2009 North Carolina Pediatric Society Annual Meeting Day #3

Good morning! Some advice: if you're planning on going for a run near the Grove Park Inn bring a map or a GPS or something. PS: people working in their yards around the Grove Park Inn are happy to give you directions. Also the Mountain Rescue Team could not be more polite.

Onward to Day #3!

Adrian Sandler, MD Autism Spectrum Disorders

• Prevalence of ASD 6/1000
• Review of Hans Asperger and Leo Kanner’s early descriptions of autistic behaviors
• Triad: qualitative impairment in reciprocal social interaction; qualitative communication impairment; narrow, restricted range of interest, insistence on sameness, repetitive behaviors
• Of the three, impaired social relatedness is really the core of the diagnosis (theory of mind development abnormal)
• Language: form of language dissociated from function of language
• Repetitive behaviors - very insistent on routines, special interests, pre-occupation with parts of things, stereotypic movements
• Myths: child is not affectionate, does not form attachments, never makes eye contact, does not communicate, engages in serf-stimulatory behaviors or repetitive behaviors all the time.
• Not all children with poor social skills have Asperger’s syndrome.
• The autism epidemic: dramatic increase in awareness, recognition of broad spectrum, earlier diagnosis, epidemic of over-diagnosis of Asperger syndrome and high-functioning autism.
• Brain abnormalities: macrocephaly in early childhood (30%). Brainstem abnormalities suggest onset in 1st trimester. MRI is not diagnostic, not a routine part of the evaluation.
• Sibling concordance is 7%, older parental age is a risk factor
• Chromosomal abnormalities: 22q deletion, 15q11-q13 inverted duplications, many other genes implicated
• Syndomes: Fragile X, Rett, Tuberous sclerosis, Down’s
• Whole genome arrays are turning up new syndromes like 16p11.2, PTEN.
• Genetic syndromes now identifiable in 15 to 20% of all patients with ASD’s
• Earliest signs: joint attention, social interaction, play behavior all delayed/impaired
• Watch for following a point by 10 months, pointing to an object by 12 months, pointing to indicate interest by 15 months.
• In the second year look for child to manipulate parents’ hands as though they are tools in the child’s control.
• Ask open-ended questions: “How does he usually communicate to you? What are his favorite things to do?”
• Home movies research demonstrates even experts cannot identify autism earlier than 12 months of age.
• Home movies confirm that regression does occur in about 1/3 of children with ASD, usually between ages 12 and 24 months.
• Research on siblings also shows a threshold of around 12 months to identify children with ASD
• For children ages 4 to 6 the Social Communication Questionnaire is helpful.
• In Asheville the MCHAT has not led to a large increase in the number of patients referred to the CDSA. of 63 referrals only 20 came in, only 5 had ASD (6 had developmental language disorder)
• Improved functional behavioral assessment could reduce over-prescription.
• Easy to prescribe for each symptom (sleep, agitation, constipation) leading to polypharmacy
• Medical home can help avoid over-prescribing for ASD symptoms

Sara Sinal, MD Recognition of Child Abuse

• Law requires you to inform law enforcement and DSS of serious physical abuse
• Must report suspected abuse to DSS but not to law enforcement.
• Skin injury (excluding burns) is the most common presenting sign
• Head injuries are most common cause of death from child abuse, but abdominal injury has the highest percentage of deaths per injury
• Risks: poverty, unmarried mom, living with unrelated adult, child with disability/prematurity/multiple birth, substance abuse in family
• Document extensively in the chart, include photographs when possible
• Be sure to note who witnessed the event, what happened after the event, and what the mechanism of injury was
• Does the story change over time, was the injury blamed on a younger sibling?
• Document past medical history, especially failure to thrive in infancy, fracture under one year of age, deaths or serious injuries in siblings
• Examine skin in mouth, genitals very carefully, also look carefully at TM’s, extremities
• For bruising get basic coagulation evaluation, consider hematology consult.
• Amylase, lipase, and LFT’s screen for abdominal injury (SGOT > 80 suggests abdominal CT)
• Check calcium, phosphorous, Alk phos, 25-OH vitamin D with fractures.
• Osseous survey under age 2, not over age 5, depending on suspicion between ages 2 and 5
• MRI or CT if bruising to face or head.
• Abdominal CT if bruising to abdomen
• Can’t really age bruises by color, no matter what they say on CSI!
• Look for pattern injuries such as looped cord, tennis shoe prints, coat hanger, etc.
• Remember mongolian spots, phytophotodermatitis, vasculitis, cupping/coining, pot-mortem insect bites.
• Burn patterns: dipping, hot liquid thrown at child, contact with flame.
• Less common burns: chemical, frostbite, microwave/oven burns
• 39% of burns requiring hospitalization result from abuse/neglect.
• Scene investigation is critical
• Mimics of burns: severe diaper rash, bullous impetigo, epidermolysis bullosa
• Fractures in 11% to 55% of abused children, 50% will have multiple fractures
• The younger the child the more likely a fracture is from abuse
• Spiral femur fractures are not unusual in children who are mobile, but under 1 year of age remain a red flag for abuse.
• Paul Kleinman, MD has published tables of fracture types versus likelihood of abuse
• Differential diagnosis: Osteogenesis imperfecta, Rickets, Menkes syndrome, bizarre diets causing copper deficiency, non-weight-bearing children with osteopenia, premature birth with history of parenteral nutrition, Lasix, Leukemia, osteomyelitis, Vitamin A toxicity
• http://www.niams.nih.gov/Health_Info/bone/osteogenesis_Imperfecta/default.asp to learn all about osteogenesis imperfecta
• Risks for abusive head trauma: mom <21>
• 64% of parents gave no explanation in the face of seriously ill child
• Retinal hemorrhage present in 76%
• Permanent injury rate 50%, death 22.5%
• Trigger: crying in young infants
• Abdominal trauma has a 45% to 50% fatality rate
• Victims often young, preverbal. Hard to see signs of injury, no easy studies (CT abdomen)
• Hollow viscus injury suggests abuse

Jane Bellet, MD Practical Approaches to Common Skin Disorders

• Describe lesions well when communicating with dermatologists
• Atopic dermatitis is exemplified by pruritis. These kids scratch!
• Both frequency and severity of atopic dermatitis has been on the increase
• Eyelid involvement is a hallmark of eczema
• Look for early age of onset, atopy, xerosis.
• Must rule out scabies, contact dermatitis, seborrheic dermatitis, psoriasis, ichthyoses
• For eczema look for lymphadenopathy, hypo- or hyperpigmentation (don’t put steroids on those spots if inflammation is gone), pityriasis alba, lichenification, superinfection, papular variants in African American children.
• Bathe at least once a day, short (5 to 15 minutes maximum).
• MOISTURIZE!
• Topical steroids
• Itch control: use antihistamines!
• Treat superinfection!
• Try wet wraps, wet pajamas, gloves/socks over medications (don’t wash for 10 to 14 days)
• Look for Tubifast Garments, may be covered by insurance http://www.skincareworld.co.uk/pharmacy/our_products/tubifast/garments.htm
• Medicate with strong enough medications, enough quantity
• OINTMENTS better than creams. Oils good for the scalp
• Good meds: hydrocortisone 2.5% ointment, Triamcinolone 0.1%, Mometasone 0.1%
• If you’re looking at Fluocinolide 0.05%, Clobetasol 0.05% think dermatology referral
• Protopic 0.1% is preferable to Elidel. Best preserved for use around the eyes.
• Remember Protopic will burn if areas of open skin are present
• Hydroxyzine is best for itch control, 0.5 mg/kg in daytime, 1 mg/kg at night.
• Doxepin useful in severe cases
• ZYRTEC is a LOUSY medicine for itch control in atopic dermatitis.
• Treat superinfection with oral antibiotics.
• Get a bacterial culture in superinfection!
• Mupirocin for all open areas, can mix with topical steroids
• Cephalexin, Clindamycin, Trimethoprim/sulfa best agents
• Seal in steroids with moisturizer
• Oral steroids are NOT indicated for atopic dermatitis
• TINEA CAPITIS. Consider fungal culture if picture is not clear.
• Still treat with griseofulvin, 20 mg/kg/day (microsize), 10-15 mg/kg/day (ultramicrosize). Give with fatty foods! Treat 6 weeks.
• Now terbinafine granules are available, 2-4 week course. Consider LFT’s. Save this for griseofulvin failures.
• Oral fluconazole, itraconazole, ketoconazole are alternative back up meds
• Id reaction: usually starts after onset of therapy, must treat through it.
• Kerion: treat fungal infection, but also consider oral antibiotics for bacterial superinfection. Some people try oral corticosteroids x 2 to 4 weeks.
• Try two courses of therapy, then refer to dermatology
• Vitiligo: white hairs are a clue if any question about diagnosis (poliosis).
• Vitiligo over joints is especially difficult to treat
• Wood’s lamp can help with diagnosis. Presence of rash in that spot in the past suggests post-inflammatory hypopigmentation
• Vitiligo is characterized by DEpigmentation, not HYPOpigmentation
• Treatment starts with potent topical steroid BID. Can consider Protopic, especially on face. Phototherapy is helpful. Can use 308 nm excimer laser
• Coverups: Dermablend, Covermark
• Consider checking thyroid antibodies in non-segmental vitiligo (very rare to have a thyroid condition with vitiligo)
• Reassure parents most people won’t turn completely white.
• ALOPECIA AREATA
• Usually sudden loss of hair, sharply demarcated, smooth without any hair at all, may have pitting of nails (Scotch plaid pitting)
• Consider trichotillomania, tinea capitis.
• If there are just a few patches prognosis is good.
• The younger the child the worse the prognosis
• Treat x 3 to 6 months to see if something is going to work.
• Use class II or I topical steroids
• Dermatologist may use intralesional corticosteroids
• Also anthralin, minoxidil, squaric acid, dphenylcyclopropenone
• Pediatrician can start topical steroid while waiting for referral, but most parents will want a referral.
• www.naaf.org

2009 North Carolina Pediatric Society Annual Meeting Day #2

For those of you looking for the late sessions yesterday I have to apologize. I shredded a tire on the way into Asheville, and I spent the late afternoon learning more about tire shops in Asheville than about pediatrics. But it's a new day, and I have a shiny new tire, so let's go! Also welcome to Marc Yandle from The Children's Clinic and Sarah Adams from Carolina Pediatrics, here now to join the party.

Surgical Pearls

Mike Hines, MD Vascular Rings

• Consider aberrant large vessel anatomy in frequent URI’s, LRI’s (vascular ring). Can be very tough to find on scan due to ligamentous completion of ring. Usually these kids get treated for reflux, asthma, laryngomalacia. Can be found with barium swallow. Can by fixed thoracoscopically.
• Pearl: a swallow study is easy to get, great for diagnosing vascular ring.
• Pearl: can’t judge the size of a PDA based on the sound of a murmur. Large PDA can be quiet on exam. The PDA murmur is CONTINUOUS, LUSB. Unrestrictive PDA can lead to irreversible pulmonary HTN within a year.
• Pearl: check femoral pulses at every age, not just infancy; mild coarctations may go undetected until child gets bigger - children grow, aortic coarctations don’t! Automatic BP cuff in children is inferior to your physical exam, don’t count on it to rule out coarctation.

