NC Pediatric Society Fall Open Forum 2010

Those of us who had the privilege of sleeping at the Sheraton Imperial Hotel Durham awoke this morning at 5:30 to a shrill repeated whooping sound that could only mean one of two things. Either someone had pulled the fire alarm, or we were under attack from the Klingons. I rolled over, fumbled with my phone, brushed my teeth, and armed the photon torpedoes. Being on the ninth floor I figured I had time to pack up the MacBook before heading for the stairs, but thankfully the whooping stopped and an apologetic voice came over the loudspeakers to let us know we could go back to sleep. I did so until 6:30, when I put on sneakers and ventured downstairs to discover the only workout facility is the Gold's Gym next door. It would seem having a whole professional gymnasium is far better than having one rickety treadmill and an old Universal stack, but it's only better if it opens before 8:00 AM, which this one does not. So it was back up nine floors to brew the Starbucks sachet in the room and wonder aloud who thinks a cup of coffee that size needs only two tiny creamers. I should have taken advantage of the fire alarm to beg the other guests for their cream. Or maybe that's what they used to put out the fire.

Karen Breach, Laura Gerald, and John Rusher

Former AAP President David Tayloe of Goldsboro Pediatrics talks with Gordon Coleman of the Practice Formerly Known As The Children's Clinic. This is a little Wilmington inside joke, as Wilmington Health Associates recently re-named the venerable pediatric practice. Those in the community now know it as

Executive Director Steve Shore makes last minute preparations.

Introductions from NCPS President Karen Breach, MD and Executive Director Steve Shore

In a tradition that extends to the first NCPS Open Forum, held in a cave, we all pass around the microphone and introduce ourselves.

Brandon Rector, NC Immunization Program

Vaccine Update

• As of yesterday 92% of flu vaccine has been shipped to providers' offices
• By now everyone should have received at least half of their ordered flu vaccine
• Syringes are coming in a little slower than usual, also the Sanofi multiple-dose vials
• Multiple-dose vials should be in offices by Tuesday
• Provider agreements are coming out earlier than usual this year, please return those so site visits can start happening.
• Next week the holiday shipping schedule will be out. Order by November 12th for delivery by Thanksgiving, also varicella and MMRV won't be shipped if ordered after that date until 2011. These are the frozen ones.
• The immunization branch will be covering vaccines for college freshmen and TDaP for your office staff with the little leftover money from the old Universal Vaccine program.
• The branch will now allow providers to order whatever brand of vaccines they prefer when a choice is available.
• NC has had over 100 pertussis cases so far.
• There is a new screen from NCIR for mass vaccinations to make entry easier. Call the branch to have that feature activated if you need it for something Iike a flu clinic.
• Doctors in the room seem to perceive a fall off in patient demand for flu vaccine.
• People still seem to fear the H1N1 vaccine.
• Dr. Tayloe asks if Medicaid will cover TDaP for post-partum mothers and their partners. Yes for moms, no for dads.
• If your insurers are not reimbursing vaccines adequately then send a letter to Dr. Tayloe or Dr. Graham Barden. The AAP Department Of Insurance is fighting these issues as they come up.
• Immunization Branch ships flu vaccine to practices pretty much the same day it arrives in their offices.
• Per Dr. Barden there are two national distribution centers, all flu vaccine east of the Mississippi comes from Memphis, and our shipments seem to lag compared to the Western states' whose shipments come from Sacramento.
• CDC now recommends a booster of meningococcal vaccine at age 16

Gerri Mattson, Jane Foy

Gerri Mattson, MD, MPH

NC Division of Public Health

• We now have a $2.1 million grant for home visiting programs for mothers, infants and children.
• Hope to implement in 2011, but still awaiting guidance on implementation
• LAUNCH: Linking action to unmet needs in child health. Address social and emotional needs of children ages birth to 8 years. This program is also in the development stage, but it should offer support for screening services in pediatric offices.
• Innovative Approaches Projects are building care systems for youth with special healthcare needs, partnering with local health departments and service providers in four counties in the state.
• Child Service Coordination being redesigned to provide a children's care management system. Partnership with NCPS, NCAFP, department of medical assistance.
• Kindergarten Health Assessment (does NOT have to be blue!). We are now looking at using this form to collect and track health information about kindergarten aged children in North Carolina. 0.5% listed obesity as a problem on the form, 13% were actually obese by BMI.
• Early Hearing Detection and Inteverntion. There are notebooks for intervention that are supposed to be sent to providers who diagnose a child with hearing loss. If you have not gotten this when you should have, please call. Once a child is diagnosed the state steps in and mobilizes a number of services for the child. A tele-audiology pilot is now being tested.
• Alice Lenihan with WIC has passed out surveys to help make recommendations to the NC General Assembly about nutritional standards in child care facilities. Email her with your thoughts at alice.lenihan@dhhs.nc.gov.
• Cynthia from UNC metabolic and genetics clinic notes that reimbursement for special formulas for children with metabolic disorders is woefully inadequate.
• Alice Lenihan replies that if you have a child with a metabolic disorder on Medicaid contact the division of public health for assistance. They are aware and working on this problem.

Alice Lenihan

Jane Foy, MD

District Vice Chair, District IV

• Academy has a new informatics center. The director is hoping to acquire stories from pediatricians about problems we have had with our EMR's.
• Affordable Care Act need funding for pediatric specialty training.
• New AAP priorities are early brain and child development, foster care for the coming year.
• Mental Health Toolkit available from the Academy. Made with no PHRMA money at all. There is a practice readiness inventory. You can click on any item in the inventory and find resources to help your practice achieve that particular goal. There are also algorithms for incorporating mental health services at every phase of your practice. There is also coding guidance for every step in the algorithm. The toolkit takes seven commonly presenting symptom clusters and provides evidence based guidance on what you can do for these patients in a primary care environment.

Karen Breach, MD returns to the floor for a brief business meeting.

Introduction of Executive Committee

• NCPS has fallen behind on budget, has not raised dues in five years and has fallen well behind the consumer price index, will likely need a small increase this year.
• Bylaws are being updated, will be up for a vote at the Winter Open Forum, will be on website for review prior to that meeting.
• Our lobbyists are working to prevent pharmacists from delivering vaccines to children down to age seven, which would severely disrupt the Patient Centered Medical Home as many children would never come in for wellness exams.
• This coming election is likely to have a large impact on pediatricians and children, please vote.

