NC Pediatric Society Spring Open Forum 2011

The Charlotte Motor Speedway, as seen from my window.

This year’s Spring Open Forum was held in beautiful Concord, NC, a township which boasts not only the vast, world-renowned Charlotte Motor Speedway, but also...hang on, I’m checking Google...did I already mention the Speedway?

I had to savor the irony as I sat in my car outside the “Speedway” this afternoon in traffic so stationary I just cut off the motor and pulled out my iPad. That said, our proximity to the race track afforded us car buffs a glance at some of the gorgeous antique vehicles whose owners filled the hotel for a big auto show this weekend. The meeting was at the Embassy Suites Concord, a hotel built on the same basic architecture as a tube sock. As some of the hotel’s patrons grew boisterous last night the always-observant Dr. Christoph Diasio noted our seats in the lobby put us in the path of whatever might come over the low walls of the upper floors. We all scooted a little.

Executive Director Steve Shore has pulled it off yet again.

President Dr. Karen Breach opens the meeting with introductions. We pass around the microphone and give our names and where we're from, as we have done since before the time of amplified sound.

Vice President Dr. John Rusher updates us on the substantial challenges we face in the new legislature.

• Thanks Steve Shore, our Executive Director, for his indefatigable work. Reminds us that we also have a professional lobbyist, who costs money, and is working hard on our issues.
• Recommends going to www.ncleg.net to follow legislation and find out whom to contact to advocate for children's health. Put in your none digit zip code to find your representatives.
• You can use the Find A Bill function to look up particular legislation.
• Contact our office and we can supply you with simple, well-organized talking points.
• Please let us know if you have a personal relationship with a legislator. These relationships are critical to getting our message across.
• Senate Bill 246: pharmacists want to give vaccines to children age 14 to 18 without a physician's prescription. Would give vaccines down to age 7 with prescription. This would threaten the medical home model. Versions are present in the House and the Senate. Pharmacists will argue there is an access issue. For the children they want to vaccinate (privately insured) there is no access issue. We would want to see all vaccines entered into NCIR within 24 hours, would want to see that the prescribing MD does not work for the pharmacy, would want them to provide services to Medicaid and uninsured children as well. We would want the Rx requirement to extend up to age 18. Pharmacists see this bill as a route to becoming primary care providers alongside physicians. Training the pharmacists to use the NCIR would cost the state over $2 million, a cost the state can I'll afford right now. Additional costs would be involved in expanding the NCIR to accommodate these new "providers."
• Liability/Tort Reform. Our specific interest is in decreasing the statue of limitations for MD's who can currently be sued for 18 years after their care of an infant. Most states use age 10, understanding if you care for a child of any age the statute of limitations would extend for a minimum of three years. The OB's would like to see the same amendment.
• Minor Consent Bill would force MD's to report treatment of STD's, pregnancy to parents in 48 hours in direct contradiction to current laws protecting adolescents' privacy. Often the promise of confidentiality is what allows us to catalyze open conversations between teens and their parents and to get teens the early treatment they need when they fear they will be abused or kicked out of their homes. From a public health standpoint the passage of such a bill would almost certainly lead to increases in teen pregnancy and STD's. Another issue regards teens who are being abused by a member of their own household and who fear to report that abuse. If you have such stories, please share them with us.
• Per the accountable care act all states need to have health information exchanges in the next year and a half. We will make sure pediatrics is represented appropriately.
• Hoping to move the age of juvenile justice from 16 to 18 in keeping with most other states. This is supported by an awful lot of developmental science.

Beth Rowe West, RN, MSN, NC Immunization Branch

• Applying for a variety of grants related to expanding vaccine access.
• CDC requiring site visits to every provider every other year, so be looking for your friends from the Immunization Branch.
• Regulations may limit the ability of private providers to vaccinate children with VFC vaccines. Technically they will have to be given at Community Health Centers in communities where they are available.
• State immunization conference is August 10 to 12, please attend or send staff from your office. Also there are webinars on the website for training.

