NCPS Annual Meeting 2011, Friday, August 19th

This weekend we have to share the Grove Park Inn with the Southern Governors Association, which includes the governors themselves. That means we’re also surrounded by burly guys wearing sidearms and little ear-pieces on curly wires. Some of us are now talking into our sleeves, just trying to blend. Unfortunately we blow our cover every time we pass a child in the corridor and bend down and start making googly eyes. This, I think, explains why so few pediatricians work as international spies.

As always I'm just typing as fast as I can. This isn't meant to be a comprehensive review of the whole meeting, especially since I'm going home to my kids Saturday evening, missing some of the best sessions. This blog is really just a teaser to get you all to come to the next meeting, sidearms optional.

8/19/2011

Our President, Dr. Karen Breach

Executive Director Steve Shore makes all this happen. Here we see him bustle.

Miriam Labbock, MD & Emily Taylor, MPH

Update On Breastfeeding

• Majority of pediatricians in practice don’t know the AAP guidelines
• Immediate skin to skin contact after birth
• Breastfeed within one hour
• Breastfeed exclusively for six months
• Continue for at least one year, don’t just stop then
• Need related maternal nutrition and care
• The first six weeks require some real work and adjustment
• Delay cord clamping - leave the cord unclamped for 2 minutes, baby gets more iron
• Best first food is high in protein and iron like meat, beans
• ANY formula use is an insult to the infant’s gut and immune system
• Formula changes epigenetics, gut flora
• US has the worst survival rate in the developed world for full term babies; breastfeeding would help
• Controlling for SES being a minority STILL predicts increased rates of increased infant death
• Problem: formula supplementation still occurs frequently in the newborn nursery
• Why change now?
• Patient satisfaction, AUQR prevention guidelines, ethical considerations, shorter return hospitalizations, minimal cost, surgeon general’s call to action, IOM closing the gaps in preventive services campaign, new growth standards, Joint Commission Perinatal Care Core Measure
• Ten Steps To Successful Breastfeeding - these steps lead to dramatic increases in women achieving their intention to breastfeed:
• have a written policy
• all staff should be able to implement the policy
• inform all women about the benefits of nursing
• help mothers initiate skin to skin
• show mothers how to maintain lactation
• room in
• no other food and drink for babies
• encourage feeding on baby’s cues
• make sure moms have follow up for breastfeeding support
• North Carolina Maternity Care Breastfeeding Designation awards hospitals for following even some of the ten steps
• http://www.breastfeedingtraining.org
• www.aap.org/breastfeeding/curriculum/tools.html
• http://cgbi.sph.unc.edu/healthcare
• http://www.ncbfc.org
• http://www.bfmed.org

YMCA Healthy, Fit, and Strong Program

Robert P. Schwartz, MD

• Three month program for kids 6-11 years of age with BMI over 85th percentile and no serious medical conditions
• Physical activity sessions three times a week, involving family members as well
• Continued for 6, 12 months, $25 gift certificate at the end of the program
• Lessons on moving, eating smart, eating out, etc. using slides, notes, talking points, and questions
• At 12 months 48% of kids had a lower BMI, 45% were unchanged, and 7% had seen increases in BMI percentile
• Activity levels increased for most children. Screen time decreased for most. Dining out decreased, but not significantly. Sweetened beverage consumption decreased. Fruit and vegetable consumption increased, more for fruits.
• This program can be instituted at any YMCA in the state! Contact the NCPS about starting one in your community if you don’t already have one.
• The cost for printing materials is around $5 per child
• Registered dietitian will need some salary
• Costs end up around $2750 for 20 families enrolled including scale and stadiometer, staff, equipment, games

Brandon Rector, MSW

NC Immunization Branch

• Monitoring patrons at Olive Garden Fayetteville when a waitress was diagnosed with Hepatitis A, so far no outbreak but people are being prophylaxed
• Flu vaccine being shipped 60,000 doses. Starting with Fluzone, Flurix now. This is about 12% of the expected doses for the season.
• Flumist has been shipped to the CDC, but not yet in NC.
• Flu recommendations are only six pages long, pretty much says vaccinate everyone as soon as possible
• Pertussis cases continue to spread in NC, although not as quickly as in California
• Remember that protecting children involves vaccinating pregnant women with Tdap
• Dr. Peter Morris urges doctors to alert the Heath Department at the earliest suspicion of HAV infection, not to wait until the diagnosis is made and all the studies are back.
• Blue Cross/Blue Shield NC is willing to pay our offices for vaccinating parents with Tdap according to Dr. Christoph Diasio if parents are covered by their insurance!
• http://immunize.nc.gov is the new and updated website!