Dr. David Tayloe

Healthcare Reform Update

• Your NCPS dues are your best investment. Our success in keeping Medicaid payments close to Medicare has made North Carolina one of the best states in the country to care for all children.
• There is a law on the books that requires Medicaid payments to be the same as Medicare, and we may have to bring that law to bear in the near future to protect access for children.
• AAP priorities for health care reform are Coverage, Benefits, and Access. Getting Bright Futures guidelines written into the law was an enormous victory for children and the Academy.
• CHIPRA reauthorization was a huge victory. It gives us the opportunity to ensure Children's access to care for a long time.
• Today's focus is on the Affordable Care Act. This is where we are still learning. Feel free to call the Academy for help (see website).
• Go to members only channel at aap.org for the State Heath-State Implementation of the Affordable Care Act.
• Joining the Section On Administration And Practice Management (SOAPM) can make a lot of advice and resources available.
• What is a heath insurance exchange? A large insurance pool composed of many small businesses with 100 or fewer employees. Families in these exchanges may be liable for up to $10,000 in out of pocket expenses. States may abandon CHIP once they do this it may be very difficult for families with children with special needs.
• There will be an adult version of CHIP. There will also be a public co-op eventually, still being designed.
• Most important for us is first dollar coverage for preventive heath services. This already went into effect in September, for non grandfathered plans. The danger here is that insurers will not let us collect co pays but will not increase their payment buy the value of the co pay.
• Medicaid will expand to include also adults under 133% of poverty level in 2014.
• Federal government will take over much of Medicaid burden from the states.
• Medicaid payments will go up to be the equal of Medicare in 2013-2014.
• We're going to have to fight to keep CHIP being funded.
• Hospitals are worried money they get now for uninsured patients (DISH) will go away once everyone is insured, not sure they'll come out on the positive.
• Recovery Audit Contractors will be strengthened, which may be bad for us if it continues as it has, every five years. New plan is to look for outliers and audit those offices.
• We are working on what it would look like in North Carolina to have a pediatric Accountable Care Organization. Our model needs to be different from the adult model, need to be measured on wellness provision, not management of chronic disease. Why this is not just the HMO model all over again has to do with quality of care measures, but there is some danger of repeating the same mistakes.
• Center for Medicaid and Medicaid Innovation is starting up to serve as a think tank on how we implement.
• Patients Bill Of Rights. Gives states the teeth they need to monitor the insurance plans.
• Medical malpractice has a pittance of money to investigate how to reform the tort system, but Obama is opposed to caps on malpractice, even though those are the only items that seem to really decrease the cost of malpractice insurance.
• Early Childhood Visiting Program. Evidence based programs to assist at risk children. Check with Gerri Matson on whether a program yet exists in your county.
• Prevention And Public Health Fund
• Office of Health Insurance Consumer Assistance. This puts a human in every state to help patients who have complaints about their insurance programs.
• School based health centers. Pays for bricks and mortar, not for staff.
• Community Transformation Grants. Supports evidence based community level programs to improve health.
• Graham Barden, MD reminds us that if the Sustainable Growth Rate does not get fixed it could lead to a 30% reduction in Medicare payments next year, which, if our rates are tied to Medicare, could be devastating. Dr. Tayloe replies that the AMA is hoping to do away with the SGR altogether. Nothing in the reform bill so far helps insure that health care costs will fall.
• Critical Access Behavioral Healthcare Agency (CABA) encourages mental health providers to cluster in larger organizations. This should be a good trend. medical homes could step in and serve this role if they choose.

Sarah Armstrong, MD and Sheree Vodicka, MA, RD, LDN

Childhood Obesity Overview, Clinical and Community Resources

Sarah Armstrong

• Obesity increased from 5% in the 1960s to 17% now. Children in poverty, African American girls and Hispanic boys at greatest risk, although in some groups poverty is not a risk factor.
• Rates are at least stable since around 2003, except among very obese boys and a couple of small subgroups. Are we as fat as we can get?
• We now call BMI over 85% overweight, over 95% obese. Should probably carve out over 99% as a special group, but have not yet done so.
• Huge barrier is the belief that education will not work even if you had time to do it in your clinic.
• Diabetes prevention program and Look AHEAD studies have shown that lifestyle modification really does work, in adults.
• TODAY trial showed adding lifestyle change to metformin does work.
• HEALTHY trial (not an acronym). Here school based intervention didn't move BMI but did improve comorbidities.
• Younger patients do better with lifestyle modification than older patients. Important to focus on the parent, especially with younger children.
• There are four stages of management. There is prevention focus, structured weight management, comprehensive multidisciplinary management, and tertiary care intervention.
• We should be checking BMI at every well child exam. This is getting much better.
• Prevention plus can involve any level provider delivering a consistent message to patients. Suggest 5-3-2-1-almost none program. Five servings of fruits and vegetables, three structured meals a day, less than two hours television, one hour of vigorous activity, almost no sugar sweetened beverages. Follow up every six months.
• Stage two includes monthly follow up, labs, special personnel trained in weight management strategy, could be a nurse, dietitian, counselor. Could use tracking devices, tailored meal plans.
• Stage three includes weekly visits, usually requires a dedicated space for the practice. Usually a collaboration between pediatricians, dietitians, and community based programs. Some private programs like weight watchers may qualify, but look at the specifics. Stage three is available at a few places including Wake Med (Energize Program), Goldsboro, Asheville. YMCA has been very involved in this, working with former NCPS president Bob Schwartz.
• Stage four is really thinking about bariatric surgery.
• Practice needs to agree upon a coordinated evidence based message on obesity.
• Have a written protocol for structured management of children with overweight/obesity.
• Involve the whole office staff in designing the protocol.
• Perform periodic chart reviews to see that the protocol is being followed.
• NICHQ has a toolkit for help your practice comply with and implement guidelines in three easy steps.
• Getting paid for all this is critical to success, this is part of the NICHQ information.
• USPSTF now recommends referring children age 6 and over to weight management program.

Sheree Vodicka

Works with Physical Activity And Nutrition Branch of NC Division of Public Health

• Eat Smart, Move More. Sixty plus organizations across the state, including ours.
• Healthy eating and activity should be the norm, not the exception!
• Screen BMI. create culturally relevant weight management services. Insure access to those resources.
• www.eatsmartmovemorenc.com is a great set of tools and resources we can all access. This includes pediatric obesity management tools, can be downloaded and printed for your staff.
• Site includes listing of pediatric tertiary care centers for obesity.
• Send consumers to www.myeatsmartmovemore.com
• Insurance does cover medical nutrition therapy in many cases. Medicaid, BCBS, state health plan all cover dietary counseling to some extent. In4kids study at Duke is looking at financial feasibility of having an RD in your practice.
• Role Modeling: if you're going to talk the talk...
• The website has free resources for worksite wellness. Start with your own practice!
• Cooking is becoming a lost art as children and even their mothers fail to learn how to cook food.
• Diet beverages do not seem to promote weight loss! Push water!
• Can promote diluting juice gradually down to nothing.
• Evidence based messages are: decrease soda, cut off the tv, have family meals, decrease eating out, breakfast, decrease portion size.

