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.

AAP NCE October 11th, 2008

The first full day of the NCE began with a "Fun" Run in support of the Friends Of Children fund. This involved waking up at 5:30 AM in order to make coffee and slap contact lenses in my eyes in time to meet the shuttle to Boston Commons downstairs at 06:15. A handfull of us stood outside hopping around in the cold and hoping the shuttle would come to the Westin, being the poor sister to the host hotel. But the shuttle did come eventually, and I rode over with NC Pediatric Society President Marian Earls and her husband, both runners. We chatted about the coming flood of uninsured patients to Guilford Child Health and about GE Centricity EMR before our bus disgorged us onto the Commons.

There we found a hoard of impossibly enthusiastic race volunteers, tables full of Powerade and Power Bars, and possibly the ugliest race tee shirts ever printed. But I was freezing cold in my little shorts and grateful for the insulation, so I donned my shirt and pinned on my race number. We warmed up to the encouragement of a personal trainer hired specially for the event by the AAP. She wore a headset and led about 100 of us through mass exercises and stretches. None of us had the heart to tell her randomized controlled trials have failed to determine whether stretching before running is actually helpful. And then we were off, running three times around the Commons, uphill the entire way. I will say only that I finished and, yet again, I did not suffer a myocardial infarction. But if you ever meet the Kentucky chapter president's wife, do not challenge her to a race. She will whoop up on you (yes, you Sean Lucas).

The heinous but warm official race tee shirt.

By the time I was clean, dressed, and caffeinated the first of the sessions were already underway. I joined my dad in room 301 where we learned about Intercultural Communications To Improve Culturally Effective Pediatric Care from Geri Ann Galanti, PhD and David Katz, MD. Dr. Galanti, a cultural anthropologist, reminded us to ask questions to guage what parents' concerns actually are, and not to treat their beliefs with open scorn. We should ask what the parents think the cause of the disease is and find out what worries them about the course of therapy we prescribe. She also reminded us many pharmacalogically active folk therapies are not viewed by parents as medications per se but are given in the form of teas - if we don't ask the questions broadly enough, we don't get the whole answer. Bottom line: if you don't fully understand parents' belief systems and practices you will fail to collect the right information and compliance will be abysmal.

Dr. Katz served as a civilian advisor to American forces in Afghanistan, and he brought several lessons to us from that conflict. The Medical Civic Action Program (MEDCAP) undertaken by our military forces often undermined the role of Afghani public health services by providing temporary, "bandaid" solutions to problems that were more endemic. Also, if you join one of those missions you are likely to get shot at, and so are the patients who seek your help. He emphasized that whenever we intervene in third world healthcare we focus on building sustainable infrastructure for administering care as opposed to handing out medications that last for a month and then run out. It seems we do much more good strengthening the local care systems than just seeing some kids and leaving on the next plane back to civilization.

From there it was on to the first Plenary sessions. We arrived just in time to hear the children's choir sing the Star Spangled Banner. Once we took our hands off our hearts we found seats at the far left of the ballroom and settled in to hear the opening address from AAP President Renee Jenkins.

But first things first: there's an annual art contest for the NCE, and we got to see the winners in the junior and senior divisions:

Afterward Dr. Jenkins took the stage and spoke about her year as AAP president, framing it in terms of "tiara moments" and "target moments." Tiara moments, for example, included the passage of the Genetic Information Nondisrimination Act. A target moment was when Jenny McCarthy organized protests around the AAP announcement of new vaccine initiatives. The speech was starkly political, noting that the United States currently falls at the bottom of developed countries on measures of child health, doing worse than such superpowers as Hungary, the Czech Republic, Poland, and Greece. She cited the defeat of SCHIP expansion as a major setback to the cause of children's health and reviewed the Telluride Principles of investing in our children as a way of ensuring the secure future of our country. She shared the Vision of Pediatrics 2020 and suggested that this year's election would give us an opportunity to alter the rather dismal trends in children's healthcare over the last eight years.

Following Dr. Jenkins's speech the Education Awards were given to Dr. Kurt Metzel for his pioneering work in pediatric continuing medical education and to Dr. David Bernhardt for his contributions to the field of sports medicine.

Then Timothy Shriver took the stage, looking and sounding every bit the Kennedy he is. He spoke eloquently on the Special Olympics movement and how it has morphed from a simple athletic contest into a force for promoting the competent medical care of intellectually disabled children and adults throughout the world. We learned how 15% of Special Olympics athletes at a screening had to be sent directly to the ED for untreated acute and chronic medical conditions. If any of us is interested, the Special Olympics hosts a variety of training programs to help medical professionals better address the needs of the intellectually disabled. Also, Timothy was not amused by the movie Tropic Thunder.

