Ohio Pediatrics - Spring 2017

SPRING 2017

A QUARTERLY NEWSMAGAZINE OF THE OHIO CHAPTER, AMERICAN ACADEMY OF PEDIATRICS

Food Insecurity Screening: Resources to Use in Your Office

Partnership for Safety of Children Around Firearms: A Physician Fact Sheet for Conversations

NEW Injury Prevention Plus SEEK Learning Collaboratiave

Real Families Speak Out About BCMH Ohio AAP Advocates for Ohio’s Most Vulnerable Children

In This Issue...

President’s Column • 3 BCMH Advocacy Win • 4 Members in Motion • 7 “Store It Safe” Program • 12 Resident’s Column: Warm Weather Reminders • 15

Issue Theme: Advocacy The Ohio AAP’s Advocacy Pillar coordinates the Chapter’s legislative efforts and overall messaging. Pillar members also aim to be the “experts at the table” for children’s issues in the state of Ohio.

Advocacy

A Deeper Dive: Prenatal Exposure to RSV • 20 Ask the Lawyer: Cell Phone Use • 21

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Rise in infant drug dependence is felt most in rural areas

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Born into suffering: More babies arrive dependent on drugs

New York Times

orn b s ie b a b S U e r o M eroin h e k li s e t ia p o o t addicted Fox News

USA Today

2017 OHIO AAP ANNUAL MEETING October 27–28, 2017 Crown Plaza Dublin 600 Metro Place N, Dublin, OH 43017 Find a full brochure at http://ohioaap.org/AM

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www.ohioaap.org

Shielding Our Medicaid Kids Robert Murray, MD, FAAP President, Ohio Chapter, American Academy of Pediatrics In playground dodge ball, avoiding being hit with the ball in the chaos of the moment is the first rule. Just staying in the game is a momentary victory. Last one standing wins. In this tumultuous political climate, balls are flying at the child from every direction.

Recently we deflected two important ones: at the national level with Medicaid, and at the state level with BCMH. Our health care system has many problems and we all acknowledge it. We pay too much and get too little. The complexity of the health care system burdens the sick and makes it hard for us to give consistent care. But in spite of its many challenges, currently 95% of the children in the US have health care coverage. This was a bipartisan triumph reflecting decades of effort, using S-CHIP and Medicaid expansion as the principle tools. This year, in looking for ways to cut the budget without involving Social Security or Medicare, Congress targeted Medicaid. The pediatric community and the public pushed back. Consequently, many legislators stood to protect Medicaid. Slashes to the program were avoided, but only temporarily. This issue is not resolved. New balls will be thrown as budgetary pressures rise.

Medicaid is a crucial pillar of child health. For every child covered by CHIP in Ohio, there are 6.5 covered by Medicaid.

Nearly 50% of enrollees in Ohio Medicaid are children, yet they account for only 20% of the expenses. It’s a great investment.

For states like Ohio, Medicaid represents the state’s largest source of federal dollars. These dollars are carefully targeted at prevention, screening, early identification, and comprehensive interventions for health and mental health among children with the greatest risk. Medicaid allows children with medical disorders to remain active within their schools and stay socially connected with their peers. It affords children a chance for a full, productive life, despite their clinical or socio-economic challenges.

Recognizing the tremendous opportunity that additional federal funds for Medicaid offered to Ohio, Governor Kasich took the courageous step of expanding enrollment in the face of widespread political criticism. This single decision cut the uninsured population of our state in half. Levels of uninsured Ohioans – and in particular, Ohio children – are now at historic lows. Expansion has offered a disproportionate benefit to rural populations. It improved the economic stability of families, lowered debt, raised parental ability to work, lowered food insecurity, and improved child health outcomes, according to data from Ohio Medicaid. Any retreat will threaten the health and well-being of children.

Medicaid restructuring proposals aren’t going away, unfortunately. The most recent proposals employ the term www.ohioaap.org

“state flexibility.” The idea is to install per capita caps on Medicaid federal expenditures.

Funds are given to states as block grants. Any spending over that cap to ensure complete quality care is borne by the state. The US has not had such a system since the 1960s War on Poverty, but when it did, coverage and benefits dropped in response, a fact that was discussed by Goodman-Bacon et al in a Perspective article in the NEJM in February 2017. If this idea becomes law, as federal funding for the block grants shrivel over time, Ohio children will have to compete with high-need adults for a shrinking pool of critical intervention dollars. Disabled children, those with mental health conditions, and those needing rehabilitation services, who rely on Medicaid support, would face increasing jeopardy as budgets shrink. The current Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) for children would surely be an early victim of the restructure. At least for now, such vital services remain in place.

Here in Ohio, the same high-need population faced a new challenge, this time from efforts to improve cost through program restructuring. What looked benign – folding BCMH programs into Medicaid – actually represented a substantial change in access, resources, expert care, and case monitoring.

OAAP leadership and parents affected by the BCMH proposal spent hours educating legislators on the nuances of BCMH and how process changes would threaten our state’s most needy children. The language was removed because the House recognized the complexity of the issue. It may soon be back again as a stand alone proposal.