Sarah Armstrong, MD, David Collier, MD, PhD, Jenny Favret, MS, RD, LDN, Eliana Perrin, MD, MPH, Joey Skelton, MD, John Tomcho, MD

Panel And Participant Discussion - Obesity Treatment Pearls from NC Obesity Programs

Eliana Perrin, UNC

• Focus on prevention. Work on forming functional partnerships between parents and pediatricians.
• Use BMI charts to reassure parents who think their normal weight children are too thin.
• Surveys show most doctors in NC still are not using BMI charts in the office. Color coding the charts can make them easier to understand.
• Using BMI charts works much better than using height and weight charts alone to screen for obesity.
• Pediatricians' counseling really does make a difference when children get home.
• If you think of yourself as thin you have a hard time counseling parents on obesity, also the case if you feel you are overweight.
• In counseling we must be aware of what parents are dealing with. Don't use a boilerplate talk that doesn't take the individual's circumstances into account. Remember that parents with poor math skills may not understand what you're saying.

David Collier

ECU Comprehensive Pediatric Healthy Weight Center

• The comorbidities of obesity are largely mediated by inflammation. Their clinic keeps an on site periodontist to address issues from periodontal disease.
• Average child is age 12 with a BMI of 39, two or more comorbidities.
• Labs include insulin, glucose, liver function tests, thyroid function, CRP
• Stress motivational interviewing, family therapy, evaluate patient and family members for depression
• About half their patients have a significant drop in BMI
• Waiting list is now six months long, even this clinic cannot do recommended 12 week follow up schedule

Joseph Skelton, MD

Brenner FIT Program

• Tertiary care program including bariatric surgery
• Clinic is overwhelmed by demand, one response has been phone coaching. First hurdle is helping families understand what the program actually is.
• If family doesn't fill out the intake form for clinic it is a good predictor they will not comply with other demands of the clinic.
• Behavioral approach is critical. They use tracking forms customized to each family.
• Experimenting with a telemedicine program now, putting monitors in referring pediatricians' practices

John Tomcho, MD

Carolinas Weight Management and Wellness Center

• Seeing adolescents, age 12 and above
• Duke Healthy Lifestyles Program
• Have two locations in Durham and Raleigh
• All providers are trained in motivational interviewing. There is a network of trainers called MINT you can find to train you and your providers. http://www.motivationalinterview.org/index.shtml
• On site physical therapy and mental health professionals. Physical therapy is often key to making it possible for these kids to exercise.

Questions and answers

• Jennifer Lail of Chapel Hill Peds asks about new recommendations that we use World Health Organization growth charts up to age 24 months. The old CDC charts we have been using are historical, but the WHO charts look at how children should grow if they were fed ideally, so these are ideals. An example is children up to age four months kids included in the sample data are exclusively breast fed.
• WHO charts will lead fewer parents to worry about failure to thrive in breastfed children.
• WHO charts are also akin to BMI, using length squared as opposed to CDC weight to length ratio.
• Question about BMI and trained athletes. BMI is a screening tool, works best in prepubertal children. You can make a judgement when looking at a muscular athlete as to whether there's a real obesity problem.
• Color coded growth charts are available at the Eat Smart Move More website
• Question about who gets bariatric surgery. The restrictions on surgery are quite strict. You really need a child who has participated in and failed an intensive program. So far the outcomes at at least one center have been quite poor. Patient and family psychological evaluation is key.
• The older an overweight child is when intervention begins the worse the likely outcome. Much study is now dedicated to evaluating what factors even in utero and certainly in the first two years of life contribute to obesity later on. Think for example about how much very young children are watching TV, being constrained in things like swings, slings, and saucers and prevented from moving. Rapid weight gain in infancy may be a real red flag to look at.
• In patients on atypical antipsychotics metformin may be helpful when insulin resistance is present. Interestingly if you give atypical antipsychotics to children with anorexia nervosa they still don't gain weight.
• A dramatic weight gain during infancy in a formula fed infant is more alarming. Parents looking at bottles stress about making sure the baby is getting enough and tend to blunt the learning of satiety clues. Nursing infants are more likely to learn to follow hunger and satiety cues. Even bottle feeding breast milk may have the same impact as formula here. That said the protective effect of breast feeding on obesity is tenuous, the evidence could be much better.
• Kids with ADHD have more obesity because their lack of impulse control outweighs their increased activity (so to speak).
• Activity is a goal in and of itself, regardless of whether you'd call it "moderate" or "vigorous". Try to ask the patient to trade thirty minutes of TV time for any activity whatsoever. Being outdoors will also improve their vitamin D levels.
• ICD9 still does not consider obesity a medical diagnosis, so we still have to code for the comorbidities. Worst case is families get billed for your services after being denied by insurer.
• Obese children do not have higher rates of actual depression although they do have lower self esteem and some depressive symptoms.
• We are working with WIC to improve their practices, but it is possible past practices have contributed to the obesity problem. Alice Lenihan answers this concern. Notes WIC has stopped providing juice for infants, working on eliminating it for children. She notes mothers tend to gain weight from one pregnancy to the next. WIC is kicking off a five star breastfeeding program for hospitals in North Carolina. There is now less milk on the WIC program and that milk is now low fat for children over age two years. There is also a push for whole grains. Working hard now on improving nutrition in child care centers. WIC has eliminated BPA in their breast pump components.
• North Carolina Medicaid covers obesity, as does Blue Cross Blue Shield NC, the state health plan. Another problem is that no show rates for these appointments are often quite high. Technically the abnormal weight gain code is not applicable in the case of obesity, but people around the room report they are being paid and have not yet gone to jail. V85.54 and 53 codes count, but they don't cover labs and the reimbursement is miserable, on a par with the price of a Fun Size Snickers bar.

Sadly I had to stop at this point and drive back to Wilmington for a neighborhood Halloween party. This meant missing perhaps the most critical lecture, an introduction to motivational interviewing. I did learn we have a MINT certified instructor here in Wilmington at UNCW, and Gordon Coleman and I may try to arrange a training session for anyone who wants to come. I'll send around an email if we can make it happen.

One last note. At Executive Committee I always walk away terrified at the forces arrayed against access to healthcare for children. A very few very dedicated people at the NCPS and the Academy are fighting terribly hard against interests with much more money and power to ensure the patients we serve get anything at all. If we do not all chip in, involve ourselves, and help in the effort, the children will get trampled by political and economic forces that have no interest in their wellbeing. Please, please involve yourself in the Pediatric Society and the AAP. Become an AAP Key Contact on the Member Center and take five minutes to call a legislator when a children's issue comes up. Donate to the NC Peds PAC. Go out and vote for candidates likely to support Medicaid, CHIP, WIC, and the other programs that attempt to provide a modicum of stability to the most vulnerable and yet most important members of our society. And if you hear a whooping sound at 5:30 AM, get your boots on and set your phasers for extra half and half.

San Francisco Monday, October 4th

No everyone believes that just because the words "fun" and "run" rhyme they should appear together. But some of us have a running problem, and the Academy accommodates us each year with a 5K somewhere scenic. This year our reward for standing on the sidewalk jumping up and down blowing on our hands waiting for a shuttle bus was to stand in Golden Gate Park jumping up and down blowing on our hands, looking at the bridge. You might think the public bathrooms would be warmer than the parking lot. You would be wrong, and more exposed. This year budget constraints kept the organizers from hiring a perky trainer to lead us in deep lunges to a disco soundtrack before the race. Budget cuts are not all bad. The academy has some truly gifted athletes, my term for the hoards who crossed the finish line ahead of me.

