Focus on Pediatrics Winter 2018 by Prisma Health

Medical-Legal Partnerships Supporting Adolescents and Young Adults with Cancer Ask the Faculty: Burnout

Vol. 30.1 Winter 2018

on Pediatrics

Vaccines: Deal of the Century

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 Karen Cantu Donna Carver, CFRE Kristi Coker, PhD, MHA, RN Jeanine Halva-Neubauer Jennifer Hudson, MD Emily Hughes Eric Nash 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

A New Beginning As most of you are aware, the larger Greenville Health System (GHS) organization is in the midst of significant and important governance changes, optimizing itself for the eventuality of population health management. Now is the perfect time to also transition our Children’s Hospital programs to new leadership. So, on November 30, 2017, I officially passed the baton of leadership over GHS Children’s Hospital to Robin LaCroix, MD, who will serve as chair of Pediatrics and medical director of Children’s Hospital. Dr. LaCroix was selected after an intensive internal search and is superbly qualified to step into this role. After completing her Pediatrics residency at GHS, she spent a brief time in primary care before going to Emory for a fellowship in Pediatric Infectious Diseases. She returned to Children’s Hospital as our first medical director in that specialty and demonstrated a penchant for leadership early on. For the past three years, she has served as vice chair for Pediatric Quality and Medical Staff Services, which involved the responsibility of managing our hospital-based employed pediatricians. I have no doubt that Dr. LaCroix is ready to lead our Children’s Hospital programs and our more than 150 employed pediatricians and pediatric specialists to exciting new heights.

As for me, I have shifted my full focus to being vice president for Development at GHS Health Sciences Center, and doing my part to make philanthropy a strategic imperative in the new order. It has been a distinct privilege and honor for me to serve since 1990 as the inaugural medical director of Children’s Hospital and to help mold the programs we have in place today. When I first arrived in Greenville, I viewed the children’s program as a jewel in the rough. I still think of it that way, and I anticipate that we will continue to grow and provide outstanding care and new initiatives for our patients and their families. The future for Children’s Hospital is bright, and I am grateful and proud to have been part of its history!

William F. Schmidt III, MD, PhD Chair Emeritus, Department of Pediatrics

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

Dr. LaCroix was selected after an intensive internal search and is superbly qualified to step into this role.

CONTENTS

Vaccines: Power of the Provider 2 Evidence shows the primary care provider often is the most important factor in families deciding to receive vaccines.

A New Tool for Better Health

Medical-legal partnerships offer providers support in helping patients with healthharming legal needs.

Equipping Patients and Families for Total Health 22 Pediatric Equipped for Life™ offers patients and families coordinated care that connects their home health needs with their overall medical care.

5 2

Meeting Needs Beyond Medicine 28 The Adolescent and Young Adult Oncology Program provides support for an often overlooked group of patients with cancer.

Departments What’s New? 4 MAiN Model Expands, NICU Webcams, Vestibular Rehab Program

6 5

Medical Staff Spotlight 8 Meet Our New Physicians

Academic News 11

Collaborative Takes Aim at Toxic Stress

CME 12

Pediatric Anxiety

Quality Counts 17

Early-onset Sepsis Calculator

Case Study 18

Iron Deficiency Anemia

9 22

Special Program 20

Pediatric Pharmacy Provides an Rx Just for Kids

Celebrations 24

Accreditation and Philanthropic News

Clinical Research 26 Diabetes

Bulletin from the Bradshaw Institute 27 Highlights from the Bradshaw Institute for Community Child Health & Advocacy

Ask the Faculty 30

28 13

Burnout

On the cover: Jeanne Earp, RN, a nurse at The Children’s Clinic, administers a vaccine to a nervous Louise Grounsell, 2, while mom Ansley Grounsell offers comfort and distraction.

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

LEAD STORY

Vaccines: Deal of the Century Don’t let your patients miss out! Centers for Disease Control and Prevention and other organizations have conducted extensive analyses of the cost effectiveness of administering vaccines during childhood and adolescence. This work is especially timely as the US has experienced recent outbreaks of pertussis, measles and mumps. First, a bit of history: The Vaccines for Children program began in 1994 and targeted nine diseases. Subsequently, five more vaccines were added during 1995-2013. With approximately 50% of younger children being eligible for Medicaid, this program made vaccines available to that group. Thus, the barrier previously linked to vaccine cost was removed. The

Affordable Care Act further enhanced availability by mandating that vaccines be covered by insurance. And the results of the analyses? Every dollar spent on vaccines in the US saves $10 of direct and indirect costs from illness. Globally, that cost savings is as high as $16 dollars. Sadly, the uptake for vaccines is less encouraging: Only 72% of US children between the ages of 19-35 months are fully immunized. Fortunately, by kindergarten—with mandatory school vaccine requirements in place—93% of enrolled children are vaccinated. However, in South Carolina, 2% of children are home schooled. Home schooling removes the mandatory requirement and leaves the vaccine decision up to the parent(s). This new paradigm has presented challenges to pediatricians, who now are called on to “sell the value of vaccines” rather than rely on the argument that vaccines are required by schools.

Selling the Value of Vaccines

Vaccine counseling can be time consuming and lead to provider frustration. However, evidence supports the primary care provider as being the most important factor in families choosing to receive vaccines. Of families surveyed, 80% reported their decision to vaccinate was positively influenced by vaccine counseling.

Joe Maurer, MD, pediatrician with The Children’s Clinic, reviews the vaccination schedule with Ansley Grounsell, whose daughter Louise, 2, is a patient at the practice.

When providers continued by discussing the benefits of immunization, 47% of parents ultimately accepted the vaccines after initially refusing them. Identifying specific concerns can allow providers to address concerns directly.

Helping families understand how diseases are spread may help with accepting vaccines, too. An example is that measles and pertussis are airborne: Unless families want to live in a bubble, they will be at risk. At Disneyland, many cases were not even close to the index patient, and suspension of the virus in the air and its persistence on objects led to susceptible children being infected. Another belief is that we have good treatments; therefore, people don’t die from infectious diseases now. However, many viral diseases—measles among them—do not have treatments. For pertussis, complications even when treated can lead to death. People often forget that shingles in a family member can result in varicella in the unimmunized child, which can become severe even with treatment. In sum, telling stories from personal experience or sharing your approach to vaccinating your children can send powerful messages.

Herd This?

The fallacious thinking that a child or family will not be affected by disease is common as many parents believe that herd immunity will protect them. Case in point: In the measles outbreak in California, 3% of kindergarteners had a nonmedical exemption for vaccines, but a whopping 45% of the cases had not received the vaccine. Herd immunity often takes as much as 95% vaccine coverage in a community to protect the unimmunized. Finally, many families want to use alternative vaccine schedules. These schedules have not been studied for the best immunogenicity and have no evidence to support fewer side effects. Educating families on the rigorous process of vaccine testing can help them understand that alternative schedules could diminish the effectiveness of vaccines and leave children unintentionally unprotected. Remember: You as pediatric providers—trusted, respected caregivers for children—can use empathic education and listening around vaccine hesitancy to overcome many fears that prevent families from vaccinating their children.

Herd immunity often takes as much as 95% vaccine coverage in a community to protect the unimmunized. Article author Robin N. LaCroix, MD, is a pediatric infectious disease physician and medical director of GHS Children’s Hospital.

Summary of the Latest Review Involving Vaccination As made by Alain Joffe, MD, MPH, FAAP, reviewing Kemper AR et al. in the Oct. 23, 2017, issue of Pediatrics “Drinking Water Before Vaccination Does Not Prevent Postvaccination Presyncope” Presyncope (and more serious but less common, syncope) can occur postvaccination. Because studies show that drinking water before blood donation can ameliorate these negative reactions in adolescents, research was conducted to determine if consuming water also may reduce postvaccination symptoms. Researchers randomized 1800 adolescents (ages 11–21) scheduled for one or more intramuscular vaccinations to receive usual care or to consume as much water as they could from a 500-mL bottle. After vaccination, patients were observed for 20 minutes and completed a symptom survey. Almost two thirds of patients drank 500 mL; three quarters consumed more than 250 mL. No instances of syncope occurred in either group. There were no significant differences in rates of presyncope between intervention and control groups when either a liberal (37% and 35%) or restrictive (9% and 7%) definition of presyncope was used. Rates also were comparable between groups when the analysis was limited to patients who consumed 500 mL and were vaccinated within 10 to 60 minutes. The bottom line: Even drinking 500 mL of water before vaccination did not reduce risk for presyncope in adolescents. In multivariable analyses, the following were associated with greater risk for presyncope: • Age under 15 years • History of presyncope/syncope • Receiving more than one vaccine • Increased level of prevaccination anxiety • Increased level of postvaccine pain

Influenza Vaccination Tips • Annual seasonal influenza vaccination is recommended for everyone 6 months and older • Both trivalent and quadrivalent inactivated influenza vaccines are available in SC • Quadrivalent live attenuated influenza vaccine is NOT recommended in the US during the 2017-18 influenza season • All children with egg allergy of any severity can receive an influenza vaccine without taking extra precautions beyond those recommended for any vaccine • Pregnant women may receive an influenza vaccine at any time during pregnancy 3

WHAT’S NEW? Children’s Hospital of Greenville Health System (GHS) announces the expansion of a program to treat neonatal abstinence syndrome, launches webcams in its neonatal ICU and offers a new service for families receiving an autism diagnosis.

MAiN Model to Expand A model of proactively caring for babies at risk for neonatal abstinence syndrome (NAS) in a low-acuity nursery setting— as opposed to care in a NICU—is slated to expand to 10 S.C. hospitals over the next five years. The Managing Abstinence in Newborns (MAiN) program has been pioneered at GHS Children’s Hospital for more than a decade and is the only known example in the country of standardized care being provided in a low-acuity nursery setting. Here are some of the program’s reported outcomes: • Average length of stay of 8.3 days compared to 15 days for NAS newborns in all S.C. hospitals

Thanks to the NICU webcams, mom Crystal Fuller is able to observe her son, Jeremiah, at any time and from anywhere on her phone.

• Overall breastfeeding rate of 39% • Readmission rate within 30 days of discharge of 7%, with none having a primary diagnosis of withdrawal

NICU Webcams Help Parents Stay Connected

Navigating the Autism Maze

One of the most difficult experiences for mothers and fathers with a baby in the NICU is the emptiness they feel as they go home without their newborn. NICU webcams, an innovative audio and video technology, allow families to stay connected during the infant’s stay.