It took decades to achieve full health and mental health coverage for Ohio’s children. Those gains could easily unravel.

In an Op-Ed letter to the New York Times, (End the Partisan Warfare on Health Care; March 10, 2017), Governor Kasich continued to defend Ohio’s Medicaid expansion and press for rational health care deliberations. As pediatricians, so should we. These issues are so fundamental for child health and so important to our vision for pediatric care, it requires all of us to speak up.

The Academy will continue to monitor and advise on developments in Washington. The Ohio Chapter will keep you updated on state legislative and regulatory proposals.

Comprehensive health care for children should not be a negotiating point in budget discussions. Pediatricians speak for children, so we need to be playground loud and aggressive to be the winners at the end. Write, call, chatter, email, Tweet, and channel your inner child.

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Ohio AAP Wins Removal of BCMH Changes from State Budget Families who rely on the Bureau of Children with Medical Handicaps (BCMH) have reached out to the Ohio Chapter, American Academy of Pediatrics and its members to extend their thanks for the Chapter’s fight to keep the important program.

As part of his two-year, $66.9 billion budget, Gov. John Kasich (R) proposed moving the BCMH program into Ohio Medicaid.

The proposal would have allowed families currently receiving BCMH services to stay on the program, but a child born in Ohio, whose parents did not meet the Medicaid poverty criteria for BCMH (225% of the federal poverty level), would have no longer been eligible for BCMH services.

“BCMH is a safety net for families who have insurance but can’t afford the high costs of illnesses and conditions like cystic fibrosis, blood disorders and spina bifida,” said William Cotton, MD, FAAP, co-chair of the Ohio AAP’s Advocacy Pillar. “It was important for us to fight for the state’s sickest children.”

The Ohio AAP’s advocacy team worked for over a month and a half, held many meetings with families and legislators to gather stories and discuss the benefits and challenges of the BCMH program. One of the many families who reached out to the Ohio AAP was Liz Skerl, a mother living in Hilliard.

“We were so fortunate to receive BCMH after my daughter was hospitalized for testing following a complex febrile seizure,” said Skerl. “Although I am a stay-at-home mom, our family does not meet the requirements to receive any government assistance.

A parent should not have to worry about medical bills while Skerl Family deciding the best course of treatment for their sick child.”

James Duffee, MD, MPH, FAAP, testified before the House Health and Human Services finance subcommittee on behalf of the Ohio AAP on Thursday, March 23, 2017.

“Because of the high likelihood of harm to Ohio’s children with special needs, the Ohio AAP cannot support the proposed structural changes to the program, the transition 4

Spring 2017 • Ohio Pediatrics

of children with medical complexity to managed care, or the future limitations in eligibility that are included in the proposed operating budget,” Dr. Duffee told the committee.

Several families with children with disabilities also made pleas to the committee in their testimony. Before the committee hearing even ended, committee chair Rep. Mark Romanchuk, announced his committee would recommend the cuts would be pulled from the budget.

“Getting this provision removed from the budget was no small effort,” said Melissa Wervey Arnold, the Ohio AAP Chief Executive Officer. “We were proud to stand with these families and our members to ensure that children in Ohio have access to the services and support they need.”

“Thank you for what you all are doing for our families,” said Brittney Underwood, whose son has a rare genetic condition called mandibulofacial dysostosis.

“Calvin requires an organic, tubefed formula, which is not covered by Medicaid but is covered by BCMH. It is over $13 a pouch and he eats 3 1/2 of them a day. If we were to lose be BCMH we would have to cover this and we could not afford to do this, which would be detrimental to his health and his well-being.”

Underwood Family

While this proposal was removed from the state budget, legislators are expected to introduce a standalone measure to continue deliberations over the future of the BCMH program.

“This is not over for these families or for the Ohio AAP,” said Dr. Cotton. “We do recognize that there need to be some changes to the existing program to make it stronger, as well as ensure its long-term survival. We are committed to working with legislators and the Kasich administration to make these changes.”

Author: Melanie Farkas Editor’s Note: As of printing of this newsletter, a new measure had not been introduced. Check OhioAAP.org and the email newsletter, Ohio AAP Today, for updates. www.ohioaap.org

Statehouse Update Danny Hurley, Lobbyist, Capitol Consulting Group The 132nd General Assembly is in full swing as legislators consider the state operating budget and many other important pieces of legislation. The Ohio Chapter, American Academy of Pediatrics has been very active testifying on bills, meeting with members of the House and Senate, and working with the Kasich Administration.

Governor Kasich unveiled his fourth operating budget in February; the budget included significant tax reform packages and a number of changes to Medicaid and other public health programs. Hearings on the budget proposal, formally introduced as House Bill 49, have been ongoing since then and legislators have until June 30 to finalize the bill and get it to the Governor’s desk. On the tax front, Governor Kasich again proposed an increase in the state tobacco tax along with an equalization of taxes on vapor and other tobacco products. The Ohio Chapter testified in support of these tax increases before the House Ways and Means Committee. This isn’t the first time the Kasich Administration has tried to increase taxes on cigarettes and other tobacco products; this proposal faces an uphill battle due to push back from retailers and tobacco companies.