By the time I got back, showered, fed, and caffeinated I walked in to the plenary a little late. Enough running for one day. Here's what I did catch.

Neil Risch, PhD

Ancestry Matters: Ethnicity And Disease Risk

• Genetics divide the human population into about 6 groups based on continent of origin
• Different Asian populations have different genetics, meaning calling Asian a race is genetically nonsensical
• So how does self-reported race/ethnicity correlate with genetics? Actually almost perfectly!
• Because race and culture are linked it's almost impossible to tease out what group differences are genetic and which ones are cultural, from a statistical standpoint.
• You can look at populations of mixed race and see if certain outcomes track with what percent of markers come from a given genetic cluster, but this still doesn't rule out confounders that are not purely genetic, like skin color
• Another strategy is to look at ancestry-based polymorphism affecting a single gene. One such study showed a gene from African populations that codes for FSGS susceptibility but also confers protection against Trypanosomiasis.
• Race, ethnicity, and ancestry do matter from a genetic and medical standpoint
• Gene environment interactions are key

Russell Chesney, MD

Vitamin D, it's not just for bones anymore

• Not so much a vitamin as a hormone!
• It resembles other steroid hormones
• It serves as a gene transcription promotors
• Receptors are present in more than 30 tissues
• It promotes transcription of more than 300 proteins and peptides
• It has multiple immune mediation functions
• Sources are local, mainly sun exposure, influenced by diet and obesity
• Measured by circulating OH-D1,25
• Impacts rates of ovarian cancers, MS, RA, IBD, wheezing, DM, HTN, multiple common cancers
• Suddenly it seems we think vitamin D does everything!
• Why are we deficient? Not enough sunshine.
• NHANES study gave us accurate population based values of vitamin D levels, data from 2000-2004
• Concentrations fall off with age, worse in women, African Americans
• In children and in pregnant women we see large percentages of the population with levels below the deficiency cutoff
• Tuberculosis is more prominent where vitamin D is lowest
• Vitamin D may provide large scale protection against influenza, that may be why flu spreads in the winter!
• Per 2008 recommendations all kids and babies need 400 IU a day.
• That's a teaspoon of cod liver oil
• 400 IU seems to be at the effective threshold
• Side effects probably occur way over the recommended upper limit of 1000 IU a day
• Supplements should be given to all ethnic groups
• There will be a revised recommendation 11/30/2010!

Dr. Wesley Burks

Food Allergy: oral desensitization therapy, closer to a cure?

• 6-8% of young children are food allergic, but parents think it's more like 30%
• Milk, soy, wheat' shellfish, and nuts account for the bulk of food allergies
• Food allergies have doubled over the last decade
• Reactions occur within two hours of ingestion
• Peanut IgE levels do not predict severity of clinical reaction
• About 1/3 of reactions are ton accidental exposures
• Deaths usually occur in people who know they are allergic
• About 20% of children will eventually outgrow their peanut allergy
• It's the protein, not the oil that causes peanut allergy
• For peanuts it's ingesting the protein that causes severe symptoms, although as little as 1/1000th of a peanut can do it
• There are some promising therapies, including anti-IgE, Chinese herbal medicine.
• Engineered recombinant protein may reduce IgE binding, but not effective
• Goals of therapy are clinical desensitization, clinical tolerance
• Two types of ingested therapy are oral and sublingual (OIT, SLIT)
• OIT starts with daily increased doses from 6 to 4000 mg over about ten months, followed by a food challenge
• Hopefully tolerance will continue after treatment ends, that's the definition of tolerance
• In a small study of 25 patients the difference between treatment and placebo was enormous
• Almost half children had prolonged tolerance off treatment
• But about 20% of children cannot tolerate this type of therapy
• SLIT is better tolerated, only 5% of children cannot tolerate it
• Again the early numbers are showing dramatic success at achieving desensitization
• Whether either therapy will lead to prolonged tolerance remains unknown

Gail Pearson, MD

Avoiding Hand Me Down Information: Why Children Need Pediatric Studies

• First of all, they have diseases adults don't have
• Example of polio vaccine, involved 8 million US children
• Second example, hypoplastic left ventricle repair
• Second, they get diseases adults do get, but with different manifestations
• Example pediatric heart failure does not respond to enalapril the way adult CHF does, in fact not at all
• Example, we still are not sure how and when to check children's cholesterol levels
• Third, children develop and adults don't
• Fourth, expert opinion is fallible
• Example, blood letting in the 1600's. Earliest randomized controlled trial, six times as many people died in the control group (the ones who had blood letting)
• Children's research has led to dramatic improvements in survival for preterm births, leukemia, HIb
• First recommendations for Children's research were promulgated in1978, with first legal guidelines in 1983
• Example of horror: willow brook school for the mentally handicapped in the 1960's infected children with hepatitis on purpose
• Children are diverse, vulnerable, require more protection, cannot take pills, don't represent a lucrative market, don't vote
• National Heart Lung and Blood Institute has a program to promote clinical studies in children and address parental fears
• Children And Clinical Studies Campaign

Paul Offitt, MD

America's Anti-Vaccine Movement, A Perspective

• There're have been incidents that probably should have sparked vaccine resistance and didn't
• Examples are early polio vaccine that caused ten deaths, 200 cases of parlysis. Also a yellow fever vaccine contaminated wi hepatitis, given to US soldiers. Children infected with TB in 1929 instead of BCG
• The birth of fear: April 19, 1982. Locally produced documentary on DPT vaccine causing children to get seizures, mental retardation. Entitled DPT, Vaccine Roulette.
• That show was disseminated nationally, made big news. This spawned a grass roots movement, the National Vaccine Information Center, a flood of lawsuits
• Pharmaceutical companies abandoned the business, so the government stepped in to establish the compensation fund
• The NVIC perpetuates the message that there vaccines have supplanted infectious diseases with chronic diseases. They have come out against every new vaccine with claims they would cause diabetes, seizures, SIDS, MS, all false claims
• The autism scare has had several phases, starting in 1998 with Andrew Wakefield's claim about MMR.
• Doing the research to absolve vaccines takes many years, never makes news.
• Next idea was thimerosol causes autism, 1999. Now we have enormous studies ton disprove that idea, have spent many millions
• Now Dr. Robert Sears scares parents that children just get too many vaccines, The Vaccine Book
• We are now seeing breakdown in herd immunity involving whole communities: mumps, measles, HIb, pertussis
• We are faced with a difficult choice. We want to keep parents in the practice and do the best we can for those patients. That said, that delay does put children at risk as herd immunity has broken down. Our waiting rooms become dangerous.
• The measles outbreak provides a model of this problem, where young children who got the disease were infected in the waiting room
• Now we need studies to see what is the best approach to help bring parents back on board

