Annual Meeting, September 16, 2012

North Carolina Pediatrics Society Annual Meeting Day #3

Welcome to the official blog of the NC Pediatrics meetings! Thanks to Blogger, we'll be going in reverse order, starting with day #3 and working our way back to day #1, like Benjamin Button, but a blog. If you're big on chronological order, just start with the September 14 post, and read up!

This meeting was perhaps the most amazing yet, and not just because Dr. Perri Klass, famous author and founder of Reach Out And Read gave the keynote address, and not just because AAP Executive Director Errol Alden came, but they did help. I've already come back to my practice with a head full of new ideas and practice changes, and I'm really excited about the moves afoot to improve care statewide. At the same time, I hope you won't skim over the policy updates. Children need our advocacy more now than ever, and I urge you to heed the calls below to get involved.

As always, I must clarify that this is not an official record of the NC Pediatric Society, just my best attempt to keep up with the amazing stream of information coming at me from what may have been the best group of speakers ever! If you notice a typo or something that doesn't look right, please let me know. For official slides and handouts please contact the speakers or the North Carolina Pediatric Society office (link at the top of the page). Enjoy!

Dr. Karen Breech turns the President’s gavel over to Dr. John Rusher, who, in his first act as President, presents Dr. Breech with a plaque and our gratitude for two amazing years of service.

Dr. Jennifer Crotty and Dr. Daniel Ostrovsky present resident poster awards from this weekend’s record-breaking set of poster presentations. “No Bones About It, An Unusual Case of Scurvy” #3. “Diagnosis and Screening Of Pediatric Hypertension In Primary Care Physician Offices” #2. “Autism Screening In Spanish-Speaking Patients.” #1.

Michelle Trager Cabrera, MD, Assistant Professor of Pediatric Ophthalmology UNC

Understanding Amblyopia and Strabismus

• Review of eye anatomy: cornea, iris, lens, anterior chamber, angle & trabecular meshwork, ciliary body, sclera, retina, choroid layer, optic nerve (CNII), vitreous cavity/posterior chamber, conjunctiva, episclera (under the conjunctiva)
• Afferent visual pathways: optic nerve signals cross to lateral geniculate nucleus, prject to striate cortex with monocular and binocular cells. 70% of the cells in the striate cortex are binocular.
• Binocular vision arises from simultaneous perception of separate but slightly dissimilar images arising in each eye, appreciating them as a single image. Process is called “fusion”.
• Binocular vision allows a single image, stereopsis, enlargement of the visual field, compensation for the blind spot.
• Monocular cues can give clues to depth and distance, so some function is preserved even with monocular vision.
• Newborns have poor visual acuity, around 20/800 or worse. By 4 months 20/400, 8 months 20/100, 1 year 20/50. 6 month old babies still see quite blurry images.
• Amblyopia is decreased visual acuity NOT attributable to organic eye disease. Caused by damage to the lateral geniculate nucleus and striate cortex during the sensitive period of visual development.
• Amblyopia is a spectrum of vision loss, from mild to severe. Defined as >2 lines of eye chart difference. Most common cause of vision loss in children. Much more common with premies, low birth weight, developmental delay, positive family history
• About half are associated with strabismus.
• Pattern deprivation: something blocking the entrance of light to the retina.
• Strabismus: eyes are mis-aligned.
• Optical defocus: child needs glasses, but is not wearing them, so receives a blurry image, worse with more difference between the two eyes.
• Window of effective therapy is between age 7 and 14, around age 9 on average
• How do we test vision in a pre-verbal child?
• Light-wince reflex in newborns.
• Fix-and-follow response over age 3 months (toy or light must be silent). Check one eye at a time as well as both together.
• Research: visual evoked potential for pre-verbal children. 
• Preferential looking test in the ophthalmology clinic, uses card with stripes of varying widths. Child prefers stripy side rather than gray box.
• Verbal child: optitype testing with pictures, letters. Use heel of hand, not fingers for one-eye testing!
• Refer for lack of wince to light response, failure to fix and follow by age 3 months,  vision worse than 20/40 in young kids, worse than 20/30 if over age 6, difference in eyes greater than 2 lines of vision chart.
• Treatment: provide clear retinal image, occlude the good (sound) eye with patch or drops.
• Exotropia: “wall” eyes, Esotropia: “cross” eyes. Hypertropia: one eye looks upward.
• Strabismus in children is asymptomatic due to suppression of the wandering eye!
• Why treat early? Strabismus could suggest treatable underlying disease, could cause amblyopia, could signify life-threatening condition, could save binocular vision, can prevent social and developmental problems in school.
• Negative social attitudes toward strabismus patients starts around age 5 years (dolls used to guage behavioral responses). Esotropia and exotropia elicited a lot of negative responses.
• Children with strabismus show increased rates of depression, anxiety, and social phobia.
• Often waits until school age for surgical repair, since that’s when social consequences begin.
• Corneal light reflex test: shine light straight at the child, look at where the light falls in relation to the pupil. Center it in one eye, then glance at the other eye for comparison. If light falls on iris rather than the pupil, child has strabismus.
• Cover testing: difficult, especially in uncooperative child. Get a good fixation target. Cover one eye with the heel of your hand, not your fingers, watch the uncovered eye for movement, a quick flick movement, will occur in the other eye when you switch. The movement is in the opposite direction of the gaze abnormality (compensating)
• Ophthalmologists can use prisms to neutralize strabismus, measuring just how many degrees of strabismus are present.
• Binocular vision test: Worth 4 dot test. Stereopsis testing. 
• Pseudostrabismus: looks like esotropia due to wide nasal bridge or prominent epicanthal folds. Doesn’t mean child cannot also have true strabismus.
• Harder to judge strabismus with darker iris color. Look at the whole iris in those cases.
• Causes of strabismus: visual deprivation, refractive error, idiopathic (developmental delay, prenatal drug/EtOH exposure), congenital disease, orbital disease, rare syndromes.
• Refractive error is also called accomodative esotropia. Can be fully corrected with glasses. Accomodative convergance mechanism is simply too strong.
• Infantile esotropia starts before age 6 months.
• Intermittent esotropia: starts around age 2. Tend to have good vision, good stereopsis.
• Head tilt: cranial nerve 4 palsy. Try pulling the child’s head the other direction to see what happens to his eyes!
• Strabismus can be normal at birth, should resolve by 2-3 months of age, when child begins to fix and follow.
• When to refer? Any child >3 months old with strabismus on your exam or based on caretaker’s history, even if you don’t see it. Children with strong risk factors such as genetic syndromes, prematurity, cerebral palsy.
• Strabismus surgery: lateral rectus, medial rectus insert anteriorly on the surface of the sclera, covered by conjunctiva. Superior rectus elevates, inferior rectus, lateral rectus, medial rectus, superior oblique, inferior oblique. Superior oblique turns in, depresses globe. Inferior oblique extorts and elevates the eye.
• Most common procedure: rectus muscle resession, which removes muscle from globe, re-attaches so it’s more slack. 
• Resection is a strengthening procedure, shortens the muscle.
• Q&A: visual evoked potentials are probably not a useful routine screening tool. May just pick up normal-variant delayed visual maturation in infancy.
• Q&A: Red reflex, look for symmetry from one side to the other. Difference may be from anisometropia as well as cataracts, tumors. Leukocoria is reason for urgent referral.
• Q&A: mild refractive error in the school years can often be followed annually without corrective lenses. With age, child is more likely to notice visual error, usually around age 9 years. Myopia likely to worsen with progressive eye growth.
• Q&A: photo-screeners probably work reasonably well. Evaluate relative red reflex.  Pick up strabismus, anisometropia.