In addition to the tobacco tax proposals, HB 49 included controversial language that would transfer the Bureau of Children with Medical Handicaps (BCMH) from the Ohio Department of Health to the Ohio Department of Medicaid.

The Ohio Chapter, along with several provider and patient advocacy organizations successfully lobbied against this effort. The BCMH – Medicaid merger will be removed from the budget, however legislators are expected to introduce a standalone measure to continue deliberations over the future of the BCMH program.

Outside of the budget process, the Ohio Chapter is supporting legislation to make much needed reforms to step therapy protocols in Ohio. House Bill 72, sponsored by State Reps. Terry Johnson (R-McDermott) and Nickie Antonio (D-Lakewood) and Senate Bill 56, sponsored by State Senators Peggy Lehner (R-Kettering) and Charleta Tavares (D-Columbus) have received a handful of hearings in their respective chambers.

The bills have strong support from patient and provider organizations, but face opposition from health insurance plans. The Ohio Chapter is also supporting legislation that would prohibit the sale of over-the-counter drugs that contain dextromethorphan to minors. House Bill 73, sponsored by State Rep. Jeff Rezabek (R-Clayton), is identical to a bill that passed the House in the 131st General Assembly.

Finally, lawmakers and the Kasich Administration are considering additional restrictions on opiate prescribing www.ohioaap.org

in Ohio through a pair of bills and rules from the Ohio Board of Pharmacy and State Medical Board. House Bill 167 and Senate Advocacy Bill 119, sponsored by State Rep. Jay Edwards (R-Nelsonville) and State Senator Bob Hackett (R-London) respectively, would restrict primary care physicians from prescribing opiates for longer than three days without additional training. The bills effectively codify existing CDC recommendations for the management of acute pain using narcotics. Separate from this effort, the Kasich Administration is unveiling new rules that would restrict physician prescribing of opiates for acute pain to seven days for adults and five days for children. There would be exceptions for patients in significant pain or situations where a physician feels a longer prescription is necessary.

The Ohio Chapter remains committed to advancing legislation to improve Ohio’s immunization rates and address bicycle safety in the 132nd General Assembly. We also will be part of discussions regarding primary care workforce issues, epi-pen pricing, and scope of practice bills for nonphysician clinicians.

Editor’s Note: The state budget is under consideration now and may change from what is stated at the time of this publication. Check OhioAAP.org and Ohio AAP Today for more current updates.

The Ohio AAP extends its thanks to the following staff, members and partners who offered legislative testimony over the past quarter: Melissa Wervey Arnold William Cotton, MD, FAAP James Duffee, MD, MPH, FAAP Henry Spiller, MS, D.ABAT David Stukus, MD, FAAP

James Duffee, MD, MPH, FAAP testifying on BCMH to a finance subcommittee on March 23, 2017.

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Ohio AAP Takes Part in #Docs4Coverage Capitol Hill Visit The Ohio Chapter, American Academy of Pediatrics joined AAP chapter leaders from all 50 states, the District of Columbia and Puerto Rico, to travel to Capitol Hill in late February to urge members of Congress to protect children’s health care coverage.

William Cotton, MD, FAAP, co-chair of the Ohio AAP’s Advocacy Pillar, met with staff members from both Ohio senator’s offices during the visit to explain the Academy’s priorities for children’s health to a new congress and presidential administration.

The main messages were: keep Medicaid strong, extend funding for the Children’s Health Insurance Program and presesrve the Affordable Care Act’s gains for children.

William Cotton, MD, FAAP and Colleen Kraft, MD, FAAP

Colleen Kraft, MD, FAAP, a Cincinnati pediatrician and president-elect of the national American Academy of Pediatrics, attended meetings in the nation’s capitol as a representative of the national organization.

In total, chapter leaders visited more than 150 congressional offices. The visits were made possible by the Friends of Children Fund.

The new Ohio children’s health care coverage fact sheet may be found at OhioAAP.org/pillars/advocacy.

Left: William Cotton, MD, FAAP with a staffer of Sen. Rob Portman (R-OH) Right: William Cotton, MD, FAAP with a staffer of Sen. Sherrod Brown (D-OH)

Ohio Pediatrics: A publication of the Ohio Chapter, American Academy of Pediatrics

Chief Executive Officer: Melissa Wervey Arnold Lobbyists: Dan Jones & Danny Hurley, Capitol Consulting Group

Officers: President: Robert Murray, MD, FAAP President-Elect: Michael Gittelman, MD, FAAP Treasurer: Jill Fitch, MD, FAAP Immediate Past-President: Andrew Garner, MD, PhD, FAAP

