Understand how BPD is associated with growth, what nutritional status’s impact is on lung function and phases of “pro-growth” management strategies including the optimal growth scoring tool.
Uh, thank you, everyone. Hello to everyone in Phoenix and to those joining virtually. Um, thank you for the invitation to present today on nutrition, growth, and achieving the optimal state and severe BPD and as mentioned, I'm one of the neonatal dietitians at Nationwide Children's Hospital, and I work exclusively in our BPD unit. And like many of you who have cared for these patients, we understand how complex this disease is and how challenging it can be to manage. And we also see that these infants struggle with growth and development that is complicated by so many factors. So today we'll just review some of those factors, um, and what it takes to achieve growth and the optimal state in the setting of severe BPD. Next slide. I have nothing to disclose, but I do have some cute pictures. So it's well documented in the literature that um infants with BPD suffer from poor growth, and in particular linear growth, and we know that poor nutritional status will have a negative impact not only on lung growth, but alveolar development and lung function. And nutrition is a crucial part of BPD recovery and should be viewed comprehensively. So we want to view nutrition with a broad lens. We want to ensure that not only are we providing enough energy for growth, but to meet metabolic demands, we also want to think of nutrition in terms of lung healing and tissue repair, and then also thinking about those important considerations, those non-nutritional factors that can have a significant impact on nutrition and growth. And then finally, achieving a pro-growth state has been identified as an important management strategy and severe BPD and I'll spend more time talking about that in the next slide. And once the state's achieved, then the infant can progress to the optimal state, which is our ultimate goal. Next slide, please. So how do we achieve optimal growth in infants with severe BPD? And this image nicely illustrates that concept of a pro-growth state. And you can see in the center that optimal growth overlaps with respiratory progress, which overlaps with developmental gains. And in a clinical setting, we're always trying to find the right balance here by not focusing so heavily on one area that we lose sight of the others. And the nutrition subgroup of the BPD collaborative recognized that achieving good growth in our babies with severe BPD was not just about maximizing calories and protein. And we saw that growth in BPD happened when we address some of these issues focused here on the left-hand side of your screen. Some of those barriers to growth, such as avoiding inflammation, avoiding infection, while managing inflammation, judicious use of our corticosteroids, minimizing diuretic exposure, reducing stress, and reducing painful procedures, while at the same time focusing on factors that we know promote growth. So those listed there on the right-hand side. Making sure we're providing adequate respiratory support, um, doing appropriate developmental therapies, using our non-pharmacologic comfort measures, asking parents to be involved with daily cares, doing diaper changes, holding is a, is a big growth promoting factor, and then, of course, good communication among disciplinary team members. And we found that if we used this type of management strategy while at the same time providing excellent nutrition and using our chronic care model, which means not making a lot of changes day to day, that we can achieve this pro-growth state where we begin to see all these great things happening in our infants optimal growth, developmental gains, and respiratory progress. Next slide, please. So why is growth so complex and challenging and severe BPD? Well, the natural state of a healthy child is a pro-growth state. Our infants should, you know, they should feel comfort, they should have adequate nutrition. They should feel these positive experiences in a low stress environment. All of those are very important for growth and development to occur, especially in that first two years of life. But what about our infants with BPD? What do they often experience? They have frequent shortness of breath, anxiety, fatigue, periods of hypoxia. They're in an ICU, so it's not a very nurturing environment. Um, they sometimes lack of sleep, appropriate developmental sleep. Um, they're often immobile, they have less touch, more stress, inflammation, and the list goes on and on, and all those factors can interfere with growth and development. So our optimal state goals are based on what we would expect for healthy children in the 1st 2 years of life, steady developmental progress, and appropriate growth on standardized curves. Next slide, please. The disease process is certainly um a journey for infants with severe BPD and can be tracked by specific goals, and these four phases of BPD were defined by our team at Nationwide Children and published in a paper back in 2019. And the idea here was to describe a typical path from the acute phase or phase 1 to the convalescent phase or phase 4, which is our optimal state, and we wanted to conceptualize how the patient may look in each of these phases. And clinically we found that if over time we were waiting medications and waiting respiratory support at the right pace, particularly in phase 1 and 2, that we would start to see emerging skills and stability that was being gained in a fairly predictable manner, and that included linear growth by phase 3. So in terms of growth in each of these phases, in phase one, you can picture an infant in phase one very acutely ill, unstable. They probably have central IV access. They could be on high-dose steroids or high respiratory support. Growth in this phase, we would see