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VIRGINIA•PEDIATRICS American Academy of Pediatrics • Virginia Chapter 2 PRESIDENT’S MESSAGE 3 DATES TO REMEMBER 4 CME INFORMATION 5 SOLID ORGAN TRANSPLANT IN CHILDREN 8 NEONATAL MULTIDISCIPLINARY FOLLOW-UP PROGRAM FOR THE NICU GRAD 9 THE ROLE OF WEIGHT LOSS SURGERY IN ADOLESCENTS WITH SEVERE OBESITY 12 APPLICATION OF THE 5-A’S MODEL IN PEDIATRIC PRIMARY CARE SETTINGS 15 HYPOTHERMIA TREATMENT FOR THE INFANT WITH NEONATAL ENCEPHALOPATHY 18 PEDIATRIC WORKFORCE SHORTAGES 21 EARLY IDENTIFICATION OF CONGENITAL EAR DEFORMITIES ALLOWS FOR NONSURGICAL CORRECTION 23 CME REGISTRATION & EVALUATION FORM 24 DELEGATE THOMAS A. GREASON AWARDED VA-AAP CHILD ADVOCATE AWARD! 24 VA- AAP POSTER SYMPOSIUM WINNERS 24 MULTIDISCIPLINARY GUIDELINES FOR THE CARE OF LATE PRETERM INFANTS The Virginia Chapter was the recipient of the compeve AAP Richmond Center Flight Aendants Medical Research Instute Grant to move Tobacco Cessaon efforts forward in Virginia. This grant provided a Vising Lectureship, September 18th - 20th, 2013 featuring Dr. Jonathan Winickoff from Massachuses General Hospital for Children in Boston as the vising professor. Dr. Winickoff is a praccing pediatrician, teacher, advocate, and leader in tobacco cessaon research. The grant partnered the Virginia Chapter, AAP, Virginia Department of Health, Virginia Foundaon for Healthy Youth, and Children’s Hospital of King’s Daughters. Dr. Winickoff met with leaders from the Virginia Chapter, AAP and the Virginia Foundaon for Healthy Youth to promote leadership for tobacco cessaon for pediatric pracces. He met with Virginia Health Department officials involved with tobacco cessaon efforts. Dr. Winickoff presented, “Smoking Cessaon” at Pediatric Grand Rounds at CHKD. He also met with the residents who underwent advanced training on promong tobacco cessaon with parents of pediatric paents vising the clinic. Dr. Winickoff then spent the aſternoon with the precepng pediatric residents and medical students with Dr. John Harrington and his colleagues at the CHKD Academic Pediatric Pracce. Dr. Winickoff presented “Third Hand Smoke: Clinical and Policy Approaches” at the Donald Lewis Pediatric Conference in Williamsburg. A major effect of Dr. Winickoff’s visit was to begin teaching pediatric pracces how to integrate parental tobacco cessaon using the simple, “Ask, Advise, Refer” system into their office flow. For more informaon on bringing this technique into your pracce please visit hp://www2.aap.org/ richmondcenter/Clinicians_ClinicalPracce. html or contact Dr. Bob Gunther at [email protected]. Fall | 2013 Issue IN THIS Drs. Robert Gunther, AAP District IV Vice Chairperson, Jonathan Winickoff, AAP/FAMRI Vising Lecturer and Barbara Kahler, VA-AAP Vice President at Donald W. Lewis Pediatric Update 2013. We welcome your opinions and ideas. Please send comments on arcles, ideas for new arcles,leers to the editor, suggesons for making Virginia Pediatrics more useful and address changes to: Virginia Pediatrics Jane Davis: Execuve Director 2201 West Broad Street, Suite 205 Richmond, VA 23220 • Phone: (804) 622-8135 • • Fax: (804) 788-9987 • • email: [email protected]About Us Publicaon of an adversement in Virginia Pediatrics neither constutes nor implies a guarantee or endorsement by Virginia Pediatrics or the VA-AAP/VPS of the product or service adversed or of the claims made for the product or service by the adverser. :: newsleer design + layout :: Atlas Branding Agencies :: • Next Issue: Winter 2013 • • Deadline for entries: 12/2013 • Chapter Grant Moves Tobacco Cessation Forward
Transcript
Page 1: Virginia Pediatrics Fall 2013 Newsletter - American Academy of Pediatrics Virginia Chapter

VIRGINIA•PEDIATRICSAmerican Academy of Pediatrics • Virginia Chapter

2 PRESIDENT’S MESSAGE3 DATES TO REMEMBER4 CME INFORMATION 5 SOLID ORGAN TRANSPLANT IN CHILDREN 8 NEONATAL MULTIDISCIPLINARY FOLLOW-UP PROGRAM FOR THE NICU GRAD 9 THE ROLE OF WEIGHT LOSS SURGERY IN ADOLESCENTS WITH SEVERE OBESITY12 APPLICATION OF THE 5-A’S MODEL IN PEDIATRIC PRIMARY CARE SETTINGS15 HYPOTHERMIA TREATMENT FOR THE INFANT WITH NEONATAL ENCEPHALOPATHY 18 PEDIATRIC WORKFORCE SHORTAGES21 EARLY IDENTIFICATION OF CONGENITAL EAR DEFORMITIES ALLOWS FOR NONSURGICAL CORRECTION23 CME REGISTRATION & EVALUATION FORM24 DELEGATE THOMAS A. GREASON AWARDED VA-AAP CHILD ADVOCATE AWARD!24 VA- AAP POSTER SYMPOSIUM WINNERS24 MULTIDISCIPLINARY GUIDELINES FOR THE CARE OF LATE PRETERM INFANTS

The Virginia Chapter was the recipient of the competitive AAP Richmond Center Flight Attendants Medical Research Institute Grant to move Tobacco Cessation efforts forward in Virginia. This grant provided a Visiting Lectureship, September 18th - 20th, 2013 featuring Dr. Jonathan Winickoff from Massachusetts General Hospital for Children in Boston as the visiting professor. Dr. Winickoff is a practicing pediatrician, teacher, advocate, and leader in tobacco cessation research. The grant partnered the Virginia Chapter, AAP, Virginia Department of Health, Virginia Foundation for Healthy Youth, and Children’s Hospital of King’s Daughters. Dr. Winickoff met with leaders from the Virginia Chapter, AAP and the Virginia Foundation for Healthy Youth to promote leadership for tobacco cessation for pediatric practices. He met with Virginia Health Department officials involved with tobacco cessation efforts. Dr. Winickoff presented, “Smoking Cessation” at

Pediatric Grand Rounds at CHKD. He also met with the residents who underwent advanced training on promoting tobacco cessation with parents of pediatric patients visiting the clinic. Dr. Winickoff then spent the afternoon with the precepting pediatric residents and medical students with Dr. John Harrington and his colleagues at the CHKD Academic Pediatric Practice. Dr. Winickoff presented “Third Hand Smoke: Clinical and Policy Approaches” at the Donald Lewis Pediatric Conference in Williamsburg. A major effect of Dr. Winickoff’s visit was to begin teaching pediatric practices how to integrate parental tobacco cessation using the simple, “Ask, Advise, Refer” system into their office flow. For more information on bringing this technique into your practice please visit http://www2.aap.org/richmondcenter/Clinicians_ClinicalPractice.html or contact Dr. Bob Gunther at [email protected].

Fall | 2013

IssueIN THIS

Drs. Robert Gunther, AAP District IV Vice Chairperson, Jonathan Winickoff, AAP/FAMRI Visiting Lecturer and Barbara Kahler, VA-AAP Vice President at Donald W. Lewis Pediatric Update 2013.

We welcome your opinions and ideas. Please send comments on articles, ideas for new articles,letters to the

editor, suggestions for making Virginia Pediatrics more useful and address

changes to:

Virginia Pediatrics Jane Davis: Executive Director

2201 West Broad Street, Suite 205 Richmond, VA 23220

• Phone: (804) 622-8135 • • Fax: (804) 788-9987 •

• email: [email protected]

About Us

Publication of an advertisement in Virginia Pediatrics neither constitutes nor implies a

guarantee or endorsement by Virginia Pediatrics or the

VA-AAP/VPS of the product or service advertised or of the claims made for the product or service by

the advertiser.

:: newsletter design + layout :: Atlas Branding Agencies ::

• Next Issue: Winter 2013 •• Deadline for entries: 12/2013 •

Chapter Grant Moves Tobacco Cessation Forward

Page 2: Virginia Pediatrics Fall 2013 Newsletter - American Academy of Pediatrics Virginia Chapter

Welcome to the Fall edition of the Chapter newsletter. The Chapter continues to work for the betterment of children’s health more actively than ever.

It’s a very political year in Virginia. The Chapter continues its involvement in all our usual and innovative projects, focusing on but not limited to childhood health and education, proper nutrition starting from birth to combat obesity, tobacco cessation, mental health, and oral health, but we have decided to do an unprecedented endorsement of a candidate. Our history is supporting the welfare of children with a bipartisan non-political attitude, respecting both conservative and liberal thought, but this year is quite different.

Here’s our official statement regarding Democratic Senator Ralph Northam, a Chapter member, and pediatric neurologist at Kings Daughters Hospital.

“RICHMOND, October 1, 2013- The Virginia chapter of the American Academy of Pediatrics, which represents over 1,200 pediatricians and pediatric associates in the Commonwealth, is pleased to announce its endorsement of Senator Ralph Northam, MD, for Lieutenant Governor.

The Virginia AAP has represented Virginia’s pediatricians and advocated for Virginia’s children since 1934. Our endorsement of Senator Northam marks the first time in our chapter’s history we have officially endorsement a candidate. Our chapter has chosen to do so because Senator Northam is a fellow pediatrician who shares the same values and commitment to children

2

www.virginiapediatrics.org

as our organization. Senator Northam is the ideal candidate we would hope to see elected to a statewide leadership position.

“Dr. Northam has spent his entire career in service to others,” said Dr. William Rees, President of the Virginia chapter of the American Academy of Pediatrics. “Whether it was serving children through his pediatric medical practice, serving our country as an Army physician in Desert Storm or serving the citizens of Virginia in the Senate, he has demonstrated a strong commitment to his community. We are confident he would serve Virginians as Lieutenant Governor with the same integrity and leadership he has shown in every position he has held. The Virginia AAP is pleased to call Senator Northam a member and a friend and we are pleased to endorse his candidacy for Lieutenant Governor.”

As Senator Northam’s record in the Virginia Senate proves, he has a keen understanding of children’s issues and recognition of the intersection of children’s health and childhood education. With our constantly evolving health care and education environment, Senator Northam is the right person to guide Virginia forward.

“I have had the privilege of working with Dr. Northam at Children’s Hospital of the King’s Daughters,” said Dr. Natasha Sriraman. “As his colleague, I can personally attest to his strong work ethic and dedication to his patients. I have no doubt he will bring these same values to the position of Lieutenant Governor and show the same commitment to the citizens of Virginia.”