GHS Children’s Hospital’s Division of Developmental-Behavioral Pediatrics has partnered with Family Connection South Carolina, an organization providing support and information to families who have children with special health needs, to support parents when they learn their child has autism. The partnership involves establishing a permanent Family Connection staff person within Developmental-Behavioral Pediatrics who can meet with parents as soon as they receive an autism diagnosis to help them navigate next steps and community resources, as well as help them process their thoughts and feelings. The partnership represents an improvement on previous protocol, which involved giving families written information about next steps and available resources.

In GHS’ Bryan NICU, parents are given a secure log-on that lets them connect from their computer or phone to view their infant. Parents can check in 24/7 to keep a watchful eye on their newborn. The webcam also allows physicians and nurses to video patient rounds so parents can stay updated on the care plan for their infant. The videos will offer family education related to infant care to help families prepare to take their baby home. With permission from parents, grandparents and other family can receive a secure access to virtually visit with the infant. Parents and families are able to continue to bond with their infants even though many miles may separate them.

NICU Offers End-of-life Suite

Program Aids Vestibular Rehab

The Bryan NICU now offers families a private, homelike space to spend time with their newborn and make memories when the baby’s death is imminent.

The Vestibular Rehabilitation program at Kidnetics®, GHS Children’s Hospital’s pediatric therapies arm, identifies and treats children with various forms of vestibular dysfunction, including canal dysfunction, dizziness/nausea with movement, vertigo, trauma and vestibular hypo-function.

The End-of-life Suite provides a space where photographers can be brought in; baptisms can take place; parents can bathe, dress and hold their babies; and family and friends can gather. The suite serves as a “home within the hospital” and helps make a traumatic experience more bearable. Funds for the suite were provided by a family who had experienced infant loss.

New Guidelines on Pediatric Hypertension Screening The American Academy of Pediatrics has issued updated guidance on pediatric hypertension screening. The guidelines suggest that children’s blood pressure be screened using new tables based on normal-weight youths, while blood pressure tables for adults be used for adolescents ages 13 and older.

Krayon Kiosk Premieres In September, the Krayon Kiosk opened in the waiting area at Children’s Hospital Outpatient Center at GHS’ Patewood Medical Campus. This fun center, which includes iPads with multiple apps that children can use to express their creativity, was made possible by the staff at Patewood Café Express. Staff members donated their tips to the Virtual Toy Drive, a GHS Office of Philanthropy & Partnership offering, to make this project happen.

In this program, occupational therapists provide treatment of the inner ear and visual systems and offer training in postural control.

Camper Care Center Opens Clement’s Kindness Fund for the Children; Greenville County Parks, Recreation & Tourism; and GHS Children’s Cary Stroud, MD, center, former medical director Hospital honored of Pediatric Hematology/Oncology for GHS Children’s Hospital and current director of the Dr. Cary E. Stroud as Pediatric Supportive Care Team, was honored at namesake of the Dr. a ceremony celebrating the opening of the Dr. Cary E. Stroud Camper Care Center. Cary E. Stroud Camper Care Center at Pleasant Ridge Camp & Retreat Center. Dr. Stroud was instrumental in founding Pediatric Hematology/ Oncology in 1986. The center, now known as the BI-LO® Charities Children’s Cancer Center at GHS, has tripled in size and offers a complete range of treatments for patients with pediatric cancer or serious blood disorders. Dr. Stroud served as medical director until 2013, when he moved on to start the Supportive Care Team at Children’s Hospital. Pleasant Ridge Camp & Retreat Center, home of Camp Courage and Camp Spearhead, is owned and operated by Greenville County Parks, Recreation & Tourism and provides individuals with medical, physical or intellectual limitations a place to experience camp. The addition of this care center will allow more individuals with illnesses and disabilities to attend camp. Clement’s Kindness helped fund the development of the center with a major gift of $431,000 through its partnership with Camp Courage, a special camp program for patients and families of BI-LO Charities Children’s Cancer Center.

Siawn Norris passes time in the waiting room by exploring an app on the new Krayon Kiosk. 5

FEATURE STORY The innovative Medical-Legal Partnership debuted October 2, 2016.

Medical-Legal Partnership: New Tool for Better Health Addressing health-harming legal needs can improve patients’ and families’ long-term health.

“Creating health for the children in our communities requires us to rewrite the narrative on health beyond the walls of the traditional healthcare provider and into the community,” said Dr. Sease. That means examining factors that lie in these communities that may be affecting health. Kirby Mitchell, JD, an SCLS attorney who directs the MLP, said oftentimes remedying the issues uncovered involves legal issues and the aid of an attorney—something generally beyond the reach of families living in underserved communities.

Furman student Mary Frances Dennis, left, an intern with the MLP, gathers information from a family at the Center for Developmental Services.

“A lot of wonderful low-income families simply do have very serious and widely varying health-harming civil legal needs, and these can—and do—include all kinds of issues ranging from employment law and public benefits to education and family law,” Mitchell noted. “We are determined to be holistic and responsive to patient needs and meet the patient families where they are.”

Greenville Health System (GHS), Furman University and South Carolina Legal Services (SCLS) have formed the state’s first Medical-Legal Partnership (MLP). This collaboration focuses on reducing health-harming problems that have legal remedies while educating clinicians, attorneys and students about these issues.

Meeting them where they are, though, requires the help of pediatricians, who come into more regular contact with these families. While Mitchell and Dr. Sease don’t expect general pediatricians to drill down to the exact nature of and solution to a family’s non-medical need, they are hopeful these providers will make use of this new care coordination tool when it seems appropriate.

Kerry Sease, MD, MPH, medical director for the Bradshaw Institute for Community Child Health & Advocacy, part of GHS Children’s Hospital, emphasized that this new partnership is a valuable tool in an age where the definition of health care is being stretched.

“I always talk about the MLP being a tool in our care coordination toolbox,” Dr. Sease stated. “It’s probably the most sophisticated tool we have in our toolbox, but it needs to be seen as part of the continuum.”

In its first year, the MLP received 210 patient referrals. 6

Need IHELP?

Dr. Sease added that a handful of screenings can help determine the presence of a health-harming legal need when patients come in to be seen by their doctor. One is the IHELP model. The letters in the name have the following meanings: • Income supports and insurance • Housing and utilities • Employment and education • Legal status • Personal and family stability “We’d love every practice to do the IHELP screening, but that may or may not be realistic,” Dr. Sease pointed out. “Regardless, we’d like practices to be screening for the social determinants of health and to have an understanding of what a health-harming legal need might be. If they suspect such a need may exist, they can refer to the MLP.”

“We are determined to be holistic and responsive to patient needs and meet the patient families where they are.” — Kirby Mitchell, an SCLS attorney who directs the MLP Kirby Mitchell, JD, presents information about the MLP at GHS’ Nurturing Developmental Minds Conference in February 2017.

Dr. Sease said from there, a newly hired MLP coordinator would be able to do a more sophisticated intake and triage of the family to determine how best to meet the family’s needs. For instance, if the need is not truly legal in nature, the coordinator still could connect the family with the appropriate community resources that could help resolve the issue. “The clinician in the office doesn’t have to wonder, is this a legal need? Is this just a resource need?” Dr. Sease explained. “The clinician can just say, ‘My patient has a need beyond what I can help in the office right now,’ and we can take care of it from there.” One example Dr. Sease gave was families living in substandard housing with mold, insects or rodents that may be affecting health issues such as asthma. A single family—or even a number of families—may not have the influence or resources needed to get the problem resolved, but when the MLP becomes involved, conditions often improve.

The Powers That Be

The MLP officially debuted in October 2016. Students from Furman University also play a role in the partnership by observing and participating in discussions around patient needs, both in the exam room and the conference room. Nancy Powers, MD, a pediatrician with DevelopmentalBehavioral Pediatrics at GHS and a Furman alumna, is another of the leaders behind the MLP effort.

“Dr. Powers was instrumental in developing the proposal to create the MLP—the only one of nearly 300 MLPs in the country that partners with an undergraduate institution,” said Eli Hestermann, PhD, executive director for Pre-Professional Studies at GHS as well as The Institute for the Advancement of Community Health at Furman University. Dr. Powers recently was recognized with the Richard Furman Baptist Heritage Award for her commitment to removing social and legal barriers to care for vulnerable populations and for helping start the MLP in Greenville. Mitchell noted that while they’ve tried to be strategic in their approach to the MLP, case types vary widely, ranging from guardianship issues for children with developmental disorders to family issues such as visitation, custody and orders of protection. “My hope is that community pediatricians will feel more comfortable and confident talking with and investigating their patients’ needs that are not strictly medical,” he summarized. “Our goal is for physicians to engage their patients about the social determinants of their health, including legal problems.”

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

Meet Our New Physicians Children’s Advocacy Medical Program (CHAMP)/ Pediatric Abuse & Neglect

Inpatient Pediatrics Holly Dawson, MD, completed her medical training at American University of the Caribbean. She completed her Pediatrics residency at Batson Children’s Hospital/University of Mississippi Medical Center in Jackson. Dr. Dawson can be reached at (864) 797-1404.

Lyle L. Pritchard, MD, earned her medical degree from the Medical University of South Carolina (MUSC) in Charleston. She completed her residency training in Pediatrics at MUSC and the University of Alabama at Birmingham. She has spent the last 19 years working as a child maltreatment healthcare provider in the S.C. Children’s Advocacy Medical Response System, where she provided child maltreatment exams and served as a medical team member for Beyond Abuse children’s advocacy center, serving Greenwood, Laurens, Newberry and Abbeville counties. Dr. Pritchard can be reached at (864) 335-5288.

Melissa R. Eldridge, MD, earned her medical degree from Chicago Medical School at Rosalind Franklin University in North Chicago. She completed a Pediatrics residency at University of South Carolina School of Medicine/Palmetto Health Children’s Hospital. Dr. Eldridge can be reached at (864) 512-6544.

General Pediatrics Ryan Bromm, DO, FAAP, completed his medical training at the College of Osteopathic Medicine of the Pacific in Pomona, Calif. He completed a Pediatrics residency at GHS Children’s Hospital. Dr. Bromm is working as a pediatrician at Center for Pediatric Medicine. He can be reached at (864) 220-7270. Meredith Eicken, MD, MPH, earned her medical degree from Vanderbilt University School of Medicine. She completed her Internal Medicine-Pediatrics residency and the Kraft Fellowship in Community Health Leadership at Massachusetts General Hospital in Boston. Dr. Eicken is working as a pediatrician at Center for Pediatric Medicine. She can be reached at (864) 220-7270. Gary Goudelock, MD, earned his medical degree from Emory University School of Medicine in Atlanta. He completed a Pediatrics residency at Children’s Medical Center in Dallas. Dr. Goudelock worked at Pediatric Associates–Easley for more than three decades before retiring in 2015. He has returned to practice part time with the Center for Pediatric Medicine. He can be reached at (864) 220-7270. 8

(864) 797-1404.

