San Francisco Saturday, October 2nd

A big, geeky fan of a movie called The Highlander (http://www.imdb.com/title/tt0091203/) I've come to think of the AAP National Conference and Exhibition as The Gathering, where a group of people with unique skills are called together in a special place at a special time. The only difference is there are about 7,000 of us, and instead of slaying each other, we just stand around and talk. I understand the organizers considered a big supernatural death match, but the impact of the "There can be only one" policy on membership dues was deemed prohibitive.

Coming to San Francisco from the East Coast means you're going to watch the sun rise wether you want to or not.

The weather and scenery are perfect for running, and the people here love to take strangers' photos!

I knew there was a Chinatown, but apparently there's also a Dutch Block.

Registration was a breeze. I nominate the staff of the Moscone Convention Center to take over and run the Centers For Medicaid And Medicare Services. I spent the afternoon in my first ever official meeting, of the Council On Communications And Media. We determined that Communications and Media are good, except when they're bad. Further details are available at our programs today. In the meantime I've had a chance to explore the city, pretty much having all my preconceived notions confirmed. People here wear berets and ride around in cable cars under redwood trees eating Ghirardelli chocolate while reciting free-form poetry, no surprise. What I never imagined is that there are still bad neighborhoods in a city where the average home price is so high I couldn't rent a broom closet. A friendly person on the street stopped me before I wandered into a district notorious for its drug dealers, muggers, and Farmville programmers. Whew!

Okay, time for breakfast, more meetings, and then the big show. The plenary always begins with a stunning musical performance by a young musician. In my case it also begins by rushing to my seat at the last possible minute, just in time to stand for the National Anthem but not in time to write down our young performer's name.

AAP President Dr. Judith Palfrey

Presentation of Education Award

Gil Fuld, MD of the Council On Communications And Media presents award to Dr. Deepak Kamat of Wayne State, Childrens Hospital of Michigan

Dr. Palfrey then gives a moving lecture, as she is so good at doing. She gets tearful thanking her husband, Dr. Sean Palfrey.

• Look at policy through the eyes of a child.
• Kids need health: to be born wanted.
• Half of US pregnancies are unintended.
• Preterm birth rates are rising from 7 to 9 percent of births
• Only 13% of babies are breastfed to 6 months
• 15 to 20% of children are uninsured
• Children want quality health care in the hospital
• Kids want good health habits.
• But messages from business and popular culture compete with good health habits, using peer pressure to do so.
• Many children live without basic security.
• One in fifty children in the US are homeless.
• Poor nutrition is rampant
• 1.2 million children are food insecure in the US, comparable to some developing countries
• 700,000 children are in foster care, often due to severe maternal depression
• What are we to do next as pediatricians?
• Dr. Julius Richmond inspired Dr. Palfrey to engage in her advocacy for children.
• Must balance knowledge base, political will, and social strategy in order to advocate successfully for children.
• Since 1960 the budget share dedicated to children has fallen from 20 percent to 9.5 percent, dead last in the developed world.
• Childrens' health care is 1/17 of total federal healthcare expenditure.
• The AAP has taken leadership in advocating for children to ensure the health care reform bill accounted for children's needs.
• The law includes provisions for children, including Bright Futures, Medical Home, and parity with Medicare.
• We will have to keep fighting and hard to make sure our success is not dismantled.
• Many solutions lie in partnerships with other community organizations.

• This year we have partnered with the First Lady to tackle childhood obesity.
• Michelle Obama speaks by video about the Let's Move Campaign.
• AAP is developing a new campaign for healthy living prescriptions to give families.
• We can now join the let's move campaign at www.aap.org/obesity/letsmove and sign the pledge. You can become an official Let's Move practice.
• Final message: look at the world through the eyes of a child.

Keynote Speaker, Richard Louv, Author of Last Child In The Woods

• Over the last three decades children have spent less and less time in nature. With each generation parents feel more fear about letting children wander from the home, so that the radius of freedom has shrunk from six miles to the front door.
• This trend contributes to obesity, use of video games and television, and social isolation.
• The actual number of acts of violence against children have been falling for decades, and when they do occur they are usually by family members and friends.
• The news media repeat the news of these handfuls of crimes until we sense they are much more common than they are.
• Family nature clubs are spreading throughout the country to encourage families to meet in nature together.
• Clubs encourage a sense of safety in numbers, makes it more likely for everyone to actually go.
• At least one study demonstrates that contact with nature can reduce symptoms of ADHD.
• Creating a picture of hope for the future is critical, and we have the power to do so in our practices.

Dr. Michael Rich of Harvard Medical School, Center For Media And Child Health

Finding Huck Finn

• The AAP has taken leadership in attending to Communications and Media sincenthe 1970's.
• Under age 2 over 25% of children have a television in their rooms.
• Television can teach, with Sesame Street as the gold standard.
• Educational television improves performance even at age 17.
• Children who watch violence have higher rates of anxiety, aggression.
• Kids who watch more sexual content become sexually active 2 years earlier.
• Kids who watch movies with lots of smoking, drinking, are much more likely to engage in those activities.
• Media violence can cause anxiety, fears, nightmares, even PTSD.
• Violence in media causes desensitization to violence. We adapt to what is around us.
• Violence in media can increase aggressive behavior
• The correlation between these exposres is stronger by far than the correlation between not using condoms and getting HIV.
• All media is educational, it's just a matter of what is being taught.
• What kills children now is acquired health risk behaviors, and those behaviors are learned through the entertainment media.
• More homes have 7 televisions than have 1
• Media use takes up more time in a child's day than any other single activity (ages 8 to 18)
• Daydreaming is when we develop creativity, link thoughts together.
• Creativity occurs when our minds seem quiescent. Boredom is good!
• Media are neutral tools' but they are very powerful.
• Used thoughtlessly they contribute to the leading causes of morbidity and mortality in our country.
• Sexting: what are we doing? Arresting children.
• Kids lack impulse control, they have sexual curiosity, they have tremendous media know how, and adults are comparatively clueless.
• Ask about media in your history.
• Talk about media in your anticipatory guidance
• Make media part of parenting: talk about expectations, not rules
• Make sure the ground rules are that parents have open access to the child's technology.
• Media come after sleep, homework, activity.
• The five C's of a healthy family:
• Control time
• Content matters
• Context is important
• Critical thinking
• Create and model media mastery
• We must learn how to move in the digital world, let them teach us.
• Http:button.askthemediatrician.org can be added to your website.
• Join CMCH on Facebook
• Recommit to media as essential knowledge for pediatricians
• Use your pediatric credibility to teach families and teach in your community

