Corinne Cross, MD (Host): This is Pediatric Insights, Advances and Innovations with Children's Health, where we explore the latest in pediatric care and research. I'm your host, Dr. Cori Cross. The NeuroNICU program was born at Parkland Hospital in 2018. Dr. Lina Chalak was granted an award from UT Foundation Crystal Charity Funds to expand the program to Children's Health in collaboration with Parkland and UT Southwestern in order to better serve patients at Children's Health.

The NeuroNICU program is one of the few programs in the nation that integrates a comprehensive clinical care system, a fellowship program to train the next generations of NeuroNICU providers, and a robust research platform to further new knowledge in the field. Today we will learn more from the two physicians behind the only NeuroNICU in the state of Texas.

 We are joined by two amazing physicians, Dr. Michelle Mackie, a Neurologist at Children's Health and Assistant Professor at UT Southwestern, and Dr. Lina Chalak, who is the Director of the Neurological Neonatal Intensive Care Unit, NeuroNICU, program at Children's Health.

She is also the Interim Division Chief of the Neonatology Endowed Buchanan Chair and a Professor of Pediatrics at UT Southwestern. These two wonderful doctors specialize in the care of infants with neurological conditions such as seizures or brain injuries, hypoxic ischemic encephalopathy, prenatal brain injury, and congenital malformations. Thank you so much for joining us.

Lina Chalak, MD: Thank you for having us today.

Michelle Machie, MD: Yes. Thank you so much.

Host: So let's jump right in. The Children's Health NeuroNICU provides a comprehensive, specialized family approach to caring for babies from even before they are born. Tell us a little bit about the NeuroNICU approach and who the team consists of.

Lina Chalak, MD: I think the best thing to describe the NeuroNICU team is the interdisciplinary nature of it. So you cannot have a NeuroNICU by just having one expertise or one specialty. Dr. Machie and myself stand today to represent the whole team, ad, we have an amazing team. It started in 2017, in the concept phase, where I was able to get this program started, in representing the neonatal intensive care and partnering with my colleague, a pediatric neurologist, Dr. Jen Thomas, who at that time, was finishing her subspecialty in pediatric neurology, and equally shared a passion about the neonatal brain. So, what we've done is following a specialized training, we were able to get the teams mobilized. And when we talk teams, we talk about Neurosurgeons, we talk about Neuroradiologists, Epileptologsist, Pediatric Neurologists, and Neonatal Developmental experts. We have this interdisciplinary team of experts that share a passion about the neonatal brain, and we have the setup, where we have those experts share the care of the babies, round together at the bedside, do afternoon rounds, and teaching symposiums and family counseling, all those activities. Whether it's clinical care or education or research, target the best possible outcome for the newborn brain in development and target a team of experts.

So we're just two proud members of that team and we're just so excited to tell you more about this program.

Host: It sounds amazing and truly multidisciplinary. What I'm really interested in is your family centered approach. This is definitely a reframing of how we typically approach NICU patients. Tell us a little bit about how this is different and the effects you've seen from this type of approach on both your patients and their families.

Michelle Machie, MD: So, we in our NeuroNICU program, truly value a very different perspective to approaching family centered care. It goes beyond just meeting a baby in the NICU and providing care in that moment. We want to treat the entire family, the baby, the mother, the father, the siblings as one single unit, and care for them throughout this vulnerable period of early childhood development. And that goes from before the baby is born, meeting the family, to following them in the NICU. And not just one time. Our team makes the effort to go back multiple times, because if you think about a family who's come in, and been told that their baby has brain injury or brain differences for any reason, it's the worst day of their life.

And so we go back multiple times. We have extensive conversations about what does this mean, not only for the baby and their development, but for the entire family. A lot of times, it changes the entire family dynamic from what does going out of the house and getting in the car and going to the grocery store look like, can be vastly different when you have a child with special needs. So we follow these babies from the NICU from before they're born to the NICU, to the clinic. And not only that, we also have members in our group who are really focused on parental stress and mental health and the emotional trauma that can come with that. Dr. Margaret Hogue is one of our NeuroNICU faculty who's Neonatology and Developmental Behavioral Pediatrics trained.

And she's focusing on parental stress and mental health symptoms in the NICU and specific interventions that we can do to improve the parental outcomes and the baby outcomes.

Host: No, you make an amazing point because it isn't just about that little NICU baby. It's about the siblings and the parents and it really does change the entire family dynamic. I want to talk a little bit about what you touched upon, that the care for these infants starts before they're born. That a lot of times because of imaging, because of what we have prenatally, we're able to know a little bit about what's coming. Talk to us a little bit about how you help mothers during their pregnancy and then also about how, if a mother finds out there's something going on, how does she get plugged into your center?

