Welcome to the 2024 edition of Child Health, where we reflect on how our rich legacy of pediatric healthcare at Dartmouth Health Children’s and the Geisel School of Medicine at Dartmouth serves as a foundation for discovery, innovation, education, and advocacy. Two of the greatest challenges facing children and adolescents today are mental health and obesity, which we are addressing in novel ways.
We recently enhanced and expanded the Dartmouth Health Children’s Pediatric Mental Health Access Initiative to address the growing crisis of mental health in youth. This initiative brings mental health expertise and personnel into primary care settings where children and adolescents feel more comfortable and more likely to reveal symptoms. Additionally, tools like “Behavior Bridge” empower families to implement lessons early for mental health conditions in order to help prevent later impairments.
At Geisel School of Medicine, cutting-edge research is revealing new insights into childhood obesity. Our researchers are highlighting the role of both genetics and environmental influences—such as food advertising—in shaping children’s health. By understanding these factors, we aim to create more effective personalized interventions and more compelling advocacy for policies that protect children from harmful marketing practices.
In our first story, you will read about 50-year-old Jesse Blanchard, born 4 months premature and weighing under 2 pounds. His survival, made possible by the nascent neonatal intensive care unit (NICU) at Mary Hitchcock Memorial Hospital, is a testament to the pioneering spirit of neonatal medicine at Dartmouth Health Children’s. While our leadership in family-centered newborn intensive care remains recognized, we have an opportunity to evolve our Intensive Care Nursery facility to remain cutting edge over the next half century.
These stories are just a few examples of how your generosity enables Dartmouth Health Children’s to always push the boundaries of pediatric medicine and science, helping all children live their healthiest, happiest lives. Thank you for your ongoing support of our mission.
With deep gratitude,
Keith J. Loud, MD, MSc Physician-in-Chief, Dartmouth Health Children’s Chair and Associate Professor of Pediatrics, Geisel School of Medicine
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Meet One of the First Intensive Care Nursery Babies—All Grown Up
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Expanding Access to Mental Health Care for Kids
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Understanding and Preventing Child Obesity
To learn more or to support any of the initiatives described in this issue of Child Health, please contact Polly Antol at Polly.Antol@hitchcock.org or at 603-646-5316.
EXECUTIVE EDITOR
Anne Holden
MANAGING EDITOR
Eva Botkin-Kowacki
CONTRIBUTORS
Jeremy Martin
Ashley Festa
Will Bailey
Brian Buckley
CREATIVE DIRECTION
Farah R. Doyle
DESIGN PRODUCTION
Farah R. Doyle
Laura M. Young
PHOTOGRAPHY
Lars Blackmore
Rob Strong
Mark Washburn
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FROM INFANCY TO ADULTHOOD
How Neonatology Has Grown Since This Premature Baby Was Born
In the spring of 1974, Melinda Blanchard went into labor at just 24 weeks. During those first couple hours, she and her husband Bob drove their Volkswagen bus from their home in Vermont’s Northeast Kingdom all the way to Mary Hitchcock Memorial Hospital in Hanover, N.H.
Though Saint Johnsbury Hospital was closer, they chose Mary Hitchcock for its budding neonatal care facilities, crucial for such a premature birth.
Upon their arrival, nurses did their best to stop the premature labor—they plied Melinda with alcohol, a standard practice at the time to suppress contractions. Their efforts delayed the birth by 57 hours.
“She was singing ‘Rocky Mountain High,’” Bob recalls with a chuckle.
Giving birth to her son, Jesse, was far more sobering. Even after the alcohol-induced delay, his odds of survival were less than 4%. “And his chances went down after that,” Bob recounts. “He weighed just under two pounds. I could hold him completely in one hand, with his head in my fingers and his legs dangling over my wrist.”
Tucked in the corner of Mary Hitchcock’s adult Intensive Care Unit (ICU), Bob and Melinda watched their son’s life hang in the balance inside an incubator, where he suffered from frequent episodes of apnea.
Jesse Blanchard was born at just 24 weeks in 1974. He was one of the first babies in the early neonatal intensive care unit (NICU) at Mary Hitchcock Memorial Hospital in Hanover, N.H. Now, he’s an artist living in New Mexico.