Ohio Pediatrics Editorial Board Members: Sherman Alter, MD, FAAP – Blue Ash Mary Ayers, MD – Cleveland Jaclyn Bjelac, MD, FAAP – Cleveland Jennifer Burkam, MD, FAAP – Canton Jennifer Hardie, MD, FAAP – Lebanon Kathleen Matic, MD – Dayton Emia Oppenheim, PhD, RD, LD – Columbus Thomas Phelps, MD, FAAP – Novelty Roopa Thakur, MD, FAAP – Beachwood Greg Walker, MD, FAAP – Cincinnati

Delegates-At-Large: Sarah Denny, MD, FAAP Kelsey Logan, MD, FAAP Katherine Krueck, MD, FAAP Advocacy Chair Liaison: William Cotton, MD, FAAP Hospital-Employed Physician Liaison: Christopher Peltier, MD, FAAP Foundation Board Chair: Charles Spencer, MD, FAAP’

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Editor: Melanie Farkas Ohio Chapter, American Academy of Pediatrics 94-A Northwoods Boulevard | Columbus, Ohio 43235 (614) 846-6258

www.ohioaap.org

Members in Motion

Kathi Makoroff, MD, FAAP Jan. 13, 2017 Child Abuse and Neglect Regional Training

Carrie Barnes-Mullett, MD, FAAP Jan. 29, 2017 - Interview on safe media on WBNS 10TV in Columbus

Sarah Denny, MD, FAAP Mar. 26, 2017 - “Storing It Safe” Firearm Safety Program on WBNS 10TV in Columbus

Jonathan Thackeray, MD, FAAP Feb. 10, 2017 Ohio Injury Prevention Partnership Meeting

Elizabeth Zmuda, DO, FAAP Feb. 11, 2017 - Interview on obesity prevention on WBNS 10TV in Columbus

Sherman Alter, MD, FAAP Mar. 22, 2017 Immunization Advocacy Day Ohio Statehouse

Jessica Bushmann MS, RD, LD Mar. 11, 2017 - Cooking demonstration at the WBNS 10TV Health & Fitness Expo in Columbus

Kristen Rost, Ohio Children’s Trust Fund Jonathan Thackeray, MD, FAAP Apr. 15, 2017 - Interview on child abuse awareness on WBNS 10TV in Columbus

Sarah Denny, MD, FAAP Alex Denny April 13, 2017, 2017 - Bike Helmet Safety Interview on WBNS 10TV in Columbus

www.ohioaap.org

Ohio Pediatrics • Spring 2017

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Recognizing Child Abuse in Your Practice Taylor Ballenger, MD As frontline medical providers working with children, pediatricians are well aware that minor injuries occur commonly in otherwise normal, healthy kids. In fact, one study found that 20.9% of children less than 3 years presenting for well-child visits were found to have bruising1.

Given how commonplace minor injuries are in children, the challenge can be recognizing when a bruise is not the result of an accidental childhood mishap. Add in the endless stream of paperwork, phone calls, and bronchiolitis, and it can be easy to see where a bruise here or a burn there might start to get shuffled directly into the “normal” bin.

April was Child Abuse and Neglect Awareness Month.

According to the CDC, in 2012 there were an estimated 686,000 victims of child maltreatment with an estimated 1,640 resulting deaths. Unfortunately, some studies even estimate that as many as 1 in 4 children in the U.S. experience some form of maltreatment in their lifetime2. Of those victims, 70% are under the age of 3 years2.

With our youngest and most vulnerable patients at highest risk for abuse and neglect, it is important that we be able to recognize early signs of maltreatment. An important concept is the idea of the sentinel injury – the initial injury that should alert us to the potential for abuse. A recent study found that across 18 different institutions, 0.7% of visits for children less than 24 months were identified as having “putative sentinel injuries” with the rate of an abuse diagnosis for children with at least one sentinel injury ranging from 3.5% to 56.1% depending on age and injury type3. For visits with no sentinel injury identified, the rate of abuse diagnosis was only 0.03%3. When the authors examined specific types of injuries such as rib fractures, abdominal trauma, or intracranial hemorrhage, the rate of abuse diagnosis was greater than 20% for each injury3. This could suggest that certain exam findings are more likely to be associated with child maltreatment. One such critical finding is any injury to a young or pre-ambulatory infant, as one study found that during well child exams only 0.6% of normal infants less than 6 months had bruising and only 2.2% of non-cruising infants had bruising1,4. Other suspicious exam findings include involvement of multiple organ systems, multiple injuries in different stages of healing, injuries with an associated pattern, injury to non-bony or unusual locations (pinna, back of the ears, face, hairline, trunk, buttocks, thighs, or hands), unexplained significant injuries, or other evidence of neglect (such as evidence of malnutrition, growth failure/failure to thrive, untreated diaper rash or wounds, etc.)1,4. While some injuries can be normal and accidental, any bruising to a young, preambulatory infant should raise concern for abuse or illness1.

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However, sentinel injuries can get missed. A 2016 study found that of subjects diagnosed with abusive head trauma, 31% had prior opportunities to detect abuse and that 25% of those could have been identified in a medical setting such as an emergency department or primary care clinic5.

The study also noted that the most common identified prior opportunities included non-specific complaints such as vomiting and bruising5. This could suggest that one reason we miss these sentinel injuries is that they are non-specific and hard to identify in isolation.