Dr. Amina Ahmed, Pediatrics, Pediatric Infectious Diseases, Carolinas Medical Center/Levine Children’s Hospital

A Decade Of newborn hearing Screening in North Carolina

• At Carolinas they have been screening children for congenital CMV infection, then following up with regular hearing screening, as up to 15% develop hearing loss.
• Many of the babies who refer based on hearing screen never make it to follow up!
• Congenital hearing loss is the most common birth defect, affects 1-2:1,000 live births, up to 3/1000 by age 5 years. Many babies have delayed-onset hearing loss, often from congenital CMV
• Most common cause at birth is genetic, usually non-syndromic. Then CMV, perinatal infections. Usually asymptomatic.
• As kids age, CMV takes on a larger percentage of the overall hearing loss diagnoses.
• Half of children with hearing loss are NOT easily identified at birth.
• The earlier you intervene in hearing loss, the better the clinical outcomes!
• In the 1980’s, it became clear we had good screening tests. In 1993 the NIH consensus statement on screening came out. In 1994 the JCIH statement came out, and in 2000 the AAP endorsed and promoted universal newborn hearing screening.
• Data clearly endorse the efficacy of hearing intervention prior to age 6 months. Outcomes are clearly better.
• Early Hearing Detection and Intervention Program (EHDI), state by state.
• Both to identify and to TRACK these babies, make sure they have a medical home.
• Back in 2000, the evidence supporting intervention was not completely clear. By 2008 there was no question based on evidence-based literature to support early intervention.
• Screening newborns is now standard of care throughout the US. US Preventive Services Task Force supports recommendations.
• Mean age of diagnosis is now 2-3 months instead of 2-3 years!
• 2007 JCIH revised statement: identify hearing loss by age 1 month, refer by age 3 months, start intervention by age 6 months.
• High-risk babies should all see audiology: NICU grads, caregiver concern, positive family history, use of ototoxic medication, exchange transfusion, in-utero infections, facriofacial anomalies including ear pits, physical findings suggesting syndrome, head trauma, chemotherapy, neurodegenerative disorder, post-natal infections like HSV.
• Otoacoustic emissions test (OAE). Put noise into the ear, look for cochlear response.
• aABR is automated auditory brainstem response, tests the nerve, catches more disease. More expensive, harder to perform.
• A child who fails aABR should NOT then be cleared by a positive OAE!
• Results are either “pass” or “refer”. Many children who “refer” actually have normal hearing. Depends on operator of hearing test, they need good training.
• Now referral rate is 2-4% from most hospitals.
• Can use two-stage approach: re-test within two weeks at the birth hospital. We need to track whether these babies are making it back!
• The older kids are, the harder it is to perform a BAER test, so refer to audiology as early as possible!
• At age 6-36 months testing is behavioral audiometry, OAE, tympanometry, ABR.
• Looking for causes of hearing loss consider genetic testing early. The ENT is probably not referring to genetics.
• Congenital CMV is the most common congenital infection, usually asymptomatic, but up to 15% go on to have hearing loss, which usually develops later than the newborn screen.
• Who gets lost to follow-up? Babies who transfer hospitals, transfer MD’s, don’t have medical homes, whose moms didn’t hear about the importance of follow up. Poverty appears to play a big role in who follows up. Rural settings are more challenging.
• NC is meeting the benchmarks for newborn screening, but we don’t appear to be doing a good job of getting children to their 3-month follow up visits when the refer from screening.
• The MD/provider should ideally be the person to reinforce the message of how important it is for parents to follow up.
• Refer to AUDIOLOGY before referring to ENT! Audiology should respond faster, and they will get the ENT involved if the hearing loss is confirmed, may be able to avoid a lot of unnecessary ENT referrals!
• www.ncnewbornhearing.org
• Q&A: If in the future we can get congenital CMV screening at birth, we may be able to flag high-risk children for repeat hearing screening at age 3 months, but we’re not there yet.
• Q&A: Gerri Mattson, MD, MPH. All the birth hospitals are now part of a statewide network of hearing screening tracking. Now interest in giving primary care providers access to the system as we have for newborn screening and immunizations