Gerri Mattson, MD, MPH

Children and Youth Branch, NC Department of Public Health

• Medical Home Approach To Care and Title V Services
• Look for newborn screening results at www.slph.state.nc.us
• If a patient did not get a newborn hearing screen at birth you have up until 2 weeks of age to get one
• Various programs exist to support families throughout the state. In New Hanover County we have a Strengthening Families Program
• Family centered care should be building on family strengths, supporting children in participating in care and decision making, supporting transitions to adult care, honoring cultural diversity.
• Care Coordination For Children (CC4C) is the new name for the care management program
• Look for other resources from churches, other health care providers, schools, community organizations, etc.
• Look at the AAP cultural competency tool kit at http://practice.aap.org/content.aspx?aid=2990

Teaching Program Updates

Leonard Feld, Carolinas Medical Center/Levine Children’s

• Added pediatric rheumatologist, new GI specialist
• Contact them for a free pediatric dosing guideline
• Liver and bone marrow transplant programs have done extraordinary success rates clinically
• http://lchk.org check out the center for advancing excellence in pediatric quality of care
• They have managed to almost eliminate central line infections in their units using quality of care implementation

Joseph St. Geme, DUMC

• Fifteen new faculty members, endocrine, pulmonary, psych, adolescent specialists
• 16 new interns in pediatrics, 6 new med-peds, 20 fellows
• Now using night teams and day teams, working on handoff protocols to deal with work hour guidelines
• Now with 14 new NICU beds
• Renovating wards for new work space
• Growing cardiac transplant and surgery programs for children
• Growing intestinal and liver transplant programs as well

Dr. Dale Newton, ECU/Brody School Of Medicine/Pitt County Memorial Hospital

• New family practice center, new dental school
• Now starting construction on a pediatric hospital wing
• Also creating a new pediatric ED, under construction
• Golden Corral founder has made enormous contributions
• New faculty include new PICU docs, cardiologist, endocrinologist, GI specialist, med-peds, neonatologist, nephrologist, ID specialist, pediatric surgeon

Julie Byerly, UNC

• Alan Stiles is stepping down as chair of pediatrics, now down to three final candidates, hope to name chair this fall.
• Graduating class is bringing lots of students into pediatrics, med-peds
• Residency class is growing, leading to more individualized educational tracks
• Primary care track involves 5 residents, lots of community activity, involvement at Guilford Child Health
• Tracks for pediatric neurology and anesthesia as well
• New pulmonary, ED, neonatology faculty joining
• Celebratory event in September to celebrate the career of Harvey Hamrick, September 23rd, Friday evening

Dr. John Abramson, Wake Forrest

• Ten new pediatric and surgical faculty members
• New tissue engineering institute created an anal sphincter in animal model, pioneering work
• New tertiary obesity clinic
• Focus on quality improvement, now in the top quartile of the University Consortium Database

Dr. Victor Perry, UNC Pediatric Neurosurgery

Prenatal Surgery of Myelomeningocele Repair: An Update

• New randomized trial to look at outcomes of prenatal versus postnatal repair came out in the NEJM February 9, 2011
• Plan was to disallow any non-participating institution from trying the procedure until the article came out.
• Randomized to prenatal versus immediate postnatal repair, same surgical teams in both cases.
• End points at 12 months: death, need for shunt. 30 months developmental outcomes
• Study stopped early due to strong positive outcomes for prenatal repairs
• One advantage is that prenatal group can go to term rather than face early cesarean delivery for repair
• Prenatal surgery represents the new treatment paradigm
• UNC is set to perform this procedure now