Recognizing potential abuse is important, but the signs can be non-specific and physical abuse can impact children of any age, socioeconomic status, or ethnicity4. Understanding the risk factors for abuse can help us recognize when a bruise is a sign of something more serious. Risk factors for abuse include4,6: • • • • • • • • • • • • • • • •

maternal smoking low infant birth weight age less than 4 years child with a disability or special needs non-biologic adult/caregiver in the household parents’ history of child maltreatment young parental age single parent lower education level higher number of dependents lower income social isolation family chaos or violence poor parent-child relationships community violence poor social connections ...continued on page 30

www.ohioaap.org

Ohio AAP Encourages Pediatricians to Address Food Insecurity Feeding America estimates 16.8% of Ohioans face food insecurity – they do not have reliable access to a sufficient quantity of affordable, nutritious food – and that Ohio’s children suffer at an even higher rate of 23.8%. This leaves the physical and mental health of more than 628,000 children at risk each day.

The Ohio AAP has long addressed the health risks of childhood obesity, and now the Foundation Pillar has created an action group to create and implement resources to decrease food insecurity for children in Ohio. Led by Ohio AAP President Robert Murray, MD, FAAP, the group consists of Ohio AAP members, including residents and medical students, and outside partners working on food insecurity issues, such as the Ohio Department of Education and State Library of Ohio.

Common causes of food insecurity include unemployment, high housing costs, low wages and poverty, and lack of access to SNAP (food stamps). However, data suggests that 67% of Ohio’s food insecure children are eligible for assistance.

Helping pediatricians connect families with short and longterm resources to ensure access to nutritious meals is one way to address this gap in services. Two actions have been identified to make the most impact on food insecurity for Ohio’s children using available resources, including: •

Implement a validated 2-Item screen and follow up resources for food insecurity in all Ohio children’s hospitals through residency clinics • Two policy statements from the AAP (2016 Statement on Poverty and Child Health, and 2015 Promoting Food Security for All Children) highlighted this screening as an effective method for quickly identifying families at risk for food insecurity • The Chapter created a website to assist with food insecurity resources for short-term assistance once food insecurity is identified, and is developing a bank of long-term resources that can be easily accessed to minimize physician time needed to address positive screens

www.ohioaap.org

•

•

Hospitals or residents will collect data on the results of these screenings and resource referrals whenever possible to determine the effects of this effort Spread the Summer Food Service Program (SFSP) of the USDA to all Ohio children’s hospitals, or connect hospitals with sites in their neighborhoods • Using a model piloted by Arkansas Children’s Hospital, in 2015 the Ohio AAP began educating Ohio’s children’s hospitals on how to become SFSP sites or support the existing sites in their areas • Toledo Children’s Hospital was the first Ohio children’s hospital to become a site in 2016, and has stated plans to continue in 2017 • Many other hospitals have begun considering becoming a site this year, or have developed a relationship with local sites to serve their patients

The Ohio AAP will pursue these actions in 2017 by meeting with hospitals and communities, and providing education to members on how they can become involved in Ohio’s food crisis.

Ohio AAP members are encouraged to use the Food Emergency handout found on page 10 and access resources on food insecurity at http://ohioaap.org/food-insecurity/.

For more information on upcoming activites of this ad hoc action group, please contact Hayley Southworth at hsouthworth@ohioaap.org.

Food Insecurity Questionnaire: 1. Within the past 12 months, we worried whether our food would run out before we got money to buy more. (yes or no) 2. Within the past 12 months, the food we bought just didn’t last and we didn’t have money to get more. (yes or no) Ohio Pediatrics • Spring 2017

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Food Emergency WIC: WIC is the Special Supplemental Nutrition Program for

Summer Feeding:

Women, Infants, and Children.

Children ages 1 through 18 are eligible to receive free meals during the summer months at participating program sites.

Individuals ages 19 through 21 who have been identified as having mental or physical disabilities and are following Individualized Education Programs (IEPs) through their current enrollment in educational programs also are eligible for free summer meals.

WIC helps income eligible pregnant and breastfeeding women, women who recently had a baby, infants, and children up to five years of age who are at health risk due to inadequate nutrition.

WIC provides nutrition education, breastfeeding education and support; supplemental, highly nutritious foods such as cereal, eggs, milk, whole grain foods, fruits and vegetables, and ironfortified infant formula; and referral to prenatal and pediatric health care and other maternal and child health and human service programs.

Contact:1-800-755-GROW (4769) or https://www.odh.ohio.gov/en/odhprograms/ns/wicn/wic1.aspx

SNAP:

The Ohio Food Assistance Program (federally known

as Supplemental Nutrition Assistance Program, SNAP).

SNAP assists low-income individual purchase food to keep them healthier and reach nutritional levels.

A household may consist of an individual or a group of individuals who live together and usually purchase, prepare, and eat their food together.