The mission of the Virginia Chapter, American Academy of Pediatrics is the attainment of optimal health, safety and

well-being of Virginia’s children. As a pediatric neurologist and lifetime advocate of children’s issues, we believe Dr. Northam will help lead Virginia in making this mission a reality for Virginia’s children. We are pleased to endorse Senator Ralph Northam for the office of Lieutenant Governor.“

The Chapter is dedicated to the welfare of children above any political issues, we have always taken a bipartisan approach to engage all legislators, but we believe this year that we see a highly biased and unenlightened approach to children’s issues from Senator Northam’s opponent.

----------------------------------------------------------- Our 2013 Child Advocacy Award awarded in Williamsburg in September went to Delegate Tag Gleason from Loudoun County for his support of the recent Autism support bill, and the Epipen law requiring our public schools to carry adrenalin to administer to any child experiencing anaphylaxis. He is a Republican from Loudoun County and a strong advocate for the welfare of children.

-----------------------------------------------------------The chapter and its Pediatric Council continue to support pediatricians and medical centers across the Commonwealth against the recent RAC audit involving esoteric coding procedures regarding nebulizer treatment in the office or medical center clinics. RAC is a national audit originating at the federal level and passed down to each individual state. If your practice has been affected by this audit without any merit, please note that Tennessee has dropped its audit on the same topic as it realized the audit was totally without merit. Please contact Louis Elie at DMAS and voice your concern.

V IRGINIA•PEDIATRICSPre s i d e n t ’ s•MESSAGEWilliam C. “Biff” Rees, MD, MBA, FAAP President Virginia Chapter | American Academy of Pediatrics

... continued on page 3

Page 3: Virginia Pediatrics Fall 2013 Newsletter - American Academy of Pediatrics Virginia Chapter

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([email protected] or 804-786-5590). The Chapter is very willing to cooperate on work regarding fraud and abuse, not this sort of audit, and we continue to work allied with MSV on these unnecessary audits.

-----------------------------------------------------------

Medicare Medicaid equity checks for the first 6 months of the year have been received across the state; however, I know that at least one MCO (Anthem) as of October 7, 2013, has still failed to pay. If there are other Medicaid MCOs who haven’t yet paid for the first six months, please contact Jane Davis, our Executive Director, at [email protected]. We need to know.

-----------------------------------------------------------

There are so many pediatricians doing very worthwhile projects across state with National AAP Councils, Section, and Committees. Unfortunately, our central office may not know about you and your volunteerism. Please let us know what you are doing. Eventually - usually unexpectedly - we learn of what great work you are doing, and we can be very supportive.

-----------------------------------------------------------

I’m always looking for volunteers. We have a very active membership but are always looking for new ideas that can better children’s lives. I realize how difficult and time consuming the life of a pediatrician can be, but volunteering several hours a month to a worthy cause can be very personally rewarding. If you’ve got a great idea and dedication, we can be very supportive. Don’t hesitate to get in touch with Jane Davis, [email protected], our Executive Director.

Sincerely,

Twitter: @DrBiffRees

... continued from page 2

Dates to Remember ...MOHSEN ZIAI PEDIATRIC CONFERENCE

November 1st & 2nd, 2013Ritz Carlton, Tyson’s Corner

McLean, Virginia

For more information, please visit www.inova.org/pedscme or contact Marchelle D. Albertson at [email protected].

PEDIATRIC GENERAL ASSEMBLY DAYRegistration Open.

Thursday, January 30th, 2014Williamsburg Lodge

Williamsburg, Virginia

The home base for the Pediatric General Assembly Day isHilton Garden Inn

Located at 501 E. Broad Street In Richmond.This venue is a flat, 3.5 block walk from the General Assembly Building.

Shuttle service will also be available.The Hilton Garden Inn offers valet parking

and is convenient to several public parking lots.

For more information go to www.virginiapediatrics.org after January 1st, 2014.

VIRGINIA•PEDIATRICS

Page 4: Virginia Pediatrics Fall 2013 Newsletter - American Academy of Pediatrics Virginia Chapter

Children’s Hospital of The King’s Daughters and the American Academy of Pediatrics, Virginia Chapter

Present

VIRGINIA PEDIATRICS NEWSLETERAmerican Academy of Pediatrics – Virginia Chapter

Continuing Medical Education This activity has been planned and implemented in accordance with the Essential Areas and policies of Medical Society of Virginia

through the joint sponsorship of Children’s Hospital of The King’s Daughters and the American Academy of Pediatrics – Virginia Chapter.

Children’s Hospital of The King’s Daughters designates this enduring material for a maximum of 2 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Content DirectorC. W. Gowen, Jr., MDProfessor of Pediatrics

Chair, Department of Pediatrics, EVMS Senior Vice-President for Academic Affairs, CHKD

CME CommitteeMichelle Brenner, MD, Nancy Leigh Gainfort, RN, BSN, C.W. Gowen, Jr., MD,

Eric Y. Gyuricsko, MD, John Harrington, MD, Kamil Cak, DMin BCC, Janice Karr, Rosalind W. JenkinsJamil Khan, MD, Windy Mason-Leslie, MD, Amy Perkins, Amy Sampson

Natasha Sriraman, MD

How to Obtain Credit:Review the articles on pages 5-22. Complete the VA-AAP Newsletter Registration and Evaluation Form on page 23 and return to the Children’s Hospital of The King’s Daughters, CME Office, 601 Children’s Lane, Norfolk, VA 23507 or 757-668-7122. You may also visit

https://www.surveymonkey.com/s/vaapfall2013 and complete online. Please allow 8 weeks to receive your certificate.

Disclosure of Significant Relationships with Relevant Commercial Companies/Organizations

The Children’s Hospital of The King’s Daughters endorses the Standards for Commercial Support of Continuing Medical Education of the Medical Society of Virginia and the Accreditation Council for Continuing Medical Education that the providers of continuing

medical education activities and the speakers at these activities disclose significant relationships with commercial companies whose products or services are discussed in educational presentations.

For providers, significant relationships include large research grants, institutional agreements for joint initiatives, substantial gifts or other relationships that benefit the institution. For speakers, significant relationships include receiving from a commercial company

research grants, consultancies honoraria and travel, other benefits, or having a self-managed equity interest in a company.

Disclosures:

The following authors have disclosed that they do not have an affiliation with any organization that may or may not have an interest in the subject matter of this CME activity and/or will not discuss off-label uses of any FDA approved pharmaceutical products or medical devices.

Timothy E. Bunchman, MDRonald K. Evans, MDDavid A. Lanning, MD

William B. Moskowitz, MD, FAAPKaren Hendricks-Munoz, MD, MPH

Rajanya S. Petersson, MD

The CME committee members and content director have disclosed that neither they nor their spouses or partners have an affiliation with any corporate organization that may or may not have an interest in the subject matters of this CME activity.

The following authors have disclosed that they have an affiliation with an organization that may or may not have an interest in the subject matter of this CME activity and/or will discuss off-label uses of FDA approved pharmaceutical products or medical devices.

NONE

Page 5: Virginia Pediatrics Fall 2013 Newsletter - American Academy of Pediatrics Virginia Chapter

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Over the last 3 decades significant advances have been made in solid organ transplant in children. Since the beginning of the single kidney transplants in children in the latter part of the 70s and 80s, advances in immunosuppression techniques have al-lowed for other solid organ transplants to follow. Pediatric liver transplants became more common in the 80s and 90s, as well as did pediatric heart and then eventually pediatric lung transplant. Following that small bowel transplant or abdominal vis-ceral transplants in general have seemed to follow.

What has improved the outcome in children with single organ transplants is advancement of surgical technique, improved health of the patient at the time going to transplant as well as improved research and advancements in immuno-suppressive agents.

Pharmaceutical studies in children with use of mycophenolate mofetil (MMF), Calcineurin inhibitor agents (tacrolimus and cyclosporine) as well as advances in T-cell induction agents (Thymoglobulin and Campath), have allowed for improved immunosuppression at initiation and for maintenance of transplant immunosup-pression in children.

Just as advances in single organ transplant has occurred, the complexity of children has changed over time. It is now not uncommon practice that children require more than one solid organ transplant either at that time or in sequential thera-py because of other organ abnormalities.

The numbers of children with multiple solid organ transplants are growing over time. If one excludes the visceral trans-plant children, which often can include small bowel, liver and case of kidney at

V IRGINIA•PEDIATRICS

the same time, isolated kidney trans-plants, combined with heart, or liver transplants combined with kidneys, or kidneys and/or heart and livers are few but growing over time.

Data to date has identified that multiple organ transplant children often seem to be more immunosuppressive naive and require less immunosuppressive agents than those children with solid organ trans-plant. The etiology of this is unclear, but clinical experiences identified that organ transplant often combined with liver transplant allows for less immunosuppres-sion requirements.

Over the last two and a half years in co-operation with our surgical colleagues at VCU, our Pediatric Nephrology section has reestablished the solid organ transplant for children. This has predominantly been in the area of kidney transplant. Most recently, we have also taken on the task of high at risk or high antibody children at the time of transplant. Active research by our group has allowed for immuno- reduction allowing for high risk antibody children to be immuno- reduced to allow for transplantation.

Three unique transplants have occurred over the last six weeks at the Children’s Hospital Richmond at VCU.

This has included a young man who had a failing heart secondary to failing con-genital cardiac disease. He underwent a cardiac transplant back in November 2012. At that time the child was placed on veno-arterial extracorporeal mem-brane oxygenation (ECMO) for 24 hours and then maintained on outpatient he-modialysis. Eight months later, the child has received a deceased donor kidney transplant and now is back and functional in school on chronic immunosuppressive agents. This young man is active in sports and has seen no untoward side effects of the organ transplant.

Secondly, a young man who had end-stage renal disease secondary to reces-sive polycystic kidney disease had a failed kidney transplant at an outside institution. Subsequently, the child underwent a liver transplant because of hepatic fibrosis as-sociated with recessive polycystic kidney disease. The family sought out our care, traveling here 100 miles, because of his high antibodies because of multiple solid organ and blood exposure. Upon immu-no-reducing this patient, we were able to identify the mother who historically could not be a donor to becoming a donor and recently has undergone a living donor kidney transplant. This young man now is off dialysis and has a totally functional liver transplant that has been functional for 3 years and now his recently functional kidney transplant, returning to school in the fall of this year.

Lastly, a young man who had a failed kidney transplant done at another institu-tion has been cared for by our group. This patient also has a high antibody count

... continued on page 6

Timothy E Bunchman, MDProfessor & Director Pediatric Nephrology Children’s Hospital of Richmond at VCU

Objective: Discuss advances in solid organ transplants in children.ACGME Competencies: Patient Care and Medical Knowledge.

Solid Organ Transplant in Children

Page 6: Virginia Pediatrics Fall 2013 Newsletter - American Academy of Pediatrics Virginia Chapter

and has been less responsive to immuno-reduction as a potential recipient from his mother. This young man was the 1st recipient of a “chain” transplant done at VCU. This is a where an altruistic donor donated a kidney into the national kidney program (NKR) and this kidney was flown from out-of-state to this child. This child’s mother, who could not be a donor for this child, then had a kidney donated to someone in another state. The person who received that kidney in the other state, a family member then that had a kidney removed and was sent to another state. This concept of a chain is a novel idea at the Children’s Hospital of Richmond at VCU is participating in to enhance the donor pool and to allow children to come off dialysis.

