Focus on Pediatrics - Summer 2018 by Prisma Health

Adolescent Transition Readiness Tool Multidisciplinary Approach to Treating Plagiocephaly CME: Toilet Training

Vol. 30.2 Summer 2018

on Pediatrics

New Therapies Improving Pediatric Care

Focus on Pediatrics is published by Children’s Hospital of Greenville Health System. Medical Editor Joseph L. Maurer, MD Managing Editor Lark Reynolds GHS Photographer AV Services Art Director GHS Creative Services Editorial Board Nichole Bryant, MD Donna Carver, CFRE Carl Cromer, MSN, FNP-BC Jeanine Halva-Neubauer Carley Howard Draddy, MD Jennifer Hudson, MD Emily Hughes Desmond Kelly, MD Terri Negron, MN, RN Janine Sally, MS, CCC-SLP Robert Saul, MD Kerry Sease, MD, MPH If you would like your name added to or removed from our mailing list or have any comments, questions or suggestions, please send the appropriate information to: Marketing Services Greenville Health System 300 E. McBee Ave. Suite 200 Greenville, SC 29601 (864) 797-7544 The information contained in the Focus is for educational purposes only—it should not take the place of medical advice or diagnoses made by healthcare professionals. All facilities and grounds of Greenville Health System are tobacco free. “Greenville Health System” and GHS symbol design are trademarks of Greenville Health System.

FROM THE MEDICAL DIRECTOR

Looking Back … and Ahead Children’s Hospital of Greenville Health System (GHS) was officially established in 1985, the realization of a vision by local pediatricians Bill DeLoache, MD; Pete Matthews, MD; and “Stonewall” Harold Jackson, MD. William Schmidt III, MD, PhD, was hired in 1988 to head the program, and Buddy the Bear became the icon for this new venture. At that time, GHS Children’s Hospital had two neonatologists, one pediatric cardiologist, one pediatric surgeon, one pediatric allergist, and many local pediatricians who served in the pediatric ICU and on the wards. Today, we care for over 400,000 children a year with employed pediatricians, subspecialists, nurse practitioners and a host of specialty trained pediatric support staff. Children’s Hospital itself has grown to an 80bed NICU, 12-bed PICU, eight-bed intermediate unit and a Children’s Emergency Center staffed 24/7 with pediatric attendings.

will provide evaluations and comprehensive care to complement the medical home as well. In addition, the new Pediatric Behavioral Health division offers a multimodal approach to behavioral and mental health issues. Patewood Memorial Hospital now is staffed 24/7 by Children’s Hospital pediatricians to provide care for the approximately 125 babies delivered there every month. The 2017 alignment of GHS and Palmetto Health has allowed us to further collaborate with Palmetto Children’s Hospital and develop programs like SC First Pediatric Rehabilitation Hospital at Palmetto Health. The opportunity to work as a team will improve the key health indicators for children in the Upstate and Midlands. The future of pediatrics in the Upstate and South Carolina is bright, and I am honored to help bring needed services to families we serve.

Pediatric resident and post-graduate education at Children’s Hospital prepares future generations to care for children, with programs welcoming 11 Pediatric residents, five Internal Medicine-Pediatrics residents and a Developmental-Behavioral Pediatrics fellow each year. Pediatric Pain Medicine soon will join the many offerings at Children’s Hospital, providing a multidisciplinary approach for children with chronic pain. An Adolescent Medicine program

Robin N. LaCroix, MD, Chair, Department of Pediatrics

The Pediatric Pain Medicine program is set to launch later this year; it will be the first of its kind in the Upstate.

CONTENTS

New Therapies Improve Quality of Life for Children and Families 2 Forward-thinking investment in training and equipment brings specialized therapies to children and families.

Helping Adolescents Bridge the Gap

Transition readiness assessment tool helps providers walk patients through the transition to adult care.

The Power of Music 20 Hugworks Children’s Network offers emotional support to children and families.

5 2

A Collaborative Approach to Plagiocephaly 22 Primary care providers, physical therapists, prosthetists/orthotists and surgeons team up to provide the best care for these small patients.

Departments What’s New? 5 Transport Telehealth, New Child Safety Seat Inspection Station, Trach “Go Bags”

Medical Staff Spotlight 7

18 5

Meet Our New Physicians

Academic News 8

Congratulations, Graduates! Welcome, New Residents!

CME 11

Toilet Training

Quality Counts 14 Project REVISE

Feature Story 15

What Does Magnet® Status Mean for Patients?

9 20

Case Study 16

Pediatric Hypertension

Clinical Research 21 Pediatric Pulmonary Research

Celebrations 26

Accreditation and Philanthropic News

Bulletin from the Bradshaw Institute 28 Healthy Greenville Grant

Ask the Faculty 30 Pediatric Migraines

On the cover: A patient practices reading symbols on a page while walking along a pattern taped to the floor.

22 13 To access this publication online, go to www.ghs.org/publications.

LEAD STORY

New Therapies at Kidnetics

It’s easy to take for granted the simple functions we perform every day, whether it be standing up to walk across the room, reading a book or using the bathroom. But for some children, performing what should be an easy task is a monumental struggle, and for their parents, answers can seem few and far between.

Floor Therapy programs both started within the last two years and fill a crucial gap for parents who oftentimes weren’t aware such therapy existed.

Two new programs at Kidnetics®, the pediatric therapies arm at Children’s Hospital of Greenville Health System (GHS), aim to provide some relief. The Vestibular Rehabilitation and Pelvic

“We’d been doing therapy for almost nine years, and I’d never heard of that type of therapy,” Clutter recalled.

Take Nikki Clutter. Her 8-year-old son, Ian, has cerebral palsy and has been seeing a physical therapist at Kidnetics for years. Once, when Clutter mentioned to Ian’s therapist that he continued to have bladder control issues, especially when he laughed, the therapist suggested pelvic floor therapy.

Pelvic Floor Therapy

The therapist explained pelvic floor therapy a bit more and introduced her to Stephanie Tindle, PT, DPT, the physical therapist who heads the Pelvic Floor Therapy program. Clutter scheduled an evaluation and learned that Ian could benefit from such therapy. “Cerebral palsy affects the muscular system, and the bladder is a muscle,” said Clutter. “Through the evaluation, we realized that this therapy could be very beneficial in strengthening those muscles, to the point that a lot of his issues could potentially be resolved over time.” Ian began aggressive therapy once a week with Tindle in fall 2017. The therapy includes a lot of education on diet and routine, along with a physical component. Equipment purchased by GHS enables Tindle and another pelvic floor therapist, April Kleckler, PT, DPT, to integrate play into biofeedback training, which increases both the likelihood of a successful outcome and the child’s cooperation. Surface electrodes are placed on the outside of the body to read muscle activity. Through the biofeedback equipment, movements are projected onto Tindle’s laptop in an interactive way that resembles a video game for the child.

Top: Nikki Clutter (left) and son Ian talk with Stephanie Tindle, PT, DPT, about Ian’s progress before a pediatric pelvic floor therapy appointment; bottom: Tindle discusses nutrition choices with Ian during a therapy session.

“A patient performs exercises, and when done correctly, they cause a space shuttle to zoom through space, a dolphin to jump out of the water or a gymnast to jump over a pole,” Tindle stated. “These interactive things make it more interesting for the child.”

Vestibular Rehabilitation

In the Vestibular Rehab program, Holly Ellingworth, OT, also has benefited from leading-edge technology purchased by the system. The program identifies and treats children with dizziness and balance (vestibular) disorders. A rotary chair— one of only two in the Southeast for pediatric vestibular rehab— helps diagnose and treat children who come to Ellingworth for therapy. “The chair is in an enclosed space, and it’s completely dark,” Ellingworth explained. “While children are sitting in the chair, they’re wearing infrared goggles that can specifically target their eye movements.” Eye movements are measured while the chair remains still and moving images are projected onto the wall. Then, eye measurements are taken while the chair rotates at different frequencies. This rotation can help identify vestibular hypofunction or hyperfunction, or issues with ocular motor dysfunction. It also can be used from a treatment standpoint to help children with their sensitivity to movement. The Vestibular Rehabilitation program began in late 2017, after therapists like Ellingworth pushed for a program to keep children and their families from having to travel out of state. Ellingworth started small, with about 10 patients, and hopes to grow over time through partnerships with GHS’ divisions of Pediatric Otolaryngology and Pediatric Neurology. “The Vestibular Rehab program covers the gamut, from allowing children to read effectively to moving through space better in activities of daily living,” said Nathan Alexander, MD, a pediatric otolaryngologist with GHS Children’s Hospital. “Some who have relatively brief issues with imbalance that don’t respond to conservative measures may see a great benefit from the equipment and training offered through Kidnetics. Others who have more longstanding insults to their sensory integration need the long-term support to strengthen their vestibular system as much as possible to allow them to realize where they are in space.” Beth Clark’s 12-year-old daughter, Abigail, has a handful of medical conditions, including mitochondrial disease and epilepsy. Abigail has spent years in speech, occupational and physical therapy addressing various symptoms. But one troubling symptom had her mother perplexed. “She has had a lot of queasiness and a lot of things that make her very sick to her stomach,” noted Clark, who is a supervisor for Kidnetics’ Speech Therapy program. “We’ve always had this longstanding issue.” One thing that caused Abigail to feel queasy was reading—so much so that her mom had to read schoolbooks to her so that Abigail could complete her assignments. One day when Clark was discussing this issue with coworkers, someone mentioned

Top: Holly Ellingworth, OT, watches Abigail Clark’s eye movements on the screen during a vestibular rehabilitation therapy session; bottom: Abigail sits ready for action in the rotary chair, one of only two chairs of its kind available for pediatric vestibular rehabilitation in the Southeast.

that the new Vestibular Rehabilitation program could possibly help. So Clark took Abigail to be assessed. “I just thought the queasiness was something we were going to have to live with, but Holly was able to pinpoint some key things about Abigail’s eyes and how they move and how that impacts her vestibular system. She was able to offer Abigail some strategies to help her feel better and help her eyes have better coordination,” Clark remarked. 3

“Stephanie was able to show us how to increase his fiber intake, and she talked to him about it, too, because he’s old enough to understand that a doughnut is not as good for him as an apple,” Clutter pointed out. “So she’s helped make him consciously aware, which has really helped us.”

Spread the News

The value of both programs in improving quality of life for both the patient and the family can’t be understated. “In my training, they talked a lot about the suicide rate for children with bowel and bladder issues,” Tindle stated. “It’s high. So for these children to reach some of these milestones and gain control of their bladder and bowel function for the first time—it’s life-changing.”

Top: Abigail practices reading symbols on a page while walking along a pattern taped to the floor. Left: Ellingworth works with Abigail on her balance during a therapy session.

Since Ian started therapy, Clutter said that he now can make it through a whole school day with underwear that still smells fresh and clean in the afternoon. “That is a huge milestone where we’ve seen improvement,” she stated. “And we can laugh now. I haven’t seen him have an accident because he was laughing in several months.” Clark noted that while Abigail’s nausea has begun to slowly subside, two other changes occurred much more quickly. “One big, noticeable thing is that her handwriting is extremely neat now,” Clark pointed out. “It used to be disorganized and all over the place. The other thing is that she’s a much stronger reader now. It used to be she would keep having to start over because she would lose what line she was on, which would make it really difficult to understand what she was reading.”

Ownership Is Key

Abigail takes part in weekly therapy sessions with Ellingworth. Sessions include different activities that involve movement in general and head movement in various planes. Ellingworth also gives Abigail at-home activities. “Abigail is really good about following through with them,” said Clark. “She’s really motivated by them, because she feels like they really make a big difference.” Clutter agreed that ownership over compliance with treatment recommendations has been important in Ian’s pelvic floor therapy, too, especially when it came to education about diet choices to address constipation.

Both Clutter and Clark want to spread the word about the availability of these therapy programs at Kidnetics that have helped their children so much. Clutter stressed, “I know I’m not the only mom out there struggling with these types of issues in their child.” Tindle added that the therapists share in the excitement. “Because there were so few providers in the area and even in surrounding states, these children were just unserved until now,” Tindle said. “I’ve heard several parents of children who are 10 or 12 years old say, ‘We’ve been dealing with this issue their whole life and had no idea such therapy was even an option.’ Well, it wasn’t in the area until we brought it here, so we’re very thankful for that opportunity.”

The value of both programs in improving quality of life for both the patient and the family can’t be understated. 4

WHAT’S NEW? Children’s Hospital of Greenville Health System (GHS) launches a new telehealth initiative, unveils a hospital-based car seat inspection station and announces a new camp experience for medically fragile patients.