Contact: http://jfs.ohio.gov/ofam/foodstamps.stm

Contact: 1-866-3-HUNGRY (1-866-348-6479) or http://education.ohio.gov/Topics/Other-Resources/Food-andNutrition/2016-Summer-Food-Service-Program

School Meals: Any student of high school grade or under who is enrolled in an eligible school, or a student under age 21 who resides in an any public or nonprofit, private licensed Residential Child Care Institution may participate.

Additional benefits may be available to a student when his or her parent or guardian submits a free and reduced-price school meals application. Based on the household size and income, the student may be eligible for meals free or at a reduced price.

Contact: http://education.ohio.gov/Topics/Other-Resources/ Food-and-Nutrition/National-School-Lunch-and-Breakfast

Ohio Chapter, American Academy of Pediatrics Local Resources: Use this database to find a local food bank or food pantry in your area. You can access a map to see the best location.

Contact: http://ohioaap.org/EmergencyFoodInfo

Good4Growth.org www.ohioaap.org

Injury Prevention Plus SEEK Learning Collaborative

The Ohio Chapter, American Academy of Pediatrics (Ohio AAP) has developed a new learning collaborative opportunity for primary care physicians focused on implementing a hybrid of the Ohio AAP’s Injury Prevention Screening Tool and the nationally recognized Safe Environment for Every Kid (SEEK) Tool. By participating in this collaborative, physicians will become more efficient and effective in screening, discussing and referring families to resources based on the injury and psychosocial risks they identify for children from birth to four years old.

Why Address Injuries?

Injuries are the number one cause of morbidity and mortality among children in the United States. In children less than one year of age, unsafe sleep positioning and environments, motor vehicle collisions, drowning, and physical abuse most commonly cause these injuries. Screening for risk, and counseling families on age appropriate safety behaviors, is every healthcare provider’s responsibility. However, many practitioners, do not adequately or consistently address these topics during well child visits.

Why Address Family Environment?

Child maltreatment continues to be a major problem in the United States, with over 3.3 million reports made to Child Protective Services annually, involving about 6 million children.

Maltreated children are at risk for many short- and long-term negative consequences, including medical, development, learning, social and mental health problems.

There is more to keeping children healthy than treating ear infections and providing preventative care, such as delivering immunizations. Parental depression, substance use in the home and food insecurity are psychosocial problems that can impact a families’ ability to care for and raise healthy children. The mission of SEEK is to strengthen families, support parents and parenting and thereby promote children’s health, development and safety – and help prevent child abuse and neglect.

Addressing Injuries and Family Environment at Well Child Visits for Children from Birth to 4 Years Old The Ohio AAP’s Injury Plus SEEK collaborative aims to build upon the existing relationships between primary care providers and families by addressing these potential problems and risky behaviors. Two screening tools (birth to 1 year, and 1-4 years) have been developed for easy implementation into www.ohioaap.org

clinical practice to allow providers to seamlessly screen for risks. These tools also include talking points for practitioners to address risky behaviors and psychosocial problems for: • • • • • •

Alcohol and Substance Use Food Insecurity Family Relations Fall Prevention Car Safety Safe Sleep

•

Maternal Depression/ Parental Stress General Home Safety Supervision Water Safety Fire/Burn Safety the Injury Plus SEEK

• • • • Benefits of Participation in Learning Collaborative In the summer of 2017, the Injury Plus SEEK Learning Collaborative will launch a first wave for interested primary care providers; an additional learning collaborative will launch in late 2017 or early 2018. Throughout the six month collaborative, participating providers will receive: • Training to briefly assess and initially help address risky behaviors and prevalent psychosocial problems • Screening tools to assess these risky behaviors and psychosocial problems in children from birth to 4 years of age • Easy to use scoring sheets and recommended talking points for each area identified as risky • Maintenance of Certification (MOC) Part IV credit for up to 21 medical specialties participating as part of the American Board of Medical Specialties (including 25 points by the American Board of Pediatrics and 20 points by the American Board of Family Medicine) • 10 points of American Board of Pediatrics MOC Part II Self-Assessment • Networking opportunities with other healthcare providers interested in injury prevention and family environment screening • Community resources for family referral to address psychosocial concerns and risky behaviors • Sleep sacks for distribution to patients in your office • A cash stipend to assist with time and expenses of project implementation • Guidance and quality improvement coaching from the Ohio AAP For more information on the Injury Prevention Plus SEEK Learning Collaborative, or to register to participate, please contact Hayley Southworth, at hsouthworth@ohioaap.org or (614) 846-6258.

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“Store It Safe” Program Launches The Ohio Chapter, American Academy of Pediatrics (Ohio AAP) teamed up with firearm owners, pediatricians and others to create the Partnership for Safety of Children Around Firearms, and a messaging strategy called “Store it Safe,” to encourage safe storage of firearms and educate families about safety issues. The Partnership officially launched on March 6, 2017 with a meeting and press conference at the Kiwanis Club of Columbus.

“Twenty-five percent of Ohio counties have had gun-related accidental injuries and deaths in children under 18 since 2015,” said Melissa Wervey Arnold, CEO, Ohio Chapter, American Academy of Pediatrics. “It was clear we needed to address this growing issue and pull resources from other organizations to form this first-of-its-kind partnership.”