Dr. O. Marion Burton, AAP President, with AAP update

• Thanks North Carolina for help in building a Medical Home Model in South Carolina.
• Reviews the Academy's strategic plan. Current priorities are children with special healthcare needs and in foster homes, early brain and child development.
• Genetics and environmental epigenetics loom as future priorities.
• Our early brain and child development priorities are to optimize the life trajectories of children by assessing the family's environment and meeting the needs of the family.
• AAP mental health toolkit is a critical resource to help doctors integrate mental health into primary care.
• Culturally effective care toolkit is new, helps us serve various diverse ethnic populations more effectively. Affects health disparities, health equity.
• Pediatrics 2020 gives us roadmap for adapting our practices in a rapidly changing environment. The medical home is the primary driver of quality care.
• We continue to work with Michelle Obama on the Let's Move initiative to battle obesity. Next priority is to help military families.
• Immunization victory: Brueswitz vs. Wyeth. Supreme Court upheld Vaccine Injury Compensation Program. Decision protected the entire vaccine program, which was saved in the 1980's by the development of the program in the first place.
• New CPT codes cover vaccine counseling, administration of multiple-antigen vaccines. Adoption by insurers has been spotty, but the AAP is working hard at getting them on board. Tricare does cover these codes, Vaccines For Children program lags due to wording of the law itself.
• AAP Richmond Center Of Excellence continues to work against children's exposure to secondhand smoke with the help of the flight attendants' organization.
• Helping Babies Breathe program launched in June 2010 to train personnel in newborn resuscitation in the developing world. The goal is to decrease infant mortality by 75% by 2015.
• www.Healthychildren.org website has become one of the most trusted sources of health information on the web.
• American Board of Pediatrics Maintenance of Certification remains contentious, AAP is working closely with their board and making progress to improve the process.
• Section on Medical Students, Residents, and Fellowship Trainees has been amazingly active, working on impressive initiatives.
• In pediatrics most subspecialties do not match the earnings of a general pediatrician,exceptions being cardiology, critical care, neonatology. Working on providing better financial incentives for pediatric subspecialty training.
• Greatly disappointed in administration's decision to remove all funding from pediatric training in children's hospitals.
• Pediatric Hospital Medicine has a new and growing section within the AAP. They will be launching a journal this summer.
• Our Washington office is working hard to protect appropriations for children's programs such as NIH, CDC, Head Start, WIC, etc.
• The Affordable Care Act gave pediatricians much of what we desired in terms of access to care, benefits, and coverage for children's care.
• When we talk to lawmakers none of them say they want to harm children, but then they propose slashing and burning children's programs.
• Christoph Diasio: Will efforts to help military families include better access for children with Tricare?
• Burton: Not yet.

Steve Shore, Executive Director, Update on NC Pediatric Society Foundation

• Involved in reach out and read program
• Outreach and enrollment for children in health insurance
• Please consider a $100 gift to our upcoming giving campaign, which is tax-deductible
• Materials are in development to make it easier to consider the Foundation in estate planning.
• We are working on working with a number of large foundations on working toward child health promotion.

Academic Center Updates

• Leonard Feld, MD, Levine Children's. Great match results this year. New director of adolescent medicine, expanded cardiovascular services. Expanded GI division to six doctors. Level IV NICU recognized with award from Joint Commission. Both live and online CME coming up for board review this summer. Published a new version of the Pediatric Dosing Handbook, free from Levine Childrens.

• Chuck Wilson, MD, ECU. New dental school opening, new children's hospital planned. Dale Newton will be retiring.