Annual business luncheon

• Dr. Palfrey stands to introduce everyone on the dais
• John Almquist, MD
• Marion Burton accepts the presidency
• The Affordable Care Act is a downpayment on children's care. But it is endangered, and the children may get thrown out with the bathwater
• Stay in contact with the Advocacy arm of the AAP and be involved in making sure children get the care they need
• We hope to establish a Cabinet level Office For Children

The Child With Recurrent Infection

Sarah Long, MD

• Case history: a fatigued 15 year old girl with positive review of systems
• In history get details of vague symptoms. What kind of sore throat? Is weakness focal? Does fatigue mean increased sleep hours? Does poor appetite mean weight loss? Is there true pallor? Cyanosis? Do shooting pains follow a neurological distribution?
• Are there big time social stressors?
• Does the exam suggest illness, or is it inconsistent with complaints? Check eye grounds when headache is a complaint.
• How are CBC, CMP, CRP, and UA?
• In adolescent girls remember pregnancy is a possibility
• Sexual abuse may present with diffuse physical complaints
• Certainly depression is a possibility
• Many of these patients just have primary fatigue
• It appears this syndrome affects Caucasians, girls, children of educated patients
• Onset seems acute always
• NIH defined chronic fatigue syndrome in adults in the 1990's
• This diagnosis probably does not apply to teens
• Depression does suppress immune function to some extent
• EBV titers are not to be followed for disease progression, EBV is not the cause of chronic fatigue syndrome
• When EBNA turns positive the infection is over
• Lyme disease is not the cause of chronic fatigue in children
• Hypoadrenalism is not the cause of chronic fatigue in children
• Orthostatic hypotension is not the cause of chronic fatigue in children
• Joint laxity may be present in these kids, but significance is unclear
• Orthostatic intolerance is probably really just de-conditioning, and it improves with exercise
• These kids seem to have had very high expectations of them prior to disease onset. Have not lost weight. Age over 12 years. Tend to cooperate with exam enthusiastically.
• Validate symptoms.
• Force return to school on a graduated basis.
• Advise graduated exercise, ideally with a physical trainer.
• Let the patient know she'll feel worse to begin with, and there are no expectations of performance.
• Advise parents to stop asking child how she feels
• Change focus to health, not illness.
• As primary care provider stay in charge of the illness. Discourage more and more consults.
• If child cannot go to school she needs to be seen in the office. This cuts down on missing school. When the child gets a tutor, game over!
• Might code Adolescent Sleep And Stress Disorder

James Jarvis, MD

• There are about three rheumatologic concerns to keep in mind with prolonged fever
• Between fevers kids may look great!
• Daily, timed fevers that make children look awful when febrile, fine when afebrile, accompanied by macular rash is classic for JRA
• Remember platelets usually rise when ESR rises. If platelets are low think Acute Lymphocytic Leukemia.
• Don't order an ANA unless you're trying to confirm lupus, because normal children have elevated ANA about 30% of the time.
• In a case where patient gets three days of fever every month start thinking about cyclic fever syndromes
• JRA fevers occur daily, at predictable times, and kids look good between fevers, unlike with Kawasaki's, when they seem irritable all the time
• Don't think JRA if WBC is under 15K or platelets are under 300K
• Dermatomyositis may present with daily, low grade fevers, fatigue with minimal activity
• Look at nail-bed capillaries
• Check CPK, CMP, aldolase
• Get these children to a pediatric rheumatologist no matter where you live!
• Parents will report fatigue more than muscle weakness

Dr. Long again, case of four year old boy with fever every thirty days, swollen nodes, no mouth ulcers

• If these are viral illnesses the symptoms tend to vary somewhat from one to the next
• Ask if fevers recur at predictable intervals.
• How many days do the fevers last?
• Do antibiotics or antipyretics help or not?
• Do immunizations trigger the fevers?
• The more URI symptoms you hear about the less you suspect cyclic fevers
• How well are they between episodes of fever?
• What is the ethnic background of the patient? There are exceptions, so don't write off a familial fever just because the ethnicity is wrong
• Does anyone in the family have amyloidosis? That's the end result of familial fever disorders
• Get a urine culture or two, CBC, CMP, immunoglobulins. Avoid imaging studies without symptoms to suggest an infectious focus
• PFAPA: periodic fever, aphthous stomatitis, pharyngitis, adenopathy. Not all elements are always present.
• PFAPA affects preschoolers, not infants. Child looks glassy eyed prior to fever occurrence. Fever is the cardinal symptom. Seems to occur in happy children, happy families!
• Disease lasts 4.5 years on average, but longer if it starts younger
• Cimetidine seems to help about a third of patients
• Prednisone, one dose, aborts the attacks but not a good long term plan.
• Tonsillectomy seems to cure the syndrome in over 90% of patients!
• If the fit for the diagnosis isn't good then don't take out the tonsils

Dr. Jarvis presents the next case, a 13 year old girl with six days of daily fever, fatigue, abdominal discomfort, hypertension, white cells and red cells in urine.

• Lupus. ANA lessnthan 1:1000 just is not exciting. If you order an ANA also check C3, C4, and urinalysis with microscopy
• Remember UTI's don't cause hematuria
• Adolescents with lupus look sick
• Next case 15 year old Native American girl with rales, fever, hypertension. IHS doc checked a C-ANCA, and it was positive, proof of Wegeners

Dr. Long discusses cyclic neutropenia.

• Look for ulcers, gingivitis, fevers every 3 weeks for 5-7 days.
• If presentation is appropriate check CBC twice a week.
• Autoinflammatory syndromes are relatively newly described, include FMF, Hyper-immunoglobulinemia D, TRAPS, all genetic. These can be successfully treated now.

From there it was on to dinner with the Pediatric News Editorial Advisory Board. Watch the exciting publication for some serious pediatric muck-raking! Also, I promise future issues will be gut-busting hilarious! I look forward to next year's Conference and Exhibition in Boston!

San Francisco Sunday, October 3rd

Say what you will, the signage was nothing if not comprehensive.

Sunday always begins with the traditional Division Breakfast, a chance to get to know other pediatricians from your part of the country while standing in line for burritos. This exercise involves the dual challenge of making it to the meeting room by 7:00 AM after your first big night out and not spilling eggs down your shirt while leaning over to shake hands. I succeeded at one of these.

Opening by Francis Rushton, Chair, Division IV

This year we skipped the tradition of passing the microphone around to introduce ourselves, as we only had an hour and, being from the South, many of us talk slow. Dr. Rushton then passed the floor to our tireless legislative lobbyists.