Victor Perry, MD Neurosurgical Pearls

• Consider encephalocele with any mid-face abnormality. The earlier you diagnose the better.

Duncan Phillips, MD Inguinal Hernias

• Pediatric inguinal hernias affect 2% to 5% of kids, 10:1 male to female, more common in premies.
• Inguinal hernias do NOT resolve spontaneously (hydroceles do).
• 31% of children under age 2 months with inguinal hernias will develop incarceration, with a high rate of complications.
• So DO NOT wait until age 6 months to do the repair! Any baby over 2 kg in weight should undergo repair by a pediatric surgeon.

John van Aalst, MD Arhinia and Obsessive-Compulsive Disorder

• Congenital absence of the nose, 25 cases reported in the literature but many more cases occur.
• Very difficult to reconstruct.
• Presents a case of a successful nose reconstruction.
• But the child found having nostrils disturbing for some reason and began cramming foreign bodies in her new nostrils to the point they no longer serve as functional breathing apparatus.
• Lesson: must take the whole patient into account. Even when you can perform the surgery technically there are social and psychological issues that can contribute to poor outcomes.

David Wallace, MD Red Eye

• Microbial keratitis: more common in contact lens wearers, with corneal abrasion, previous eye surgery.
• Management must be aggressive, with corneal scraping, antibiotics.
• Red eye with contact lenses is a corneal infection until proven otherwise!
• Never sleep in contact lenses.
• Children/young teenagers should be carefully assessed before prescribed contact lenses.
• Viral conjunctivitis: purulence = bacterial. Pre-auricular lymph node = viral. May be difficult to differentiate, and often use antibiotics regardless, but if discharge just watery may observe.
• Neisseria is especially dangerous, invasive, may lead to blindness. Treat with ceftriaxone or cefotaxime, not topical agents.
• Sulamyd stings, so not often used. Parents prefer drops, but ointment is better for corneal abrasions.
• Erythromycin, not great for gram negative.
• Polytrim (sulfamethoxizole/polymyxin) works great, especially for nasolacrimal stenosis-related infections.
• Fluoroquinolones cost a ton, but Vigamox good for corneal abrasion.
• Gentamycin/Tobramycin can be toxic to the cornea with prolonged use.
• Phlyctenular keratoconjunctivitis: eyelid margin irritates surface of the eye, causing yellow-white nodules at the limbus. Treat with antibiotic/steroid combination.
• Stye/Chalazion: may have to be drained under anesthesia.
• Preseptal cellulitis: associated with sinusitis, trauma, insect bite. Commonly strep pneumoniae, occasionally Heamophilus influenza.
• On exam if eye is proptotic, EOM not intact, pupil not reactive that’s orbital cellulitis. Also look for pain with EOM. Get blood cultures, CT scan. Treat with IV antibiotics.

Subspecialty Pearls

Ali Calikoglu, MD Hypocalcemia

• Main source of vitamin D is skin synthesis. Little is made in the winter and at more northern latitudes.
• Can make 600 IU of vitamin D with 6% body surface area exposed to sunlight 15 to 30 minutes two to three times per week (Caucasian).
• African-Americans on average need ten times as much.
• Proper use of sunscreen reduces Vitamin D synthesis by 99% (SPF 15).
• Breast milk is a poor source of vitamin D, provides only 15% of daily requirement.
• Vitamin D is rare in foods, present only in fish, fortified milk. But only a small percentage of milk has enough vitamin D, and lower fat milk has less (fat-soluble vitamin, so it can be in the bottle but not bioavailable).
• Calcium supplements are only effective in the presence of adequate Vitamin D.
• Rickets = Skeletal findings. If no skeletal findings, it’s severe vitamin D deficiency.
• Don’t check 1,25(OH)D levels. It’s not informative, and it costs $400. Just check Vitamin 25 (OH)D level.
• 30 ounces of formula contain 400 IU of vitamin D, but there’s nothing wrong with a little extra supplementation. In Europe they use 2000 IU a day.
• Calcium lactate is an excellent calcium salt for supplementation. Calcium chloride causes diarrhea. Calcium carbonate remains an excellent supplement because it has the highest overall concentration of calcium.
• Normal serum calcium level does not exclude rickets.
• Poly-vi-sol and Tri-vi-sol taste lousy. Now available in the US: Bio-D-Mulsion 400 IU per drop, Solar D Gel caps 400 IU and solution 400 IU per drop, Just D 400 IU per drop.

Amina Ahmed, MD Malaria in International Adoptees

• Consider malaria in hepatosplenomegaly.
• Need three malaria smears to rule out malaria. Don’t trust just one smear.
• Remember malaria can be chronic, indolent, not just acute in presentation.
• Falciparum is most common, most dangerous in terms of morbidity, mortality.
• Vivax and Ovale may relapse years after initial infection due to hypnozoites in liver.
• Children may be partially treated in native country, arrive to US asymptomatic then develop symptoms later.
• Smears may be all negative during dormant phase of malaria infection.
• Cyclic fevers are a late presentation of malaria, not a reliable sign.
• Hosts may be partially immune, present with subtle symptoms long after exposure.
• Most common symptoms fever, hepatosplenomegaly, elevated transaminases, thrombocytopenia.
• Malaria smears are recommended in asymptomatic refugee children from sub-Saharan Africa.
• Rapid antigen sensitivity is low.
• PCR is more useful for species identification, available at CDC, takes months to come back.
• Treatment: go to CDC website for updated therapy. Treat for Falciparum always.
• Liberia is rising in number of international adoptions as a result of war.
• Screening for infectious disease in adoptees/refugees:
• Hepatitis B serology (sAg, sAb, cAb)
• Hepatitis A antibody
• Hepatitis C serology
• Syphilis (RPR/VDRL and treponemal test)
• HIV 1 & 2
• VZV antibody
• CBC with differential
• Stool for ova and parasites (3) and Giardia and Cryptosporidium antigen
• TST
• Trypanosoma cruzi serology in children from countries with endemic infection
• Strongyloides and Schistosoma species serology in children with eosinophilia and negative O&P
• Malaria smears (3) in children from sub-Saharan and West Africa

Charlie J. Sang, Jr. MD Continuous Cardiac Murmur

• Continuous murmur usually from PDA, but any AV fistula can cause a continuous murmur.
• Also consider aorto-pulmonary window, Sinus of Valsava aneurysm, aorto-pulmonary collaterals, anomalous origin of coronary arteries, coronary fistula
• Anomalous origin coronary artery: may come from left or from right.
• Anomalous left coronary infants get pale and sweaty with stress, this is angina.
• Anomalous right coronary artery is ten times as rare, less symptomatic presentation due to low pressure system.
• EKG and CXR may be normal in ARCAPA, usually abnormal in ALCAPA
• Echo will show dilated coronary arteries in both. Mitral insufficiency in left but not right.
• Functional murmurs are typically positional
• Venous hums resolve in supine position
• Organic continuous murmurs may cause changes in PE, ECK, CXR, SpO2
• Peaceful tachypnea points to organic heart disease

John Foreman, MD The Boy With Fatigue (Renal Failure)

• Top causes of anemia in NC: Iron deficiency, sickle cell, beta thalassemia, chronic disease, acute infections
• Anemia 101: look at cell lines, indices, retics, Fe, TIBC, % sat.
• Basic evaluation of anemia:
• Microcytic: Fe deficiency, lead, Thalassemia
• Macrocytic: B12 deficiency, folate deficiency, Thyroid disease
• Normocytic:
• Increased reticulocytes - hemoglobinopathy, hemolytic anemia
• Decreased/normal retics - parvovirus, chronic disease, acute blood loss, chronic renal disease.
• Chronic renal failure rare in children
• Anemia can be fixed with erythropoietin
• Also need calcitriol, calcium carbonate, phosphate binders.
• Can treat comlications like anemia, rickets, growth failure, heart disease
• Can also slow progression to end stage renal disease

Awards Luncheon

David Tayloe, Jr., MD, President American Academy of Pediatrics

• Priorities in healthcare reform: Child-specific benefits, default enrollment choice for parents and caregivers, affordable premiums and cost sharing, medical homes for all, appropriate payment for MD’s.
• Would like to make sure health access is complete for all children.
• Currently ERISA-exempt plans are not addressed and may be allowed to provide sub-standard coverage for children.
• Full benefits for children would be based on AAP recommendations, Bright Futures, and EPSDT.
• Medicaid payments will become 100% of Medicaid, which would still be better that the already very good rates in NC.
• Ensure care delivered in a medical home.
• Ensure access to pediatric physicians and pediatric subspecialists
• We need much more than CHIP, leaves 12 million uninsured children.
• Americans really do strongly support covering all children (87% in favor)
• RSV prophylaxis guidelines in Redbook differ from what Medimmune would like, but Committee on Infectious Diseases has been unanimous on our recommendations. You may be approached by your Medimmune rep on this issue, but please know the Redbook guidelines are strongly evidence-based.

Jane Foy, MD presents plaque for AAP Best Large Chapter to Marian Earls, MD and Herb Clegg, MD along with Steve Shore. This is a highly competitive award and NCPS has won 6 times since 1981 (may not win again for three years after winning once).

Poster presentation awards given by Greg Talente, MD. Thirty-four participants this year in a poster session which is unique to the NCPS.

Herb Clegg, MD presents Good To Kids award to Holy Angels organization for contributions to children's welfare in NC. They provide residential care to children and adults with mental and physical disabilities who are medically fragile.

Practice Manager of the Year to Debbie Cashion of Catawba Pediatric Associates, PA.

Olson Huff, MD presents Outstanding Achievement Award to K. Michael Dennis, MD for a career spent advocating for children's health and well being in NC. Also presented award to William W. Lawrence, Jr., MD for his service in the Division of Medical Assistance from 2004 to 2008.

Pam Silberman, JD, DrPH receives Tom Vitaglione Child Advocacy Award in absentia, presented by Marian Earls, MD. She is president of the North Carolina Institute of Medicine.

Peter Morris, MD presents the James D. Bernstein Excellence in Public Service Award to Leah McCall Devlin, DDS, MPH for her long career in public health including time spent as Director of the Division of Public Health and State Health Director.

Denny, Katz, Simon, Tinglestad Academic Service Award presented by Dr. Marian Earls and Dr. Kay Gable to Kenneth B. Roberts, MD for his work in the Moses Cone Health System and UNC.

Bill Hubbard, MD presents the David T. Tayloe, Sr. Award for Outstanding Community Service presented to Sue Hollowell Lee, MD for service in multiple capacities including the Pamlico County Child Fatality Prevention Team, the Juvenile Crime Prevention Committee of Pamlico, the Jones County School Health ADvisory Board, Pamlico County Community Child Protection Team, Smart Start Board, and HeartWorks Children's Medical Home Mission.