Sara K. Sheehan, MD, earned her medical degree from University of South Carolina School of Medicine in Columbia and completed her Pediatrics residency at Palmetto Health Children’s Hospital, also in Columbia. Dr. Sheehan is working as a pediatric hospitalist at Patewood Memorial Hospital. She can be reached at

Pediatric Cardiology Angela M. Sharkey, MD, completed medical school at Saint Louis University in St. Louis, Mo. She completed her residency training in Pediatrics at Cardinal Glennon Children’s Hospital in St. Louis and a fellowship in Pediatric Cardiology at the Children’s Hospital of Philadelphia. Dr. Sharkey also is serving as senior associate dean of Academic Affairs for the University of South Carolina School of Medicine Greenville. She can be reached at (864) 454-5120.

Pediatric Emergency Medicine Zachary T. Burroughs, MD, completed his medical training at MUSC in Charleston. He completed his residency training in Pediatrics and a fellowship in Pediatric Emergency Medicine at Wake Forest Baptist Health in Winston-Salem, N.C. Dr. Burroughs can be reached at (864) 455-6016.

(864) 455-6016.

Jimme Sierakowski, DO, MPH, FAAP, completed his medical training at Nova Southeastern University College of Osteopathic Medicine. He completed a Pediatrics residency and a fellowship in Pediatric Emergency Medicine at the University of Florida in Jacksonville. Dr. Sierakowski can be reached at

Pediatric Endocrinology Mary Gwyn Roper, MD, earned her medical degree from MUSC in Charleston. She completed a Pediatrics residency at Medical College of Virginia Hospital in Richmond and a fellowship in Pediatric Endocrinology at the University of North Carolina, Chapel Hill. Dr. Roper can be reached at (864) 454-5100.

Pediatric Otolaryngology Edward B. Penn Jr., MD, completed his medical training and a residency in Otolaryngology, Head and Neck Surgery at the University of Kansas School of Medicine in Kansas City. He completed a fellowship in Pediatric Otolaryngology at Ann and Robert H. Lurie Children’s Hospital of Chicago. Dr. Penn can be reached at (864) 454-4368.

Pediatric Psychology Cortney Rieck, PsyD, completed her doctorate of psychology degree in clinical psychology with a concentration in health psychology at Widener University in Chester, Pa. She completed a postdoctoral Pediatric Psychology fellowship at the University of Arkansas for Medical Science in Little Rock. Dr. Rieck is embedded with the Division of Pediatric Hematology/Oncology. She can be reached at (864) 455-8898.

Pediatric Sleep Medicine Jonathan P. Hintze, MD, completed his medical training and a residency in Pediatrics at Saint Louis University School of Medicine in St. Louis, Mo. He completed a Sleep Medicine fellowship at National Jewish Health/University of Colorado in Denver. He can be reached at (864) 454-5660.

Pediatric Hematology/Oncology Alan R. Anderson, MD, completed his medical training and a Pediatrics residency at MUSC in Charleston. He completed a fellowship in Pediatric Hematology/Oncology at Emory University Aflac Cancer Center. He spent eight years with Children’s Hospital’s Division of Pediatric Hematology/ Oncology before spending the last two years providing medical care to children in Botswana, Africa. Dr. Anderson can be reached at (864) 455-8898.

Pediatric Neurology Sunjay R. Nunley, MD, earned his medical degree from West Virginia University School of Medicine in Morgantown. He completed residencies in Pediatrics and Child Neurology and a fellowship in Clinical Neurophysiology (EEG) at Nationwide Children’s Hospital in Columbus, Ohio. Dr. Nunley can be reached at (864) 454-5110.

Pediatric Urology Anthony J. Tracey, MD, MPH, completed his medical training and a Urology residency from Tulane University School of Medicine in New Orleans, La. He also earned a master’s degree in public health from the Tulane University School of Public Health. Dr. Tracey completed a Pediatric Urology fellowship at Emory University School of Medicine in Atlanta. He can be reached at (864) 454-5135.

Supportive Care Team Arun L. Singh, MD, completed his medical training at Saba University School of Medicine in the Caribbean. He completed a Pediatrics residency at the University at Buffalo School of Medicine/Women’s & Children’s Hospital of Buffalo and a fellowship in Pediatric Critical Care Medicine at Emory University School of 9

Medicine/Children’s Healthcare of Atlanta. He also completed a Pediatric Hospice & Palliative Medicine fellowship at Johns Hopkins University/Johns Hopkins Children’s Center in Baltimore. Dr. Singh can be reached at (864) 455-5129.

Jurs

Nuguri

Matthias

New Community Pediatricians Dennis G. Jurs, MD, and Shyla Nuguri, MD, have joined Spartanburg Pediatric Health Center. They can be reached at (864) 707-2135. Katherine M. Matthias, DO, has joined Pediatric Associates– Easley. She can be reached at (864) 855-0001.

Senior Council Launches The Senior Council for Children’s Hospital of Greenville Health System (GHS) is an opportunity for physicians age 65 and older who are beginning to consider steps toward retirement, have moved to reduced hours, or have retired, to remain socially connected to Children’s Hospital. Quarterly meetings will provide information on the advancement of pediatric health care, advocacy and outreach in the community. Other opportunities may include a physician volunteer program and mentoring residents. The continued physician shortage means that reaching age 65 doesn’t necessarily mean full-time retirement. Late-career physicians bring experience and knowledge that continue to benefit Children’s Hospital. Physicians can determine the level of their involvement in the council, which will help them maintain a connection with colleagues. If you have related questions, contact Donna Carver, director of Children’s Services in GHS’ Office of Philanthropy & Partnership, at (864) 797-7735 or dcarver@ghs.org.

Dr. Howard Draddy Assumes New Role Carley Howard Draddy, MD, has assumed the role of Pediatric Vice Chair of Medical Staff Affairs and Quality. Dr. Howard completed her Pediatrics residency at Children’s Hospital in 2008. She helped start a hospitalist/nursery program and a pediatric urgent care at AnMed Women’s and Children’s Hospital, and served as medical director for GHS’ Pediatric Hospitalist program at AnMed for seven years. She has spent the last four years serving as senior medical director for Pediatric Primary Care. She also was instrumental in bringing Children’s Hospital’s Delivery Buddy telehealth program to outlying GHS nurseries.

Nursing News Kristi Coker, PhD, RN, has moved to the role of director of Nursing Operations at Greenville Memorial Hospital. She has spent the last 12 years in various roles for Children’s Hospital, including nurse manager of the Pediatric Intensive Care Unit, Pediatric Hematology/Oncology and Pediatric Surgery. For the past three years, Kristi has served as director of Nursing for Children’s Hospital. She will continue to serve in this role during the search for her replacement.

Mark Your Calendars! The 2018 Nurturing Developing Minds conference will take place Feb. 23, 2018, with the theme of “Building Resiliency.” The conference will feature keynote speaker Andrew Garner, MD, PhD, FAAP, associate clinical professor of Pediatrics at Case Western Reserve University School of Medicine and chair of the American Association of Pediatrics leadership workgroup on Early Brain and Child Development. This year’s conference also includes R. Christopher Sheldrick, PhD, research associate professor at Boston University School of Public Health and Janice M. Gruendel, senior fellow at the Institute for Child Success and fellow at the Zigler Center at Yale University.. This regional conference provides an innovative learning opportunity for a broad interprofessional workforce and features national experts on brain development and function, the impact of adversity, and interventions to support developmental resilience. A selection of breakout sessions will give participants the opportunity to learn practical applications to use in their daily work with children and families. To register for the conference, visit hsc.ghs.org/cme/conferences.

ACADEMIC NEWS Children’s Hospital of Greenville Health System (GHS) is one of eight pediatric residency programs tackling toxic stress in childhood.

Collaborative Takes Aim at Toxic Stress As evidence mounts showing that toxic stress during childhood can have long-lasting negative health and developmental impacts, residency programs around the country are focusing attention on this important issue. The Pediatric Residency Program at GHS Children’s Hospital is participating in the Carolinas Collaborative with all seven other pediatric residency programs in South and North Carolina to figure out the best ways to train residents in community and child advocacy. The collaborative is supported by the AAP Community Pediatrics Training Initiative (CPTI), which has set up, trained and mentored similar collaboratives in Missouri, California and New York. The eight programs are working toward two main goals: • Strengthen faculty development and resident community health education

defined curriculum, with a menu of options that programs can choose from to use in their own training programs,” she stated. She also noted that the collaborative is discussing how to continue the positive work beyond the two years of grant support it received from The Duke Endowment. “If we can do a good job training our residents and we as a faculty and a state really support this type of work, the idea is that, long-term, the collaborative would have big impacts on the health of children in our area,” Dr. Sease summarized.

Carolinas Collaborative 2 States 8 Pediatric Residency Programs 1 Team

• Reduce toxic stress and improve outcomes for children To reach these goals, collaborative members have begun sharing and improving advocacy curriculum and are developing new curriculum where appropriate. Each program also is undertaking meaningful health promotion and prevention projects in partnership with community-based groups in their local area. Kerry Sease, MD, MPH, medical director of Children’s Hospital’s Bradshaw Institute for Community Child Health & Advocacy, serves as co-lead of the collaborative. At Children’s Hospital, the Pediatric Residency Program has partnered with the West Greenville Community Center and the Julie Valentine Center to provide the Positive Parenting Program, or Triple P, for residents of Greenville’s underserved communities. The program promotes the independence and health of families by enhancing parents’ knowledge, skills, confidence and self-sufficiency, and by creating non-violent, protective and nurturing environments for children. In the area of curriculum, Dr. Sease said the programs have identified five learning goals as priorities for pediatric residents to understand about community health and advocacy, and they are in the process of developing learning objectives to meet those goals. “We hope by the end of the two years, we’ll have a

Kerry Sease, MD, MPH, medical director of Children’s Hospital’s Bradshaw Institute for Community Child Health & Advocacy, serves as co-lead of the collaborative. 11

CONTINUING MEDICAL EDUCATION

CME: Pediatric Anxiety Disorders 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 16. 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 Lance Feldman, MD, MBA, 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. 12

With a prevalence of up to 1 in 5 children and adolescents, anxiety disorders are some of the most common difficulties of childhood. These disorders, including generalized, separation and social anxiety, can cause significant impairment at home, in school and in social settings. Studies even have linked these early-onset anxiety disorders to lifelong difficulties including anxiety, mood and substance use disorders. Thankfully, many evidence-based treatments exist that clinicians can offer patients to aid recovery.