variable weight trend, um, likely related to fluid balance, and we would see poor linear growth. By phase two, in the transitional phase, edema is slowly resolving as the nutritional status improves, and we're starting to see emerging linear growth toward the end of this phase. By phase 3, which is our pro-growth phase, weight gains pretty predictable for corrected age. Um, this is a place of stability where they're gaining skills, they're on or on low dose steroids or off steroids, and so this is where linear growth is really starting to emerge and be present. And then by phase 4 and the convalescent phase or optimal state. Patients ready to go home. They have high respiratory reserve, low variability. This is where linear growth is present, it's ongoing, and our weight for length ratio is starting to become more proportionate um in this phase. And next slide, please. So our multidisciplinary team at Nationwide Children's wanted a way to objectify what we were seeing clinically. So we came up with the idea of developing a scoring tool as a means to track progress through these phases, taking into account these four categories here listed on the slide. So respiratory concepts, neuroregulation and neurodevelopment, infection and inflammation, and nutrition and growth. And we invited expert multidisciplinary teams from centers in the BPD collaborative, and these experts included um respiratory therapists, PTOT, developmental psychologists, nurse practitioners, pharmacists, dieticians, and neonatologists. And our goal was to generate concepts within each of these categories and develop measurable items that we felt were important to guide and predict progress through the phases of BPD. Next slide, please. So this slide describes our tool development process, which involved a very systematic approach, um, and we developed our scoring tool, the optimal state scoring tool over a two year period. Not many of us in the group were experts in the tool development process, but we were fortunate enough to have two developmental psychologists who are very familiar with tool development, and they really helped lead the way. So just to review quickly what we did here, first as we established our instrument purpose. Next, we generated those four categories that I just reviewed. We generated concepts within there, the categories, and then scoring items, and then we also created a key to help better define um and give a better definition of those scoring items, which helps scores. And then the nationwide Children's group um piloted the scoring tool in our BPD unit while other centers followed along. They gave feedback. We had multiple discussions about feasibility, the scoring items, and we were constantly making revisions until we got a final draft. At that point, lastly, we presented it at the BPD larger BPD collaborative um meeting, and then we incorporated their feedback. And in the end, through all this, we were able to validate that all of our concepts and items were seen as important markers in the progress uh for patients with BPD and that it really helped provide a roadmap in the clinical practice. Next slide, please. So I'll just briefly touch on these concepts, um, categories in the next 4 slides. All the information is here, you can review it in detail. Um, but on the left are the concepts and on the right-hand side of the slide are the scoring items. So for this respiratory domain, we considered baseline oxygen saturation levels, respiratory support, work of breathing, and right heart function. Next slide, please. The neuroregulation and neurodevelopmental domain considers state control, ability to learn, sleep cycles, endurance with activity, and ability to play, and Holly will go over this in more detail later. Next slide, please. The infection and inflammation domain considers the presence of growth suppressive medications such as steroids and diuretics, the presence of intravenous line, and then inflammatory triggers. Next slide, please. And then finally, the nutrition and growth domain considers weight gain, linear growth, weight for length ratio, enteral nutrition intake, GI stability, and bone and health parameters. Next slide, please. And this is what the optimal state scoring tool looks like on paper. I know that's hard to read and read and it looks, um, difficult to use, but I can tell you after using it for many years, it's very easy to use, um, especially once you're more familiar with the, with the tool. Um, so the four categories are listed there on the left and the scoring items are listed on the right. Uh, baby can receive up to 24 points. That's the total amount that can be achieved on the tool. And for scoring purposes, the scorer or expert in that category would look at one week's worth of data in the chart to determine the score. So if the item was being met 6 out of 7 days of the week, or 85% of the time, then the point would be assigned. They would get a 1. Um, some of the items are clearly more subjective than the others, um, but through multiple discussions with our group, we try to make them as objective as possible. Next slide, please. So as the patient achieves points or goals on the scoring tool, they demonstrate progression through the BPD phases. And we found that over time, scores will increase or decrease throughout hospitalization, but as the infant gains stability, especially by the end of phase 2, early phase 3, we see that there tends to be less fluctuation in the points and more consistent gains. And this tool can be pretty useful in the clinical setting, and that, again, it helps give that objective measure to track progress, and it really serves as a reminder to all those important um concepts. It helps also with consistency between caregivers, and then it allows us to see what happens when a change is made. So for example, if you wean oxygen or you make a ventilator change, that