Steve Shore receives special 10th anniversary award from Drs. Jane Foy, Marian Earls, Gerri Mattson, and Deborah Ainsworth to celebrate his first decade of service with the nation's best chapter of the AAP.

2009 North Carolina Pediatric Society Annual Meeting

Okay, y’all, I left my camera at home this time, thinking a bunch of photos of people at the podium really isn’t going to add much. But I will take notes on the presentations and try to include the most interesting bullet points.

Friday, 8/21/2009

Executive committee:

• Please send in BC/BS complaints to NCPS for negotiations over court settlement.
• Look at new OSHA requirements for cleaning crews. Yes, they exist, and yes, they’re slightly ridiculous.

Open Forum:

Brandon Rector, MSW Immunization Branch, Gerri Mattson, MD, MSPH

Division of Public Health

• H1N1 Recommendations continue to evolve
• Make sure health department knows you want to give H1N1 vaccine in your office.
• Still hoping for two-way interface between EMR’s and NCIR
• Remember HIB booster is now available
• State Fluzone Influenza vaccine to be shipped starting Monday.
• Seasonal flu vaccine is recommended for all children ages 6 months to 18 years.
• H1N1 recommendations are in flux, to be addressed in a later talk.

Newborn CF Screening Review

• Screening is identifying about 10% of CF carriers, not the intent of the program
• If immunoreactive trypsinogen (IRT) is >95% then DNA testing is done (46 most common)
• DNA testing can still miss some mutations.
• Kids with two mutations get preferential scheduling by CF centers. Must be 14 days old, 2 kg in weight.
• If IRT >99.8% then sweat chloride. Also if one or two genes positive.
• Sweat chloride must be done at accredited CF center. (Duke, Kings Daughters in Norfolk VA, Mission, UNC, Wake Forest, Western Carolinas CF Center)
• Genetic counseling is recommended for infants with CF or with mutation.
• Notification comes to physician of record by phone, fax, and mail. ONLINE results do not include abnormal CF results.

UNC EMR web access should be available to community physicians!

H1N1 Influenza

• Obesity and pregnancy are significant co-morbidities for influenza death risk.
• May only have 45 million doses of vaccine against H1N1 by October
• Priority groups are likely to be more limited than initially thought.
• Healthcare workers, pregnant women, contacts of 0-6 month infants, and children 6 to 60 months along with other young people with underlying illnesses will be in the first tier along with elderly adults.
• Oseltamivir dosing for children under 12 months can be found at the CDC website.

Francis Rushton, MD, Healthcare Reform

• 12 million uninsured children in the US now.
• AAP DOES endorse healthcare reform, although it does not back a specific bill.
• Overall pediatricians, pediatric specialists, and children stand to benefit from universal care.
• Kaiser Family Foundation and AAP websites both help with the details of current proposed legislation.
• This is NOT the English healthcare plan.
• HB 3200 would raise what we get paid to 100% of Medicare.
• HB 3200 would provide reimbursement for medical home services, financial assistance with medical training.
• Please be vocal in your communities in support of universal care for children.

• Also, be aware Redbook recommendations on RSV prophylaxis and Medimmune’s recommendations differ.
• AAP budget only $800,000 or 1% in the red.

Pediatric Palliative Care

• Kids Path Program is available in Lower Cape Fear Hospice, includes counseling for children who have suffered a loss of a parent or sibling.
• Palliative care is not just about end of life, but about quality of life when coping with the challenges of a complex or life-threatening disease.
• Individualized Care Planning and Coordination Model

Frank Loda, MD Purple Crying Project www.dontshake.org

• Make sure practicing physician reinforces to family (not just mother) the importance of not shaking babies.
• There are cards for MD’s to hand to parents to confirm they received the Purple Crying DVD and get their feedback on it.
• The project is now contacting practices to participate in distributing these materials.
• If you don’t already have these materials please contact the program at jana.thompson@duke.edu

NC KIDBase Access System for Emergencies, Gloria Hale, NC State Office of Emergency Medical Services

• EMSC is Emergency Medical Services for Children, based in NC Office of EMS
• Goal is to optimize emergency care to children from the point of entry to the system through child’s return home.
• Ensures essential pediatric equipment is present on ambulances, improve safety of pediatric ambulance transport
• Ambulance crashes are much more common than private vehicle crashes, so kids really should be properly secured.
• Create emergency care guidelines for schools when school nurse is not available.
• Develop hospital guidelines for inter-facility transfers
• Kids Information Data base Access System for Emergencies: ensure children with special needs receive the care they need in medical emergencies.
• KIDBase medical information form is a double-sided form to be completed by parent/caregiver and by primary physician
• Get your copy of the form here: http://www.co.dare.nc.us/depts/ems/KidbaseForm.pdf
• Make sure families keep a copy of this form in the child’s “go bag”, also at school or daycare if needed

Carol Ford, MD on NC Institute of Medicine Adolescent Health Task Force

• Create evidence-based roadmap to improve health of children aged 10 to 20 in NC
• Portrait of adolescent health to be released next Tuesday!
• Call to Action December 15, 2009 to kick off roadmap from task force.
• Working toward new adolescent Health Check based on EBM practices.

NCPS Spring Open Forum 2009

There are all sorts of places one might spend a perfect spring Saturday morning: the beach, the back yard, a dimly lit Hilton conference room in Durham. I chose that last one, since that's where the North Carolina Pediatric Society's Spring Open Forum was being held. Several dozen of our pediatric colleagues from around the state made the same choice, which seemed the least we could do given all the work Steve Shore and Marian Earls put into the agenda. The program was so good in fact I started to feel sorry for all my colleagues on their boats or on the sidelines of their children's soccer games. So I snapped a few pictures and took some notes so you wouldn't feel like you'd missed too much.

Opening: Dr. Marian Earls, FAAP, President of the North Carolina Pediatric Society

Pass around the microhone, introductions. Weirdest coincidence: almost everyone there was a pediatrician!

Thanks to Laura Buxenbaum, our host from sponsor Southeast United Dairy Industry Association. Got milk? We did, in abundance. Also pastries, fruit, and coffee.

 Brandon Rector, MSW, Immunization Branch

• Stimulus package may direct some money toward influenza vaccines in schools, NCIR rollout to all providers.
  
• Six competitive grants for stimulus money, but not sure for what.
  
• Immunization rates have been falling in NC and nationwide.
  
• Hib shortage: still do three doses ActHib, 2 doses Pedvax.
  
• Reminder recall is part of the NCIR, look to see who is behind and call parents to bring them back in.
  
• Do we want the state to start finding children who are behind and reminding their parents to get them in. Medical, parental choice, and religious exemptions are coded in the registry.
  
• Larry King Live had an episode last night with Jenny McCarthy again.
  
• Alternative schedules: you are supposed to use the ACIP schedule as the standard if you’re part of the state program, but you are not prohibited from using an alternate schedule at parents’ insistence.
  
• McKesson is now contractually obligated to ship vaccines within three to five shipping days (Monday through Wednesday) and it takes the state one day to transmit your order to McKesson. If you order on a Thursday that means you’re looking at a week before they’re ready to ship.
  
• US and European vaccines are manufactured to the same standards.
  
• HBV vaccine supplies are variable right now, may see some supply interruptions but so far we have enough to get through May. No schedule changes at this time.
  
• State is working toward a universal vaccine program in North Carolina.
  
• Some practices in Mecklenburg County are working on a two-way NCIR interface.
  
• Several doctors brought up concerns that if schools perform influenza vaccines they may not enter them into the NCIR in a timely fashion. Can the state inform physicians when their patients have received the influenza vaccine?
  

 John Rusher, MD, JD, FAAP with legislative update.

Representative Jennifer Weiss from Wake County here to receive Presentation of Excellence in Public Service Award.

Jennifer Weiss: 

• Hard to get safety bills passed due to sentiment people should make their own choices. Pediatricians need to keep pressing legislators to get these bills passed.
  
• Legislative priorities from John Rusher:
  
• Get coverage for universal vaccination program from the state legislature. Seems like funding may hold steady or even increase.
  
• SCHIP/NC Health Choice. Federal matching funds will come to NC to cover children's healthcare in families up to 200% of the poverty line. Probably will not need to have a waiting list for families to join. Kid's Care, which should cover children up to 300% of poverty line, is likely not going to happen.
  
• Medicaid reimbursement should remain at 95% of Medicare, which makes ours one of the best states in the nation for Medicaid reimbursement.

We have 25 bills of interest pending in the NC Legislature. Some highlights:

• House Bill 2: Prohibit smoking in public places. Amendments are filtering this bill, but it is headed to the Senate. Latest amendment for businesses that don't admit minors.
• House Bill 88: Healthy Youth Act. Provides choice of abstinence or more accurate comprehensive sex education program. Most parents chose the more comprehensive program, even in New Hanover County.
• House Bill 523: Increasing folic acid supplementations to prevent neural tube defects.
• Several bills to improve school cafeteria foods and reduce presence of vending machines.
• Senate Bill to ban texting while driving and teenage mobile phone use while driving.
• Senate Bills to implement Child Fatality Task Force findings to reduce shaken baby, SIDS, mainly funding educational programs.
• S699: Cement plant moratorium and study. I got to give a three-minute summary of the Titan issue.
• Budget continues to shrink as economic predictions catch up with current conditions. Unemployment may go as high as 14% in North Carolina ultimately.
  
• Please participate in Pediatric White Coat Wednesdays April 22, May 20, and June 10th. Or call John Rusher and he'll get you in any day of the week.
  

 

Tara Larson, Division of Medical Assistance

• New Medicaid Director is Dr. Craigan Gray, MD, MBA, JD. Has practiced as an OB/Gyn in Asheville.
  
• Federal Matching Funds (FMAP) will be around 74% of the State's outlay, which is enough to cover the Medicaid budget as certified. This is a big deal, since we thought we might run over budget by $200 million.
  
• Governor's budget was good news. Senate's budget is being released next week, some rate reductions expected in physician payment. Senate is looking to bring NC Medicaid closer to the less well-paying programs in other states, but we argue that will just increase ER use and waste money rather than save it.
  
• Health Information Technology funds: still organizing in the state; feds have not specified what the qualifications will be to get our hands on those funds. Hope to fund electronic records, exchange of information between providers.
  
• Also should be able to pay hospitals more federal dollars for providing indigent care to the uninsured (DISH). The cap is going up on those funds. Additional $200 million.
  
• NC is one of the 16 states the Government Accounting Office will be monitoring for use of recovery money. This means lots of documentation and accountability, lots of red tape for the State.
  
• Medicaid is auditing personal care services, use of preferred drugs, utilization of hospitals, specialized therapies (OT, PT, Speech, Audiology) to make sure usage is appropriate and care is coordinated with medical home.
  
• Formulary is currently open, but a preferred drug list may be on the way, especially if we run short of money in Medicaid.
  
