LLUCH, and the hospital is equipped with a pediatric intensive care unit, as well as postoperative follow-up care units.

Dr. Conception acknowledges that Loma Linda has many of the features necessary for the program. "I look at the pediatric liver transplant program as the greatest way to give the Inland Empire population the highest level of care in an institution that offers the best technology," Dr. Conception adds.

That may be coming soon--it may be only a matter of time.

Fighting the battle against cancer: pediatric oncology

Research is producing more effective drugs against numerous cancers occurring in children. At LLUCH, Dr. Ofelia Alvarez's fight against the dreaded illness on behalf of her pediatric patients is being aided in part by two potent drugs: granulocyte stimulating factor (GCSF), and Ondansetron. Both medications have been on the market for the past three years and their contributions to the improvement of the quality of life of pediatric patients is becoming more and more evident.

GCSF speeds up production of granulocytes, a naturally occurring cell in the body which is necessary for production of white blood cells. Children who undergo chemotherapy to combat the growth of cancerous cells are susceptible to a variety of infections. White blood cells decrease the chances that they will have infections.

The use of GCSF is now successful standard care for both children and adults.

Ondansetron and similar medicines reduce nausea and vomiting associated with chemotherapy. Children who take the drug feel fewer of the side effects that usually characterize cancer treatments.

"The physician's desire is to minimize toxicity to patients," Dr. Alvarez explains.

Apart from reducing side effects, Dr. Alvarez says that cancer treatment has become more aggressive. Some of her patients with brain tumors, sarcomas, and lymphomas are being treated with proton beam therapy which minimizes the exposure of non-cancerous cells to radiation.

While many of her patients visit the hospital occasionally, several require round-the-clock attention. Presently, Loma Linda pediatric oncologists are following 900 cancer patients, with 25 to 30 in the hospital at any one time.

The addition of the Children's Hospital to LLUMC is beneficial to pediatric cancer patients, as well as other patients, because it provides an environment that not only attacks diseases but nurtures the child as well, Dr. Alvarez points out.

"Our staff provides care and emotional nourishment so that the child's development is not interrupted as we fight the disease," she concludes.

Growing up together: kidney transplant kids and their doctors and nurses

Every year, children who are on the waiting list for kidney transplants, on dialysis at home or in the hospital, or recipients of new kidneys get together for a big Christmas party courtesy of their doctors and nurses at LLUCH.

It's a tradition that's been around for as long as some of the nurses can remember. But each year it brings a fresh sense of novelty and fun, says Marian Wells, RN, a pediatric nephrology nurse who is the driving force behind the festivities. There are gift exchanges, food, and even a nephrologist who dons Santa Claus garb.

Last year, surgeons at the Transplant Institute performed 54 kidney transplants and 10 kidney/pancreas transplants.

Children can receive kidney transplants at almost any age. After they get a transplant, they continue to come for check-ups by the hospital's pediatric nephrologist or kidney specialist.

They have to get their kidneys checked periodically. It's a relationship that lasts a lifetime.

"We've seen some kids grow up and come back as adults," Ms. Wells notes.

The Christmas party gives children with kidney problems a chance to meet other kids just like them. It gives their parents the chance to meet other parents.

"It's comforting for families to meet other families that are going through the same thing," Ms. Wells says.

Carol Maas, RN, pediatric transplant coordinator, points out that the party is wonderful for medical personnel as well. "The nurses get out of our role of testing, poking, and prodding," she explains. "We can have fun with the kids."

The party is sponsored each year with the help of donations from local companies and private citizens. More donations are always welcome.

From SCOPE, Spring, 1997


[LLU Children's Hospital]