The promise of saliva assays knows few boundaries

This article was originally published 9/19/2022 in ConvergenceRI.com.PROVIDENCE, R.I. – This week, Dr. Jill Maron, MD, MPH, the Pediatrician-n-Chief at Women & Infants Hospital, will be presenting a series of lectures at the 10th annual “Current Concepts in Neonatal Care” conference in California, featuring the results of her cutting-edge clinical trials, focused on non-invasive saliva assays of newborns.One of her talks, entitled “Integrating Salivary Diagnostics Into Newborn Care: From Assessing Development to Predicting Morbidities,” showcases how the saliva assays can enable caregivers to monitor development in newborns in real time, focused on feeding responses.For Dr. Maron, the results from the clinical trials represent the culmination of her work for the last 15 years, focused on non-invasive saliva assays, with the next steps leading to the potential to translate the research into market applications, improving health care outcomes for newborns – and potentially jumpstarting the creation of a new technology hub in Rhode Island, focused on saliva assays.As Dr. Maron described in an interview with ConvergenceRI a year ago, “We don’t hurt a baby to collect saliva. There is an enormous amount of information that can be obtained from a baby’s saliva. And, it gives us that real-time window into what they are doing developmentally or from an infection standpoint today – what is going on today with them.” [See link below to ConvergenceRI story, “On the cusp of a revolution in the care of newborns.”]Here is the ConvergenceRI interview with Dr. Maron, with the promising results from her clinical trials putting the research enterprise in Rhode Island in the spotlight.ConvergenceRI: Of all the interviews I conducted last year, yours is one of the ones that still resonated the most for me. Because you are, in my opinion, opening up a whole new way to look at the delivery of health care for newborns with your innovative approach of using the clinical, non-invasive assays of saliva. Let me begin there. Are you still excited by it and the scope of your research?MARON: I absolutely am. And, I think what we’ve shown over the years, which I think is really exciting, is that we are able to utilize just a drop of saliva from these babies and detect multiple analytes – whether it is a microbe, a protein, or a gene being expressed.We are able to really integrate that technology into newborn care. And, that first major hurdle has been passed and validated. Not just in my own lab, but in other labs around the country, around the world, and at companies that are developing assays to salivary testing.The next big hurdle that I have, that I will probably spend the next 15 years [working on], is how do we harness that information that we know is readily there, readily detectable, into clinically actionable, meaningful, reliable readouts for the caregiver.And, that is a big challenge for us, because these babies are continually developing; they can be as small as 400 grams or as big as 4,000 grams.Their anatomy is changing during that time. And so, we have to have a very good understanding of what “normal” is for each week that we see for different birth-weight categories.That’s where we stand now. It’s not, “Can we do it?” or“Is there a wealth of information there?” All of these things have been shown to be true – and validated.The field is now charged with, “OK. How are we going to develop the assay or assays that provide really meaningful clinical data?’ConvergenceRI: Where are you with your clinical trials? How are those clinical trials progressing? Will the challenges that you just [articulated] get answered by [the results] from those clinical trials?MARON: That’s a great question. One trial is just completing. We are finishing our final follow-up data collection. And that [trial] looked at how premature babies learn to feed, from a developmental standpoint.And, in our data analysis, what we learned was that we actually could do an intervention with a baby to help progress a more mature oral feeding pattern.When we did that, we could actually watch what systems were developing more rapidly in that baby. So, for example, oral motor skills, the hunger signaling pathways, that are so essential to us understanding knowing when to eat: we eat when we feel hungry. We actually could chronicle that over time. Now, this particular assay is really developmentally focused. It would be years in a baby that we are worried about, [and] don’t know why they are not eating. We want to help them reach this first developmental milestone.So, as we are going through that data, and I actually will be out in California next week presenting it, one of the things that we learned was that it is really essential to do feeding interventions while they are actually being fed through a tube.And, during that process, we can actually see their hunger signaling begin to mature, which helps them expedite their feeding skills.ConvergenceRI: Where are you presenting this data in California?MARON: In Southern California, outside of LA, it’s Symposia Pediatrica. We also will be attending a week-long conference where I will be presenting data from all the clinical trials. The genetic trials, the feeding one I just spoke about, and