• Computer Service Corporation is our new vendor for Medicaid payment processing and provider enrollment. They will start doing the processing of applications, and all of this will be online. Turn-around time from application to approval should go from 12 weeks to 10 days.
  
• Will be reviewing all existing providers, re-credentialling. Don't worry, you won't have to submit new applications or change provider numbers.
  
• National Provider Identifiers must be in place by May 1st. If you don't use it, claims will be denied.
  
• UNCOLA: not Sprite. This is the Cost of Living Increase, which impacts the Federal Poverty Level. Sometimes people lose Medicaid eligibility or suddenly have deductibles in place of full eligibility. About 9000 Medicaid recipients will be affected this year, mostly adults and older teens.
  

NC Health Choice:

• We may reach our cap of 6% and have to put a hold on new enrollment.
• Kid's Care just isn't going to happen.

New Medicaid billing guide released April 1st:

• Now paying annual visits from ages 2 to 20 instead of q 3 years.
• New coverage for autism services, paying for MCHAT testing on the same day as a wellness exam.
• New payment for mental health screening.
• New Adolescent Package will expand coverage for teen care, may go into effect 7/01/2009.
  
• New waiver for people with traumatic brain injury to get Medicaid coverage, being introduced in the legislature, not yet approved.
  
• Applied Behavior Analysis may be covered as autism therapy.
  

Gerri Mattson, MD, MSPH, FAAP, Dr. George Retsch-Bogart MD, & Alice Lenihan, MPH, RD, LDN on NC Divison of Public Health

Gerri Mattson: expanding Newborn Cystic Fibrosis Screening; NC will be second-to-last in the nation to add this (Texas will be last). 

• First test is IRT (immunoreactive trypsinogen) level, then if 95%ile follow up with DNA testing.
  
• Report will be sent to provider.
• If screen is abnormal then patient should have sweat chloride testing at an accredited center (there are 6 available).
• There is a follow up coordinator to make sure these kids get followed up.

Dr. George Retsch-Bogart reviewed two-tiered screening plan and the research and data that led to current plan. The testing is going to also identify infants who are carriers.

• Abnormal results will be called, faxed, and mailed.
  
• Results will not be available on line.
  
• Sweat chloride testing should only be done at CF Care Centers.
  
• Newborns with two mutations have a higher probability of CF.
  
• CF Foundation information will be available for providers and families.

Changes in WIC program, Alice Lenihan:

• Moving away from whole milk for every child over age 12 months.
• State does not have enough funds to purchase enough vitamin D for everyone. Only providing it for infants who are exclusively breastfed.
• Will need to write prescriptions for fruits, vegetables through WIC if children are on exempt or specialty formula products.Will be able to prescribe tofu in place of milk products. This is for cultural or religious reasons.

Open Information Session by Steve Shore:

Dr. Francis Rushton, President District IV with District Update

• Please vote in district and national elections.
• We have a new logo for the AAP. This is a way to visualize our priorities. Increased focus on health equity. Adding a new issue, early brain development.
• Academy's financial status not so good. Looking at a $1.8 million deficit. This is around 2% of the budget.
• No draconian budget cuts are planned.
• Healthcare reform is big on our agenda, and the Obama budget looks like it may lead to increased payments for primary care providers. David Tayloe is strong on this subject.
• The AAP is seeing a decline in subscription renewals and publication purchases. Dues coming up soon, hard to know how it's going to go.
• Please remember all the professional value your AAP membership offers you.

Frank Loda, MD, Presenting the Purple Project

• PURPLE crying DVD given in the hospital, this is the first dose.
• At first follow up visit we should give parents a reminder, and give the the DVD if they haven't already watched it. This is the second dose.
• Third dose is working with community groups to support their work on educating parents.

Dr. Paul Harrison, Wake County Medical Society on NCIR Patient Recall

• Wake County Medical Society: Urged to use NCIR recall function. They can upload our data from anyone age 9 and over to utilize this to generate data on people who need immunizations. 
• We have to sign a HIPAA compliance statement. 
  
• Must provide four pieces of data: patient's name, parent's name, address, date of birth.
  

Dr. Lorrie Hicks

• Pediatric palliative care coalition of NC
• Seek to educate health care professionals and families.
• Working on policy changes at the legislative level. Children on home health care cannot also receive palliative care benefits.
• Resource for families and physicians throughout the state.
• There will be a meeting in Raleigh, April 28th if you're interested in this topic.

Department Chair Reports

• Duke, Joe St. Jeme. Good match results, lots of new faculty in many divisions. New Cardiac ICU open. New echo lab open. New campus in Wake County for specialty practice. Communications Task Force working on communicating with referring pediatricians.
• Julie Byerley, UNC. US News & World Report ranked the pediatrics program #22 in the nation. We plan to be ranked even higher. Great match results. Also working on Raleigh clinics for specialty care. New airway team with a center focusing on airway issues, tracheostomy care.
• Dale Newton, ECU. State budget cuts continue to climb from 2% to 10%, but fortunately only 25% of the budget comes from the state. Bad news is uninsured patient burden continues to rise. Great match results this year.
• Mike Lawless, Wake Forest. Hosting a Practical Pediatrics course in two weekends. Felt good about match results.

 

Lieutenant Colonel Barbara L. Bowsher, MD, FAAP, Chief of Pediatrics, Womack Army Hospital, Ft. Bragg

• What is it like to live on a military base? Supportive, everyone understands.
• Families have to move often, sometimes every year. A few can stay in one place for prolonged periods although this can be a detriment to promotion.
• Kids have to start over all the time, get used to new cultures, new friends. Kids lose their familiar routines.
• Moving doesn't happen at any predictable time of year. School changes occur randomly, and kids may lose academic credits with each move.
• Children transferring from Junior to Senior High School have an especially tough time. Also children moving from their Junior to Senior years in high school.
• Athletes may lose their rankings or even their entire sport.
• May go from a small school to a large school.
• Even if you stay your friends are always leaving.
• For parents deployments are now much longer than they used to be, often 15 months.
• Special challenges face families with only one parent or with two military parents. May be discharged if can't arrange child care.
• Reserve military are now being treated just like regular military, often very far from home. They do then get active duty benefits, which help the family.
• After deployment National Guard/Reserve soldiers have to re-create their old lives. Often require psychiatric services.
• Pre-deployment phase: lots of frustration, surprise. Families may move back to hometown.
• Deployment: often lots of community support. Family left behind have to do it all, including dad's job (or mom's job). Kids worry a lot about parents' safety. Kids have new responsibilities.
• Post-deployment: everyone has changed, everyone has a new routine. Kids have grown, developed, changed. Starts with a honeymoon phase, about 6 months. Then whatever marital issues were there before are still there. PTSD and traumatic brain injuries have a big impact. Returning soldier feels isolated.
• 1.2 million children are involved in military families. 700,000 kids in reserve/guard.
• NC is among the top states in the nation in terms of injured military personnel.
• Strengths: patriotism, sense of community, schools and community centers, travel.
• Research in mental health issues is rapidly expanding.
• Teens with deployed parents have increased HR and BP.
• Risk of physical abuse goes up when parents return from deployment.
• Up to 35% of returning soldiers need mental health services in the first year.
• HEADS exam: home, education, activities, depression, sex/drugs/alcohol.
• Kids may present with psychosomatic complaints.
• Parents may be in denial about how hard this is for the kids.
• What do they want? First listen to them. Try to understand.
• Resources: handouts from military, family readiness groups, on-base social workers, family advocacy program, army community services, primary care manager.
• Find someone else in the community teens/kids can talk to.
• Facilitate communication with deployed parent.
• Ask how the parent is doing during the child's visit. Let them know they'll see changes in their children.
• Look for Military OneSource to find resources.

Holly Haines, MD, Wake Forest University School of Medicine on Bisphenol A

• Started with alarmist news clips about BPA.
• Rachel Carson's Silent Spring demonstrated that very low doses of chemicals in the environment can have profound effects in certain combinations and at certain vulnerable periods of development.
• Studies in the Great Lakes in 1988 demonstrated endocrine disruptions in the offspring of certain birds exposed t environmental chemicals. Coined the term "endocrine disruptor."
• BPA is an estrogen agonist that helps make polycarbonate plastic. Terribly useful: clear, shatter resistant, heat-resistant.
• Also critical for epoxy resins that line food cans, bottle tops, and water pipes. Great for preventing corrosion, very flexible.
• 7 billion pounds of BPA are produced worldwide, one of the most widely used commercial chemicals today.
• BPA can be found in food, water, dust, air.
• The chemical bonds are unstable, releasing BPA into fluids. More rapid release with heat, washing, acidic or basic fluids.
• BPA is hydrophobic, so dissolves better in milk than in water.
• Leaching rate increases 55-fold with boiling water, continues to leach after exposure to heat at an increased rate.
• Highest leaching rates are in the very foods we're most likely to feed toddlers.
• 93% of NHANES participants had BPA in their urine. Highest levels are in children.
• So how much exposure is too much? EPA based threshold on animal experiments. That reference dose is 50 micrograms per kg per day. Safety dose has not been updated since the 1980's, and the true safe dose has never been defined.
• Toxic Substances Control Act passed in 1976 declared that all existing chemicals at the time were safe. The EPA would have to prove the chemicals do harm in order to regulate them.
• Levels of 2 to 20 mcg/kg/day cause reproductive abnormalities in mice in a 1997 study.
• With endocrine receptors you cannot presume a linear dose-response curve to any given chemical. There may be a threshold or even a "U" shaped curve. No one knows what that curve looks like for BPA.
• 2002 EPA announced it would not include low dose considerations in testing and screening protocols for endocrine disruptors.
• 81% of studies on low-level BPA exposure have demonstrated significant effects.
• Human studies published 9/2008 in JAMA. Mean BPA level correlated with DM and CAD. Causality could no be determined.
• FDA now admits significant concern about the effects of low-dose BPA on humans. FDA subcommittee in October, 2008 determined current levels defined as adequate are not.
• American Chemistry Council contends no risk to human health, "...making our lives safer, healthier, and easier."
• Retailers and manufacturers starting to withdraw BPA-based baby bottles and children's products.
• What can we do? encourage nursing, use BPA-free bottles, avoid canned liquid formula especially, avoid #7 plastic bottles.
• Not the same as phthalates, which make PVC products more flexible. They are also endocrine disruptors in utero in early development. May be associated with rhinitis, eczema, asthma.

NC Pediatric Society Winter Open Forum

To begin I have to thank Steve Shore and the executive committee for planning the Winter Open Forum within two blocks of a Starbucks (of course how hard would you have to work to find a conference location that isn’t within two blocks of a Starbucks?). Having started my drive from Wilmington to Charlotte at 5:00 AM, I was relieved to see the familiar mutant mermaid beckoning like a strip mall siren on Bruton Smith Blvd. On the horizon was the Embassy Suites, its glass-pyramid roof designed to make IM Pei cry.