Photo courtesy of Maggie Blanchard
“ Somebody at Dartmouth taught me how to cut a diaper in half—actually, in quarters—because there were no preemie diapers.
—Melinda Blanchard, Mother of Jesse
“I remember flicking his heel when he would stop breathing. He would turn blue and the alarms would start to go off,” Melinda says, her voice still tinged with the fear of those moments.
“It was one hurdle after another,” Bob adds.
During his ten-week stay at Mary Hitchcock, Jesse also struggled to feed, a dire sign for a premature infant. “When you’re just two pounds, you can’t afford to lose much weight,” Bob emphasizes. These moments of crisis were as frequent as they were terrifying. Back then, success stories for such premature babies were exceedingly rare. Neonatal intensive care was in its infancy and scarcely resembled what it is today.
“We used makeshift endotracheal tubes and mask
CPAP,” says Kathy Albright, Jesse’s nurse at the time. “It was all very new and experimental. Every day felt like we were walking a tightrope. We were in the pioneer days—proving there was a need for a neonatal unit at Dartmouth to cover the state of New Hampshire and part of Vermont.”
Incubating a New Era of Neonatal Care
In 1974, neonatal intensive care at Dartmouth was housed within the adult ICU of the former Mary Hitchcock Memorial Hospital in Hanover. In the early 1980s, the neonatal intensive care unit (NICU) was moved to its own space near the obstetrics department and the regular nursery, improving the care environment for newborns.
This painting by Jesse Blanchard hangs in the Children’s Hospital at Dartmouth Hitchcock Medical Center (CHaD) and captured the attention of Joanna Celenza, Intensive Care Nursery (ICN) family support specialist, 25 years ago when her twins were patients in the ICN.
This arrangement continued until 1991, when the Children’s Hospital at Dartmouth Hitchcock Medical Center (CHaD) opened in Lebanon, featuring a new dedicated space for the Intensive Care Nursery (ICN).
Prior to this dedicated unit, newly minted specialists cared for premature infants like Jesse in an improvised setting. Only two incubators were available, one for Jesse and another for a premature baby girl, Melinda recalls.
Both machines lacked the modern features of today’s more sophisticated devices—integrated monitoring systems; precise oxygen, temperature, and humidity controls; easy access for medical procedures; and noise reduction. Bereft of this last capability, the constant drone of incubator motors produced noise levels far exceeding today’s safety standards. This prolonged exposure, occurring at such a critical stage of development, put premature infants like Jesse at significant risk of noise-induced hearing loss.
Amid the din, hospital staff still made the new parents feel at home. Allowing the Blanchards 24/7 access to their son was a significant departure from typical policies of that era. “We lived far away. The hospital’s flexibility in allowing us to be there around the clock made all the difference. We felt like part of Jesse’s care team,” Bob says.
Some nights, Melinda and Bob would sleep in their Volkswagen bus in the hospital parking lot, just to be nearby. After days spent at the hospital, they would drive back up to the Northeast Kingdom. “Then we would look at each other and say, ‘What the hell are we doing here? We need to be with him,’” Bob recalls.
“And we’d drive back down. Everyone at Dartmouth let us come. There were no hours or rules. They knew how important it was.”
Neonatology’s Journey to Whole-Child Care
More than fifty years later, Melinda and Bob, now in their seventies, still vividly remember the compassion of the nascent neonatal intensive care team at Dartmouth. “They taught us how to care for Jesse and involved us in every aspect of his treatment,” Melinda says.
“I had never held a child,” she admits, adding that she was just 21 years old, a college senior. “Somebody at Dartmouth taught me how to cut a diaper in half— actually, in quarters—because there were no preemie diapers.”
This family-centered approach was quite novel for the times. In the 1970s, neonatal care focused primarily on medical interventions and survival, rather than broader aspects
Jesse Blanchard and his family in New London, N.H., in July 2024. The Blanchard family—(from left to right) Sidney, Jesse, Maggie, and Oliver—were back in New England to visit an old friend from Norwich, Vermont.
Photo courtesy of Jesse Blanchard
of infant development and parental involvement. One of Jesse’s doctors, Carol Little, MD, says most physicians “took care of organs and didn’t focus on the whole child or family. That wasn’t part of medical consciousness then. Neonatology led much of that change.”
