Focus on Pediatrics Winter 2017 by Prisma Health

Beads Celebrate Courage of Patients with Cancer Centering Brings Moms Together CME: Osteoporosis

Vol. 29.1 Winter 2017

on Pediatrics

New Structure Positions GHS for Success

Focus on Pediatrics is published quarterly 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 Sally Cade Karen Cantu Kristi Coker, MSN, 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

Population Health and Pediatrics Like many of you, in medical school I learned the science of medicine and how to provide excellent care for individual patients. My focus was to become an expert in treating disease (in my case, pediatric cancer), not necessarily preventing it. My guidelines were the 4 A’s: ability, accessibility, affordability, and affability. Worrying about the health of populations and disease prevention was the business of our public health colleagues, not practicing physicians and hospitals. That paradigm started to shift in 2008 when Donald Berwick published in Health Affairs what has since become known as the “triple aim” for improving the health of populations—improving the experience of care (accessibility and affability), improving the health of populations (ability) and reducing the per capita cost of care (affordability). Since then, policies have been enacted to transition our nation to what we today call “population health.” Already, our adult colleagues who care for Medicare patients are paid less for treating disease and more for keeping panels of patients healthy, providing a pleasing patient experience

and offering high-quality care at a lower cost to payers. Medicaid is close behind. The shift to population health has led Greenville Health System to dramatically increase and regionalize our patient base as described by our new president, Spence Taylor, MD, in our cover story. While the national focus is now on adult populations, that focus will broaden to pediatrics quickly as health planners begin to realize that most preventable diseases of adults get their start in childhood. As I’ve said many times, pediatric anticipatory guidance is a perfect fit for population health. And let’s not forget the 4 A’s!

William F. Schmidt III, MD, PhD

CONTENTS

Changes at Greenville Health System: A Primer 2 It’s been a year of significant changes for GHS, but each one is intended to help the organization move toward better care for our communities.

CenteringParenting Offers a Personal Doctor Visit Experience 19 Moms enjoy more time with the doctor and each other with the CenteringParenting approach.

Beads Celebrate Courage in Children with Cancer

Beads of Courage can help patients with cancer remember their journey through diagnosis and treatment.

5 2

Ask the Faculty: Media Guidelines 26 How should the new American Academy of Pediatrics (AAP) media guidelines change how we educate families?

Departments What’s New? 5

Step-down PICU Unit, Cancer Program for Adolescents, Helping Parents CEASE Smoking

19 5

Medical Staff Spotlight 6 Meet Our New Physicians

Academic News 8

Resident Project Takes Aim at Cyberbullying

CME 9

Osteoporosis in Children

Quality Counts 13

Antimicrobial Stewardship

22 9

Celebrations 14

Accreditation and Philanthropic News

Case Study 17 Infantile Hemangiomas

Clinical Research 24

Researchers Study Treatments for Diabetes, EoE, RSV

13 26 On the cover: Spence Taylor, MD, talks with William Schmidt III, MD, PhD, during Dr. Taylor’s visit with physicians at The Children’s Clinic.

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

LEAD STORY Greenville Health System (GHS) has made significant changes over the last year as the organization strives to be a leader in the changing healthcare environment.

Leading the Way in Health Care’s New Frontier

Spence Taylor, MD (center), talks with Dane Pierce, MD (left), and William Schmidt III, MD, PhD, during Dr. Taylor’s visit with the physicians at The Children’s Clinic.

Health care has seen tremendous changes in the last decade. Shifting payment models, focusing on healthy populations and increasing the emphasis on high-quality outcomes are examples of the changes organizations are adapting to these days. GHS has been creating a strategy to be successful in this new environment, and the formation of the Strategic Coordinating Organization (SCO) is one piece of this strategy. The SCO—a private, not-for-profit organization—will serve as a health company providing strategic direction and support to affiliate organizations, including GHS. With Mike Riordan being charged with leading the SCO, Spence Taylor, MD, was asked to step into the role of president of GHS. 2

Dr. Taylor explained the reasoning behind GHS’ organizational changes this way: “Health care is changing, and these significant changes require us to think and act differently. For example, we will no longer be paid or reimbursed based on the number of services we provide; instead, we will be rewarded for our performance and ability to improve health outcomes, reduce healthcare costs and enhance the patient experience across populations. Our organizational changes will allow us to keep our health care strong and local in this new environment.” In Dr. Taylor’s first 90 days in his new role, he launched a listening tour to visit with employees and gather insight as he crafted his vision for the organization. “We have a strong system and amazing employees who are really committed to our patients,” Dr. Taylor said. “However, we do have some issues to address. How can we strengthen the relationships between our clinicians and our patients? And how do we manage the health of the populations we serve?”

Keeping the Focus Local

As Dr. Taylor and GHS leadership considered how the organization could best address these issues, it became increasingly clear that some segmentation was needed. “Dividing GHS into regions allows us to address the unique needs of the communities we’re serving,” Dr. Taylor said. “The model develops smaller work units that can promote innovation and collaboration at and across all levels of the organization.” GHS now comprises a Central, Eastern, Southern and Western Region, with each region led by what Dr. Taylor calls the “dyad model” of a physician-administrator team. “Dyads are partnerships that will allow GHS to become a clinician-run organization focused on patient-centered care,” Dr. Taylor said. “The dyads in each region will be responsible for understanding the clinical needs of the region and managing GHS resources effectively and efficiently to meet these needs.” In addition to the clinician-administrator team, a second dyad will consist of a closer tie between the physician and a nursing executive. “This dyad will be responsible for developing interprofessional practice at GHS,” Dr. Taylor said. “We must have physicians and nurses working together as a team.” Dr. Taylor said the new model appears at the top levels of leadership as well, with Greg Rusnak, GHS’ chief operating officer and executive vice president, serving as his administrative counterpart and Michelle Taylor-Smith, vice president of Patient Care Services and chief nursing and

experience officer, working closely with him on the clinical side. Each region will have a high degree of autonomy over how services are delivered within that region, Dr. Taylor added. “To meet the needs of each community, our strategies may look different from region to region. For example, the Western Region’s wellness, education and business strategies may not be the same strategies chosen to address the specific needs of the Eastern Region,” he noted.

A Service Line Touching Each Region

When it comes to Children’s Hospital, Dr. Taylor stated there would be “a unifying Children’s Hospital strategy across all of the regions coordinated from region to region to region.” William F. Schmidt III, MD, PhD, medical director of GHS Children’s Hospital, agreed. “Children’s Hospital programs are already in each of the four regions, so we’ll be paying much attention to how our product line works across and augments all of our regions,” he said. “That includes our pediatric therapies, the Bradshaw Institute for Community Child Health & Advocacy, the Ferlauto Center for Complex Pediatric Care, Child Life, and all of our physician initiatives.” Dr. Schimdt also was appointed as Western Region chief clinical officer and will work closely with Jeanne Ward, the chief operating officer for that region. The region includes the Oconee, Easley, Clemson and Anderson communities. Dr. Schmidt will remain in his role as Children’s Hospital’s medical director and chair of the Department of Pediatrics.

The Regional Model Central

Greenville/Greenville Memorial Medical Campus Patewood Medical Campus Simpsonville/Hillcrest Memorial Hospital North Greenville/LTACH

Southern

Laurens/Laurens County Memorial Hospital

Eastern

Greer/Greer Medical Campus Spartanburg

Western

Oconee/Oconee Memorial Hospital Easley/Baptist Easley Anderson

Dr. Taylor listens to feedback from pediatricians at The Children’s Clinic during his visit there. Dr. Taylor met with doctors at every GHS practice after becoming president of GHS in 2016.

“I’m excited to be leading the Western Region,” Dr. Schmidt pointed out. “It is loaded with talent and untapped potential. Clemson University sits right in the center and could be a great resource for community-based population health initiatives.”

Physicians as Owners

Dr. Schmidt offered reassurance to GHS pediatricians concerned about his additional role taking focus away from Pediatrics: “I see this as a natural result of our phenomenal growth. With the new changes occurring on a regional level, we are delegating in Pediatrics more responsibility to our three vice chairs and five senior medical directors, and they are showing up as great leaders. Pediatrics is in good shape.” (See box below.)

“Our physicians own the standard of care within this community, and they need to be very proud of that,” Dr. Taylor said. “They’ve created the future workforce in this community, and they need to be very proud of that, too. They’ve created a mechanism to care for everyone, from infants to the elderly, no matter the time of day or their ability to pay.”

Vice Chairs Robin LaCroix, MD—Pediatric Quality and Medical Staff Services George Haddad, MD—Pediatric Clinical Services Desmond Kelly, MD—Pediatric Academic and Community Services Senior Medical Directors Carley Howard Draddy—Pediatric Primary Care and Pediatric Telemedicine Services Robert Saul, MD—Pediatric Medicaid Services R. Austin Raunikar, MD—Pediatric Specialty Care Services John Chandler, MD—Pediatric Surgical Services Kerry Sease, MD—Pediatric Academic and Community Services

Both Dr. Schmidt and Dr. Taylor hope the new regional strategy will give GHS’ physicians more of a feeling of ownership in their organization.

He continued, “Our work at GHS is very mission focused. That’s why our physicians are here, and we hope they will not walk away from that mission.” Dr. Schmidt also hopes to engage physicians—including pediatricians—in the Western Region in a more effective way. “Some of the physicians outside of our central area now feel a little neglected, and they have many good ideas to offer,” he said. “We want them all engaged.” He himself plans to remain fully engaged as well.

“I am a pediatrician, but I’m also thrilled with being able to do something bigger,” Dr. Schmidt emphasized. “For me, it’s exciting to build new programs without walking away from pediatrics.”

WHAT’S NEW? Children’s Hospital of Greenville Health System (GHS) opens a step-down PICU unit, welcomes back an assistant for Dr. Schmidt, adds a car safety seat inspection location, and announces GHS’ Adolescent & Young Adult Oncology program.