then the infectious disease, with salivary-cytokine data. I will send you the link, Richard.ConvergenceRI: That would be great. Thank you. Is there an opportunity for this data to be presented here in Rhode Island? Are you now focused, as I understand the research enterprise, you do it, and then you have to get it published?MARON: Exactly. And then, hopefully, that leads to more funding. As we are finishing our final follow-up visits with our infants; because we followed them up through 18-24 months, there will be a series of papers that will be coming out of this work, and then we will regroup, to say: Where do we want to take it from here? How do we want to use that information?And, is there a way to bring this a little bit closer, either toward the research aspect, or to marketing side?I think the feeding study really shows us that you can monitor development in these babies in real time with our salivary [assays].There is great potential there. There is always the real goal of bringing this to market, and getting it into the NICU. But, it is also the fact of sharing it with your colleagues, so that their own labs can do the validation, which is important. But, more importantly, to me, is, to grow off of these studies, to say: I want to look at this problem. I want to look at that. And, I know that these developmental markers are going to be in their saliva, so I don’t have to stick them for blood.I don’t have to do something invasive, something that you don’t want to do to babies.ConvergenceRI: Is there an opportunity to share this data in Rhode Island?MARON: Yes, of course.ConvergenceRI: Hypothetically, if I, as an interested party, wanted to set up an opportunity for you to present this data, how would I do that?MARON: You could just reach out to me. At national meetings, at international meetings, I am happy to speak about what we are finding, to anyone in the state. Obviously, we are continually writing grants. But always, if there were interested parties, or other grant opportunities that I am not aware about at the state level, that would be interested in funding more of this research, I am obviously always open to that.And, I would be happy to share the experience I’ve had since 2008, now going on 14-15 years, working in saliva, and the story that has had to unfold to get us to this point, acknowledging that we still have a ways to go.ConvergenceRI: That would make a great thing for ConvergenceRI to co-sponsor, at some point. In 2016, I sponsored a conference on toxic stress in children. I have always been looking for topics where there was an opportunity to bring forward the research and how that affects policy. There is so much that the politicians don’t get – if I said that properly.MARON: I understand.ConvergenceRI: There is a new capital campaign underway at Women & Infants Hospital. It seems to be successful. There seems to be greater interest in undertaking new research at Women & Infants. I saw there was a recent news release about some new funding. Could you talk about the role of research and how your work has hopefully spurred on an interest in expanding this kind of research?MARON: Absolutely. I want to relate it to the capital fund-raising effort that’s going on, to put it in context. Over 10 years ago, they gave us a state-of-the-art NICU. And, this is really the opportunity to give us a state-of-the-art labor-and-delivery facility for the state of Rhode Island, which is so important.Along with that, as philanthropy speaks to potential donors, they have the potential to invest in research. And, the research aim for this is really perinatal [before birth], with a mother focus, for sure, because it is [focused on] labor-and-delivery initiative, so most of the research is spearheaded a little bit more toward women’s health and perinatal health.Saliva for me knows no boundaries [emphasis added]. I don’t know if we talked about this in our last conversation, but one of the other areas I have been looking at is the development of non-invasive maternal assay to screen for pre-eclampsia [a dangerous complication in pregnancy, characterized by high blood pressure].That work I brought here, it got funded here at our perinatal institutes, and here moms at the clinics are providing saliva samples, and we are trying to see,could we have detected those at risk for pre-eclampsia later in the pregnancy.The team is collecting saliva and analyzing it. In terms of the perinatal concept, not just in neonatal, we are really looking at the moms as well. That work certainly has taken off since I came here.Again, early stages of this [research] take a lot of work to do to prove that saliva could be a viable option, but these are the types of assays that not just the field needs, but the world needs, because when we look globally, women worldwide are actually dying of eclampsia, because they can’t get to a clinic in time, and they are not screened as well as they are in the United States.One of the other areas that we talk a lot about in perinatal health is how do we bring some of these assays globally, and is there an opportunity for us there.So, I think over the course of the last year, we started that dialogue, and for me, it really is perinatal. I always say: “My babies have a medical history; it is called their mother.” [emphasis