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.
1 comment:
And your posts are definitely good medicine!
Diane
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