Dr. Kenneth Roberts

AAP Clinical Guideline: The Diagnosis and Management of the Initial Urinary Tract Infection in Febrile Infants and Young Children* Unanswered Questions - Unquestioned Answers

• Technical report: http://pediatrics.aappublications.org/content/128/3/e749.full
• Guidelines themselves: http://pediatrics.aappublications.org/content/128/3/595.full
• Read the guidelines, technical report if you’d like (above)
• Idea from the 1960’s: smoldering pyelonephritis eating away at our children’s kidneys without symptoms. This idea never made any sense, but it survived until the 1990’s, reflected in the 1999 guidelines. It does not seem to be true, and it never was.
• Yes, this is a paradigm shift from the last forty years, which is probably a good thing!
• Population addressed: infants and young children 2 months to 24 months of age with unexplained fever. Around 5% have UTI, and rates of scarring are higher than in older children.
• Can’t really say what this means for children under 2 months of age, and these guidelines do not address that age group. Committee is meeting this month to consider this population.
• Risk levels also appear to be lower in older kids: Miralax is probably the best UTI prophylaxis in this age group!
• There are 7 key action statements, 8 areas for suggested further research.
• #1 If a clinician decides a child is going to need antibiotics for fever, please get a catheterized urinalysis for UA and culture BEFORE starting antibiotics! This is a high-quality, level A recommendation.
• Suprapubic aspiration is the “gold standard” but no one does them any more. Catheterization is comparable. If a catheter goes into the vagina, leave it there and use it as traction and don’t use it again!
• Bag urine is NOT suitable for culture. It is essentially a vaginal wash. False positives are 88% overall, 99% in circumcised boys!
• #2 If a child is not so ill as to need antibiotics, then assess likelihood of UTI. If likelihood is low (1-2%), then you can follow clinically. If likelihood is higher, then get catheterized specimen or, alternately, get any kind of urine for UA, then get a cath if UA appears possible.
• Risk factors: Girls: white race, age <12 month, temp >39 C, fever > 2 days, absence of another source of fever.
• Boys: non-black race, temp >39 C, fever >24 hours, absence of another source of fever, UNCIRCUMCISED (risk over 1% regardless of other risk factors)
• #3 UTI diagnosis requires both positive culture (>50,000 CFU of a true uropathogen) AND a positive urinalysis.
• A positive urinalysis has positive leukocyte esterase and/or nitrites, microscopy has white cells and/or bacteria.
• Asymptomatic bacteruria is not a disease, just a condition of white girls and women due to bacterial attachment, lead to positive cultures with NEGATIVE urinalyses! This is why we want both culture and UA to be positive.
• #4 Initial antimicrobial treatment can be oral or parenteral, they are equivalent!
• Choice of drug is based on local sensitivity. Be aware that sensitivity reports from local labs are based not on individual patients, but on individual samples, meaning that chronically ill, hospitalized patients skew the results in hospital labs.
• Duration of treatment: 7-14 days, data are lacking to say just how long.
• #5 Febrile infants with UTI should undergo renal and bladder imaging, but this is a weak recommendation (level C). Yield of abnormal findings worth doing anything about is quite low, even though abnormal findings themselves are quite common.
• #6 VCUG are not recommended for routine performance after the first UTI if the ultrasound is normal!
• Based on meta-analysis of six studies of whether prophylaxis versus no prophylaxis and whether it prevents renal scarring in the future. Meta-analysis showed NO benefit!
• Urologists thought the meta-analysis was inappropriate since studies were not all using the same methodologies, inclusion criteria. So Dr. Roberts wrote the six authors of those studies to try and obtain comparable data from their data sets.
• All six agreed, providing data set of 1,091 infants. Prophylaxis clearly made no difference, but the higher the grade of reflux, the higher the rate of recurrence, regardless of whether you’re on prophylaxis. Therefore a recurrence of UTI is in and of itself a good indicator of the presence of high-grade reflux.
• Is there harm for waiting until the second UTI to get VCUG? Rates of renal scarring take off around the 3rd to 4th UTI.
• British guidelines already recommended a similar approach, and follow up studies showed no increase in the rates of recurrent UTI in this age group.
• Active treatment of VUR does not reduce the occurrence of chronic kidney disease based on large prospective follow up studies.
• If you look at the original studies that got us to treating VUR in the first place, they were badly flawed by confounding co-morbidities.
• #7 Following a confirmed UTI, parents should be instructed to seek prompt medical evaluation for future febrile illnesses to insure that recurrent infection can be detected and treated promptly.
• Areas for future research: what is the true relationship between UTI’s and reduced renal function/HTN? What alternatives are there to invasive collection of urine? What is the role of VUR and VCUG in disease in the first place. What is the role of prophylaxis in VUR? Are there genetic or racial differences in what we should do? What is the proper duration of treatment for UTI?
• Q&A: Is the imaging recommendation the same for boys and girls? What about posterior urethral valves? Prenatal ultrasound, timely newborn voiding, absence of UTI by age 2 months probably screens out most of the cases of posterior urethral valves. Kids whose valves are diagnosed later probably also have a better prognosis.
• Q&A: is a negative dipstick urine a true negative urinalysis in the absence of microscopy? The white cells damage the kidneys, not the E. coli. Microscopy is better, but LE is a pretty sensitive indicator of the presence of white cells in the urine. May send a child out without treating based on negative dipstick, but if symptoms persist another day you probably need to get that child back that day and re-evaluate. Not sure what to do with a positive culture in the setting of negative UA.
• Q&A: if we have the prenatal ultrasound results, do we still need an ultrasound after the first UTI? Data are being accumulated, probably not able to answer that question just yet. May depend in part on the quality and site of the prenatal ultrasound.
• Q&A: Is there a source of quantitative data on WBC’s and bacteria in pediatric urinalyses? Good studies from Hoberman on bacteruria in children. 
• Q&A: Word of caution from Duke urologist: agree with guidelines, thinks they’re great, but be aware that some kids may move, seek care in multiple locations, and MD’s may not be aware that their “first” febrile UTI is not really their first episode. Be aware of that risk. Also, remember this guideline is for kids aged 2 months to 24 months, does not cover children who may have dysfunctional voiding, etc. Don’t apply these guidelines to children who are outside the covered age group.