Erin Wallace, Federal Affairs

• Health Reform was very successful for us, at least to begin
• Two major implementations occurred September 23
• All Bright Futures provisions get paid for in new plans
• Children may remain on parents' plans up to age 26
• No exclusions for preexisting conditions in new health plans or ones that change substantially
• Over the last six months we've been working on the details of writing the law
• Many components have been authorized but not appropriated
• There is much advocacy left to do to get appropriations, enroll children
• The Federal Affairs website is full of useful details

Dan Walters, Federal Affairs

• Now federal provisions are going to states, where there're is often little money to implement health reform
• Many states have commissions to implement health reform, and these offer opportunities for advocacy
• Many states have filed suits to prevent implementation of health reform
• Some insurers have withdrawn child only health plans, but some states are stepping in to keep this from happening. California has done this already.
• States are asking insurers to justify prohibitive rates when present
• States are deciding how to run health insurance exchanges, high risk pools. They may defer this job to the Federal government if they choose
• By 2014 Medicaid will be extended to adults, payment to physicians will increase to 100% of Medicare
• Insurance plans that are grandfathered will not be held to these requirements, and the definition of such plans is still being worked out.

Francis Rushton emphasizes that we all need to learn what an accountable care organization is. It's not clear whether they will be good or bad for us, but we need to stay involved as they are formed so we have a seat at the table.

Incoming President Marion Burton from South Carolina is recognized. Dave Tayloe is out visiting other divisions, but former AAP President Steve Edwards is here as well.

Multiple District IV members have been recognized with national awards.

Dr. Josh Honnecker of Kentucky is our representative to the chapter forum at the Annual Leadership Forum. He will present any resolutions we have to the AAP leadership. Submit by early November for consideration.

These proposals are how the grass roots membership impact AAP policy

Jackie Noonan speaks on behalf of Friends of Children, Chilren's future Fund. The AAP Is a moor source of philanthropy for children affected by disasters in places like Haiti and Pakistan

Jane Foy, District Vice Chair announces a new push on Vaccine Hesitancy

• The mental health toolkit is available, which Jane did tremendous work to create. She will be giving a workshop Tuesday morning on using it.
• The toolkit involves tools on getting paid for providing mental health care in the office

Jennifer Williams, outgoing residency coordinator introduces obesity campaign for residents

Melissa Hudgins talks about Young Physicians group, working on advocacy projects, reminds us to involve our younger partners in practice. Time management is a big focus for them.

Voter participation was low in this year's AAP election despite reaching out in multiple electronic media and electronic voting.

Chapter officers stand to introduce themselves

Herb Clegg stands to promote the PROS research network for practices. Now recruiting for a big teen smoking cessation study

Fill out your surveys on reimbursement, because that's the only way the AAP knows how to advocate for improved reimbursement for specific services we provide

Steve Edwards stands to remind us that the process of implementing health reform at the state level is a tremendous opportunity both for success and for failure now, and we need to be involved in how it's done.

Breakfast over, it's time to dash through the crowd in search of a good lecture. I knew whom I wanted to hear:

Extreme practice makeover

Herschel Lessen, MD

• Physician demographics a shifting to physicians who train fewer hours, do fewer things during their training.
• Costs have been shifted to patients, which increases the value of procedures, decreases the value of thinking.
• This means all primary care is a commodity. That means as far as the patient is concerned quality is level across all physicians, quality does not matter at all.
• Therefore competition is all about volume.
• 77% of patients in the US are covered by one of three managed care corporations.
• Success is no longer to be taken for granted, survival is as good as it gets
• To survive you have to get bigger, better.
• Many Practices are in need of an economic makeover
• Pediatric salaries are bimodal, most make very little, but a reasonable number make a whole lot. Who are those doctors?
• Best size is 11 to 25 physicians
• It is a huge problem that physicians don't think administration deserves the same level of reward as caring for patients
• We are the only medical specialty that sees making money as morally wrong
• Doing good and doing well are not mutually exclusive. This is hard for many pediatricians to embrace.
• Many pediatricians are very resistant to change, but you don't change, you die.
• Models: the Marathon Man practice. Working every day, all day, doing everything yourself. Burnout risk is high. Some join big practices then have no control.
• Problem: poor planning. No one taught us business skills. We lack knowledge of internal and external data. We never have a business plan.
• The health of your practice depends on your knowledge of your numbers.
• Another model: the Dwindling Practice. Providers keep leaving, numbers shrinking. These doctors were stuck in buildings they owned, so they could not move. They had lousy coding and insurance contracts. They saw too few patients a day. These practices had huge problems with change.
• Know what your revenue is, how many patients are actually in your practice, how many visits you have and how many visits the average patient makes. What is each patient worth? Average revenue divided by total number of patients. Know what payer gives you the most per patient seen.
• What is the cost per patient? Total overhead divided by number of patients. If a payer is giving you less than that number, renegotiate or drop them.
• Average revenue per visit should be a bit over $100. You may want to back out vaccine costs since they are now so high, both as income and as expense.
• Make sure you know what you are paying for everything. Negotiate everything.
• Know your personnel needs. Some staff make you a lot more money then they cost. Don't be afraid of overhead when that overhead makes you money.
• Develop a written budget!
• Then monitor the budget and keep track of how you're doing.
• Get an area map with zip codes, see how many children are in each zip code, how many come to your practice. Focus your marketing where there are lots of children and they don't yet come to your practice!
• How do you decide when to expand? You can add doctors to lighten your workload, but then you have to know if there are enough patients to fill those doctors' schedules.
• Get good advice, it's worth the money.
• You can go to an American College of Physician Executives course.
• Make a business plan! Look at productivity of providers, drop those who cannot make their salaries.
• Problem: poor structure. A small practice often lacks infrastructure. The idea is to keep the doctors doing what only they can do, offloading other jobs to less highly compensated people.
• Having a lot of partners is often not a good thing. Give the employed physicians a good deal in terms of lifestyle, pay them fairly but not like the partners who take the risk and share the burdens.
• For partners you need people with business skills who really want to be involved in management
• Problem: poor governance. You must have clear lines of governance. Consensus only works if you're very small. More effective to rule by executive committee. Worst is veto power by passive aggression where one partner undercuts what the others decide by not cooperating. This is the single most dangerous person in any practice. One person should know and control the schedule.
• Know what your practice culture is. What's important to you? Control? Lifestyle? Compensation? Embracing of change? How hard do you want to work?
• Don't try to control those things where someone else does them better than you. Trust the personnel who are good at their jobs.
• Define the partnership in a written, detailed agreement, and look at it every few years.
• You need buy in to the governance structure.
• Problem: poor efficiency. How many patients per provider per day do you need to see? What types of patients are seen by each physician during different seasons? Analyzing patient flow and wait time is critical.
• Monitor schedule, adjust work flow based on demand. The scheduling partner should know what kinds of patients different providers like to see. Must tweak schedule frequently based on demand.
• Doctors must be aware of their schedule and know how far behind they are. Need adequate staff and rooms to keep all the balls moving. Patients who need more prep time should arrive early soothe doctor is not waiting on them.
• Use handouts, follow up visits to get complex explanations done. Make sure nurses do everything they can do that the doctor doesn't have to.
• Use protocols for tests, like throat cultures.
• Problem: poor contracting. Read every contract every year. Find your lowest payer, then beat them up.
• Negotiate everything, but know what's important. Know your code frequency and fight for even small increases in the ones you use most.
• Code aggressively! At least 25% should be level four, probably more. Five percent should be level 5.
• Under coding is as bad as over coding.
• Do coding audits!
• Do as little as possible for free, such as writing letters and filling out forms.
• Make sure copays are payed at the time of service.
• Accept credit cards.
• Problem: poor customer service. The bar is so low that it's easy to outperform others.
• Everything about your practice speaks to the consumer.
• Seek good advice. A good administrator will pay off many times over. Rely on SOAPM.
• Have a health care attorney.
• Use a management consultant from time to time.