George Little, MD—Carol’s husband and then-assistant professor of pediatrics at Dartmouth Medical School—was a major reason for this big leap forward and is
now heralded as one of the forefathers of neonatology. In 1973, he developed a patient-centered system of care for newborns, establishing the earliest iteration of the Intensive Care Nursery at Dartmouth, which he says “quickly became a model” for integrating families into the care team.
Over the past five decades, Dartmouth’s facility has evolved from a modest two-bed addition to the adult ICU to a state-of-the-art 30-bed Level 3 NICU. It now stands as the premier critical care center for newborns in New Hampshire and surrounding regions, treating approximately 450 babies annually. This growth reflects the broader evolution of neonatology from a pioneering field to a comprehensive specialty.
Now, family-centered practices actively encourage parental involvement, recognizing the crucial role families play in infant development. Tammy Lambert, MSN, RNC-NIC, the current nurse manager of the Intensive Care Nursery at CHaD, takes pride in even the smallest details of this approach. “The word ‘visitor’ is almost forbidden on the unit—the families are our partners,” she says. “We want families to feel like parents in the unit.”
Neonatology now also places a much stronger emphasis on creating healthy environments. The ICN pays close attention to noise reduction, appropriate lighting cycles, and minimizing stressinducing stimuli. These advancements, along with comprehensive support services, have significantly improved both survival rates and long-term outcomes for vulnerable newborns.
Carol Little adds that parents played a major role in neonatology’s evolution. “Part of that movement was led by
Intensive Care Nursery founder and medical director George Little, MD, and head nurse Linda Brown, RN, work with the original transport isolette in the early days of the Intensive Care Nursery, when it was just two beds rolled into the corner of the adult Intensive Care Unit.
families demanding more,” she reflects. “The Blanchards and families like them set the standard for family-centered care. They taught us how to collaborate with families by teaching us, leading us, and in doing so, they helped bring neonatology from infancy to adulthood. It’s part of the collaboration—the trust—that benefited us all.”
“Jesse was my teacher,” Albright, his nurse, agrees. “We all learned so much about the power of observation. Watching Jesse’s skin tone or how his body changed. He communicated to us in ways we hadn’t realized were important. They’re still important today: just looking at the baby and asking, ‘What are they telling us?’”
Steven Ringer, MD, PhD, Section Chief in Neonatology at Dartmouth Hitchcock Medical Center, says that while advances in neonatology have been remarkable, like any art or science worth mastering, he still sees room for improvement. “The environment, the structure, and their impact on babies and families remain critically important issues—sometimes glaringly—in the Dartmouth unit. We’re all learning together. The Blanchards have taught us where we’ve come from and where we need to go.”
Hope in the Hallway
Today, Jesse is 50 years old and a thriving artist living in New Mexico, married with two children. Wearing hearing aids since early childhood, possibly due to the incubator noise, he has found his calling in visual art. “I try to make happy art,” Jesse says. “Silly as that sounds, maybe there’s something innate in that.”
Several of his pieces now hang on display in CHaD, gifts of gratitude that serve as visual reminders of the progress in neonatal care and symbols of hope for families navigating their own NICU journeys.
Joanna Celenza, ICN family support specialist, recalls seeing Jesse’s art during her own experience giving birth to premature twins 25 years ago. “The hallway parents walk down to get to the ICN is a long one,” she says, “and when you have a baby in critical care, you don’t always know what you will walk into at the end.” But every day, she would gaze at Jesse’s “bright, cheery, abstract piece”—a canvas of comfort, of inspiration, in which she “saw something different [every day], just like my experience as a parent in the ICN.”
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The environment, the structure, and their impact on babies and families remain critically important issues—sometimes glaringly—in the Dartmouth unit. We’re all learning together. The Blanchards have taught us where we’ve come from and where we need to go.
Dartmouth Health Children’s Launches PEDIATRIC MENTAL HEALTH ACCESS
INITIATIVE
Among the many factors contributing to the mental health crisis faced by America’s youth, access to quality care remains a problem. Children and families encounter numerous barriers to care, such as transportation, time away from school and work, a shortage of providers, and ongoing stigma of seeking mental health care. These obstacles often prevent children from receiving the care they need in a timely manner—or at all.