Transport Telehealth Brings the For Children with a Trach, Physician into the Ambulance ‘Go Bags’ Help Families Be Prepared GHS Children’s Hospital’s pediatric intensive care unit (PICU) has added a new tool to improve the care delivered to patients during transport from outlying hospitals. The PICU Ground Transport team now has a mobile telehealth unit that accompanies them on trips to pick up sick children for transport to Children’s Hospital.

In the past, team members would consult by phone with the PICU doctor on call, but the mobile telehealth unit enables the doctor to see the patient on video and talk with the patient and family in addition to the transport team. Members of the transport team say the monitor gives them an added layer of support knowing that the PICU physician at Greenville Memorial Hospital can see the same things they see when picking up patients for transport. The project was funded by The Duke Endowment.

GMH Launches Child Safety Seat Inspection Station A new child safety seat inspection station opened to families at Greenville Memorial Hospital in April. This station is the first hospital-based inspection station in the state and will provide easy access for parents leaving the hospital to ensure their newborns are properly secured.

Parents of babies and children who require placement of a tracheostomy tube need extensive training on how to care for their child’s tracheostomy tube and must carry certain equipment and supplies with them at all times in case of an emergency. Thanks to financial support from Equipped for Life™ (GHS’ provider of home medical equipment), these families now are given a “Go Bag” containing all of these emergency supplies when they leave Children’s Hospital. Parents of these children participate in a series of education and training sessions while their children are in the hospital, including a 24-hour period where they must demonstrate that they can take care of their child. Routine changing of the tracheostomy tube and emergency procedures are part of this time frame. “These patients are very complex and fragile and have an increased risk of morbidity and mortality with a tracheostomy tube at home,” said Michael Fields, MD, PhD, medical director for Pediatric Respiratory Care Services at Children’s Hospital. “These children tend to keep the trachs for a few years, and a ‘Go Bag’ is a life-saving tool to help the families keep everything they need with them at all times.” Children’s Hospital sees approximately 10 children who require tracheostomy tube placement each year.

The station was funded by Kohl’s Corp. and, like GHS’ other nine stations, is staffed by certified child passenger safety technicians. It is open for appointments weekdays from 9 a.m.-3:30 p.m.

Pediatric Behavioral Health Office Debuts GHS Developmental-Behavioral Pediatrics has become two divisions. The only change to the original division is its name, which is now Developmental Pediatrics. The new division, Pediatric Behavioral Health, is located in Greenville at 200 Patewood Drive, Ste. A100. Phone is (864) 454-5612 and fax is 454-5121. Providers • Debbie Davis, MD (Psych) • Julie Jones, PsyD • Cara Reeves, PsyD • Stephanie Dutch, NP (Psych) • Monica McDowell, LPC (Psych)

Camp Cary’s Kids Launches for Medically Complex Patients Regional Senior Camp Cary’s Kids, a weekend family camp for medically Medical complex patients and those receiving supportive care services Directors Named from GHS Children’s Hospital, will hold its inaugural session Aug. 24-26 at Pleasant Ridge Camp and Retreat Center in Marietta, S.C.

The first camp will be open to patients 11 and older, their parents/caregivers, and siblings 5 and older. Camp Cary’s Kids is designed to be a family vacation-like experience for these families who may not often be able to take vacations. Families will create lasting memories during pampering sessions for parents, ropes course activities, swimming, canoeing, hiking, campfire songs and a family craft. Healthcare professionals will be on-site to assist with medically complex care. A session of Camp Cary’s Kids for patients younger than 11 will be offered in the spring of 2019. GHS’ Office of Philanthropy & Partnership is working to create an endowment for camps so that the variety of camps available to Children’s Hospital patients can continue to be supported for many years. Any Children’s Hospital physician interested in developing a camp experience for a specific population should contact Denise Wiklacz at dwiklacz@ghs.org or Donna Carver, CFRE, at dcarver@ghs.org.

Senior medical directors for Pediatric Primary Care have been named for Greenville Health System’s different regions. Jeff Stoeber, MD, is senior medical director of Pediatric Primary Care for the Central and Eastern regions. Allison Ranck, MD, is senior medical director of Pediatric Primary Care for the Western and Southern regions.

GHS Launches Comprehensive Sickle Cell Disease Program The Comprehensive Sickle Cell Disease Program, led by pediatric hematologist/ oncologist Alan Anderson, MD, is the first program of its kind in the Upstate. The new program provides care for all patients with sickle cell disease, from children to adults. Both inpatient and outpatient services will be provided, including red blood cell exchange apheresis. In this innovative, nonsurgical therapy, a patient’s red blood cells are removed and replaced. For more information or to make a referral, call (864) 455-5680.

MEDICAL STAFF SPOTLIGHT Children’s Hospital of Greenville Health System (GHS) welcomes several new physicians to the GHS Medical Staff.

Meet Our New Physicians Developmental Pediatrics

New Director of Nursing Announced

Karen Ratliff-Schaub, MD, earned her medical degree at Northeastern Ohio Universities College of Medicine in Rootstown, Ohio. She completed her residency training in Pediatrics at Medical College of Ohio in Toledo and served as a post-doctoral fellow at the University of Maryland in Baltimore, Md. Dr. RatliffSchaub served as chief of the Division of Developmental and Behavioral Pediatrics at Mercy Children’s Hospital in Toledo from 1997 to 2005; she also served during that time as medical director of the Pediatric Feeding Team and Myelomeningocele Team. She comes to Children’s Hospital from Nationwide Children’s Hospital in Columbus, Ohio, where she worked as a developmental-behavioral pediatrician since 2008. Dr. RatliffSchaub can be reached at (864) 455-5115.

Carl Cromer, MSN, FNP-BC, was named director of Nursing for GHS Children’s Hospital in January. Cromer began working with GHS in 2011 as a direct care nurse in the Neuro/Trauma Intensive Care Unit. During the last six years, he has worked in the Children’s Emergency Center in a variety of roles, including direct care nurse, charge nurse and supervisor. Most recently, he was nurse manager of the Children’s Emergency Center and chair of the Nurse Management Council for Greenville Memorial Hospital.

New Community Pediatrician Jaime R. Brown, MD, has joined Spartanburg Night Clinic. She can be reached at (864) 804-6998.

Inpatient Pediatrics Patricia C. Onuegbu, MD, earned her medical degree from Mercer University School of Medicine. She completed her Pediatrics residency at Florida State University/Sacred Heart Children’s Hospital in Pensacola, Fla. Dr. Onuegbu is working as a pediatric hospitalist for Children’s Hospital at AnMed Health in Anderson. She can be reached at (864) 454-5612.

Pediatric Cardiology Susan E. Haynes, MD, completed her medical education at Medical University of South Carolina in Charleston after graduating from Presbyterian College in Clinton, S.C. She completed a Pediatrics residency at University of South Alabama, USA Childrens & Women’s Hospital in Mobile, Ala. Dr. Haynes completed a fellowship in Pediatric Cardiology at University of Iowa Children’s Hospital in Iowa City, Iowa. She can be reached at (864) 454-5120.

Tom Moran Retires Tom Moran retired from his role as director of Children’s Hospital Outpatient Services in January. Moran joined Children’s Hospital in 1989 as program director for the Neonatal Follow-up Clinic. Over the past 28 years, Moran played an important role in a number of Children’s Hospital initiatives, including bringing eight pediatric subspecialties together under one roof to establish the Children’s Hospital Outpatient Center in 2008; creating satellite locations of multispecialty pediatric practices in Anderson, Spartanburg and Greenwood; and growing pediatric primary care services to low-income families through expansion of the Center for Pediatric Medicine.

ACADEMIC NEWS Children’s Hospital of Greenville Health System (GHS) congratulates all of our residents and fellows who graduated in May 2018 and welcomes 11 new Pediatric residents, five Medicine-Pediatrics residents and a new Developmental-Behavioral Pediatrics fellow.

Congratulations, Graduates! Pediatric

Eric Bankert, DO, has begun a Primary Care Sports Medicine fellowship at Greenville Health System. Lindsey Gouge, MD, began work at Parkside Pediatrics in Greenville, S.C. Meghan Jordan, MD, began work at Parkside Pediatrics in Greenville, S.C.

Dr. Bankert

Dr. Gouge

Dr. Jordan

Dr. McGee

Dr. Nix

Dr. Ragsdale

Dr. Riyad

Dr. Stoichita

Dr. Twitty

Dr. R. Winningham

Dr. V. Winningham

Matthew McGee, MD, will begin work at the GHS-owned practice of Christie Pediatric Group in Greenville, S.C. Ashtin Nix, MD, began work as assistant program director of the Pediatric Residency Program at GHS Children’s Hospital. Colton Ragsdale, MD, began work at Wee Care Pediatrics in Layton, Utah. Christine Riyad, MD, has moved to London, England, to pursue a career in international medicine. Andreea Stoichita, MD, began work as assistant program director of the Pediatric Residency Program at GHS Children’s Hospital. Grace Twitty, MD, has begun a Neonatal-Perinatal fellowship in Gainesville, Fla. Rob Winningham, MD, has begun work at Sherwood Family Medical Center in Sherwood, Ark. Victoria Winningham, MD, has begun a Neonatal-Perinatal fellowship in Little Rock, Ark.

Medicine-Pediatrics

Craig Anderson, MD, is working with Spectrum Health Medical Group Internal Medicine/Pediatrics in Grand Rapids, Mich. Marla Chapman, MD, has joined The Childrenâ&#x20AC;&#x2122;s Clinic of Hattiesburg in Hattiesburg, Miss. Clay Crosby, MD, will begin working at GHS Heritage Internal Medicine & Pediatricsâ&#x20AC;&#x201C;Wren in Piedmont, S.C.

Dr. Anderson

Dr. Chapman

Dr. Crosby

Dr. McQueen

Dr. Paulk

Dr. Fleming

Dr. Gray

Dr. Groot

Dr. Pasquali

Dr. Payne

Dr. Raffaele

Dr. Roland

Dr. Suhrstedt

Dr. Sundlie

Dr. Williams

Dr. Yu

Katie McQueen, MD, has begun a Combined Adult & Pediatric Hematology/Oncology Fellowship at Louisiana State University in New Orleans, La. Ryan Paulk, MD, has begun an Allergy & Immunology fellowship at Washington University in St. Louis, Mo.

Welcome, New Residents! Pediatric

Aubrey Fleming, MD: Marshall University Joan C. Edwards School of Medicine, Huntington, W.Va. Brittiany Gray, MD: Mercer University School of Medicine, Macon, Ga. Jessica Groot, MD: Texas Tech University Health Sciences Center School of Medicine, Lubbock, Texas Paige Pasquali, MD: University of Oklahoma College of Medicine, Oklahoma City, Okla. Ella Payne, MD: University of South Carolina School of Medicine Greenville, Greenville, S.C. Jennifer Raffaele, MD: Albany Medical College, Albany, N.Y. Rebecca Roland, MD: East Tennessee State University James H. Quillen College of Medicine, Johnson City, Tenn. Frederick Suhrstedt, MD: University of South Carolina School of Medicine, Columbia, S.C. Shane Sundlie, MD: University of South Carolina School of Medicine Greenville, Greenville, S.C. Grace Williams, MD: University of Alabama School of Medicine, Birmingham, Ala. Alex Yu, MD: East Tennessee State University James H. Quillen College of Medicine, Johnson City, Tenn.

Resident and Faculty Awards The following doctors and caregivers were recognized at Pediatric Residency Program graduation ceremonies:

Dr. Applegate

Dr. DeRidder

Dr. Latham

Matthew C. McGee, MD: Pediatric Resident Teaching Award (voted on by first- and second-year Pediatric residents) Grace A. Twitty, MD: Pediatric Resident Teaching Award (voted on by medical students)

Dr. Nickols

Dr. Okafor

Medicine-Pediatrics

Kevin Applegate, MD: University of North Carolina School of Medicine, Chapel Hill, N.C. Phillips DeRidder, MD: University of South Carolina School of Medicine Greenville, Greenville, S.C. Amauri Latham, MD: Virginia Commonwealth University School of Medicine, Richmond, Va. Jordan Nickols, MD: University of South Alabama College of Medicine, Mobile, Ala. Kimberly Okafor, MD: University of Louisville School of Medicine, Louisville, Ky.

Developmental-Behavioral Pediatrics Fellow Fellowship graduate Steven Ma, MD, has joined GHS Children’s Hospital as a faculty member in the Department of Developmental Pediatrics.

New Developmental-Behavioral Fellow Meghan Doyle, MD, has joined Children’s Hospital as a fellow with the Division of Developmental Pediatrics. She earned her medical degree from the University of Toledo College of Medicine and completed her pediatric residency training at the University of Texas Southwestern Medical Center and Dell Children’s Medical Center in Austin, Texas.