PICU Expands Children’s Hospital now offers an eight-bed step-down unit adjacent to the Pediatric Intensive Care Unit (PICU). This area can house patients as they transition from the PICU to other pediatric units. The unit also allows Children’s Hospital to have cardiorespiratory monitoring outside of the PICU environment. Children who are receiving high-risk medicines or need close monitoring but are not critically ill can be cared for outside of the PICU. This expansion allows the 12 beds in the PICU to be available for the sickest patients requiring the most intensive care and ventilation support. “Because we have the only pediatric intensive care unit in upstate South Carolina, we need that capacity,” said William F. Schmidt III, MD, PhD, medical director of Children’s Hospital.

Ninth Car Seat Inspection Site Another permanent car seat inspection station has been added in the Upstate. The Lake Cunningham Fire Department in Greer offers car safety seat inspection services for expecting parents and parents of young children. The nine stations are sponsored by Safe Kids™ Upstate, a part of Children’s Hospital’s Bradshaw Institute for Community Child Health & Advocacy.

‘New’ Assistant Karen Cantu has returned to the position of administrative assistant to William Schmidt III, MD, PhD, Children’s Hospital’s medical director. In addition to serving Dr. Schmidt, Cantu supports Robin LaCroix, MD, vice chair of Quality and Medical Staff Services for the Department of Pediatrics, and Jennifer Hudson, MD, medical director of Newborn Services and associate program director of the Pediatric Residency Program.

Cancer Program Aims at Young Patients GHS recently launched the Adolescent & Young Adult (AYA) Oncology Program for patients ages 15-39. The program is intended for patients with new and existing cancer and will focus on several areas: clinical trial participation, cancer genetics, reproductive and fertility counseling, and personalized resource access for the AYA population. The program also will maintain an AYA registry with the ultimate hope that patients will participate as survivors in the Lifetime Clinic at the GHS Cancer Institute. Patients will be seen every Wednesday in the Pediatric Hematology/Oncology Clinic at the BI-LO Charities Children’s Cancer Center. If you have questions about the program or wish to make a referral, call (864) 455-8898.

CPM Helping Parents CEASE Smoking Children’s Hospital’s Center for Pediatric Medicine (CPM), North Greenville Outpatient Center and CPM–West have joined an initiative that aims to curb children’s exposure to secondhand smoke in the home called CEASE (Clinical Effort Against Secondhand Smoke Exposure). The program includes three components: • Ask—At every visit, the provider asks the parent if the child lives with anyone who uses a tobacco product or vapes • Assist—The pediatrician can prescribe nicotine replacement therapy (NRT) to the parent • Connect—Refer tobacco users to the SC Smokers’ Helpline for support and counseling in tobacco cessation The American Academy of Pediatrics (AAP) advises that all clinicians be familiar with pharmaceutical options for smoking cessation and offer them to parents if needed. GHS’ Department of Pediatrics has been awarded an AAP Richmond Center Visiting Lectureship grant for spring 2017. A national expert on tobacco cessation and second-hand smoke will conduct talks and workshops to multi-specialty groups at GHS March 30-31.

She can be reached at (864) 455-8401. 5

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

Meet Our New Physicians Anesthesiology

Neonatology

Emergency Medicine

Orthopaedics

General Pediatrics

Pediatric Nephrology

John J. Freely Jr., MD, earned his medical degree at St. George’s University School of Medicine in Grenada, West Indies. He completed his residency in Anesthesiology at Rush University Medical Center in Chicago and a fellowship in Pediatric Anesthesiology at Northwestern University McGaw Medical Center in Chicago. Dr. Freely works with Greenville Anesthesiology and can be reached at (864) 522-3700.

Jeremiah Smith, MD, earned his medical degree from Southern Illinois University School of Medicine. He completed his Pediatrics residency at Indiana University’s Riley Hospital for Children in Indianapolis and a fellowship in Pediatric Emergency Medicine at Carolinas Medical Center in Charlotte, N.C. Dr. Smith is working in the Children’s Emergency Center and can be reached at (864) 455-6016.

Mary A.S. Putnam, MD, earned her medical degree from Eastern Virginia Medical School in Norfolk. She completed her residency training in Pediatrics at Children’s National Medical Center in Washington, D.C., and completed a residency fellowship in Health Policy at the George Washington University Milken School of Public Health. Dr. Putnam is working at Children’s Hospital’s Center for Pediatric Medicine–West. She can be reached at (864) 220-7270.

Name Changes

Ashley T. Flesher, MD, formerly Ashley T. Godwin, MD, is a pediatrician at Pediatric Associates–Powdersville.

Matthew F. Halliday, MD, has joined Neonatology at Children’s Hospital as a member of Pediatrix Medical Group. He earned his medical degree from the Medical University of South Carolina (MUSC) in Charleston. Dr. Halliday completed his Pediatrics residency at the University of Alabama’s University Medical Center in Tuscaloosa and a fellowship in Neonatology at MUSC. Dr. Halliday can be reached at (864) 455-7939.

David E. Lazarus, MD, earned his medical degree from the University of Tennessee College of Medicine in Memphis. He completed a residency in Orthopaedic Surgery at Emory University in Atlanta. Dr. Lazarus completed a Pediatric Orthopaedics and Scoliosis fellowship at Rady Children’s Hospital in San Diego. Dr. Lazarus is working with GHS Orthopaedics/Steadman Hawkins Clinic of the Carolinas. He can be reached at (864) 797-7060.

Sudha Garimella, MBBS, earned her medical degree from Pondicherry University in India. She completed her Pediatrics residency at Women and Children’s Hospital of Buffalo in Buffalo, N.Y., and a fellowship in Pediatric Nephrology at the University of Buffalo. Dr. Garimella spent the last six years as medical director for the Pediatric Dialysis Unit at Women & Children’s Hospital of Buffalo. She can be reached at (864) 454-5105.

Ann Marie Patterson Ravindran, MD, formerly Ann Marie Patterson, MD, provides GHS inpatient pediatrics at AnMed Women’s & Children’s Hospital.

Pediatric Neurology

Michael A. Babcock, MD, graduated from Medical University of South Carolina in Charleston. He completed his residency training in Pediatrics and then Child Neurology at Vanderbilt Children’s Hospital in Nashville, Tenn. Dr. Babcock can be reached at (864) 454-5110.

New Community Pediatrician

We welcome the addition of Katherine M. Spinks, MD, to GHS Internal Medicine, housed at the new GHS Medical Center– Boiling Springs. Dr. Spinks is trained in Medicine-Pediatrics. She can be reached at (864) 599-0731.

Pediatric Ophthalmology

Keith L. McCormick, MD, earned his medical degree from the University of North Carolina at Chapel Hill. Dr. McCormick completed his residency training in Ophthalmology at Duke University Eye Center followed by a fellowship in Pediatric Ophthalmology and Adult Strabismus at Eye Consultants of Atlanta/Scottish Rite Children’s Hospital. He can be reached at (864) 454-5540.

Dr. Sease Elected VP of SCAAP Kerry Sease, MD, MPH, was elected vice president of the South Carolina chapter of the American Academy of Pediatrics at the organization’s annual meeting in July 2016. She will serve a two-year term followed by a two-year term as president.

Pediatric Sleep Medicine

Roni Socher, MD, FAAP, FCCP, graduated from Tel Aviv University’s Sackler Faculty of Medicine in Israel. He completed his Pediatrics residency along with a fellowship in Pediatric Pulmonology at State University of New York Health Science Center at Brooklyn. Dr. Socher also completed a Sleep Medicine fellowship at University of Buffalo. He can be reached at (864) 454-5660.

Radiology

Erin M. Horsley, DO, earned her medical degree from New York College of Osteopathic Medicine in Old Westbury. She completed a Pediatric Emphasis Diagnostic Radiology Alternative Pathway residency at Drexel University College of Medicine’s Hahnemann University Hospital in Philadelphia, Pa. Dr. Horsley also completed a fellowship in Musculoskeletal Radiology at Duke University Medical Center in Raleigh-Durham, N.C. She is working with GHS Radiology and can be reached at (864) 295-4410.

Drs. Boineau, Abrams Retire Children’s Hospital bid farewell to two seasoned veterans in September 2016. Randel S. Abrams, MD, served Children’s Hospital for 23 years as a pediatric surgeon. In 1982, while he was a partner at Greenville Surgical Associates, Dr. Abrams performed the first neonatal intensive care unit surgery at what was then Greenville General Hospital. He was one of the first pediatric surgeons to work for Children’s Hospital and made tremendous sacrifices to make sure pediatric patients had access to the surgery they needed. For two years, he was the only pediatric surgeon on the staff and was on call every night. “He has a work ethic that’s unlike what we usually see,” recalled William F. Schmidt III, MD, PhD, medical director of Children’s Hospital. “He’s great with families, and he’s a steady clinical surgeon with great hands.” Franklin G. Boineau, MD, retired after serving 11 years with the Division of Pediatric Nephrology. Dr. Boineau came to Children’s Hospital from Tulane, where he led the transplant program. At Children’s Hospital, Dr. Boineau helped develop the Division of Pediatric Nephrology and recruit additional specialists. “Dr. Boineau is an excellent clinician and a good teacher,” Dr. Schmidt recounted. “He’s well-respected by the residents, and he’s been a good, solid guy we could count on.”

ACADEMIC NEWS A Pediatrics resident at Children’s Hospital of Greenville Health System (GHS) takes a step to curb cyberbullying.

Project Targets Cyberbullying through proper nutrition and physical activity. Unfortunately, the topic of mental health doesn’t come up as often.” Her research prompted her to develop some tools to aid parents, children and physicians in initiating conversations about cyberbullying. Staff at CPM continue to make these tools available to patients and physicians in an effort to raise awareness around cyberbullying.

QI Projects Win Awards Two posters by GHS Medicine-Pediatrics residents won awards at the SC American Academy of Pediatrics meeting in July.

The Accreditation Council for Graduate Medical Education (ACGME) requires a full rotation devoted to advocacy for every pediatric residency program, a testament to the central role of advocacy in a pediatrician’s work. Each resident at GHS Children’s Hospital completes this curriculum as a longitudinal experience under the direction of Lochrane Grant, MD. Beginning this year, each Pediatrics and Medicine-Pediatrics resident will participate in a local poverty tour to provide better insight into the lives of the population these physicians serve. An advocacy project, based on an area of need identified by each resident, already is mandated for these residents.