Timothy Shriver left the stage to Francine Cournos, a psychiatrist and former foster child who spoke movingly of her experience in the foster system and of the pediatrician who inspired her to become a physician herself. She reminded us that children placed in foster care are terrified and grieving the loss of their families, and it should not surprise us they are not eager to bond with new parents or us. She pointed out behavior we might label "oppositional defiant disorder" is simply adaptive in foster children whose sole power over their new existence is the power to say "no". The good news is that by listening to these children and validating their concerns we can be forces of stability in their lives and not merely more sources of trauma.

Finally we heard from Jean Kilbourne, EdD, who spoke on the early sexualization of children in modern society. As father to a nearly 9 year old girl, this one struck home. She displayed such egregious examples as "Lingerie Barbie," the "Child's Pimp and Ho Costumes" for Halloween (sizes 4-6), and Abercrombie and Fitch print ads showing nude teenaged models in a menage a trois. Grand Theft Auto, the most popular video game with American teens, encourages players to have sex with prostitutes then murder them in a variety of violent ways. Jean pointed out that in America we have allowed corporate marketers to suggest throughout the media that sexual roles are appropriate for young girls and that girls and boys should view women as sexual objects, made all the more alluring by the variety of products they can purchase at the local mall. This trend, combined with the ascendance of "abstinence only" sex education, has led the US to lead the developed world in teen pregnancy (most common in areas of the country where abstinence only sex ed is mandated). At this point 1/3 of American girls become pregnant during their teen years. Jean Kilbourne also offered up the coming election season as an opportunity for us to reverse this disturbing trend.

Then it was on to the breakout sessions. But first, a few observations about the convention center. Over every toilet you see the following:

I'm pleased the management cares to protect me, but I'm confused about what I'm being protected from. These dispensers hold sheaves of paper rings, but I can't see what good they would do me faced with, say, a charging rhino or a stray bullet. But you never know; I tucked a few in my bag just in case.

The bathrooms also sport electric hand driers, but these are unlike anything I've ever seen. They're like ram jets mounted to the walls, propelling air with enough force not only to get the water off your hands but to levitate the whole wall:

We need these in Southeastern North Carolina. I'm looking into getting a distributorship.

Unlike 2005, when I was last at the NCE, you no longer sign up for teaching sessions. Instead you just run to the room where your chosen lecture is and hope you get a seat. I was too late for "Neurology In the Office", and by the time they barred that door, all the other good lectures were also closed. So I wandered down to the vast exhibition hall to see how many cheap ballpoint pens I could cram in my bag. The photo below does not begin to show what an overwhelmingly vast maze greets you:

Many of you know I'm a card-carrying member of No Free Lunch, which means I have a moral proscription against accepting free goodies from pharmaceutical and formula companies. This was a major bummer in 2005, when attendees often left the exhibit hall weighted down with two or more giant tote bags full of schwag. This year things have changed. There were still whole villages dedicated to pharmaceutical and nutritional companies, but they were not nearly as dominant. The most elaborate had to be Ross Nutritional's high-tech waterfall:

But there were many, many booths dedicated to various charitable organizations, professional societies, and physician recruitment firms. What did this mean for me? You guessed it: tons and tons of guilt-free pens, flash drives, letter openers, hand sanitizers, and breath mints. Disturbingly for someone deeply invested in an EMR, the electronic health record companies were few and far between, with only two or three exhibitors compared to the dozen or so in 2005.

Having learned my lesson, I arrived early for Dermatologic Therapeutics with Dr. James Gary Dinulos, a man whose skin and hair were flawless. I learned that when thinking about dermatologic therapy I had to consider where it was going: the mucous membranes, eyelids, and scrotum absorb 36 times the topical medication absorbed by the palms, soles, or nails. I also learned a critical difference between ointments and creams: creams have lots of alcohol and preservatives, and when applied to raw, inflammed skin they burn like a mother. Ointments are more soothing, and also more potent in terms of penetration. Ointments are also better in the diaper area, where stool and urine tend to cause excoriation. Oils, including olive oil, can help loosen the scale from seborrheic dermatitis prior to the application of antifungals or steroids to calm the disease. Another tip: use creams in the summer when sweating is an issue, oils in the winter when moisturization is key. I've never prescribed powders, but nystatin powder is perfect for moist intertriginous areas where yeast likes to dwell. Gels and foams are best for hair-bearing surfaces. Medicated tapes like Cordran can help with conditions like lichen simplex and picker's nodules, where manipulation makes things worse.

The pearls from the derm lecture just kept coming: Show parents how to apply creams; some just dab them on, failing to rub them in. People can actually have allergic reactions to topical steroids. Calcineurin inhibitors are safe when used as directed (intermittently). Group A strep loves red, inflammed neck folds in infants. Oral corticosteroids can lead to eczema rebound and ultimately make things worse. Avoid long-term use of mupirocin, to which antibiotic resistance is growing. Think about eczema herpeticum in eczema that just won't go away. Ceramide creams like Ceravae may prove anti-inflammatory by improving the quality of the skin barrier. Don't use any steroid on the face more than two weeks. Every acne regimen should include at least some benzoyl peroxide and at least one retinoid (tea tree oil acts just like benzoyle peroxide). Short-contact therapy can reduce the irritation associated with retinoids while preserving the benefits. I want to take this guy home with me.