The Partnership, which includes Buckeye Firearms Association, Black Wing Shooting Center, Kiwanis Club of Columbus and many other interested parties, was founded on the belief that gun ownership is a personal choice. The Partnership will not engage in debating firearm owner rights.

The goals of the Partnership are to: • Prevent firearm-related, unintentional deaths and suicides among children and teens • Change the approach in talking about firearm safety • Store it Safe and teach children safety around firearms Kiwanis Club of Columbus provided $10,000 to purchase gun lock boxes that are being distributed at two and three-year-old well-visit check-ups in several Nationwide Children’s Hospital pediatric offices in central Ohio, in

Left to right: Gerard Valentino, Buckeye Firearms, Melissa Wervey Arnold, Ohio AAP CEO, Jack D’Aurora, Kiwanis Columbus, Andy Loeffler, Black Wing Shooting Center, Sarah Denny, MD, FAAP

addition to education about safe gun storage. Buckeye Firearms donated an additional $1,000 for the purchase of additional gun boxes.

“We believe strongly in the second amendment, but we also believe in being a responsible gun owner and protecting our children,” said Gerard Valentino, co-founder, Buckeye Firearms Association. “This partnership is unique and we’re thrilled to be part of it and have all parties at the table to discuss gun safety.”

Physicians are welcome to use the fact sheet provided on page 13 and the family handout on page 14 in their offices during discussions with patients. For more information about gun safety and Ohio AAP’s initiatives, along with handouts available in Spanish and Somali, visit: http:// ohioaap.org/firearmsafety.

Ohio AAP Awarded Subgrant for Immunization Activities The Ohio Chapter, American Academy of Pediatrics (Ohio AAP) was awarded a sub-grant from the Ohio Department of Health (ODH) for two new and exciting immunization programs.

Pathways Community HUB Collaboration The Ohio AAP received funding to work with the six Pathways Community HUB locations in Ohio to create a set immunization curriculum for their community health workers and provide resources around immunizations to share with the at-risk families they work. This program is being led by Mike Gittelman, MD, FAAP. DTaP Drop-Off Program The fourth dose of the DTaP (diphtheria, tetanus, pertussis) is one of Ohio’s lowest antigens in the childhood vaccine series. The Ohio AAP is working with ODH to create a program to educate Ohio providers on this disparity and provide strategies to get their two year-old patients up-to12

Spring 2017 • Ohio Pediatrics

date on the vaccine. Regional presentations will take place in June 2017, dates and times will be announced soon.

Contact Melanie Farkas if you have any questions at (614) 846-6258 or mfarkas@ohioaap.org.

More than 40 people gathered for a meeting on Apr. 3, 2017 between the Ohio Pathways Community HUB sites and the Ohio AAP.

www.ohioaap.org

PHYSICIAN FACT SHEET Provided by the Partnership for the Safety of Children Around Firearms About the Program The Ohio Chapter, American Academy of Pediatrics has teamed up with firearm owners, pediatricians and others to create The Partnership for Safety of Children Around Firearms, and a program called Store It Safe.

Store It Safe is about keeping children safe from accidental gun deaths. To help achieve this goal: • We are encouraging pediatricians and office staff to discuss firearm safety at well-child visits.

• We are not keeping track of discussions on gun safety in any child’s chart.

Physician Talking Points on Safety • This messaging is for children visiting at the 2-year-old and 3-year-old office visit.

• There is no collection of information about gun ownership. This information is to be discussed with all families who have a 2 or 3-year-old child, whether they share that they own a gun or not.

Step 1: Introduction of safety by pediatricians or staff at every 2 or 3-year-old visit.

Statement to be made: As your child continues to be more mobile in the house, it is important to have barriers in the home to prevent your child from being injured. A few important barriers that you should have in place at all times are: a) All medicines should be locked and out of reach of your child b) All detergents and cleaners should be locked away and out of reach of your child c) Pools should have fencing around them and inflatable pools drained when not in use d) Guns should be stored in a lock box when not on the body of the owner.

Step 2: Give Handout for Families on gun/barrier safety at every 2 or 3-year-old visit.

Questions?

Contact Program Manager Hayley Southworth at (614) 846-6258 or hsouthworth@ohioaap.org.

For more information, go to www.ohioaap.org/firearmsafety

www.ohioaap.org

Ohio Pediatrics • Spring 2017

13

PARENT FACT SHEET Provided by the Partnership for the Safety of Children Around Firearms About the Program The Ohio Chapter, American Academy of Pediatrics has teamed up with firearm owners, pediatricians and others to create The Partnership for Safety of Children Around Firearms, and a program called Store It Safe.

Store It Safe is about keeping children safe from accidental gun deaths. To help achieve this goal: • We are encouraging pediatricians and office staff to discuss firearm safety at wellchild visits.

• We are not keeping track of these discussions or including any information in your child’s chart.