Annual Meeting, September 15, 2012

NC Pediatric Society Annual Meeting 2012

Day #2

This one starts with the legislative update. Please, read every word. If you practice pediatrics in North Carolina, there is stuff in here that will affect you deeply, not to mention the wellbeing of the children you serve.

John Rusher, MD, JD, President-Elect

Legislative Update

• This year’s session was a short session as opposed to a long session, largely dedicated to the budget and little else
• Our policy issues got little attention, but they will be back in the long session to come.
• Governor Perdue used the veto stamp on the budget, but the budget was overridden. So, what did we and children keep and lose?
• Medicaid has a $220 million budget gap. It was plugged in some ways, but there will be ongoing issues.
• Budget includes an assumed $60 million in savings from Community Care Of North Carolina. The legislature seems to have faith that CCNC will continue to succeed in their mission to improve care value.
• So far the MD’s reimbursement rate did not get cut. In North Carolina docs get about 90-91% of Medicare rates, which is close to the best rates in the country.
• NC Health Choice program did not lose funding, enrollment remains open for now. Enrollment is at its highest level at 150,000 kids.
• Early childhood education got decimated. No funding for Pre-K education. Smart Start was essentially eliminated, with a $7 million cut by replacement with a federal grant that in all likelihood will not happen. Funding was predicated on Medicaid not running a deficit, which it always does.
• Judge Howard Manning in Wake County ruled that the cuts to Smart Start is unconstitutional, but the Legislature is appealing that ruling. Court of Appeals agreed with Judge Manning, so the case is now appealed to the Supreme Court. In the meantime, the cuts will continue.
• Foster care saw a $6.7 million recurring cut
• Community services for mental health and develompental disability: $20 million recurring cut
• Tobacco prevention devastated by loss of successful youth and adult funding from the tobacco settlement. What’s left is the NC Quitline.
• Infant mortality prevention: Healthy Start Foundation eliminated despite record of success.
• Scope of practice issues: Independent licensure board for Professional Midwives. Did not move forward, but may come back.
• Naturopathic licensing act: would have enabled naturopaths to diagnose and treat major illnesses, order and interpret labs and diagnostic imaging. Did not pass, likely to come back.
• Pharmacists Immunizing Bill: would allow pharmacists to give vaccines to children down to age 7 without a doctor’s order. Sent back to the boards of pharmacy, nursing, and medicine for an attempted solution.
• Juvenile Justice: only in NC and NY are 16 and 17 year old children tried as adults for non-violent felonies. Change to juvenile court did not make it through this year, but we hope to see it passed next year.
• Air Toxics Program Reform. Lowered NC standards for pollutants down the Federal list of toxins, less protective of health. We fought it, lost.
• Indoor tanning beds: bill did not pass, so kids can go get skin cancer with a parent’s permission down to age 13. The data are overwhelming that tanning beds at this age make a strong contribution to skin cancer (see yesterday’s notes)
• Mental Health Delivery. The Local Management Entities will be consolidated into 11 regional Managed Care Organizations to monitor and pay for mental health services. Many providers that we rely on are now subject to immense regulatory obligations and are simply getting out of the business of serving the children we see. We continue to work with all the stakeholders to figure out how we can continue to provide good integrated mental health care. Please send John stories and facts from your community so that we can bring these issues before the people who run the program and try to make it work. (Peter Morris: Most states have moved away from mental health carve-outs because they work poorly and usually lead to loss of funds, but we are embracing them now.)
• Future Issues: The Election. What might happen if we have a governor and both houses controlled by the same party?
• We are likely to see many bills that we have seen thwarted return, and funding problems we face now are likely to worsen.
• How is legislation around the Affordable Care Act going to affect pediatricians? The ACA as it is passed now is tremendously beneficial to pediatricians, including no copay for preventative care, use of Bright Futures Guidelines, ratcheting up Medicaid reimbursement rates to be equal to Medicaid. These gains are at risk in this election. We will have to be very vocal about defending these provisions should they come under attack.
• Dave Tayloe is working hard to make sure that the children’s health care package that comes out of the Health Benefits exchange is strong, but it looks more likely that NC just won’t set one up at all, and the federal government will do it instead. Per Dr. Tayloe, NC has already missed the deadline for setting up the exchanges. There is still time to request an essential benefits package for children based on a letter from our Governor to the Center for Medicare and Medicaid Services (CMS) that must be submitted by September 30th.
• We are working hard with CCNC to create a statewide child accountable care organization (see yesterday’s notes).
• NC may create a separate department of Medicaid, under study.
• NC is considering transferring the Division Of Public Health to the UNC Healthcare System or School Of Public Health.
• Please VOTE! Legislators can track WHETHER you voted, although not HOW you voted.
• Sign on to Steve Shore’s listserve for updates
• Visit www.ncleg.net to identify and contact your state legislator and obtain updates on pending legislation.
• Get involved! Get to know your local representative. You may know these people or have some ties. Go introduce yourself, and offer your services as an expert in pediatrics. Give your contact information, and be available with data, communication, testimony. Now is a good time to do it, because during the session they get a lot busier.
• Please write a check this weekend (or whenever) to the NC Peds PAC (must be a personal check, not a business check)
• Senator Purcell announces that the subcommittees that used to meet to take public input on legislation are not meeting any more, so we have lost a major avenue for talking to legislators. We have to reach legislators earlier.
• Christoph Diasio recommends walk-in flu vaccine clinics as a way to serve our patients better.