Anxiety Evaluation

The most commonly presenting symptoms of anxiety disorders in children and adolescents are vague, general physical symptoms such as stomachaches, headaches, sore throats and sleep changes. These symptoms often are worse on Mondays. Parental concerns for these children typically include behavioral changes, irritability, anger and mood lability. Modifiable risk factors such as sleep, diet, exercise and interpersonal relationships (peers and family) also should be assessed. It is extremely important for the clinician to evaluate for the context of the symptoms as well as any specific situations that

may appear to worsen concerns. Once anxiety is suspected, an evaluation for all causes of anxiety-like symptoms should be clinically considered. Evaluate for these non-psychiatric causes: • Medications (including prescriptions, supplements, herbals and over-the-counters) • Substance use (drugs, alcohol, caffeine, nicotine) • Medical considerations (hyperthyroidism, Cushing’s disease, mitral valve prolapse, carcinoid syndrome, pheochromocytoma) Possible metabolic considerations (labs) include … • Complete blood count • Comprehensive metabolic panel • Thyroid-stimulating hormone • Urinalysis • Urine drug screen Office screening tools that can be used (by patient or parent) include … • Screen for Child Anxiety Related Disorders • Multidimensional Anxiety Scale for Children • Hamilton-Anxiety Scale Consider common co-morbid psychiatric disorders, including … • Major depressive disorder • Attention-deficit hyperactivity disorder (ADHD)

Diagnosis

Once a clinical interview with the child and parent has been conducted, medical considerations have been vetted and a positive rating scale obtained, a diagnosis can be established. Generalized anxiety disorder (GAD) is a clinical diagnosis based on a constellation of symptoms occurring more days than not for at least six months (Table 1). The anxiety must affect the child in multiple settings (e.g., school, social, work, etc.), and the child must find it difficult to control the worry. Separation anxiety is marked by persistent and excessive fear of untoward events or harm about major attachment figures (Table 2). These children also often manifest with multiple somatic complaints. Social anxiety disorder, or social phobia, is fear of being judged or negatively evaluated by peers (Table 3). In children, signs often include acting out behaviors or declining to speak or participate in social situations.

Treatment

Cognitive Behavioral Therapy Unless the anxiety is completely overwhelming or the child is unable to function, therapy should be the firstline treatment modality. Cognitive behavioral therapy (CBT) has the greatest evidence base for anxiety treatment. CBT principles, including automatic thoughts, cognitive distortions and core beliefs, revolve around the premise that thoughts, behaviors

Table 1—Generalized Anxiety Disorder

Excessive anxiety and worry, occurring more days than not, for at least six months, with one or more of the following: • Restlessness or feeling keyed up or on edge • Being easily fatigued • Difficulty concentrating or mind going blank • Irritability • Muscle tension • Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)

Table 2—Separation Anxiety Disorder

Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following: • Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures • Persistent and excessive worry about losing major attachment figures or about harm to them, such as illness, injury, disasters or death • Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure • Persistent reluctance or refusal to go out, away from home, to school, to work or elsewhere because of fear of separation • Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings • Persistent reluctance or refusal to sleep away from home or sleep without being near a major attachment figure • Repeated nightmares involving separation • Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated • The fear, anxiety or avoidance is persistent, lasting at least four weeks in children and adolescents and typically six months or more in adults

Table 3—Social Anxiety Disorder (Social Phobia) • Marked fear or anxiety is exhibited about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking) and performing in front of others (e.g., giving a speech). – Note: In children, the anxiety must occur in peer settings and not just during interactions with adults. • The individual fears that he or she will act or show anxiety symptoms in a way that will be negatively evaluated (i.e., humiliating or embarrassing; will lead to rejection or offend others). • Social situations almost always provoke fear or anxiety. – Note: In children, fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking or failing to speak in social situations. • Social situations are avoided or endured with intense fear or anxiety. • Fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context. • Fear, anxiety or avoidance is persistent, typically lasting for six months or more.

and emotions are each independent and can be controlled by the individual. Some common cognitive distortions include all-or-nothing thinking, magnification, minimization, overgeneralization and personalization. Patients learn to identify negative automatic thoughts stemming from an anxiety-provoking situation and come to realize when their behaviors are affected, often evident through the triggering of either the fight (increased heart rate, sweating, shortness of breath, etc.) or flight (avoidance) mechanism. Patients then are taught techniques to ease anxiety by developing positive coping skills and reducing the stress response. The result is an improved ability to handle scary situations and regulate emotions. Mindfulness, progressive muscle relaxation and guided imagery—offshoots of CBT techniques—have become increasingly popular. Techniques, including grounding and enhancing consciousness, can buttress defenses and provide improved resolve in stressful situations. Exercises such as deep breathing and guided relaxation demonstrate to children that they can deliberately affect their heart rate and breathing and that they have the power to regain control over common anxiety symptoms. Recent popularity likely is due in large part to the proliferation of mobile devices and the accompanying programs and applications (apps) devoted to this subject. Psychopharmacology It is postulated that serotonin, norepinephrine, dopamine and GABA all play a role in the pathophysiology of anxiety. Specific brain structures implicated in stress and fear include the amygdala and the medial and ventromedial prefrontal cortexes. For these reasons, medications targeting these neurotransmitters are commonly prescribed.

The sentinel article on treating child and adolescent anxiety is the Child and Adolescent Anxiety Multimodal Study. Almost 500 participants were randomized to 12 weeks of CBT, sertraline, CBT and sertraline or placebo medication. While all subjects receiving active treatment improved, subjects receiving the combination of CBT and sertraline improved most.

sertraline, fluvoxamine, fluoxetine and paroxetine. In clinical practice, it generally is recommended to start SSRIs at low doses, closely monitor side effects and titrate the medication to a minimally effective dose after one to two months. Always remember to inquire about medication compliance in the age group before increasing the dosage.

It is important to note that no medications are approved by the Food and Drug Administration (FDA) to treat generalized, separation and social anxiety disorders in children. Many recommendations, therefore, come from consensus opinions and clinical experience in the field, as well as extrapolation from other relevant clinical trials (i.e., medications approved for adult anxiety disorders or approved for childhood obsessive compulsive disorder).

As a group, SSRIs are well tolerated with common side effects including gastrointestinal upset, insomnia and headache. Closely monitor for behavioral disinhibition, though rare. Discuss with patients and their parents the FDA black box warning for an increased risk of suicidality in children and teens when prescribed antidepressants. While best practice guidelines suggest office follow-up in 1-2 weeks after starting the prescription, busy clinicians find this impossible and instead have staff contact the child or parents to assess for safety and efficacy in that timeframe.

Selective serotonin reuptake inhibitors (SSRIs) are commonly used as firstline medications for anxiety disorders in children and adolescents. In particular, fluoxetine and fluvoxamine are FDA approved for obsessive-compulsive disorder (OCD) for children ages 8-17, and sertraline is FDA approved for OCD for ages 6-17. As a result, those medications often are used for these somewhat similar afflictions. Specifically, positive clinical trials in children with anxiety disorders have been published for

Clomipramine, a tri-cyclic antidepressant, also has FDA approval for OCD in children over 10 years old. Fluvoxamine and clomipramine, because of side effects and possible medication interactions, usually are not considered firstline medications. Paroxetine, because of its short half-life, also is not desirable.

Table 4 — Commonly Prescribed Pediatric Anxiety Medications Medication

FDA Approvals

Dosing Range

Clinical Pearls

Fluoxetine

OCD 8-18 y/o, GAD >18 y/o

5-40 mg

• Longest half-life • Watch for activation

Fluvoxamine

OCD 8-17 y/o

25-200 mg

• Side effects • Rx interactions

Sertraline

OCD 6-17 y/o, GAD >18 y/o

25-200 mg

• Watch for GI upset

Venlafaxine XR

GAD >18 y/o

37.5-150 mg

• Monitor BP • Taper slowly to D/C

Clomipramine

OCD >10 y/o

25-100 mg

• Side effects • Rx interactions • Consider EKG • Lethal in overdose

If two SSRIs fail adequate clinical trials of adequate dosages, selective norepinephrine reuptake inhibitors and other antidepressants frequently are considered. Venlafaxine extended-release and mirtazapine have had positive clinical trials in children and adolescents with anxiety disorders. Notably, buspirone did not separate from placebo in a clinical trial in children with generalized anxiety disorder. Generally, benzodiazepine use in children and adolescents is not advised. Clinical trials have not shown efficacy of these medications to treat pediatric anxiety disorders. Concerns surrounding tolerance and abuse also make these medications less desirable. Clinically, however, benzodiazepines may have short-term benefits when an immediate response is required and other treatments, such as therapy and medication, have already been initiated but have not yet begun to help. Benzodiazepines often will provide a rapid improvement in anxiety symptoms, but these results are not sustained and may even worsen with continued use. As previously noted, children with co-morbid depression or ADHD may require more nuanced treatments. It often is difficult to differentiate symptoms of anxiety and depression; this differentiation is essential, however, when determining response to therapy and medications in an anxious youth. It is important to discuss realistic expectations of medications in this population, as children with co-morbidities usually are more complicated and may require referral to a child psychiatrist. When prescribing medications for a child with co-morbid anxiety and ADHD, treating anxiety is essential before initiating treatment for focus and concentration. Medications that help patients focus and concentrate may exacerbate underlying fears and anxieties; this worsening often will improve once the anxiety disorder is appropriately treated. At that time,

References

1. Sakolsky, D & Birmaher B. Pediatric anxiety disorders: management in primary care. Curr Opin Pediatr 20:538-43. 2. Mohatt J, Bennett SM & Walkup JT. Treatment of Separation, Generalized and Social Anxiety Disorders in Youth. Am J Psychiatry 2014;171:741-48. 3. Bharr, NV. Anxiety Disorders. Medscape. Accessed 10/2017. http:// emedicine.medscape.com/article/286227-overview#a4 4. Piacentini J et al. 24- and 36-week Outcomes for the Child/Adolescent Anxiety Multimodal Study (CAMS). J Am Acad Child Adolesc Psychiatry 2014;53(3):297-310. 5. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). Arlington, Va.: American Psychiatric Association. 6. Wehry AM, Beesdo-Baum K, Hennelly MM, Connolly SD & Strawn JR. Assessment and Treatment of Anxiety Disorders in Children and Adolescents. Curr Psychiatry Rep 2015 July; 17(7): 591.

pharmacologic treatment for ADHD can be cautiously restarted at the lowest effective dosage.