Ken Kosik, MD

From Molecules to Mind, Neuroscience and Pediatric Mental Health

• We know about molecules and cells, but then we jump to the human minds, and the connection can be very vague.
• The extraordinary abilities of certain savants show us what the power of the human mind may be.
• New field: connectomics. The idea is mapping the connections of the entire nervous system
• A blind musician can repurpose the entire occipital cortex to music.
• Diffusion tensor imaging allows us to see white matter tracts and quantify connections.
• What we cannot perceive is the connections at the synaptic level.
• Autism spectrum disorders are 90% heritable, but with largely unknown underlying genetic determinants
• The genes that are tarring to emerge as suspects control synapse development
• Copy number variations are turning out to be more important the single gene variants
• These too seem to involve genes that encode synaptic proteins
• Angelman syndrome is a model of such genetic variations
• Williams Syndrome also involves repeats, both us usual mental talents and deficiencies
• Daydreaming involves intense activity in a part of the brain not usually lit up with other more focused activities. This seems to be the part that involves creativity and imagination.

COCM session

Holroyd Sherry award to Dr. Lewis First

Vic Strasburger on body self image

• Trying to walk the line between helping Americans not be obese and trying not to promote anorexia
• The BMI of Miss America has declined in a linear fashion over the decades
• Over 100 pro anorexia websites on the Internet
• Miss Bimbo video game encourages anorexia, popular in France and England
• Problem dieting behavior occurs in 60% of girls by sixth grade
• Exposure to mass media, particularly teen magazines, increases abnormal body self image
• Few good studies show causality of eating disorders from media, but there is a good study from Fiji.
• Media education programs help, but many start too late, since dieting often begins in grade school
• Mike Vespa, celebrity photographer from Wire Image shows us what they do to alter images, using actress Whitney Able

Michael Gerber, MD

Diagnosis and Management of Acute Pharyngitis

• 6% of all visits to pediatricians
• Most cases are viral!
• GAS is 15 to 35% of cases
• Antibiotics do help in treatment of GABHS, shorten illness, reduce complications
• So how do you know which patients to treat?
• Carriage rates vary by season, between 8 and 13%
• Family spread is common, around 43% of families with a primary case will go on to have a secondary case.
• Weve gotten better about over prescribing, down from 78.5% of visits for pharyngitis in 1989 to 68.6% in 2000, but still way too high! Down to 54% by 2003 in a separate study
• Of the antibiotics prescribed, 27% were not appropriate
• Guidelines are really from the American Heart Association but endorsed by AAP
• If clinical picture suggests strep you still need a confirmatory test.
• Treat if either test is positive
• If rapid antigen detection test is negative then you need to back it up with a culture
• Follow up throat cultures are not recommended. You can assume positives are just carriers.
• In 2004 compliance with guidelines by pediatricians and family practitioners was abysmal, with only 2% always complying, 15% never complying.
• Are any rapid antigen detection tests sensitive enough to use without backup culture? No.
• There are not enough data to say if one rapid test is better than any other.
• False positives are very rare in rapid antigen detection tests.
• Sensitivity is lousy, around 70%
• From one office to the next sensitivity of rapid test varies sometimes dramatically
• Sensitivity of blood agar plate culture at a reference lab is quite high, close to 100%
• Penicillin remains the drug of choice, including amoxicillin
• Amoxicillin can be used once a day to treat strep and works as well as anything else 50 mg/kg/ maximum 1 gram
• Many cephalosporins also work, but they are broad spectrum and therefore less desirable. Of course daily azithromycin is also effective.
• Cephalosporins are not superior to penicillin in treating real strep infections, but may appear to be superior in studies that don't eliminate carriers from their data sets
• If a child has anaphylaxis to penicillins do not try using cephalosporins
• For less severe allergies, use a narrow spectrum cephalosporin
• Clindamycin is next down the list.
• There is 5% resistance to macrolides, so they remain a poor choice in allergic patients
• You can and should use the same agent twice for relapses or incomplete cures.
• For a third time, you can use Clindamycin
• Check the March, 2009 guidelines for an algorithm on whom to test.

From there it was on to the California Academy of Science by Shuttle for the big evening event. There was a moment there when it looked like the Academy might lose some members in a tragic bus-rushing mob incident, but a second shuttle arrived just in time. They closed the rain forest biosphere just as our group arrived, which at least saved me from being shot in the neck with a poison dart by the inhabitants. I also didn't orient myself in time to get a planetarium ticket, but there was plenty of museum left to see. Below are photos of all sorts of freaky creatures in the aquarium. In addition to the pediatricians there were also fish, snakes, and toads! I ate in the Moss Room and had an amazing gourmet meal of, and I was conflicted here, fish. Dinner went late, and I missed the shuttles back. For those of you traveling to San Francisco here's a tip: no cabs ever, ever pass the California Academy of Science after 10:30 PM.