may be reflected in the total score the following week. And then it can act as a road map again for parents and staff. Next slide, please. So to test the utility of the scoring tool, Our team scored patients with severe BPD with a post menstrual age of at least 38 weeks or greater, and they were on different modes of respiratory support. Some of those patients um were steroid dependent and some were not, and these were our known groups. So we would expect patients in the, the steroid dependent group to have slower rates of linear growth. And we hypothesized that the optimal state scores would correlate with linear growth trajectory. So if you look at these two graphs, um, graph A being linear growth trajectory over time, and then B being the optimal state score trajectory over time. We found that the steroid groups, so the light gray dots, had slower linear growth, which we would expect, but they also showed slower gain in optimal state scores over time than those in the non-steroid dependent group, the dark gray group. And in fact, the non-steroid dependent group's rate of total change in optimal state scores was 4 times faster, and in linear growth was 2 times faster than the steroid dependent group. Next slide, please. So our preliminary data analysis showed that overall total scores tended to decrea increase over time, but the steroid dependent group showed significantly slower rates of change in total score and in length, and this preliminary data helps show construct validity of our scoring tool in that optimal state scores corresponded to clinical improvement as measured by improved linear growth. Next slide, please. So in summary, the optimal state scoring tool was developed to objectively capture the clinical status of infants with BPD and to track progress over time. And pilot data reflect correlation with item achievement or increasing optimal state scores and linear growth acceleration in known groups. Trending scores may help teams make medical decisions to optimize the balance of respiratory stability, developmental progress, growth suppressive factors, and nutrition. And currently, our nutrition subgroup is working on a multi-center study with 8 other centers, and our goals are to reproduce that pilot study on a larger scale to see if that um statistical correlation still exists between the optimal state scores scores and linear growth, and we want to evaluate feasibility. Is this tool um feasible for other teams to use at other centers? So that's kind of what we're working on now. And I just want to acknowledge Doctor Susan Lynch, who was previously our program director at Nationwide Children's for our BPD um comprehensive program. Um, she was very instrumental in getting this project up and running and developing, um, the optimal state scoring tool, so I really just want to acknowledge her, thank her and give her credit too. Thank you. Thank you, Jen. And did you plan on staying for the remainder of the, the talk? Mhm. I Yes I just wonder you know people still love your story, OK, so. So Holly and I are here to um talk a little bit about um our experience here at Phoenix Children's um with the optimal state scoring tool. Um, we are very excited as a center, um, through the lead of Doctor Griffiths to be um part of this multi uh site study. Um, and I think, you know, um, the information that we find from the multi-site study will really um help sort of help the care that we provide for we keep babies. Um, so here, um, as Jen mentioned, um, in order to sort of participate in this study, um, we formed a multidisciplinary team, um, involving, um, our neonatologist, um, who, uh, graciously. Agreed to participate. um, we have our developmental specialists, um, our PTOT colleagues, um, pharmacy, and dietitians, and, uh, what's great about having this team is, um, each of us are able while we come together to score together, we have our sort of expertise, um, in terms of which sections of the tools, um, we are scoring. Mm. Um, so where are we right now? Um, as Jen mentioned, it is a multi-center prospective clinical trial to assess the feasibility, reliability, and validity of the uh tool across various clinical sites, um. And so in order to get started, all of the team members here at Phoenix Children's um underwent provider education uh that was provided through Nationwide Children's, um, on the scoring tool, and we all completed, um, training scenarios, um, just to make sure that we all understood how to do the scoring, um, and, uh, to make sure that there would be, um. So The quality between the scores and depending on who was scoring to make sure that um we weren't scoring differently. Um and then um we had done um a couple practice runs um and started scoring weekly um just this month. Um, and I think also one of the um benefits of participating in this is we've gotten our dietitian and our developmental team really involved with our weekly lab measurements, which is one of the things we're looking at in this study we thought was very important to make sure that we had um as accurate length measurements as possible, which can be um hard to accomplish in this population. And then plans moving forward, um, so I think um we are hoping, I should mention that um this project and obtaining the The tool scores um will also help us in the clinical sense in terms of being able to understand um the changes that we make clinically and how that helps our babies or potentially, um, you know, are we not progressing as we would like because we need that change, um, also help with discharge readiness and neurodevelopmental outcomes. And I think, um, you know, as a team we meet weekly for BPD rounds. Um, and that's a great multidisciplinary time to sort of talk about each patient at the bedside, but this is also another time during the week where we're all able to get together, um, and, um, talk about how the