Bernadette Wood, MD, and Sarah Wells, MD, earned first place for their poster on implementing the SEEK screen at Children’s Hospital’s Center for Pediatric Medicine. The SEEK screen is used to identify children at risk for safety issues or food insecurity while also identifying parents in need of assistance. Jeremy Loberger, MD, earned second place with his poster on reducing the amount of time to receive antibiotics for children with sickle cell disease and fever in GHS’ Children’s Emergency Center.

Residents present these projects at the end of the year. One project from 2015-16, completed by Christine Riyad, MD, addressed the relatively new issue of cyberbullying. “Bullying, particularly cyberbullying, has become such a rampant problem with serious—and often fatal—consequences, but it often goes unnoticed,” Dr. Riyad said. “I noticed that at any given clinic visit, my patients were using some form of electronic device, yet I had never discussed internet safety.” Dr. Riyad continued, “I have many lengthy conversations with parents about maintaining a healthy lifestyle for their children

Bernadette Wood, MD (left), and Sarah Wells, MD, stand alongside their poster on implementation of the SEEK screen at the Center for Pediatric Medicine.

CME: Osteoporosis in Children 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 12. 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 Melissa D. Garganta, MD, has disclosed that she has no significant financial interest or relationship with any company that may be considered an actual or potential conflict of interest with this educational activity. The planning committee have listed no duality of interest with regard to potential relevant financial relationships for the FOCUS enduring activity. The CME committee have listed no duality of interest with regard to potential relevant financial relationships for the FOCUS enduring activity with the exception of Sandra Weber, MD (Committee Chair), Grant/ Research Support–Eli-Lilly, NIH, and Pfizer and William A. Coleman, MD (OB/GYN), Consultant–Merck. The Greenville Health System (GHS) designates this enduring activity for a maximum of 0.50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. The Greenville Health System is accredited by the South Carolina Medical Association to provide continuing medical education for physicians.

The roots of adult osteoporosis are established in childhood. The most recent Surgeon General’s report on bone health in 2004 estimated that by 2020, more than 54% of U.S. adults will have osteoporosis—equivalent to approximately $16 billion a year for fracture and non-fracture care. Bone mineral density (BMD) in childhood shows a high degree of tracking over time, indicating that the rising osteoporosis rate is preventable. Skeletal health and bone mass accrual in childhood is thought to be the most important modifiable factor affecting skeletal health over the lifespan. Approximately 4060% of adult bone mass is accrued during adolescence, with about 25% during the two-year period of peak height velocity. By age 18, 90% of bone mass accrual is complete. While certain factors affecting bone health cannot be modified, such as ethnicity, gender and genetics, there are several modifiable factors in childhood that pediatricians can target for early intervention. These modifiable factors include diet, exercise, weight and hormonal status.

Factors Affecting Bone Health in Children Adequate Intake of Calcium and Vitamin D Dietary intake of calcium from infancy through childhood affects bone mass and mineralization. Over 99% of the bodyâ&#x20AC;&#x2122;s calcium is stored in the skeleton. Dietary calcium is absorbed passively along the entire length of the small intestine and actively in the duodenum and jejunum via vitamin D-mediated transport. Vitamin D is a fat-soluble, cholesterol-derived hormone required for calcium absorption. Less than 20% of dietary calcium is absorbed without adequate vitamin D intake. Vitamin D is not readily available in many foods. The optimal source is UVB sunlight exposure. Dairy products and some cereals are fortified with vitamin D. Children at highest risk for vitamin D deficiency include those who are female, adolescent, obese, African-American or Latino. Those who live in more northern climates or have little sun exposure also are at higher risk. It is estimated that 47% of teenagers in the U.S. have vitamin D deficiency. Other Dietary Concerns Soft drink consumption is associated with increased obesity and lower intake of milk and other calcium-fortified beverages. In large quantities, dark cola drinks can impair calcium reabsorption in the kidney because of a high renal phosphate load. Children and teens should be discouraged from drinking these beverages as they provide no health benefit and can prevent adequate calcium and vitamin D intake.

It is estimated that almost 90% of children consume diets containing too much sodium. High sodium-containing foods can interfere with calcium retention in the kidney because of competition between sodium and calcium for the calcium transporter in the proximal tubule. The result is increased urinary calcium excretion. Children and teens should be encouraged to limit the amount of pre-packaged and high-sodium meals consumed to the recommended <2,300 mg sodium daily for ages 6-18 years and <1,500 mg per day for African-American children. Body Weight, Exercise and Mobility Maintaining an ideal body weight has a direct impact on bone health. BMD is directly correlated with body mass index (BMI); patients who are underweight are at risk of developing osteoporosis. Conversely, increased adiposity in children is associated with increased risk of fracture, likely secondary to higher rates of vitamin D deficiency and decreased weightbearing exercise in these patients. Children who participate in high-impact exercises for just 10 minutes a day three days per week have increased BMD compared those who are sedentary. Ideal exercise for children with growing bone should include cross-training with several activities, such as running, jumping, tennis, soccer, gymnastics, etc. Doing so will prevent excessive, localized high impact on growing bone but provide generalized increased BMD. Female adolescent athletes who become underweight lose the protective effect of exercise on BMD because of low BMI and often amenorrhea.

Children who are immobilized secondary to injury or illness experience rapid declines in bone mass. Chronic conditions such as inflammatory bowel disease, juvenile idiopathic arthritis and cystic fibrosis are associated with reduced BMD. Studies show that up to 78% of children with cerebral palsy have BMD that is more than two standard deviations below the mean for their age and gender, and that over 25% of these children have a long-bone fracture by age 10. Medications Glucocorticoid medications acutely increase osteoclast activity and reduce apoptosis, resulting in increased resorption of bone. Long-term use of these medications also suppresses osteoblast formation and increases osteocyte apoptosis, which results in impaired bone microstructure and reduced bone mass. Patients with chronic illnesses are at high risk of reduced BMD secondary to glucocorticoid use. Oral glucocorticoids carry the highest risk of impact on bone; however, studies show that cumulative effects of long-term, high-dose inhaled corticosteroids also may decrease BMD. Other medications shown to reduce bone mass include anticonvulsants, chemotherapy agents, proton pump inhibitors, selective serotonin reuptake inhibitors, Depo-Provera and anti-retrovirals. Depo-Provera carries an FDA black box warning to warn prescribers about the negative effect on bone mass secondary to hypothalamic suppression and reduced circulating estrogen levels. Hormonal Status and Other Medical Concerns Hyperthyroidism, growth hormone deficiency and other endocrine conditions such as hyperparathyroidism and Cushing’s Disease are rare in children but are associated with low bone mass. Low BMD also is seen in patients with eating disorders secondary to low weight and testosterone or estrogen deficiency. Female athletes with low body weight also may experience suppression of the hypothalamic-pituitaryovarian axis, resulting in amenorrhea, which further worsens fracture risk.

The Pediatrician’s Role in Prevention and Screening Children with obvious limb bowing or deformity should be referred to subspecialties such as endocrinology, genetics and orthopaedics for evaluation and care. However, while some metabolic bone diseases present with bowing or limb deformities, bone disease can be silent until a fracture. Therefore, it is important that pediatricians know which patients are at risk and appropriately screen for osteoporosis. Patients at known risk for osteoporosis, such as those on chronic corticosteroids, those with cerebral palsy, immobilization, known hypogonadism and any chronic inflammatory disease or eating disorder, should have routine screening for factors affecting bone health. The American Academy of Pediatrics (AAP) recommends that at-risk children be screened for vitamin D deficiency with a serum total 25-

Institute of Medicine Recommendations: Dietary Reference Intakes for Calcium

1 to 3 years old—700 milligrams of calcium daily 4 to 8 years old—1,000 milligrams of calcium daily 9 to 18 years old—1,300 milligrams of calcium daily Dietary Reference Intakes for Vitamin D

1 to 18 years—600 IU of vitamin D daily

OH vitamin D level; these include patients who are AfricanAmerican or Latino, BMI >95th percentile, those with celiac disease or any malabsorption syndrome, and those children taking chronic corticosteroids, anticonvulsants and antiretrovirals. Dual-energy X-ray Absorptiometry (DEXA) DEXA is the preferred method for evaluation of bone mass in children. There are now well-established standards for children from ages 5 to 18, and DEXA typically is readily available, takes less than 10 minutes, is painless and provides less radiation than a standard chest X-ray. DEXA measures the bone mineral content (BMC) of the lumbar spine and total body in pediatric patients and calculates an areal BMD, which is the BMC minus the area of the region scanned. Caution must be used when interpreting DEXA reports in children, as age, gender and pubertal status affect results. Z-scores should be used and compared to age-matched means, and scores should be adjusted for height in those with short stature and for bone age in those with growth or pubertal delay. Low BMD is defined as a Z-score less than -2. The diagnosis of osteoporosis in children is considered to be a low BMD and significant fractures, which are those of the long bones or vertebral compression fractures. The International Society for Clinical Densiometry recommends ordering a DEXA for those children who have one of the following fractures: two or more long bone fractures by age 10 years, three or more long bone fractures at any age up to 19 years, or vertebral compression fractures at any age. The AAP recommends also obtaining DEXA for patients with high-risk medical conditions such as cerebral palsy. DEXA should be repeated no more frequently than every six months and typically are monitored every one or two years. Newer bone imaging modalities such as quantitative ultrasound and quantitative CT, emerging in adult populations, appear to be a more accurate measure of true volumetric BMD. However, there are no available pediatric reference ranges for these methods. 11