Stoked on mocha I barely noticed it was 16 degrees out as I dashed across the parking lot into the warmth of the hotel conference center. Immediately I saw familiar faces from residency and the AAP, including our mastermind, Steve Shore. I grabbed a seat at the front and pulled out my camera, only to find the battery dead. I apologize for the cellphone photos that accompany this blog, but I needed some sort of visuals.

Steve Shore springs into action as our President Dr. Marian Earls opens the session.

As is our tradition we began by passing the microphone around the room so each of us could introduce ourselves. If the AAP ever takes this up we’ll have to schedule an extra couple of days. Naturally the turnout from the Charlotte area was good, but Shelby Pediatrics took the cake; apparently they rented a bus.

Brandon Rector, MSW

Brandon Rector, MSW, of the NC Immunization Branch hosted the first session. Here are the take-homes:

• Flu season is just now starting.
• Fluvirin, Flumist, Fluzone are all still available.
• Flumist expires shortly after shipping, so you may only have a month or a couple of weeks to use it upon receipt.
• Updates are coming out all the time, so pay attention.
• Boostrix can now be used up to age 18 years.
• NCIR is working better over the last two months but did have an outage last week related to password service. 
• Practices not yet on NCIR should be getting on soon.
• Plain HIB will not be back until mid-2009, when both Merck and Sanofi should be shipping again.
• There will be a lecture at the NC Pediatric Society State Conference August 12th to 16th, “Immunizations - The Real World, NC”
• For those with EMR a one way interface with NCIR is in beta testing.
• State flu vaccine can be given to anyone, including parents if you’re into that kind of liability.
• Private vaccine may be given side-by-side with state vaccine.
• H1N1 influenza is currently the dominant strain.

John Rusher, MD, JD

Next up was my residency classmate John Rusher speaking on reimbursement and legislative issues. I didn’t actually know John was a lawyer or I’d have been nicer to him. I guess I’m naive, but before John spoke I’d honestly never considered the impact of combination vaccines on administration fee revenues. Here are the bullets I got (not literally).

Reimbursement Issues

• Administration fees for vaccines within Medicaid increased to $17.21 for first vaccine + $9.71 for each additional vaccine.
• Unintended consequence of combination vaccines is a decrease in physician reimbursement.
• At least 70% of MD’s use combination vaccines. 30% are still ordering single antigen vaccines.
• NCPS has asked private insurers to increase reimbursements, although it’s not clear how they’ll respond.
• David Tayloe commented that Glaxo makes Pediarix so NC has an incentive to promote it. Humana will reimburse for combination vaccines with an additional $10. Texas Medicaid has also started reimbursing more. Not yet clear what NC Medicaid will do about this. Goldsboro Pediatrics may have to give up Pediarix for this reason.
• Tara Larson of NC Medicaid says they’re still looking at it.
• When the state calculates whether to purchase a combination vaccine they factor in the savings on administration fees.

Legislative Issues

• SCHIP reauthorization (NC Health Choice). State is waiting for Senate vote, since Feds cover 75% of this cost. May be signed in the next week or two by Obama.
• $2 Billion gap in state budget projected for 2009. Beverly Purdue is pushing the feds for $1 billion but will also cut $1 billion from the state budget.
• Compared to other states NC has excellent Medicaid reimbursement, an effort which will continue over the next year.
• Also pushing to protect/keep the state’s very successful vaccine program.
• Our reimbursement for sub-specialists is relatively poor in NC, and this contributes to a shortage here.
• Talk to any local legislators you know, also make the NCPS aware. Get on the Key Contact list.
• Participate in White Coat Wednesday at the State Legislature, occurring on four Wednesdays this spring.
• Statute of limitations for malpractice regarding infants is 19 years in NC; one practice was sued 3 days prior to expiration. We are working on that along with Medical Mutual.
• Please contact your state legislators and let them know you’re available to discuss pediatric issues. Also talk with Health Policy Advisor for Senators Hagan and Burr. Only takes 1-2 minutes, but matters.

Dr. Marian Earls, Deborah E. Carroll PhD, Vivian James

Next Dr. Marian Earls, Deborah E. Carroll PhD and Vivian James clarified how North Carolina is dealing with autism referrals. This topic is so big even three people talking very fast could only skim it.

• 2007 Recommendations: 
• Surveillance q visit. 
• Screen with MCHAT at 18, 24 months.
• Risk Factors (2/4): 
• Sibling with ASD
• parental concerns
• other caregiver concern
• pediatrician concerns
• If 2/4 risk factors present skip the screening and go to evaluation. 
• Evaluations should include Audiology Evaluation, ASD evaluation, Early Intervention Evaluation.
• Add Developmental and Behavioral Pediatrician, Geneticist, Neurologist PRN relevant concerns.
• Deborah Carroll expounded on what the CDSA will provide: 
• IFSP (Individualized Family Service Plan), 
• Early Intervention. Please alert CDSA as soon as possible.
• Department of Public Instruction: Vivian James. What do you do for a child who has turned three?
• Now releasing a flowsheet to describe how they (Preschool Exceptional Children Program) deal with referrals. 
• Trying to clarify what information pediatricians need to send with a referral. 
• Now have a form for two-way release of information.
• Working on training evaluators in diagnosis of autism.
• They need information up front: contact information, release of information form, vision/hearing screen, developmental screen, behavioral health screening.
• Idea is to increase consistency among the offices across the state.
• Health Department can expedite child service coordination.
• TEACCH is not so much for diagnosis as for management of autistic children in schools.

Tara R. Larson, Acting Director, Division of Medical Assistance 

Our next speaker was Tara R. Larson, on the topic of Psychological Testing for School Children. If you see Medicaid patients you might consider dropping Ms. Larson a little thank you note every time you pay your rent.

• It looks like SCHIP will survive, expand.
• CPT codes were updated in January to add codes for mental health, substance abuse screening and treatment.
• Trying to simplify Edits/Audits to reduce limitations on what can be billed on the same day. Can we do more in an office visit and provide multiple kinds of interventions/activities?
• Looking for: Depression, Anxiety, ADHD, Substance abuse, Learning Disabilities, Physical/sexual abuse, Autism.
• Check out www.icarenc.org for evidence-based tools.
• Parents are experiencing increases in depression and substance abuse, domestic violence.
• Domestic violence: screen all females age 14 or over.
• Only schools can bill Medicaid for educational assessment. Schools were given a loophole to the Free Care Rule (you can’t bill Medicaid if you don’t bill everyone). Schools may bill for evaluation that results in an IEP.
• Providers can bill ASQ, mental health and substance abuse screening provided along with E&M (there are some limitations on number or hours per day and should not be done in the hospital).
• Psychologists can be co-located with physicians.
• Mental health practitioners must have whatever supervision is required by their boards.
• Adolescent package: based on Bright Futures model. Not yet implemented, but going to physicians advisory board.
• National Provider Identifier required as of May 1, 2009.
• New Medicaid Management Information System has been contracted. Will require consultation with offices’ billing managers to implement.
• David Tayloe commented: agencies that provide services to exceptional children have financial disincentive to serving more children. Currently psychologic professionals cannot bill for evaluations that are requested by the schools.

Paul Miles, MD

Dr. Paul Miles next took the podium to clarify why maintenance of certification has become so complicated. He put the process in a historical context starting with the idea physicians should have some process to ensure basic competency and tracing the evolution of how we define competency. Apparently it’s no longer enough to pass a test once shortly after we graduate residency. Spoiler alert for those who were "grandfathered in": the NC Medical Board may require you to participate in Maintenance of Certification even if the American Board of Pediatrics doesn't.

• Medical knowledge was the first thing we could test, but it’s now clear knowledge alone is not enough.
• 1933: AAP founded.
• 1952: First randomized trial.
• 1975: First practice variation study
• Dartmouth Health Atlas: 
• Demonstrates variation in care using Medicare data. 
• Shows an inverse proportion between spending on care and outcomes. 
• Mayo is the model for implementing standards.
• 2000: Institute of Medicine Reports - the system does not revolve around delivering quality of care.
• You need to be able to measure and improve the quality of care you deliver. Not just the individual but the entire team must be involved. This is the idea behind the maintenance of certification process. Evolved from one test to a q 7 year test to a perpetual process.
• Improving access is great, but alone it won’t fix the problems in pediatrics. Controlling costs, improving quality are the other legs of the stool.
• “Trust me, I am a physician,” is no longer enough. The new age of transparency will require us to demonstrate our outcomes are adequate. What’s new is that we can define and improve quality of care.
• The Board of Pediatrics will have a major role in helping reduce the unexplained variations in quality of care.
• Adults get recommended care 54% of the time, children 46% of the time. (Mangione-Smith) Figures likely worse for children with barriers to care.
• Certification now includes four parts. The real roll-out is next year 2010.
• Over five years will need to acquire 100 points in practice improvement and continuing education. Every five years register and pay fee. Every ten years take maintenance of certification exam. Must have valid and unrestricted medical license.
• Subspecialists will have their own exams, but activities will count toward whatever.
• Website will tell you what part 2 and part 4 activities you have to complete.
• The nice thing is exam dates will be extended an extra three years.
• If you have a permanent certificate you may voluntarily participate in the maintenance of certification program. Start by passing the test, then you enter the five year cycle. If you wait until 2010 you must pass the test and acquire your 100 points over two years instead of five years. Results will be posted on the Internet. There is a rumor the State Licensing Board of NC may require maintenance of certification even for permanent certificate holders (Chuck Willson).
• Part I: Professionalism in Practice. Valid, unrestricted medical license. Disciplinary Action Notification System.
• Part II: Lifelong Learning & Self-Assessment. Multiple choice questions based on PREP program. There is a menu of activities you may participate in.
• Part III: Cognitive Expertise. Secure Exam Every 10 Years
• Part IV: ABP approved quality improvement projects. May participate in web-based modules (nutrition module available on AAP website). Another module on Patient Safety is available to all physicians, not just pediatricians. IPIP (Improving Performance In Practice) gives 20 points and may contribute almost all 100 points over five years. Also AAP EQIPP modules available.
• Example is Reducing Catheter-Associated Bloodstream Infections to Zero. Has prevented 65 deaths, 600 infections, saved $12 million.
• At onset of IPIP 3% of kids were getting “perfect” asthma care. After two years went up to 88%. Initially the physicians paid to participate. Then they negotiated to be paid, and some people really stepped it up.
• North Carolina Health Quality Alliance. About half the time interventions we all agree should happen don’t regardless of problem or setting. Everyone collects exactly the same data so it can be compared across practices and regions. Starting in Eastern and Western NC and then spreading it across the state.
• When group provided perfect care, they had a 50% drop in admissions for asthma, a 40% drop in ED visits.
• IPIP provides tools, help establishing a database, comparisons and fellowship with other practices, CME and MOC Part 4 credit, some financial support, access to national leadership in quality improvement.
• IPIP expects you to form a team, participate in dinner meetings, analyze data, commit to changing practice systematically, testing whether changes worked, meet with coaches.
• www.abp.org will tell you what you need to do.

Dr. Miles's point was best summed up by the above Margaret Bourke-White Depression-era photo. We have some of the best health care in the world, but we don't make it uniformly available.