Matthew Grisham, MD, and Michael Babcock, MD: John P. Matthews Jr., MD, Outstanding Faculty Teaching Award (given by residents to a general pediatrician and to a subspecialist for superb teaching and enthusiasm for resident education) Robert Saul, MD: Paul V. Catalana, MD, Exemplary Character Award (given by the graduating class to a caregiver who exhibits the qualities of honesty, fairness, compassion, altruism and leadership by example) Bryan Neonatal Intensive Care Unit: 2018 Division of the Year Award (chosen by Pediatric residents) Colton Ragsdale, MD, and Rob Winningham, MD: Margaret L. Wyatt, MD, Outstanding Grand Rounds Award Kelly Shymkiw, MD: Pediatric Resident Journal Club Award Craig Anderson, MD: Medicine-Pediatrics Resident Achievement Award (chosen by Pediatric faculty for teaching and research skills and commitment to education) Meghan Jordan, MD: Miracle Maker Award (given by Pediatric faculty for extraordinary care, community service and furtherance of health education) Kindal Dankovich, MD: Inpatient Care Award (voted on by inpatient Pediatric faculty) Gretchen H. Vandiver, MD: Jill D. Golden, MD, Primary Care Award (for outstanding care in the outpatient setting as voted on by ambulatory Pediatric faculty)

CONTINUING MEDICAL EDUCATION

Toilet Training CME Credit Information

To receive possible continuing medical education (CME) credit for this article, please complete the online Q&A that can be accessed on page 13. Both physicians and nurses are eligible to test for the credit. It is the policy of the GHS Continuing Medical Education Committee to ensure balance, independence, objectivity and scientific rigor in all its individually sponsored or jointly sponsored education activities. Article author Matthew Grisham, MD, has disclosed that he has no significant financial interest or relationship with any company that may be considered an actual or potential conflict of interest with this educational activity. The planning committee have listed no duality of interest with regard to potential relevant financial relationships for the FOCUS enduring activity. The CME committee have listed no duality of interest with regard to potential relevant financial relationships for the FOCUS enduring activity with the exception of Sandra Weber, MD (Committee Chair), Grant/ Research Support–Eli-Lilly, NIH, and Pfizer and William A. Coleman, MD (OB/GYN), Consultant–Merck. The Greenville Health System (GHS) designates this enduring activity for a maximum of 0.50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. The Greenville Health System is accredited by the South Carolina Medical Association to provide continuing medical education for physicians.

The triumph of independent control of an activity of daily living—toilet training, in this case—is momentous for both child and parent. However, the path to success is littered with obstacles, particularly a lack of patience. Equipping parents with facts and guidance about the process is critical to establishing appropriate expectations that mitigate anecdotal social media stories of potty training boot camp shared by parents claiming instant results. Objective, normative data for the average toddler achieving this milestone provides perspective for parents who may have a preconceived timeline, and these discussions should begin as early as the 12-month well child visit. While some cultures in other parts of the world train their children within the first 6 months of life, the average age in the United States to begin training has risen steadily over time. Even so, the average duration of training has remained essentially unchanged. Roughly 25% of children achieve daytime continence by age 24 months; this number grows to 85% by 2.5 years and to 98% by 3 years.1 Bowel and daytime bladder continence may develop concurrently, though most children will achieve bowel

continence slightly earlier than urinary continence, with the duration of training an average of 6-7 months. Male gender and firstborn are predictive factors for requiring more time—both approximately 2-3 months longer than their counterparts. Nocturnal continence often requires years of training and typically is achieved by 5-7 years of age, with 20% of 5-yearolds still having some bedwetting.

Table 1: Developmental-Behavioral Signs of Readiness 3 Child can imitate behaviors 3 Child can place items where they belong 3 Child demonstrates independence by saying “no” yet with diminishing oppositionality 3 Child expresses interest in toilet training and desires control of elimination 3 Child desires to please 3 Child can walk to and sit on toilet with stability 3 Child can pull clothes up and down 3 Child possesses expressive language skills to communicate the need to use the toilet 3 Child maintains a period of two hours of dryness 3 Child knows the difference between wet/soiled and dry/clean diaper Table 2: Toilet Training Steps • Find a potty chair that allows the child’s feet to rest securely on the floor • Allow the child to personalize and “own” the chair • Place the potty chair(s) in a convenient location for ease of accessibility and in areas where the child can imitate the sitting of others • Encourage the child to sit on the chair fully clothed to garner comfort • Transition the child to sit naked on the chair once comfortable, placing a soiled diaper in the potty to help make the connection as to the chair’s purpose • Dispose of the stool or urine in the adult toilet once the connection is made • Recognize behaviors signifying a need to go (such as facial expression, squatting, hiding) and invite the child to use the potty chair • Praise successful attempts, including use of rewards such as sticker charts • Transition to training pants or cotton underwear after one or more weeks of success • Start nocturnal and nap training once daytime dryness is achieved by encouraging voiding immediately before sleep as well as upon awakening

In addition to setting appropriate parental expectations, parental motivation for toilet training should be evaluated. Expecting another child, anticipating a move or planning to transition to out-of-home childcare, all with their associated strain, often are cited as reasons for wanting to toilet train. Some parents equate early toilet training with higher intelligence, but this sentiment may lead parents to mischaracterize a child not toilet trained by a specific age as lazy, defiant or intellectually challenged, creating unnecessary tension. Interestingly, onset of toilet training before 27 months of age is not associated with earlier achievement of continence.2 In other instances, pressure may come from daycare or older family members. Such pressure, felt by parents and/or the child, can lead to unsuccessful training, including withholding of urine or stool, and should be addressed before the onset of training.

Ready, Sit, Go

Child readiness to begin toilet training hinges on both physiologic and behavioral factors. While voluntary neurologic control required for training may not be complete until 18 months of age (a common age at which many parents begin considering toilet training), an assessment of developmental readiness of the child to toilet train should be undertaken (Table 1). Timing of the attainment of these milestones varies among children (often not until 2.5 years), but without this crucial step, a fruitless, frustrating time for the trainer(s) and trainee is likely to ensue. Some experts recommend waiting three months after achieving these indicators before starting to train. The parent-oriented approach, involving regular scheduled toilet times with praise for correct elimination yet with punishment for accidents, has drawbacks of behavioral problems, including temper tantrums, as well as the potential for physical abuse as part of the corrective measures. Guidelines based on Dr. T. Berry Brazelton’s approach were published by the American Academy of Pediatrics (AAP) in 1998,3 endorsing training driven by the child’s readiness and at a pace unique to each child. This method is associated with higher rates of continence, more efficient training and low regression rates (Table 2). Handwashing and identifying developmentally and ageappropriate vocabulary or nonverbal cues (for children with autism spectrum disorder and/or intellectual disability) for

Table 3: Toilet Training Troubleshooting Challenge

Tips

Difficulty standing to void in male child

Males should void sitting down until bowel training is mastered

Refusal to sit/stool on toilet

Assess for stressors; evaluate for constipation and address as indicated; delay training for 1-2 months or until child demonstrates interest

Fear of flushing

Provide reassurance; offer child the opportunity to flush; encourage child to wave goodbye before flushing; avoid flushing while child is sitting on the toilet

Child unable to reach potty chair in time

Assess placement of potty chair; dress child in loose, easy-to-remove clothing; offer child a few gentle invites during the day

Frequent accidents after a period of continence

Assess for stressors; evaluate for constipation and address as indicated; evaluate for signs/ symptoms of UTI

Child straining to eliminate

Evaluate for constipation and address as indicated; recommend potty chair for improved leverage if using over-the-toilet seat

Nocturnal or nap enuresis

Discuss typical age of achievement of night/nap continence; inquire about family history of similar issues or renal disease; UA +/- culture if symptoms or exam suggests UTI or renal disease

bodily functions and fluids should be included in this process as well. These basic steps may require modification to match a child’s abilities or temperament. While setbacks are the norm, forcing any of the steps is likely to lead to unnecessary obstacles. Consistency of a positive approach emphasizing encouragement from all involved in training—parents and daycare providers alike—for each step is essential as is avoidance of punishment for inevitable accidents, such as forcing the child to wear soiled diapers for extended periods.

providers who know what will work best for the child likely will be necessary. However, caregivers also should be encouraged to seek support from their pediatrician should difficulties arise. The pediatrician then can assess the need for additional education, evaluation or involvement of specialties such as developmentalbehavioral pediatrics, pediatric gastroenterology, pediatric nephrology or pediatric urology. The end result should be greater satisfaction and success for all parties.

Article author Matthew Grisham, MD, is the Pediatric Residency Program director of Children’s Hospital of Greenville Health System.

Although AAP guidelines generally discourage starting toilet training before 24 months of age, capitalizing on the child’s readiness and interest is a window of opportunity that, when missed, can lead to delays in mastery. However, it also is advisable to delay training until 2.5 years of age for children whose caregiver is impatient or easily frustrated. These frustrations often stem from minor setbacks, more frequently seen during times of stress (e.g., illness), which may be misperceived as toilet training failure.

References

Providing anticipatory guidance to parents about commonly encountered hurdles before the onset of training may help curtail these concerns through knowledge of realistic expectations (Table 3). Numerous books, videos and electronic applications geared toward children are available to assist with child engagement in toilet training. In addition, parental resources, such as the AAP’s guide to toilet training (2nd ed.) or healthychildren.org, are available, including specific information on children with special healthcare needs

CME Questions Available Online

Successful toilet training depends on many factors, such as interest, readiness and lack of stressors of the child, along with parental investment of time, patience and positivity in the wake of setbacks throughout the process. No single approach works for every child, and tailoring these steps by parents and care

1. Parker S, Sices L. Toilet training. In: The Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care (3rd ed.). Augustyn M, Zuckerman B, Caronna EB (eds.). Lippincott Williams & Wilkins, Philadelphia. 2011:393. 2. Blum NJ, Taubman B, Nemeth N. Relationship between age at initiation of toilet training and duration of training: a prospective study. Pediatrics 2003;111:810. 3. American Academy of Pediatrics. Toilet Training: Guidelines for Parents. AAP, Elk Grove Village, Ill. 1998.

As a convenience for our audience and to conserve resources, Focus on Pediatrics has transitioned to an online format for the Q&A portion of CME articles. Here is a link and a QR code you can use to access the CME questions online. http://www.ghs.org/PediatricsElectronic 13

QUALITY COUNTS

Project REVISE Children’s Hospital of Greenville Health System (GHS), along with three other sites in South Carolina and 132 others nationwide, recently participated in Project REVISE (Reducing Excessive Variability in Infant Sepsis Evaluation). Project REVISE is a quality improvement effort led by the Value in Inpatient Pediatrics Network, part of the Quality Improvement Innovation Networks at the American Academy of Pediatrics (AAP). Young infants with fever often are admitted to the hospital for invasive testing and IV antibiotics because of concern for serious bacterial infection (SBI), a practice that has historically been considered the standard of care. The last AAP guideline on managing the febrile infant appeared in 1993; many studies of criteria to define infants as low or high risk for SBI were conducted before Hib and Prevnar vaccination, with its associated herd immunity, and universal Group B strep screening and prophylaxis. It is estimated that as many as 60 percent of febrile infants are treated unnecessarily. The goals of Project REVISE were to use evidence and expert consensus to guide management strategies through algorithms to reduce unnecessary testing and hospitalization, decrease length of stay, and avoid delayed treatment and/or undiagnosed SBI. The algorithms for evaluating and treating febrile, wellappearing infants age 7-60 days were adjusted at individual sites to meet the needs of each site without compromising project goals. High-risk infants are defined by ANY of the following: • Gestational age of 37 weeks or less • Complicated neonatal course • Chronic illness or complex medical condition • Previous hospitalization for possible infection or ALTE/BRUE • Treatment with antibiotics in the past 14 days before presentation • WBC <5,000 or >15,000 • Bands >1,500 • UA positive for nitrites or WBC >5/HPF • CRP >20 mg/dL • Focal infiltrate on chest X-ray (only if respiratory symptoms are present)

Low-risk neonates age 7-28 days no longer require empiric antibiotics but should be admitted for observation. If a baby does not meet all low-risk criteria, CSF studies should be obtained and antibiotics given. Additionally, an HSV workup should be initiated if suspected. For infants age 29-60 days, low-risk patients can be discharged home if parents are comfortable and competent to safely monitor and care for the child, have reliable means of receiving communication from the hospital/ED and reliable transportation, cultures will be followed daily, and the patient can follow up within 24 hours. Length of stay was lowered to 24 hours of observation and negative cultures if follow up was ensured for low-risk infants and 36 hours of negative cultures for high-risk infants. Each site collected data pre- and post-change in practice. Data were collected on 20,570 infants and then submitted to a national database for analysis. At GHS Children’s Hospital, our team reduced antibiotic use in these infants by 24 percent and LOS by 8-12 hours. No SBI was missed as a result of the practice change. This project is an excellent example of collaboration across our institution both in the inpatient and ED setting to improve quality and potentially reduce harm without jeopardizing patient safety.

