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As associate medical director of the Neonatal Intensive Care Unit (NICU) at University of Iowa Health Care Stead Family Children’s Hospital, Amy Stanford (14MD, 17R, 20F, 21F) is part of a team with globally recognized expertise in life-sustaining care for extremely premature infants. Stead Family Children’s Hospital NICU outcomes for babies at 21-22 weeks’ gestation are among the best in the world. Case in point: Nash Keen of Ankeny, Iowa — born just hours after passing the 21-week mark and whose NICU care Stanford oversaw — holds the Guinness World Records distinction as the world’s most premature baby.
For years, the NICU at Iowa has been known for its care and successful outcomes, and its reputation has been bolstered with the implementation of neonatal hemodynamics, which uses targeted neonatal echocardiography to obtain detailed images of a baby’s heart, valves, and vessels. This allows the NICU team to accurately assess cardiac function and blood flow to all parts of the body, including the brain and lungs, and implement precise treatments.
In the United States, neonatal hemodynamics is still an emerging field — only a handful of NICUs have neonatologists formally trained in hemodynamics. There are currently two dedicated neonatal fellowship programs in the country, and the first was established at Iowa by Patrick McNamara, MB, BCh, director of the neonatology division in the Stead Family Department of Pediatrics. The training program, led by neonatologist Danielle Rios, MD, MS, has welcomed U.S. and international teams to Stead Family Children’s Hospital to learn the Iowa approach in preparation for establishing their programs.
Stanford, who in 2021 became the second trainee in the U.S. to complete the neonatal hemodynamics fellowship program, shares details about its
We have several structured screening programs in place, but the hemodynamics team can be involved for any baby, preterm or term, whenever the primary team has concerns. Here, all babies born under 27 weeks receive a screening targeted neonatal echocardiogram within the first 24 hours of life. Babies born between 27 weeks and 29 weeks and six days also have a mandatory screening echocardiogram, typically within the first week.
Beyond prematurity, we also use hemodynamics for specific high-risk conditions. For example, infants with congenital diaphragmatic hernia get a screening echo within the first few hours of life so we can better understand their cardiopulmonary physiology and tailor management early on. Hemodynamics is also heavily involved with ECMO referrals, where we see patients immediately upon arrival to help with stabilization and ongoing management. And we routinely evaluate infants with significant perinatal complications who develop hypoxic-ischemic encephalopathy [a condition caused by lack of oxygen to the brain during or shortly after birth], focusing on cardiac function and optimizing hemodynamics to support neurologic recovery. Importantly, outside of these screening pathways, the primary team can request a hemodynamics consult and echocardiogram at any time for any infant — including full-term babies — if there are concerns about cardiovascular function or instability.
It is central to how premature and critically ill babies survive and recover. These infants can often look stable on the surface, but their cardiovascular system is still immature, so blood flow to vital organs like the brain, lungs, kidneys, and gut can be very unpredictable. By closely assessing cardiac function and systemic and pulmonary blood flow, we can identify problems early — things like poor ventricular performance, abnormal shunting, or elevated pulmonary pressures — before they become clinically apparent or lead to injury.
Once we understand the underlying cardiovascular physiology, we can tailor interventions much more precisely, rather than relying on one-size-fits-all treatments. For example, in a premature infant with hemodynamically significant patent ductus arterious [an unclosed gap in the aorta], optimizing blood flow can reduce the risk of brain injury by improving cerebral perfusion, lower the incidence of kidney injury and necrotizing enterocolitis by supporting renal and gut blood flow, and improve lung disease overall. In premature infants, this targeted approach can directly impact survival — but just as importantly, it improves quality of survival by reducing long-term complications.
In all critically ill infants, understanding the heart–lung interaction allows us to adjust ventilation, medications, and fluids in ways that support recovery rather than add stress to an already fragile system. It also enables us to deliver targeted therapies and closely monitor response, so that once an infant stabilizes, we can thoughtfully and safely wean support. This approach not only reduces unnecessary exposure to therapies but ultimately helps babies recover more efficiently and get home sooner.
So, in short, hemodynamics allows us to move from reacting to instability to anticipating and preventing it, which improves survival and leads to better short- and long-term outcomes.
We’ve seen significant improvements in our ECMO referrals, with most infants stabilizing without needing ECMO. Our congenital diaphragmatic hernia patients also have better survival because we can precisely understand and support their underlying physiology. In fact, we have papers under review showing that in our high-functioning unit, where excellent neonatology care is coupled with hemodynamic care, rates of chronic pulmonary hypertension are extremely low. That said, our approach is always twofold — we can’t provide outstanding hemodynamic care without also delivering excellent general neonatology care.
I think the next big steps will be expanding access by training more clinicians and standardizing care. Clinically, advances will come from better integration of real-time data to guide precise interventions and linking cardiovascular management to long-term outcomes, like reducing chronic pulmonary hypertension and improving neurodevelopment.
Dr. McNamara has certainly had a huge impact, but what makes Stead Family Children’s Hospital a leader is the integration of hemodynamics into a high-functioning, team-based NICU. Our NICU leads the U.S. and the world in the care and survival of extremely premature infants. Every level of our team — including nurses, respiratory therapists, dietitians, pharmacists, and advanced practice providers — plays an integral role in improving care. Beyond that, our educational programs and research initiatives attract both U.S. and international teams who want to learn and bring these approaches back to their own centers, helping to grow the field and advance care globally.
The key takeaway is that we truly care about our patients. Our team works tirelessly — coming in overnight or on weekends, whenever patient care demands it — to ensure the best outcomes. Iowans can rest easy knowing that Stead Family Children’s Hospital has one of the best NICUs in the world, and their babies are in excellent hands.