Pediatric Surgical Subspecialties

Dr. Danielle Walsh, ECU

Appendicitis

• Occurs between ages 5-55. Most common surgical emergency in those ages.
• May be as common as 1:400 by the teen years, may affect 7% of the population over a lifetime.
• 5% of kids brought to ED for abdominal pain will have appendicitis.
• Lumen gets occluded, appendix becomes inflamed, perforation may occur
• About half of kids will have the classic history, but half will just report RLQ pain.
• If pain PRECEDES vomiting, that is more likely to be appendicitis.
• Fevers are rarely over 39 C
• Perforated appy more likley to be symptomatic over 36 hours, have fever, come with diffuse pain, have peritonitis, have leukocytosis or leukopenia
• Up to 1/3 of kids have perforated by the time they present to a caregiver
• If a child is jumping around he probably does not have appendicitis.
• Don’t do a rectal.
• Start your exam far away from the RLQ, move there gently.
• Look for psoas sign: only way to diagnose the 15% of retrocecal disease.
• CBC and UA are the only needed lab studies, HCG for teen girls
• CRP, ESR not helpful.
• New urine mass spec study may become standard of care in the future, but currently investigational.
• Pediatric Alvarado Score: can be used to predict likelihood of disease, reliable
• Send home if no nausea or anorexia, no maximal tenderness in RLQ, ANC < 6750 (98% accurate)
• Plain films are not that helpful except to prove constipation.
• 30% of kids with appendicitis have a fecolith. If kids have fecolith and RLQ pain, then appendicitis is indicated. Without pain, they tend to pass on their own.
• Ultrasound: non-invasive, useful in teen girls and non-obses children, diagnostic if appendix is >6 mm with fluid, noncompressible, and has a blind end. 85% sensitivity, 94% specificity. Depends on how often the center does ultrasounds.
• CT scan is very accurate, but comes with ionizing radiation. Give IV plus PO contrast, but not rectal contrast. 94% sensitive, 95% specific. The American College Of Radiology recommends ultrasound first, CT if nondiagnostic, unless child has a suspected perforation.
• Surgical assessment by a pediatric surgeon is 95% accurate, but that’s at a pediatric surgical center like Boston Children’s.
• So here, start with exam, labs, ultrasound, which you can recheck in 6-12 hours. If still uncertain at that point, at CT is useful. You can always transfer to peds surgery for observation/evaluation.
• Please give antibiotics early if you suspect appendicitis!
• Standard of care is now laparoscopic appendectomy, 24 hours of IV antibiotics. Usually a one-day stay.
• If child has perforated, then management varies. If recent, still get an appendectomy. If late, walled-off abscess > 5 cm, then drain is placed, antibiotics given, schedule appendectomy in the future.
• In between there is some wiggle room for OR versus non-operative management.
• Antibiotics are usually Unasyn, Zosyn.
• Interval appendectomy usually occurs 6 weeks to 3 months after abscess treatment, but 1/3 of kids don’t make it that long due to recurrent pain or failure to improve.
• If you wait to take out the appendix, then 40% get better without surgery. So then is appendicitis really a surgical emergency?
• Delayed versus emergent surgery made no difference in outcomes in kids and adults. Proven with 32,782 patients over 3 years.
• You can wait up to 24 hours to take out an appendix if other care is appropriate.
• In the pre-antibiotic era 80% of appendicitis patients recovered in 5-7 days!
• Treatment efficacy for abx alone was 90.8%, 89.2% for surgery, with less complications without surgery.
• Only study in kids was 16 patients, but 15 got better on antibiotics alone.
• Meta-analysis demonstrates fewer complications when antibiotics alone were used in place of surgical management. At least 60% of patients got better. The pediatric studies are ongoing, so this is not yet standard of care, but it may be coming as the pediatric literature expands.

Jonathan Routh, MD, MPH, DUMC

Robotic & Minimally-Invasive Surgery In Pediatric Urology

• Technically this is off-label, as robotic surgery is only FDA-approved for adults.
• Minimally invasive surgery has gotten much better in recent years, so why do surgeons choose one technique over another?
• Benefits include improved cosmesis, improved parental satisfaction, reduced post-operative pain, less narcotic use, shortened postoperative recovery.
• What are the problems? Cost is higher, although comparable if you don’t count buying the equipment. Operative time is longer, 3 hours versus 1 hour. Also, there is a substantial learning curve.
• What surgeries CAN be done robotically? Any, but not all SHOULD be done robotically!
• Kidney and ureteral surgeries are good candidates. Badder surgery varies, probably better for older kids, teens, but not for younger kids.
• Most often used for pyeloplasty, ureteral re-implantation.
• Hidden Incision approach (HIdES) puts incisions at belt line, umbilicus, idea is to triangulate the organ. Robot is a lot more patient with awkward positions.