Whereas solid organ transplant is not without risk including complications of viral infections as well as malignancies, the goal of solid organ transplant is to get children back to school and to allow them to become functional members of society.

In a very short period of time that cooperative effort between Transplant Surgical Group as well as Pediatric Nephrology at VCU has allowed for not only enhancement of unique approaches of solid organ transplant, but multiple organ transplants in children with excellent outcomes. This past year Pediatric Nephrology of the Children’s Hospital of Richmond at VCU was designated as a “top Pediatric Nephrology program” by the U.S. News and World Report which grades medical systems and programs in the US. This recognition was in part due to our programs advancement in outcome and care of children with kidney disease in Central Virginia.

6VIRGINIA•PEDIATRICS... continued from page 5

Neonatal Multidisciplinary Follow-Up Program for the NICU Graduate: Resources for Infants, Parents and NICU Providers

Objective: Recognize the importance of follow-up for the high risk NICU graduate and available resources to achieve optimal development.ACGME Competencies: Patient Care, Practice-based Learning and Improvement, Medical Knowledge and Systems-based Practice.

Karen D. Hendricks-Muñoz, MD, MPHDepartment of Pediatrics, Division of Neonatal Medicine Children’s Hospital of Richmond at VCUVirginia Commonwealth University School of MedicineTazuddin Mohammed, MDStacey Dusing, PT, PhDDepartment of Physical Therapy Virginia Commonwealth University

Infants born high-risk or preterm often continue to have complex medical and developmental concerns after discharge from the Neonatal Intensive Care Unit (NICU). With improved neonatal care and changes in length of hospitalization increas-ing numbers of high risk infants are discharged home on oxygen, medications, apnea monitors, high-calorie formulas, as well as nasogastric and gastrostomy feeding tubes.

The transition to home and outpatient pediatric care can be facilitated by dedicated high-risk infant follow-up programs that bridge the specialized multidisciplinary care that these infants and their families require. The ideal follow-up program can facilitate clinical care continuity and provide anticipatory guidance for parents and pediatricians as well as make refer-rals to early intervention programs with knowledge of specific state wide eligibility standards or refer the infant directly to the indicated therapy services. These programs can also cre-

ate opportunities to understand the medical outcomes and needs for these infants that can lead to improved care through research1 as well as further educate pediatricians and other health care professionals who will care for these infants in the future.

continued on page 7...

Page 7: Virginia Pediatrics Fall 2013 Newsletter - American Academy of Pediatrics Virginia Chapter

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The American Academy of Pediatrics (AAP) has emphasized the need and importance for multidisciplinary follow-up programs with a policy statement since 2008.1 Most academic centers throughout the country aim to provide comprehen-sive follow-up including evaluation for growth and organ function as well as target development, physical and oc-

cupational therapy need, psychological development with important standards for feeding and nutritional support.1,2 Infants classified as high-risk include those infants born preterm, with special health care needs or dependence on technology. Additionally, high risk infants may include those born into high family circumstances as well as infants with anticipated early death.Furthermore, the Institute of Medicine report on improving healthcare quality has identified ‘care coordination’ and ‘children with special health care needs’ as priority focus areas to improve the quality of healthcare for children, adding further importance for the need for high risk infant follow-up programs.3 Recently,

V IRGINIA•PEDIATRICS

continued on page 8...

a large randomized prospective trial identified that comprehensive follow-up care from highly experienced caregivers significantly reduced life-threatening ill-nesses and total days of pediatric inten-sive care by more than 40% for a high-risk inner-city infant population discharged from the NICU. On average, 1 of every 13 infants provided with this comprehensive

care was prevented from developing a life-threatening illness.4

The ChoR Neonatal Continuing Care Program:The Children’s Hospital of Richmond at VCU Neonatal Continuing Care Program follows a standard assessment of need for who should be followed, how long and by whom based on the AAP recom-mendations. The Program has a threefold mission to:

• Offer interdisciplinary follow-up ser vices to an at-risk graduate of the CHoR or other newborn intensive care unit (NICU)• Complement the care provided by the

continued from page 6...

child’s medical home and provide feed back to the referring NICU• Educate clinicians related to the ongoing needs of the at-risk NICU graduate

The Children’s Hospital of Richmond at VCU Neonatal Continuing Care Program offers periodic screening by a multidis-ciplinary team including neonatologists, developmental pediatricians, genetics, nutritionist, pulmonary specialists, occu-pational therapists and psychologist. The program provides psychosocial support to families as needed. Services are tailored to the needs of each child but gener-ally include assessment of the medical, nutritional, neurologic, developmental and psychosocial needs of preterm and high-risk infants after discharge. Program Neonatal follow-up evaluations include the following:

• Physical exam• Nutritional counseling• Neurologic exam• Developmental testing• Parent support and referral to Early Intervention Services

The Children’s Hospital or Richmond at VCU Neonatal Continuing Care Program does not serve as a primary health care provider but strongly supports ongoing participation with the child’s primary care provider, the medical home and commu-nity services. Rather, the staff in the Neo-natal Continuing Care Program specializes in assessing and managing infants with underlying medical problems that can have an impact on subsequent develop-ment. For example, to meet the complex medical needs of an infant with ongoing chronic lung disease from bronchopul-monary dysplasia, we have a program to manage supplemental oxygen and bronchodilator/diuretic therapy, coupled with neuro-developmental support as well as the nutritional services needed to complement pulmonary growth. Thus, the Neonatal Continuing Care Program serves as a hub of clinical care activity for infants with complex needs and their families.

Page 8: Virginia Pediatrics Fall 2013 Newsletter - American Academy of Pediatrics Virginia Chapter

VIRGINIA•PEDIATRICS 8

... continued from page 7

Table 1. Eligibility Criteria for early intervention services in Virginia

1. A child and family may receive early intervention supports and services if the child is: up to three years old and has certain levels of developmental delay, differences in development and/or a diagnosed condition.

2. A child with a developmental delay or differences in development is not developing like other children his age, The delay or difference can be in one or more of the following areas:

Thinking, learning, and playing Moving, seeing, and hearing Understanding and using sounds, gestures and words Developing relationships

Taking care of one's self, including eating and dressing

3. A child is eligible who has a diagnosed condition that will very likely cause a developmental delay. This includes:

Genetic disorders, such as Down syndrome Cleft lip and/or palate NICU stay of greater than or equal to 28 days Autism Spectrum Disorder Vision and/or hearing loss

Modified from - Infant & Toddler Connection of Virginia5 Infant Referral guide, http://www.infantva.org

The staff helps to coordinate care and refer infants with continuing medical and social needs to appropriate specialists and programs such as home-care nursing, early intervention/therapy programs and subspecialty consultations if necessary. We aim to maintain close communication with primary physicians so a coordinated plan of medical management is maintained. A summary of each visit evaluation is sent to the child’s medical home and if appropriate to the referring newborn intensive care unit. With parent approval, the summary is also sent to other providers involved in the child’s care. When indicated, the Program assists with or refers to secure appropriate intervention and financial services. This may include referral to the Infant & Toddler Connection of Virginia5 (http://www.infantva.org) or other developmental services when indicated. The Infant & Toddler Connection of Virginia program provides early intervention services and support for infants through age three as well as resource information for physicians, providers and families, see Table 1 for outlined Eligibility Criteria.

Conclusion:

Medical care for neonatal illness continues to improve through important research that includes understanding factors important to improve neonatal outcome. Given the substantial care provided to at-risk infants in the neonatal intensive care unit it is important for caregivers to provide these infants and their families with comprehensive multidisciplinary follow-up care. This comprehensive care will bridge the needed transition to home and accurately assess potential infants who may benefit from specific therapeutic interven-tions important to improve long term outcome for these vulnerable patients. References

1. American Academy of Pediatrics Committee on Fetus and Newborn. Policy Statement. Hospital discharge of the high-risk neonate. Pediatrics 2008; 122: 1119–1126.2. Vohr B, Wright L, Hack M, Aylward G, Hirtz D. Follow-up care of high risk infants. Pediatrics 2004; 114: 1377–13973. Adams K, Corrigan JM eds, Priority Areas for National Action— Transforming Health Care Quality. The National Academies Press: Washington, DC, 2003.4. Broyles RS, Tyson JE, Heyne ET et al. Comprehensive Follow-up Care and Life-threatening Illness among high-risk infants. A randomized controlled trial. JAMA 284(16) 2070-2076, 20005. Infant & Toddler Connection of Virginia, http://www.infantva.org

Page 9: Virginia Pediatrics Fall 2013 Newsletter - American Academy of Pediatrics Virginia Chapter

9VIRGINIA•PEDIATRICS

continued on page 10 ...

Objective: List essential elements in the work-up of an ad-olescent with severe obesity that has not been successful with non-surgical measures for weight loss and what the surgical treatment options are at CHoR at VCU.ACGME Competencies: Patient Care, Practice-based, Learning and Improvement, Medical Knowledge.

The Role of Weight Loss Surgery in Adolescents with Severe ObesityEdmond Wickham III, MD, MPH, FAAPAssociate Professor, Division of Endocrinology & MetabolismMelanie Bean, PhDAssistant Professor, Division of Pediatric Endocrinology & MetabolismPoornima Vanguri, MDGeneral Surgery ResidentNancy Thompson, CPNPSurgery Nurse PractitionerClaudio Oiticica, MDAssociate Professor of Surgery and PediatricsDavid Lanning, MD, PhDSurgeon-in-Chief, Children's Hospital of RichmondVirginia Commonwealth University Medical Center

Rates of pediatric obesity have increased rapidly over the past several decades (1). Though the prevalence of obesity in the pediatric population appears to have stabilized over the last few years, it remains very high, with 16.9% of children in the United States meeting obesity criteria (body mass index [BMI] > 95th percentile).(1) Obesity is associated with increased risk of numerous medical and psychological comorbidities, which may already be present in childhood and adolescence, including type 2 diabetes mellitus (T2DM), hypertension, hyperlip-idemia, non-alcoholic fatty liver disease, (NAFLD), obstructive sleep apnea, depres-sion, eating disorders and poor quality of life.(3) Overweight youth are over twenty times more likely to remain obese as adults placing them at increased risk of early mortality.(4,5) Consequently, it is not surprising that obesity has emerged as the second leading cause of preventable premature death in the United States.(2) Moreover, some experts project that the life expectancy of today’s youth is shorter than that of their parents, highlighting the significant impact of obesity.(4,5) As a result, the treatment and prevention of obesity are paramount to reduce morbid-ity and mortality among affected youth. In 2007, an Expert Committee, includ-ing the American Academy of Pediatrics, proposed a four-step, tiered approach to weight management in 2-19 year olds.(6)

Stage 4 intervention was recommended for children >11 years old with a BMI >95th percentile and significant comorbidi-ties who had not experienced significant weight loss with less intensive approaches (Stages 1-3). According to Expert Panel recommendations, Stage 4 care may include meal replacements, low calorie

diets, medications and surgery in addition to ongoing intensive lifestyle modification and should be conducted in a specialized tertiary care setting.(6) In concordance with the central role of behavior change in this staged approach to pediatric obesity treatment, many family-based pediatric

obesity programs have been developed. However, results of even the most com-prehensive adolescent obesity treatments are often suboptimal, particularly for adolescents with severe obesity.(7,8) To im-prove health of these adolescents, more intensive treatment options are needed.