Michelle Machie, MD: Yes, and that's so important because as our technology is advancing and medicine is advancing, we have new skills and techniques and treatments that we can offer to families before the baby is even born. So, in the case of neurological disorders, we're often being consulted for things like ventriculomegaly, which is increased fluid spaces in the brain, or prenatally diagnosed congenital brain malformation, or spina bifida, which is myelomeningocele, and we have a really multidisciplinary group that extends to our fetal program at Children's.

We have an entire clinic dedicated to the care of the fetus and we in neurology often partner with our neonatology specialists and our neurosurgeons to meet with those mothers and families who have babies affected by neurological disorders. And so these parents often come to care when they're getting their routine sonograms and evaluations done by their OBs. And typically at those visits around 20 weeks, the obstetrician can start to notice if there are any brain differences that would require specialty evaluation. And at that point, their physician would refer them to our fetal center and our fetal center has been working for years to improve the care for many complex prenatal conditions, including those brain disorders that I spoke about.

Lina Chalak, MD: I just love and echo everything Dr. Machie mentioned. It's critical to understand that this program is unique. Think of it from the perspective of that fetus to five. It starts with the pregnancy, with the mother, with our obstetrical colleagues, and our interdisciplinary team. It covers the baby intensive care stay as long as it is. Some of them stay for until their due date, which if they're preterm could be six to eight months in the NICU, and we are there every single day for our babies with the whole team. And then it spans to after discharge and that home environment and the follow up clinic. And it's that multidisciplinary approach to care with the experts and the specialists dedicated to ensuring every single intervention, whether it's nursing or MD related or subspecialty or after discharge; it has a brain, neonatal brain oriented approach. Everything we do, from the way we hold the baby, to follow up, to anything we do, is how does it make baby's brain better, and am I doing my very best, absolutely, to help the parents through this. And we have seen the most wonderful outcomes for our mightiest and tiniest warrior babies. Babies are resilient and we owe it to them and to ourselves to give the very best we can every single day.

Host: I love that. Could you share with us some of the positive patient outcomes you've witnessed from your program and how this changed approach has really impacted the patients and their families?

Lina Chalak, MD: I will share with you from my perspective as a neonatal intensivist. I see babies at the edge of the viability, and when I started my career, the edge of viability was maybe 26, 27, 28 weeks of gestation, and now it's 22 and 23 weeks of gestation. These babies have just finished that first trimester. And their organs are finally formed enough so that we could sustain life outside of the womb.

And when we counsel those parents, and we tell them about all the possibilities; I love that I could talk to my families at 22, 23 weeks, and tell them what 10, 20 years ago we used to tell people at 27 weeks and 28 weeks, and say, your baby could be a doctor, could be a gymnast, could be anything your baby wants to be, and we will dedicate every single effort towards that and then we see them come back. We have those reunions and you see those babies come and now they're like 10 and 20 and 30 year olds. Some of them are actually, they have their own babies and you just see the impact of what you do. And how they're proud of their functions in life, of carrying what they do and being at their best of potential.

And it's stories like this, whether it's premature babies or babies with asphyxia, that the parents might lose hope. And you're like, no, we have treatments and we see their outcomes and we see them come back to us. And, Dr. Machie can attest because she sees them longer and longer now, and she can tell you how they're thriving. And it's those stories that change your perspective, and that we make sure when we show up, we are fully dedicated and present to give those babies that bright future that they deserve. Michelle, do you want to weigh in on that?

Michelle Machie, MD: Yes, absolutely. And I think something that Dr. Chalak said that resonated with me is just this word, hope, because our families are again, going through whatever it is that the baby has; when it's the brain that's involved, it's very scary and it's really easy and quick that families and parents start to lose hope or wonder if their baby will make it or will they walk or will they talk or will they go to school or will they have an independent life.

And I really hold it as part of my job to bring that permission to hope, that it's okay to have hope back to the families, because what we know about baby brains is this phenomenon called neuroplasticity, where the brain has the capacity to rewire, regenerate, form new connections in ways that the adult brain doesn't.

And we see it time and time and time again in our neuroNICU, that the babies always do better than any doctor says they will. And so sometimes if the family has seen a doctor from another facility that perhaps is not as familiar with baby brain care and development, that they've come away with the worst possible outcome.

And in the rare situation, that's true, but we are seeing remarkable strides in these babies and their development. I follow them from the NICU to my clinic where I get to see them every four to six months and watch them grow. And we see babies with severe perinatal asphyxia, or HIE, who are meeting every developmental milestone. And that 23 weeker who beat every odd to make milestones on time and just thrive and exceed expectations. And so I feel like it's my duty, and I know that Dr. Chalak feels the same, to inspire these families to have hope for their babies.