Dr. Francis Rushton, Chair, Chapter IV

AAP Update

• AAP Strategic Plan: pillars remain access, quality, and finance for children’s health care
• Planks are early Brain and Chld Development, Special Health Care/Foster Care Needs, will be adding epigenetics
• Access: health Care Reform. The ACA gave us some tremendous gains for children’s health care. Eliminates preexisting conditions, caps, gained coverage up to age 26, adds 37 million people to coverage, provides wellness benefits based on Bright Futures Guidelines
• Problems: Medicaid is under attack. Worse in South Carolina, already faced a 2% cut to providers, looking at an additional 10% cut
• Accountable Care Organization draft guidelines are universally disliked, going back for revisions
• Still not clear what an ACO is going to look like
• Working on quality initiatives. Steering Committee on Quality Improvement And Mmanagement. eQUIP program allows you to improve quality in your practice and meet Maintenance of Certification guidelines.
• Small work groups looking at how the AAP can do more for early brain development
• Looking at how we can have a more active involvement in international and cooperative children’s health initiatives like the wildly successful Helping Babies Breathe program
• We are part of the International Pediatric Associations organization, working with other national societies.

Introductions of Everyone

Olsen Huff, MD introduces the Kids In Parks Program

• Carolyn Warden speaks on the need to get kids outside and back into parks
• Kids In Parks website allows kids to register, log their journeys, get a prize like a backpack or a walking stick! Funded by Blue Cross/Blue Shield among others
• Taking kids outside has real benefits for mental health and school performance
• Opening a new national franchise, taking the model from NC nationwide
• 95% of kids say it’s fun, many have never been in a state or national park before

Dr. Marian Earls

• CHIPRA grant to NC is funding our work in helping EHR vendors find a format that actually serves the delivery of healthcare to children
• Please contact her if you’re interested in becoming involved in this project
• Already working with several major vendors in filling in the gaps in pediatric EMR implementation

Some of us, including Dr. Susan Mims on the right, brought our box lunches outside. There was some concern that sitting on the wall high over the courtyard might lead to a tragic headline, but everyone made it back inside safely, although with more sun exposure than our dermatologists might condone.

2011 Annual Business Meeting

• Starting with a moment of silence for our members who have passed on since the last meeting.
• Recognition of our Executive Committee members
• Review of our Open Forums, now each featuring a theme for the CME lectures
• The PROS program is currently recruiting practices for a study of teen smoking
• Dr. Scott St. Clair, treasurer, presents report on our financial health. We’re doing okay, about on track. Appreciate participants in the special assessment to cover increased lobbying expenses this year.
• Dr. Paul Trani elected to the Executive Committee
• Dr. Peter Morris makes a plea for donations from pediatricians to the NC Pediatric Society Foundation, a body that is separate from the NCPS and allows us to receive grants and do work for children the NCPS cannot do for a variety of reasons. Please donate before the end of the year, $100!
• Chapter Recognition to Dr. Susan Mims, Executive Committee member from 2007 to 2011
• Award of Appreciation to Dr. Scott St. Clair for his service in putting together Resident Career Days since 2006