Pediatric Musculoskeletal Pain Syndromes

Dr. Laura Schanberg, Duke Children's

• Big three pain problems in pediatrics: headaches, abdominal pain, musculoskeletal pain
• Pain frustrates us because we cannot measure it.
• Pain involves environmental, biological, and social factors that all contribute to whether a patient communicates a complaint of pain.
• Pain reports do not track well with objective measures of disease severity. Much of the variance is accounted for by coping.
• Many different stresses to the organism can set off chronic pain symptoms, both physical and psychological trauma.
• Inflammatory diseases can lead to chronic pain syndromes that are not due to the disease process.
• Glial cells rare thought to be involved in the perpetuation of pain syndromes long after the initial pain trigger is gone.
• Cerebral cortex has efferent impact on peripheral pain receptors. Affect and behavior matter.
• We used to believe normal children don't complain of pain, newborns cannot feel pain.
• 5% to 20% of healthy children complain of pain. We have better assessment tools now to determine whether children are experiencing pain.
• Females and older children are at highest risk. Pain reports diverge by sex starting just before puberty.
• This pain may impair function in very real ways.
• Growing pains vary by society, from 4% in the UK to 18% in Denmark.
• 25% of children on who present to pediatric rheumatology clinics have pain syndromes.
• They are difficult to treat.
• In children with pain syndromes look for a role model for pain. Parents whose children have fibromyalgia are much more likely to report pain themselves.
• Fibromyalgia comes with lots of associated symptoms. These kids have central pain processing disorders which makes them more sensitive to other forms of discomfort.
• There are two sets of criteria for fibromyalgia. Dr. Schamberg feels the broader criteria involving other complaints are more valid. Must be over eight years old, have fatigue, sleep disorder, tender points.
• Tender points are not specific types of anatomical sites. Patients often cry when you push with your thumb using four kilos of pressure. Often crying occurs with less pressure than that.
• Pain thresholds are lower for these patients with lab testing of pressure, hot, cold stimuli. These patients cannot give you a precise pain history in terms of nature or location of pain.
• Patients feel like they have soft tissue swelling without any physical signs of swelling.
• Arthritis kids feel better with activity, kids with fibromyalgia feel worse.
• Overlap with chronic fatigue, irritable bowel, PMS, pelvic pain. All one disease, depends on what part of the elephant is being looked at. Chronic fatigue and fibromyalgia cannot usually be distinguished in children.
• Real physiologic changes are present in the brain and in the pain processing system. We must show them that we believe they really do have pain.
• We have to mesh the mind/body dichotomy in order to treat these conditions.
• Treatment starts with education and reassurance. They don't have to be afraid that they will feel like this forever or be unable to live with the pain. Knowing they are not going to be crippled helps.
• They MUST return to school. Staying home these children do not get better.
• The goal of therapy is function, not the absence of pain. Therapies must have a time limit and a goal.
• When one therapy does not work, just stop it.
• Therapies should foster self-reliance.
• People with chronic pain syndromes feel uniquely unable to control or deal with their pain.
• Evidence-based interventions include aerobic exercise, CBT, amitriptyline, cyclobenzaprine (short term, precludes school), pregabalin (adults only so far). Best to combine modes of therapy.
• Drug therapy tends to work poorly, in part because there are so many different symptoms of these diseases. Nonsteroidals are useless.
• For chronic pain syndromes drugs are not the answer. Have to break the cycle of poor sleep, fatigue, mood, pain.
• The first thing that happens at initiation of exercise is that the pain gets worse. Start low, go slow.
• Daytime sleep does not help! Must stop the naps! Amitriptyline seems to help with sleep regulation at 10 mg to 25 mg.
• Screen for increased caffeine intake.
• Cognitive behavioral therapy can be a useful intervention. Focuses on changing thoughts, feelings, behaviors around stresses. Biofeedback alone probably will not help.
• Conquering Your Child's Chronic Pain by Lonnie Deltzer at UCLA, very helpful book.
• The primary care pediatrician knows the child, the family, and the community resources best, has the best shot at successful treatment.
• Consider before and after EKG when starting amitriptyline. Remember it does not treat depression in kids.

Srikumar Pillai, MD, Jeff Gordon Children's Hospital, General Surgery. Pediatric Acute Abdomen