Author Carley Howard Draddy, MD, is vice chair of Quality and Medical Staff Affairs and medical director of Pediatric Telehealth and Special Projects for Children’s Hospital. The team who worked on Project REVISE at Children’s Hospital—Liz Tyson, MD; Karen Eastburn, DO; Kevin Polley, MD; and Jeremiah Smith, MD—won an award for Best Investigation in High Value Care at the GHS Health Sciences Center’s Research Showcase in April.

FEATURE STORY Greenville Health System (GHS) now boasts two of the state’s five Magnet®-designated hospitals!

What Does Magnet Status Mean for Patients? On March 15, Greenville Memorial Hospital—including GHS Children’s Hospital—achieved Magnet designation. This prestigious honor awarded by the ANCC Magnet Recognition Program® represents the gold standard for nursing excellence. Less than eight percent of hospitals worldwide have received this designation. Greenville Memorial Hospital (and the Children’s Hospital) is one of five Magnet-designated hospitals in South Carolina. Another GHS hospital, Greer Memorial Hospital, which includes pediatrics, also has attained Magnet status. Magnet designation is based on excellent nursing care and patient outcomes. This designation recognizes the dedication of over 350 pediatric nurses and our commitment to excellence, quality, innovation and safety in the care we deliver to children and families at Children’s Hospital. Such designation supports our hospital’s campaign to attract and retain the top talent in pediatric nursing by providing a desirable and empowering work environment for them. Magnet-designated hospitals outperform the national benchmarks in quality, patient experience and nursing satisfaction, which, in turn, draws more patients who seek the highest level of care. Magnet recognized the Small Baby Unit in the Bryan Neonatal Intensive Care Unit (NICU) as a “gem.” The Small Baby Unit focuses on the specialized needs of infants born earlier than 28 weeks (7 months) gestational age, or weighing less than 1,000

Beyond words: GMH nurses celebrate receiving Magnet recognition.

grams (2.2 pounds) at birth. The multidisciplinary team in this unit includes neonatologists; neonatal nurse practitioners; neonatal nurses; respiratory therapists; lactation consultants; neonatal nutritionist; and speech, occupational and physical therapists. The team works together to provide evidence-based practices to ensure the best outcomes for these fragile patients. I am proud and honored to work alongside so many dedicated, compassionate and innovative nurses who care for our young patients daily. Their commitment to serving the children of our community is second to none! Article author Carl Cromer, MS, FNP-BC, is director of Nursing for Children’s Hospital.

Magnet recognized the Small Baby Unit in the Bryan Neonatal Intensive Care Unit (NICU) as a “gem.”

CASE STUDY

Pediatric Hypertension History

CH is a previously healthy 17-year-old female admitted to Childrenâ&#x20AC;&#x2122;s Hospital of Greenville Health System (GHS) from a local ER with edema and hypertension (HTN). She described intermittent bilateral leg swelling over the previous year but was never edematous and had normal, stable vital signs when seen by her primary care provider. The leg swelling was persistent over the preceding month, and the acute development of periorbital edema prompted her emergency visit. She denied any recent illness, urinary abnormalities or vision changes but admitted having intermittent headaches the previous 2 months. Review of prior ER visits revealed blood pressures (BP) at the 95th percentile for her age, but no laboratory evaluation was undertaken at those encounters.

Exam and Evaluation

On admission, CH was pleasant, though anxious about her symptoms, but without any obvious distress. She was afebrile and mildly tachycardic with a BP of 145/95. Her cardiac, pulmonary and abdominal exams were normal, and she demonstrated moderate pitting edema of bilateral lower extremities as well as the face. Laboratory evaluation in the emergency department included a UA with microscopy notable for proteinuria (>500), hematuria (98 RBCs), including hyaline and RBC casts. Her CMP demonstrated hypoalbuminemia and mild hypokalemia without evidence of acute kidney injury. 16

A mild normocytic anemia (Hgb 11.2, MCV 84) was noted on her CBC, and her inflammatory markers were elevated (CRP 40.7, ESR 102). Further evaluation to help discern the etiology of her glomerulonephritis included normal C3/C4 levels, normal IgA, negative ASO antibody, negative HIV screen and negative viral hepatitis panel. After consulting with GHS Pediatric Nephrology, CH was started on lisinopril along with intravenous methylprednisolone while awaiting renal biopsy results. A diagnosis of IgA nephropathy was ultimately made, and cyclophosphamide was added to her regimen. She was discharged on lisinopril for its reno-protective effects as well as daily oral prednisone for the subsequent 3 months. Monthly cyclophosphamide infusions were scheduled by Pediatric Nephrology, and she was given leuprolide to preserve reproductive function in light of her cyclophosphamide therapy per a reproductive endocrinology consultation.

Pediatric Hypertension

Normative blood pressure values, readily available in The Harriett Lane Handbook (available for free on clinicalkey.com through GHS), are based on a childâ&#x20AC;&#x2122;s sex, height percentile and age. The AAP released a new pediatric HTN guideline in 2017 to update the diagnosis and management of pediatric HTN. Thirty Key Action Statements (KAS) were made in the article, including new BP charts and new classifications for HTN: elevated BP (>90th percentile), Stage 1 HTN (>95th percentile) and Stage

2 HTN (>95th percentile + 12mm Hg). “Prehypertension” was replaced by “elevated BP” in the new guideline. At the time that elevated BP or HTN is identified, the clinician should recommend lifestyle changes including the DASH (Dietary Approaches to Stop Hypertension) diet, increased physical activity and healthy weight loss. Recommendations regarding reevaluation and treatment initiation also were made. In children with elevated BP, the BP should be rechecked at 6 and 12 months from initial abnormal BP, and, if not improved, ambulatory blood pressure monitoring (ABPM) and diagnostic workup are warranted. For patients with Stage 1 HTN, BP should be rechecked at 1-2 weeks and again at 3 months. At 3 months, if HTN persists, patient should receive ABPM, diagnostic workup and medical treatment. For Stage 2 HTN, BP should be rechecked within 1 week, along with ABPM, diagnostic evaluation, medical treatment and referral to specialty care. Children >6 years old do not require an extensive workup for HTN if they have a family history of HTN, are obese and/or do not have history or physical exam concerning for secondary HTN (KAS 11). These recommendations reflect that primary HTN is the predominant cause in children >6 years old. Renal and renovascular disease, including renal artery stenosis (RAS), are the second most common causes of HTN. Although no evidence-based criteria for identifying patients with renovascular disease exist, some experts have suggested evaluating children with Stage 2 HTN or significant diastolic HTN.

If the decision is made to pursue screening tests, all patients should receive a UA, BMP/CMP and lipid profile with subsequent renal ultrasonography if age <6 years, abnormal UA or abnormal renal function. If the patient is obese or adolescent, then HgbA1c, AST/ALT and fasting lipid panel also are recommended. Table 1 contains a list of physical exam findings, historic features and additional testing for children with identifiable causes of HTN. When starting medical therapy for HTN, clinicians should begin treatment with an ACE inhibitor, angiotensin receptor blocker, long-acting calcium channel blocker or thiazide diuretic (KAS 21). The goal of therapy should be to reduce BP to <90th percentile and <130/80 in children >age 13 (KAS 19). Patients involved in competitive sports may resume participation once cardiovascular and end-organ risk have been assessed and BP has been reduced below Stage 2 HTN thresholds (KAS 28, 29).

References

1. Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics. 2017; 140(3): e20171904. 2. Weaver DJ. Hypertension in Children and Adolescents. Pediatrics in Review. 2017; 38: 369-382.

Table 1 provides a list of diagnostic studies for evaluation of renovascular disease; however, consultation with specialty care (e.g., Pediatric Nephrology) is recommended to help determine which patients require screening and what imaging modalities are most appropriate.

Article author Christopher Graves, MD, is a third-year Pediatric resident at Children’s Hospital of Greenville Health System. This article was written under faculty direction of Matt Grisham, MD, a pediatric hospitalist and Pediatric Residency Program director.

Table 1 Physical Exam and Historic Features

Diagnosis

Clinical Evaluation

Excessive drowsiness/excitability, snoring, tonsillar hypertrophy

Obstructive sleep apnea

Polysomnography

Tachycardia, poor weight gain or weight loss, brittle hair, sweating, proptosis

Hyperthyroidism

TSH, FT4

Central obesity, moon facies, posterior neck and shoulder “fat pad,” hirsuitism

Cushing’s syndrome

24-hour urine-free cortisol, dexamethasone suppression test

Abdominal bruit, abdominal mass, neurofibromatosis, history of umbilical artery catheterization

RAS/renovascular disease

Renal US, CTA, MRA, nuclear medicine scans

Home built before 1950, abdominal pain, developmental delays

Lead exposure

Serum lead level

Cardiac murmur, right arm SBP >lower extremity SBP by >20mm Hg

Aortic coarctation

Echocardiogram

Hypernatremia, hypokalemia, metabolic alkalosis, muscle weakness

Hyperaldosteronism

Serum renin aldosterone ratio

High-risk social behaviors, agitation, withdrawn from family, decreased school performance

Drug use (cocaine, amphetamines, decongestants)

Urine drug screen

NEW TECHNOLOGY A template in the Epic electronic health record helps pediatricians empower their adolescent patients.

Transition Tool Sets Up Teens for Winning Health By Lark Reynolds

that transition begins with learning a set of skills and includes preparing the family for the things they need to think about as that child legally becomes an adult—from a medical perspective, but also emotionally and legally.” Dr. Hinton is part of a team at GHS Children’s Hospital that created a readiness assessment tool for preparing adolescents to transition their care. The tool, housed in Epic, originally was developed for CPM’s population of patients with asthma, but it can be customized for any population and any practice. Dr. Hinton described the “a-ha” moment that launched the tool: “I was in the clinic one day and had an asthma patient who was poorly controlled and who needed to transition, and the thought just hit me—we really don’t have anything for these patients.”

A Tool for All GHS Providers

Sarah Hinton, MD, chats with Samona Whitner, a patient at Children’s Hospital’s Center for Pediatric Medicine, during a checkup.

Whether pediatric patients are relatively healthy or have significant health problems, there comes a time when they must transition to adult care providers. The process may differ, but for both types of patients, the steps are similar. As patients grow into adolescents, they must begin to understand and take ownership of the conditions affecting them and the care they receive. And that process begins much earlier than the transition itself. “Most people think about the actual transfer of care when we talk about adolescents transitioning to adult care,” said Sarah Hinton, MD, a physician at the Center for Pediatric Medicine (CPM), part of Greenville Health System (GHS). “But really, 18

Using transition-readiness resources from the national website GotTransition.org, the team put together an assessment tool and created it within Epic (.transition) so that it is available to any GHS provider or practice. “The tool can be plugged in to any note, any chart that anyone’s working on,” Dr. Hinton stated. “Specialists, general providers— anyone can use it.” The process at CPM now begins when patients turn 14. Early goals for the patient include knowing what medicines he or she is taking and how to contact the doctor’s office to make an appointment. Over time, goals build to knowing what to do in case of an emergency and how to refill medicines. “Every year at the well visit, we ask a couple more questions and make sure the patient is on track,” she said. While the tool is ready for use, Dr. Hinton recommends defining what transition looks like as a first step. That may differ from practice to practice and provider to provider.

“For a lot of our patients at CPM, 18 makes sense for transitions,” she pointed out. “Many practices will continue to follow patients through college. The AAP came out with a policy statement within the last couple of years saying that while pediatrics is the care of pediatric diseases, sometimes that care does extend into what we consider adulthood, and that’s OK.” Next, she suggested, determine the answers to a couple other questions: • When do we want to start addressing this transition? • How frequently do we want to address the transition with patients and families?

