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Pediatric
Sept/Oct
2012
Perspectives
Medical Perspectives for Indiana’s Children
Numbers to Know
One-Call Transfer (Newborn
and Pediatric Transport)
317.338.5000
Gastroesophageal Reflux Concerns
in Infants
By Cheryl Little, MD
Physician Referral Line
866.788.3627
Irritability and spitting up are common to virtually every
infant at some time in their first months of life. These
symptoms are occasionally first indications of more
serious conditions of esophagitis resulting from pathologic
gastroesophageal reflux (GER).
Hospitalist on Call
317.338.3550 pager ID 8564
Hilbert Pediatric Emergency
Department 317.338.4366
Administrator:
Anne Coleman, RN
317.415.7777
Physician Liaison:
Kelly Volk
317.313.7303
Please send your comments,
questions or suggestions
for future issues of
Pediatric Perspectives
to Hollie Adams at
[email protected].
Infants presenting with reflux symptoms may be treated
initially with one or more standard approaches:
Dr. Little is a board
certified pediatric
gastroenterologist.
She completed
her pediatric
gastroenterology
fellowship at
Walter Reed Army
Medical Center in
Washington, DC.
She completed
her residency
and internship at
Letterman Army
Medical Center in
San Francisco. She is
currently accepting
new patients at the
Peyton Manning
Children’s Hospital
in Indianapolis. For
patient referrals, call
(317) 338-9450.
• Thickening the feeding with rice cereal or over-thecounter thickeners
• Positioning the baby upright for 30 minutes after feeding
• Smaller and more frequent feedings
• Prescription H2 blockers such as Zantac, to reduce acid
content
If these treatments do not improve the symptoms within
a few weeks, a referral to a pediatric gastroenterologist is
appropriate.
There are several key indicators that an infant is suffering
from something more serious than the degree of
gastroesophageal reflux common to many babies. When
these indicators are present, a referral is also appropriate:
• Refusal to feed
• Arching or crying when feeding
• Vomiting or spitting up 1 – 2 hours post-feeding
• Poor weight gain or weight loss
• Acute dehydration
• Malnutrition
• Blood in vomit or stool
• Bile in vomit
Continued on page 6
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Dear Colleagues,
Peyton Manning Children’s Hospital at St.Vincent welcomes the following pediatric specialists to
our health ministry:
Anne Coleman, RN
Administrator
Peyton Manning
Children’s Hospital at
St.Vincent
and St.Vincent
Women’s Hospital
Paul W. Halczenko, MD, Pediatric Intensivist, joins us from Florida Pediatrics Associates in
Orlando. He is a graduate of Pennsylvania State University College of Medicine. Paul completed a
combined internal medicine-pediatrics residency at the University of Rochester and a combined
adult-pediatric critical care fellowship at the University of Pittsburgh Medical Center. 317.338.1433
Babak Salimi, MD, Pediatric Intensivist, is a graduate of St. George’s School of Medicine in
Grenada, West Indies. He earned a master’s degree from Northeastern Illinois University in Chicago
in biology/immunology. Babak completed his pediatric critical care fellowship at Kosair Children’s
Hospital – University of Louisville, Louisville, KY. He completed his pediatric residency at Riley
Children’s Hospital in Indianapolis. 317.338.1433
Cheryl Little, MD, Pediatric Gastroenterologist, has joined the practice of Pediatric Gastroenterology Center. She is a
graduate of the Medical College of Ohio at Toledo, and completed her fellowship at Walter Reed Army Medical Center,
Washington, DC. Cheryl is board certified in pediatric GI, and her practice focus is functional abdominal disorders and
liver disease. 317.338.9450
Jared Mott, DO, Pediatric Neurologist, is a recent clinical neurophysiology (epilepsy) fellow at the University of
Michigan, with prior fellowship in pediatric neurology at U of M. He completed his pediatric residency at SUNY Upstate
Medical University in Syracuse, NY. Jared is a graduate of Touro University College of Osteopathic Medicine (TUCOM) in
Vallejo, CA. He has joined the Pediatric Neurology practice with Drs. Lisa McGuire and James Pappas. 317.338.1600
Amanda Paschal, MSN, RN, CPNP, CPON, CPN, Pediatric Oncology/Hematology, has joined Children’s Center for
Cancer and Blood Diseases at Peyton Manning Children’s Hospital at St.Vincent. Amanda is a board certified pediatric
nurse practitioner; she holds a master’s degree in nursing from Indiana University. 317.338.4673
Jonathan H. Wilhite, MD, Pediatric Orthopedic Surgeon, returns to Indiana from his pediatric orthopedic surgery
fellowship at Orlando Health’s Arnold Palmer Hospital for Children in Orlando. He is a graduate of the Indiana University
School of Medicine, where he completed his surgical residency program. Jonathan also received a master’s degree in
exercise physiology from IU-Bloomington. He has joined the practice of Pediatric Orthopaedic Surgeons of Indiana.