Clinical Considerations

Before suggesting treatment for anxiety disorders, providers should consider the entire clinical picture to determine the best next step. For mild to moderate anxiety, low- vs. high-intensity modalities must be evaluated. In these situations, therapy or lifestyle modifications may prove beneficial enough with psychopharmacologic interventions. As well, family history and family functioning must be contemplated in the setting of the anxiety presentation. For moderate to severe anxiety, the combination of therapy and medication management with an SSRI likely is indicated. It is important, however, to clearly define treatment goals with the child and parents to ensure realistic objectives and monitor for ongoing success.

Conclusion

Pediatric anxiety disorders often present with somatic and behavioral complaints. Diagnostic considerations should be reflected on during all patient encounters. Once diagnosed, anxiety disorders respond well to therapeutic and psychopharmacologic interventions, with the combination of CBT and SSRIs as the current best practice guidelines for moderate to severe anxiety.

Article author Lance Feldman, MD, MBA, is a child and adolescent psychiatrist with GHS Psychiatry.

CME Questions Available Online 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

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18-0159 Revised 1/18

QUALITY COUNTS

Improving Treatment of Earlyonset Sepsis Neonatal earlyonset sepsis (EOS) is defined as blood and/ or cerebrospinal fluid culture-proven infection in the newborn less than 7 days of age. The current incidence of EOS ranges between 0.5-1.2 cases per thousand live births. The percentage of newborns treated with antibiotics is 200fold higher than the incidence of EOS. Previously, in the Level I Newborn Nursery at GHS Children’s Hospital, every baby born to a mother with chorioamnionitis would get a complete blood count (CBC), blood culture and empiric antibiotics even though the vast majority of babies are well-appearing with negative final blood cultures. A study by Escobar et al. looked at neonatal sepsis risk at birth based on objective maternal factors, demographics, specific clinical milestones and vital signs during the first 24 hours of life. From such data, a risk classification scheme for EOS was developed. The Neonatal EOS Calculator then was applied retrospectively to 183 infants with culture-proven EOS and 569 population-matched controls. The calculator takes into account the newborn’s clinical presentation, including vital signs, classifying them as well appearing, equivocal or clinical illness. The risk of EOS changes based on the clinical classification once initial data have been put into the calculator. As the risk of sepsis increases and the number needed to treat decreases, the calculator will recommend more intervention.

Cost Benefits

From July-September 2016, 62 infants were born at GHS’ Greenville Memorial Hospital to mothers diagnosed with chorioamnionitis. Seventy-seven CBCs were collected as some infants had more than one during their course. Sixty-two blood cultures were performed, and all 62 babies received empiric antibiotics.

The EOS calculator also was applied to each of these newborns and recommended routine care for 56, lab work only for four, and empiric antibiotics for two babies. All blood cultures were negative final with the exception of 1 contaminant with negative repeat blood culture. If the neonatal EOS calculator had been used to guide clinical decision making during these three months, a savings of $34,574.80 for patients could have resulted.

Intangible Benefits

Use of the EOS calculator with all infants at least 35 weeks’ gestational age born at risk for early-onset neonatal sepsis can safely decrease unnecessary laboratory evaluation, invasive procedures (IV placement) and empiric antibiotic use in the neonatal period. Parental anxiety is increased when new infants require these interventions. This anxiety can impair maternalinfant bonding and breastfeeding. By eliminating these unnecessary interventions, we hope to provide more highvalue, patient-centered care to newborns and their parents.

Intervention and Results

On February 13, 2017, the Neonatal EOS Calculator was officially implemented in the GMH Level I Newborn Nursery. Newborns with risk factors for EOS were identified. The EOS calculator was run on these newborns, and their clinical status was monitored for the first 2-4 hours of life to determine overall risk for EOS. If indicated, the first dose of antibiotics was administered by 6 hours of life. As of June 7, 2017, a 93% reduction in the rate of empiric antibiotics and a 70% reduction in the amount of lab work obtained had taken place. Of newborns who received routine care, no readmissions for sepsis occurred within the first week of life. Article authors Andreea Stoichita, MD, and Meghan Jordan, MD, are third-year residents in Children’s Hospital’s Pediatric Residency Program. Their poster on this topic earned first place at the annual meeting of the S.C. Chapter of the American Academy of Pediatrics in July 2017, and their article on the topic was published in the November 2017 issue of GHS Proceedings.

CASE STUDY

Iron Deficiency Anemia An 18-month-old, previously healthy male of East Asian ancestry presented to his pediatricianâ&#x20AC;&#x2122;s office for a routine well-child check. He had missed his routine visits after 9 months of age. A fingerstick hemoglobin acquired during the rooming process was 4.5 g/dL, prompting an urgent request for evaluation by the nursing staff. Upon entry to the exam room, a pale but otherwise wellappearing toddler is moving a chair across the floor, and the parents deny any concerns about his activity level. History reveals no black or melanotic stools, and parents deny any evidence of jaundice outside of the immediate newborn period, which did not require intervention. They are unaware of any ingestion of non-nutritive items, and their home was built within the last few years. Dietary history includes exclusive breastfeeding for the first 6 months with subsequent introduction of solids, particularly fruits and vegetables, then weaning to whole milk around 13 months.

Further questioning reveals that the toddler drank approximately 64 ounces of whole milk a day for several months with picky eating habits. Family history is negative for anemia. Examination reveals conjunctival pallor, a II/VI systolic murmur, no palpable hepatosplenomegaly and no rashes. The confirmatory CBC in the office revealed a normal white blood cell count and platelet count with a hemoglobin of 4.1 g/dL, hematocrit of 14.0, MCV of 47.9 fL. Despite an otherwise well appearance, the patient is admitted for further evaluation and management of his severe microcytic anemia.

Evaluation and Management

In these cases, a thorough history assessing for risk factors for iron deficiency (Table 1) and potential hemoglobinopathies determines the extent of evaluation warranted for children with mild (Hgb >10 g/dL) or moderate (Hgb 7-10 g/dL) anemia. The American Academy of Pediatrics (AAP) published a guideline for iron deficiency anemia in children ages 0-3 years in 2010.

These guidelines recommend an oral trial of 4-6 mg/kg/day of elemental iron, given with vitamin C (e.g., orange juice) for palatability and improved absorption, for patients with mild anemia whose history is consistent with iron deficiency. For those with moderate anemia, adding a reticulocyte count or ferritin and C-reactive protein to the initial evaluation was recommended. An increase in the hemoglobin by 1 g/dL after one month or an increase in the reticulocyte count after 72 hours of appropriate iron therapy supports the diagnosis of iron deficiency anemia. The severity of this child’s anemia prompted an extensive workup, and his iron studies were consistent with iron deficiency—a low serum iron, elevated total iron-binding capacity and low ferritin. The reticulocyte count of 3.1%, when accounting for his degree of anemia, demonstrated an insufficient response by the bone marrow and was consistent with iron deficiency. His lead level was undetectable, and the peripheral smear revealed hypochromic, microcytic anemia with normal myeloid or lymphoid lines. Given the degree of anemia and increased risk of hemoglobin E and thalassemia based on his ethnicity, a hemoglobin electrophoresis was completed without evidence of hemoglobinopathy. Stool guaiac also was negative. A slow 4 mL/kg transfusion of packed red blood cells was given on the first day of admission and then repeated the next day while monitoring for signs of volume overload and cardiovascular compromise. His hemoglobin before discharge was 8 g/dL with an outpatient plan to encourage iron-rich foods, limit cow’s milk and continue oral iron supplementation (at above dosing) for a few months beyond the point at which the hemoglobin normalized for age to replenish stores.

Screening and Prevention

Bright Futures recommends routine anemia screening for all children, regardless of risk factors, around 1 year of age as iron deficiency (the most common nutrient deficiency worldwide) has been associated with poorer long-term neurodevelopmental and behavioral outcomes. Screening of infants and children in subsequent years should first begin with an assessment of risk factors as opposed to routine hemoglobin measurement of every child at each well-child visit, preventing trauma to the child in addition to saving healthcare dollars. While no formal AAP recommendation addresses adolescent screening, the CDC recommends checking menstruating females at least every 5-10 years and even yearly in those with low-iron diets, heavy menses or history of iron deficiency anemia. In contrast to the 2017 AAP Section on Breastfeeding recommendation for exclusive breastfeeding the first 6 months of life, the 2010 AAP Committee on Nutrition

Table 1: Risk Factors for Iron Deficiency in Infants & Young Children • Use of low-iron infant formula • Exclusive breastfeeding >4 months without supplemental iron • Less than 2-3 servings of iron-rich foods/day • Cow, goat or soy milk before age 1 year • Greater than 16-24 oz./day of cow’s milk by children >1 year old • Prematurity or low birthweight • Low socioeconomic status

guidelines recommend introducing iron-rich foods, particularly meats or fortified cereals, between 4-6 months of life (once developmentally ready). Limiting cow’s milk to 16-24 oz./day in children >1 year and eating a diet that includes red meats, cereals and vegetables containing iron should be part of the dietary guidance provided to families. Electronic medical record reminders incorporating routine screening at 1 year and screening questions to assess the need for measurement in later visits can help assure compliance with these recommendations, and age-appropriate dietary guidance can be included in the after-visit summary for parental reference. Matthew Grisham, MD, is medical director of Children’s Hospital’s Pediatric Residency Program.

Suggested Readings

• Baker RD, Greer FR, Committee on Nutrition American Academy of Pediatrics. Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age). Pediatrics. 2010;126(5):1040–1050. • Hagan JF, Shaw JS, Duncan PM. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th edition. Elk Grove, IL: American Academy of Pediatrics; 2017. • Hastings CA, Torkildson JC, Agrawal AK. (2012). Approach to the Anemic Child. In Handbook of Pediatric Hematology and Oncology: Children’s Hospital and Research Center Oakland, 2nd Edition (pp 1-9).

SPECIAL PROGRAM Pediatric Pharmacy program provides for the unique medication needs of children.

Rx for Children By Becky Wilhoit

What began over 15 years ago with a single pediatric clinical pharmacy specialist has transformed into a vital and growing part of how patients at GHS Children’s Hospital are treated.

As the reach and reputation of Children’s Hospital grew, though, so did the need to have a specialized, full-service pharmacy dedicated to orders for even the tiniest patients.