Lanier Cansler, Secretary of the NC Department of Health & Human Services

I have to plead great ignorance to the subtle (or even obvious) aspects of state politics as they impact pediatric practice in North Carolina. But the people at the meeting who weren't so ignorant seemed very, very happy to welcome Lanier Cansler. The following of his statements got my attention.

• The state is trying to cut 7% from Medicaid overall.
• Hoping to find ways to cut budget without an across-the-board cut in reimbursements. They would prefer to accomplish this by improving preventive care, chronic disease management.
• They would very much appreciate physicians' contributions to this effort.
• Best thing that could happen here is for the Senate version of the SCHIP bill to include funds for NC Kids Care.

Next we heard a brief update from the chairs of all the major pediatric referral centers here in North Carolina. I have to apologize for my sketchy notes here. These people talked fast, at times overwhelming my typing skills.

Dale Newton, update from ECU

• Just opened cardiac medicine unit.
  
• Pediatric cardiology offices have moved, but inpatient services remain in children’s hospital. Plan is to add 100 beds total to the hospital, including new pediatric ED.

Carolinas Medical Center Charlotte. 

• 14 months into new pediatric hospital.
• Recruited tons of specialists.
• Opened three satellites.
• Holding Pediatric Board Review Course in May in Charlotte.
• Developing a quality improvement curriculum for residents.

Clemmons, Duke

• 13 bed pediatric cardiac intensive care unit, now full.
• New pediatric echocardiography facility.
• New Pediatric Obesity fellowship 2-year program.

Alan Stiles, UNC

• Deaths of several pioneering staff, ending with Rebecca Soccolar.
• New director of bone marrow transplant.
• Raleigh clinic open and seeing patients.
• New ICU space being built.
• Trying to get services to patients.
• Starting newborn screening for cystic fibrosis (George Retsch-Bogart)

Following was an open discussion on whether anyone will continue going to cesarean deliveries. Rural practices cannot recruit new physicians when this requirement is in place.

 

Dr. David Tayloe, President, American Academy of Pediatrics

Our next speaker was David Tayloe, currently on loan to the Academy from North Carolina. The AAP has been instructed to return him to North Carolina after a year with no new scratches or dents. Dr. Tayloe challenged us with a profound question I have to confess I hadn't given any thought to: if neonatologists, critical care specialists, and hospitalists take over our hospital duties, pediatric specialists manage our complex patients, and retail-based clinics see all the ear infections, is there any role left for general pediatricians? Below is my best effort to summarize his points.

• Strategic planning committee working on Vision of Pediatrics 2020
  
• Looking at Access, Quality, Payment
  
• Medicaid, SCHIP, Vaccines for Children, MediKids, Health Care Reform are all key to our reimbursement.
  
• New bill includes Medicaid Payment Advisory Commission to report to Congress on payment issues, which Medicare has always had. This is “huge.” Talk to your senator to push this. Will have to go to conference, and this will be controversial. Also the inclusion of children of legal immigrants is locked out for five years now, which is unconscionable.
  
• Trying to improve the Vaccines For Children Program to make other states as good as NC.
  
• Pushing MediKids as a safety net for uninsured children who fall in the gap between Medicaid and private insurance. Would include graduated premiums.
  
• Quality - Chapter Alliance for Quality Improvement. EQIPP program on asthma, ADHD, Nutrition/Obesity. Patient Centered-Primary Care Collaborative and National Committee for Quality Assurance. These associations are designed to save corporations money by making sure patients have a patient-centered medical home.
  
• Payment: Equal Access Clause of OBRA 89. Try to make sure MediKids doesn’t move children from private insurance to a lower-paying version of Medicare. Medicaid payment should mirror payment of private insurance to make sure access to care is fair in a given market. 
• Generalist and specialist income: how do we address the special issues affecting high-cost special needs children?
  
• Community pediatrics: our job is shrinking, taken up by retail based clinics, neonatologists, and hospitalitst. Need to make sure something is left of general pediatrics. 
• We’re the only country where pediatricians are front-line for children’s primary care. In other countries generalists and mid-level practitioners are the front line.
  
• How are we going to get care into rural areas? Can the academic centers do this job?
  
• Can debt relief help bring more people to general pediatrics?
  
• Health Equity. How do we address poverty, language barriers?
  
• Immunization Alliance - stop the autism craziness. DAN (can they be brought into best medical evidence?). Restore public trust in immunizations.
  
• Mental Health - Jane Foy is working on this.
  
• Foster care - we have a White Paper and a manual from the Academy for guidance on caring for these children.
  

I have to apologize to Dr. Marian Earls, Dr. Jennifer Lail, and Dr. Gerri Mattson for failing to photograph their presentation. I got to typing so fast I never picked up my phone, unlocked the keys, toggled to camera, hit "take photo," and snapped their pictures. I have to admit here, I tend to get droopy eyelids whenever I see the words "Medical Home." What's the big deal? But as these three spoke my eyes grew wide. Medical Home means improved quality of care, more efficient visits with the most challenging patients we have, and maybe even more reimbursement. I'm awake! See if you can follow this.

Dr. Earls

• Can we get some sort of payment for being a medical home?
  
• Risk Stratification: psychosocial risks can predict IQ. High risk kids underperform low risk kids on ASQ, worse by increasing age.
  
• SHEPHERD Index looks at child and parent psychosocial risks. Strong predictor of low reading, low math, behavior problems.
  
• Registering complexity coding sheet, ICD-9 codes, claims from CMIS.
  
• Risk factor scale includes medical risk factors, child’s family risk factors, agency involvement, ethnic background, CP, Autism, CF, MD, etc. Includes parent with non-English speaking caregiver, psychologically or medically disabled parents, teenaged parents, parent with >3 children.
  
• Registry allows practice to list these kids, make sure they’re getting adequate follow up care. Can look at each risk factor to see where the needs are.
  
• If you know you have a large number of patients with a specific condition you can create a pathway for that condition.
  

Dr. Lail

• Pilot program looking at children with special healthcare needs in suburban private practice with 2 offices, 12 MD’s (9 full time equivalents). 22% are self-pay. 
• Registry is the “left ventricle” of the medical home. 
• Complexity scores help get children proper appointment times. Can help staff plan for visits, connect families together based on diagnosis. Clinic calls family in advance to assess parental concerns. Care coordinator makes sure all the information needed for the visit is actually in the chart when the patient arrives. Includes gathering information from specialists, studies.
• Transitioning: find a “champion” to create the registry. Link registry to appointment scheduling. Start by asking providers which children always are special needs. 

Dr. Mattson: Planning for Transition With Youth With Special Health Care Needs

• Identify your special needs patients when they’re around age 12 and start planning at that point for transition.
  
• Shift health care responsibilities to patient when possible.
  
• Involve specialists, adult providers, family, and other support systems.
  
• Carolina Health And Transition Project. Will provide a web-based toolkit. 
• Start with Portable Medical Summaries. Also Emergency Information Forms. Then Transition Readiness Checklists, Transition Action Plan, Welless Baselines, Health Insurance Resources. 
• Can patient understand and explain needs, carry insurance card, call for refills, carry emergency information?
  
• Identify 1-2 skills to work on, agree on a plan, identify timeframe to accomplish the plan, agree on a future date to assess progress/update plans.
  
• Baseline report goes by body system to report whether something is going worse or better, whether needs are present. Can be used to plan for the visit ahead of time.
  
• What is your office age limit? Need to establish a policy.
  
• Do you have a special transition visit?
  
• Can you build a relationship with an adult provider in the community to aid with transitioning?
  
• Code based on time, because it will take a lot of time. Reimbursement will be most appropriate this way. Be sure to include discussion of duration, specific tools. May use prolonged service codes in addition to E&M code.
  
• Send letter to adult providers: are you accepting new patients? How should the new patient access the practice? Which providers are most interested in seeing these patients?

Finally we turned in our CME sheets and course evaluations, piled into our cars, and returned to the far corners of the state, our heads full of new ideas. It took about 45 minutes to drive a mile back to the I85 onramp due to holiday traffic. If you're passing through Monroe, NC may I recommend the Target, which has a Starbucks inside it! If that's not retail heaven I don't know what is.

Schedule permitting I'll try to do this again April 4th at the Spring Open Forum at the Research Triangle Park Hilton. I'll bring a charged camera.

AAP NCE October 13th, 2008

Okay, I have to admit the late nights are starting to get to me. It's not so much the hallucinations (those can be quite entertaining) but the fact I woke up too late to grab a Starbuck's. You can see a whole viscious cycle getting started there. Without coffee I speed-walked late into the Hynes Convention Center and managed to grab a seat in Dr. Laura Jana's lecture, "In Or Out: Managing Infection Control In Child Care And Schools." Immediately I knew two things: I was going to need to take copious notes, and Dr. Jana must be as big a fan of Project Runway as I am (Heidi Klum: "In fashion one day you're in, the next day you're out.").

We were especially fortunate to be joined by Dr. Susan Aronson, who negotiated and co-authored the AAP's new guidelines on the subject, released this weekend. Pearls follow, but here's the spoiler: kids with conjunctivitis, even with red eyes and pus, can stay in school! They generally don't even need therapy which, it turns out, makes no difference in outcomes or contagion. That cry of relief you hear ringing out across the land is from every parent who ever left work to pick up a child and ended up shelling out $70 at the pharmacy for a tiny bottle of Vigamox. Free at last!

But of course there was much more: Fever alone may not warrant school exclusion, but fever with behavior change does. Any illness that makes the child unable to really participate in school or requires excessive attention from teachers/caregivers deserves exclusion. Simple diarrhea (not out the diaper) doesn't win a trip home, but vomiting twice in 24 hours does. Children with lice can wait until the end of the day to go home and may return the next morning if they've been treated. Per Dr. Aronson a special effort has been made this year to ensure the AAP guidelines, CDC guidelines, and Redbook recommendations all match. Now it's up to us to work with public health authorities in North Carolina to get our guidelines somewhere close to these others. Last time I checked ours still suggested sending kids home if their snot is green. We've known for years that doesn't make sense. On the other hand, if the mucous is blue that's a kid I want to see and pronto!

Next up were the Plenaries, today on some seriously Star Trek stuff happening in genetics. The keynote speaker was George Q. Daley of Harvard (they must have like a dozen researchers there!). His thing is turning highly differentiated cells like fibroblasts into pluripotent cells without going through the trouble of nuclear transfer into ennucleated oocytes (the Dolly method). Instead his lab uses a soup of various promoters first developed in Japan (it may be a type of miso, I dropped my pen at just that moment). The cellular DNA un-methylates, like a movie in rewind, leaving a cell capable of re-differentiating into pretty much anything else. Because the process currently involves the use of oncogenic viruses, it's not quite ready for human experimentation, but mice with sickle cell have been cured using such stem cells. Dr. Daley also warned that patients are bombarded by quack commercials on the internet from clinics that promise to use these therapies right now. He reminds us that not even Dr. David Banner would try it in humans. But it's not far off, which could bode well for replacing the neurons I've lost in the last few days. ((I've already noticed the sleepier I get the more parentheses I use.))