In the adult population, weight loss sur-gery (WLS) is associated with significant and sustained reductions in adiposity.(9)

Moreover, WLS appears to be superior to conventional medical therapy in the treatment of adults with obesity and T2DM, frequently resulting in diabetes remission.(10,11) Given these findings, WLS is becoming a more widely accepted treatment option, with demonstrated improvements in weight and resolution of comorbidities, in adolescents with severe obesity and associated comorbidi-ties who have experienced inadequate weight loss despite adherence to at least 6 months of intensive lifestyle modifica-tion.(12,13) Importantly, it is recommended that WLS patients are carefully selected to improve the likelihood of positive surgi-cal outcome. These criteria are evolving, particularly in regards to adolescents. Ac-cording to the “Best Practice Updates for Pediatric/Adolescent Weight Loss Surgery from 2009,” the American Society for Metabolic and Bariatric Surgery (ASMBS) recommends the following selection criteria for the pediatric population: BMI of greater than or equal to 35 kg/m2 with major co-morbidities (T2DM, moderate to severe sleep apnea [apnea-hypopnea in-dex>15], pseudotumor cerebri, or severe NAFLD ) or a BMI of greater than or equal to 40 kg/m2 with other weight-related comorbidities (hypertension, insulin resis-tance, glucose intolerance, substantially impaired quality of life or activities of daily living, dyslipidemia, or sleep apnea with apnea-hypopnea index>5). (14,15) In addition to BMI/comorbidity criteria and demonstrated adherence with a super-

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vised intensive lifestyle modification program, it is recommended that adoles-cent WLS candidates be physically mature and demonstrate a clear understanding of the of the implications of surgery as well as the need for ongoing adherence with lifestyle changes and long-term follow-up. Furthermore, significant mood disorders (anxiety/depression), eating disorders, and substance abuse should be treated and stable prior to surgical consideration. To ensure these criteria are met, adoles-cent WLS candidates should undergone comprehensive pre-surgical assessments by a multidisciplinary team, ideally with pediatric expertise, including a surgeon, medical specialist, psychologist, registered dietitian, and physical therapist/exercise physiologist.(15,16)

Multiple WLS techniques have been stud-ied in the adolescent population, each with demonstrated efficacy and a low complication rate when performed by an experienced surgeon.(13) Three of the most common WLS procedures performed in adolescents include the Roux-en-Y gastric bypass (RYGB), adjustable gastric band (AGB), and sleeve gastrectomy (SG) and each of these procedures can be performed laparoscopically. The RYGB procedure involves first creating a small gastric pouch and then bypassing the duo-dendum to reduce the amount of calories that the body will absorb. Although RYGB has been demonstrated to be an effective procedure in adolescents and has largely been considered the gold standard for WLS in the past, this approach is associ-ated with a significant risk of malabsorp-tion and micronutrient deficiencies. (13) The AGB in an implantable device placed around the upper part of the stomach and then can be inflated with saline, restrict-ing the intake of food. Thus, unlike RYGB, the AGB procedure does not involve a malabsorptive component. Although the AGB has been studied in adolescents and is associated with significant weight loss, the results are less robust than with RYGB. (13) Moreover, there appears to be a high incidence of late complications with the AGB that may require re-operation. (13) Final-

ly, the AGB is not currently FDA approved for use in patients younger than 18 years of age. With the SG, 78-80% of the stom-ach is removed surgically; however, unlike the RYGB portions of the small intestine are not bypassed. Increasing data sup-port the efficacy of SG in the adolescent population and rates of SG are increasing at many pediatric obesity centers. (17)

The Healthy Lifestyles Center at the Chil-dren’s Hospital of Richmond at Virginia Commonwealth University offers compre-hensive, family-based Stage 3 and 4 care for children and adolescents with obe-sity, including evaluations for WLS when appropriate.(13) For adolescents deemed appropriate surgical candidates following our team’s comprehensive evaluation, we offer laparoscopic SG. As part of an approved clinical research protocol, we also offer laparoscopic greater curvature plication (LGCP), which is where the greater curvature of the stomach is rolled into the rest of the stomach and secured with sutures. This effectively creates a tube similar to the gastric sleeve resection yet no portion of the stomach is resected. Preliminary studies only in adult patients have demonstrated very good weight loss as well as reduction of weight-related comorbidities with LGCP.(18) While there are no dedicated studies of LGCP in the adolescent population, the low risk of complications, lack of malabsorption problems, and potential reversibility have led many providers to consider its use as an appropriate intervention for this population. In summary, data support the potential role of WLS, in addition to inten-sive lifestyle modifications, in carefully-selected adolescents with severe obesity and weight-related comorbidities. Several distinct WLS techniques have demon-strated significant reductions in excess weight and improvement or resolution of many comorbidities in this population; however, further research is warranted to develop minimally invasive techniques that optimize the balance of clinical response and risk profile. Following WLS, patients require ongoing multidisciplinary care to address physical, emotional, and

metabolic changes that occur after the procedure, promote ongoing support for sustained behavior change, and prevent weight regain.

References1. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. JAMA. 2012;307:483-490.2. Stein CJ, Colditz GA. The epidemic of obesity. J Clin Endocrinol Metab. 2004;89:2522-2525.3. Dietz WH. Health consequences of obesity in youth: childhood predictors of adult disease. Pediatrics. 1998;101:518-525.4. Serdula MK, Ivery D, Coates RJ, Freedman DS, Williamson DF, Byers T. Do obese children become obese adults? A review of the literature. Prev Med. 1993;22:167-177.5. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med. 1997;337:869-873.6. Barlow SE, Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120 Suppl 4:S164-92.7. McGovern L, Johnson JN, Paulo R, et al. Clinical review: treatment of pediatric obesity: a systematic review and meta-analysis of randomized trials. J Clin Endocrinol Metab. 2008;93:4600-4605.8. Oude Luttikhuis H, Baur L, Jansen H, et al. Interventions for treating obesity in children. Cochrane Database Syst Rev. 2009;(1):CD001872. doi:CD001872.9. Maggard MA, Shugarman LR, et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med. 2005;142:547-59.10. Schauer PR et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. New Engl J Med. 2012;366:1567-76. 11. Mingrone G et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med. 2012;366:1577-1585.12. Treadwell JR, Sun F, Schoelles K. Systematic review and meta-analysis of bariatric surgery for pediatric obesity. Ann Surg. 2008;248:763-776.13. Barnett SJ. Bariatric surgical management of adolescents with morbid obesity. Curr Opin Pediatr 2013; 25:515-520.14. Pratt JS, Lenders CM, Dionne EA, et al. Best practice updates for pediatric/adolescent weight loss surgery. Obesity (Silver Spring). 2009;17:901-910.15. Michalsky M, Reichard K, Inge T, Pratt J, Lenders C, American Society for Metabolic and Bariatric Surgery. ASMBS pediatric committee best practice guidelines. Surg Obes Relat Dis. 2012;8:1-7.16. Austin H, Smith K, Ward WL. Psychological assess-ment of the adolescent bariatric surgery candidate. Surg Obes Relat Dis. 2013;9:474-480.17. Nadler EP, Barefoot LC, Qureshi FG. Early results after laparoscopic sleeve gastrectomy in adolescents with morbid obesity. Surgery. 2012:152:212-7.18. Brethauer SA, Harris JL, Kroh M, Schauer PR. Laparoscopic gastric plication for treatment of severe obesity. Surg Obes Relat Dis. 2011;7:15-22.

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IntroductionA 2012 review by Hébert et al. evaluating perceptions of the importance of physi-cal activity (PA) counseling in the primary care setting suggested that between 61-99% of physicians and nurses either agreed or strongly agreed that PA should be promoted in the primary care setting. (1) However, the major reported barri-ers to PA counseling across the reviewed studies were lack of time, lack of knowl-edge or training in PA counseling, lack of success in changing patient behaviors, and lack of available counseling protocols. In an attempt to address some of these reported barriers, this article provides 1) an overview of the importance of and recommendations for PA for patients and their families and 2) practical suggestions for physicians in the primary care setting for encouraging active lifestyles.

A Framework for Assessing and Encourag-ing PA in Clinical PracticeThe 5-As is a simple, yet evidence-based, intervention model originally developed for smoking cessation and includes the following steps: Assess, Advise, Agree, Assist, and Arrange (see Table 1 on page 14). Clinical interventions with the aim of changing specific behaviors, like increas-ing daily PA, can be effectively carried out within the framework of these 5 steps (2-5). In this article, we present the 5-As inter-vention model within the context of mo-

tivational interviewing (MI). MI is a brief, directive, patient-centered counseling style to help patients resolve ambivalence about behavior change. Chief tenants in MI include expressing empathy, rolling with resistance, developing discrepancy between the patient’s values and their current behaviors, and supporting self-efficacy to make changes (6).

AssessAssess/Ask about current levels of PA, amount of sedentary behavior, attitudes toward PA, and readiness to change be-havior. In a 2008 study utilizing 2003-2004 NHANES PA data obtained from acceler-ometers, only 42% of children ages 6-11 years met the recommended 1 hour of moderate or higher intensity PA per day. More alarming was the precipitous drop in the percentage of adolescents (12-19 years) and adults meeting the daily PA recommendations, with only 8% and 5%, respectively, meeting the PA recommen-dations (7). Furthermore, a cross-sectional study of youth from 34 countries has found that overweight youth consistently have lower levels of PA and higher levels of television viewing as compared to normal weight peers (8). Utilizing a few targeted questions in the primary care setting can provide a general picture of a family’s PA participation, their level of sedentary behavior, and their attitudes toward PA. Specific questions assessing

frequency, intensity, and duration of phys-ical activity should be included along with questions regarding types (e.g., television, computers, video games, smart phones, etc.) and duration of screen time. Alter-natively, health behavior assessment and counseling instruments, such as the “Start the Conversation” Instrument developed by Perrin, et al. at the University of North Carolina at Chapel Hill can be utilized to provide a structured means of assessing PA and other behaviors in the primary care setting (9). It is important to note that health behaviors are often sensitive topics and may involve feelings of embar-rassment, fear, and stigma; therefore it is recommended to seek permission from the patient and parent prior to initiating the discussion.