added]And, what happens to their mother during pregnancy directly impacts the baby. And so, I don’t shy away from trying to integrate some of the things I do [in my research] to the pregnant mother as well.ConvergenceRI: That sounds really smart, if I am allowed to compliment you.MARON: Oh, thank you.ConvergenceRI: One of the other clinical trials that you said you were involved with, if I am remembering it correctly, had to deal with neonatal abstinence syndrome. And, the interventions around treatment, because aside from being able to diagnose using the sound of the infant’s cries that one of your colleagues was working on, because it is still very difficult to understand exactly what is going on. I was wondering what the status of that clinical trial was – and what you found?MARON: I have been fortunate to be the mentor to the PI [principal investigator] who has really taken off on that research. Her name is Dr. Elizabeth Yen. And, she continues to run the trial up at my old institute in Boston.What she has also been doing, which I had never done, is she does MRIs of the baby’s brain – both those who were exposed to narcotics in utero, and those who were not.And she is starting to identify key areas that that initial paper is in revision at Pediatric Research. So, I am hopeful that will come out in the next one-to-two months, assuming all goes well.What she has been showing, in the human model, involving saliva, is that there is an increase in inflammatory response in babies who are exposed to opioids in utero, and that inflammatory response may induce some white matter brain damage. And, she correlates findings in saliva [assays], both as inflammation, cytokines, plus some of the markers we’ve been looking at for several years now, regarding reward signaling, in this population, with MRI findings that indeed have seen white matter changes.While animal studies have suggested that his were true, her work is really the first to show, in humans, these pathways hold true.That is really exciting for her. I am fortunate to be on all of these papers, overseeing the research. We met today, reviewing that data. I am hopeful that she will take off with this, and make this her own career.ConvergenceRI: All this research would seem to have incredible relevance to the real world, as it were. In terms of the potential of what research into saliva assays can show us, I was wondering, given all the things that are going on with COVID, and what’s called “brain fog” – there was a new article that Ed Yong just published in the Atlantic, trying to define what that is, whether this type of saliva assay would be helpful in terms of what it might potentially find in helping with the diagnoses related to Long COVID?MARON: Right. It is a great question. I can tell you, and perhaps we spoke about this before, it’s well known in the field that for whatever reason, there is an enormous amount of nervous system genes and proteins in saliva.In fact, there has been a lot of work done in [saliva] assays on the football field, soccer field, etc., for concussion risk. Where the individual who’s received the injury would spit, and it could be read out to say, what is your concussion risk?It’s really about nerve injury, that is what they are measuring. There have been other assays that have looked to see if they can [identify] the risk for autism, early on.My lab is one of the first to show these markers were there, but others have gone on to validate it. The areas that I am most familiar with have found the concussion assays, and the potential for autism assays as a screening. But, what I think is amazing is that when we talk about the brain or neurological injury, there is so much information in saliva.How it gets there, there is a lot of speculation. There is a lot of innervation in the base [of the brain], at the connection between our nose, up to our brain. [We don’t know if it is just passing through, or deliberate.] But it needs to pass in through the salivary glands and then, you know, it has some type of effects, systemically. I don’t think any of us know. Just that multiple labs are seeing it. And then, some are trying to really hone in on it, to develop practical assays.ConvergenceRI: Out of curiosity, and I may have asked you as part of the last interview, but there is this proposal to create a new state health laboratory to replace the current facility, which was overwhelmed by the demands from COVID. There is funding for it, but I have no idea what is happening with that proposal, But, as part of that, there was an opportunity to go in and secure corporate sponsors for some of that space at the health laboratory.It seemed to me that there was the opportunity to create an enterprise around saliva assays potentially. Do you need more space for your lab and more funding for the research you are doing?MARON: Yes, yes, and yes. You always do. It is interesting, because I was unaware of that [state health lab initiative]. And I was in conversations, I am working with another company that was securing funding, where we are going to be looking at both saliva and poop from the babies, we are going to collect diapers and their saliva, and we are going to be looking at how they get colonized, early in life, with different microbes, and how their bodies