A Learning Process for Everyone

As adult providers begin to increase their comfort level with conditions that have historically been relegated to pediatric providers, the transition for these patients is becoming smoother. “Across the system, we are in the beginning stages of building a network of adult providers willing to accept patients in transition,” Dr. Hinton said. “We hope that we can create an algorithm for practices to follow to help guide them through the basics of transition.” Dr. Hinton admitted that it’s a learning process for everyone. She picked up on a strategy used by Kent Jones, MD, at the system’s Ferlauto Center for Complex Pediatric Care that relates to the order of transitioning services. “Dr. Jones has found a lot of success in transitioning the specialty areas one at a time to the adult provider, so that he can serve as the stability during that time. Once all the adult

specialty issues are addressed, he then can find an adult primary care provider.” Of course, another barrier to adolescents transitioning to adult care is insurance—particularly for CPM patients. “Because a lot of our children are on Medicaid, they lose that coverage when they turn 19,” Dr. Hinton emphasized. “So if they don’t have an alternative—if they can’t go on mom or dad’s insurance or aren’t working themselves or can’t pay for their own policy—a lot of them become uninsured. Not all of our practices at GHS are set up well to be able to take care of those patients.” It’s a particularly dicey situation for patients with medical conditions that don’t hinder them from performing expected duties and responsibilities. “For general Medicaid in this state, you have to have a low income and have what is considered a disabling condition,” Dr. Hinton noted. “The folks who fall in the cracks are those who have some medical problems, but not so much that they can’t work and go to school.” The tool continues to be improved, and Dr. Hinton shared that it’s a group effort. According to Dr. Hinton, Jeff Gerac, MD, a Med-Peds member on the Epic Implementation team, has been instrumental in developing many of the tools. Dr. Hinton’s main hope for the tool is to help other practices that may have questions around transition issues and the how-to’s. “There is a learning curve for these patients,” she remarked. “Giving them more autonomy to express and take care of their own healthcare needs is the key to ensuring a good transition.”

The transition readiness assessment template has been created within Epic (.transition) and is available to any GHS provider or practice.

SPECIAL PROGRAM

Hugworks Children’s Network Hits the Right Notes “There’s some quality about their music that catches people’s attention and can either brighten the mood and foster silliness and happiness or, if needed, can calm and soothe,” Durham said. Diane Crawford, CEO of KidLinks, said a lot of thought and research goes into the developing the music. “What makes us unique are the messages,” Crawford stated. “While music is wonderful for children anytime and can help kids who are having a hard time really find a way to connect with their emotions, our songs are thoughtfully prepared and embedded with positive messages, with help from child life specialists.”

Lindsey Metz, CCLS, a child life specialist, shows a young patient some of the songs on Hugworks Children’s Network.

In 1983, a young musician was invited to sing for pediatric patients at Columbus Children’s Hospital (now Nationwide Children’s Hospital). The musician, Jim Newton, realized during that performance how his traditional repertoire fell short of what these patients needed, given their situations. A profound experience with one patient, though, convinced him that filling that gap was what he was meant to do. Now, 35 years later, Newton is the driving force behind Hugworks Children’s Network (HCN), an online portal for therapeutic music entertainment created by the 501(c)(3) charity KidLinks and accessible anywhere there’s an internet connection. Children’s Hospital of Greenville Health System (GHS), which benefits from multiple live performances by Newton and his fellow KidLinks musicians each year, was the first of two partner hospitals in the U.S. to sponsor and support the network. Emily Durham, MA, CCLS, supervisor of Child Life Services at GHS Children’s Hospital, said the music produced by KidLinks possesses a special quality. Something special happens when child life specialists walk into a room and pull the site up on an iPad for a child, she pointed out.

The site features music files sorted both by album (there are four English and three Spanish albums) and by category. Categories range from “Expressing Feelings” and “Cooperation & Teamwork” to “Fun/Silly.” There also is a category devoted to healing and health care. Hugworks offers free music videos—some animated and others featuring calming images—of many of its songs. On the drawing board are digital books, games and character-building activities. Songbooks and CDs are available for purchase. While child life specialists at Children’s Hospital and elsewhere make use of HCN with patients in the hospital, Crawford emphasized that the value behind the network really is its ability to go anywhere with patients and families. “It’s not only that they get to see it and visit it while they’re in the hospital, but it also serves as a virtual support network after they go home,” she remarked. Durham added that the breadth of material on topics covering the emotional challenges children face in the hospital is well organized on the site. Thus, it’s easy for parents to access exactly what they’re looking for. “It’s a great resource for physicians to share with our families that is absolutely free, developmentally appropriate, and meets patients and families where they are,” Durham summarized.

GHS Children’s Hospital Physician Directory For admission to Children’s Hospital: (864) 455-0000

Phone Fax Phone Fax Robin N. LaCroix, MD 455-8401 455-3884 Darryl R. Gwyn, MD 455-7146 455-5380 Medical Director; Chairman, Department of Pediatrics Robert S. Seigler, MD 455-7146 455-5380 Adolescent Medicine Developmental Pediatrics/Gardner Center for Developing Minds Sarah B.G. Hinton, MD 220-7270 241-9211 Ryan A. Baker, MD 454-5115 241-9205 Allergy, Immunology and Asthma James H. Beard Jr., MD 454-5115 241-9205 Erin M. Mullaney, MD 675-5000 675-5005 Meghan Doyle, MD 454-5115 241-9205 John M. Pulcini, MD 675-5000 675-5005 Tara A. Cancellaro, MD 454-5115 241-9205 Ambulatory Pediatrics/Center for Pediatric Medicine (Medicaid) Gerald J. Ferlauto, MD 454-5115 241-9205 J. Blakely Amati, MD 220-7270 241-9211 Charles R. Hatcher III, MD 454-5115 241-9205 Jessica P. Boyd, MD 220-7270 241-9211 Desmond P. Kelly, MD 454-5115 241-9205 Ryan D. Bromm, DO 220-7270 241-9211 Steven H. Ma, MD 454-5115 241-9205 Elizabeth W. Burton, MD 220-7270 241-9211 Darla H. McCain, MD 454-5115 241-9205 Meredith A. Eicken, MD, MPH 220-7270 241-9211 Nancy R. Powers, MD 454-5115 241-9205 Sarah R. Emerson, MD 220-7270 241-9211 Karen L. Ratliff-Schaub, MD, MBOE 454-5115 241-9205 Janelle E. Godlewski, MD 220-7270 241-9211 Emergency Medicine Gary M. Goudelock, MD 220-7270 241-9211 Zachary T. Burroughs, MD 455-6016 455-6199 Lochrane Grant, MD 220-7270 241-9211 Elizabeth L. Foxworth, MD 455-6016 455-6199 Matthew P. Grisham, MD 220-7270 241-9211 Jacqueline J. Granger, MD 455-6016 455-6199 Sarah B.G. Hinton, MD 220-7270 241-9211 Alison M. Jones, MD 455-6016 455-6199 Mark B. Krom, DO 220-7270 241-9211 Matthew B. Neal, MD 455-6016 455-6199 Cristina M. Lopez, MD 220-7270 241-9211 Kevin A. Polley, MD 455-6016 455-6199 Dolores P. Mendelow, MD 220-7270 241-9211 Jimme J. Sierakowski, DO, MPH 455-6016 455-6199 Ashtin D. Nix, MD 220-7270 241-9211 Jeremiah D. Smith, MD 455-6016 455-6199 Mary A.S. Putnam, MD 220-7270 241-9211 John D. Wilson Jr., MD 455-6016 455-6199 Robert A. Saul, MD 220-7270 241-9211 Endocrinology Kerry K. Sease, MD, MPH 220-7270 241-9211 James A. Amrhein, MD 454-5100 241-9238 Andreea I. Stoichita, MD 220-7270 241-9211 Elaine A. Apperson, MD 454-5100 241-9238 Cady F. Williams, MD 220-7270 241-9211 Melissa D. Garganta, MD 454-5100 241-9238 Anesthesiology Bryce A. Nelson, MD, PhD 454-5100 241-9238 Carlos L. Bracale, MD 522-3700 522-3705 Mary Gwyn Roper, MD 454-5100 241-9238 Michael G. Danekas, MD 522-3700 522-3705 Ferlauto Center for Complex Pediatric Care Lauren H. Doar, MD 522-3700 522-3705 W. Kent Jones, MD 220-8907 241-9211 Jake Freely, MD 522-3700 522-3705 Robert A. Saul, MD 220-8907 241-9211 John P. Kim, MD 522-3700 522-3705 Cady F. Williams, MD 220-8907 241-9211 Richard F. Knox, MD 522-3700 522-3705 Gastroenterology Laura H. Leduc, MD 522-3700 522-3705 Liz D. Dancel, MD 454-5125 241-9201 Steven W. Samoya, MD 522-3700 522-3705 Michael J. Dougherty, DO 454-5125 241-9201 Matthew R. Vana, MD 522-3700 522-3705 Jonathan E. Markowitz, MD, MSCE 454-5125 241-9201 Randall D. Wilhoit III, MD 522-3700 522-3705 Colston F. McEvoy, MD 454-5125 241-9201 Behavioral Health Genetics Debbie Davis, MD (Psych) 454-5612 454-5121 David B. Everman, MD 250-7944 250-9582 Julie Jones, PsyD 454-5612 454-5121 R. Curtis Rogers, MD 250-7944 250-9582 Cara Reeves, PsyD 454-5612 454-5121 Gynecology Bradshaw Institute for Community Child Health & Advocacy Dianna T. Gurich, MD 455-1600 522-4455 Kerry K. Sease, MD, MPH 454-1100 454-1114 Melisa M. Holmes, MD 455-1600 522-4455 Cardiology Benjie B. Mills, MD 455-1600 522-4455 Susan E. Haynes, MD 454-5120 241-9202 Hematology/Oncology (BI-LO Charities Children’s Cancer Center) Benjamin S. Horne III, MD 454-5120 241-9202 Alan R. Anderson, MD 455-8898 241-9237 Jon F. Lucas, MD 454-5120 241-9202 Nichole L. Bryant, MD 455-8898 241-9237 David G. Malpass, MD 454-5120 241-9202 Rebecca P. Cook, MD 455-8898 241-9237 Manisha S. Patel, MD 454-5120 241-9202 Leslie E. Gilbert, MD, MSCI 455-8898 241-9237 R. Austin Raunikar, MD 454-5120 241-9202 Aniket Saha, MD, MSCI, MS 455-8898 241-9237 Angela M. Sharkey, MD 455-7992 455-8404 Infectious Disease Child Advocacy Medical Program Joshua W. Brownlee, MD 454-5130 241-9202 Mary-Fran R. Crosswell, MD 335-5288 241-9277 Sue J. Jue, MD 454-5130 241-9202 Nancy A. Henderson, MD 335-5288 241-9277 Robin N. LaCroix, MD 454-5130 241-9202 Lyle L. Pritchard, MD 335-5288 241-9277 Inpatient Pediatrics Critical Care Greenville Michael G. Avant, MD 455-7146 455-5380 April O. Buchanan, MD 455-8401 455-3884 Eric L. Berning, MD 455-7146 455-5380 Gretchen A. Coady, MD 455-4411 455-4480 Christina M. Goben, MD 455-7146 455-5380 Continued on back

