World-class Pediatric Care for When the Unexpected Happens

Today, Lamar Carter Jr. is an active, thriving toddler—an image that would have been unimaginable when he was born almost two years ago with multiple life-threatening conditions. His remarkable outcome was made possible by the extraordinary prenatal and pediatric care he received at Mass General for Children, one of the few hospitals in the United States equipped to handle such complex cases.

"Before he was born, Lamar was known to have some issues that were highly treatable," said pediatric nephrologist Weizhen Tan, MD. "But sometimes with newborns, the unexpected happens. And when it does, as it did with Lamar, it's good to know your child is at a hospital capable of delivering the highest level of care."

Early detection at the Fetal Care Program 

When Alicia Carter became pregnant with Lamar Jr., she and her family were living in Charlotte, North Carolina. During her first trimester, an ultrasound caught two significant concerns in her baby: an enlarged kidney and an arteriovenous (AVM) malformation in the liver, a potentially deadly disease. Both conditions would need to be treated once Lamar Jr. was born. 

Soon after, the family moved to Norwood, Massachusetts, where Alicia began prenatal care at Newton-Wellesley Hospital. There, an ultrasound at 24 weeks showed that Lamar Jr. also had: 

• Ureteropelvic junction (UPJ) obstruction, a blockage where a kidney meets the ureter (the tube that carries urine from the kidney to the bladder)
• Bilateral hydronephrosis, a buildup of fluid in both kidneys caused by the UPJ obstruction
• A mass on the liver

Fortunately, Alicia was receiving care from the MGfC Fetal Care Program at Newton-Wellesley. The program includes obstetricians, maternal-fetal medicine specialists, and other doctors who have expertise in managing high-risk pregnancies and see children from all Mass General Brigham hospitals. 

"If the Newton-Wellesley fetal care team detects any anomaly, they'll refer the family to the MGfC fetal care program, which can consult any of the specialists at MGfC if needed," Dr. Tan said. "Even though Lamar's conditions were understandably scary for his parents, our doctors and surgeons have treated them many times before. We have all the resources needed to care for a complex patient like Lamar."

Expertise in pediatric nephrology and urology

The day after the ultrasound, Alicia and Lamar Sr. had their first appointment with Dr. Tan and pediatric urologist Beth Drzewiecki, MD. 

The two doctors outlined the plan for the next few months. The fetal care team at MGfC would continue to closely monitor both mother and baby for the rest of the pregnancy, with guidance from various specialists. After birth, Lamar Jr. would need an operation to repair the UPJ obstruction. Since both kidneys were affected, surgery might need to be done soon after birth.

"At our first visit, Dr. Drzewiecki made sure we understood the procedure, why it was necessary, and the aftercare," Alicia said. "She was always very welcoming and informative." 

Dr. Tan also earned praise for his communication skills. "He's been very involved with us every step of the way, always reaching out to us via Patient Gateway or phone," Alicia added. "And if there's ever anything we don't understand, he'll break it down for us." 

When Lamar Jr. was born, his care team discovered additional medical issues. He was experiencing meconium aspiration, which occurs when a baby's first stool gets into the lungs during or before delivery. This required immediate intubation (insertion of a breathing tube into the airway) and resuscitation. 

Lamar Jr. was then moved to the Neonatal Intensive Care Unit (NICU). There, he was started on antibiotics to treat meningitis, a rare bacterial infection that had spread to his blood and potentially into his cerebrospinal fluid. 

A team of pediatric specialists, including Drs. Tan and Drzewiecki, cared for Lamar Jr. in the NICU, with support from specialists in infectious diseases, hepatology, cardiology, gastrointestinal surgery, gastroenterology/nutrition, and hematology. Neonatal physicians and nurses coordinated his care and the efforts of the entire team.

The antibiotics successfully cleared Lamar Jr.'s bacterial infection within a couple weeks. Meanwhile, the mass on his liver and the AVM malformation, both of which the team carefully monitored, gradually went away without any intervention.

"He began eating more and getting bigger," Lamar Sr. said. "He did a complete 180 in the NICU." 

Much to the relief and delight of his family, Lamar Jr. was able to go home after about three weeks.

Although Lamar Jr. had been discharged, treating his UPJ obstruction remained a priority. Ultrasounds revealed the blockage in his left kidney was getting worse, causing urine to build up. At three-and-a-half months, he returned to MGfC, where Dr. Drzewiecki conducted pyeloplasty surgery.

Pyeloplasty in infants involves making a small incision (cut) on the side of the body. That allows the surgeon to access and remove the part of the UPJ causing the blockage and place a stent (small tube) to reattach the kidney and ureter. The stent is removed a few weeks later, after the area heals. 

"Operating on such a small baby with tiny tubes and a very swollen kidney is a technically difficult surgery," Dr. Drzewiecki said. "It's important that a fellowship-trained pediatric urologist performs the operation." 

Follow-up ultrasounds showed the swelling in Lamar's kidneys steadily decreasing, meaning the surgery was a success.

Evidence-based medicine and continuity of care  

Unlike independent children's hospitals, MGfC is part of a larger adult hospital, Massachusetts General Hospital. This enhances the quality of care that children and their families receive. 

To understand why, first consider the ability to practice evidence-based medicine, where doctors make treatment decisions based on the best available scientific evidence. Much of this evidence comes from clinical trials, which test new treatments and devices. However, children are often excluded from these trials due to medical concerns.

At MGfC, doctors have a solution to this: their close collaboration with Mass General doctors who treat adult patients. 

"It's easy for us to leverage the cutting-edge, evidence-based medicine and clinical trials our adult colleagues use and apply that knowledge to some of our pediatric patients," Dr. Tan said. "That's not so easily done at a pediatric hospital that's not affiliated with an adult hospital." 

A second important benefit MGfC offers is continuity of care. For example, some newborns have chronic kidney disease and/or will require a kidney transplant when they're older. In cases like these, Mass General can eventually take over their long-term care. 

"If your child has a lifelong disease, MGfC can take care of them now," Dr. Tan said. "And when they outgrow pediatric care, we can seamlessly transition them to adult care, thanks to our close relationship with Mass General." 

As he nears his second birthday, Lamar Jr. is thriving and hitting all his developmental milestones. 

Dr. Tan will continue to monitor Lamar Jr.'s kidney function as he grows, but the long-term outlook is excellent. "He has no restrictions on his diet or activity level, and he's not on any related medications," Dr. Tan said.

The Carters are thrilled that Lamar Jr. has found a medical home at MGfC. 

"He's doing so well, and we're blessed for the care he has received," Alicia said. "We were so scared when I was pregnant, but the end result has been great."