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.