Phone Fax Phone Fax Karen Eastburn, DO, MS 455-8401 455-3884 Ophthalmology Keith L. McCormick, MD 454-5540 241-9276 Jeffrey A. Gerac, MD 455-4411 455-4480 Janette E. White, MD 454-5540 241-9276 Matthew P. Grisham, MD 455-8401 455-3884 Orthopaedic Oncology Amanda G. Hartke, MD, PhD 455-8401 455-3884 Scott E. Porter, MD, MBA 797-7060 797-7065 Russ C. Kolarik, MD 455-7844 455-3884 Orthopaedic Surgery Elizabeth S. Tyson, MD 455-8401 455-3884 Michael L. Beckish, MD 797-7060 797-7065 Teresa A.W. Williams, MD 455-4411 455-3884 Christopher C. Bray, MD 797-7060 797-7065 Anderson David E. Lazarus, MD 797-7060 797-7065 Sara M. Clark, MD 454-5612 454-5121 Otolaryngology Liz G. Dewald, MD 454-5612 454-5121 Nathan S. Alexander, MD 454-4368 241-9232 Patricia C. Onuegbu, MD 454-5612 454-5121 Robert O. Brown III, MD 455-5300 455-5353 Ann Marie Patterson Ravindran, MD 454-5612 454-5121 Michael S. Cooter, MD 454-4368 241-9232 Allison B. Ranck, MD 454-5612 454-5121 Paul L. Davis III, MD 455-5300 455-5353 Senthuran Ravindran, MD 454-5612 454-5121 Robert L. Eller, MD 455-5300 455-5353 Elizabeth A. Shirley, MD 454-5612 454-5121 William D. Frazier, MD 454-4368 241-9232 Teresa A.W. Williams, MD 454-5612 454-5121 Ross M. Germani, MD 454-4368 241-9232 Miranda L. Worster, MD 454-5612 454-5121 John T. McElveen Jr., MD 919-876-4327 919-876-6800 Greer Patrick W. McLear, MD 454-4368 241-9232 Matthew N. Hindman, MD 455-4411 455-4480 Eddie B. Penn Jr., MD 454-4368 241-9232 Patewood John G. Phillips, MD 454-4368 241-9232 Holly Dawson, MD 797-1404 797-1405 Andrew M. Rampey, MD 454-4368 241-9232 Melissa R. Eldridge, MD 797-1404 797-1405 Charles E. Smith, MD, DMD 454-4368 241-9232 George C. Haddad, MD 797-1404 797-1405 Plastic Surgery & Aesthetics Carley M. Howard Draddy, MD 797-1404 797-1405 J. Cart de Brux Jr., MD 454-4570 454-4575 Patricia C. Onuegbu, MD 797-1404 797-1405 Psychology Ann Marie Patterson Ravindran, MD 797-1404 797-1405 Kristina M. Kania, PhD 454-5115 241-9205 Rebecca P. Wright, MD 797-1404 797-1405 Anne M. Kinsman, PhD 454-5115 241-9205 Minor Care Frederick P. List, PhD 454-5115 241-9205 Children’s Hospital After-hours Care (Greenville) Julie M. Maldonado, PhD (formerly Kellett) 454-5115 241-9205 Staffed by current GHS pediatricians 271-3681 271-3914 Cara Reeves, PhD 675-FITT 627-9131 Children’s Hospital Spartanburg Night Clinic Jane A. Ford, PsyD 454-5115 241-9205 Staffed by current GHS pediatricians 804-6998 596-5164 Benjamin A. Jones, PsyD 454-5125 241-9201 Neonatology/Bryan Neonatal Intensive Care Unit Ermindo J. Natale, PsyD 454-5115 241-9205 India C. Chandler, MD 455-7939 455-3685 Cortney V. Rieck, PsyD 454-5115 241-9205 Benton E. Cofer, MD 455-7939 455-3685 Pulmonology Nicole A. Cothran, MD 455-7939 455-3685 Michael J. Fields, MD, PhD 454-5530 241-9246 J. Thomas Cox, MD 455-7939 455-3685 Sterling W. Simpson, MD 454-5530 241-9246 Amber E. Fort, DO 455-7939 455-3685 Steven M. Snodgrass, MD 454-5530 241-9246 Matthew F. Halliday, MD 455-7939 455-3685 Radiology R. Catrinel Marinescu, MD 455-7939 455-3685 455-7107 455-6614 Bryan L. Ohning, MD, PhD 455-7939 455-3685 Michael B. Evert, MD Erin M. Horsley, DO 455-7107 455-6614 Jeffrey M. Ruggieri, MD 455-7939 455-3685 455-7107 455-6614 Michael S. Stewart, MD 455-7939 455-3685 Michael A. Thomason, MD Rheumatology M. Whitson Walker, MD, MS 455-7939 455-3685 Lara M. Huber, MD, MSCR 454-5004 241-9202 Nephrology & Hypertension Sarah B. Payne-Poff, MD 454-5004 241-9202 T. Matthew Eison, MD 454-5105 241-9200 Sleep Medicine/Center for Pediatric Sleep Disorders Sudha Garimella, MD 454-5105 241-9200 Dominic B. Gault, MD 454-5660 241-9233 Scott W. Walters, MD 454-5105 241-9200 Jonathan P. Hintze, MD 454-5660 241-9233 Neurology Roni Socher, MD 454-5660 241-9233 Michael A. Babcock, MD 454-5110 241-9206 Supportive Care Team Emily T. Foster, MD 454-5110 241-9206 Arun L. Singh, MD 455-5129 455-5075 Addie S. Hunnicutt, MD 454-5110 241-9206 Cary E. Stroud, MD 455-5129 455-5075 Augusto Morales, MD 454-5110 241-9206 Surgery Sunjay R. Nunley, MD 454-5110 241-9206 John C. Chandler, MD 797-7400 797-7405 William C. Taft, MD, PhD 454-5110 241-9206 Robert L. Gates, MD 797-7400 797-7405 Neurosurgery James F. Green Jr., MD 797-7400 797-7405 E. Christopher Troup, MD 797-7440 797-7469 Keith M. Webb, MD 797-7400 797-7405 New Impact: A Healthy Lifestyle Program Urgent Care (Anderson) Laure A. Utecht, MD 675-FITT 627-9131 512-6544 512-6995 Newborn Services Callie C. Barnwell, MD Artur A. Charowski, MD 512-6544 512-6995 Jessica P. Boyd, MD 455-8401 455-3884 Anna C. Neal, MD 512-6544 512-6995 Jennifer A. Hudson, MD 455-8401 455-3884 Jonelle M. Oronzio, MD 512-6544 512-6995 Urology Regina D. Monroe, MD 454-5135 241-9200 ghschildrens.org 18-0631 Revised 7/18 J. Lynn Teague, MD, MHA 454-5135 241-9200

CLINICAL RESEARCH UPDATE Research studies at Children’s Hospital of Greenville Health System (GHS) are approved by the system’s Institutional Review Board.

Pediatric Pulmonology Research The Division of Pediatric Pulmonology is involved in much ongoing active research related to our Cystic Fibrosis (CF) program, pediatric asthma and developing collaboration with our primary GHS research partner, Clemson University. The pediatric CF program continues to participate in the IRBapproved CF patient registry. Over many decades, this registry has made a vital contribution to a vast database of CF-related outcome measures, trends and opportunities for research that have directly shaped clinical care in many positive ways. The national CF Foundation (CFF) registry has been a longstanding example for other chronic diseases since its inception in the 1950s. Our annual program-specific registry report is used to constantly guide quality-improvement (QI) efforts for our patients and families, resulting in ongoing projects. Some of these projects have been presented at the national CF meetings in the past. Related to our ongoing CF QI, several multidisciplinary team members recently began participating in the CFF’s Virtual Improvement Program—Fundamentals 3. This program was begun by attendance at an introductory short course at last year’s national CF meeting in Indianapolis and has been followed by regular meetings related to our QI project. The project focuses on improving nutritional parameters in our youngest CF patients immediately after diagnosis. Our participation in this program includes virtual coaching and meetings with QI experts, and interaction with other participating CF centers. An added benefit of our participation in this program has been outstanding team-building and an early improvement in clinic processes and workflows related to our project goals. Christy Clarke, LMSW, a CF center social worker, presented an abstract on mental health assessment in a CF clinic population at the Southeastern Symposium on Mental Health in May. In alignment with an increased recent emphasis from the CF Foundation on the role of mental health in this chronic disease and their published guidelines, our multidisciplinary team has focused on improving screening and treatment for various mental health disorders for both patients and families.

Dr. Goutam Koley, MS, PhD, professor of electrical and computer engineering at Clemson University, recently was awarded a Clemson University School of Health Research (CUSHR) fellowship for protected time to spend in Pediatric Pulmonology developing ongoing collaboration and research projects related to pediatric asthma, in addition to exploring opportunities for other research endeavors. Steven Snodgrass, MD, and Dr. Koley have been the recent recipients of a transformational GHS seed grant. This grant will be used to specifically study the environments of children with high-risk asthma and to employ environmental monitoring devices to assess the role of particulates, volatile organic compounds, and other factors. The goal of the project is to be able to link high-risk patients to additional resources for expanded case management, environmental control measures and education, and ultimately improve outcomes and overall asthma control. A related project is in its early stages to study similar environmental factors at the GHS Wonder Center, a day treatment program program for medically complex children. Many of these children have chronic underlying respiratory problems that may be impacted by their environment. Dr. Snodgrass and Dr. Koley are working to build a strong continuing research collaboration that will include working with others at GHS Children’s Hospital, especially within the Bradshaw Institute for Community Child Health & Advocacy and in School-based Health Centers.

MAiN Program Continues to Gain Momentum Researchers working on the MAiN (Managing Abstinence in Newborns) program at GHS had an article published in the June 2018 edition of the Joint Commission Journal. It was accompanied by an editorial by Maya Balakrishnana, MD, medical director of Quality for the Florida Perinatal Quality Collaborative, and Gautham Suresh, MD, DM, MS, section head and service chief of Neonatology at Texas Children’s Hospital in Houston and member of the Advisory Board of the Joint Commission Journal, on the importance of evidencebased management for neonatal abstinence syndrome. Jennifer Hudson, MD, medical director of Newborn Services at Children’s Hospital, and Rachel Mayo, PhD, a professor with Clemson University’s Department of Public Health 21 Sciences, are co-lead investigators.

COLLABORATING FOR BETTER CARE Multidisciplinary approach to treating plagiocephaly yields positive results.

The Shape of Heads to Come By Anne Smith

Parents and Pediatricians: The First Line of Defense Plagiocephaly can become apparent when a baby is between 2 and 4 months old. As soon as a concern arises, parents should contact their pediatrician. Megan Davis, a Greenville mom of three, observed late last year that her youngest son’s head had an atypical shape.

“About a month after Roman was born, I noticed his head didn’t look like his brothers’, but I couldn’t put my finger on why,” Davis recalled. Her next step—calling a physician—was the right one, according to Joe Maurer, MD. Dr. Maurer is a pediatrician with The Children’s Clinic, a practice of Greenville Health System (GHS). Pediatricians are the first line of defense for parents and caregivers’ concerns of any kind, he added.

Roman Davis sports his cranial remolding helmet. Photo provided by Megan Davis.

The first few months of a baby’s life are a time of tremendous growth. One area of especially noticeable change is a newborn’s head, which starts out soft to ease passage through the birth canal. That malleability sometimes means babies’ skulls can develop an unusual shape. Plagiocephaly is quite common and develops when a baby’s head experiences repeated pressure in one area, flattening it in that spot. Sometimes brought on by a baby’s preference for sleeping or sitting with the head turned consistently in the same direction, plagiocephaly is a treatable condition that requires early intervention. Treatment can include performing special exercises, varying sleep and play position, wearing custommade cranial remolding helmets and, in some cases, having surgery.

“I recommend parents ask me their questions right away, as opposed to worrying or going online,” Dr. Maurer said. “I’d rather be the source of answers than have them get information that may not be accurate or applicable.” A pediatrician can offer more than just reassurance to families, noted Andrew Burgess, MD, of GHS Pediatrics & Internal Medicine–Wade Hampton. “We often send parents home with exercises to incorporate into their baby’s routine, as well as guidelines for tummy time and sleep positioning,” Dr. Burgess stated. “Outcomes suggest that early physical therapy is very beneficial, and a referral to PT may be our next step in cases where it’s warranted.” Elizabeth Hitchcock, a physical therapist with Kidnetics®, the pediatric therapies arm of GHS Children’s Hospital, reiterated that early intervention makes all the difference: “Before 3 months of age, newborns’ heads are so malleable that plagiocephaly is more easily treated with conservative measures.”

An Increasing Concern

The incidence of plagiocephaly has skyrocketed in recent decades, according to Hitchcock. “The Back to Sleep program started 25 years ago to reduce sudden infant death syndrome (SIDS), and it has been a wonderful success,” she remarked. “SIDS deaths have been cut in half simply by placing babies on their backs to sleep. As a result, though, the incidence of positional plagiocephaly has increased markedly. Infants are lying on their backs so much that their heads aren’t rounding out as they would otherwise.” Hitchcock pointed out that simple solutions exist to this conundrum. “A physical therapist’s first intervention to all parents, whether they are concerned about baby’s head shape or not, is to advise as much tummy time as their baby will tolerate,” she said. “Not only will it strengthen infants’ back, neck and shoulder muscles, but it also takes pressure off the back of their heads. Incorporating snippets of tummy time throughout the day, aiming for at least one hour, will allow the baby’s head to reshape beautifully.”

Benefits of Physical Therapy

When positioning alone does not allow an infant’s skull to properly reshape, families are referred to physical therapy. The same is true for babies with torticollis, a tightening of the neck muscle, which makes them look to one side or the other and interferes with typical head shape development. Mary Jones, Kidnetics’ physical therapy supervisor, stressed that cases don’t need to be severe to benefit from therapy. “We would rather see parents and tell them that they don’t need us than find out later that we should have intervened months beforehand,” Jones emphasized. “Particularly if plagiocephaly is due to a muscle tightness in the neck or a baby’s habit of looking in one direction, allowing it to become a longer-term habit can make it harder to resolve. If we see an infant early, we can work through issues faster.” When caregivers are referred to Kidnetics, they can expect a therapist to observe their infant’s range of motion, take measurements of the head and make decisions based on those findings. Kidnetics sometimes sends patients to GHS’ Center for Prosthetics & Orthotics after taking initial measurements. Many families see positive changes simply from positioning their babies upright in baby carriers, adjusting their sleep positions, providing more tummy time and incorporating recommended exercises. “We may see them for a month, measure again and see enough improvement to let parents continue these new habits at home,” stated Jones.