“When I first started, there wasn’t a pediatric pharmacy in Children’s Hospital,” recounted Heather Hughes, PharmD. “Up until about 14 years ago, children’s pharmacy was handled alongside adult pharmacy.”

At the urging of William Schmidt III, MD, PhD, then chairman of the Department of Pediatrics and medical director of Children’s Hospital, the Pediatric Pharmacy unit came into being around 2002. At the time, just two pediatric clinical pharmacy specialists were on staff—Hughes and Beth Addington, PharmD, BCPPS. The unit has since quintupled to 10. Each pediatric clinical pharmacist has specialized qualifications, such as residency training and certifications, expanding their pediatric knowledge beyond that of a traditional pharmacist. This expertise is particularly important, as child patients present multiple medication challenges, not the least of which is the urgency of their care and the inherent complexity of their dosing needs. The Pediatric Pharmacy initially was open eight hours daily, but it quickly became clear these hours wouldn’t sustain the needs of Children’s Hospital. “We started with those eight-hour days and eventually expanded to 12 hours so that we could mirror the nursing staff shifts,” Hughes recalled. “And then we bumped it up so we were here from 7 a.m. to 9 p.m. Eventually, Dr. Schmidt just knew that the right thing to do for these patients was 24-hour-a-day availability.” The Pediatric Pharmacy staff’s 24/7 availability all but eliminates the agonizing wait parents and patients once experienced for getting urgent, specialized prescriptions filled. In addition, these experts are uniquely qualified to address the highly complex process of examining weight, or sometimes even surface area, to ensure the proper dose for each child. “One of the things that makes our job so challenging is that you can’t look at the dose of a medication and know at first glance if it’s appropriate for an 18-month old, a 3-year old or even an older child of 8 to 10 years old,” said Addington.

Helping the Medicine Go Down

Following a weight-based or body surface area formula (common in chemotherapy regimens) for determining the best dosage for children, pharmacy staff members remove the margin of error that might otherwise be present. Still, other factors unique to pediatric care remain. “We have 5-year-olds who prefer to swallow tablets, so sometimes the best weight-based dose has to be adjusted to the nearest tablet size,” Addington explained. “Or we might have a 15-year-old who still prefers liquids. We have to take all these factors into account so that the patient will actually take the medicine.” In pediatric patients who aren’t accustomed to swallowing capsules, taste can be an issue, too. “We sometimes have our medical students do a taste test,” Hughes pointed out. “Liquid clindamycin, for example, tastes really bad. So when we’re training students or residents, we’ll often have them change the dose to the nearest capsule size. Parents can either help their child swallow the capsule or sprinkle it on some food to make it easier for the child to take.” The Pediatric Pharmacy serves the entirety of GHS Children’s Hospital—200 beds—including the Newborn Nursery, Children’s Emergency Center, Bryan Neonatal Intensive Care Unit, Pediatric Intensive Care Unit, Pediatric Intermediate Unit, Pediatric Hematology/Oncology, Pediatric Surgery, Pediatric Infusion Center and Epilepsy Monitoring Unit. Plus, the Pediatric Pharmacy serves patients both in the hospital and in outlying GHS facilities. “We work with patients at outlying facilities, providing counsel ahead of transfers, advising on medications and answering questions,” Addington noted. Aside from transfers and pressing needs, these pharmacists often field questions about medications, drug interactions and the best way to dose certain patients. A typical day for Hughes, Addington and their staff can include assessing patients admitted overnight and the conditions they face, reviewing patients’ current medications for potential interactions with new orders, and attending rounds with physicians. “I look at the relationship we have with our doctors and nurses, which is what makes us so different,” Addington emphasized. “We communicate constantly, and we’re used to having physicians and nurse staff poke their heads in our door anytime they need us.”

Heather Hughes, PharmD, (far right) and Beth Addington, PharmD, BCPPS (center), stand with Bethany Lynch, PharmD, a pediatric clinical pharmacist for the Bryan Neonatal Intensive Care Unit.

“We communicate constantly, and we’re used to having physicians and nurse staff poke their heads in our door anytime they need us.” — Beth Addington, PharmD, BCPPS

Pediatric clinical pharmacists on the staff also are part of a systemwide Pharmacy & Therapeutics Committee for GHS. “Pharmacy & Therapeutics Committee is a subset of staff who decides what prescription formulas will be considered ‘on formulary’ across GHS,” summarized Hughes. “We’re setting standards and building controls for how medication is ultimately delivered to patients here. That’s huge for ensuring medications are used properly and safely throughout GHS.”

COLLABORATING FOR BETTER CARE Pediatric Equipped for Life™ (PEFL) offers patients and families a convenient source for durable medical equipment.

Equipping Patients and Families for Total Health

Dana Dann, RRT, a clinical coordinator with Pediatric Equipped for Life, shows Bryce Roling how to use his CPAP machine while Bryce’s sister, Riley, observes.

Dominic Gault, medical director of Pediatric Equipped for Life (PEFL), remembers thinking several years ago how efficient it would be to offer a durable medical equipment (DME) supplier for patients at Children’s Hospital of Greenville Health System (GHS) that was a part of that same health system.

PEFL falls under GHS’ for-profit arm, Greenville Health Corporation. It is offered to patients and their families as one choice among many that can provide similar services. The aim with PEFL is to deliver a seamless experience in the midst of a challenging time.

At the time, pediatric specialists had strong relationships with durable medical equipment suppliers in the community. Although the arrangement worked well, Dr. Gault saw an opportunity to improve patient care.

A Smooth Transition

He explained, “We wanted to enhance the DME-patient relationship, and probably more uniquely, the DME-physician relationship. We tried to integrate that triangle and make sure that we connect all the lines, instead of having two different groups talking to the patient, but with no continuity.” 22

For instance, the main PEFL store is in the same building as many outpatient pediatric specialists like Dr. Gault, who also serves as medical director of the Division of Pediatric Sleep Medicine “The family can get set up quickly,” Dr. Gault shared when discussing the advantages of an in-house DME service. “Families don’t have to have a second appointment to take care of that—they can get their equipment as they walk out the door.

Or if something’s broken, it gets fixed right then. I don’t have to worry that the patient is going to go for days with a broken CPAP mask.”

stay there for many hours, just to make sure that everything is right, the equipment is set up appropriately, and that the patient is going to thrive under those conditions.”

Because of its position as part of a larger health system, PEFL offers a broad selection of specialized items. Of particular benefit to physicians, Dr. Gault said, “PEFL is willing to listen to the doctors and find those things that are hard to locate.”

Those respiratory therapists are specially trained in pediatric care, too.

Randy Lydick, supervisor of Respiratory Care Services at GHS, noted that PEFL staff help families understand how to use the equipment, visiting patients at the bedside to walk families through how to use their device—even if they choose a different DME supplier. “We partner with the nurses and physicians at the bedside to ensure all patients are trained appropriately and all their equipment is prepared, whether they choose our services or not,” Lydick said. “We want the best outcome for the patient, and we want to be able to decrease readmissions.” Being part of a larger vision—achieving the best outcome for the patient and avoiding hospital readmission—helps ease the pain of providing some non-reimbursable services. Not only can PEFL lean on the financial reserves of the larger health system, but its staff also can see—and play a role in—the big picture of patient health. “We all have the same goal,” Dr. Gault emphasized. “We’re under the same GHS umbrella. If we have to provide an extra tracheostomy tube because it’s necessary for a patient to avoid infection so they don’t end up in the ER and get admitted to the hospital, that benefits everybody. Other DME companies may not be able to see as well the benefit of managing the patient’s health.”

Pediatric Respiratory Expertise

Sometimes, particularly when patients are discharged from GHS Children’s Hospital, respiratory therapists visit families’ homes to help set up equipment. “For the most complicated patients—the ventilators and tracheostomies and even difficult oxygen patients—we do extensive training in the hospital before we discharge the patient,” stated Lydick. “Then, we go home with the family and

“They’re not just general respiratory therapists who come into Children’s Hospital or to our practice, but actual pediatric respiratory therapists who have had extensive experience in the hospital and with pediatric DME and pediatric ventilator management,” Dr. Gault pointed out. Khristie Tate, RRT, RCP, clinical coordinator with Pediatric Equipped for Life, said as part of the total patient health mindset, the respiratory therapists know the importance of patients complying with their instructions for using home health equipment. Items such as CPAP machines automatically send wireless reports detailing patient use. “It shows us how long they’ve worn it, if their mask is leaking, whether they’re continuing to have apneic episodes,” Tate noted. “There is a lot we can get from that report. And it’s web-based, so we could even pull it up from home, if we needed to, during on-call hours for instance.”

Expanding Availability

Dr. Gault added that PEFL works with patients in the Lowcountry and in other states. “A lot of what DME does is equipment—that equipment can be shipped and sent.” As for the future, Dr. Gault hopes to integrate PEFL at the practice level. “We hope to have equipment available in the practices, based on each practice’s needs, whether it’s biliblankets, nebulizers, breast pumps or something else. The idea is, it should be available at the practice so that families can get the equipment they need when they need it.” Pediatric Equipped for Life has two GHS locations—the main store at Patewood Medical Campus in Greenville and the Children’s Hospital Outpatient Center in Spartanburg—with the adult branch of Equipped for Life™ supporting pediatric services on GHS’ Greenville Memorial Medical Campus and its Oconee Medical Campus.

“We want the best outcome for the patient, and we want to be able to decrease readmissions.” — Randy Lydick, supervisor of Respiratory Care Services at GHS 23

CELEBRATIONS

Children’s Hospital of Greenville Health System (GHS) has many reasons to celebrate! team and grateful for the support we receive each year from listeners and sponsors.” The Dream Gap, funded through Radiothon and donors, allows Children’s Hospital to have the resources necessary to provide a comfortable environment for patients and their families. The Dream Gap includes tools, programs and services that go beyond a normal operating budget and are not paid for by insurance.

Radiothon Marks 10 Years GHS Children’s Hospital’s annual Radiothon raised over $307,000 and celebrated its 10th anniversary on August 3-4. In partnership with Entercom Upstate, Radiothon takes place in the lobby of Greenville Memorial Hospital with live broadcasts on each of the seven Entercom stations: 106.3 WORD, ESPN Upstate, Classic Rock 101.1, 93.3 The Planet, Magic 98.9, B93.7, and 96.3 The Block. On-air personalities share stories and interviews from patients and families, who have been served by the hospital’s Bryan Neonatal Intensive Care Unit, Roger C. Peace Rehabilitation Hospital, BI-LO Charities Children’s Cancer Center, and other programs and services.

