Ignite | Fall 2022
My Gracious: Petrea Cober
BY RODERICK L. INGRAM SR.
At some point in our adult lives, many of us will be in a physical condition that warrants some level of feeding support to deliver calories and nutrition to our system. When that support cannot be done orally, we will then rely on either parenteral nutrition (intravenous feeding) or a method of feeding that provides calories through a tube that connects to our stomach or small intestine — a gastrointestinal tract method known as enteral nutrition.
Neither sounds very pleasant. And the mere thought of these alternative but necessary methods becomes even more painful when one imagines their own child in need of them.
Maybe there are no good words to describe the feeling a parent must have during these times. Perhaps there are even fewer words of comfort that a care provider can offer to ease a parent’s concerns. The expression “my gracious,” is not one that immediately comes to mind. Yet this phrase — a combination of concern and knowledge wrapped in a blanket of hope and kindness — seems perfect, especially when you hear it from Petrea Cober, Pharm.D., a highly skilled pediatric specialist, nutrition expert and physician consultant by design. A clinical pharmacist, postgraduate year one (PGY1) residency director at Akron Children’s Hospital, and NEOMED professor by trade. A southern comforter by nature.
“In neonatology, nothing that is pharmaceutically made, is made for a baby … like they don't make the stuff. So, I have to manipulate things through dilutions and different processes to make it in a form that I can get into the baby,” the nationally recognized parenteral and enteral nutrition expert said, explaining a really complex challenge in the simplest way.
INQUIRY AND EXPERIENCE
“I am a NICU [Neonatal Intensive Care Unit] person by heart and now a neonatal pharmacist,” Dr. Cober said. “While my husband [Eric] was in medical school at Penn State, I was a first-year pharmacy resident. I had applied for a second-year residency in pediatric pharmacy so I took some more advanced peds rotations, but I also told them that I would like to do more nutrition rotations, but they didn’t have a pharmacist who did nutrition support.” So, she asked if she could work with a dietitian to explore more on parenteral nutrition.
Dr. Cober then went to the University of Michigan to complete her second-year residency in pediatric pharmacy. She was still very interested in nutrition support and asked if the U-M’s very talented nutrition support pharmacist could take her on a rotation even though he primarily worked with adults. No problem. Dr. Cober suggested a special rotation in the children's hospital, and the attending physician agreed. “He was like, ‘Oh, I need a body!’” Dr. Cober added with her signature self-effacing humor.
Upon completing the rotation, which included managing various nutrition support patients throughout the children’s hospital, she was presented with a job offer. “Eric was going to be in Michigan for his residency and then fellowship for many years, so I was definitely interesting in hearing about the new position,” Dr. Cober said. “They said they have a new position that would work with a pediatric surgeon, who needs lots of help with nutrition. And they thought I would be great for this job. I said ‘OK, but remember I'm not that blood-and-guts kind of girl.’
“I stepped into the role and within the first month I realized they needed a lot of help with nutrition because they were managing all of the surgical babies in the NICU, all of the surgical patients in the PICU [Pediatric Intensive Care Unit], and children with short gut syndrome [also known as short bowel syndrome — a condition in which the body is unable to absorb enough nutrients from food because there’s not enough small intestine],” Dr. Cober said. “And so, I became the University of Michigan’s pediatric parenteral nutrition person.”
Dr. Cober’s forward-thinking attending physician approached her one day with an idea. “He came to me on a Friday afternoon at 4:30 and goes, ‘I just went to this conference and I want to try something that someone's doing,’” Dr. Cober chuckled while explaining the interaction. “I'm like, oh goodness don't ever trust a surgeon when they say ‘I've got something for you,’ because it's gonna be a doozy.”
The attending expressed his concern for the hospital’s kids with intestinal failure who were on parenteral nutrition. He said there were a lot of infections in their IV access site and wanted to try a method he learned about at the conference.
“He said he heard about some Hem/Onc [Hematology/Oncology] children who received a solution of 70 percent ethanol in their catheter to clear out the infection. And it worked,” Dr. Cober said. “I said ‘well, that’s going to take me a little bit more than 30 minutes on a Friday to get this process started.’ And he said, ‘well, let's make a protocol and see what we can do.’”
The thought of putting 70 percent ethanol in a child’s IV access makes people nervous. As a result, the protocol ended up being 20-pages long.
But it was a new approach. And one that led to a presentation by Dr. Cober at a conference of the American Society for Parenteral and Enteral Nutrition (ASPEN).
“I had never heard about these people before. But because I was a pharmacist and it [ASPEN] was a multidisciplinary organization that does nutrition support, I said sure,” Dr. Cober noted. “So, I go to the conference and it's like what I do all day long — you know, writing nutrition support and taking care of these children. So, I thought, ‘well, this is really interesting.’
“I present my poster on our project and get a lot of questions about it. They have different sections, you know, like pharmacists and pediatrics. I go to the pharmacy one and find people like myself who do pharmacy and peds. So, I asked, ‘How can I help this organization more?’”
EAST BY NORTHEAST
Raised by math and science teachers and growing up as the oldest of four children in East Tennessee, Petrea Cober was destined to be a pediatric pharmacist. She always had to take care of the younger children, so her pediatric interest came as no surprise. The pharmacy part that emerged wasn’t as clear, but she was really big into math and science — foundations to do well in the profession. Dr. Cober’s talents and experiences were a recipe for teaching or pediatrics, but she didn’t want to just be a teacher and since she didn’t like “blood and guts,” medicine wasn’t desirable. By the time she reached the ninth grade though, Dr. Cober knew she wanted to be a pharmacist.