A discussion about the family’s perception and attitudes toward PA should take place in a developmentally appropriate fashion and include all family members. Provid-ers can elicit information about activity interest from children by asking questions about what the child likes to engage in and/or a sport or hobby that they would like to develop. Parents play a crucial role in developing appropriate attitudes by reducing or eliminating barriers to PA, providing opportunities for activity, and encouraging children when they engage in activities. Parents also influence behav-ior by explicitly role modeling their own engagement in PA. Parents can structure environments to increase the likelihood of their child engaging in PA. Some examples include removing televisions from bedroom environments, engaging in regular family bike rides, or taking their children to the park with equipment to

11VIRGINIA•PEDIATRICSEncouraging Families to Be More Active: Application of the 5-As Model in Pediatric Primary Care SettingsRonald K. Evans, PhDAssociate ProfessorDepartment of Health and Human PerformanceDirector of Clinical Exercise Physiology, Comprehensive Pediatric Obesity Research and Treatment Center

Carrie B. Tully, MSHealth Psychology ResidentComprehensive Pediatric Obesity Research and Treatment Center

N. Romesh Wijesooriya, MD, FAAPAssistant Professor of PediatricsInterim Division Chair, Division of General PediatricsChildren’s Hospital of Richmond at VCU Virginia Commonwealth University

Objective: Discuss the importance and recommendations for physi-cal activity for patients and their families. Recall practical sugges-tions for encouraging family physical activity using the 5-A’s model. ACGME Competencies: Patient Care, Practice-based Learning and Improvement and Interpersonal Communication Skills.

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play soccer. Research suggests that adoles-cents with increased parental and peer supports for PA were more likely to continue participation in physical activities (10).

It is vital for providers to assess a fam-ily’s/patient’s readiness to change before moving forward with a behavior change plan. A practical way to assess a fam-ily’s readiness to change PA may include asking each member of the family about their regular PA and whether they are concerned about their amount of PA or fitness. Providers may assess the patient’s or patient’s parents’ thoughts about whether anything needs to be changed in the family to increase PA. Patient’s reasons for change can be elicited through provider counseling including, “What would be the benefits of getting more PA?” as well as their barriers with questions like, “What makes it hard to get more PA now?” Awareness of both the drivers and barriers for increased activ-ity will allow the provider to help make a tailored intervention plan. If a family/patient does not express a readiness to change, the development of a plan for change will be futile. Additional time spent answering questions that the fam-ily/patient might have pertaining to why PA is important may be warranted. If a family/patient does express a readiness, a collaborative plan with the patient/family should be developed.

AdviseAdvise the patient about the health benefits of and the recommendations for PA. The importance of daily PA for overall health and physical fitness of adults and children is well documented (11, 12). Struc-tured PA (exercise) of sufficient frequency, intensity, and duration has been shown to positively contribute to improvements in health-related physical fitness, includ-ing improved cardiorespiratory fitness,

musculoskeletal fitness, and body com-position. Further metabolic and cardio-vascular benefits of habitual PA include increased insulin sensitivity, improved blood lipid profiles, reduced adiposity, and reduced blood pressure values. PA pro-grams have also been shown to positively impact cognition and brain and psychoso-cial functioning. In addition to structured exercise programs, increased daily lifestyle PA (taking the stairs, walking to school, general play activities, etc.) and reduc-tions in sedentary behaviors (screen time) contribute to healthy weight management and overall health and well-being.

The Centers for Disease Control and Pre-vention (CDC) recommends that children and adolescents (6 – 17 years) accumulate at least 60 minutes of age-appropriate and enjoyable PA each day (13). The CDC further suggests that the majority of the 60 minutes each day should be moderate or higher intensity aerobic activity (e.g., brisk walking or running) with vigorous intensity activities included 3 days per week. The CDC also recommends a vari-ety of activities that also includes muscle strengthening (push-ups, weight training, etc.) and bone strengthening (jumping rope, running, etc.) activities as part of the daily 60 minutes on at least 3 days each week.

For adult family members, the American College of Sports Medicine recommends 150 minutes per week of moderate to vigorous PA (12). This can be accomplished by engaging in 30-60 minutes of moderate intensity exercise 5 days per week or par-ticipating in 20-60 minutes of vigorous PA 3 days per week. Additionally, accumula-tion of the desired amount of daily PA can be accomplished through either several intermittent exercise sessions throughout the day (at least 10 minutes in duration) or continuous PA. It is also recommended that adults engage in resistance training on 2-3 days per week concentrating on the major muscles groups. Lastly, flex-ibility and functional fitness training (bal-

ance, coordination, gait, etc.) should be included as part of the fitness routine to maintain joint range of motion and overall physical function. Gradual progression of exercise frequency, intensity, and time is recommended to improve exercise adherence; however, those individuals not capable of meeting these minimum recommendations should be encouraged to participate in activity within their toler-ance, as some health benefits can still be realized (12).

AgreeAgree on realistic PA expectations and col-laboratively develop individual and family activity plans based on stage of behavior change and focusing on specific goals. Once the family’s current level of PA and readiness to change has been assessed and awareness of the links between inactivity and negative health outcomes have been established, a “common ground” should be sought on one or more specific behavior change goals designed to increase daily PA or reduce sedentary activity (2) . Eliciting from patients what family activities they have enjoyed in the past, the reasons they do these activities, and what it would be like to do activi-ties more frequently may help providers collaboratively set personally-relevant goals for families that align with their own values. This collaborative approach is pre-ferred for health-behavior change as this provides family members with a sense of personal control in the process. Addition-ally, allowing the patient to contribute to the decision-making process is more likely to contribute to adherence and compli-ance since the PA goals will be set based on the families expectations, their stage of readiness for change, and their prefer-ences for how to institute the changes (2). The collaborative development of action plans (e.g., exercising with a friend 3 days per week) for meeting overall health goals (e.g., reducing body weight and/or improving blood pressure) is preferred as this provides a specific course for ad-dressing the behavior (14). Additionally,

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it is preferable to focus on 1-2 specific behaviors thereby reducing the chance that the patient may feel overwhelmed by the behavior change process. A useful tool in MI practice is creating a “Menu of Options” that allows the provider to direct patients toward goal setting. This tool should be used once the patients have communicated their reasons and need to take action, and the encounter has transitioned into behav-ioral goal setting. Orient the family to the menu of options by stating that other families have found it helpful to focus on the following areas to increase PA, includ-ing, for example: 1) family walks, 2) join a sport/dance team, 3) reduce screen time to 2 hours or less per day, 4) join a gym, 5) plan family outdoor game days, and 6) plan active video game challenges. The menu should include a few blank spaces for the family to write in their own ideas for how to get started with physical activ-ity. The menu accomplishes two objec-tives: it can help families pick an area on which to focus for the short term, as well as provides an overview of other behav-ioral interventions that may be indicated in the long term. The provider should assist the family in setting specific and realistic goals in one to two areas, to build self-efficacy to continue to make changes in other areas.

AssistAssist in identifying and addressing bar-riers; providing resources, assisting in finding and consulting with appropriate providers. Once specific family PA goals are agreed upon, provide assistance to the family by helping to identify possible barriers to PA participation (3, 4). Table 2 (on page 14) provides a list of commonly stated barriers to PA participation. Addi-tionally, providing strategies to overcome barriers will increase the likelihood of successful family behavior change. Some useful strategies to enhance adherence with PA participation include using pe-dometers or similar technologies to moni-tor PA, setting realistic goals, developing specific action plans, and strengthening social support for activity (e.g., exercise

with a friend or family member) (3). Of note, the patient’s ability to engage in PA may be impacted by the safety of his/her neighborhood and access to facilities. Us-ing a nonjudgmental stance to ask ques-tions about the availability of resources to promote the family’s increased PA is most appropriate. Providers may also need to assist in identifying additional providers, including exercise physiologists, dietitians, psychologists, health behavior specialists, or other medical specialties that are nec-essary to appropriately address specific health behavior issues. Table 3 (on page 14) provides additional available sources that provide information on physical activ-ity.

ArrangeArrange for regular and short-term follow-up. Just the knowledge that follow-up will occur is known to be a motivating factor for patient compliance with physician recommendations, therefore it is impor-tant for the clinician or practice staff to schedule some form of follow-up to evalu-ate the progress toward the agreed upon behavior change plan (2). This follow-up can be done in person at an office visit, by telephone, via e-mail, or by other avail-able means of communication. Typically, a shorter-term follow-up (approximately 1 month) is preferable to longer-term fol-low-up as this will provide an opportunity to re-evaluate behavior change goals and make any necessary adjustments that may enhance the likelihood that the behavior change will be realized. During follow-up, the first 4-As should be revisited and mod-ifications to the original behavior change plan should be instituted based on the patient’s progress toward realizing their goals, positive experiences that they have had since the previous visit, their success with overcoming specific barriers, and any potential relapses that have occurred (2).

In summary, families should be encour-aged to participate in regular PA as a means of increasing physical fitness, reducing adiposity, and improving car-diovascular health, metabolic indices, and psychosocial well-being. The pedia-

trician’s office provides an ideal setting to initiate a conversation regarding the importance of the role of PA and related health benefits. We have outlined a brief, useful model built on the principles of motivational interviewing to enhance clinician-patient-parent communication about PA in a pediatric primary care set-ting. Pediatricians can promote appropri-ate PA behaviors among their patients by briefly assessing current health behaviors and readiness to change, advising patients and parents about PA recommendations and the importance for overall health, agreeing on 1-2 specific PA behaviors that should be addressed, assisting the patients in identifying and overcoming barriers to the behavior change, and ar-ranging for close follow-up.

References 1. Hébert ET, Caughy MO, and Shuval K. Primary care provid-ers’ perceptions of physical activity counseling in a clinical set-ting: a systematic review. Br J Sports Med. 2012;46:625-31.2. Whitlock EP, Orleans CT, Pender N, Allen J. Evaluation behavioral counseling interventions: An evidence based ap-proach. Am J Prev Med. 2002; 22(4): 267-84.3. Smith BJ, van der Ploeg HP, Buffart LM, Bauman AE. Encouraging physical activity: Five steps for GPs. Austr Fam Phys. 2008; 37(1/2): 24-8.4. Estabrooks PA, Glasgow RE, Dzewaltowski DA. Physi-cal activity promotion through primary care. JAMA. 2003; 289(22): 2913-16. 5. Huang JS, Sallis J, Patrick K. The role of primary care in promot-ing children’s physical activity. Br J Sports Med. 2009; 43:19-21.6. Miller WR, Rollnick S. Motivational interviewing: Preparing people for change. New York, NY: Guilford Press; 20027. Troiano RP, Berrigan D, Dodd KW, et al. Physical activity in the United States measured by accelerometer. Med Sci Sports Exerc. 2008; 40(1): 181-88.8. Janssen I, Katzmarzyk PT, Boyce WF, et al. Comparison of overweight and obesity prevalence in school-aged youth from 34 countries and their relationships with physical activity and dietary patterns. Obesity Reviews. 2005;6(2):123–32.9. Perrin EM, Vann JC, Benjamin JT, et al. Use of pediatrician toolkit to address parental perceptions of children’s weight status, nutri-tion, and activity behaviors. Acad Pediatr. 2010; 10(4): 274-281.10. Mabry IR, Young DR, Cooper L a, Meyers T, Joffe A, Duggan AK. Physical activity attitudes of African American and white adolescent girls. Ambulatory Pediatrics. 2003;3(6):312–6.11. US Department of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1999, pp. 64–142.12. Garber CE, Blissmer B, Deschenes MR et al. Quantity and quality of exercise for developing and maintaining cardiorespi-ratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise. Med Sci Sports Exerc. 2011; 43(7): 1334-5913.Centers for Disease Control and Prevention. 2008 Physical activity guidelines for Americans. www.Health.gov/paguidelines.14. Bodenheimer T and Handley MA. Goal-setting for behav-ior change in primary care: An exploration and status report. Patient Ed and Counsel. 2009; 76: 174-180.