Abigail Martin, MD, Assistant Professor Of Surgery, Transplant, DUMC

Breast Disease In The Pediatric Population

• Neonatal gynecomastia. Normal reaction to maternal estrogen, gets better on its own. Families freak out some when there is colostrum.
• More concerning is mastitis in this age group, usually in first month of life, more often females, most often Staph aureus. Half can get abscess. I&D may risk damage to the breast bud, so many surgeons aspirate first and hope to avoid more invasive surgery.
• Galactocele is a cystic lesion filled with milk or viscous material. More common in boys than in girls. Treatment is excision of the swollen duct, usually do very well.
• Polythelia/athelia, affects 1-2% of the population. Treatment is excision. Pubertal patients may develop polymastia, the development of breast tissue with accessory nipples.
• Preamture thelarche in prepubertal girls. Occurs in the absence of other signs of puberty as opposed to in the presence of precocious puberty. Tends to be transient in toddlers. Non-pathologic in toddlers. Try to avoid biopsy. Rarely results from hypothyroidism, but standard screening is not needed.
• Precocious puberty is breast development with other signs of puberty. Most patients have idiopathic or pseudo-precocious puberty. May be due to meds. Ovarian, or adrenal tumors may be the cause, primary hypothyroidism, McCune-Albright Syndrome.
• Pubertal boys: gynecomastia or metastatic nodule.
• Gynecomastia is common, up to 60% of boys affected within 1-2 years of puberty. Only 2-3% have an underlying cause. May include medications, street drugs, Klinefelter, testicular or adrenal tumors, thyroid disease, chronic liver disease.
• Overweight boys should try to lose weight. About 1% of boys with gynecomastia will undergo surgery, usually subcutaneous mastectomy.
• mastitis in pubertal girls. may or may not be associated with pregnancy/lactation. Most commonly Staph aureus. Start with antibiotics and warm compresses, avoid tight clothing. May lead to abscess.
• Virginal hypertrophy. Rapid, painful increase in breast tissue, usually present at puberty, thought to be due to oversensitivity to estrogen. Not pre-malignant, no hormonal abnormalities. May treat with Danazol or by plastic surgery, but best to wait until growth is complete. Danazol may have androgen side effects.
• Tuberous breasts have a small, narrow base, wide nipple complex. Normal hormones, normal histology. Can undergo mammoplasty by a breast surgeon, ideally late in teens or in early twenties.
• Amastia. Usually not apparent until puberty. If bilateral, call endocrine! Usually unilateral, such as with Poland syndrome. May also be iatrogenic due to surgery occurring in infancy such as thoracotomy, chest tube, central venous line, radiation therapy for cancer. Plastic, reconstructive surgery is the intervention.
• Bloody nipple discharge may be mammary duct ectasia, intraductal papilloma, chronic nipple irritation from sports bras. Send discharge for culture, cytology.
• Mammary duct ectasia usually presents as bloody discharge, occasionally as a mass. Due to abnormal duct development leading to dilatation. May lead to abscess, may require excision.
• Intraductal papilloma: mass or bloody discharge. Bilateral in 25%. May see ductal cells in cytology report. Diagnosis is by ductogram, treatment excision.
• Breast cancer: very low incidence in patients under age 20 years. Accounts for <0.1% of breast cancer cases
• Fibroadenoma. Well circumscribed, only excised if >5 cm in size. Otherside just observe. Giant Juvenile Fibroadenomas are the large ones, should be excised if bothersome.

John A. van Aalst, D, Director Prediatric and Craniofacial Plastic Surgery, UNC Children’s Hospital

Positional Plagiocephaly: who Should Prescribe Helmets, and Should Insurance Cover the Costs?

• Head shape problems are all about pattern recognition.
• The vast majority of kids with head shape issues are not going to need treatment.
• Don’t miss scaphocephaly, trigonencephaly, true plagiocephaly from lambdoid suture closure.
• Many populations through history have purposely distorted the skull. Mayans, for example, used boards to create a high-domed head, probably for religious reasons. Native American populations carried kids on papoose boards, creating flat occiputs. Head molding continues to be a cultural practice in a variety of indigenous cultures.
• Usually the metopic closes by 2 years, often sooner, as early as 6 months. Others close later.
• Surgical cases get worse with time. Easy to miss in kids with multiple other co-morbidities.
• 60% are scaphocephaly, 20% trigonencephaly (increasing) and plagiocephaly.
• Growth should to perpendicular to sutures, but when a suture closes it goes parallel
• With positional deformity, you get a parallelogram-type shape.
• Positional plagiocephaly has increased with back to sleep campaign, may affect 45% of normal babies to some extent. Often present at birth, persist with ongoing pressure to that skull surface.
• Most commonly due to torticollis. Treat the torticollis, not the head.
• Usually deformational plagiocephaly improves, although not always.
• Brain growth in these kids is normal!
• Look for improvement in the first five months to six months of life as milestones improve. Work with families on positional strategies.
• Usually no helmet until at least 6-7 months of age.
• Early strategies (3-5 months) get pressure off the side of the head that is flat. May use triangular pillows, crib position, activity/stimulation/feeding to the opposite side. Document objective signs of improvement (timing determines success)
• Brace shop at UNC makes helmets.
• Treatments: moderate to severe, observe. Extremely severe, do treat with a helmet.
• Helmets timing: start around 6 months, end around 12 months, may work as long as 18 months, but really no benefits beyond 18 months of age.
• There are NO randomized trials to assess outcomes in the long term.
• Cost may be prohibitive, $1500 to $3000, rarely covered by insurance.
• Most patients improve with positioning. Compliant helmet patients in a small trial saw 54% improvement.
• Currently any provider or physical therapist can prescribe these helmets per Medicaid guidelines.
• Medicaid covers helmets on a case-by-case basis, similar to other payers.
• New Medicaid policy: only prescribed by neurosurgeon, craniofacial surgeon, craniofacial team, no one else!
• Kids with co-morbidities probably benefit the most from helmets.
• Post-operative helmets are always covered!
• Refer early to craniofacial teams to distinguish positional from true plagiocephaly!
• Stay in charge of the management of the patient rather than just turning it over completely to PT with an “evaluate and treat” order. Many kids get referred straight to orthotics from PT.