“Caregivers walk away with tools that benefit their babies long after they leave Kidnetics.” — Elizabeth Hitchcock, physical therapist with Kidnetics Hitchcock, who spearheaded Kidnetics’ torticollis physical therapy program, added that head shape and neck tightness have more than just aesthetic consequences: “Over time, babies can develop facial asymmetries, which may lead to feeding issues, using one side of the body more than the other, and even vision difficulties. It’s about a lot more than a roundshaped head; catching these cases early can prevent long-term issues.” Rather than treating just the infant, Kidnetics therapists make sessions a family affair. “We demonstrate massage techniques, how to improve neck range of motion, how to perform exercises that will strengthen their babies,” Hitchcock explained. “Caregivers walk away with tools that benefit their babies long after they leave Kidnetics.”

Cranial Remolding

If physical therapy and repositioning do not improve a child’s head shape or when a pediatrician and PT team determine additional reshaping efforts are needed, the next step may be a referral to the GHS Center for Prosthetics & Orthotics for cranial remolding. “These specialists create molding helmets to help round out a baby’s head shape,” remarked Katie Lichty, NP, with GHS’ Division of Pediatric Neurosurgery. “Patients usually respond very well to custom-made helmets.” These helmets function alongside a baby’s natural growth to reshape the skull in a customized orthotic lined with foam. Regular reviews and adjustments ensure that the patient is responding to treatment as expected. But not every baby referred to the center needs a helmet. “We see about 300 children a year for a plagiocephaly evaluation and may only recommend treatment on half of

them,” said Todd O’Hare, a certified prosthetist/orthotist and manager of the center. O’Hare added that the process is gentle, not painful. He continued: “Patients have weekly follow-ups, often for 10-18 weeks, and then that chapter of a baby’s life is closed. It’s a new and scary thing for parents, but their babies are in experienced hands here. Our level of specialized technology for evaluation and treatment sets us apart. We’ve focused on treating infants with plagiocephaly for over 15 years, and we see at least three to five children per day for evaluations, fittings and follow-ups.”

When Neurosurgery Is Needed

Occasionally, babies with plagiocephaly or similar concerns are referred to Christopher Troup, MD, at GHS Pediatric Neurosurgery to rule out craniosynostosis, a condition in which a baby’s skull bones fuse together and create an atypical head shape. “An infant’s skull is actively molding, so it is not one solid thing,” explained Dr. Burgess. “It has different suture lines that separate it until it’s fully fused. If a suture closes prematurely, it limits the skull’s ability to grow as the brain does, and that’s a cause for concern.” Babies presenting with craniosynostosis get an instant referral to Dr. Troup and his team. “We are fortunate to have a world-class pediatric neurosurgeon here in Greenville,” Dr. Maurer emphasized. “Professionally, he is unmatched; personally, he is entirely committed to the care of his patients and families.” Dr. Burgess concurred: “Many cities our size don’t have access to a surgeon at his level without hours of travel. He and his team of nurse practitioners are a tremendous resource to Children’s Hospital and our patients.” Lichty said that Pediatric Neurosurgery performs several suture surgeries a month for patients with craniosynostosis, usually seeing 20-25 plagiocephaly cases a week. “A lot of times these babies are referred for abnormally shaped heads,” she said. “When we assess and possibly scan them, we can determine their exact diagnosis and how to treat it.” For Roman Davis, a referral to Pediatric Neurosurgery and a CT scan confirmed that the 3-month-old had sagittal craniosynostosis, which required surgery. His mom admitted the timing was perfect. Lichty agreed, noting that the window of time for action ideally is less than 5 months old, but there are other surgical interventions available if the child is older.

Top: Jeanne-Marie Beaupre, CPO, a prosthetist/orthotist with the Center for Prosthetics & Orthotics, shaves down the foam inside a cranial remolding helmet; bottom: Beaupre examines a young patient during a follow-up appointment.

“We are fortunate to have a worldclass pediatric neurosurgeon here in Greenville.” — Joe Maurer, MD

Above: Roman Davis immediately after his surgery for sagittal craniosynostosis at age 3 months; right: Family photo of Roman Davis and his parents and older brothers. Photos provided by Megan Davis.

“The brain has nowhere to go when a baby’s skull sutures are fused,” Davis pointed out. “We are thankful to have corrected this issue when we did.” Sending a baby into surgery isn’t something she anticipated, Davis acknowledged, but “Dr. Troup put us at ease. Skull surgery seems overwhelming, but he made us feel like it would be like a simple trip to the dentist. The process could not have gone better.” After surgery, families can see an immediate improvement. “Even before we leave the operating room, we see the head round out,” Lichty stated. Within 48 hours of surgery, Davis recalled that Roman looked “like a completely different baby, like he was meant to look all along.” “Today, he’s busy crawling around with a perfectly round little head,” she said. “It’s not a condition that will affect him at all long term. He will be able to run, jump, play and do everything his brothers do.”

Continuity of Care

the puzzle. It’s the ideal set-up for patients with plagiocephaly, craniosynostosis and other differential diagnoses.” Jones pointed out the convenience of storing all patients’ health information on a central electronic medical record: “We have our notes on Epic, share every session’s details with our patient’s pediatrician and collaborate with the orthotics team, too. We can see each round of measurements as they’re updated, so the whole team stays informed.” For every member of the GHS team, the vision is long-term, according to Hitchcock. “We want to take away the mystery and emphasize that head shape concerns are transient,” she remarked. “This time next year, the family should not be worrying about these issues.”

Within GHS, patients’ families have access to many specialists under one umbrella.

O’Hare appreciates that within GHS, his patients’ families have access to many specialists under one umbrella, saying, “We communicate, collaborate and bring every necessary piece to 25

CELEBRATIONS

Children’s Hospital of Greenville Health System (GHS) has many reasons to celebrate! Camps Receive Funds from Charitable Events Camp Cary’s Kids, GHS Children’s Hospital’s summer camp experience for children with complex medical conditions, received a donation of $20,000 from the Rose Ball, one of Greenville’s longest-running charitable community events. The ball was held in September 2017. Meanwhile, the St. Paddy’s Day Dash & Bash, a 5K walk/run and post-run event on March 17, contributed $18,000 of the funds raised to Children’s Hospital’s Camp Buddy, a camp experience for children with diabetes.

2017 Virtual Toy Drive Tops $69,000 The 2017 Virtual Toy Drive Campaign, sponsored by WYFF 4, raised $69,044.38 for GHS Children’s Hospital patients and families. Those funds will help purchase items to enhance the care and quality of life for children while they are hospitalized, such as art supplies, books, DVDs, clothing and distraction items. Although the 2017 campaign has ended, the Virtual Toy Drive website is available throughout the year for those who want to donate in 2018!

Local Business Donates Buddy Boxes ScanSource, a Greenville-area business, organized an event for employees in January in which team members packaged 475 Buddy Boxes—boxes filled with age-specific toys, activities and comfort items given to children while they are in the hospital or having an outpatient procedure or a long visit. 26

Dr. Schmidt Awarded State’s Highest Civilian Honor William F. Schmidt III, MD, PhD, founder and a longtime medical director of Children’s Hospital, was awarded the Order of the Palmetto in May. The Order of the Palmetto is the state’s highest civilian honor. “I’m humbled and honored by this award, but it really represents the work of many people in many different areas of expertise and service over many years,” Dr. Schmidt said. He was recruited to GHS in 1990 as medical director of what would become Children’s Hospital. The pediatric cancer specialist grew the program from a few general pediatric practices to the area’s largest children’s hospital, providing primary and specialty care for 400,000 children yearly. “Our goal has always been to provide children with access to high-quality health care as close to home as possible,” Dr. Schmidt said. During his 27-year tenure as medical director, he grew the hospital to offer over 40 pediatric medical and surgical specialties. Children’s Hospital also has the most advanced trauma center for children in the Upstate. It has the Upstate’s only pediatric cancer center, which Dr. Schmidt partnered with BI-LO Charities to expand even further. His work with community partners like the Clement’s Kindness Foundation also helped create Camp Courage, a summer camp for children with cancer and blood-related diseases. Dr. Schmidt is the founding president of the South Carolina Children’s Hospital Collaborative. The collaborative brings together the four S.C. children’s hospitals to advocate for children’s healthcare needs in the state.

CELEBRATIONS

GMH Achieves Magnet® Recognition

Dance Marathons Support Children’s Hospital

GHS’ Greenville Memorial Hospital, which houses Children’s Hospital, was granted Magnet recognition by the American Nurses Credentialing Center (ANCC), reflecting a commitment to nursing professionalism, teamwork and superiority in patient care.

Six local colleges and universities—Erskine College, Furman University, University of South Carolina Upstate, Wofford College, Western Carolina University and Clemson University— pledged monies from their Dance Marathon fundraisers to Children’s Hospital.

The ANCC’s Magnet Recognition Program® is the highest national honor for nursing excellence and distinguishes organizations that meet rigorous standards for delivery of care. Just 471 out of over 6,300 U.S. hospitals have achieved Magnet recognition, placing GMH on an elite list of top nursing hospitals in the country. Research demonstrates that Magnet recognition provides specific benefits to healthcare organizations and their patients, including higher patient satisfaction with nurse communication, a lower risk of 30-day mortality and lower fail to rescue rates, and higher job satisfaction among nurses.

Funds from the Dance Marathons totaled $316,155. Those funds will be used for the renovation of the Healing Garden on Greenville Memorial Medical Campus (which houses GHS Children’s Hospital), to create an endowment for supporting Children’s Hospital camps, to support a Child Life staff position for children with a parent in the hospital and to support other critical needs. Gov. Henry McMaster declared April 25 as “South Carolina Dance Marathon Day” to honor and recognize the work Dance Marathon programs are doing for children’s hospitals in the state. Students involved with Clemson Miracle (the university’s Dance Marathon) traveled to the State House for the occasion. GHS’ Office of Philanthropy & Partnership currently is working with high schools around the Upstate about the possibility of developing Dance Marathons at that level, too.

GMH also earned an A in the spring 2018 Leapfrog Hospital Safety Grades, which reviews 27 measures of publicly available hospital safety data.

Dr. Saul Receives Award from AAP Robert A. Saul, MD, medical director of General Pediatrics at GHS Children’s Hospital, was awarded the 2018 David W. Smith Award for Excellence in Genetics and Birth Defects Education from the American Association of Pediatrics (AAP). This award was created in 2010 as a biennial teaching honor to celebrate individuals for lifetime accomplishments as a genetics and birth defects educator. Dr. Saul, a former researcher with Greenwood Genetic Center, is the sixth awardee.

Students with Clemson Miracle (the university’s Dance Marathon) hold up the amount raised at the school’s Dance Marathon this spring.

Celebrations continue on page 29

BULLETIN FROM THE BRADSHAW INSTITUTE This section highlights an area of focus for Bradshaw Institute for Community Child Health & Advocacy, part of GHS Children’s Hospital.

Comprehensive School Health Greenville County Schools, United Way, Girls on the Run, Girlology and SHARE Head Start. Central components of the project are in place. Health promotion programs Farm to Belly, Wheels to Wellness, Hallways to Health and School-based Health Centers (SBHCs) have been implemented in multiple Greenville County Schools and will expand to other locations this fall.

The Bradshaw Institute is behind initiatives such as School-based Health Centers in four upstate middle schools.

Bradshaw Institute for Community Child Health & Advocacy was one of the initial nine grantees of the Greenville Health Authority’s (GHA) Healthy Greenville initiative for projects to improve the health of Greenville County residents. In 2017, Bradshaw Institute was granted $3.38 million over five years to create a streamlined, comprehensive health initiative that serves Greenville County’s highest-need children. This program will provide students with health education, nutritional and physical activity opportunities, and psychological support through Compassionate Schools training. In 1998, a landmark study found that traumatic adverse childhood experiences (ACEs) were directly related to common causes of death in adulthood, including obesity and diabetes, as well as negative behaviors like smoking and binge drinking. Research shows that 60% of adults in the Upstate have experienced at least one ACE, and 17% have experienced four or more. Bradshaw Institute’s health promotion interventions address ACEs by building resilience in children as young as preschool to protect them against these potential negative coping behaviors and poor health outcomes. The project aims to further develop and integrate the comprehensive school-based health initiatives already active at Bradshaw Institute. All activities occur within Greenville County with a focus on West Greenville. Community partners include

Girls on the Run, underway at GHS, will be able to establish several more sites, and hundreds of girls will receive scholarships to take part. Girlology is being implemented across Greenville County; this new collaboration will help expand its reach to some of the highest-need children. Compassionate Schools training also is underway in middle schools targeted by United Way of Greenville County’s OnTrack Greenville program, and a trauma-informed coordinator has been hired. The project was organized into five workgroups: • Clinic Infrastructure/Expansion • Health Promotion in Schools • Health Promotion with Community Partners • Compassionate Schools • Research/Metrics In addition, the Bradshaw Institute is a partner in OnTrack Greenville’s Middle Grades Success Initiative and operates SBHCs at Tanglewood Middle School, Lakeview Middle School, Berea Middle School, and Greenville Early College. GHA funding will allow the Bradshaw Institute to hire a second clinical team to expand the capacity of the current SBHCs and open a new center at Carolina High School this fall.