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Table 1. Components of the 5-As Model for Increasing Physical Activity

Table 2. Addressing commonly reported barriers to family physical activity participation

Table 3. Additional resources for information related to physical activity

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15VIRGINIA•PEDIATRICSHypothermia Treatment for the Infant with Neonatal Encephalopathy

Objective: Summarize the importance of available therapy for infant experiencing neonatal hypoxic ischemic encephalopathy including the limited time frame to implement therapy and the sources available.ACGME Competencies: Patient Care, Practice-based Learning and Improvement, Medical Knowledge and Systems-based Practice.

Karen D. Hendricks-Muñoz, MD, MPH, FAAP Russell Moores, MD, FAAPDepartment of Pediatrics, Division of Neonatal Medicine, Children’s Hospital of Richmond at VCU, Virginia Commonwealth University School of Medicine

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Despite advances in perinatal care, mod-erate to severe acute perinatal hypoxic ischemic encephalopathy (HIE) remains an important cause of mortality and acute neurological injury with subsequent long-term neurodevelopmental disabilities in term infants. HIE is a complex process evolving over hours to days, which pro-vides a unique window of opportunity for the neuroprotective treatment interven-tion of hypothermia. Therapeutic hypo-thermia provided to decrease the core or cerebral temperature by 2°C to 4°C, initiated within 6 h after birth, is the most promising neuroprotective intervention for infants with moderate to severe HIE, and has currently become a standard of care for these infants. Hypothermia ther-apy decreases mortality without increas-ing major disabilities in survivors.1 Given the unexpected nature of this illness, it is important that those involved in caring for these infants – obstetricians, family physicians, community pediatricians and neonatologists – recognize when cooling may be beneficial so as to rapidly provide this effective therapy.

Incidence:The incidence of neonatal encepha-lopathy in the United States ranges from 2-5 per 1000 live term births.2 With an annual birth rate of 4 million infants it is expected that 8,000-20,000 infants will be diagnosed with this disorder each year in the United States and approximately 200-500 infants in the state of Virginia. Neonatal encephalopathy does not always progress to permanent neurologic impair-ment. However, as many as 20% of term newborn infants with encephalopathy after perinatal asphyxia will die during the neonatal period and 25% of those who survive will have permanent neurologic disability.3 However, a moderate degree

of neonatal encephalopathy can be as-sociated with a spectrum of long-term disabilities ranging from normal outcome to significant motor or cognitive disabili-ties. Up to 40% of infants with moderate neonatal encephalopathy after perinatal asphyxia and 100% of those with severe encephalopathy die or develop neuro-sensory impairments, including cerebral palsy, mental retardation and hearing loss.3,4 The outcome of those infants with mild encephalopathy is generally normal, including normal cognitive function at school age.

Time of Risk:Risk of brain injury and resulting encepha-lopathy may occur at any time during gestation, or labor and delivery during the perinatal period. Encephalopathy is due to hypoxemia, ischemia or both that occur as a result of an acute intrapartum event sufficient to cause neuronal injury. The American Academy of Obstetrics and Gynecology (ACOG) defines this event as evidence of metabolic acidosis (ph < 7 and base deficit > 12) in fetal umbilical cord ar-terial blood obtained at the delivery.5 Ad-ditionally, term newborn infants with evi-dence of an acute intrapartum insult and/or difficult transition from fetal to neo-natal life requiring resuscitation at birth such as placental abruption, hemorrhage, prolapsed umbilical cord, abnormal fetal heart rate tracings as well as abnormal Apgar scores and need for resuscitation after birth, should be carefully considered in establishing hypoxic-ischemic etiology of encephalopathy. Evidence of multior-gan failure in infants with severe encepha-lopathy is helpful and used as additional diagnostic criteria in the recognition of the hypoxic-ischemic insult, however it is not specific or essential.

Mechanism of Injury: The underlying mechanism for perinatal brain injury is an interruption of placen-tal blood flow followed by impaired gas exchange that leads to cerebral deficits in oxygen and substrates.3 Infant gestational age, as well as the nature, severity and duration of the hypoxic-ischemic insult will determine the extent and locations of neuronal injury. Initial mechanisms of fetal defense against hypoxia-ischemia, such as peripheral vasoconstriction and redistribution of blood flow to the brain and heart at the expense of visceral organs and skeletal muscle are over-whelmed with continued exposure to hypoxia-ischemia.

Advances in neuroimaging such as magnetic resonance imaging (MRI) using diffusion weighted and diffusion tensor imaging allow greater delineation of brain tissue, including detailed integrative neu-ronal pathways. Therefore, MRI is a sensi-tive method for evaluation of brain injury patterns, determination of timing of injury and prognostication in newborn infants with encephalopathy.6,7 The predominant pattern of brain injury found to be most strongly associated with long-term unfa-vorable neurologic outcome, greater than the severity of injury in any given region including the parasagittal watershed area, is injury to the basal ganglia and thalamus. Abnormal signal intensity in the posterior limb of the internal capsule was also a strong predictor of impaired neurodevelopment by 12 months of age. Magnetic resonance spectroscopy (MRS), either proton or phosphorus variety, of-fers complementary diagnostic value in evaluation of cerebral tissue metabolic status providing more specific and sensi-tive determination of neurodevelopmen-tal outcome than MRI and can be useful in

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early clinical man-agement decisions in infants with severe neonatal encephalopathy.8

Clinical Presentation:Clinical presentation of infants with neonatal encephalopathy after perinatal asphyxia can range from a subtle hy-peralert state or mild hypotonia, to severe symptoms of stupor, coma, and profound hypotonia and absent reflexes. Clinically subtle signs and symptoms of neonatal encephalopathy, as well as difficulties in neonatal seizure recognition may lead to a delay in the diagnosis and proper neuroprotective cooling intervention. Clinical guidelines identified in Table 1 and 2 may be useful for the clinician in the Delivery Room or the Nursery. The use of Cerebral Function Monitor (CFM), a single or double channel amplitude-integrated EEG (aEEG), can provide the clinician with a method to identify the presence of brain injury and determine the severity of encephalopathy and outcome.6,9 Addition-ally, continuous CFM/aEEG monitoring may be helpful to monitor for seizure activity during the 72 hours of the cooling process, to identify responses to antiepi-leptic drugs, and to identify improvement in brain function over time as the sever-ity of clinical encephalopathy has been shown to be a strong predictor of neuro-developmental outcome. Infants without clinical signs of moderate encephalopathy for less than 5 days, will generally have a normal outcome. Persistence of encepha-lopathy for greater than 7 days or abnor-mal cerebral background activity on aEEG/conventional EEG is frequently associated with later neurologic impairments.

Delivery Room Management: The treatment of depressed infants after intrapartum asphyxia includes resuscita-tion in the delivery room (DR) that follows the latest Neonatal Resuscitation Program (NRP) guidelines.9 Indeed, conditions that delay the recovery from the primary phase of brain injury such as hypoxia,

hypoglycemia, hypotension, and blood loss/anemia must be corrected as soon as possible, see Guide for Delivery Room Management, Table 1. Both hypothermia (cold stress) and hyperthermia, which has been shown to be associated with worsening brain injury, should be avoided. Once adequate ventilation and circulation is established, newborns with suspected hypoxic-ischemic encephalopathy should be transferred urgently to a Neonatal Intensive Care Unit (NICU) capable of initiation of hypothermia treatment. At the Children’s Hospital of Richmond at VCU Hypothermia Center, we recom-mend that referring physicians provide: 1) adequate oxygenation and ventilation as wide changes in pCO2 can affect cerebral blood flow, 2) maintaining the arterial blood pressure within the normal range for gestational and chronological age and 3) switching off the radiant warmer to achieve passive hypothermia while main-taining core temperatures between 35 0C + 0.5 0C in preparation for the transport. Furthermore, seizures are very common among infants with neonatal encepha-lopathy due to hypoxia-ischemia. Infants with Sarnat stage 2 encephalopathy who present with clinical seizures have a 50% risk of subsequent neurological impair-ment.3 Additionally, prolonged seizures may exacerbate brain injury initiated by the precipitating acute hypoxic-ischemic injury. Therefore, treatment of neona-tal seizures early with phenobarbital is recommended to reduce the possibility of further brain injury.

Therapeutic Hypothermia: Therapeutic hypothermia aims to lower the temperature of the vulnerable deep brain structure to 32o C-34o C and derives most of its protective effect from a graded reduction in metabolism, decreased en-ergy utilization, reduced excitotoxic amino acid accumulation, reduced production of nitric oxide, suppressed free radical activ-ity, suppression of the inflammatory cas-cade and inhibition of neural apoptosis. Two methods of hypothermia therapy are currently available for the neonate

with encephalopathy: whole-body cooling (placing the infant on the cooling blanket or mattress circulated with coolant fluid to maintain esophageal/rectal tempera-ture of 330 C -340C) and selective head cooling (circulating cold water in a cap fitted around the head with mild body hypothermia to 340 C -350C rectal temper-ature). To date, both methods of thera-peutic hypothermia have been equally effective.

CHoR at VCUAt the CHoR Hypothermia Program a multidisciplinary team lead by the Neo-natologist provides whole body cooling with continuous video EEG monitoring in conjunction with a consulting team that includes pediatric neurology pediatric cardiology and pediatric nephrology, see selection criteria Table 2. We recommend that all infants who undergo cooling or therapeutic hypothermia are followed after discharge in the Children’s Hospital of Richmond at VCU Neonatal Continuing Care Program or assist families to obtain this care from their referral center to support their ongoing neurodevelopment. The Children’s Hospital of Richmond at VCU NICU Hypothermia Center can be contacted at 804-828-9956 for referral or case consultation.

Conclusion:Neonatal hypothermia can be a lifesav-ing treatment for the infant with HIE. Although research is ongoing to identify long term population responses, neonatal hypothermia therapy currently is the only evidenced based treatment for infants at risk for neonatal encephalopathy.1 Given the current 6 hour window of recognition needed to initiate treatment it is impor-tant for providers to quickly and accurate-ly assess potential infants as candidates to receive this therapeutic intervention for improved neurologic outcome.

For referral or case consultation, contact The Children’s Hospital of Richmond

at VCU NICU Hypothermia Center 804-828-9956

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17VIRGINIA•PEDIATRICS

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Table 1. Guide for the Delivery Room Management of Depressed Infants at Risk for the Neonatal Encephalopathy after Perinatal Hypoxic-Ischemic Insult.

References

1. Shankaran S, Pappas A, McDonald SA, et al. Child-hood outcomes after hypothermia for neonatal en-cephalopathy. NEJM 2012 May 31;366(22):2085-92.

2. Wyatt JS, Gluckman PD, LIU PY, et al. Determinants of outcomes after head cooling for neonatal encepha-lopathy. Pediatrics 2007; 119: 912-213. Perlman JM. Brain injury in the term infant. Semin Perinatol 2004; 28: 415-24

4. Pin TW, Eldridge B, Galea MP. A review of develop-mental outcome of term infants with post-asphyxia neonatal encephalopathy. Eur J Paediatr Neurol 2009; 13: 613-18.