Lina Chalak, MD: Absolutely. It's that astonishing capacity for growth and repair that they have that inspires all of us. Every single intervention, when you do it to a newborn brain in development, it's so much more impactful than if you do it to an adult or to anybody else through their lifetime. So we have those unique opportunities during windows of brain development that only this specialty has access to. The sky is the limit for that potential because of that ability of growth and repair of the newborn brain.

Host: It's truly miraculous, both the newborn brain and how medicine has advanced so that we have so many more things at our disposal that has made viability change from when I was doing my residency to today. It's really miraculous. So I understand that your team has a one year accredited Neonatal Neurocritical Care Fellowship Program. It's so important that other people are learning what it is we're talking about. Can you share a little bit about the program and its certification through the United Council of Neurological Subspecialties?

Lina Chalak, MD: Absolutely. I think the journey to get there was amazing. We started with this clinical program to save vulnerable baby's brain. And then we added the research and all of a sudden we realized, if we do not train the next generation of the pipelines, what's going to happen in 10, 20, 30, 40 years! And so we started with the fellowship where somebody finishes their training in neonatal intensive care and or pediatric neurology or developmental care and then they dedicate a whole year to the neonatal neurology specialty.

And that was in 2018, 2019, way before we were able to achieve the accreditation. There are five programs in the country, so we are one of the five, that we're offering this unique special training in neonatal neurology, and we realized the world needs more of this because we were getting so much demand. Actually, Dr. Machie was our inaugural first neonatal neurology fellow, and her accomplishments were so amazing during that one year, whether it's in education or research; we were able to get her faculty position hired. We got her hired on the spot because of the immense need. So then we went from being two to being three teaching and preaching.

And then we hired the next person after her, who, which Dr. Hogue, started as a neonatal intensivist, did her specialty. And, Dr. Machie told you about her project, regarding parental vulnerability child syndrome and things like that. We hired her on the spot and then we started recruiting talent from the outside to train them so that they could start their own program.

So one of our graduates is now at Dell's Austin and started her program. And we just got one new fellow, Dr. Tahina, from Ann Arbor. So we get to train her and there is no limit, basically. There is so much need for the specialty that the other four hospitals and universities and ourselves got together and were able to get the accreditation process, and now the specialty is officially accredited by the United Council for Neurological Subspecialties, and we are one of five programs in the country that can offer this unique fellowship program. We are proud of every single one of our graduates, they're all in faculty positions, helping train the next generation of physicians and clinicians and scientists, all focused on the neonatal brain as a specialty.

Michelle Machie, MD: And I would add that the Neonatal Neurology or Neonatal Neurocritical Care Fellowship, as it's now accredited, is really extensive. And a lot of people don't know much about the field, but when you come into this one year training fellowship, you're going to be immersed in baby brain care.

You're going to go to our Level 3 and Level 4 top NICUs and spend four to five months just taking care of new babies who are born and the multiple different medical problems that they present with from seizures, to HIE, to brain malformations, to rare neurogenetic disorders. We also offer and incorporate a lot of elective and research time.

So that might be participating in the multiple fetal consultations that we do, getting immersion in neonatal EEG, neonatal MRI, and becoming more specialized with those techniques, as well as incorporating management of cerebral palsy, time in our developmental clinic to focus on neurodevelopmental outcomes, or time in our genetics clinic to focus on rare genetic disorders.

So it really is comprehensive and it adds a lot of value to someone who wants to take care of baby brains.

Lina Chalak, MD: I would love to add that part of our interdisciplinary team meetings that happen even before the baby is born, based on the condition and the diagnosis; is we partner with the parents to find out where is the best place to give birth that allows them to be there for their baby, that allows the baby to be moved to a level four, like our Children's Hospital, if the baby needs to be moved, or to stay closer to home if the baby needs to stay closer to home.

So our network of hospitals is wide enough that we are able to really partner with the parents and with the treatment team to see what is the best plan of care. So we follow that precision approach where to care for the baby, how to care for the baby in partnership with all our team members and our parents.

Host: This is so encouraging because I think that you, you really make the point that the type of care that you're able to give at a center like you have is just above and beyond and it really should be the gold standard and what patients and their families can access. And so only with training like you're doing there, are you able to grow and to bring this to people around our country.

Lastly, I think our listeners would love to hear a little bit about the research aspect of your program. Could you each share with us a little about the research you're currently involved in?