patients are doing, um, of course, decide what patients are eligible to enroll based on inclusion criteria, um, but it just gives us another view altogether about how our our behaviors. Uh, I'm gonna pass over to Holly so she can talk a little bit about neurodevelopmental impairments. Hi, everybody. Um, I am the physical therapist on the neonatal intensive care unit here at PCH, um, and so I want to speak a bit about the role of the developmental team on this interdisciplinary, um, team approach that we take, uh, in our unit. And so, um, to start, I'd like to address some of the common considerations uh with this population and why this population is particularly vulnerable to significant delay with progression of their milestones. Um, the most obvious is their premature birth. Their birth occurs at a period of immature, uh, musculoskeletal and neurological, uh, gestational development, and so they are not really ready to regulate or function in the context of the outside world. And so they are vulnerable to altered development of these systems if we're not uh careful in the intervention that we provide and then associated impairments and delays that result. So we need to have intervention in a continuum of care that supports and maximizes the ongoing maturation of their systems, of their immature systems. Um, also, these babies, as we all know, have often medical comorbidities. They may have a few or they may have multiple that make their uh medical status very complex, and so these can further compromise their stability and also further complicate the progression of their development. Um, these, these babies experience chronic trauma and stress, and we know there are many studies that have shown that the detrimental effects of chronic stress on long-term, um, developmental outcomes for years to come, and some of these stressors we actually can definitely help control or mitigate. Um, they may have stressors that are caused by environmental factors, so their medical lines, their general cares, their tests and procedures that they undergo, surgeries that they undergo, um, insufficient positioning support or insufficient environmental modifications to minimize the stress. The separation from parent and a lack of bonding with their parents is an issue, um, just to name a few, uh, of that sort, but also by the medical status they have stressors, so they may have repeated anoxic events. They may have inadequate or respiratory support, so they have chronic work of breathing. They're in a perpetual state of fight or flight, so um they're not able to engage. They have, uh, oftentimes repeated infections, nutritional imbalances, and all those kinds of things. So it's important that we are all aware that we do take an interdisciplinary approach and that we work collaboratively to mitigate these effects, to try as much as we can to make the positives outweigh the negatives that they experience. Um, parent presence and engagement is also a big challenge, obviously. Um, parent presence and bonding is a key to reducing stress experience and supporting, uh, supporting improved developmental outcomes in the long run. And so we know that these families face multiple barriers. Um, the babies that, that we're talking about are, they're prolonged hospitalizations. They are often there for many months, so they have outside life obligations with jobs and other kids and socioeconomic factors that We have to help try to manage with them, but also their own stress and trauma that they're experiencing from this, uh, this birth and, and journey with their baby, uh, that may or may not have been expected at all. And so that makes them less available to connect and also, um, maybe have a fear of their own baby. And so we have to, as a team, help them to overcome that. And then the prolonged hospitalization in general, I think we've alluded to a lot of these things, uh, today, but they are The hospital for many months, so they're in a very limited environment. They have a deprivation of sensory experiences. They're immobilized, often, often excessively swaddled because they, we have medical lines that we have to protect and all of that. Um, they're in bed for very prolonged periods of time. They have decreased opportunities for active movement, for proprioceptive and kinesthetic input, and they often are on sedatives for regulation and so they can't even engage as much as they, they would normally be able to. Um, and then of course they have limited social interaction, which is further compounded if they happen to be on isolation precautions too, so all of that becomes even worse. So just a quick oversight of our developmental team, we're very lucky to have uh we have physical therapy, occupational therapy, speech and language pathology, and then a team of developmental specialists, and we all collaborate to try to prevent uh to provide um comprehensive developmental care. And so it's really important that we're involved at a very early stage, so we would start with. Providing neuroprotective care, um, multi multiple care provider cares as well, um, and give proper positioning supports and clustering of care and then facilitate early and ongoing parent bonding activities and, and education, um, and as they grow, of course, we're gonna provide a graded progression of developmental activity and accumulation. And motor experiences and pre-feeding and feeding experiences and then opportunities for appropriate play and sensory experiences. So we'll be the ones bringing equipment to the room, bringing toys to the room when they're ready for those kinds of things, teaching staff and family how to utilize those and um and give them a regular schedule of some activity and stimulation. Um, so we provide interventions and activities with the goal of promoting physiological function, including strength, endurance, functional movement patterns, oral