5. Hankins and Speer M. Defining the pathogenesis and pathophysiology of neonatal encephalopathy and cerebral palsy. Am College of Obstetricians and Gy-necologist. High Risk Obstetrics Series: Expert Review 2003 102 (3) 628-636.

6. Dag Y, Firat AK, et al. Clinical outcomes of neonatal hypoxic ischemic encephalopathy evaluated with diffusion-weighted magnetic resonance imaging.Diagn Interv Radiol 2006; 12:109-14.

7. Miller SP, Ramaswamy V, et al. Patterns of brain injury in term neonatal encephalopathy. J Pediatr 2005; 146: 453-60.

8. Thayyil S, Chandrasekaran M, et al. Cerebral magnetic resonance biomarkers for predicting neuro-developmental outcome following encephalopathy: a metaanalysis. Pediatrics 2010; 125(2):382-395.

9. The American Academy of Pediatrics, The American Heart Association: J.Kattwinkel. Textbook of Neonatal Resuscitation, 6th edition, 2010.

10. Wachtel E and Hendricks-Muñoz KD. Current Management of the Infant who presents with neona-tal encephalopathy. Current Problems in Pediatric and Adolescent Health Care, 2011 May-Jun;41(5):132-153

Table 2. A guide for selecting patients eligible for cooling Inclusion Criteria:

A. Infants >35 weeks gestation with ONE of the following:

• Apgar score of < 5 at 10 minutes after birth • Continued need for resuscitation, including endotracheal or

mask ventilation, at 10 minutes after birth • Acidosis defined as either umbilical cord pH or any arterial pH

within 60 minutes of birth less than 7.00 • Base Deficit > 16 mmol/L in umbilical cord blood sample or

any blood sample within 60 minutes of birth (arterial or venous blood)

If the infant meets criteria A.

then assess for neurological abnormality: B. Moderate to severe encephalopathy (Sarnat 2 or 3) consisting of an altered state of consciousness (as shown by lethargy, stupor, or coma) and at least one or more of the following:

• Hypotonia • Abnormal reflexes including oculomotor or pupillary

Abnormalities • Absent or weak suck

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“It's not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change.”--Charles Darwin

An evolution of the pediatric workforce is underway that demands innovation, flexibility, work-life balance, and diversity in academic and practice options. But the structure of the pediatric workforce as it adapts and evolves may not be aligned with the changing nature and needs of the healthcare delivery system. Workforce shortages present a significant challenge. Will these provider gaps lead to the devel-opment of innovative workforce models that leverage technology, long-distance medicine, and the use of non-physician professionals to fill critical care gaps? Or, will there be a persistent maldistribution and shortage of pediatric providers that lead to worsening health outcomes for children?

I wrote this introductory paragraph a few years back as president of the VA-AAP. Nothing has changed; in fact, the situa-tion has likely worsened. An AAP advisory committee 5 years ago stated, “The cur-rent pediatric workforce is not meeting the primary care, subspecialty, or surgi-cal needs to provide quality health care for our country’s children. Key reasons include the geographic maldistribution of physicians, an increase in the number of chronically ill children, and an increasingly diverse patient population.”

Access to care in Virginia remains an is-sue. Medicaid expansion in Virginia is still being actively debated. While the Medic-aid-to-Medicare fee rate ratio in Virginia was .74 with a widening gap, heightening concerns beg whether the short- term

(2 year) Medicaid fee increase will be sufficient to improve access. Workforce adequacy and future supply, not only in subspecialty areas, but in general pediat-rics is now in question. And, funding from our state and the federal government for medical education and GME is truly at risk.

The AAP Committee on Pediatric Work-force (COPW) launched the State Phy-sician Workforce Survey earlier this summer with Virginia being the first state to be surveyed. The survey was designed to help the Chapter better understand its current pediatrician workforce; and to have the insights, information and data that will help us effectively advocate, on a variety of topics, on behalf of our patients and families and our profession. The re-mainder of District IV (NC, SC, TN, KY) will be surveyed in the near future and the combined results will be very telling. We hear statements all the time regard-ing workforce shortages and difficulty accessing pediatric subspecialists. Figure 1. shows the data from Pletcher et al (J Pediatr, 2010;156:1011-1015).

(See Figure 1 on page 20)

The supply of some pediatric subspecial-ists is inadequate to meet the health needs of children. For most subspecialties, there are 100,000-200,000 children per provider across hospital referral regions. Most pediatric subspecialists practice in academic settings, leaving many rural areas and regions at some distance from academic centers without any subspecial-ists. It should be no surprise that approxi-mately 1 in 3 children must travel 40 miles or more to receive care from a pediatri-

cian certified in adolescent medicine, developmental behavioral pediatrics, neurodevelopment disabilities, pulmonol-ogy, emergency medicine, nephrology, and rheumatology.

Even in regions with subspecialists, fami-lies often face long wait times to obtain an appointment. In a 2010 national survey of children’s hospitals, the average wait time to see a pediatric neurologist was 9 weeks (currently at CHoR at VCU, < 3 weeks). An appointment with a developmental- behavioral pediatrician requires a wait of 13 weeks (currently at CHoR at VCU, 1-5 weeks). 68% of primary care pediatricians practicing in rural communities and 49 percent of non-rural pediatricians re-ported dissatisfaction with waiting times for subspecialists.

(See Figure 3 on page 20)

And there are disparities in referrals as well. A recent GAO report found that 84% of physicians treating children insured by Medicaid or CHIP had great or some difficulty making specialty referrals; 26% of physicians treating privately insured children had great or some difficulty mak-ing specialty referrals. “For all children, physicians had the most difficulty making referrals for mental health, dermatology, and neurology.”

This is not simply a Richmond problem, or a Virginia problem; this is a national prob-lem. Federal caps on residency slots (all residencies) already have exacerbated the looming physician shortage—expected to reach 130,000 by 2025—and have kept hundreds of U.S. medical school graduates from completing their training and inter-national medical graduates from entering

Pediatric Workforce Shortages: Yes, Richmond (and Washington), We Have a Problem

Objective: The reader will be able to discuss the depth and breadth of the Pediatric workforce shortages and the possible solutions of the national problem.ACGME Competencies: Professional; Systems-based Practice.

Bill Moskowitz, MD, FAAP, FACC, FSCAI, member COPWProfessor, Pediatrics and MedicineChair, Pediatric CardiologyVice Chair Clinical Operations, Department of PediatricsDirector, Pediatric Cardiac Catheterization LaboratoryThe Children's Hospital of Richmond at VCUVA-AAP Immediate Past President

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the nation's physician workforce. Last year more than 500 U.S. medical school gradu-ates were not matched to a residency program, a number that is expected to grow each year.

Many pediatric subspecialties report very low numbers of physicians currently being trained. The ABP has reported that there are less than 3 dozen first year fellows in training in adolescent medicine, develop-mental behavioral pediatrics, and pedi-atric rheumatology. The crisis is further compounded by the aging and anticipated retirement of our existing pediatric sub-specialty workforce. With the exception of those specializing in emergency medicine the mean age of pediatric subspecialists exceeds 50 years. Job vacancies (active recruitments) lasting more than one year are common for pediatric neurology, endocrinology, pulmonology, gastroen-terology, and developmental-behavioral pediatrics.

As the workforce continues to shrink, de-mand for pediatric subspecialty care has reached unprecedented levels. The pedi-atric population has experienced dramatic increases in the incidence and prevalence of millennial morbidities -(e.g., mental health, obesity, hypertension, complex patients) and an increased proportion of children with special healthcare needs (technology dependence). The propor-tion of visits to pediatric subspecialists increased significantly from 1980 to 2000, from 1.6 percent to 4.5 percent. The per-cent of pediatric outpatient visits resulting in referral increased from 3.5% in 1999 to 6.1% in 2007 (Merline et al., 2010).

Short-term solutions to shortage of pediatric subspecialists Primary care pediatricians must become comfortable with managing more chronic patients themselves. Residency programs should increase training in chronic condi-tions and their management to enable and empower PCP practices. At a mini-mum, this would assist them in increasing

“triage” of who they send to subspecial-ists and who they keep to manage them-selves. Subspecialists should educate PCPs by providing CME meetings in their local area as well as disseminating diagnostic and care pathways used at the academic medical centers so that the PCPs can try them first, before referring to the subspe-cialist.

Changes in health care policy, including GME funding and reimbursementThe Josiah Macy Jr. Foundation's 2009 Report stated that the graduate medi-cal education (GME) system needs to be better aligned to meet the physician workforce needs of the country. “At pres-ent, most hospitals base decisions about the specialty residency programs they will support and the number of residents they plan to train on the specialty needs of hospitalized patients rather than on the needs of patients from their communi-ties who may lack the care they need.” The AAP Policy Statement: “Financing Graduate Medical Education to Meet the Needs of Children and the Future Pedia-trician Workforce” (Pediatrics 2008;121: 855–861) makes many recommendations and raises several questions: How should GME change to ensure adequate supply of pediatricians of all types? How should healthcare financing be structured to en-sure an adequate supply of pediatric pri-mary care physicians? Health care policy must address geographic maldistribution of physicians and mid-level providers, and include tools (telehealth) and incentives.

Increasing the number of GME slots to match the increase in US medical school output is an important but only a par-tial solution. Children’s Hospitals GME should be funded in a manner that does not require an annual appropriation; and specific workforce needs must have a greater weight in the determination of GME funding decisions. There are several options: 1) Increase Federal funding; Fed-eral funders need to be more proscriptive of the type of providers needed; 2) Create

an all-payer system, but who will direct the allocations?; 3) Cap GME specialties felt to be in excess, and increase slots for those we need (more PCPs, but which specialties?); and 4) Un-link GME slots from hospitals, so that pediatric training in ambulatory settings can increase.

Has the time come to consider unlinking pediatric subspecialty practice from aca-demic medical centers? Certainly many if not most pediatric academic medical centers have multispecialty outreach or satellite clinics increasing access to medi-cal and surgical subspecialties. In the past decade, the use of telemedicine to deliver subspecialty consultations to remote communities has been rapidly increasing. However, despite the increased adoption of telemedicine, several obstacles remain. Should we consider fast-tracking future pediatric subspecialists? The NAS (Next Accreditation System) from the ACGME has been rolled out with milestones for the assessment of resident competence using entrustable professional activities (EPAs). This may provide some informa-tion on the feasibility of shortening the pediatric residency period for those with plans to continue onto subspecialty training.

And, we need to address the “longer training in order to make less money” reality for those “hard to access” special-ties recognized nationally with shortages of providers. The mean debt burden of pediatric residents currently is $180,000. This makes the financial implications of choosing a career in pediatrics signifi-cant. An increasing number of graduating pediatric residents are opting to enter fellowship and although the choice is clearly based on many factors (prestige, intellectual stimulation, interest in specific diseases or organ systems, the desire to work with certain patient populations, lifestyle issues, and research and academ-ic aspirations), economic considerations are certainly important.