“I remember telling people and that I'm going to be a pharmacist and I'm going to work in a hospital,” said Dr. Cober. “You know, because when I was a ninth grader, all you saw was retail pharmacists, and that was it. But I knew about these pharmacists who worked at hospitals.”
Dr. Cober attended Lipscomb University in Nashville, Tennessee, and earned a B.S. degree in biochemistry before enrolling at the University of Tennessee Health Science Center to pursue her Doctor of Pharmacy degree.
“After finding out during undergrad what it took to become a pediatric pharmacist, I was like ‘I'm going to become one.’ In pharmacy school, I really made sure I did everything it took to become a pediatric pharmacist. I did the pediatric elective, but back then we didn't even have pediatric pharmacy organizations for students, so you would become a member of the American Pharmacists Association [APhA], but you would join organizations that were peds-focused like poison control and asthma education. I also did a peds research project and a ton of pediatric rotations.”
She took on everything that was available to her.
“In my final year in pharmacy school, there was a pediatric rotation in nutrition support at the Le Bonheur Children's Hospital, where the pharmacist actually ran that service. So, the physicians would call and they would say that ‘you have this much fluid to give my patients,’” Dr. Cober noted. “And that's all they would say to you. So, we were taught to write everything that patients would get intravenously and we’d do all the calculations — we didn't have computer programs.
“And I really enjoyed it. [Upon earning a Pharm.D. degree] I went on and did my first- and second-year residencies, following my husband to the University of Michigan, which led to work with ASPEN, where I periodically would teach how to write parenteral nutrition,” Dr. Cober added. “The mentor I had at Michigan was a surgeon named Daniel H. Teitelbaum. And when he became the President of ASPEN, he nominated me to be on a committee. So I got involved in several committees.”
Those experiences led to Dr. Cober becoming a pediatric pharmacist first at the University of Michigan and then at Akron Children’s Hospital, where she’s been for the last 12 years. Staying in contact with those at U-M and remaining involved with ASPEN, she has been able to make parenteral nutrition her own, chairing several committees.
She had also been faculty at U-M, but as the youngest pediatric member, she received all the lectures that no one wanted.
Wanting to go to a place where she could really help people and teach people, she found NEOMED.
Reflecting on her upbringing, Dr. Cober says, “I come from very rural East Tennessee, and when my husband finished all his training, we were looking at places where I could be able to teach a lot more pediatrics. Rootstown is a lot like my hometown.
“I remember starting the first day at NEOMED. They said, ‘we understand you like nutrition.’ I said ‘yeah, I’m board certified.’ So, they added that their nutrition person had just left, and asked if I could teach in like two months. And I was like, sure.”
As a huge advocate within ASPEN and many other pediatrics and pharmacy organizations, Dr. Cober emphasizes the need to teach people nutrition support skills, because technology does it for them now and they don't understand how to do it themselves.
As a professor of Pharmacy Practice at NEOMED, she makes an effort to teach the extremely practical applications of nutrition support and pediatrics. She tells students that they need to have this knowledge to be able to answer general pediatrics questions, or if they're in the pharmacy, to explain how to compound medicine.
“I’m now a fellow of the American Society for Parenteral and Enteral Nutrition and I always tell people that it all started with this weird project I got on a Friday at 4:30. And it really has led to who I am in my professional identity as a pediatric pharmacist and as a nutrition support person,” Dr. Cober said.
Because there aren't many pediatric nutrition support pharmacists left, she spreads her knowledge whenever possible.
She once met a person at the pediatric pharmacy conference who was interested in nutrition support. “She came up to me and she talked to me, and I said, ‘Oh, I got stuff for you,’” Dr. Cober recalled. “So, I've slowly been handing things down, you know and getting her involved in similar things. I tell her someday I gotta retire and there's some people above me that are already retiring, so I got to train the junior generations, or I won't get to retire,” Dr. Cober chuckled.
MESSAGE TO FUTURE LEADERS
Dr. Cober’s work in preparing future pediatric pharmacists is a pretty heavy load. She not only teaches pharmacy students at NEOMED, she also teaches pharmacy and medical residents at Akron Children's. And she teaches pharmacy residents, new trainees, dietitians and many others within ASPEN. She’s intent on sharing her experiences.
Her life with husband, Eric, 13-year-old son Ben, and Sophie — their “crazy” golden doodle — is also pretty full. And as she teaches preschool at church and often works with Ben’s various activities, life is also fulfilling.
“I tell people that if I wasn't going to become a pediatric pharmacist, I would have been a kindergarten teacher. I've always been drawn to children — those in the NICU in particular. You know, they got the bad luck of the draw,” said Dr. Cober.
Recognizing the realities of her work, she adds, “Students come to me on rotations often and they ask how do I deal with it when babies die? And I say, ‘well you know what, those babies didn't do anything to get here and it's not always fair. But I do everything I possibly can to get them home [with their parents].’ Unfortunately, some of them don't get to go home. But I know that I have done everything [I can]. I know that there is nothing that I have not tried or done to help them get better.”