feeding patterns, things like that. Um, we promote physio, uh, promote uh sensory state and physiological regulation, neurobehavioral organization, growth, sleep, and brain development. Um, and then also another major goal of what we do is to reduce the secondary complications and issues that are associated with this, uh, medical status. And so, um, we do have things that we can prevent and, you know, so we wanna make sure we're, uh, we're preventing things such as musculoskeletal impairments associated with poor positioning or a lack of opportunity for movement and motor activity. Um, we wanna make sure that we're promoting skin health and integrity. That we're preventing head molding issues and that we are also preventing sensory aversive behaviors. We did do a lot of noxious sensory experiences and, um, and also a lack of sensory stimulation. And so those combined can cause some, some issues down the road with sensory dysregulation, and we want to make sure that we're preventing that as much as possible. And finally, of course, to facilitate parent bonding, um, we are very Involved with the families we often are of a rather regular visit for them and we um are often the the staff member who helps to teach them how to be a parent to that parent or to that child, how to handle the child, overcome some of the fears of the child, and so it's really important that we give them the confidence and the independence to make them a participant in that progression of their development. Um, and that's really reassuring and and fulfilling to parents anyway. So as it relates to this, uh, optimal state scoring tool, um, Doctor Griffiths has led, uh, our initiatives in our, on our unit to improve practice with objective measures of development as it relates to the delivery of medical care, um, of the severe BPD population. And so that includes this tool, the uh the uh the state scoring tool, um, and so we know, um, as Doctor Gibbs alluded to that that as clinical decisions are being considered, it's important to see not only how these babies function and regulate at rest. But it is really important and more meaningful maybe information of how they respond to age-appropriate activity. And uh so with the supports that we're providing in the, in the medical intervention we're providing, are they able to participate at the, at the stage that they should be at? So as these babies age and grow, what is their capacity for handling an increasing stimulate increasingly stimulating environment and interactive. How do these babies respond to the demands of a developmentally appropriate sim stimulation or activity? And as we're tracking and we look at the scores, are the scores reflected, uh, reflecting that, um, as they undergo a change in respiratory support or as we're weaning a medication, do the scores change in a way either positive or negative to help us know what we uh what we're doing is working? And then, um, so it gives us some insight on patient stability and the ability to progress forward, um, or alternatively to maybe back down on some of the changes we're making to allow them to adjust. Um, I just liked the quote. This came from the, um, the template study that was provided to us as a, as we joined the collaborative groups to, to start implementing this tool. The ultimate goal of care is to establish a pro-growth state for healing that will allow appropriate growth and development, lung and brain development, and improved neurodevelopmental outcomes. So we're really looking very comprehensively at these, at these. Babies, um, I will go over just real quickly the areas of assessment on the optimal state scoring tool for the development, uh, neurodevelopmental area, partly because um most of the objective measures through that test are pretty easy to gather from the medical chart. The one area that really isn't easy to gather from any kind of records is. The developmental state that they're in. And so it really is dependent on us as clinicians working with these babies regularly, but also collaborating with nursing and parents and other care providers to capture um the the status of these children week to week. So we are scoring once a week and it's supposed to be reflective of the, the last 6 out of 7 days. Etc. and so, um, we obviously don't see the babies on at that with that level of frequency, but if we collaborate the whole team together and with our other resources, um, we can, we can get this information. So the first area looks at neuroregulatory medications and just, just evaluates whether or not the child is needing um more than 2 neuro regulatory medications to remain stable. Um, the second area engagement and stability, looks at, uh, based on corrected age, so there are different criteria for different ages, looks at their ability to maintain an alert, calm, and engaged state with a readiness to learn for at least 30 minutes out of bed. Um, their sleep wake cycles, we are looking at whether or not they have sustained, uh, sustained periods of sleep, sustained periods of wakefulness that makes sense with the day and night, so starting to differentiate day and night, um, and looking at that as, uh, as, uh, one of the criteria. The postural tolerance. So again, getting out of bed, having them positioned in an upright position that being held or put into a supportive seat, can they tolerate that for 30 minutes or more without showing signs of uh increased work of breathing, without uh having desaturation events? So with the, uh, with the expectation being at least 93% oxygen saturation or above. Um, the fifth one is head control. So again, taking them out of bed, having them in supported upright, and are they showing, uh, postural reactions to be able to, to initiate head control, and those criteria are then teased out for the different corrected agents as well. And then Finally co-regulation or self-regulation, so