To help alleviate some of these barriers, the Departments of Psychiatry and of Pediatrics launched the Pediatric Mental Health Access Initiative at Dartmouth Health Children’s, a multifaceted portfolio of programs that address various aspects of the youth mental health crisis with a specific focus on improving the impact and accessibility of quality care.
DHMC child psychiatrist
Katherine Shea, MD ’09, MPH ’15 (right), and behavioral health clinician manager Chase Trybulski, LCMHC, discuss the pediatric collaborative care model for implementing mental health care in pediatric primary care settings.
“There are people who are suffering every day, so we are trying to address these mental health problems earlier and expand quality services,” says Francine Morgan, MBA, the program director for the Pediatric Mental Health Access Initiative. “If you aren’t feeling like yourself, going to a therapist should be the same as going to your primary care doctor for strep throat. You can find information on Google, but that’s not quality care.”
Morgan says the initiative relies on three primary areas for success: connecting departments across the Dartmouth Health Children’s system, collaborating with external community partners, and innovating solutions to address persistent problems. The initiative currently spans the departments of pediatrics, psychiatry, community and family medicine, and population health, initially funded with a $1.5 million gift from the family and friends of Jonathan Guloyan, who dealt with mental health issues for many years before his death by suicide.
“We are trying new ways to reach providers and patients where they are,” Morgan says. She notes that the programs within the Pediatric Mental Health Access Initiative are “multiple doorways that lead to the same goal.”
Pediatric Collaborative Care: Creating the Model
Successful collaborative care models for mental health conditions have been well studied in adults, but there’s little research into how such models would work for pediatric populations. So, as part of the Pediatric Mental Health Access Initiative, the Dartmouth departments of pediatrics and psychiatry have joined together to greatly extend their implementation of a pediatric collaborative care model (dubbed PediCoCM, for short) in pediatric primary care settings throughout the health system. Clinicians are providing timely access to mental health care for children and gathering evidence to hone the model.
“Kids are more likely to engage with a mental health intervention when they’re in a familiar environment,” says Katherine Shea, MD ’09, MPH ’15, a child psychiatrist at Dartmouth Hitchcock Medical Center and assistant professor of psychiatry and of pediatrics at the Geisel School of Medicine at Dartmouth. “When a need is identified at a primary care visit, a behavioral health clinician (BHC) can come in at that moment and foster engagement early. The idea is to capture kids early to prevent exacerbation of psychiatric symptoms.”
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Going to a therapist should be the same as going to your primary care doctor for strep throat.
—Francine Morgan, MBA Program Director, Pediatric Mental Health Access Initiative
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It’s different from adult mental health care because kids come with families, so a lot of the work we do is with parent-child interactions.
PediCoCM is designed to help children with mild to moderate depression, anxiety, substance misuse disorders, and disruptive behavior through an integrated model that has been shown to improve access to care, improve patient outcomes, and reduce costs. BHCs are licensed, master’s-prepared clinicians embedded in primary care clinics to meet face-toface with patients, follow up with children and families about progress, and support primary care physicians in providing mental health interventions. BHCs meet weekly with Shea, who provides medical expertise as a child psychiatrist, making recommendations for changes to treatment if a patient’s symptoms are not improving.
“It’s different from adult mental health care because kids come with families, so a lot of the work we do is with parent-child interactions, not just medication,” Shea says, noting that the model is still in development; for example, clinicians are still figuring out the best ways to follow up with teens. (“They don’t like to talk on the phone,” for example, Shea explains.)
In addition to embedded clinicians in a primary care setting, the collaborative care model also involves patient screening and a patient registry to track progress and follow up. A PCP “champion”—either
an MD, DO, or APRN who is especially interested in improving mental health care access—will also be working at each primary care site to facilitate the PediCoCM program development, implementation, and evaluation.
“The collaborative care model provides short-term, evidencebased care within a week, rather than a child waiting months for an appointment,” Shea says. “Children really do improve when they get care quickly.”
Teleconsult Access Line for Providers
Pediatricians are often on the front lines of mental health care for children and adolescents, yet they may lack the specialized training and support required to meet the mental health needs of some of the most complex cases.
Child psychiatrists at Dartmouth Health Children’s are now able to bridge the gap between pediatricians and mental health specialists through the Child Psychiatry Teleconsult Access Line, which is part of the New Hampshire Mental Health Care Access in Pediatrics (NH MCAP) initiative that promotes access to children’s behavioral health care within the state.
