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.