317.338.7674
Be sure to read the information on the back cover about the upcoming Fall Pediatric CME conference on Oct. 3. Don’t
miss this great opportunity to learn and earn CME credits.
This Issue
The issue of Pediatric Perspectives focuses on several medical problems common to infants and toddlers. Our pediatric
specialists are experts in their field and work diligently to provide the highest quality individualized patient care.
Thank you for the trust you place in us as your partner in pediatric care.
Pediatric Perspectives
September/October 2012
2
866.788.3627
Asthma in Infancy: Managing the Uncertainty Principle
By Dr. Olatunji Williams
Dr. Williams will present “Asthma Management” at the annual pediatric conference on Oct. 3.
Although asthma can present in infancy, confirming the diagnosis is difficult in infants and toddlers,
as the majority of children will experience resolution of their symptoms by 3–4 years of age. The
reasons for this are not fully known but are likely related to the relatively smaller airways of infants
in comparison to older children and their developing immune system. Recurrent coughing and
wheezing in the first year of life is one of the most common reasons for referral of infants to a
pediatric pulmonologist. And with good reason, because although asthma does present in infancy
so does a myriad of “asthma mimics” such as congenital airway anomalies, chronic aspiration and
severe gastroesophageal reflux disease.
Peer reviewed research studies (most notably the Tucson Children’s Respiratory Study, University of Arizona, 2002)
have indicated positive predictors or risk factors for the development of asthma in young children presenting with
recurrent coughing in infancy. The positive predictors of asthma, with the first two being the most commonly relied
upon, are:
• A family history in first-degree relatives (parents or siblings)
• Another allergy, with eczema being the greatest risk factor
• Eosinophilia, a marker for atopic diseases, as identified by blood test
When evaluating young children with recurrent coughing and wheezing who do not have these positive risk factors for
asthma, it is prudent to consider asthma mimics early.
Treatment of symptoms is the priority for any child presenting with respiratory distress. For recurrent coughing
and wheezing, the most common treatment is albuterol as needed to relax the airways and relieve symptoms. This
happens also to be the most common treatment for asthma. If a child does not improve with treatment, further
diagnostic evaluation is required. An infant or toddler should never be described as having “poorly controlled asthma”
without further evaluation.
Referral to a pediatric pulmonologist should be considered for the following:
• A child less than 12 months old who does not respond promptly to traditional treatment for wheezing
• A child has recurrent symptoms in the absence of any of the asthma risk factors listed above
• Recurrent respiratory symptoms starting at birth or in the first month of life
Dr. Williams is a board certified pediatric pulmonologist. He completed his pediatric pulmonology fellowship at Texas
Children’s Hospital, Baylor College of Medicine in Houston. His pediatric residency was at The Children’s Hospital –
University of Oklahoma Medical Center, Oklahoma City, where he was chief resident. He is currently accepting new
patients at the Peyton Manning Children’s Hospital in Indianapolis.
For patient referrals or consultations, call 317-338-2825.
Pediatric Perspectives
September/October 2012
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866.788.3627
Allergies in Early Childhood
What About Probiotics?
By Frank Wu, MD
For the estimated more than 23 million Americans who
have some type of allergy, many allergies first appeared
during infancy or childhood.
The Atopic (Allergic) March
Allergists refer to the “Atopic (or Allergic) March,” which
describes the natural or typical progression of allergic
diseases that often begin in early childhood. These include atopic dermatitis
(eczema), food allergies, allergic rhinitis (hay fever), and asthma. Eczema and
food allergies typically appear first, often beginning the first three to 12 months
of life, and reaching their highest prevalence during the first two years of life.
They often precede the development of allergic rhinitis, the most common of all
childhood allergies, and asthma. Eczema and certain food allergies are often
outgrown or show improvement during the preschool years. Allergic rhinitis,
other food allergies, and allergy-associated asthma tend to persist, although
this type of asthma may improve. The severity of allergies in early childhood
may predict the persistence and progression of allergy in later life.