I stayed in room 311 for Five Critical Cardiac Problems That Are Important To Diagnose (as opposed to those critical cardiac problems that you can miss without fear of repercussion) with Dr. Stuart Berger. Big pearls: Tachypnea is often the first and sometimes the only sign of significant cardiac disease in newborns. If there's any question of a ductal dependent lesion, start PGE-1 first, get your echo later. Prostaglandin is safe, not giving it is potentially lethal. An active precordium on physical exam should always peak your interest. Not all cyanotic heart disease presents with obvious cyanosis. The absence of a murmur alone does not rule out significant cyanotic heart disease, specifically transposition of the great arteries. Diagnosing dilated cardiomyopathy early is much better than diagnosing it late. Decreased blood pressure is the very last sign of heart failure and should never be used to reassure yourself heart disease is absent. When wheezing fails to respond to bronchodilator therapy think heart disease. Also consider heart disease in any child with unexplained persistent abdominal pain and vomiting. "Drop attacks" could be seizures, but they could also be long QTc syndrome. Always suspect long QTc in deaf children. When a tachycardic heart rate doesn't vary it's likely the problem, not the symptom.

I find once my head is stuffed with clinical pearls it's best to drive the points home by having a drink. So I headed to the Westin bar with my parents and Nancy Chase, a pediatric cardiologist at University of Tennessee. There I had lots of crackers, having last eaten a chicken salad at 10:30 AM.

The Academy hosted a grand shindig at the Boston Public Library across the street, but my folks had already scoped out an Italian joint in the North End, so I can't tell you anything about the library gig. I can tell you I had the best veal maybe ever and if anyone tells my daughter I ate veal I met a guy at the bar who will make sure you never tell her anything else. I leave you tonight with the moon over Boston as seen from my window. Who knows what pearls tomorrow will bring?

AAP NCE October 10th, 2008

My fellow Southeastern North Carolina Pediatricians, it is with great pleasure and a sense of profound responsibility that I accept this self-appointed position as our representative to the American Academy of Pediatrics 2008 National Conference and Exhibition. I can assure you all that as your non-elected servant I will do my best to share with the rest of the pediatric community both the stunning accomplishments and pressing needs of our burgeoning medical community by the sea. I hope that, by way of this blog, you can all feel as though you, too, are here in Boston communing with your peers, eating free shrimp, and going back to the open bar again and again until you can no longer find it. Perhaps I've said too much. So, to change the subject, let's start back at ILM airport.

First off, I've got a free sleeve of otoscope specula for the first person who can identify the following celebrities:

These guys were in line behind me at security, and some German tourists came up and begged to take photos with them. I'm now so old I no longer know or care just who today's youth idolize, but if you're in tune with the young people please, I want to sell these photos to the tabloids.

Upon arriving in Boston I made my way to the Westin Copley Place. The Marriott Copley Place is the official host hotel, but the Westin is $10 a night cheaper, and it's all one big Copley Place, so whatever. There I hooked up with my dad, John R. Hill, MD, FAAP, the actual elected representative of Tennessee. He gets ribbons on his nametag. Mine came with a nice little safety pin.

Here my senior partner Tom Blackstone can see where I got my penchant for pink shirts.

The view from the 34th floor of the Westin. I think that's the Charles River out there.

Dad walked me through the luxury mall to the Marriott to get my official girly-man nylon conference bag in fetching tan and seafoam. The conference theme this year is "More Than A Feeling," referencing an 80's hit by a band I think was popular around Massachusetts.

This year's bag comes with a water bottle to stave off the dehydration that so often occurs after ten hours of lectures on common pediatric topics.

At 6:00 PM the North Carolina chapter hosted a reception for the incoming president, our own David Tayloe. I did get to shake his hand, but he moved on before I could snap a photo. I also saw District IV Chairman Francis Rushton, who gave a shout-out to former classmate Grady Morgan at The Children's Clinic. (Grady, Francis wants to know why you didn't reply to his last Christmas card. I promised I'd pass that on.) Also there was Colleen Kraft, recent AAP Presidential Candidate. Colleen trained Patrick Renton and would like to come to Wilmington to give a grand rounds, I think just to see Patrick as a grown-up pediatric hospitalist.

Colleen Kraft agrees to pose with me for a photo while scanning the room for a security officer.

From there it was on to the grand welcoming ceremony with a live band, lots of food, and more open bar. As I was stumbling around the ballroom I ran into none other than President Elect Judith Palfrey.

Judith Palfrey agrees to pose with me for a photo while scanning the room for a security officer.

So that's it so far. We've been welcomed, fed, and given free wine and beer. I'm expecting more of the same tomorrow, but apparently there are also some courses we're supposed to go to. I'll take notes and post again tomorrow night with all the breaking news from Boston. So far I just have this feeling, but then again it feels like something...more.