Next up was Francis. He started with slides demonstrating the explosion of disease-associated genes discovered since the completion of the human genome draft in 2003. Genome-mapping services are already being offered commercially to patients, often without the intervention of a physician. While prices now hover around the cost of a decently equipped BMW, Francis anticipates a fall to around $5000 by next year, and $1000 within five years. Of course this has the potential to be the next full-body CT scan: you have the information but now what? But aside from the obvious implications of personalized screening, risk-factor modification, and medication selection he highlighted three diseases for which genetic data has already led to promising therapy. First was cystic fibrosis. In patients whose mutation codes for a chloride channel that makes it to the cell membrane but fails to work, a new drug called VX770 (catchy, huh?) can actually normalize sweat chloride as well as such endpoints as FEV1. We now know Marfan's patients have increased signalling of TGF-beta, which can be stopped by good old off-the-shelf losartan. Trials have shown losartan can stop aortic root dilataion dead in its tracks, leaving Marfan's patients alive in theirs. Patients with progeria have a cleavage failure of the Lamin-A protein, making it toxic to cells. They therefore experience early cell death and all the signs of advanced aging, leading inevitably to death by age 13 or so. Now animal trials have shown a farnesyl transferase inhibitor not only halts disease progression but reverses it, putting fibroblasts back into aortas that had been stripped of them. Human trials are ongoing now.

Francis with a cool DNA tie.

Dr. James Roberts then took the stage to talk about pesticide exposure and children. He emphasized the distinctions between organophosphates (remember SLUDS from medical school?) and pyrethroids (look for tachycardia, paresthesias, seizures, pulmonary edema). Atropine does not help with pyrethroid exposure, so knowing the difference is a big deal. The scarriest thing he told us was around 20% of parents have used pesticides in the last month, and when parents rather than professionals apply the chemicals they are more heavy-handed and so more likely to poison children in the home. I envision a new ad campaign for Orkin: "We kill the pests, not your kids. Even if your kids are pests. That's your problem." It could be pithier, but it's a work in progress.

I will confess to missing the talks on endoscopic surgery for hydrocephalus and on the pediatrician's role in preventing school violence (personally I check my children for concealed handguns every morning as they board the minivan, but I know not everyone is as dilligent). Did I mention I needed some Starbucks?

Staring out the window of the Hynes Convention Center I realized I was looking directly at the Berklee College Of Music, the Julliard of Jazz. I should really come to Boston sometime when there's not an AAP meeting. Reading over the materials in my hotel room I've learned they have a professional sports team and several universities, including at least one considered among the finest in the entire Northeast. Also it looks from here like there may be a bar, possibly two.

Next up was the AAP Business Luncheon. The food looked like this:

Nothing says "business" like grilled chicken salad. Some people went up to the podium and said some stuff, and there were enough standing ovations to make up for the run I skipped this morning. I gathered from my seat at the very back of the room that the AAP remains solvent even in the current financial crisis. We have lost much in the passings of Dr. Julius Richmond and Dr. Ralph Feigin. Someone is still going to edit Pediatrics in the coming year. And last, but not least, we must get Jenny McCarthy to shut up before our children all get measles. Oh, and without saying so much as to threaten our nonprofit status it would be nice if our next President were someone who might expand funding for children's healthcare and research rather than freeze it. I have to admit I wasn't paying great attention because I had the good fortune of sitting next to Lynn Wegner, a residency classmate who now runs the AAP section on developmental pediatrics. Also at our table were three of the AAP's most popular young authors of books on childcare for parents. Dr. Laura Jana (remember her from the first lecture?) and Dr. Jennifer Shu, co-authors of Food Fights and Heading Home With Your Newborn, and Dr. Tanya Remer Altmann, the eponymous Mommy of Mommy Calls. I always suspected the cool kids sat in the back of the room.

Lynn Wegner

Drs. Altmann, Shu, and Jana

Sated with chicken salad and, finally, coffee, I made my way to the Clinical Breastfeeding Skills talk given by Drs. Joan Younger Meek and Michelle G. Brenner. They actually had several nursing mothers in the room, including a lactation consultant who is co-nursing her infant and her three-year-old. While Americans get all wierd about nursing kids beyond 12 months, they remind us the AAP says to nurse as long as it makes both parties happy (although not at night once there's teeth). The World Health Organization actually recommmends nursing to age 2 years, although they deal with a lot of populations that don't have Juicy Juice to fall back on. I walked out of this lecture realizing that a lot of what I've written off as "mom just doesn't make milk" is probably due to issues with latching. I also learned a bunch of cool advice to give in place of my current stammering. A sampler: Don't wait for the baby to cry; nurse as soon as he/she shows early signs of hunger. Get skin to skin contact as soon as possible after birth. If nursing is more than mildly painful baby's mouth isn't open wide enough. Teach every mom at least two different nursing positions. Colostrum is a laxative. Keep your hand off the top of the baby's head - it makes him extend his neck. LGA babies may lose more than 10% of birthweight and still be healthy. Pacifiers tend to derail nursing if used in the first 3-4 weeks, but using your finger as a pacifier is at least neutral and may even help.

Next I successfully found a spot on the floor for Dr. Warren Bishop's standing-room-only talk on The Fussy Infant. I'd tried for this one earlier, only to be turned away yet again on orders of the fire marshall. Now, despite being in a great deal of physical discomfort, I realized why this talk was beyond capacity. Not only did Dr. Bishop have excellent evidence-based guidelines for the diagnosis and management of colic, the dude is hillarious! I've seen professional stand-ups get fewer laughs. I can't reproduce his gags here, but I did scribble down a few of his bullet points: Soy and hydrolyzed formulas really do help colic symptoms in as many as 30% of patients. Soy is cheaper, so you may as well start there. In nursing infants, dairy-free diet for mom has a 30% chance of helping as well. Lactose is not, I repeat NOT the problem, so skip all that expensive lactose-free stuff. Gripe water and chamomile tea really do help, so try them (but not foreign versions, which may be contaminated with lead). Swaddling and parental counselling are also helpful to a point. Dicyclomine works great, but with the minor adverse reaction of killing infants. Simethicone does not kill anyone but has the minor drawback of doing absolutely nothing. But here's the real bombshell from this lecture: no matter what you think you've observed, really solid well-constructed studies have repeatedly shown antacid therapy, be it histamine-2 blockade or proton pump inhibition, DOES NOT HELP COLIC. PH probe studies have demonstrated even when a colicky infant does have reflux, the episodes of colicky crying don't correlate with the episodes of reflux. I loved this talk, since my favorite medicine is the one I don't have to use.

After I finally got to stand up again, I wandered back to the hotel to get ready for the evening. Dad was kind enough to smuggle me in to the Executive Committee reception on the 50th floor of the Prudential tower. They have some wicked fast elevators there. The view is also really spectacular:

Boston at night.

Fenway Park, where apparently some kind of baseball game was going on. That would explain the blimp out our window.

Aside from explaining why a nobody like me was helping myself to crabcakes, I did get to talk with some really cool people and hear more about how the AAP plans to fight for children's needs in the coming year.

The very charming Karen Hendricks, whom I've met before in DC. Karen is proof that not all lobbyists are bad, just the ones who don't work for us.

Finally, and only because there were no security personnel to be found, I got my photo with David Tayloe:

Then it was time to leave the blimp crabcakes and return to the sidewalk, an efficient means of getting to a restaurant around here. I've noticed Bostonians seem to have a fascination with lobsters:

The giftshop just outside the Convention Center.

The giftshop just inside the hotel.

My mom's neck.

My plate.

You know, I think we in Wilmington need to decide on one local fish or crustacean and use that as a basis to brand the town. Instead of the Azalea Festival, why not the Flounder Festival? Why not Flounder Coast Plastic Surgery? Every time I've handed someone here my card they've recoiled: "Isn't Cape Fear a kind of scary name for a pediatric practice?" You know, I guess we're used to it. But it could be better: Flounder Pediatrics. I'm making it my first order of business when I get back. But first I'm thinking I may need a little sleep. Yeah, the lobsters crawling up the walls of my hotel room are telling me nighty-night.

AAP NCE October 12th, 2008

This morning started with an activity somewhat less grueling than a 5K run: the District IV breakfast meeting. My dad was sure I would never make it, so he took off without me, but indeed I got in the door by 7:10 and grabbed the only seat left, next to incoming AAP President David Tayloe. I got to shake his hand again and, just as I was pulling out my camera to try for a photo, he made a break for the door, stopping only to talk to the security staff and gesture in my direction.

Francis Rushton handed the mike around the room as we were finishing our eggs, and all fifty of us got to introduce ourselves and say a little about our involvement with the AAP. There are people all over our region really getting some stuff done! I was inspired to get more involved and really make a contribution to the Academy, some day.

From there we headed to our first lectures. Having been a "late bloomer," (some would argue I never did bloom) I thought it only appropriate to attend a talk on precocious and delayed puberty by Dr. Paul Boepple. The pearls: Boys with PP are more likely to have a CNS tumor than girls. Think CNS for very early presentation of PP. Isolated thelarche in a girl is probably no big deal, especially if growth and bone age are normal - observe. Isolated adrenarche is often also benign, but it can be a precursor of polycystic ovaries, especially in overweight girls. Watch ovarian masses - tumors grow, cysts shrink. Since the tumors don't tend to metastasize, you have time. If you see cafe au lait spots with ovarian cysts, think McCune-Albright syndrome (look at the skeleton). The testicle exam is the key to diagnosing male PP; if they're too large for age but appropriate for Tanner stage, get a brain MRI! If you see freckles in the inguinal or axillary regions, think neurofibromatosis type I and get a brain MRI. In delayed puberty in males, check the testicles again; if they're developing at all, you probably can follow clinically. When growth falls off, always look for celiac disease.

From there we gathered in the cavernous ballroom for Plenary Sessions.

I wound up seated next to Olson Huff, MD, of Asheville, legislative guru of the AAP.

I also ran into my former chair at UNC, Dr. Roberta Williams, now back in LA.

Today's talks were all on early brain development, starting with John Gabrieli's amazing review of functional MRI studies and the development of memory. Briefly, memory for objects, places, and faces lives in different brain regions. At age 7, children's memory of objects is fully developed. But place and face memory develop (and triple their neural real estate) up to age 21. Then he led us through the neural geography of dyslexia. Specifically how reading involves both Broca's and Wernicke's areas, as visual input has to be translated into auditory concepts (we evolved to HEAR language, not to SEE it). Children with dyslexia light up the visual patch when they read, but nothing's happening in the auditory center. What's coolest is that with successful therapy you can see the auditory processing center get fired up. Olson Huff leaned over to conjecture whether chronic otitis media could lead to reading problems and if the PCV-7 vaccine could then improve reading scores.