Identifying Triggers
Identifying the patient’s allergy symptom triggers, usually using skin prick
testing, is most important to determining effective treatment. Symptoms
may be diminished simply by avoiding or reducing exposure to the identified
triggers, whether they are certain foods, environmental exposure (e.g.,
mold, dust, pet dander, pollen), drugs or topical substances.
Current medications are highly effective in treating allergy symptoms.
Despite the best medication and environmental control, sometimes patients
need immunotherapy (allergy shots). If needed, treatment with allergy
shots is recommended for children ages six and older.
When to Refer
Early intervention may offer better outcomes for children with allergies.
An allergist/immunologist can provide expert consultation for a number of
diseases and conditions, which can be divided into two categories:
• Allergies and allergy-associated diseases commonly followed by primary
care physicians or other specialists. These include asthma, rhinitis/
conjunctivitis, chronic sinusitis, urticaria and angioedema, and atopic
dermatitis (eczema).
• Conditions in which an allergy or immunology consultation is usually necessary
for definitive diagnosis and treatment. These include anaphylaxis, food/drug/
latex allergy, and frequent infections in which immune deficiency is suspected.
Dr. Wu completed his specialty training at the National Jewish Hospital for Allergy and
Clinical Immunology, University of Colorado at Denver. He is a graduate of the College
of Medicine, National Taiwan University, and completed his internship at Cook County
Hospital in Chicago, and his residency at the University of Chicago. He is a fellow of the
American Academy of Allergy, Asthma and Immunology and the American College of
Allergy, Asthma and Immunology. For patient referrals, call 317.872.4213.
Pediatric Perspectives
September/October 2012
4
The debate about the efficacy of probiotics,
ingestible live bacteria (micro flora),
is currently receiving much attention.
The theory behind their use is that
supplementation with healthy bacteria
causes favorable colonization in the intestine,
which can alleviate symptoms or prevent
certain conditions such as diarrhea, food
allergies, eczema and bacterial overgrowth.
In its clinical report, “Probiotics and
Prebiotics in Pediatrics,” published in
the December 2010 issue of Pediatrics
magazine, the American Academy of
Pediatrics reviewed clinical evidence
surrounding the use of probiotics for
children. In brief, they reported:
• In otherwise healthy children and infants,
administering probiotics early in the course
of diarrhea from acute viral gastroenteritis
can reduce its duration by one day
• Probiotics have been found to be modestly
effective in preventing antibiotic-associated
diarrhea in otherwise healthy children
• There is some evidence to support the
use of probiotics to prevent necrotizing
enterocolitis in infants with a birth weight of
more than 1000g
• Probiotics added to infant formula and
other foods marketed for use in children
do not appear to be harmful to healthy
infants and children. According to the
AAP, the overall health-benefit efficacy of
adding probiotics to infant formula remains
to be demonstrated in large randomized
controlled trials
While there is encouraging evidence and
much enthusiasm for probiotics being a
“natural” treatment, definitive data about
their long-term use are needed. The
long-term health benefits of probiotics in
the prevention of cancer, allergy or other
diseases or the ability to provide sustained
beneficial results on the developing immune
system beyond early infancy, remain to be
proven. Continuing research is needed to
answer these questions:
• Can probiotics enhance natural immunity
in infants and children?
• Can probiotics prevent or mitigate allergic
diseases?
• Are they safe in the long term?
Caution is advised when purchasing
probiotic supplements to determine the type
and quantity of live bacteria, the optimal
dosage, and the quality control used in
manufacturing the product.
866.788.3627
Cora’s Law: Enacted to Save Newborns
By Robert Jansen, MD, Neonatologist
Since Jan. 1, 2012, all birthing facilities in Indiana
are required by state law to perform pulse
oximetry newborn screening to detect critical
congenital heart defect (CCHD). Senate Bill 0552,
also known as Cora’s Law, was named for 5-dayold Cora Mae McCormick, who died suddenly on
December 6, 2009, in her mother’s arms while
breastfeeding.
Cora’s mother, Kristine Brite McCormick, was motivated by this
personal tragedy to try to make certain others’ lives might be saved.
Kristine worked diligently for two years to share Cora’s story to raise
awareness of CCHD, and with the help of State Senator Brent Waltz,
her efforts were rewarded with passage of the newborn screening law.
Saving Lives: Baby Gabriel’s Story
Already, the newly required screening has prompted intervention for
serious medical complications and saved lives, including the life of
Baby Gabriel, born in February in Jasper, Indiana.