Pediatric healthcare providers anywhere in New Hampshire can call the access line at 603650-4741 and schedule a free telephone consultation with a
child psychiatrist at Dartmouth Health Children’s, enabling pediatricians to address their patients’ behavioral and mental health issues more effectively within their practice.
The teleconsultation line, which is a collaboration between Dartmouth Health Children’s and the University of New Hampshire’s Institute for Health Policy and Practice, will alleviate multiple barriers to timely mental health care for children. After talking with a child psychiatrist, pediatricians will be able to offer mental health care immediately in a setting that’s familiar to the child and family, preventing the need for the patient to wait weeks or months to see a specialist.
“We will disseminate our knowledge to pediatricians anywhere in
New Hampshire to help them care for their patients, so these conditions can be treated earlier to prevent worsening symptoms,” says Jennifer McLaren, MD, DFAACAP, section chief of child and adolescent psychiatry and the medical director of the New Hampshire Bureau of Developmental Services. “If the child psychiatrist recognizes a complex problem during a teleconsultation, they can recommend a referral to a specialist if the child needs a higher level of care.”
This specialized line is an outgrowth of the broader eConsults program at Dartmouth Health, through which primary care providers can request specialty consultations on individual patient cases through the electronic medical record system.
In 2021, Dartmouth Health’s Department of Psychiatry created a permanent postdoctoral child psychology fellowship to embed specialized mental health support in the general pediatrics clinic at DHMC. The first fellow to complete the program, Christina Moore, PhD, was hired as a full-time faculty member after completing the fellowship. Now she spends part of her time practicing in the primary care setting with a team of two post-doctoral psychology fellows and a pre-doctoral psychology trainee.
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We can make sure that every child has a path forward in the very moment they are diagnosed . . . They can access quality care right away, and they won’t have to wait for months for an appointment with a specialist.
—JT Craig, PhD
Child Psychologist, Dartmouth Health Children’s Assistant Professor of Psychiatry, Geisel School of Medicine
Bridging the Gaps With Tool for Parents
Families will soon have direct access to a new tool to supplement traditional behavioral healthcare called Behavior Bridge, a self-guided digital health intervention for parents of children and adolescents with behavior issues. The program is expected to be available for pediatricians to distribute to parents by early 2025.
“Getting quality care can make a long-term difference in a child’s life,” says JT Craig, PhD, a child psychologist at Dartmouth Health Children’s and assistant professor of psychiatry at Geisel. “We can make sure every child has a path forward in the very moment they are diagnosed with ADHD. They can access quality care right away, and they won’t have to wait for months for an appointment with a specialist.”
The Behavior Bridge content is delivered through video modules that provide evidencebased information and practice activities so parents can apply the skills with their child—giving the family a path forward when a therapist isn’t immediately available.
“We have packaged the most effective intervention skills into mini videos, and parents will be able to access these videos freely on their own time,” says Christina Moore, PhD, FEL ’22, lead supervisor of child psychotherapy training, a child psychologist at Dartmouth Health Children’s, and an assistant professor of psychiatry at Geisel who is working with Craig on the project. “We’ve delivered this information through telehealth with trained therapists who walk parents through the same content. So why not make it even easier for parents to access?”
Behavior Bridge is currently being tested and vetted in focus groups with child healthcare providers as well as with parents who are dealing with challenging behaviors.
“Pediatricians might not know how to help a 4-year-old with ADHD,” Craig says. “But not intervening can leave that child with significant problems throughout their life. So, this is an opportunity for pediatricians to be able to offer the parents our program and get the child the help they need.”
REWARD PROCESSING IN A CHILD’S BRAIN MAY PUT THEM AT HIGHER RISK OF OBESITY
The child obesity crisis in the United States is often blamed on bad parenting or poor self-discipline. But researchers at the Geisel School of Medicine at Dartmouth have found that genetic factors play a wider role in weight gain than we previously understood—and that there are steps we can take as a nation to help reduce obesity rates among children.
“There has historically been a misunderstanding that individuals with obesity lack self-control compared to those without obesity,” says Diane Gilbert-Diamond, ScD, professor of pediatrics, of epidemiology, and of medicine at Geisel School of Medicine.