Highlights of the work accomplished in each workgroup for Year 1 appear below: Clinic Infrastructure/Expansion • Operated four SBHCs • Completed over 570 student visits in the 2017-18 school year • Engaged with Greenville County Schools to expand services to Carolina High School

Health Promotion in Schools • Identified four SHARE Head Start Centers, three elementary schools, four middle schools and two high schools in Greenville County that follow a direct feeder pattern • Provided 290 students with Farm to Belly curriculum at two SHARE Head Start Centers • Served 79 students in four weeks of Wheels to Wellness bicycle clinic at one target elementary school; implementation is underway for two weeks of the clinic at eight community centers this summer • Collaborated with two community centers to provide afterschool Wheels to Wellness Bike Club starting fall 2018 • Implemented 33 Hallways to Health events at four target middle schools; expansion to three elementary schools and one high school will occur this fall Health Promotion with Community Partners • Provided 76 students with full scholarships to participate in Girls on the Run’s spring 2018 session in four target elementary schools

Compassionate Schools • Hired a trauma-informed social worker • Collaborated with University of South Carolina’s Upstate Child Protection Center to develop a framework for implementation Research/Metrics • Engaged with Girls on the Run, Girlology and traumainformed social worker to determine an evaluation plan for Year 1 • Continued existing evaluation efforts with Farm to Belly, Hallways to Health, SBHC and Wheels to Wellness programs • Engaged The Riley Institute about collaborative evaluation efforts between this project and OnTrack Greenville

Article author Kerry Sease, MD, is medical director of Bradshaw Institute for Community Child Health & Advocacy.

• Organized a Girlology event at Kroc Community Center this summer

CELEBRATIONS

Continued from page 27

Dr. Buchanan Selected for National Committee April O. Buchanan, MD, assistant dean for Academic Affairs at the University of South Carolina School of Medicine Greenville and a pediatric hospitalist with GHS Children’s Hospital, has been selected as the Undergraduate Medical Education Representative and Steering Committee Member for the American Association of Medical Colleges’ Southern Group on Education Affairs.

Dr. Gauderer’s Article Remains Popular As part of the Journal of Pediatric Surgery’s celebration of its 50th anniversary, the organization released its top-cited papers during that time. Holding down the No. 1 spot—by far, according to the journal—is a 1980 paper co-authored by now-retired Michael Gauderer, MD, longtime pediatric surgeon at Children’s Hospital, that describes percutaneous endoscopic gastronomy in 12 children. There have been 1,359 citations of this article.

In this role, she also will serve as member of the national Undergraduate Medical Education Steering Committee. Her responsibilities include promotion of educational innovations and research at regional and national meetings and participation in educational initiatives related to medical student education. 29

A S K T H E FAC U LT Y

Pediatric Migraines Q: I suspect a patient has migraines. What are the recommendations for treatment, and when does a child need to see a specialist for migraines? A: Headaches are a common problem seen by primary care providers, emergency department (ED) providers and neurology providers alike. The prevalence of headaches in children and adolescents has been estimated at about 58%, with about 8% having migraines (Abu-Arafeh et al. 2010). Migraines in children can lead to missed school days, difficulty completing schoolwork, missed work for parents and increased healthcare visits. A study showed that ED visits for headache increase in the fall when the school year is starting (Pakalnis and Heyer 2016).

Migraines in children and adolescents can differ slightly from migraines in adults. According to the International Classification of Headache Disorders, in order to be diagnosed with migraines, the pediatric patient should have at least five attacks of headache lasting 2-72 hours (as opposed to at least 4 hours in adults). At least two of the following must be true: unilateral location (can be bilateral in pediatric populations), pulsating quality, moderate or severe pain intensity, or the patient avoids routine physical activity since the headache makes the pain worse. In addition, the patient should experience nausea and/or vomiting or photophobia and phonophobia. When a pediatric patient presents to the PCP with symptoms consistent with migraine, lifestyle modifications and overthe-counter medications are the most important first steps in treatment. A headache log to help identify triggers can be helpful as well. Many pediatric patients are dehydrated and/ or drink caffeinated beverages, both of which can trigger migraines. Encouraging the child to increase water intake and stop drinking caffeine can be very useful. In addition, ensuring that the child doesnâ&#x20AC;&#x2122;t skip meals and gets adequate sleep (with a consistent bedtime each night) are important when discussing headache hygiene. Another important avenue of treatment is cognitive behavioral therapy (CBT) or biofeedback therapy (Trautmann et al. 2006). These are particularly important when the child or adolescent is noted to have stressors or anxiety as potential headache triggers. Over-the-counter medications such as ibuprofen, acetaminophen or naproxen should be used at the appropriate dose for age and weight to help treat the pain associated with the headache. These medications should not be used more than three times a week for more than three weeks, as this can lead to analgesic overuse headaches.

Migraines in children and adolescents can differ slightly from migraines in adults. 30

Pediatric Specialty Services

If migraines are present at least once a week, and especially if they are causing the child to miss school or visit the nurse’s office frequently, a preventive migraine medication can be considered. The most common first-line preventive medications we use are amitriptyline (up to 1 mg/kg/day) and topiramate (up to 1-2 mg/kg/day). The Childhood and Adolescent Migraine Prevention (CHAMP) study, published in the New England Journal of Medicine in 2017, showed that there was no difference between topiramate, amitriptyline, and placebo when examining reduction in headache frequency and disability (Powers et al. 2017). Therefore, a careful discussion of side effects and family-centered decision should take place as to what preventive medication to start. If an adequate trial of appropriately dosed abortive and preventive migraine medication fails to improve migraines, a pediatric neurology referral is recommended. In addition, neuroimaging typically is performed if the patient experiences red-flag symptoms such as signs of increased intracranial pressure, sudden continuous headache, focal neurologic deficits, headaches awakening the patient from sleep or occipital headaches. Because migraines are common in the pediatric population and can cause debilitating consequences, increased education for patients, families and providers on the front line is very important. Continued lifestyle modifications along with a medication regimen, if indicated, can help children and adolescents get back to school and to the activities they enjoy.

References:

1. Abu-Arafeh I, Razak S, Sivaraman B, Graham C. Prevalence of headache and migraine in children and adolescents: a systematic review of populationbased studies. Dev Med Child Neurol. 2010;52(12):1088-1097. 2. Pakalnis A and Heyer GL. Seasonal variation in emergency department visits among pediatric headache patients. Headache 2016;56(8):1344-1347. 3. International Classification of Headache Disorders. Migraine without aura. Retrieved from https://www.ichd-3.org/1-migraine/1-1-migraine-withoutaura/. 4. Trautmann E, Lackschewitz H, and Kroner-Herwig B. Psychological treatment of recurrent headache in children and adolescents—a meta-analysis. Cephalalgia 2006;26(12):1411-1426. 5. Powers W et al. Trial of amitriptyline, topiramate, and placebo for pediatric migraine. New England Journal of Medicine 2017;376(2):115-124.

Robin N. LaCroix, MD________________________________________ (864) 455-8401 Medical Director; Chair, Department of Pediatrics Matthew P. Grisham, MD___________________________________________ 455-7895 Pediatric Residency Program Director Russ C. Kolarik, MD________________________________________________ 455-7844 Medicine-Pediatrics Residency Program Director Desmond P. Kelly, MD______________________________________________ 454-5115 Developmental-Behavioral Fellowship Program Director Adolescent Pediatrics_______________________________________________ 220-7270 Allergy and Immunology____________________________________________ 675-5000 Ambulatory Pediatrics ______________________________________________ 220-7270 Behavioral Health__________________________________________________ 455-5612 Cardiology ________________________________________________________ 454-5120 Child Advocacy Medical Program____________________________________ 335-5288 Critical Care_______________________________________________________ 455-7146 Developmental Pediatrics___________________________________________ 454-5115 Emergency Pediatrics_______________________________________________ 455-6016 Endocrinology_____________________________________________________ 454-5100 Gastroenterology___________________________________________________ 454-5125 Genetics__________________________________________________________ 250-7944 Hematology/Oncology_____________________________________________ 455-8898 Infectious Disease__________________________________________________ 454-5130 Minor Care (Spartanburg Night Clinic)________________________________ 804-6998 Children’s Hospital After-Hours Care_______________________________ 271-3681 Neonatology______________________________________________________ 455-7939 Nephrology & Hypertension_________________________________________ 454-5105 Neurology_________________________________________________________ 454-5110 Neurosurgery______________________________________________________ 797-7440 Newborn Services__________________________________________________ 455-8401 Ophthalmology____________________________________________________ 454-5540 Orthopaedic Oncology______________________________________________ 797-7060 Orthopaedic Surgery________________________________________________ 797-7060 Plastic Surgery_____________________________________________________ 454-4570 Pulmonology______________________________________________________ 454-5530 Radiology_________________________________________________________ 455-7107 Rheumatology_____________________________________________________ 454-5004 Sleep Medicine____________________________________________________ 454-5660 Supportive Care Team______________________________________________ 455-5129 Surgery___________________________________________________________ 797-7400 Urgent Care (Anderson)____________________________________________ 512-6544 Urology___________________________________________________________ 454-5135

Children’s Hospital Programs BI-LO Charities Children’s Cancer Center______________________________ 455-8898 Bradshaw Institute for Community Child Health & Advocacy_____________ 454-1100 Bryan Neonatal Intensive Care Unit___________________________________ 455-7939 Child Life_________________________________________________________ 455-7846 Cystic Fibrosis Clinic________________________________________________ 454-5530 Family Connection_________________________________________________ 331-1340 Ferlauto Center for Complex Pediatric Care____________________________ 220-8907 Gardner Center for Developing Minds_________________________________ 454-5115 Girls on the Run___________________________________________________ 455-4001 Infant Apnea Program______________________________________________ 455-3913 International Adoptee Clinic_________________________________________ 454-5130 Kidnetics® (pediatric therapies)______________________________________ 331-1350 Neonatal Developmental Follow-up Services___________________________ 331-1333 New Impact (weight management)_____________________________ 675-FITT (3488) Office of Philanthropy & Partnership/CMN____________________________ 797-7735 Pediatric HIV Clinic_________________________________________________ 454-5130 Safe Kids™ Upstate________________________________________________ 454-1100 Spiritual Care______________________________________________________ 455-7942 Wonder Center____________________________________________________ 331-1380 Day treatment for medically fragile children

For admission to Children’s Hospital: (864) 455-0000

This number connects you to GHS’ Patient Referral and Transfer Center, which can handle all arrangements for admission. You also may call 455-7000 and ask the operator to page the admitting resident.

Article author Sunjay Nunley, MD, is a pediatric neurologist and epileptologist in GHS Children’s Hospital’s Division of Pediatric Neurology.

Neonatal Transport: (864) 455-7165 To reach a Children’s Hospital doctor or program, call 1-800-4RBUDDY. Pediatric Outpatient Service Locations Call the appropriate Greenville number above for an appointment.

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(864) 573-8732 Cardiology Child Advocacy Medical Program Endocrinology Gastroenterology Hematology/Oncology Infectious Disease Kidnetics®

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GHS Vision Transform health care for the benefit of the people and communities we serve. GHS Mission Heal compassionately. Teach Innovatively. Improve constantly. GHS Values Together we serve with integrity, respect, trust and openness.

For information about Children’s Hospital giving opportunities, call GHS’ Office of Philanthropy & Partnership at (864) 797-7732 or visit ghsgiving.org.

A Royal Welcome A new four-legged staff member joined the team at Children’s Hospital of Greenville Health System (GHS) in April when King, an 18-month-old golden retriever, became the fourth facility dog on the Canine F.E.T.C.H. (Friends Encouraging Therapeutic Coping and Healing) Unit. The dogs that are part of the unit are specially trained canine therapists that provide physical, social and emotional support to patients at GHS Children’s Hospital. The funding to obtain King was donated by an anonymous benefactor who was moved by the story of a former patient at Children’s Hospital, Betsy Eye, who passed away in 2017. Each facility dog costs approximately $25,000 to train for a hospital setting. The donor had read an account of Eye’s struggle with chronic illness on a blog run by her friend and former hospital mate, Brynn Duncan, who was present at King’s unveiling celebration. King, Children’s Hospital’s newest facility dog, is an 18-month-old golden retriever that will work with the hospital’s Supportive Care Team.

Connect on Instagram: thecaninefetchunit

Visit our website: ghschildrens.org

King will work as a dedicated member of the Supportive Care Team of Children’s Hospital alongside handler Arun Singh, MD, medical director of the unit. Eye was the first pediatric patient to be admitted into this team’s care.

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