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.