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.