• Bowel obstruction: A, B,C,D, E. Absolute constipation, that is no stool or flatus. Borborygmi should be loud but may be absent. Colic, Distension, Emesis.
• The more distended the abdomen, the more distal the obstruction.
• Bile in emesis is obstruction until proven otherwise.
• Pyloric stenosis was first described in 1717. Not accepted until Dr. Hirschrpung described two cases in 1888.
• Pyloric stenosis is present in 1/500 children. Erythromycin may contribute.
• 7% of children with pyloric stenosis will have other associated malformations.
• Hydrogen ion loss causes metabolic alkalosis but paradoxical aciduria. This results from increased aldosterone excretion.
• To safely use anesthesia you have to get their bicarbonate levels down to 30 or less. Count on one day of correction for every week they've been sick.
• If you can see a pylorus on ultrasound it's abnormal.
• Ultrasound remains the best diagnostic modality. Sensitivity is 97%, specificity is 100%.
• Resuscitate with half normal saline, start without potassium until you confirm normal renal function.
• Oral atropine may resolve pyloric stenosis in 25% of cases, popular in Europe, but requires one week in the hospital.
• Intussusception, first operated on in 1873, described in 1674. Hydrostatic reduction devised in 1876 by Hirschsprung, again.
• Occur most often in spring and fall along with other illnesses, due to lympohid hyperplasia
• 80% are ileocolic
• More than half occur in the first year of life.
• Vital signs start normal. Right lower quadrant may appear flat.
• If there are peritoneal signs do not do the barium enema, they may have a perforation.
• Non operative management is successful 75% to 89%. Practice helps.
• Surgical approach has to be open; requires squeezing the intestines with the hands.
• Recurrence rate is 2% to 20%. Consider lymphoma in kids with multiple recurrences.
• Rotational anomalies, frequency is unknown, since most malrotations never present clinically. Autopsies suggest 0.5% of people have malrotation.
• 60% of patients who present will have associated anomalies, heterotaxy
• 40% of patients present in the first week of life. Only 25% present after the first year of life.
• Mortality in infants is 2-24%
• Chronic midgut volvulus may cause failure to thrive, recurrent abdominal pain and malabsorption syndrome.
• Physical exam is not helpful. Peritonitis is a late finding, with necrosis of the bowel. Upper GI is the gold standard.
• Ladd's procedure is the surgery of choice. Untwist, widen the mesentery.

Adam Ravin, MD NorthEast Plastic and Reconstructive Surgery, Pediatric Facial Injuries & Other Common Cases: When To Consult A Plastic Surgeon

• There will be a scar. But it won't end up as bad as parents fear it will.
• Sometimes you just need sedation to fix a wound properly.
• Tons of consults for dog bites, lacerations
• Taking tension off the wound is critical, layered closure.
• Debride the wound first.
• Work gently with the tissue, don't injure it more.
• Sutures should come out in 5-7 days to minimize scarring
• Orient woulda with Langer's lines of the face
• Approximate, don't strangulate.
• Running sutures risk dihiscence
• Tissue glue is for clean, superficial, low-tension wounds.
• Must document physical exam well prior to repair, especially nerve function.
• After a dog bite, make the kid NPO immediately, start antibiotics!
• Is tetanus up to date? Has Animal Control been called?
• With lip injuries vermilion border alignment is critical.
• Scars stay pink for a year, must be patient.
• With eyelid injury ectropion is a concern.
• For second degree burns apply sillvadene, attend to pain control, debride any non-viable skin, leave blister intact. Should not scar, but will discolor, sometimes permanently.
• For full thickness burns unstable, thickened scars are a risk. Early excision and grafting is the best approach.
• Contractures are what you're trying to avoid.
• Gynecomastia in males is a common referral to plastics, usually the most serious cases.
• Marijuana makes boys grow breasts!
• If not stable over eighteen months nothing needs to be done, may change.
• Not likely to improve with weight loss.
• Insurance does not often cover these procedures.
• If areola is large and puffy, inframammary fold is present, appearance is very breast-like.
• Surgical approach is to flatten the fold, use ultrasound assisted liposuction. Must wear compression for four weeks.
• In Grade IV disease the breasts look obviously feminine. Requires excision, leaves permanent scars.
• Macromastia in teen girls can cause back and neck pain, athletic limitations.
• Weight loss and nonsteroidals don't tend to be effective.
• Surgery may limit breast feeding, cause permanent scarring loss of nipple sensitivity.
• With pregnancy and weight gain they made require treatment in the future.
• Constricted breast deformity causes almost absent development on one side.
• Insurance coverage is often nonexistent.
• Wait until contralateral breast growth is nearly complete before you treat.
• Often requires tissue expanded, two stages of surgery.
• These repairs are rarely perfect, but better.