Pediatric Subspecialties

Keisha Gibson, MD, MPH, UNC

Proteinuria

• Complications of nephrotic syndrome: hypercoagulability, thrombosis, peritonitis, cellulitis, malabsorption and abdominal pain, acute kidney injury from things like ibuprofen
• Initial therapy for nephrotic syndrome: now there are consensus guidelines. Now treat for 12 weeks total: 6 weeks at 2 mg/kg/day, then taper over the next 6 weeks.
• When do you worry? When it’s fixed over supine and standing collections, worry. When it does not respond to corticosteroids after 4-6 weeks, it’s not going to be minimal change in the vast majority of cases, and prognosis is worse even if it is. If proteinuria also comes with hypertension, dysmorphic blood cells in the urine, that’s not minimal change disease. Family history of kidney disease is worrisome.
• There is an algorithm (PARADE) for evaluation and management of proteinuria and nephrotic syndrome in children. Don’t accept the first dipstick protein without a spot protein:creatinine ratio. Then get a supine sample and see if it’s positional. Check family history, physical exam, blood pressure. The next step depends on your comfort level, practice capacity. May refer as soon as you get positive proteinuria with supine urine collection.

Richard J. Chung, MD, Director of Adolescent medicine, DUMC

Complex Contraception in Adolescence

• Teens with chronic illness have high rates of sexual activity, low rates of contraception use. Not a great combination.
• Goal both to prevent unplanned pregnancy, but also to reduce pregnancy-related morbidity and mortality.
• Adding another medication can affect adherence with therapy.
• Medication interactions must be taken into account.
• Patients may be on teratogenic medications: 6% of women become pregnant while on teratogenic medications (adults study).
• Categories of contraceptives include estrogen/progestin combos, progestin only, and non-hormonal methods
• Long-acting reversible contraceptives (LARC’s) are great options for many of these patients.
• IUD’s are highly effective, may be copper or copper-progestin. Effectiveness varies.
• Menstrual suppression. May be very useful in children with chronic debilitating disease such as developmental disability.
• Four periods a year (tri-cycling) seems to be adequate for endometrial shedding.
• Biggest problem tends to be unscheduled bleeding, but these issues tend to improve within the first four cycles.
• Hormonal contraception and thrombosis is a concern for many families. Think about patients with Crohn’s disease for example.
• Thromboembolism risk is related to both estrogen and progesterone exposure, not just estrogen.
• Progestins should decrease thrombosis, but in use, especially with estrogens, this does not seem to be the case.
• Relative risk with contraceptives is 3-5x, but pregnancy is 6-10 x increased risk over baseline.
• Combination of thrombophilia and OCP’s is much higher.
• Absolute risk in teens is very low, 1-10:100,000 patients, lower in progestin-only users, maybe even no increase at all!
• Patch, ring, seemed not to increase risk of clotting, but newer studies suggest they may actually carry some risk
• Desogestrel and drosperidone seem to have 2 times the relative risk of thromboembolism over baseline.
• Most common heritable risk factors are Factor V Leiden and prothrombin mutation.
• But what is the absolute risk? Because that’s what matters, right?
• For a healthy 17-year-old, rates are 50:100,000 on OCP’s, 350:100,000 if patient has Factor V Leiden, which is 0.35%, still very, very low.
• There are guidelines from CDC, WHO, and others for use of contraceptives in patients with various chronic illnesses. IBD for example is a 2-3 risk level out of 4.
• No guideline recommends routine evaluation for thrombophilia, even if there is a first degree family member with idiopathic DVT.
• Should test if someone has ever had a personal history of venous thromboembolism. If there is a very worrisome history in a first degree relative, consider testing that relative.

Ivor Hill, MD, ChB, MD, Wake Forest University School Of Medicine

Abdominal Pain in Childhood

• What is a functional GI disorder? Variable combination of chroni or recurrent GI symptoms defined by absence of clinical findings.
• These kids have hyperalgesia, testable with distention of the intestine by balloon. PET scan shows different patterns of brain activation with intestinal distention
• Probably needs a new name.
• Rome Criteria, now in third iteration (Rome III) defines functional disorders for research and classification purposes.
• Functional disorders affect various body regions, including chest pain, fatigue, low back pain, numbness, etc.
• Pain affects 10-30% of children and adolescents, most common complaint resulting in GI referral. More common in winter, spring.
• Organic causes of pain account for about 5-10% of abdominal pain in primary care. Vast majority are functional.
• But the functional disorders can be highly debilitating, affect quality of life. People with functional pain get a lot more intervention, often to no effect.
• How do you recognize functional pain early in order to avoid excess testing and ensure appropriate management?
• History is the key to the process. Look for red flags!
• Age flags: younger than age 5, older than age 15 at presentation.
• Duration flag: shorter is more concerning, longer reassuring.
• Localization flag: the more diffuse, the less concerning.
• Severity flag: look at child’s behavior related to reported pain
• Colicky pain is more concerning than chronic.
• Pain that awakens children is much more concerning. Perk up and take notice!
• Positive family history of GI illness is more concerning
• Dietary history: sugared beverages, including juice, is a problem. Lactose intolerance is common, especially in African-Americans. Ask about sugar-free gum! Sorbitol will give you lots of gas!
• Also worrisome: growth failure, unexplained fever, diarrhea, arthritis or arthralgia, dysphagia, lethargy/weakness, vomiting, blood in stool
• Examination: focus on nutritional status, anemia, jaundice, edema. Consider rectal exam for perianal tags, fissures, fistulas, tenderness, mass. If fissures are not at 12:00 or 6:00, think inflammatory bowel disease!
• Easy labs: CBC, look for microcytic anemia, eosinophilia. ESR/CRP elevation. Do three occult hemoglobin tests. Look for O&P, fecal leukocytes.
• CBC and sed rate is better than IBD panel for finding IBD!
• Blood test for H. pylori is useless, DON’T do it!
• Food allergy testing not useful without other signs of allergy such as hives or other GI symptoms. Intollerance is something different, best addressed with FODMAP diet.
• Management: explain the disorder in terms of other symptoms like headaches
• Explain the course is benign, the condition is common, it’s going to come back from time to time. May discuss brain-gut axis; the two talk to each other. Dichotomizing brain/physical is not accurate or helpful.
• Try to avoid doing tons and tons of tests. Risks outweigh benefits.
• Choose a plan with clear objectives, not just a random shotgun when choosing diagnostic investigations.
• Use red flags to guide investigations.
• Review results specifically with family members, don’t just say, “Everything came back fine.” Frame negative results as good news!
• The interaction between the provider and the patient is going to determine how things go for the patient.
• Treatment: treat dietary factors, constipation, lifestyle. Poops should be cow patties. Exercise helps, so does sleep.
• Start with natural interventions like probiotics, peppermint oil, ginger, behavioral therapy. FODMAP diet http://ibs.about.com/od/ibsfood/a/The-FODMAP-Diet.htm really does help!