Treatment of Osteoporosis in Children Calcium and Vitamin D Supplementation Supplementation with calcium alone provides only a marginal improvement in bone mineral content in children and adolescents because of both the low bioavailability of calcium in supplement and a high-frequency concomitant vitamin D deficiency. Treatment should focus primarily on correcting vitamin D deficiency and establishing healthy dietary behaviors that include calcium intake at the recommended daily levels for age. Infants and children with serum 25-OH vitamin D levels <30ng/dL should be treated with weekly doses of ergocalciferol or cholecalciferol 50,000 IU for 6-8 weeks followed by repeat testing. Alternatively, 2,000-5,000 IU daily doses may be used. It is important that patients continue to take maintenance doses of 400-1,000 IU daily, depending on age and diet, to prevent levels from dropping following treatment. Hormone Replacement Patients with significantly delayed puberty or growth hormone deficiency should be appropriately treated with replacement hormone therapy. However, little evidence supports the use of estrogen replacement in girls with hypothalamic amenorrhea secondary to low BMI, also known as the “female athlete triad.” Focus in treating underweight female athletes should be on restoring normal body weight, which has a well-demonstrated effect on bone mass, rather than on hormone replacement alone. Bisphosphonates Newer generation nitrogen bisphosphonates are a class of medications that commonly have been used in the adult population to treat post-menopausal osteoporosis and metastatic bone cancers for many years. These medicines are becoming the standard of care to increase BMD, reduce fracture rate and improve bone pain for rare metabolic bone diseases in children (such as osteogenesis imperfecta, juvenile idiopathic osteoporosis and chronic recurrent multi-focal osteomyelitis) and in corticosteroid-induced osteoporosis. They also are becoming more commonly used in patients with immobility from cerebral palsy and associated fractures. These medications bind tightly to hydroxyapatite in bone and share a structure similar to pyrophosphate, with two phosphate groups per molecule. When absorbed into osteoclast cells, bisphosphonates inhibit the enzymes responsible for formation of the “ruffled border” of osteoclasts, thereby preventing osteoclast resorption of bone. Because of their tight binding to hydroxyapatite, bisphosphonates have a long half-life and may be detected in bone tissue several years following treatment. Data are emerging on the long-term safety and efficacy of bisphosphonates in children, but because of limited available studies, the use of these medications is restricted to pediatric 12

patients with rare metabolic bone diseases or osteoporosis with ongoing fractures. Intravenous infusions of either pamidronate or zoledronic acid typically are used in pediatrics because of concerns over absorption and compliance associated with the more commonly used oral preparations such as alendronate in adult populations. Other Medications Newer medications such as denosumab, a human monoclonal antibody to RANK-L that prevents osteoclast development, and teriparatide, recombinant parathyroid hormone, now are being used regularly in the adult population. However, studies of teriparatide in juvenile rats showed an increase in osteosarcoma tumors in growing bone. Therefore, this medication carries a black box warning against its use in pediatrics. Ongoing clinical studies are investigating the safety and efficacy of denosumab in children, particularly in the OI population.

References Consulted

• Bachrach LK. Acquisition of optimal bone mass in childhood and adolescence. Trends Endocrinol Metab. 2001;12(1):22-28. • Golden NH, Abrams SA. Optimizing bone health in children and adolescents. Pediatrics. 2014;134(4):e1229-e1243. • Gordon CM, Bachrach LK, Carpenter TO, et al. Dual energy X-ray absorptiometry interpretation and reporting in children and adolescents: The 2007 ISCD pediatric official positions. J Clin Densitom. 2008;11(1): 43-58. • Institute of Medicine (US) Committee to Review Dietary Reference Intakes for Vitamin D and Calcium; Ross AC, Taylor CL, Yaktine AL, et al., editors. Dietary Reference Intakes for Calcium and Vitamin D. Washington (DC): National Academies Press (US); 2011. Available from: https://www.ncbi. nlm.nih.gov/books/NBK56070/ doi: 10.17226/13050. • Office of the Surgeon General (US). Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville (MD): Office of the Surgeon General (US); 2004. Available from: https://www.ncbi.nlm.nih.gov/ books/NBK45513/.

Article author Melissa D. Garganta, MD, is a pediatric endocrinologist at Children’s Hospital of Greenville Health System.

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

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

Phone Fax Phone Fax William F. Schmidt III, MD, PhD 455-8401 455-3884 Darryl R. Gwyn, MD 455-7146 455-5380 Medical Director; Chairman, Department of Pediatrics Robert S. Seigler, MD 455-7146 455-5380 Developmental-Behavioral Peds/Gardner Center for Developing Minds James H. Beard Jr., MD 454-5115 241-9205 Adolescent Bariatric Surgery Eric S. Bour, MD 676-1072 676-0729 Tara A. Cancellaro, MD 454-5115 241-9205 Adolescent Medicine Gerald J. Ferlauto, MD 454-5115 241-9205 Sarah B.G. Hinton, MD 220-7270 241-9211 Desmond P. Kelly, MD 454-5115 241-9205 Allergy, Immunology and Asthma Darla H. McCain, MD 454-5115 241-9205 John M. Pulcini, MD 675-5000 675-5005 Nancy R. Powers, MD 454-5115 241-9205 Ambulatory Pediatrics/Center for Pediatric Medicine (Medicaid) Victoria L. Sheppard-LaBrecque, MD 454-5115 241-9205 J. Blakely Amati, MD 220-7270 241-9211 John E. Williams, MD 454-5115 241-9205 Jessica P. Boyd, MD 220-7270 241-9211 Emergency Medicine Elizabeth W. Burton, MD 220-7270 241-9211 Elizabeth L. Foxworth, MD 455-6016 455-6199 Janelle E. Godlewski, MD 220-7270 241-9211 Jacqueline J. Granger, MD 455-6016 455-6199 Lochrane Grant, MD 220-7270 241-9211 Alison M. Jones, MD 455-6016 455-6199 Matthew P. Grisham, MD 220-7270 241-9211 Patrick J. Maloney, MD 455-6016 455-6199 Sarah B.G. Hinton, MD 220-7270 241-9211 Matthew B. Neal, MD 455-6016 455-6199 Mark B. Krom, DO 220-7270 241-9211 Kevin A. Polley, MD 455-6016 455-6199 Dolores P. Mendelow, MD 220-7270 241-9211 Jeremiah D. Smith, MD 455-6016 455-6199 Mary A.S. Putnam, MD 220-7270 241-9211 John D. Wilson Jr., MD 455-6016 455-6199 Sara E. Ryder, MD 220-7270 241-9211 Endocrinology Robert A. Saul, MD 220-7270 241-9211 James A. Amrhein, MD 454-5100 241-9238 Kerry K. Sease, MD, MPH 220-7270 241-9211 Elaine A. Apperson, MD 454-5100 241-9238 Cady F. Williams, MD 220-7270 241-9211 Melissa D. Garganta, MD 454-5100 241-9238 Teresa A.W. Williams, MD 220-7270 241-9211 Bryce A. Nelson, MD, PhD 454-5100 241-9238 Angela M. Young, MD 220-7270 241-9211 Ferlauto Center for Complex Pediatric Care Anesthesiology W. Kent Jones, MD 220-7270 241-9211 Carlos L. Bracale, MD 522-3700 522-3705 Cady F. Williams, MD 220-7270 241-9211 Michael G. Danekas, MD 522-3700 522-3705 Gastroenterology Lauren H. Doar, MD 522-3700 522-3705 Liz D. Dancel, MD 454-5125 241-9201 John P. Kim, MD 522-3700 522-3705 Michael J. Dougherty, DO 454-5125 241-9201 Jake Freely, MD 522-3700 522-3705 Jonathan E. Markowitz, MD, MSCE 454-5125 241-9201 Richard F. Knox, MD 522-3700 522-3705 Colston F. McEvoy, MD 454-5125 241-9201 Laura H. Leduc, MD 522-3700 522-3705 Genetics Steven W. Samoya, MD 522-3700 522-3705 David B. Everman, MD 250-7944 250-9582 Matthew R. Vana, MD 522-3700 522-3705 R. Curtis Rogers, MD 250-7944 250-9582 Randall D. Wilhoit III, MD 522-3700 522-3705 Gynecology Bradshaw Institute for Community Child Health & Advocacy Dianna T. Gurich, MD 455-1600 455-2805 Kerry K. Sease, MD, MPH 454-1100 454-1114 Melisa M. Holmes, MD 455-1600 455-2805 Cardiology Benjie B. Mills, MD 455-1600 455-2805 Benjamin S. Horne III, MD 454-5120 241-9202 Hematology/Oncology (BI-LO Charities Children’s Cancer Center) Jon F. Lucas, MD 454-5120 241-9202 Nichole L. Bryant, MD 455-8898 241-9237 David G. Malpass, MD 454-5120 241-9202 Rebecca P. Cook, MD 455-8898 241-9237 Manisha S. Patel, MD 454-5120 241-9202 Cristina E. Fernandes, MD 455-8898 241-9237 R. Austin Raunikar, MD 454-5120 241-9202 Leslie E. Gilbert, MD, MSCI 455-8898 241-9237 Child Advocacy Medical Program Aniket Saha, MD, MSCI, MS 455-8898 241-9237 Mary-Fran R. Crosswell, MD 335-5288 331-0565 William F. Schmidt III, MD, PhD 455-8898 241-9237 Nancy A. Henderson, MD 335-5288 331-0565 Infectious Disease Critical Care Joshua W. Brownlee, MD 454-5130 241-9202 Michael G. Avant, MD 455-7146 455-5380 Sue J. Jue, MD 454-5130 241-9202 Eric L. Berning, MD 455-7146 455-5380 Robin N. LaCroix, MD 454-5130 241-9202 Christina M. Goben, MD 455-7146 455-5380 Continued on back

