Envisioning a Neuro ICU for Preemies at UCSF

Each year in the United States, approximately 80,000 children are born very prematurely. During the past three decades, medical science has provided these tiny preemies with an increased chance of survival - largely through treatments that ensure their lungs can function optimally. The UCSF Children's Hospital Intensive Care Nursery, founded by William Tooley, MD, in 1964 in conjunction with the Cardiovascular Research Institute, has been at the forefront of developments in this area. But higher survival rates among extremely low-birthweight infants have meant that as many as one-half of infants born at less than 26 weeks gestational age will suffer neurological complications ranging from severe bleeding to more ephemeral assaults on the "white matter" tracts and other susceptible cells in the brain. Such damage can result in mild to severe motor impairments, including cerebral palsy, and behavioral and cognitive impairments, including mental retardation. Today, neurological complications among very young premature infants are the leading cause of mental retardation nationwide. Currently, there is virtually nothing that medicine can offer to prevent these complications from occurring or to reverse the resultant damage. But doing nothing is totally unacceptable, according to David Rowitch, MD, PhD. Formerly associate professor of pediatrics at Harvard Medical School, Rowitch is now professor of pediatrics and chief of the Division of Neonatology at UCSF Children's Hospital. He also directs a basic science laboratory in the Program in Developmental and Stem Cell Biology and is a member of the Brain Tumor Research Center. "When the parents ask" - upon learning of their child's neurological complications - "'Well, what can we do about it?', it is very frustrating, as the doctor, to say, 'Nothing,'" Rowitch says. "We have no therapy to prevent the degree of damage that occurs or to optimize brain growth in the premature infants. Our approach to these problems is inadequate and totally unacceptable." Rowitch says he envisions a future in which neuroprotective drugs will become the standard of treatment for premature infants. With colleagues Donna Ferriero, MD, chief of pediatric neurology, A. James Barkovich, MD, chief of pediatric neuroradiology, and others, he hopes to create a neurological intensive care unit - a specialized unit that would be the first of its kind in the nation - for tiny babies with neurological complications to closely monitor their development. "I think that [Rowitch] is a wonderful, thoughtful scientist and will bring a real, fresh, translational look to neonatal research here," Ferriero says. "We look forward to his successfully building the Division of Neonatology." "Adults suffering a stroke are commonly cared for in a specialized ICU [neuro ICU], and this has resulted in improved therapies," Rowitch says. "Although this is an idea that makes sense for our treatment of neonates, as far as I know, there is no such facility available in any neonatal ICU in the US. I believe that UCSF is uniquely poised to develop novel treatments for this important and highly prevalent neonatal complication." Sam Hawgood, MBBS, former chief of Neonatology and now chair of the Department of Pediatrics, agrees. "The William H. Tooley Intensive Care Nursery was established at UCSF in 1964 to create a highly specialized clinical environment to tackle the problem of respiratory distress syndrome, then the predominant cause of neonatal mortality in the developed world," Hawgood says. "Four decades of basic and translational research and continuous refinement of our multidisciplinary approach to clinical care have had a dramatic impact on the survival of premature infants here and around the world. David plans on bringing the same approach of a specialized clinical environment supported by basic and translational research to the problem of neurological injury resulting from preterm birth - today's major unsolved clinical problem. It is incredibly exciting to hand over the leadership of the neonatal program to an internationally recognized physician-scientist who has the vision to lead the program in new directions while maintaining our long traditions of excellence in clinical care." Rowitch says he was drawn to UCSF because of its history of leadership in treating a variety of neonatal problems, most significantly problems of the lungs and heart, as well as the opportunity to collaborate with leading investigators in the fields of neonatal neurology and neural stem cell biology. "The brain of the developing infant is extremely delicate," Rowitch explains, "with many blood vessels that upon very slight provocation can begin to bleed, leading to catastrophic brain damage. In addition, many cells in the developing brain cannot cope with the stress associated with prematurity, and this adds to the high incidence of neurological complications." Rowitch says he envisions a day when babies' brains can be shielded from these sorts of assaults. The Rowitch laboratory, in the Program in Developmental and Stem Cell Biology at UCSF, investigates key genetic factors that determine cellular development in the brain and the response to injury. He has focused on cells called oligodendrocytes that provide myelin (an insulating substance for nerve processes) and how their development is governed by two important genes, Olig1 and Olig2. Oligodendrocytes are among the cells most affected in premature brain injury. Rowitch's research also examines overlap between mechanisms in brain development and other neurological diseases, including multiple sclerosis and brain cancer, and is supported by the National Institutes of Health, the National Multiple Sclerosis Society and the James S. McDonnell Foundation. "As the mother of a special-needs child, I applaud Dr. Rowitch for addressing a great unmet need in medicine," says Fia Richmond, founder and president of the Children's Neurobiological Solutions Foundation. "The UCSF neuro ICU promises to shepherd brain-injured newborns through a dangerous moment in their lives, and potentially spare families from the heartache of seeing their child grow up with lifelong disabilities." "Unfortunately, significant progress is not just around the corner," says Rowitch. "But I think we can lay the foundation to get there in 10 years, and that UCSF can take a leading role in changing the incidence and treatment of newborn neurological damage."