Nearly $3 million has been raised for Children’s Hospital through Radiothon over the last decade. “Radiothon is the biggest event Entercom GreenvilleSpartanburg does every year,” said Steve Sinicropi, vice president and general manager at Entercom Upstate. “It’s a labor of love for our 100+ employees and all seven radio stations. Helping fund the Dream Gap at Children’s Hospital is meaningful and satisfying, especially when we see the results and hear from affected families. I am incredibly proud of our

For example, our Dream Gap funds conscious sedation medications that prevent a child from feeling pain during a procedure. A vial of propofol costs around $200 each. Children’s Hospital provides this vial to affected families for free. When the safest, most practical option is not deemed medically necessary or reimbursed by insurance companies, we try to fill that void. Our hope is to provide the best possible care for children and their families, and our Dream Gap makes this a reality. The Dream Gap also funds therapy services such as our facility dog program, known as the Canine F.E.T.C.H. Unit. Our facility dogs help calm and comfort children who may be scared or anxious. Other examples include blanket warmers, distraction toys in patient rooms or pediatric offices, and scholarships for patients to attend Children’s Hospital camps.

Birthday Bash Raises $3K Thomas Tiller, MD, a retired pediatric allergist who worked at Children’s Hospital, celebrated his 80th birthday in June. As part of the celebration, Dr. Tiller encouraged his guests to contribute to the Children’s Hospital Seed Fund for Advanced Pediatrics. Party guests combined their resources to raise more than $3,000, which will be used to support pediatric innovations and advances in care.

CELEBRATIONS

New Children’s Garden Honors Dr. Schmidt The second phase of Greenville’s Cancer Survivors Park, located downtown along the GHS Swamp Rabbit Trail, contains a special children’s garden area, which has been dedicated as “Clement’s Kindness Children’s Garden in honor of Dr. William F. Schmidt III, MD.“ Sandra Miller, administrator with Clement’s Kindness Fund, a philanthropic organization that addresses the needs of upstate families dealing with pediatric cancers, said it’s only fitting to name the garden in Dr. Schmidt’s honor.

Jack Williams, currently being treated for cancer, perches atop the lion with his younger brother.

“He has such a passion for children with cancer and their families,” she said. “This park encompasses hope and healing, and that’s exactly what Dr. Schmidt has done for all these children.”

The 15,000-square-foot Children’s Garden encompasses two levels. It contains a large bronze sculpture of a child drawing courage from the protective embrace of a lion, a gift from GHS Children’s Hospital.

NICU Reunion Children’s Hospital’s Bryan Neonatal Intensive Care Unit (NICU) hosted a reunion for former patients who graduated from the NICU. The event took place at The Children’s Museum of the Upstate, and more than 1,000 people attended. Children’s Hospital has been holding a NICU reunion for more than 20 years to provide families the opportunity to share stories with other families and visit with the nurses and staff who were an integral part of their child’s stay.

Caregivers of the Year (left to right): Cassandra Stoops, RN; Dawn Roark, RN; Denise Wiklacz; Holly Bryan, MSN, PNP-BC; Sarah Thompson, MSOT.

Community Advisory Council Awards At its annual celebration in September, the Children’s Hospital Community Advisory Council honored several employees, community volunteers and supporters of GHS Children’s Hospital. Five Caregivers of the Year were announced: • Dawn Roark, RN: Bryan NICU • Cassandra Stoops, RN: Inpatient, PICU and Hematology/ Oncology Nursing • Sarah Thompson, MSOT: Outpatient Services • Holly Bryan, MSN, PNP-BC: Physician Practices and Specialty Care • Denise Wiklacz: Non-clinical Professional The Legislative Advocacy award went to S.C. Rep. Raye Felder, who supported the Seizure Safety in Schools Study Committee to examine issues related to epilepsy and seizure safety awareness in public schools. Carol Rosensteel won the Buddy’s Spirit award for embodying the spirit of giving back to Children’s Hospital. This honor goes to a council member. The evening’s capstone award—All for the Love of Children— went to Jamie Moon, executive director of the Institute for Child Success. Moon has been tireless in his advocacy for policies and programs that help all South Carolina children succeed.

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

Type 1 and Type 2 Diabetes Diabetes is one of the major health concerns in the U.S., not only because of the costs to individuals, health institutions and taxpayers, but also because of its short- and long-term effects. When not managed effectively, diabetes can result in heart disease, kidney disease, blindness and even death.

Pediatric Endocrinology participates in multiple clinical trials and registries for children and adolescents with both types of diabetes: Type 1 (not preventable or reversible and treated only through insulin use) and Type 2 (potentially preventable or reversible and treated with various medications).

Greenville Health System (GHS) recently designated diabetes as its primary research focus, and projects are planned or already underway across the system aimed at preventing and optimally treating this disease. The Division of Pediatric Endocrinology at GHS Children’s Hospital is a leader in this regard.

Type 1 Research Studies

Types of Diabetes

At GHS, our primary research in type 1 diabetes is through the group TrialNet. With the help of the TrialNet Natural History study, we have learned that family members of those with type 1 diabetes are 15 times more likely to develop type 1 diabetes. This risk can be determined with an initial simple blood draw to measure diabetes-related autoantibodies. Those family members screening positive for autoantibodies associated with the disease then can be monitored closely.

Type 1 Diagnosis Often diagnosed in young children, but it can be diagnosed at any age

Type 2

Diagnosis Often diagnosed in people over 40, but can be diagnosed at any age

Thanks to our affiliation with TrialNet, we also are able to offer ongoing trials to qualifying participants to try to delay or prevent the onset of diabetes.

Development The immune system will destroy any new beta cells the body produces

Development The body becomes insulin resistant and does not use insulin properly

Treatment Treated with injected or pumped insulin throughout the patient’s lifetime

Treatment Initially, treatment involves diet, exercise and/or medication; some patients may need injected insulin

Finally, those who have participated in screening, monitoring or TrialNet prevention studies may choose to continue on into the Long-Term Investigative Follow-up in TrialNet (LIFT) study. LIFT allows us to continue collecting data on participants throughout the course of their disease.

Prevention and Control Cannot be prevented; only controlled with insulin

Prevention and Control Healthy lifestyle choices lower risk of type 2 diabetes, yet genetics also plays a role; management is possible without medication, but this is not the case for all patients with type 2 diabetes

Other Types of Diabetes

Gestational diabetes is a form of diabetes developed during pregnancy LADA (also known as type 1.5) is a slower-progressing form of type 1 diabetes MODY is a form of diabetes caused by specific genetic mutations

Sources: American Diabetes Association, Juvenile Diabetes Research Fund 26

In addition to TrialNet, the T1D Exchange aims to identify factors that influence glycemic control in adult and pediatric patients. This exchange is a clinical registry of 72 centers across the country that includes the top diabetes research centers—GHS is the only recruiting site in South Carolina. Of the 35,000 subjects participating in the T1D Exchange registry, GHS has about 300 children contributing to the registry. This study has provided a wealth of information describing the population and now is shifting its goal to improving outcomes and quality of life.

Type 2 Research Studies

In the past, type 2 diabetes was considered a disease of adults. Over the last decade, however, type 2 diabetes has seen a marked increased in adolescents, mirroring increasing rates of obesity. In addition to a healthy lifestyle, the only non-insulin diabetes treatment approved for use in adolescents with type 2 is metformin.

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.

Helping Children Travel Safely Children’s Hospital of Greenville Health System (GHS) has received a Kohl’s Cares grant for 2017-18. This grant hopes to improve the lives of thousands of local families by providing support for GHS Children’s Hospital’s Child Passenger Safety programming through the Bradshaw Institute. The $310,000 grant will benefit three programs: Child Passenger Safety. This family-focused program trains community volunteers to be nationally certified child passenger safety technicians. In Greenville County, roughly 4 of every 5 families use car seats improperly. Thanks to the Kohl’s grant, the Bradshaw Institute can continue to maintain its nine child passenger safety inspection stations in the Upstate. These stations check about 650 car seats annually and, most important, educate caregivers about proper car seat installation and selection. The grant allows for the addition of a 10th child passenger safety inspection station at GHS’ Greenville Memorial Hospital (GMH), with the goal that every family who delivers a baby at GMH be given the opportunity to have the baby’s car seat inspected before discharge. Because approximately 6,000

babies are born every year at GMH, this new inspection station can have a marked impact on community safety. Safe Travel for All Children. This special-needs child passenger safety program is led by the institute’s Kathy Harper Moody and by Mary Jones of GHS Kidnetics® (pediatric therapies). They help children who need specialized or adaptive car seats. The program has an inpatient component, working with medically fragile children or children who require a specialized car seat after an orthopaedic procedure. The program also works in the outpatient setting with children who might have neurologic, behavioral or medical concerns, thus preventing them from using a conventional car seat. Special-needs car seats can cost over $2,000. The generosity of the Kohl’s Cares grant makes it possible to loan these special seats to area families. Teen Distracted and Drugged Driving Prevention Program. This grant allows Bradshaw Institute programming to prevent drugged and distracted driving among teens. Using a peer-topeer education approach, the Bradshaw Institute will partner with local high school student governments to offer interactive driving simulators for student use. Schools can reserve pedal carts for students to use along with goggles that simulate driving while impaired or sleep-deprived. Additionally, student ambassadors will be trained as facilitators and educated on how to talk to their peers about drugged and distracted driving. The goal is to reduce the number of student-related alcohol or driving collisions in the Upstate.

Continued from previous page.

Pharmaceutical companies continue to explore other potential therapies for these individuals. We are participating in two international type 2 industry-sponsored drug trials: Ellipse and T2Go. These studies are designed to prove the safety and efficacy of drugs that currently are FDA approved for adult use only. Just as we have ongoing enrollment in the T1D Exchange registry, we enroll patients in the Pediatric Diabetes Consortium. This consortium is a large registry of pediatric patients diagnosed with type 2 diabetes. It was developed to provide critically important data regarding the current state of treatment of type 2 diabetes in leading pediatric treatment centers across the nation. By tracking disease characteristics,

treatment approaches and outcomes, care providers hope to collaborate with regulatory agencies and industry sponsors to develop successful clinical trials for the approval of new drugs that can treat children and adolescents with type 2 diabetes. Providing leading-edge research gives our patients access to potential new therapies or treatments and helps us better understand the diabetes disease process. Our participants have directly contributed to the general knowledge base. Together we are improving the lives of those with diabetes through our research endeavors. Resources

https://www.diabetesresearch.org/diabetes-fact-sheet https://www.trialnet.org 27

FEATURE STORY For patients ages 15-39, the Adolescent & Young Adult Oncology Program, part of the Cancer Institute of Greenville Health System (GHS), provides support for medical— and non-medical—challenges.