Next came plenary sessions. Unlike the first day convention staff did not block the doors once all the seats were taken. The first speaker was one of my favorite people in the AAP.

Molly Droge, MD

Department of State Government Affairs

American Health Care At A Crossroads: Implications of Health Reform to States and Opportunities For Advocacy

• Affordable Care Act
• States face a $547 billion shortfall in Medicaid for 2009-2012
• 37 states will elect governors this year
• Our priorities remain the same: coverage, benefits, access to care
• ACA should cover 32 million more Americans
• Preventive care will be based on AAP Bright Futures guidelines, cover all recommended vaccines, fund medical home demonstration programs
• By 2014 all citizens, resident aliens, and dependents must have qualifyingnhealth care coverage. 40 states are trying to restrict implementation of this mandate., and there are multiple lawsuits against this mandate.
• These obstructions are unlikely to do much, but the public perceives that implementation is not likely to happen.
• That said, each state will differ in how the law is implemented, and it's critical we remain involved in that process.
• High risk pool programs: states must decide whether to do their own or go in with the federal plan. North Carolina is going it alone.
• Medicaid eligibility expands to 133% of the poverty level
• CHIP and Medicaid enrollment for children must not change until 2019
• By 2014 web based Medicaid and CHIP enrollment is mandatory
• Health Insurance Exchanges will be rolled in over time starting with business involvement and then adding larger businesses.
• Tax credits will help small business owners provide health insurance for their employees
• The exchanges will simplify the process of comparing insurance plans.
• Rate increases will have to be approved by the states
• Insurers will have to spend at least 80% of their income on medical care, and if they don't they will have to reimburse the insured
• Grandfathered plans are those patients were already enrolled in as of March
• Consumer protection reforms went into effect 9/23/2010
• California now has the first health insurance exchange
• The affordable care act was a monumental victory for children, but we must now stay involved in order to help it succeed
• Look at the AAP Member Center online for more information and guides.

Dr. Richard Oken

The Primary Care Physician: An Endangered Species?

• Primary care is the first contact with patient and can manage a complex patient over time.
• We focus on prevention, long term relationships
• Now it's getting hard to find primary care doctors.
• Many new pediatricians do not want to work full time.
• Night call is not fun
• Phone calls are triaged
• We don't do hospital work now
• Now we do ADD, obesity, behavior management, vaccinations
• New doctors come out owing $150,000
• A quarter of new docs work part time
• Hours and fees have both fallen by 25%
• Hospital pediatricians make almost $30,000 a year than us
• Specialists make much, much more money
• CRNA will make more than a pediatrician
• There was a 7.6% drop in visits from 2009 to 2010
• Concierge care is not a viable model for most pediatricians
• Preventive care provides long term, not short term benefits so shareholders do not reward it
• The RVRBS system was generated by specialists and does not reward us
• No margin, no mission.
• Financial viability is critical to our survival
• New docs care about their families more than their jobs, we have to take that into account.
• Primary care as we knew it is a failed business model

Robert L. Hendren, DO
Are Imaging And Other Technologies Helpful In The Diagnosis Of Mental Disorders?

• Neurodevelopmental model is a promising concept for understanding brain development
• More and more disorders, liken substance abuse, fall within these definitions
• Currently history and physical exam remain our most important mental health diagnostic tools
• Can biomarkers help us diagnose and monitor these diseases?
• Can we identify mental disorders with imaging studies?
• The problems are not with brain mass but with connections
• Now image for funny head, regression, family history, abnormal neurological exam, new onset unexplained disorder.
• There are providers who charge families to do SPECT scans and show them, but this is still not valid as diagnostic tools
• The Amen Clinic is one group that does a lot of this, but the literature is very weak indeed
• QEEG is another modality that some are pushing, but again the data are not there to suggest neurofeedback would be effective
• Do genomics, proteomics, or other similar technologies tell us much? When we find a genetic disorder, then sometimes yes, but otherwise now.
• The preferred test with autism is a CGH array
• Fragile X testing may be useful. Also test when appropriate for Preader Willi, Angleman, Williams, Retts, velocardiofacial syndrome, PTEN. Often history and physical exam will eve this testing.
• Should we perform metabolic studies in autism? The yield is very low, and most of the disorders are caught with newborn testing.
• For autism consider CBC, Metabolic panel. Some think FMR1, high resolution cytogenetic testing.
• Think of lead and iron screening, thyroid
• When do you look for oxidative stress biomarkers? May look at b12, folate, vitamin d, glutione,CRP
• There are no norms for provoked urine heavy metal levels, no one knows how to interpret them

Dr. Marilyn Goske

Medical Radiation: Is there a problem?

• Yes, there is.
• CT scan settings are often not adjusted for the size of pediatric patients
• Utilization of radiologic studies has gone up dramatically without improving the outcomes for children
• With computer technology an over exposed study still looks good, in fact it looks better!
• We cannot really measure the dose of radiation, only estimate it
• The current index may underestimate doses by 300%
• We don't get feedback for years. The outcomes are decades in the future
• Children are more sensitive to radiation, and risk is cumulative
• Consumers are now demanding lower doses, better justification for studies
• High dose radiation causes immediate, deterministic effects
• Stochastic effects are delayed, due to long term exposure
• It remains controversial as to whether CT scans contribute to cancer, no one really knows, but it's wise to act cautiously.
• MR and ultrasound cause no ill effects
• CT scans cause by far the greatest radiation exposure compared even to fluoroscopy
• Image Gently campaign is a social marketing campaign to encourage behavior change locally

Dr. Terry Huang

The Complexity of Childhood Obesity

• Obesity is a global crisis, not just in the US
• Even in India and China we're seeing up to 10% of children overweight
• Overweight women have macrocosmic babies, and so pass on the problem in some ways
• Worst in US are Mexican-American boys, African-American girls
• This is a systemic problem, and individual self control is not enough
• Look at the UK Foresight Programme Report, it's awesome!
• Complex systems include individuals, institutions. They interact over time, they include feedback loops, they evolve and adapt over time. A small change in one part of the system may have a huge impact in another part of the system.
• Did our emphasis on low fat diets actually drive increased carbohydrate intake? In complex systems there are often unintended consequences
• You can tax sugar, but that only helps if you improve access to healthier options
• Behavior modification alone does not work unless the surrounding systems are also modified
• Interventions will need to involve agriculture, trade, urban design, education, government
• Working on using computer models to test ideas and look for unintended consequences
• Do your best for overweight patients, but know that societal and systemic change is really the key!