Sharon Cooper, MD, FAAP, UNC School Of Medicine

Domestic Minor Sex Trafficking

• Domestic minor sex trafficking is a problem that doesn’t get the attention that international sex trafficking gets
Sexual harm is normalized in the media and in advertising, links sexuality with violence, disrespect, sexual objectification, and consumerism
• Commercial Sexual Exploitation Of Children (CSEC) is another term for Domestic Minor Sex Trafficking. CSEC is the internationally accepted term now
• Children are brought in by parents with drug dependence who sell them. Computer assisted family prostitution makes it easy for parents to sell children through chat rooms, child sex rings with live video feeds/webcams
• Adults who are sexually exploited may add their children to the activity for more money
• Sexually oriented business like strip clubs are a major entryway for sexual exploitation
• Siblings may sell their younger siblings
• Gangs may also bring children into the business.
• Group home owners and managers create placement related prostitution
• Boys who have run away are often victims of male prostitution
• Brothel based prostitution often ethnically based
• Cab Operation involves taxi cab drivers who bring offenders to expensive hotels
• Runaway, homeless children are at very high risk; offenders (pimps) look in shelters for them. Boys are often abandoned, especially if their sexual orientation is an issue for their parents
• Trucker communities in rural settings are common vectors for child sexual exploitation
• Rural areas around military communities are common vectors; men have money in these areas
• “Modeling” businesses may appear legitimate and then move toward more sexually explicit photography, including online child modeling sites
• People often blame the victim when Domestic Minor Sexual Exploitation comes up. These victims are often not the ones getting the money. They have been exploited by adults
• Most common cause of exploitation is children being sold by their own family members. Sometimes a parent’s paramour will be abusing the child and the parent will not intervene because of financial reliance on the paramour
• Homeless children on the street make it an average of seven days before they turn to “survival sex” for money, food, and shelter
• When victims are compliant, such as those who run away from home, their families tend to blame them for what happens
• Propaganda: exploiters sell these girls a “dream”
• Men wait outside of homeless shelters, offer girls a “job”
• Victims are not “sex workers”. They are coerced, threatened, and intimidated into these positions
• Trafficking doesn’t mean a child has to leave the state. Just being sold for sex is enough to qualify
• Health impacts include substance abuse, intimate partner violence, reproductive health impact, and mental health diagnoses
• When an offender is arrested what is the structure of his organization? Does he keep girls around long enough for them to grow up and consider themselves co-wives of the offender?
• Drug sales may be as important as trafficking sales for some offenders.
• If online marketing is involved, how are the girls coerced to pose?
• Is the offender the father of a child by the victim? These victims are very reluctant to leave these offenders
• Being able to document the victims’ life stories is among the most useful things we can do for them
• Sexual abuse may occur in or near the home, but sales tend to involve some travel, such as to a hotel
• “The Bottom” is a victim herself who becomes an enforcer for the exploiter
• Substance abuse is often a coexisting problem, since exploiters use drugs to manipulate victims and force them to work
• Medical evaluations should be done in a clinic, not in detention
• Finding out that children have been sexually assaulted changes the focus of the criminal justice system from treating them as offenders to treating them as victims
• Many suffer post traumatic stress disorder, more than in Iraqi war victims
• Studies demonstrate that teens who view music videos with sexually degrading lyrics > 2 hours/day are more likely to engage in early intercourse
• The demand piece of the picture is critical: without demand there would be no victimization.
• www.polarisproject.org is the national hotline for sex trafficking victims

Dr. Maria Ferris, UNC School Of Medicine Division of Pediatric Nephrology

Healthcare Transition: Lessons From The Field

• Patients with chronic kidney disease suffer cognitive impairment. Kids with hypertension, diabetes also have some impairment
• In transitioning we have to teach parents and caretakers to let go
• We have to take into account how modern teens learn that may be different from how their parents learn
• Adolescents and young adult kidney patients may take 16 meds a day (transplant), and average 9 meds/day
• Lower literacy skills lead to increased ED visits
• Parents often have mixed feelings about letting their children take responsibility for their own illness management
• Medication adherence is a major component of healthcare transition
• Definition of adherence varies by disease and the who is defining it
• Pharmacies can provide MD’s information on refill frequency, helps estimate adherence to medication use
• Transition is a continuum, it starts years before the transition and it continues for years into young adulthood
• UNC Nephrology waits for at least one year after a child leaves for college. Transitioning at the same time is too much to learn to handle
• www.unckidneycenter.org/hcprofessionals/transition Tools that you could use are here
• The TRxANSITION Passport is a tool for educating patients, fits in the wallet
• Includes ID number, current meds, allergies, clinic phone numbers, diagnoses, why they are taking each medicine
• STARx Transition Tool is a self-directed tool for assessing readiness patients can use
• Focus on what children should know at each age: 12-14, what’s your condition’s name, what medicines do you take? 15-18, nutrition, self-management, reproductive health issues
• The STARx tool provides providers with information about what their patients do and do not know about their conditions so they can focus on the patient’s most urgent needs

Paul V. Miles, MD, FAAP

Getting Started Maintenance Of Certification Part IV

• You may participate in activity online or by doing an approved quality improvement activity in your practice
• Cycle is every seven years. You don’t have to wait until the end of your cycle to get this done, although many doctors do
• Joint efforts with internal medicine and family medicine boards using the same process
• Options for subspecialists are more limited

Dr. Sarah Adams of Carolina Pediatrics joined the party after making a long, long drive with her family from Wilmington!