we look at that baby's ability to calm in a way that, uh, with interventions that are traditional interventions of just padding, singing, folding versus having to requiring PRNs in order to uh maintain their state. So we just are using these tools to have a broader picture of their status and looking at their ability to engage and participate in developmental activity or their lack of ability to do so. Um, as correlated with their physiological stability as we're scoring along the way as well, helps us gain insight on their stage of disease, the progress that they've made, and also the appropriateness of the medical management that we're providing. Thank you. That was excellent. I remember you just starting this, um, scoring and it seems like you guys have come a long way in such a short time. Um, did you want to stay up here for questions? Um, I think I'll take questions now. Does anybody have any questions for Jennifer, Jordan or Holly? I do have one question. Um, how long does this take? It sounds like you do it weekly. How long does it take? We actually, actually, yes, so we timed it and um it takes about. 5 to 10 minutes per per baby. And at any given time, we have about 7 to 9 babies that we're scoring. Um, so it's about an hour a week, um, and of course, it depends on how much discussion is happening um about each baby, um, but it, it really is not that time consuming and we not only are Providing information for this study, but also gathering a lot of clinical information. So it seems like when you do it together as a group, you're kind of removing some of that inter-observer variability of just one person doing it alone, which is nice, exactly. And that's part of the study at some point of the study, um, there we're basically gonna be scored on our ability to score the babies, um. So yeah, yeah, no, we're against each other to make sure that we're scoring equally, um, depending on, you know, who's on doing the scoring, um, but yeah, it's nice because that we we're able to look through the chart, um, as a group, um, and score the more objective, um, data from the chart, and then of course very appreciative of developmental specialists to help with the neural regulation section, um. Excellent, thank you. Are there any questions for um our online speaker? Oh yes we do. We have a question here, whoever, yeah, I'm just curious, so I know Nationwide also uses the BSRI, um, and I think you, you guys do as well, right? Um, so I'm curious like what you see is like similarities, differences. Do you feel like they could work together because I know some variables might be similar, but some are different. Uh, I feel like that, well, the BSRI, um, I think focuses more specifically on the development as it correlates with their physiological stability versus I think, um, the optimal state scoring tool is, is actually factoring in other things. that we don't measure on the BSRI like linear growth, um, following their pharmaceutical needs and things like that those factor into the BSRI, but the BSRI we're, we're really kind of I mean you can correct me if I'm wrong, but I feel like we're, we're using it in the context of, uh, when we put uh developmental. Challenge, uh, when we pose developmental challenge to these babies, how do they function physiologically? So the other thing the BSRI really is uh one moment in time kind of score, you know, you score it based on how that session went, whereas the optimal state tool looks at a week's worth of time. So in theory, a baby could have a bad day but still get a good score if on the other days they're doing well. So it's a little bit more comprehensive in that way as well. And another question, sure, um, so I know in this study your data set are, uh, kiddos with BPD, but have you like informed, I'm just curious the utility of a tool like this, which sounds great in our kids that. Don't have the diagnosis yet, or we haven't given it to them because we've played the number game, or we know they might be headed that way and just if you use it informally with them as well. Um, we, we haven't, um, I think for sure need to start even like overall like just make sure it's valid in this particular patient population, um, and then I can you know that some of the things are pretty specific. The BPD in terms of like the steroid use and um your regulatory medications and and the the respiratory things that we're scoring um but something similar could potentially help us with other patient populations and in NICU yup, so, um. Oh, OK. One thing you mentioned was how we considered doing starting the scoring at family or just here so you can people can hear you on that. Um, so there was a question about scoring at earlier gestational ages. So one of the things that we talked about when designing the study specifically was that we would wait until the babies are at a corrected age of 3837 or 38 weeks. 38 is what we decided, um, basically to ensure that they're mature enough to be showing the developmental progress, but In the future, there may be some modifications that could be done as well. Um, and as Jordan said, there are several items on this tool that are really specific to needs of BBD Kids, but there are other tools there's a respiratory scoring tool or sometimes called a trait scoring tool that Nationwide uses and Like Joe DiMaggio Children's has been using it that as a BBD collaborative, we're actually going to be doing kind of a, a QI on our clinical implementation of this, but that tool is not quite as specific to BBD and perhaps could be modified to other populations and that includes things like, you know, not just their growth, but um. You know, how many exhibations have they had? Do they have airway disease? Do they have um upper airway, you know, upper airway and lower airway disease and so other factors that potentially could be used for other populations. OK, thank you.