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Inpatient Pediatrics Orthopaedic Oncology Greenville Scott E. Porter, MD, MBA 797-7060 797-7065 April O. Buchanan, MD 455-8401 455-3884 Orthopaedic Surgery Gretchen A. Coady, MD 455-4411 455-4480 Michael L. Beckish, MD 797-7060 797-7065 Karen Eastburn, DO, MS 455-8401 455-3884 Christopher C. Bray, MD 797-7060 797-7065 Jeffrey A. Gerac, MD 455-4411 455-4480 Edward W. Bray III, MD 797-7060 797-7065 Matthew P. Grisham, MD 455-8401 455-3884 David E. Lazarus, MD 797-7060 797-7065 Amanda G. Hartke, MD, PhD 455-8401 455-3884 Otolaryngology Russ C. Kolarik, MD 455-7844 455-3884 Nathan S. Alexander, MD 454-4368 241-9232 Elizabeth S. Tyson, MD 455-8401 455-3884 Robert O. Brown III, MD 455-5300 455-5353 Greer Michael S. Cooter, MD 454-4368 241-9232 Matthew N. Hindman, MD 455-4411 455-4480 Paul L. Davis III, MD 455-5300 455-5353 Anderson William D. Frazier, MD 454-4368 241-9232 Callie C. Barnwell, MD 454-5612 454-5121 John T. McElveen Jr., MD 919-876-4327 919-876-6800 Sara M. Clark, MD 454-5612 454-5121 Patrick W. McLear, MD 454-4368 241-9232 Carley M. Howard Draddy, MD 454-5612 454-5121 John G. Phillips, MD 454-4368 241-9232 Ann Marie Patterson Ravindran, MD 454-5612 454-5121 Andrew M. Rampey, MD 454-4368 241-9232 Allison B. Ranck, MD 454-5612 454-5121 Charles E. Smith, MD, DMD 454-4368 241-9232 Senthuran Ravindran, MD 454-5612 454-5121 Plastic Surgery and Aesthetics Silvia Y. Rho, MD 454-5612 454-5121 J. Cart de Brux Jr., MD 454-4570 454-4575 Elizabeth A. Shirley, MD 454-5612 454-5121 Pulmonology Miranda L. Worster, MD 454-5612 454-5121 Michael J. Fields, MD, PhD 454-5530 241-9246 Minor Care Sterling W. Simpson, MD 454-5530 241-9246 Children’s Hospital After-hours Care (Greenville) Steven M. Snodgrass, MD 454-5530 241-9246 Staffed by current GHS pediatricians 271-3681 271-3914 Radiology Children’s Hospital Spartanburg Night Clinic Michael B. Evert, MD 455-7107 455-6614 Staffed by current GHS pediatricians 804-6998 596-5164 Erin Margaret Horsley, DO 455-7107 455-6614 Neonatology/Bryan Neonatal Intensive Care Unit Michael A. Thomason, MD 455-7107 455-6614 India C. Chandler, MD 455-7939 455-3685 Rheumatology Benton E. Cofer, MD 455-7939 455-3685 Lara M. Huber, MD, MSCR 454-5004 241-9202 Nicole A. Cothran, MD 455-7939 455-3685 Sarah B. Payne-Poff, MD 454-5004 241-9202 J. Thomas Cox, MD 455-7939 455-3685 Sleep Medicine/Center for Pediatric Sleep Disorders Amber E. Fort, DO 455-7939 455-3685 Dominic B. Gault, MD 454-5660 241-9233 Matthew F. Halliday, MD 455-7939 455-3685 Roni Socher, MD 454-5660 241-9233 R. Catrinel Marinescu, MD 455-7939 455-3685 Supportive Care Team Bryan L. Ohning, MD, PhD 455-7939 455-3685 Cary E. Stroud, MD 455-5129 455-5075 Jeffrey M. Ruggieri, MD 455-7939 455-3685 Surgery Michael S. Stewart, MD 455-7939 455-3685 John C. Chandler, MD 797-7400 797-7405 M. Whitson Walker, MD, MS 455-7939 455-3685 Robert L. Gates, MD 797-7400 797-7405 Nephrology & Hypertension James F. Green Jr., MD 797-7400 797-7405 T. Matthew Eison, MD 454-5105 241-9200 Keith M. Webb, MD 797-7400 797-7405 Sudha Garimella, MD 454-5105 241-9200 Urgent Care (Anderson) Scott W. Walters, MD 454-5105 241-9200 Artur A. Charowski, MD 512-6544 512-6995 Neurology Jennifer B. Harling, MD 512-6544 512-6995 Michael A. Babcock, MD 454-5110 241-9206 Anna C. Neal, MD 512-6544 512-6995 Emily T. Foster, MD 454-5110 241-9206 Jonelle M. Oronzio, MD 512-6544 512-6995 Addie S. Hunnicutt, MD 454-5110 241-9206 Janice L. Rea, MD 512-6544 512-6995 Augusto Morales, MD 454-5110 241-9206 Patrice T. Richardson, MD 512-6544 512-6995 William C. Taft, MD, PhD 454-5110 241-9206 Urology Neurosurgery Regina D. Monroe, MD 454-5135 241-9200 E. Christopher Troup, MD 797-7440 797-7469 J. Lynn Teague, MD, MHA 454-5135 241-9200 Newborn Services Weight Management Program (New Impact) Jennifer A. Hudson, MD 455-8401 455-3884 Erin L. Brackbill, MD 675-FITT 627-9131 Rebecca P. Wright, MD 455-8401 455-3884 Laure A. Utecht, MD 675-FITT 627-9131 Ophthalmology Keith L. McCormick, MD 454-5540 241-9276 Janette E. White, MD 454-5540 241-9276

ghschildrens.org

17-0219 Revised 1/17

QUALITY COUNTS

Antibiotic Stewardship: The Responsibility of All Microbes are continually evolving new mechanisms of resistance. This fact, coupled with the lack of development of new antibiotics to combat these organisms, has led to infections for which there are no viable treatment options. In the past 20 years, medicine has seen the rise in methicillinresistant staphylococcus, the emergence of multi-drug resistant Gram-negative bacteria and an increase in antibioticresistant gonorrhea. Bacteria such as group A streptococcus and meningococcus appear to now be resistant to classes of antibiotics that readily eliminated the infections in the past. Even treatment of common maladies such as E-coli and urinary tract infections has become problematic due to drug resistance. The problem is so widespread and is such a significant threat to providers’ ability to treat infections that CMS has mandated hospitals to develop antimicrobial stewardship programs. These programs involve teams of physicians, pharmacists and microbiologists. Effective models use new technology such as polymerase chain reaction to diagnose viral infections, thus eliminating inappropriate use of antibiotics in those situations. Other technological advances such as rapid bacterial identification allow antibiotics to be stopped, narrowed or modified to appropriate coverage more quickly. Science continues to be generated in the area of determining best practices for lengths of treatment, aiming for the shortest possible courses for acceptable rates of recurrence. In the US in 2011, 842 antibiotic prescriptions were written for every 1,000 persons. CDC estimates that 50% of all antibiotics prescribed in the US by health provider offices may be unnecessary or inappropriate. Since antibiotics in the US are controlled by licensed prescribers, control efforts rely on the prescriber. The prescriber must understand that administration of antibiotics is a procedure that carries a significant risk of generating antibiotic resistance, antibiotic complication and secondary perpetuation of Clostridium difficile overgrowth after killing normal flora.

Patients will better understand physicians recommendations to avoid antibiotics and allow viral illnesses to resolve with the body’s defense system if physicians make an intentional effort to clearly communicate the expanded risks of antibiotic use to patients. Useful talking points can be found at cdc.gov by searching “Get Smart: Know When Antibiotics Work.” This site has free printable handouts and patient education that could be incorporated in the electronic medical record (EMR) to help families understand why we do not always prescribe an antibiotic. Many of the resources also are available in Spanish. Consistent discussions about the appropriate use and non-use of antibiotics help manage patient and family expectations about treatment of common illnesses. The message to use antibiotics wisely is more important now than ever.

Article author Robin LaCroix, MD, is vice chair of Quality and Medical Staff Services for Children’s Hospital of Greenville Health System and a pediatric infectious disease physician at GHS.

CELEBRATIONS

Children’s Hospital of Greenville Health System (GHS) has many reasons to celebrate! Children’s Hospital Honors Walmart and Sam’s Club GHS Children’s Hospital recently honored Walmart and Sam’s Club for their 29-year commitment to the hospital and helping to raise more than $10.5 million in support of pediatric patients. In honor of the company’s long-term commitment—and generosity of its customers and associates—Children’s Hospital dedicated the fifth floor of the hospital to Walmart and Sam’s Club. The playrooms are open around the clock. Research shows that children who have the opportunity to play during hospital stays often can go home sooner.

November Symposium Speaker Elizabeth J. Mayer-Davis, MD, Cary C. Boshamer Distinguished Professor of Nutrition and Medicine and chair of the Department of Nutrition at the University of North Carolina at Chapel Hill, was the keynote speaker at the 25th Annual William R. DeLoache Seminar. Dr. Mayer-Davis has focused her career on diabetes. Her message at the seminar was “The Emergence of Complications in Type 2 Diabetes in Youth: Comparisons with Type 1 Diabetes.” Dr. Mayer-Davis’ research addresses the many ways nutrition can impact the risk for developing diabetes as well as the risk of complications in both type 1 and type 2 diabetes.

New Impact Wins Grant New Impact: A Healthy Lifestyles Program, an innovative program developed by GHS Children’s Hospital, is one of four nationwide recipients of the Canyon Ranch Institute Healthy World Scholarship. The scholarship program seeks to create lasting change in the health and well-being of children in lowincome communities.

William Schmidt III, MD, PhD (left), medical director of GHS Children’s Hospital, and George Maynard III, FAHP, vice president of GHS Institutional Advancement, flank Dale Wooten, a Walmart market manager, at the dedication.

New Impact is a healthy lifestyle and nutrition program for families. In addition to providing access to a variety of healthcare professionals who can help improve physical wellbeing, New Impact offers education and psychological support to ensure children are set up for success in creating healthy lifestyles. New Impact is a collaborative effort between Children’s Hospital and the YMCA for program delivery and with Clemson University for program evaluation and effectiveness research.

CELEBRATIONS

Radiothon Raises $315,105 The latest Children’s Hospital Radiothon raised $315,105, thanks to strong community support and its radio partners. These monies help support various initiatives for patients, from PlayStations and DVD players to diapers and funds for children to attend Camp Courage.

Patients Celebrate Like Champions Following the Clemson Tigers’ 35-31 win over Alabama in the 2016 College Football Playoff National Championship, the trophy made an appearance at GHS Children’s Hospital, where patients were able to check it out and interact with the Tiger Cub.