Next Harvard neonatologist Marilee C. Allen reviewed the causes and consequences of preterm birth. She reminded us that while extremely preterm kids get a lot of attention, near-term infants are overwhelmingly more numerous. The preterm birth rate is skyrocketing, a result of multifarous forces including Clomid, advancing average maternal age, therapeutic inductions for preecclampsia, and bio-psycho-social stressors (this economy is likely to fill the NICU's for years to come). The most surprising data showed that, while preterm children do indeed have lower average IQ's and more problems with learning disabilities (each independent of the other) they are actually less likely than term infants to later break the law, and they have lower rates of teen pregnancy and drug abuse than term babies. Put that in your pipe and smoke it (unless you were a premie)!

The real bombshell came from Dr. Jack Shonkoff, also of Harvard. For years epidemiologic data have suggested poverty and stress are bad for health. It gets more interesting when you factor out known risk factors like smoking, substance abuse, and obesity. You're still left with enormous health disparities that track with poverty alone. What Dr. Shonkoff did is lay out with rock-solid science the pathways that lead directly from adverse early childhood events to such diverse negative consequences as heart disease, diabetes, and cancer. He summarized how epigenomics is finding the precise stress-dependent gene methylations that link childhood stress to adult diseases. Finally now, the epidemiologic and the basic science data have dovetailed not only to show that a stressful childhood is bad for you, but to elucidate the precise mechanisms by which prolonged childhood stress makes permanent physiologic alterations that no amount of future clean living can undo. The implications for how we direct resources to children's health are profound. The one part of this that's not bleak? Strong supportive relationships protect children to some extent from these permanent psychiatric and physiologic scars. Love a three-year-old now, prevent a heart attack in 47 years. MIND-BLOWING!

Scott Hippert of the Virginia Early Childhood Foundation stood in for Virginia's governor Tim Kaine talking about the Smart Beginnings program. If this sounds suspicously like North Carolina's Smart Start Initiative that's because we did it first (and thus got the rhyming name). After hearing Dr. Shonkoff's lecture I just want to dedicate the rest of my life to Smart Start, Smart Beginnings, Smart Onsets, Smart Commencements, Smart Embarkations, and all the other similarly-named public-private partnerships, so long as they get more hugs to three-year-olds.

But it got warmer and, yes, fuzzier, when Brooklyn songwriter John Belzer took the stage to discuss his Songs Of Love Foundation. I have to say here that there was a mass exodus during Scott Hippert's introduction, and even more attendees ran for the door as John Belzer grabbed the mike. But those people will not appear in a Christmas special on the Hallmark Channel, and we will. The Songs Of Love Foundation, inspired by Belzer's late brother, engages over 100 songwriters to compose and record songs personalized for critically ill children. The tunes are created in the child's favorite genre and include details about his or her hobbies, family, and personal traits. Matthew, a child with spastic quadriplegia, was wheeled onto the stage by his parents, and we all learned his song (see below). Apparently Matthew really loves soft rock. We then did a few run-throughs to get everything right for Hallmark's many cameras and boom mikes. Finally we got to watch as Matthew Bastianelli's face absolutely lit up listening to the finished product. We were all late for our 12:30 sessions, but it was worth it.

John Belzer sings to Matthew.

I'm currently working on new sports pre-participation templates for our EMR, so I was excited to hear an evidence-based review of the AAP's latest guidelines on sports participation. I was bummed to find the doors barred, by order of the fire marshal:

Fortunately, two people slipped out of the session, allowing me an "in." The pearls I was able to glean after sneaking in: SBP more than 5 mmHg over 95th %ile for height and age should exclude a child from sports until it's evaluated and controlled. Vision should be better than 20/40 corrected. Kids who have had cardiotoxic chemotherapy probably shouldn't stress their hearts. Fever increases heat retention, insensible fluid losses, and vascular tone and should keep a kid out of the game until resolved. Make sure athletes don't stop conditioning during the summer, so they don't get heat stroke with the sudden resumption of exercise. Yes, Virginia, you can play with only one kidney, but wear a pad over it. Concussion: too much for this blog, but briefly kids need at least a week of absolutely no symptoms (including headache) before returning to play, and they should ramp up both mental and physical activity slowly. Formal cognitive testing is required beyond the old, "How many fingers am I holding up?". Peripheral nervous injury (plexopathies) should put a kid out of the game until strength is completely and fully restored to the affected region. If kids are obese, make sure their coaches give them appropriate time to acclimate - these kids are at risk for heat stroke. Athletes who have given birth really should wait at least 4-6 weeks before returning to the game (sad that we should need this one; see yesterday's Plenaries). An asthma action plan and peak flow meter should be part of any asthmatic athlete's regimen, and they should only play if they're in the green zone. Children with sickle cell can be athletes, but if they look tired they need to stop to hydrate and oxygenate.

I now had time to wander the exhibit floor, and I have to correct a statement from yesterday: there were plenty of EMR vendors. My Dad pointed out this morning that there are two floors of exhibits, and I'd only seen one. Oh. More cheap pens for me! I was assaulted at one point by the anti-circumcision lobbyists, who really wanted to press some literature into my hands. This was a big improvement over 2005, when I literally had to make my way through a phalanx of pro-prepuce picketers. As I waved off the proferred pamphlets one of the ladies asked, "Don't you want some literature?" "No," I replied, "I'm okay." "But are your patients okay?" she asked. How clever she was to turn it around on me like that! Here I have to confess I might have been more politic. I should have ignored her and walked on (they didn't have very good pens anyway). But no, I couldn't. "Oh, my patients are great," I answered, "I do amazing circumcisions!" Let me clarify here to my colleagues on the circumcision team I was speaking for all of us; we all use the same technique for anesthesia and circumcision. But it would have taken too long to say that.

Psychedelic stethescopes

Technology was big on this floor, from pulse oximeters that can estimate hemoglobin levels to a variety of automated ADHD diagnostic tools. Below: I was game to strap a little reflective bud to my head and try to hit the space bar when the eight-pointed star flashed on the screen. I would tell you whether the computer diagnosed me with ADHD, but I became distracted before completing the test.

The lady below was my favorite exhibitor of all. See, Margaret and I keep three chickens in the backyard, and many people ask how we can eat all those eggs. These people still subscribe to cholesterol myths from the 1970's. But it turns out our chickens have a lobby all their own. Feel free to email me for more information on choline and the other myriad health benefits of egg consumption. Chicken farmers of the world, unite!

Alas, I had to leave the egg lady and return to the sessions so my partners would know I'm not wasting the practice's money collecting schwag (oh, I got flash drives for each of you!). Next was The Limping Child with Dr. Joshua Hyman. I'm not sure any general pediatrician can hear enough about evaluating gait abnormalities, but I was thrilled to get a refresher. The bullet points: Limb pain that is constant rather than worse with activity suggests neoplasm or infection. Nocturnal pain should always make you think neoplasm. Knee pain frequently suggests hip pathology. Examine kids in their underwear or minimal clothing. Running accentuates antalgic gait (limp). Check out the shoes for unusual wear patterns and asymmetry. If the child keeps the hip flexed and externally rotated, there's an effusion. Vague LE complaints also suggest hip disease. When it comes to radiographs one view is no view; always get an AP and lateral. Technetium bone scans are great at localizing pathology, ultrasounds see effusions. If you can't figure out what's wrong with the kid and nothing seems serious bring him/her back in a few days. When differentiating between toxic synnovitis and septic joint effusion consider the Kocher Criteria (T>101.5, WBC elevated, ESR>40, decreased weight-bearing). Just because a toddler is screaming doesn't mean you can't get a decent foot, ankle, and knee exam in mom's lap.

From there I dashed over to G. Brad Schaefer and Margaret Bauman's talks on autism. I stopped first to join my dad in chatting with two of the Academy's point people on lactation support, getting ideas for how to rid New Hanover Women's and Children's of the cursed "nursing support packs" (just enough formula for your milk to dry up and a handy bag to carry it in). They've done it in Gastonia, for gosh sakes! But enough of that. The news on autism spectrum disorders is cool! To no one's surprise "autism" is turning out to be a final common behavioral phenotype of many, many different underlying pathologies. Dr. Shaefer's genetics clinic is successfully identifying mutations in as many as 40% of the patients that get referred. If it were up to him, all patients with an ASD would get at least a preliminary genetic evaluation.

Here were Dr. Schaefer's tips: advanced paternal age (>40, my current age, which I suppose makes me advanced?) is associated with single gene mutations. Children with very low IQ, seizures, or decreased head circumference should be evaluated. Chromosomal analysis with high-resolution karyotype has a high yield. Microarray comparitive genomic hybridization is a fantastic tool, but you have to know what you're looking for. Alterations in the 16p11.2 locus are especially common mutations in ASD. Two to ten percent of males with ASD will have Fragile X. In girls with ASD many will have mutations of MECP2 even without classic findings of Rett syndrome, suggesting a much wider phenotype than previously suspected. In males freckles on the penis and macrocephaly suggest mutations of the PTEN gene. ALWAYS confirm a child can hear before making the diagnosis of ASD.

Dr. Margaret Bauman, a neurologist whose multi-disciplinary ASD clinic has become a model for research and treatment, picked up where Dr. Schaefer left off, looking at the possible medical causes of autistic type behaviors. Her biggest take-home message: when autistic behaviors worsen, think GI disease. She showed us some clips of dramatic posturing which turned out to be due to severe erosive GERD. She refers many of her patients to GI, especially when they seem to worsen acutely. Dr. Bauman pointed out that many of the same neurotransmitters involved in ASD also regulate GI function, and people are only now beginning to look at what functional abnormalities might exist in other organ systems. Bombshell alert: a study will be published soon suggesting persistent head lag at 6 months of age as a strong early predictor of later ASD. She discouraged us from getting routine EEG's, since 15% will be abnormal in the normal population. Likewise she feels MRI/CT contribute little to autism evaluation unless other signs/symptoms suggest intracranial pathology. Endocrine abnormalities can worsen autistic behaviors in teenaged girls, and regulation of estrogen and progesterone can make things much better. Sleep disorders are often also overlooked as a cause of worsening behavior, and spastic bladder is another common and annoying problem in these kids. She suggested several red flags for metabolic disease, including mitochondrial diseases: poor exercise tolerance, not walking until 24 months of age, repeated episodes of regression, dysmorphic features, failure to make any developmental progress with therapy, multiple organ system disease, and a you'll-know-it-when-you-see-it sense that this child is just "different." She emphasized a preference for academic over commercial labs for genetic and metabolic testing, an option I don't know that we have at New Hanover.

The conference ended just as Margaret's dad arrived at the Marriott. I met up with him in the lobby and we made our way down the street to the Mandarin Oriental's bar, where my parents were already starting the evening. After drinks and dumplings we crossed the street to Atlantic Fish, where they serve seafood, much of it right out of the nearby ocean. I'll leave you with two photos from our dinner, mainly for Margaret, who is back in Wilmington filming Def Leppard videos in the yard with our three kids (I wish I were kidding here, but I am not).

Thanks for the hugs, Mom. Now we know they prevent heart attacks, cancer, and depression.