“We now know that genetic factors may cause some individuals to have a stronger drive to eat compared with others. We must acknowledge the rewarding aspects of food.”
She explains that ultra-processed foods (junk foods) such as cookies, chips, and candy are engineered to be especially rewarding to eat, and some people are genetically predisposed to have a higher
attraction to food—their dopamine reward for eating is higher—creating a cycle that is hard to break. These individuals have more motivation to eat, making it more challenging to maintain a healthy weight, even with high levels of self-control.
Understanding the biological differences in children at risk for obesity will help caretakers and healthcare providers develop personalized interventions to help them manage their weight and grow healthily, Gilbert-Diamond says.
In addition, she says there are steps we can take collectively as a nation to help reduce child obesity rates, starting with re-evaluating food advertising.
“ There has historically been a misunderstanding that individuals with obesity lack selfcontrol compared to those without obesity.
—Diane GilbertDiamond, ScD Professor of Pediatrics, of Epidemiology, and of Medicine, Geisel School of Medicine
Children themselves frequently encounter food marketing, and that can lay the groundwork for long-term challenges with weight, points out Jennifer Emond, MS, PhD, associate professor of pediatrics and of biomedical data science, and the assistant dean of the health sciences master’s program at Geisel.
During the COVID-19 pandemic, she noticed one of the educational websites her daughter used for remote learning showed ads for sugary cereals and McDonald’s Happy Meals. Emond partnered with the Center for Science in the Public Interest to urge the website to remove the ads. The website agreed to do so, but Emond stresses that food marketing to children remains a problem because there are no federal policies to hold companies accountable.
Emond has conducted numerous research studies measuring how food advertising targets children and correlates to weight gain. For example, one study showed that when a company targeted children, ads focused on entertainment, often showcasing a toy more than the food. When targeting parents, however, the company’s ads emphasized love and bonding.
“These ads are reaching kids when they’re really young, and that shapes their attitudes toward food, which can persist
as they get older,” Emond says. “Legislators need to support policies to monitor food advertising and create repercussions for companies that target children.”
Emond and Gilbert-Diamond are both member researchers at the C. Everett Koop Institute at Dartmouth, which generates rigorous science examining the influences—such as advertising and genetics—that drive unhealthy, disease-causing behaviors. With this knowledge, researchers at the Institute have become advocates for policies that protect public health, especially in children.
Gilbert-Diamond notes that other countries have seen results after implementing such laws to curb food advertisements that target children. For example, after Chile enacted stronger regulations on the marketing of unhealthy foods—including marketing to children and bans on sales of these foods in schools—research showed that fewer households bought beverages labeled as unhealthy (high in sugar, sodium, saturated fat, and/or calories). The study noted that purchases of healthy foods increased slightly as well.
Gilbert-Diamond is encouraged by those results and what it could mean closer to home. “Our research helps lay the groundwork to support similar action in the U.S.”
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These ads are reaching kids when they’re really young, and that shapes their attitudes toward food, which can persist as they get older.
—Jennifer Emond, MS, PhD
Associate Professor of Pediatrics and of Biomedical Data Science, Assistant Dean of Health Sciences, Geisel School of Medicine
meet ROWAN
A 2024 CHaD Kid HERO
Rowan began his life in the Intensive Care Nursery (ICN), as he was not getting enough oxygen to his brain when he was born. He was unable to breathe on his own, and the team at the Children’s Hospital at Dartmouth Hitchcock Medical Center (CHaD) immediately began treating Rowan— helping his brain heal in those first critical hours.
“It’s because of CHaD and the amazing staff in the ICN that Rowan is now a happy, healthy 4-monthold!” says Lauren Day, Rowan’s mom. “Every single person we met while Rowan was in the ICN was amazing—from his nurses and providers, lactation consultants, occupational therapists, speech and language [therapists], etc.
“We will never forget the exceptional care and compassion we received from everyone caring for Rowan.”
Today, Rowan continues to see CHaD specialists, including his pediatrician, his cardiology and audiology team, and the team at CHaD’s Transitional Long-Term (TLC) Clinic. Together, they are ensuring that Rowan’s childhood going forward is as normal as can be.
Rowan was one of the kid HEROs celebrated during this year’s CHaD HERO event in support of CHaD and Dartmouth Health Children’s. To learn more about the CHaD HERO, go to chadhero.org.
