Implementation Strategies for Baby NINJA (Nephrotoxic Injury Negated by Just-in-Time Action) to Prevent Neonatal Medication-Induced Kidney Injury

J Pediatr Pharmacol Ther. 2023; 28(4): 287–296. doi: 10.5863/1551-6776-28.4.287.

Sadie B. Stone, PharmD, Elizabeth Bisaccia, PharmD, Mary Soliman Zakhary, PharmD, Ferras Bashqoy, PharmD, Deborah Wagner, PharmD, and Christine Stoops, DO, MPH

Reviewed by: Cindy Bao


Acute kidney injury (AKI) is a common but often overlooked condition in the neonatal intensive care units (NICU). The AWAKEN study, focusing on neonatal AKI, revealed an incidence of 29.9%, with varying severity levels. AKI poses a substantial financial burden due to extended hospital stays and long-term complications, and it is an independent risk factor for mortality, necessitating prompt identification and intervention. While there are a variety of risk factors that contribute to the development of AKI in the NICU population, nephrotoxic medication (NTM) exposure is a common and modifiable risk factor and NTM stewardship is crucial for reducing AKI incidence.

The ongoing Baby Nephrotoxic Injury Negated by Just-In-Time Action (Baby NINJA) quality improvement (QI) project is targeted towards NICU patients at high AKI risk from NTM by monitoring serum creatinine concentrations daily during and after NTM exposure.

What was the purpose of the review?

The article seeks to describe nephrotoxic acute kidney injury (NAKI) in neonates, introduce the Baby NINJA QI project, and highlight its potential to mitigate neonatal AKI. Additionally, this review outlines effective strategies for implementing the Baby NINJA project in a healthcare setting.

What were the key findings and/or contributions of the review?

The article describes the initial NINJA project which was a multicenter QI project aimed to prevent NAKI via early identification of NTM exposure and originally only included paediatric patients who were not admitted to an ICU. It details the definitions used for NTM exposure and the NTMs that were included in the project. This NINJA QI project showed 23.8% reduction in NAKI rate through autoregressive integrated moving average (ARIMA) modeling and statistical process control analysis.

This QI project was then adapted to work within the NICU setting in 2015 as the Baby NINJA QI project. The implementation of this QI project resulted in statistically significant reductions in NTM exposures, in incidence of NAKI and in AKI intensity.

The article details important points in the implementation of the Baby NINJA QI project. Specifically, it emphasizes the importance of strong collaboration within a multidisciplinary team to achieve successful implementation – this includes neonatologists, paediatric nephrologists, clinical pharmacists, medication safety officers. The integration of Electronic Health Records is also extremely useful to provide accurate data, increase efficiency and improve implementation of the Baby NINJA project into daily clinical tasks.

The article also provides a step-by-step guide for implementation of Baby NINJA in Table 4.

What are the implications?

Neonatal AKI is a prevalent complication resulting in potential long-term issues and NTM exposure is a modifiable risk. Accurate AKI identification is crucial for prevalence estimation and risk quantification, necessitating follow-up plans for at-risk infants. Although minimizing NTM exposure is ideal, their use may be necessary for optimal clinical outcomes. The implementation of a comprehensive NICU monitoring system like Baby NINJA can significantly improve renal health in neonates. A collaborative approach involving neonatal clinical pharmacists, neonatologists and nephrologists is key to the successful implementation of Baby NINJA.

Future Areas to Explore

Dissemination of how NICUs without an EMR and/or without dedicated unit pharmacists successfully implemented Baby NINJA would be appreciated.