Lunch. Sushi. Latin Jazz in the park. Couples dance salsa on the sidewalk and children run under the trees as sunshine plays on the cool grass and a 72-degree breeze tousles your hair. Doesn't it just make you want to take a deep breath and go sit down in another dark conference room?

You Too Can Be A Breastfeeding Expert

Michelle Brenner, MD, IBCLC, FAAP

Joan Meek, MD, MS, FAAP

• www.aap.org/breastfeeding is one useful resource, the curriculum for residents is there
• www.bfmed.org is another data rich site
• Toxnet at the national library of medicine is a great resource for which medications are safe in lactation
• How do you deal with maternal-infant separation? Start with expressing milk as soon as possible. No amount is too small, and you should expect to express small amounts at first
• Ideally use hospital grade double electric pump. Pump 8-10 times a day, goal of 350-500 ml per day.
• Use warm soaks and breast massage prior to pumping. Use hands to get all the milk out.
• Milk left in the breast inhibits further milk production.
• The more milk you can remove the better the supply will be!
• Kangaroo care is important to help initiate breastfeeding after a separation from mom.
• Cup feeding is safe, can also use spoon or nursing supplementer. Syringe is best used with a little silastic tubing taped on the finger or taped to the side of the breast while baby sucks
• Nipple shields are gaining popularity, especially with moms with flat nipples ornwith low tone infants or those who don't suck well. Babies still need to suck with wide open mouths. Shields may also help transition from bottle back to breast.
• Breast pumps should not cause pain. Turn the suction down if it does! Don't stare at the pump, think about the baby!
• Hypotonic infants: any weakness of suck or abnormal mouth development may cause problems, but these babies may benefit even more from breast milk.
• Babies with poor coordination may do better at the breast than with bottle feeding.
• Use a good, firm hold like cross cradle helps these babies. Use hand expression to start milk flow. Mom should hold her breast like a taco, not a sandwich, for this position
• Using the hand to support the baby's face may help as well.
• There is a protocol for feeding the hypotonic infant at the American academy of breastfeeding medicine website
• Cleft lip and palate babies are great candidates for breastfeeding. Breast or finger may need to be used to close the lip defect.
• With palate defects it depends on the size of the defect. Holding baby upright can help keep milk flowing downward
• Breatfeeding multiples. Simultaneous nursing is ideal, but a big challenge.
• Milk volume should be fine. Remember wet nurses used to nurse 8 to 10 babies a day.
• Causes of nipple pain: incorrect positioning, suction trauma, infant anatomical issues, engorgement, milk bleb, Raynaud's, thrush, contact dermatitis
• Ankyloglossia decreases tongue length, may cause problems with breast feeding, alter normal tongue movement
• Affects 3-5% of newborns. Majority are asymptomatic, but about 25% may require clipping
• Moms complain of nipple pain, erosions.
• Infants may make clicking sounds while sucking, may be fussy, fatigued, sliding off breast, chewing on nipple.
• Tongue may appear normal but be restricted from the bottom or at the base
• Swipe your finger under the tongue. Resistance may indicate a problem.
• When problems arise with nursing keep the baby fed, protect the breast milk supply.
• The tongue should be covering the lower alveolar ridge during nursing
• Moderate exercise and reasonable weight loss are tolerable during breastfeeding.
• There is still not a good, evidence based product to improve breast milk production except for metoclopramide, but obviously this drug has some down sides.

Beth Vogt, MD

Blood Or Protein In The Urine, How much work up is necessary?

• Urine dipstick is semi quantitative, detects both heme and protein
• Heme is present in red cells but also in myoglobin
• Protein usually means albumin
• If you can do urine microscopy in your office that's best, since some elements will break down before the lab can get it.
• Bright Futures does NOT recommend any routine office urine screening and has not since 2007.
• Some school forms may require urinalysis, and every now and then you find something. In the future we will probably have a selective screening guideline for children at higher risk for kidney disease.
• Hematuria must include >5-10 RBC per high powered field as well as positive dipstick
• 4-6% of children will have hematuria on a single screen, fewer that 1% with repeat testing.
• Glomerular hematuria: blood cells get into the urine from the glomerulus.
• Include post-infectious GN, most often after strep throat
• Even after resolution microscopic hematuria will persist, often up to a year
• Chronic glomerulonephritis, most common IgA nephropathy.
• Keep chronic microscopic hematuria, then when they are sick they get gross hematuria,which resolves along with the illness
• Hereditary nephritis, most common Alport syndrome, associated with deafness
• Thin basement membrane disease is generally benign
• Extraglomerular hematuria, from outside the glomerulus
• Most common is hypercalciuria, which can lead to kidney stones
• Increased salt and protein in our diets has led to an increase in calcium excretion
• Kidney trauma may cause gross hematuria.
• Hydronephrosis, cystic kidney disease, tumors, sickle cell trait, nutcracker syndrome, and vascular malformations are other causes in this category
• Lower down there is cystitis, bladder tumors, bladder stones, trauma, STD's, urethrrhagia
• Also heavy exercise, menses
• Upper tract bleeding looks brown due to oxidation of the hemoglobin
• Protein is usually greater in higher sources of bleeding
• Evaluation of course starts with a good history
• Physical exam may include changes in weight, blood pressure, abdominal masses, edema, rashes
• Confirm dipstick two more times before getting all worried about hematuria
• Check urinalysis on parents as well. Obtain urine culture. Check urine calcium to creatinine ratio. Check kidney ultrasound.
• Kids rarely need cystoscopy
• Hematuria and protein together require more evaluation: CBC, c3, c4, ANA, ASO, BMP
• Protein: 1+ is normal if urine is concentrated. 2+ or greater is never normal
• Check spot urine protein to creatinine ratio. > 0.2 is abnormal.
• A 24 hour collection is the gold standard, but not all patients do this correctly
• 10% of kids age 8-15 will test positive initially, but only 1% on repeat testing
• Transient proteinuria is self limited, often due to illness, stress, dehydration
• Orthostatic proteinuria is the most common cause of a positive screen, levels less than 1 gram in 24 hours.
• Check a first morning urine and protein should go away, unless the child sleeps standing up.
• Fixed proteinuria is present day and night, consistent, does not go away. This indicates kidney disease.
• May be FSGS, polycystic kidneys, reflux nephropathy, others
• First step, if child is I'll then recheck when illness resolves
• If first morning urine is without protein you're done, but patient must void right before going to bed, get sample as soon as they wake up.

So word is in San Francisco they have this wharf for fishermen creatively named "Fisherman's Wharf." Apparently some people like to go down there and walk around, and they have food as well as tee shirts that say, creatively, "San Francisco." I got a chance to try this totally sour bread they call, you guessed it, sourdough. Follow me for more tips on tourism off the beaten path.

Oh, and one more thing. A lot of the tourists don't know this, but apparently there's a place there where they make chocolate. If you go at the right time they'll even sell you some.