NICU Reunion Children’s Hospital’s Bryan Neonatal Intensive Care Unit (NICU) hosted a reunion for former patients who graduated from the NICU. More than 650 people attended the event. The theme of this year’s reunion was football; players and cheerleaders from Liberty High School attended the event and spent time playing and talking with reunion guests. 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 at the NICU.

CELEBRATIONS

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. Eight Caregivers of the Year were announced: • Zoe Tighe, Bryan NICU • Claudia Brabham, Newborn Nursery and Family Beginnings • Amanda Kamman, Inpatient, PICU and Hematology/ Oncology Nursing • Holly Paine, Outpatient Services • Lori Ripple, Physician Practices and Specialty Care • Anna Gutierrez, Inpatient and Outpatient Non-nursing • Shawna McMahan, Outpatient Primary Care • Lisa Soenen, Non-clinical Professional

Caregivers of the Year (left to right): Zoe Tighe, Lori Ripple, Holly Paine, Claudia Brabham, Shawna McMahan, Amanda Kamman, Lisa Soenen. Not pictured: Anna Gutierrez

Kristy Way, then-president of CHCAC (left), and Rep. Chandra Dillard

The Legislative Advocacy award went to S.C. Rep. Chandra Dillard, chair of the Nicholtown Child and Family Collaborative, who has secured more than $100 million to address community development, human investment and infrastructure needs in Greenville and particularly in the Nicholtown community.

Kristy Way and Robin Blackwood

Dr. Schmidt and Crissy Maynard

Robin Blackwood won the Buddy’s Spirit award for embodying the spirit of giving back to Children’s Hospital. This honor goes to a council member. Crissy Maynard, director of Philanthropy and Partnership for Children’s Hospital, received a special recognition for her dedication to Children’s Hospital and for securing more than $18 million in major gifts to GHS during her two years with GHS. It was announced at the dinner that Maynard would be leaving because of health issues. The evening’s capstone award—All for the Love of Children—went to Ted Hendry, president and CEO of United Way of Greenville County. During his 15 years with United Way of Greenville County, Hendry has provided consistent leadership in moving the organization Ted Hendry and Dr. Schmidt toward a stronger focus on school readiness, high school graduation and financial stability—critical aspects in creating a cycle of success. Hendry also serves on the board of directors for the Institute for Child Success.

CASE STUDY

Infantile Hemangiomas An 8-week-old term female presented to Greenville Memorial Hospital’s (GMH) Children’s Emergency Center with shortness of breath and recurrent stridor. She was seen by her primary care physician (PCP) two weeks earlier for similar symptoms and had received a steroid injection and racemic epinephrine for presumed croup. She continued to have symptoms and was admitted to an outside hospital for further management. She was given decadron, multiple doses of racemic epinephrine and discharged with a course of oral steroids. The PCP referred her to ENT for further evaluation. Of note, the patient developed an erythematous neck rash around the time symptoms had started. It initially appeared as a red intertriginous patch on the side of her neck but had begun to occasionally bleed and drain an odorous serosanguinous fluid concerning for candida. No improvement occurred with nystatin, mupirocin or fluconazole. Endoscopy by ENT showed grossly inflamed glottis structures and possible hemangioma. She was to have a repeat endoscopy for re-evaluation but was admitted to Children’s Hospital for worsening stridor. On admission, a soft neck X-ray was performed to distinguish subglottic hemangioma vs. soft tissue infection vs. laryngomalacia. Only subglottic stenosis was visible. Her neck lesion was about 4.5 cm, telangiectatic with ulceration and mild oozing. She also had some swelling and bright erythema of the lower lip and tongue, radiating into her mouth. No fever was noted in her history. The “beard-like” distribution, intraoral vascular lesions with concurrent neck lesion, caused concerns for PHACE syndrome. An MRI of the head and neck was ordered to look for the extent of vascular lesions and for any associated cerebral anomalies. An EKG and echocardiogram to rule out cardiac manifestations of PHACE syndrome were negative. An abdominal ultrasound looking for vascular malformations also was negative. Because of her age, sedation was needed for imaging. She was intubated for airway protection and erythema of airway was noted by anesthesia. She was kept intubated and admitted to pediatric ICU. Decadron was given before extubation and a steroid weaning schedule started for her as an outpatient (she had been on steroids before admission as well). Pediatric Hematology/Oncology was consulted, and she began propranolol on a titration schedule and was monitored overnight for possible cardiovascular side effects. Topical timolol also was started.

After extubation, her stridor resolved. She was noted to be coronavirus and human-metapneumovirus positive, which likely contributed to the initial stridor. Of note, she did have some aspiration on admission, which was determined by swallow study to result from akyloglossia. Frenulectomy was performed with improved feedings, and she was discharged home to continue timolol and propranolol and follow up with ENT.

Infantile Hemangiomas

Infantile hemangiomas are the most common vascular tumors of childhood. These tumors usually are benign and appear a few weeks after birth. They sometimes have precursor lesions such as telangiectasia, pallor, bruise-like appearance and, rarely, ulceration. An initial proliferative phase of rapid growth in the first months of life is followed by an involution stage with slow, spontaneous resolution in years. Often, a residual fibro-fatty mass is evident. Infantile hemangiomas involve the proliferation of benign endothelial-like cells. There are three primary subtypes of hemangiomas: focal, segmental and indeterminate. Segmental hemangiomas are associated with a higher risk of complications, deformity and ulceration. Infants with multiple classic focal infantile hemangiomas may have extracutaneous involvement of visceral organs. Consumptive hypothyroidism also has been associated with focal infantile hemangiomas. 17

PHACE Syndrome

PHACE syndrome is a segmental infantile hemangioma and neurocutaneous syndrome associated with facial hemangiomas, usually with a dermatomal distribution and higher percent of deep tissue involvement. PHACE is an acronym for Posterior fossa brain abnormalities, Hemangiomas, Arterial malformations, Cardiac defects and Eye abnormalities. There is a 9:1 female to male predominance. Brain/cerebral anomalies are the most common extracutaneous features, with neurologic and cognitive impairments being the largest comorbidity. The most common cardiac defect is coarctation of the aorta. Eye abnormalities usually include microphthalmia and optic nerve hypoplasia. Facial hemangiomas greater than or equal to 5 cm in diameter need PHACE evaluation with MRI/MRA of the brain, cardiovascular evaluation and ophthalmologic exam.

Differential Diagnosis

Infantile hemangiomas are vascular neoplasms, which include congenital hemangiomas, pyogenic granulomas and tufted angiomas. They differ from congenital hemangiomas as they appear fully formed at birth. There are two types of congenital hemangiomas: noninvoluting and rapidly involuting, which has a rapidly involuting phase in the first year of life. The latter type has been associated with thrombocytopenia and, rarely, congestive heart failure. Pyogenic granulomas are reactive, proliferating vascular lesions of the skin and mucous membranes with a pedunculated base and are prone to difficult-to-control bleeding. They usually are seen within the skin containing capillary malformations and can be misdiagnosed as infantile hemangiomas. Kaposiform hemangioendothelioma, another benign vascular neoplasm, appears as a deep soft-tissue mass. It is associated with Kasselbach-Merritt phenomenon, a potentially lifethreatening vascular neoplasm with consumptive coagulopathy and hemolytic anemia. Tufted angiomas occur up to young adulthood and are tufts of capillaries in the dermis appearing as violaceous patches, plaques and nodules; they also have a predisposition to Kasselbach-Merritt phenomenon. Vascular malformations are different from vascular neoplasms in that they are structural anomalies and inborn errors of vascular formation. They may not become clinically apparent until later in life. Examples of vascular malformations include port wine stains and nevus flammeus. Their growth may be affected by trauma, infection and hormonal changes.

Management

Most infantile hemangiomas self-resolve. Items to consider when deciding whether therapy is necessary include cosmetic effects and developmental difficulties, such as feeding problems, vision hindrance and airway involvement. Perianal hemangiomas are at a higher risk of ulcerations. Corticosteroids used to be the mainstay treatment for hemangiomas. Propranolol, when monitored carefully, now is used for treatment, ranging from 0.5-4 mg/kg/day.

Conclusion

In summary, infantile hemangiomas are vascular neoplasms, more prominent in females than males. Consider airway involvement with a beard-like distribution hemangioma and recurrent stridor or other respiratory abnormality. PHACE syndrome should be considered with extensive facial hemangiomas and be worked up for evaluation of posterior fossa abnormalities, cardiac and arterial malformations and also eye abnormalities. Non-infantile hemangiomas can be associated with Kassabach-Merritt phenomenon (rapidly growing hemangioma, thrombocytopenia, coagulopathy and microangiopathic hemolytic anemia). Most hemangiomas do not require therapy. Treatment with propranolol is for lesions that are life-threatening, can cause functional or cosmetic impairments or could lead to psychological stress.

References:

1. Herzog CE. Benign vascular tumors. In: Nelson WE, Kliegman R, eds. Nelson textbook of pediatrics. 18th ed. Philadelphia: Saunders; 2007:21562157. 2. Chen TS, Eichenfield LF, Friedlander SF. Infantile hemangiomas: An update on pathogenesis and therapy. Pediatrics. 2013;131(1):99-108. 3. Darrow DH, Greene AK, Mancini AJ, Nopper AJ, SECTION ON DERMATOLOGY, SECTION ON OTOLARYNGOLOGY-HEAD AND NECK SURGERY, and SECTION ON PLASTIC SURGERY. Diagnosis and management of infantile hemangioma. Pediatrics. 2015;136(4):e1060-104. 4. Wahrman JE, Honig PJ. Hemangiomas. Pediatr Rev. 1994;15(7):266-271.

Article author Kym Do, MD, is a third-year Pediatrics resident and next yearâ&#x20AC;&#x2122;s co-chief resident at GHS Childrenâ&#x20AC;&#x2122;s Hospital. This article is written under the faculty direction of Amanda Hartke, MD, PhD, a pediatric hospitalist.

SPECIAL PROGRAM The CenteringParenting program at Children’s Hospital of Greenville Health System (GHS) brings moms together to facilitate better outcomes for them and for their babies.

Thomas Hardison looks to his mom, Tabitha Hardison, for comfort after receiving his 12-month immunizations during a CenteringParenting visit.