AYA Oncology Program: Meeting Needs Beyond Medicine By Anne Smith

While participating in the program, patients continue to be cared for by their primary oncologist. But the program’s codirectors—pediatric hematologist/oncologist Aniket Saha, MD, and adult hematologist/oncologist Elizabeth Cull, MD, aim to see every GHS patient in that critical age group who has been diagnosed with cancer. “Once a patient has received a diagnosis, he or she is referred to us,” Dr. Saha said. “We don’t make treatment decisions, but we do meet needs, add a voice, and give information and insight to our patients.”

Psychosocial Supportive Care

Dr. Cull explained that the program serves as an additional layer of care, often providing assistance for the non-medical needs— which can loom large—of this patient group.

Elizabeth Cull, MD (right), and Kerri Susko, LISW-CP, OSW-C, talk to a patient during an office visit at the Adolescent and Young Adult Oncology Program.

In the United States, over 70,000 people between the ages of 15-39 receive a cancer diagnosis annually. Troublingly, these adolescent and young adult cancer patients lag behind other age groups in successful outcomes. This population is underrepresented in clinical research and has distinct biologic and psychosocial needs that demand specialized care. To address that problem, GHS Cancer Institute launched an Adolescent & Young Adult (AYA) Oncology Program in 2016. The program brings together specialized care providers from both the pediatric and adult worlds. And while it’s not a patient’s primary source for treatment decisions, the program’s doctors and caregivers believe they can help improve outcomes among patients with cancer in this age group. 28

“I’d describe our program as a psychosocial supportive care clinic,” she said. “The patients who see us may not seem to have any of these needs at first, but if we spend an hour with them, not necessarily talking about the medical, a lot comes out. Can they make it to their appointments? Can they afford their medicine? From a medical perspective, accessibility and compliance are crucial.” Dr. Cull recalled learning during a first appointment that a patient had been charged a full semester’s college tuition when the cancer diagnosis had forced the patient to leave school after just one week. For other patients, the program handles aspects as varied as transportation arrangement, cancer genetics referrals, and discussions around fertility preservation and sexuality. The AYA Oncology Program team brings together a handful of disciplines to effectively meet these needs. That team includes pediatric social worker Amy Bowers, LMSW, adult social worker and counselor Kerri Susko, LISW-CP, OSW-C, and nurse

practitioner Heather Bowers, APRN. In addition to the expertise of these providers, other tools available to program participants include support groups, social media outreach, cancer-focused counselors and social outings.

embryonal rhabdomyosarcoma, something almost exclusively seen in small children. Pediatric oncologists, he noted, have far more experience caring for such patients, using a specific combination of chemotherapy.

“We hear daily that patients felt alone and disconnected until they found us,” Dr. Cull stated. “Our team is able to fill in the gaps for them.”

“Through the AYA program and by virtue of its existence, we connected her with pediatric specialists who were able to address her issues seamlessly,” Dr. Cull recounted.

She said the AYA cancer population has historically not enjoyed the benefit of the abundance of resources, clinical trials and philanthropy dollars dedicated to pediatric cancer programs, but these patients—in the midst of their own transitions to adulthood—need at least as much support as younger children.

Unmatched Access to Clinical Trials

“The AYA population can feel like something of a lost group,” Dr. Cull pointed out. “They get less attention, funding and support; but if anything, they need more support than anyone to juggle new financial independence and growing families.” Patients who experience social and emotional support are likely to have better medical outcomes. Dr. Cull added, “If their psychosocial needs are not being met, they may not fare as well, so I see our role and the primary oncologist’s role as approaching this issue from two sides.”

No Need to Start from Scratch

In its first full year, the program saw 65 patients. It was less of a launch of a new program, Dr. Saha noted, than an adaptation of many of the offerings already available at GHS, made possible by visionary leaders such as William F. Schmidt III, MD, PhD, then-medical director of GHS Children’s Hospital, and Larry Gluck, MD, medical director of the Cancer Institute. “We didn’t need to start from scratch; we just adapted GHS’ many offerings, honing them more toward AYA patients,” he stated. Dr. Cull said the program’s multidisciplinary nature aims to help make a challenging time easier for this patient group: “So much already was in place—nutrition, genetics, reproductive endocrinology—and we can support and complement what our colleagues are doing.” Another benefit to the multidisciplinary program is access to both pediatric and adult cancer specialists and social workers. “The AYA program allows for a seamless transition back and forth,” emphasized Dr. Saha. “Pediatric patients benefit, for example, from the fertility issues and genetic components we address, and adults who may have pediatric tumors are able to access specialists from both sides.” Pediatric tumors, while most common in patients under 18, also can be seen beyond the window of childhood. Dr. Saha remembered a young adult patient diagnosed with an

GHS is the only upstate hospital—and one of just three in South Carolina—to be a member of Children’s Oncology Group, a National Cancer Institute-supported clinical trials organization. This membership gives GHS patients, particularly those within the AYA Oncology Program, access to frontline treatment trials led by the world’s cancer experts. “We try to educate our patients about the importance and value of clinical trials, screening every AYA patient weekly for any supportive care or treatment trials that could benefit them, in an effort to increase enrollment and give them access to new and novel therapies,” Dr. Cull stated. Some trials—even though they are through the Children’s Oncology Group—accept patients up to age 50, pointed out Dr. Saha, so they still can benefit those who fall outside the pediatric age range. “We’re setting up patients to have the best possible outcomes,” Dr. Saha said. “Referring physicians can know they have sent their patients to the best place in the region for this kind of care.” As the AYA program wrapped up its first year, the team had already made inroads into expanding services available through the community, noted Dr. Saha. For example, the clinic’s nurse manager reached out to a local charity focused on pediatric brain tumor patients. As a result, the organization decided to expand its support to include patients up to age 35. “That’s something unexpected, something good, that just adds to what we’re doing,” Dr. Saha emphasized. “I see more of that in our future.”

“We hear daily that patients felt alone and disconnected until they found us. Our team is able to fill in the gaps for them.” — Elizabeth Cull, MD 29

A S K T H E FAC U LT Y

Overcoming Burnout:

Your Virtual Starter Kit Q: I think I’m suffering from burnout. Any tips? A: The medical community continues to recognize the significant impact of burnout on employees’ satisfaction and effectiveness in the workplace. Burnout is defined as a state of chronic stress that leads to … • Physical and emotional exhaustion • Cynicism and detachment • Feelings of ineffectiveness and lack of accomplishment The literature indicates that the incidence of burnout among healthcare providers may reach 50-70% or higher. And it’s not just providers—our residents, nurses, therapists and clerical staff are burning out, too.

Causes of burnout are multifactorial. It can start with our own ability to cope and handle stress. Underlying personal risk factors include behavioral health challenges, physical illness, lack of exercise, improper diet, sleep deprivation, and fear or inability to seek help in treating burnout. Organizational risk factors include higher productivity demands, changing methodologies (including use of electronic medical records), additional extrinsic requirements and distractions from primary tasks, loss of individual autonomy to effect changes, and organizations not moving fast enough to help solve the systemic triggers of burnout. Individuals and organizations are successfully finding solutions on both fronts. When the two work together, both will benefit from a healthier team, more efficient workforce, higher patient satisfaction, higher quality, lower patient risks and better health for the community. But what can individuals do?

Pediatric Specialty Services

Start with an honest self-assessment. The AMA offers a free baseline assessment for physicians and resident/fellows to appraise their current state with CME attached: • stepsforward.org/modules/physician-burnout • stepsforward.org/modules/physician-wellness Explore digital and analog resources. I recommend Stanford University’s WellMD website (wellmd.stanford.edu) to discover tools you could use or would like to see your team or organization use. If you like books or audiobooks, consider one of the following: • Stop Physician Burnout by Dike Drummond, MD • Healing Physician Burnout by Quint Studer • The Resilient Physician by Wayne Sotile, PhD Pick a change to make. Alice Domar, PhD, Harvard psychologist and director of the Domar Mind Body Institute at Boston IVF, notes that individuals have to determine which techniques are most helpful for them. There is no one-sizefits-all solution. Science is showing objective improvement with cognitive behavioral techniques followed by relaxation techniques. Surprisingly, group discussions about burnout do not typically improve burnout. Talking about it is not enough. Consider an app. I like the Breathe app on my iWatch. Another meditation app with lots of choices is Insight Timer (and it’s free). Schedule a 5-minute walk into your calendar. Take a few miutes for prayer or a song. Enjoy micro-vacations and minirelaxations. Get sleep. Eat healthier. Go play. Finally, be the agent of personal and organizational change. Ask your business or organization what you can do to help go beyond problem identification. Move to help identify actual system solutions that will equip you and your colleagues to regain or maintain the joy of medicine.

Robin N. LaCroix, MD________________________________________ (864) 455-8401 Medical Director; Chairman, 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 Cardiology ________________________________________________________ 454-5120 Child Advocacy Medical Program____________________________________ 335-5288 Critical Care_______________________________________________________ 455-7146 Developmental-Behavioral 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

Best of success on your next steps as you apply what you learn and share what you discover!

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. 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.

Anderson Article author R. Austin Raunikar, MD, a pediatric cardiologist at Children’s Hospital of Greenville Health System, has a special interest in helping fellow physicians avoid burnout.

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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.

Pediatrician of the Year Congratulations to Michael Fields, MD, pediatric pulmonologist at Children’s Hospital of Greenville Health System and medical director for Pediatric Respiratory Care, who received the 2017 Pediatrician of the Year award at the 26th Annual DeLoache Seminar in November. Dr. Fields was recognized by his colleagues for being “a team player both in his division and across pediatrics as a whole,” and for working “to encourage others as we each work tirelessly to deliver the best possible pediatric care.” In addition, he was lauded for developing a program to educate families, first responders, emergency department staff, and home health nurses on caring for infants and children with artificial airways. Nomination forms emphasized Dr. Fields’ dedication to patients, families and colleagues. One peer noted, “His patient care is exemplary, and patients are devoted to him. He is an excellent teacher for staff, colleagues and students.” Approximately 85 health professionals attended the seminar, which is named for the late William R. DeLoache, MD, GHS’ first neonatal medicine specialist. Michael Fields, MD (right), accepts the award for Pediatrician of the Year from William Schmidt, MD, PhD, then-medical director of GHS Children’s Hospital.

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