Gabriel, a seemingly healthy full-term baby, received the pulse
oximetry screening on his second day of life. After failing the
screening, Gabriel was diagnosed with a critical coarctation of the
aorta. The St.Vincent Critical Care Transport Team transported him
to St.Vincent Women’s Hospital NICU for corrective surgery. Gabriel’s
mother Sharon said of Cora’s law, “…the law was implemented the
first of January. If Gabriel had been born a month earlier, we might
not have him.”
Critical Congenital Heart Defect
(CCHD)
• Congenital heart disease (CHD) is the most
common birth defect.
• Approximately six to eight of every 1,000
infants born have significant heart defects
and about half of these babies will require
treatment within their first year of life.
• Prenatal ultrasounds may detect only 28% of
all defects.
• Newborn physical exams may detect 50% of
babies with heart problems.
• Prenatal ultrasounds and newborn physical
exams – combined with pulse oximetry
screening – may allow detection of up to 92%
of babies with significant defects.
• Indiana was the second state in the nation
to adopt CCHD screening as part of the statemandated newborn screening panel (IC 1641-17-2).
• Refer to the Indiana State Department of
Health section on Congenital Heart Defect
Screening and a downloadable form of the
algorithm at: http://www.in.gov/isdh/25250.htm
• Also see The Children’s National Toolkit on
Congenital Heart Defect Screening at: http://
www.childrensnational.org/PulseOx/
request-tool-kit.aspx
Proactive Practice
For the past five years, St.Vincent Women’s Hospital has been performing pulse oximetry screenings for CCHD on
newborns in the Newborn Nursery and Continuing Care Nursery. To date, the screening has detected four babies
whose CCHD otherwise may not have been detected until too late.
Infants with saturation <90% in the right hand or foot are immediately referred for clinical assessment. Infants with
three failed readings – defined as oxygen saturation measurements <95% in both extremities or >3% difference
between both extremities – also receive a clinical assessment and additional testing by a pediatric cardiologist.
St.Vincent Women’s Hospital is one of only two centers in Indiana with pediatric cardiac surgeons who specialize in the
surgical repair of congenital heart defects.
Robert D. Jansen, MD, is medical director of Neonatal Intensive Care at St.Vincent Women’s Hospital. A graduate of
Loyola University Stritch School of Medicine, Dr. Jansen completed his fellowship at Northwestern University Hospitals.
He is a fellow of the American Academy of Pediatrics.
Pediatric Perspectives
September/October 2012
5
866.788.3627
Mark Your Calendar!
13th Annual Fall Pediatric CME Conference
Wednesday, October 3, 2012
8 a.m. – 4:30 p.m.
Ritz Charles in Carmel
• This continuing medical education activity has been reviewed and has been designated acceptable
for the following:
- American Academy of Pediatrics – 6.5 AAP credits
- St.Vincent Hospital and Healthcare Center – 7.0 AMA PRA category 1 credits TM
- American Academy of Family Physicians – 7.0 AAFP credits
- St.Vincent Hospital and Healthcare Center – 7.0 Continuing Nursing Education contact hours
• Increase your knowledge of issues and advances in selected pediatric subspecialties –
presentations include:
- Newborn Update
John Wareham, MD, Neonatologist
- ENT Updates for the General Pediatric Office
Chris Miyamoto, MD, Pediatric Otolaryngologist
- Pediatric Gastroenterology
Susan Maisel, MD, Pediatric Gastroenterologist
- Social Media in Practice
Alex Djuricich, MD
- Asthma Management
Olatunji Williams, MD, Pediatric Pulmonologist
- Concussion Management
David Harsha, MD, Sports Medicine
- Infectious Disease Update
Chris Belcher, MD, Pediatric Infectious Disease Specialist
• Visit with pediatric health care exhibitors
• Network with colleagues
The conference is geared for the primary care provider.
Cost: $115 for MDs, NPs and PAs; $75 for RNs and LPNs. Residents are free. To register, or for more
information call 338-CARE (2273) or visit mdevents.stvincent.org.
Gastroesophageal reflux (continued from page 1)
GER typically presents in the first two months of life and the severity of symptoms peaks between 6 and
9 months. Diagnosis is often by an upper endoscopy (EGD) to evaluate the esophagus lining. When severe
inflammation or ulceration is identified, a coating treatment may be prescribed. Other treatments for reflux
in children may include Reglan or low-dose Erythromycin, which improves gastrointesinal motility. Severe
cases may progress to the need for a gastrointestinal feeding tube or surgery. However, these treatments
are used only when standard medical treatments fail. Children are followed closely, and typically at about 1
year of age, a careful weaning from medications will demonstrate whether the symptoms have resolved.
Pediatric Perspectives
September/October 2012
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866.788.3627