Centering Offers a Social Parenting Network In a spacious room at GHS Children’s Hospital’s Center for Pediatric Medicine (CPM), a handful of adults sit in folding chairs in a circle. They are mostly moms, but there also is a grandma present, along with a dad. A group of 12-month-old babies play on mats in the middle of the circle. The discussion, led by a pediatrician and a nurse, is lively, with lots of laughter, but also occasionally sighs of frustration over some of the challenges associated with caring for a baby. Those often are followed by words of comfort or even a hug. Later, the babies are measured, have their hemoglobin checked, receive their 12-month vaccinations and have their little teeth painted with dental varnish. This is the scene at a CenteringParenting visit. The caregivers have been meeting together for their babies’ well visits since the children were 2 weeks old, so by now they are a tightly knit group.

These group visits last two hours, which permits much more time for anticipatory guidance and one-on-one interaction with the doctor, along with discussion among the caregivers over an array of parenting topics. Groups are available in both English and Spanish. The concept builds on the CenteringPregnancy group visits that have recently received much attention for reducing premature births. “There’s a lot more time for discussion about how to do things and what to think about for that age group,” said Janelle Godlewski, MD, who heads up CenteringParenting. “There is a lot more sharing of ideas. The whole goal of Centering is the sharing of ideas among parents. They learn there are lots of different ways to do the same thing when it comes to parenting.” The topics of discussion are broader than the standard baby care issues, too. Visits sometimes involve learning songs to sing 19

with a baby or how to make your own baby food on a budget. Sometimes, parents and caregivers might participate in a group activity that helps them learn ways of coping with a toddler meltdown. “Those are things you usually wouldn’t hear at a regular doctor’s office visit,” stated Valeria Mora, who participated in Centering with her 3-year-old, Julian Perry, and now comes with her 12-month-old, Jaxon Perry. “It gets more intimate and personal, but in a good way.”

More Through the Doors

Dr. Godlewski commented that it’s often a struggle to get children in for well visits at CPM because there simply aren’t enough slots available. But Centering enables the physician to see more children in the same amount of time, all the while providing a more personal experience—and a chance to socialize—for both the parent and the child. “Our goal is essentially to have this room busy Monday through Friday, to have groups going at all times,” Dr. Godlewski remarked. “If we can use Centering as a way to bring some of those people in for well visits, it’s helpful. And it provides a better experience for the parent and child. It’s a win-win for everybody.” Tabitha Hardison, who attended Centering with son Thomas, said the relationships, both with the providers and with other parents, were some of the biggest benefits of the Centering model.

“I like the Centering visits because I get to be with the other parents, and there’s more personalization,” she said. “You would think that because you’re not one-on-one with the doctor, it would be less personal, but it’s actually not. You see the same doctor every visit, who watches your children grow and gets to know them and their personalities.” Two other physicians, Blakely Amati, MD, and Easter Pennington, MD, also participate in leading Centering visits; however, each group remains with the same physician for every visit. Dawn Coign, BSN, RN, serves as the nurse coordinator for CenteringParenting, though another nurse currently is in training to join her.

No Irrelevant Questions

The two-hour visits allow ample time to cover a range of topics, and questions often come up that might not during a shorter 15-minute interaction with a doctor in an office setting. “If you’re scared to ask a question or if you’re nervous, maybe one of the other moms would bring it up and start the conversation,” said Mora. “So you get more questions answered, even if you don’t ask them.” Dr. Godlewski said another benefit of the Centering approach to well visits is the elimination of “waiting time.” Parents participating in the program do not have to sit in the waiting room at all; instead, they proceed to the Centering room and spend the time before the visit officially begins chatting with other parents and caregivers.

Alondra Anderson plays with Dr. Godlewski while Dawn Coign, BSN, RN, prepares the baby’s immunizations and mom, Yalanda Bennett, and dad, Ronald Anderson, look on.

Sessions generally start and end on time, Dr. Godlewski pointed out, although latecomers are welcome to attend. “We’d rather they come late than not come at all,” she said. “In our general clinic, if a patient showed up 30 minutes late, they’d be rescheduled; but within the Centering model, even if they come late we’re going to see them that day.”

Getting the Word Out

Some program participants have been graduates of GHS’ CenteringPregnancy program. Dr. Godlewski said she’s also coached the residents who round in the Newborn Nursery at Greenville Memorial Hospital to talk about the program, especially with moms who fall into higher risk categories.

“The whole goal of Centering is the sharing of ideas among parents. They learn there are lots of different ways to do the same thing when it comes to parenting.” — Janelle Godlewski, MD

Others hear about the program when they bring their newborn to CPM for the recommended follow-up visit a day or two after being discharged from the hospital. It’s a great model for new parents, Dr. Godlewski noted, but especially for some high-risk groups like young moms and isolated families, “because it gives them a built-in social network that may not otherwise be available to them.” Benefits from the Centering visits extend beyond the families who gather in the room at each visit. Dr. Godlewski said she and the other providers are constantly learning from the moms about new products on the market, recalls and other useful information in the ever-changing world of baby care products. “I learn a ton from the parents that then helps me in the care of all the other kids in the clinic,” she said. “Sometimes, I’ll be able to then recommend things to other parents because one of the moms in Centering gave me the idea. It’s a learning process for all of us, which I think is great.”

Valerie Mora and her son Jaxon Perry.

The program at CPM is one of only four CenteringParenting programs in the entire Southeast. Dr. Godlewski said the program plans to gain site approval through the Centering Healthcare Institute in 2017. Researchers affiliated with GHS also have begun to study outcomes for Centering participants versus non-participants, such as breastfeeding rates, well-child compliance and immunization rates by 15 months of age. Anecdotally, the evidence already is positive, according to Dr. Godlewski. “Moms who participate in Centering have consistently given higher satisfaction scores than those who come for standard well visits,” Dr. Godlewski emphasized. “The parents really like it.”

Participants receive a guide that they can bring to each Centering visit. In the guide, parents can record health information and make notes about the baby’s development. The guide also contains a broad range of baby care information. Books are available in English and Spanish.

MEET THE PATIENT Beads of Courage help children cope with cancer treatment in a positive way at the BI-LO Charities Children’s Cancer Center at Children’s Hospital of Greenville Health System (GHS).

A Story of Bravery, Written in Beads

When Sam Brown was finishing the fourth grade, his mother, Ashland Brown, thought he was having attitude problems because he always felt tired and didn’t want to do his schoolwork. But when his fatigue kept him from swimming in the pool on a family vacation, his mother knew something was not right. After several tests, doctors determined that Sam had leukemia. He began a treatment course that would last 3.5 years and include moments where his family wasn’t sure he would survive. Throughout the ordeal, Sam and his family began to save the small glass beads he was given at each hospital visit and for various landmarks on his cancer journey. Those beads—called Beads of Courage—now live on a string some 23 feet long next to Sam’s bed, as a reminder of all that he went through on his cancer journey.

Sam Brown holds the rope with his Beads of Courage with twin brother, Jake (right), and younger sister, Jill. The beads represent landmarks on Sam’s cancer treatment journey. His favorites are the fish beads (above) he received when he had to travel to another hospital. Sam’s bead rope measures 23 feet long.

“We offer Beads of Courage to all of our patients,” said Lyndsey Hoffman, a child life specialist with the BI-LO Charities Children’s Cancer Center at GHS Children’s Hospital. “The beads allow patients to look back on their experiences and be proud of how much they have conquered.”

For instance, patients receive a black bead every time they must undergo a poke. When Hoffman and other members of the team present the children with their beads, they often engage them in conversation about the experience related to that bead and praise the children for their positive coping. “It gives the child an opportunity to express his or her feelings about that experience and creates some really good conversations,” she said. “At the end of the treatment, it’s something for the patients to look back on and see what they’ve been through and what they’ve conquered and how brave they were.”

A Reminder of the Journey

Sam said during his 3.5 years of treatment, the Beads of Courage helped him to have a positive outlook. “I think it helped me to see all the stuff I’d already done,” he said. “I would look at it and think, if I’ve already done all of that, then whatever else I have to do isn’t that hard.” Sam’s bead rope includes a number of the standard beads— black for each injection, red for each transfusion, yellow for each hospital admission—along with some special beads. For instance, he has a birthday cake bead for the year he and his identical twin, Jake, celebrated their birthdays in the hospital. “The nurses decorated Sam’s room, and they had a cake for Sam and Jake together, with both their names on it,” Ashland Brown said. “They also gave them a small air hockey table.” Ashland said the nurses often were the ones who counted out the appropriate beads and brought them to Sam. “No matter how busy they were, they made sure that if a patient wanted the beads, he or she got them,” she remarked. Sam’s favorite bead is the fish bead he received because he had to travel to Duke Medical Center after an allergic reaction to one of his medicines resulted in encephalitis. For his family, too, that was one of the scariest times during Sam’s treatment—one they weren’t sure he would survive. Hoffman said the Beads of Courage often can be a special memento for the patient’s family, too, because they have walked along with their family member through the treatment journey. “It’s so difficult to describe that three-and-a-half years,” Sam’s mother recalled. “It was like perpetually living on the edge of your seat. We were in kind of a constant state of emergency.” And for Sam’s twin, it was the first time that he slept in a room without his brother or didn’t constantly see him at school.

“They were always in all of the same classes, and they’re in all of the same classes now,” Ashland stated. “It was the first time Jake ever went to school by himself.”

Worth a Thousand Words

In addition to sitting in a prominent place in Sam’s room, his bead rope also makes appearances with Sam, Jake and younger sister, Jill, at events such as blood drives (which they organize periodically as a family), Relay for Life fundraisers, and Leukemia and Lymphoma Society events. “He’ll bring out the beads, and it takes people’s breath away when they see just how long it is,” said Ashland. “Sometimes, it does a better job than words can of explaining what he’s been through.” In addition to strings for the beads, Hoffman noted that patients can keep their beads in customized boxes crafted by members of the Greenville Woodworkers Guild specially for the Beads of Courage program. Sam, now 17, has been cancer-free for three years, and he and Jake have served as leaders in training at Children’s Hospital’s Camp Courage, a camp The Greenville Woodworkers Guild crafts beautiful for children with boxes patients can choose to hold their Beads of Courage. Patients also receive a log (shown in front cancer. His Beads of the boxes) where they can check off what beads of Courage will they receive. continue to help him—and the rest of the family—remember the many challenges he overcame. “So many of those beads are reminders of hard things, like needle sticks and blood transfusions,” Ashland emphasized. “And there are so many of them! To me, that’s a powerful reminder of how brave Sam is.” For more information about Beads of Courage, visit beadsofcourage.org or email lhoffman@ghs.org.