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On July 11, 2013, the Senate Appropria-tions Committee voted 16-14 to approve a FY2014 Labor-HHS-Education spending bill that would provide $5 million for the Pediatric Subspecialty Loan Repayment Program. This marks the first time since the program’s creation that funding for the program has been included in a Congressional appropriation bill. The House and Senate remain far apart on topline funding numbers for the health and education programs, so prospects for a compromise bill passed by both cham-bers remain uncertain. With a $5 million appropriation, the program would only be able to accommodate 64 initial two-year fellowships. The President has included the program in his proposed budget each of the last two years.

The program, Section 775 of the Public Health Service Act (PHSA), was initially authorized by the Affordable Care Act. It is part of Title VII of the PHSA, which provides workforce funding for health professions. The Title VII programs are administered by the Health Resources and Services Administration (HRSA). The law allows for up to $35,000 in loan repay-ment per year for up to three years for pediatric subspecialists or child mental health providers who agree to practice in underserved areas. By fully funding this authorization, more graduating pediatri-cians and mental and behavioral health professionals will choose to train and practice in these specialties and under-served areas, and more children will be able to access the care they need. If the fiscal year ends with a straight continuing resolution that carries current-year fund-ing into next year, the program will unfor-tunately remain unfunded in FY2014.

Figure 1

Figure 3

“Americans can be relied upon to do the right thing, when they have exhausted the alternatives.”--Sir Winston Churchill

Page 21: Virginia Pediatrics Fall 2013 Newsletter - American Academy of Pediatrics Virginia Chapter

21VIRGINIA•PEDIATRICSEarly Identification of Congenital Ear Deformities Allows for Nonsurgical Correction

Objective: To explain VCU’s protocol for identifying ear deformities in the newborn nursery, so pediatric ENT can apply ear splint for nonsurgical correction.ACGME Competencies: Patient Care, Systems-based practice.

Congenital external ear deformities are characterized as having a normal chon-drocutaneous component, that is, no deficiency of skin or cartilage, with an abnormal architecture. Most commonly, the helix and antihelix are affected, as is the conchal bowl. Surgical repair is the standard treatment for these auricular deformities at a time when the ear has completed 85-90% of its growth, typically just prior to school age. Several reports, first in the 1980’s and mostly in the Japa-nese and British literature, have shown that molding the deformed ear, especially if started within the first three days of birth, can lead to satisfactory results and obviate the need for surgical repair. Estab-lishing guidelines for early identification of congenital auricular deformities in order to begin molding therapy within three days of birth may significantly shorten the required duration of molding therapy and decrease the need for surgical repair.

Ear deformities amenable to nonsurgical correction with a simple ear splint (Figure 1), are those that can be reshaped into the correct position using digital pressure. These include Stahl’s ears (Figure 2A), cup ears (Figure 2B), and prominent ears (Fig-ure 2C). Nonsurgical correction of residual Stahl’s ear and cup ear does not seem to be effective beyond the neonatal period; however, prominent ears may be correct-ed nonsurgically up to 6 months of age, albeit less reliably and with longer periods of splinting. During the first three days of life, auricular cartilage is particularly soft and lacks elasticity; this is thought to be due to circulating maternal estrogens that rapidly decline after three days. During my training at the Mayo Clinic, I had estab-lished a protocol whereby the newborn hearing screeners were trained to identify ear deformities, leading them to refer them to otolaryngology for consultation and potential treatment. However, here at VCU, the hearing screening is per-

formed by patient care assistants instead of audiologists and audiology technicians with whom I worked before; patient care assistants cannot officially assess patients. As I had the desire to be able to offer this service to our patients, I met with the director of our newborn nursery, Dr. Linda Meloy, who was equally enthusiastic about starting this program, to find the most efficient course of action in identify-ing these. She suggested having the pe-diatrics service do the assessments, and make the referrals to us. We have been providing this service for approximately 6 months now, and usually pick up one or two newborns a week who are appropri-ate candidates for ear splinting therapy to correct their ear deformities.

Most of the deformities we see are cup or Stahl’s ears, as prominent ears are harder to see in the newborn period, and be-come more noticeable over the first year of life. There has been a large report out of Japan following 1000 newborns with ear deformities to understand the natural course of these deformities. They found that, though approximately 85% of cup ears and Stahl’s ears may self-correct over time, it is impossible to predict which 15% will not; as such, they concluded therapy should be initiated on all deformities, if the families are interested, as it is mini-mal risk. Our experience has been that splinting is only required for 10-14 days if started within the first three days of life, and we have had excellent results (before and after examples shown in Figures 3 and 4). Most infants only require the initial period of splinting. Few may require a second round for any residual deformity. The splint we use is made of a 24-gauge wire threaded through a 6 or 8 French silicone feeding tube. The ends are taped off with Steri-strips to prevent the wire from poking out. It is then attached to the ear after cleaning the ear with an alcohol pad to remove any oils. Mastisol is then

placed over the surface of the ear, and the splint is bent to fit within the helical rim of the ear until the desired shape is achieved (Figure 1). It is secured with Steri-strips, followed by Dermabond to make it water-proof. They tend to stay in place for the 10-14 day time period needed using this method.

We have not seen any skin irritation prob-lems, and parents have been quite happy with the results. It is rare that parents refuse the service. The pediatrics service is very efficient in consulting us, and we get the splints on prior to discharge from the hospital, and make every effort not to hold up discharge. In general, 24 hours is given prior to placing the consult to give the ears time to see if any self-correction will occur after delivery. A follow-up ap-pointment is made for 10-14 days from discharge, and the splints removed at that time. In general, full correction is achieved, and parents are told to return to clinic as needed if they see recurrence. We do not have long-term follow-up as of yet, and have found that parents are reluctant to return to clinic every few months if they are happy with the way the ears are looking. As such, we leave any further visits up to the parents.

Overall, we have found an efficient way to identify and correct many external ear deformities. External ear malformations in which components are physically missing, such as in microtia, are not amenable to this treatment. These would require surgical intervention for treatment if desired, once the child is old enough (usually age 6-8).

If interested in further information regarding ear deformities and potential treatment of them, please contact Dr. Raj Petersson at [email protected] or 804-828-3996.

Rajanya S. Petersson, MD Pediatric OtolaryngologyChildren’s Hospital of RichmondVirginia Commonwealth University Medical Center

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Figure 3

22VIRGINIA•PEDIATRICSFigure 1

Figure 4

Figure 2

Page 23: Virginia Pediatrics Fall 2013 Newsletter - American Academy of Pediatrics Virginia Chapter

VA-AAP Newsletter Registration and Evaluation Form (Fall 2013)

You have the opportunity to claim up to 2 AMA PRA Category 1 Credit(s) ™.

To claim CME credit, please complete the survey below.

NAME: __________________________________________________________________________________________

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For this activity, how many hours of CME are you claiming? ___________ (Max. ____ hours)

As a result of reading the articles, will you make any changes in your practice? □ Yes □ No

Please list at least 3 strategies that you plan to implement as a result of reading the articles? (answer required for credit)

1. _______________________________________________________________________________________________

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2. _______________________________________________________________________________________________

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3. _______________________________________________________________________________________________

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If you will not make any practice changes, did this activity reinforce your current practice of pediatrics? Please explain:

How could this activity be improved?

Future Topic Requests (optional):

Excellent Average Poor____________________________________________________________________________________Overall, how would you rate this activity? 5 4 3 2 1

This CME activity will expire on October 31st, 2014.Please send form to: Rosalind Jenkins, c/o CHKD, 601 Children’s Lane, Norfolk, VA 23507Please allow up to 8 weeks to receive your certificate.

Page 24: Virginia Pediatrics Fall 2013 Newsletter - American Academy of Pediatrics Virginia Chapter

Delegate Thomas A. Greason Awarded VA-AAP Child Advocate Award!The Virginia Chapter of the American Academy of Pediatrics awarded Delegate Thomas Greason the Virginia Chapter, American Acad-emy of Pediatrics Child Health Advocate Award for 2013. This prestigious award is bestowed annually on state and local advocates and government officials for their outstanding contributions to children’s health and safety.

Delegate Greason was presented the VA-AAP Child Advocate Award during the Donald W. Lewis Pediatric Update 2013 on Saturday, September 21, 2013 in Williamsburg. We applaud Delegate Greason’s on his leadership with the Autism Bill in 2011 and the Epineph-rine Bill in 2012. These bills provide valuable resources for our patients and pediatricians.

VA- AAP Poster Symposium WinnersAs part of the Donald W. Lewis Pediatric Update 2013, the Virginia State Chapter of the AAP hosted the 2nd Annual Poster Symposium. The symposium was held in conjunction with the Chapter Busi-ness meeting on Saturday, September 21, 2013. Nine (9) posters were submitted by students and residents in the Departments of Pediatrics at Carilion, EVMS/CHKD, INOVA, and VCU.

The winning poster was submitted by Jennifer Webster, DO from the Department of Pediatrics at INOVA. The study was entitled: “Utility of laboratory work, imaging, and EGD in pediatric popula-tions with chronic abdominal pain: A retrospective study.”

Second place was awarded to Joshua Jun, a medical student at EVMS who participated in the 2013 Summer Scholars’ Program sponsored by the Department of Pediatrics at EVMS and CHKD. His abstract was entitled, “Cystic Fibrosis Related Diabetes.”

The final award (3rd Place) was given to Frank Raucci, MD , a resident in the Department of Pediatrics at UVA. His poster was entitled “Predicting Economic and Medical Outcomes Based on RACHS-1 Classification in Pediatric Admission.”

Each Department of Pediatrics will be provided with funds donated in the name of the primary author to help stimu-late and continue pediatric resident research projects.

Webinar Slides & AudioMultidisciplinary Guidelines for the Care of Late Preterm Infants

Our August 8 webinar spotlighted the "Multidisciplinary Guidelines for the Care of Late Preterm Infants," an evidence-based ap-proach to providing safe and supportive care for this vulnerable group. Presenter Raylene Phillips, MD, IBCLC, FAAP, reviewed this new resource and described how its use will lead to improved outcomes for late preterm infants by providing guidance, educa-tion, and support for families and the healthcare providers who care for them. Make sure to share these slides and audio, now accessible online as a resource for parents and other advocates, professionals in the field of infant health, and physicians and clinicians providing care to premature infants and their families.

Dr. William “Biff” Rees, VA-AAP President, Barbara Kahler, VA-AAP Vice President and Jane Davis, VA-AAP Executive Director accept Special Achievement Award during District IV meeting in August.

Dr. William “Biff” Rees, President Virginia Chapter presents the 2013 VA-AAP Child Advocate Award to

Delegate Thomas A. Greason, Republican from 32nd District County of Loudoun (part).

The winning poster was submitted by Jennifer Webster, DO, INOVA. Second place was awarded to Joshua Jun, EVMS and the final award (3rd Place) was given to Frank Raucci, MD, UVA (absent – photo below). Awards were presented by Drs. C.W. Gowen, Chair, Department of Pediatrics, EVMS and “Biff” Rees, MD, President Virginia Chapter, AAP.


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