Lina Chalak, MD: Absolutely, I would love to get started on this. I came to UT Southwestern and Children's in 1998 to start my research in the field of hypoxic ischemic encephalopathy and newborn asphyxia. It's a condition that has devastating consequences. And when I started my career, really the outcomes was either death or disability and just supportive care.

You just treat the seizures. That's how we were told. And I was able to start on translational models first, that allowed us to study hypothermia and show that it could prevent the brain injury if you initiate it within hours after the insult. And just like that, we moved from translational animal models to large clinical trials.

And we were able to show and demonstrate that what we thought was a non-modifiable condition, which is birth asphyxia, it was all predetermined by what happens at the time of birth. Now you can intervene within six hours, put the baby under a cooling blanket, and slow down this reperfusion or brain injury.

And now, we have prevented death and disability in 25 percent of those infants. For every six babies that we treat, we have prevented death and disability in one of those babies. And the numbers keep to continue to improve. Now we're studying other therapies. So basically, saving vulnerable babies brain is my life's work.

I've moved from infants with moderate and severe asphyxia to now I'm leading a clinical trial on mild asphyxia. So this is a condition that we had not addressed before and now we are really in a position to show the different treatment modalities including hypothermia for those babies so that they can reach their full potential.

So this is an example of cutting edge translational research that we've moved to clinical trials to now have a standard of care therapy. And then we apply advanced brain health biomarkers, precision therapy for biomarkers that tells us how the infant's condition is fluctuating and how they're responding to those therapies.

So I work with bioengineers and others to have those heat maps that tell me non-invasively how babies brains are responding to treatment. I've actually helped support Dr. Machie start in her own neuroimaging project, and I want her to tell you a little bit more about those accomplishments because we are so proud of the teamwork and this is a project that she started when she was a fellow, and now that she's taken this to a whole new level. So I would love for her to be able to share some of it with you too.

Host: Oh, absolutely. Dr. Machie, I'd love to hear about it.

Michelle Machie, MD: So one thing about training in any fellowship program is that you're really only as good as your mentorship, and I will say that Dr. Chalak has been the most amazing research mentor that anyone could ask for, and if you look at the number of people that she's helped in terms of research mentorship, I mean, the list goes off the page, and so I came to her in my first year in my neonatal neurology fellowship and told her that I had an interest in neuroimaging, and she ran with that. She introduced me to, big brains in the field who taught me special skills and special scoring techniques to be better able to evaluate baby brains, especially those with HIE. And so under her mentorship, I published my first paper, specifically looking at mild HIE and looking at various scoring systems that we're using in terms of MRI to look at these baby brains and to really see which one is most sensitive for picking up brain injury. And from there I continue to work on now numerous projects, helping other people who are doing baby brain research look at their MRIs with better sensitivity and specificity and scoring systems.

And that's really become my niche and I really just have Dr. Chalak to thank for kind of launching me on that path to getting to do something and spend my time doing something I love.

Lina Chalak, MD: I think what we're seeing with Dr. Machie's research is she's taking it to the whole new level. So it's not about do you get an MRI, it's about who reads your newborn MRI and what level of details and how can they follow up on the findings and get you through those early interventions and through all those things that can make the baby's life better.

And I think, if anything, we'd like to emphasize it's about hope, it's about positivity. For those anybody that wants to be inspired, like for me, anytime I have a bad day. I have a book that is called Preemie Voices that I recommend. You can even have it as a podcast for the new generation or for the pregnant moms to read about.

It just inspires you. Anytime you're having a bad day, you remember why we do what we do. And there is another book called Tiny Humans, Big Lessons by Sue Ludwig that I also love. It's about showing up for your babies. And to me, it's about those testimonials. It's about the patients that we care for and their families. It's about providing them the best future we can. We owe it to them and we owe it to ourselves.

Host: You both have such passion for your patients and saving baby brains, bringing hope to your patients and their families. Speaking with the both of you has been so inspiring. I want to thank you so much for taking the time to share your expertise with us today.

Lina Chalak, MD: We're just proud to be representing our team. The team has more than 20 members and we're just proud to be part of this team and to represent this team, so that the whole world can hear about what we're doing for our babies and can join us in their efforts.

Michelle Machie, MD: Yes, thank you so much for having us.

Host: For more information about the amazing fetal and neonatal neurology program at Children's Health, you can go to childrens.com/neuroNICU, that's N-E-U-R-O-N-I-C-U. Thank you so much for your time with us today and to our audience for listening to Pediatric Insights, Advances and Innovations with Children's Health, where we explore the latest in pediatric care and research.

You can find more information on childrens.com, and if you found this podcast helpful, please rate it, review it, and share this episode, and please follow Children's Health on your social channels.