“The beads allow patients to look back on their experiences and be proud of how much they have conquered.” —Lyndsey Hoffman, Child Life Specialist

CLINICAL RESEARCH UPDATE Research studies at Childrenâ&#x20AC;&#x2122;s Hospital of Greenville Health System (GHS) are approved by the systemâ&#x20AC;&#x2122;s Institutional Review Board.

Pediatric Studies Astra Zeneca Dapa Study A 24-week, Multicenter, Randomized, Double-blind, Parallel Group, Phase III Trial with a 28-week Long-term Safety Extension Period Evaluating the Safety and Efficacy of Dapagliflozin 10mg in T2DM Patients Age 10-24 years Dapagliflozin has been shown to be effective in lowering HbA1c in adult patients with T2DM when studied as monotherapy and in combination with insulin or oral antidiabetic (OAD) medications. Overall, through its development program, dapagliflozin has been shown to improve HbA1c with a low risk of hypoglycemia, while also demonstrating positive trends for common comorbidities (weight gain and systolic hypertension) associated with increased cardiovascular risk in adult patients with T2DM. This study will be a 24-week, placebo-controlled study with a 28-week safety extension. Subjects between ages 10-24 years with confirmed diagnosis of T2DM who are being treated with diet and exercise and metformin or insulin will be screened against inclusion and exclusion criteria. Eligible subjects meeting all criteria will enter a 4-week placebo lead-in period. Subjects will be instructed to follow a diet and exercise program (in accordance with the ADA or similar national guidelines) for the duration of the study. Subjects will maintain their baseline types of antidiabetic therapy throughout the study. After the lead-in periods, subjects will be randomly selected to receive oral dapaliflozin (10 mg) or a placebo. Upon completion of the 24-week treatment period, all subjects will enter the 28-week safety extension period for monitoring. Finally, the safety extension period will be followed by a 4-week post-treatment follow-up period. The study will end when all eligible subjects complete the 56 weeks of study.

Shire OBS Study Oral Budesonide Suspension (OBS) in Adolescent and Adult Subjects (11 to 55 Years of Age, Inclusive) with Eosinophilic Esophagitis (EoE): A Phase III, Randomized, Double-blind, Placebo-controlled Study Currently, no approved medication exists to treat EoE. This study is being conducted to provide safety and efficacy data demonstrating histologic response (as measured by eosinophilic count ≤6/HPF) and improvement in dysphagia symptoms (as measured by the DSQ) following 12 weeks of treatment with OBS in adolescent and adult subjects with EoE. This is a Phase III, randomized, double-blind, multicenter, parallel-group, placebo-controlled study that evaluates the efficacy, safety and tolerability of twice-daily administration of OBS in adolescents and adult patients with EoE and dysphagia. This study will comprise three periods: 3-6 week screening, 4-week single-blind placebo lead-in and 12-week double-blind treatment. Approximately 300 subjects will be enrolled across all sites into the placebo lead-in period to allow for approximately 228 subjects to be randomized in a 2:1 ratio (approximately 152 and 76 per OBS and placebo treatment group, respectively) into the double-blind treatment period. The randomization will be performed centrally and stratified by age group (two strata total: <18 years or ≥18 years) and diet restriction for EoE or other health-related conditions (no diet restriction or any diet restriction). Stratification by age will ensure a minimum of 40 subjects in the pediatric group (11-17 years, inclusive). Stratification by age and diet will ensure balance between treatment groups for the respective stratification factors. Regeneron RSV Study A Phase III, Randomized, Double-blind, Placebo-controlled Study Evaluating the Efficacy and Safety of a Human Monoclonal Antibody, REGN2222, for the Prevention of Medically Attended Respiratory Syncytial Virus (RSV) Infection in Preterm Infants Globally, RSV is the second-leading cause of mortality in infants 1 month-1 year old and the most common viral cause of lower respiratory tract infection in children under age 5. RSV in early infancy also may predispose children to reactive airway disease in early childhood. Passive immunoprophylaxis with an RSV-neutralizing antibody is a safe and effective approach for reducing RSV-related hospitalizations in infants and has been in use for almost two decades. Palivizumab (commercially available as Synagis), a humanized monoclonal antibody, is the only RSV-preventive agent currently available. Despite the efficacy and excellent safety record of palivizumab, the majority of infants at risk for severe

RSV do not receive palivizumab (Hall 2013). While palivizumab is indicated for the broader population of high-risk children for the prevention of serious RSV lower respiratory tract disease, the American Academy of Pediatrics and other pediatric society position statements recommend restricting its use to only infants in the highest risk category because of the high cost of palivizumab (Hall 2013, Robinson 2011). The purpose of this study is to demonstrate the safety, efficacy, pharmacokinetics (PK) and immunogenicity of REGN2222, a new, fully human immunoglobulin G1 (IgG1) monoclonal antibody directed against the RSV fusion glycoprotein in infants born no more than 35 weeks 6 days GA, who are no more than 6 months of age during the RSV season in their respective geographic location.

Neonatal Abstinence Syndrome Study Highlighted A study at GHS that evaluated an early treatment model for neonatal opioid withdrawal was highlighted in a recent issue of the American Journal of Perinatology. The study, led by Jennifer Hudson, MD, medical director of Newborn Services at GHS Children’s Hospital, was a retrospective review of 117 opioid-exposed infants treated in the level I nursery with methadone initiated within 48 hours of birth. The study is the first to describe an early treatment model in a low-acuity nursery to prevent severe neonatal opioid withdrawal. Dr. Hudson also has been preapproved for teaching 10 other hospitals to use this care model over the next five years.

A S K T H E FAC U LT Y

Media Guidelines

Q: How should the new American Academy of Pediatrics (AAP) media guidelines change how we educate families? A: In late 2016, the AAP released an updated version of its media guidelines for family/patient education. While many items remain similar to previous recommendations, a few changes are worth noting. Unchanged is that for babies younger than 18 months, with the exception of video chatting if necessary, avoiding all media use is recommended. However, for children 18 months-2 years old, it now is acceptable to view some media. Usage should always happen under direct supervision of parents, and the material should be educational. Children ages 2-5 should be limited to an hour of media use a day. Material should remain educational and co-viewed by a caregiver. 26

With children older than 6, the AAP offered a reminder that parents should focus on setting consistent limits on media usage because many struggles arise from unclear parental expectations. While important that parents know these specific guideline changes, it is even more important for them to understand the basic beliefs about childhood media usage. As more avenues of media emerge, specific guidelines most likely will change, but the underlying tenets of media usage generally will remain the same. The AAP, for example, suggests that parents become â&#x20AC;&#x153;media mentorsâ&#x20AC;? to their children. This means teaching children how to appropriately use media as a tool to create, connect and learn. The goal is to help them learn to balance media use with healthy behaviors. Parents should foster certain media-free times, including dinner time and time in the car, and media-free spaces such as bedrooms. Additionally, in an age when bullying is on the rise, parents need to discuss and model good and safe online citizenship.

Pediatric Specialty Services

The AAP suggests that parents become “media mentors” to their children. This means teaching children how to appropriately use media as a tool to create, connect and learn. Many child psychologists point to evidence of potential dangers in using media too soon or too often, including inhibiting ability to focus, sense others’ attitudes or communicate. Studies show that in young children, cognitive “muscles” don’t develop as strongly if they frequently use devices that bypass the necessary steps to reason and make decisions. These devices also discourage learning the proper ways of decoding and comprehending social cues. Some evidence raises concern that many media avenues offer instant gratification and, as a result, may lead to certain “addictive” brain changes that encourage immediate and habit-forming results. Psychologists agree that proper media use does offer some benefits, including improved coordination, fine motor, communication and language skills. These advantages, though, only are evident if avenues are used appropriately. As a general rule, parents must remember that any form of media a child uses should be closely monitored and educational. Any overuse takes away from valuable time with more productive activities, including physical activity or faceto-face interactions with family and friends. Avoid use of TVs, phones or other devices at night and in the bedroom because sleep may be affected (and subsequent daytime energy level, mood and learning). Media matter must be actively evaluated and monitored by parents for content and amount. Many programs or websites can help parents decipher what is appropriate—a popular one approved by the AAP is Common Sense Media. Finally, media use is another avenue in which children learn their own behavior through modeling. Thus, parents need to make sure they are using media on a limited and appropriate basis. These discussions should be an ongoing conversation within families as the media horizon continues to expand and change.

Article author Joseph Maurer, MD, is a pediatrician at the GHSowned practice of The Children’s Clinic and medical editor of Focus on Pediatrics.

William F. Schmidt III, MD, PhD________________________________ (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

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Pediatrician of the Year Congratulations to Kent Jones, MD, medical director of the Ferlauto Center for Complex Pediatric Care at GHS Children’s Hospital, who received the 2016 Pediatrician of the Year award at the 25th Annual DeLoache Seminar in November. Dr. Jones was recognized by his colleagues for “being an angel to the medically complex children he gets to serve,” and the way he “places himself in the shoes of each member of the families he serves.” In addition, he was lauded for his commitment to providing care for “a population that is just hard—hard to coordinate, hard to manage, hard to everything!” Nomination forms emphasized Dr. Jones’ personal care and dedication to his patients, families and colleagues. One peer noted, “Dr. Jones is a team player, encouraging everyone in the office to play an active role in developing the complex care clinic. Everyone’s opinion matters.” Approximately 100 health professionals attended the seminar, which is named for the late William R. DeLoache, MD, GHS’ first neonatal medicine specialist.

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