are responding to that colonization. Because we now have a very robust understanding of just how important those microbes are.And, we were talking about lab space and lab equipment that is regulated under, whether it is CLIA [Clinical Laboratory Improvement Amendments, under the direction of the Centers for Medicare and Medicaid Services], or an FDA-approved center, so that when you get the readouts, you can clinically interpret them, and give it back to the caregiver.So, taking it out of the research realm, which is purely observational, and we’re doing it in our own hands, versus a state-run lab, or a central lab under CLIA. I didn’t know anything about that, Richard.ConvergenceRI: My job is to ask good questions. Right now, and perhaps because there is an election going on, no one seems to be talking about the new state health lab. But it seems to me that the new state health laboratory would be a ready-made fit for the type of research enterprise that you are doing, to be located there, as a way to incentivize your research. On a national level, is there a need to get more federal money focused on pediatric research?MARON: Always. When we look across NIH, I think there are 26 either institutes or centers, and the Child Health and Human Development branch is always in the lowest rung in what gets funded.Sometimes I think that our children fall to the back burner. Unless, you have a family that has been affected by a certain disorder, or they have a passion about a certain thing and maybe they guide it. But, as a society, we focus a lot more on the adult diseases than we do the pediatric ones.ConvergenceRI: If you had a magic wand and could wave it, what would you like to see happen?MARON: In terms of the salivary assays, it is the hope in my career that we are effective at bringing up at least one diagnostic assay that is clinical meaningful and really impacts the care we provide to babies in a positive way.I don’t ever want to give the illusion that this is a magic vial of fluid. We learned through the years that it does have some limitations. And the due diligence has to be done with research that takes time to do it right. But, I do believe that we have the possibility, as we continue along this journey, to really bring something in, especially for these little babies, that can help us monitor them in the neonatal setting, without inflicting any harm, and that can really add meaningful information to the clinical care team to improve outcomes. That’s what I want to see. That would be if I get there, then I can retire.ConvergenceRI: If I were a betting person, and I’m not, I have a sense that I believe you will get there. What questions haven’t I asked, should I have asked, that you would like to talk about?MARON: One other thing, and we haven’t really focused on this, and this is also an area that I am very invested in, is, I run a large genetics trial as well. This is not done in saliva; it is done in blood. But it is, we are just finishing the manuscript now for submission, we’re going to be writing the second grant. We do rapid whole genomic sequencing on critically ill infants. And, we hopefully can give the family a diagnosis very quickly.This is an extraordinarily hot area in newborn medicine globally. The integration that these genomic testing platforms [bring to health care] are revolutionary, in terms of our diagnostic capabilities. But they come with enormous responsibilities to the patient.And, I’ve been spending a lot of time navigating each of those aspects. And, I will be speaking about them in California as well. Here we have this amazing technology, but we mustn’t forget to protect the child. When we integrate it, how do we find the balance? And how do we talk about it?By enormous responsibility, I mean once you sequence someone’s DNA, it’s forever. All of us have secrets in our DNA. All of us have some [information] that is more significant than others. For a child, the things we worry about is: What if we identify an adult onset disease. How do we protect every childhood but yet protect that child, so they have the information they need, when it is appropriate.About paternity; what do we do with that? We just can’t look away. It is not appropriate. But how do we handle that, so that if the child wants to know, they have access to it.When you talk about sequencing a baby and then upload it into national databases, we are not protecting them at all, because the FBI can go in and say, “But I want it now.” These babies have never consented to be sequenced. And, these are very heavy topics. Incest is another one; how do we handle it.And, just pretending that we don’t see it, looking away, is not the answer. We have to, as a medical community, say: these tests bring an enormous amount of information that can be very helpful to our patients, maybe even life-saving. But, there is a responsibility. And, we have to protect the baby here. How are we going to do that? How are we going to say, as the child comes of age at 18, “You need to know that you were sequenced when you were born.”You have a right to have access to that information, if you want. And, we have to help you through that process, because it can be very upsetting, depending on what lies in someone’s DNA. It’s never a one-and-done test. It’s forever.