CME: GI Treatment And Referral Guidelines

Community Care Of NC

Katherine Freeman, MD, UNC Gastroenterology

• North Carolina has the 10th most kids of any state in the US, 3rd fastest-growing population.
• At the same time, pediatric GI fellowships have closed due to lack of funding.

David Tayloe, MD, Goldsboro Pediatrics

• Guideline development resulted from interviews with pediatric gastroenterologists, review of national guidelines, development of condensed draft guidelines. Created a panel to create a draft GI treatment and referral guideline for both constipation and GERD. These guidelines have not yet been finalized.

Michael Glock, MD, Wake University Medical Center

• Constipation and encopresis accounts for about 3% of general pediatrics visits, 25% of GI referrals.
• BM issues provoke a lot of anxiety for families whenever it deviates from their perception of normal patterns.
• Normal is 4 per day for infants, 2 per day at age 2, 1/day after age four, ranging from q other day to 3 times/day.
• Usually constipation results from a painful BM that then leads to voluntary stool holding. What parents think is “trying to go” is really “trying not to go.”
• Eventually the rectum habituates and develops paradoxical contractions of the external sphincter, demonstrable with rectal manometer. Withholding becomes reflexive, not voluntary.
• Historical red flags: blood in stool, meconium plug, abdominal distention, vomiting, very painful BM’s. Often constipation begins around age 6-12 months, when kids start taking solids.
• Physical exam red flags: is the anus anteriorly displaced? Is the sphincter tight? Are there rectal masses? Are there unusually placed skin tags or fissures?
• No studies if patient responds well to treatment, but prior to referral consider T4, TSH, CBC. KUB not really needed prior to referral.
• Education of family is critical. Let them know most kids will respond to treatment.
• Treatment: MUST start with disimpaction. Please, please do the clean-out before referring to GI! Use polyethylene glycol in 64 ounces of fluid (8 doses under age 5, 16 doses over age 5). Try for 8 ounces q 15-30 minutes. May repeat on day #2 if day #1 doesn’t work.
• Don’t change Miralax dose right away, give it 2 weeks or so.
• Sit on toilet comfortably 5-10 minutes TID. Blowing on a balloon, whistle, or musical instrument will help with relaxation!
• Follow up is really important! Did the disimpaction work? Is the Miralax working well? At least have a nurse call and check up on the patient.
• There is a Bristol Stool Chart http://thewvsr.com/bristolstoolchart.htm may help families describe stools. Ideally constipated patients will be having type 5 (out of 7) stools, very soft without edges. If you’d like a coffee mug with the Bristol Stool chart, click here!)
• Plan to treat for at least six months.
• Refer for any red flag, therapy failure, kids with complex medical needs., request from family.

Dr. Freeman again, GERD Draft Guideline

• Feel free to look over these guidelines and share suggestions or questions
• Reflux is physiologic in most cases, common, not associated with significant distress or problems. This is the case for 50-70% of infants, tends to decrease over the first year of life.
• GER is less frequent in toddlers and older children/adolescents
• Guidelines use a three-tiered approach based on severity of symptoms, complications of illness.
• For first tier, education, reassurance, feeding modifications should be enough.
• For tier II, may try H2 blockade (first), proton pump inhibitor (second), hydrolyzed formula. In older kids try lifestyle changes.
• Tier III includes problematic symptoms, complications. Erosive esophagitis is very rare in children, can reassure families. Trial of meds for at least two weeks prior to referral.
• Red flags: hematemesis, melena, bilious vomiting, weight problems, feeding refusal, acute onset of vomiting after age 4 months, aspiration pneumonia, recurrent wheezing, choking, true forceful vomiting.
• Consider surgical referral if anatomic abnormalities are a concern.

Dr. David Tayloe, How Will This Be Implemented By CCNC?

• Working on developing better electronic communications between specialists and primary care physicians.
• Partnering with a community collaboration partner would also be helpful
• Contact with local primary care provider would hopefully cut down on ED presentations, hospital admissions.
• Q&A: thickening formula keeps formula from coming out of the mouth, but does not prevent reflux altogether. Consider thickening to prevent failure to thrive, aspiration, assuage parents.
• Q&A: what’s the role of imaging to reassure parents? For constipation, you might want one after disimpaction. For GERD, if you have indications of pyloric stenosis, consider ultrasound.