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.