Eric Mair, MD & Timothy Saunders, MD, Charlotte Eye, Ear, Nose, and Throat Associates. Eyes And Ears: Syndromes Affecting Vision And Hearing

• Neurofibromatosis, may get optic nerve glioma, Lisch nodules on slit lamp exam. Rumors may displace sphenoid bone, cause exophthalmos.
• Only 1-5% will have visual loss
• Gliomas tend to present by age 10 years
• May require chemotherapy, radiation, surgery
• Lisch nodules are usually in contrasting color to the iris.
• Plexiform neurofibroma feels like a bag of worms in the eyelid
• Type II NF is associated with acoustic neuromas, these kids inevitably become deaf.
• Tuberous sclerosis have retinal astrocytomas.
• Von Hippel Lindau syndrome caues retinal angiomas and angiomas a in the cerebellum. May cause retinal detachment.
• Also causes endolymphatic sac tumors affecting hearing.
• Sturge-Weber syndrome is associated with glaucoma on the same side as the lesion, 70% affected.
• Hemagiomas in the mouth can bleed, sometimes severely.
• Marfan syndrome causes an upward lens dislocation. Associated with high myopia, astigmatism. You may have to remove the lens, increase already high risk of retinal detachment.
• Infantile esotropia almost always requires surgery, should be done by 4 to 24 months of age.
• 30% will require future surgery to correct vertical alignment issues.
• Infantile glaucoma: large eyes, corneal clouding, tearing, photophobia. Must identify and treat early!
• Choanal atresia has a 100% correlation with CAHRGE syndrome. Surgical emergency.
• Coloboma, heart defect, atresia choanae, retarded growth, gentile hypoplasia, ear anomalies
• Also involves optic nerve, retina
• Vision may be mildly to severely impaired
• Nystagmus is a poor prognostic sign, means vision is poor.
• Goldenhar syndrome, hemifacial micrsosomia. Often with airway obstruction, facial nerve weakness on the affected side, also abnormal cochlea.
• Microtia, ear skin tags often present.
• Have mermaids of the globe or the orbit, bilateral half the time.
• May also have coloboma of the upper lid, nasolacrimal duct occlusion.
• Duane's syndrome limits sixth nerve function
• Branchio-oto-renal syndrome. Think of this when you see pits in front of the ear.
• Look to see if there's a little hole on the neck. This is the marker. Often has a sensory hearing loss.
• Associated with renal abnormalities about 70% of the time. If you see ear pits, check the urine.
• Treacher-Collins syndrome. May be hard to maintain an airway at birth. Associated with microtia, cleft palate. Not developmentally delayed. Require team approach to care.
• Appear to have absent tissue of the lateral lower lid, may have trouble closing the eyes.
• Beckwith Wiedemann syndrome: overgrowth, large tongue, hypoglycemia, hypothyroidism. Airway management can be very challenging. Newer procedure can reduce tongue size in a minimally invasive manner.
• Achondroplasia: cervical instability, sleep apnea, airway management issues, fused ossicles in the ear.
• Velocardiofacial syndrome: cardiac anomalies, abnormal facial features, thymic aplasia, cleft palate, hypoglycemia
• Usher syndrome: most common cause of combined deafness and blindness. Autosomal recessive. Often balance problems are the first symptoms noted.
• Associated with retinitis pigmentosa. Night blindness, peripheral vision loss.
• When considering cochlear implants, the sooner you put them in the better!
• Waardenburg Syndrome, most common autosomal dominant cause of hearing loss. Most will need hearing aids. White forelock, different colored eyes.
• Alport syndrome. Progressive hearing loss after ten years of age. X-linked. Lens has anterior lenticonus, dot and fleck retinopathy. Also get glomerulonephritis.
• Stickler syndrome. Lack of collagen. Cleft palate, micro Mathis, mid-face hypoplasia, conduct hearing loss, early myopia.
• Trisomy 21: Burshfield spots, strabismus, refractive error, glaucoma, cataracts in some cases.
• More than half get obstructive sleep apnea, best to treat early. Start with tonsillectomy, adenoidectomy, tongue reduction. Often require PE tubes. Be aware of risk for atlanto-axial instability, especially in the OR.
• Pediatric exam. The big difference is having the tools to assess pediatric vision. This includes a pediatric hand held slit lamp.
• ENT exam has the benefit of a microscope, curette, fiberoptic endoscope.