Additional Ways to Keep Your 2 – 4-year-old Child Safe Since your child is more mobile, it’s important to set up your home to keep your child safe. Here are a few ideas to consider: • Guns should always be stored out of sight and locked when not in immediate possession of the gun owner. When a firearm is not on the body of its owner, it should always be stored in a lock box so children cannot access it. Even children as young as 3 years old can pull the trigger of a firearm. Also, older children can be curious and should not be able to access the owner’s gun.

• Keep medicines and household cleaners out of your child’s reach. Household products, medicines, and sharp objects should be stored locked in high places out of the child’s sight and reach.

• Fence in your pool or hot tub on all four sides. Drowning is the second leading cause of injury-related death of children nationally in this age group. If you have a disposable pool, remove water from it when not in use.

• Check for hazards in homes your child may visit. Other homes, especially those with no children or older children, may pose hazards from poisonings, falls, pools and guns.

Questions?

Contact Ohio AAP Program Manager Hayley Southworth at (614) 846-6258 or hsouthworth@ohioaap.org.

For more information, go to www.ohioaap.org/firearmsafety 14

Spring 2017 • Ohio Pediatrics

www.ohioaap.org

Resident Update

Column Coordinators: Mary Ayers, MD & Kathleen Matic, MD

Warm Weather Anticipatory Guidance Reminders Kathleen M. Matic MD

As the days get longer and the weather gets warmer, we are all finally seeing the “light at the end of the tunnel” with the winter cold and flu season. As pediatric residents, it is our duty to provide season specific anticipatory guidance to our pediatric patients and their families. The American Academy of Pediatrics developed anticipatory guidance recommendations for providers in regards to Sun/Heat Safety, Helmet Safety, Pedestrian Safety, Pool/Water Safety and so much more! The AAP Committee on Injury, Violence and Poison Prevention and www.HealthyChildren.org have abundant resources for resident physicians that are accessible on any smart phone, tablet or computer with internet access. Residents should go to www.HealthyChildren.org and click on the link for “Safety & Prevention” for resources that can be given to parents and see the boxes within this article for anticipatory guidance to give to parents and children during the warm weather seasons.

FUN IN THE SUN BABIES UNDER 6 MONTHS: • Avoid sun exposure and dress infants in lightweight long pants, long-sleeved shirts, and brimmed hats that shade the neck.

• If adequate clothing and shade are not available, parents can apply a minimal amount of sunscreen with at least 1530 SPF to small areas, such as the infant’s face and the back of the hands.

CHILDREN 6 MONTHS AND UP: • Stay in the shade whenever possible, and limit sun exposure during the peak intensity hours (between 10 a.m. and 4 p.m.).

• Children should wear a hat with a three-inch brim (or a bill facing forward), sunglasses (with 97% -100% protection against both UVA and UVB rays) and clothing that protects arms/legs when playing in the sun.

HELMET SAFETY • All children riding bikes, scooters, tricycles, and other play toys with wheels should wear a PROPERLY fitted helmet at all times.

• Children who ride as passengers in parent bikes or carriers should wear a PROPERLY fitted helmet at all times.

• Any helmet that has been involved in a crash or otherwise damaged should be discarded and replaced.

• If a child’s helmet is 5 years or older, the helmet should be replaced.

PEDESTRIAN SAFETY • Parents should be good pedestrian role models and supervise children carefully around traffic.

• Parents should teach children how to be safe pedestrians (Example: how to safely cross the street).

• When available, children playing outside should wear reflective clothing. www.ohioaap.org

HEAT SAFETY HEAT STRESS IN INFANTS • Always check the back seat to make sure all children are out of the car when you arrive at your destination.

• Place your cell phone, bag or purse in the back seat, so you are reminded to check the back seat when you arrive at your destination.

• Never leave a child alone in a car, even if you expect to come back soon. Lock your car when it is parked so children cannot get in without supervision.

HEAT STRESS IN CHILDREN • Avoid intense activity when temperatures and humidity reach critical levels.

• During outdoor activities in warm weather and/or high humidity, children should always have water or sports drinks available and should take a break from activity to drink every 20 minutes.

• Children should wear light-colored and lightweight clothing.

WATER SAFETY • Never leave children alone in or near a pool, spa or body of water.

• Install a fence at least 4 feet high around all four sides of the pool.

• Make sure pool gates open out from the pool, and self-close and self-latch at a height children can’t reach. Consider alarms on the gate or underwater alarms as a second line of security.

• Avoid inflatable swimming aids (“floaties”) as they are not a substitute for life jackets.

• If a child is missing, look for him or her in the pool or spa first.

• Share safety instructions with family, friends and neighbors. references available upon request Ohio Pediatrics • Spring 2017

15

Ohio School Breakfast Challenge Give ‘em breakfast. Give ’em a boost.

The Ohio School Breakfast Challenge is back for the 2016- 2017 school year. The Challenge encourages all schools to give their students a great start to their day with a healthy breakfast.

Why? Breakfast helps students do their best.

Research shows that students who eat breakfast perform better in school get higher test scores show better behavior have better nutrition

Students who eat school breakfast

Skipping breakfast hurts kids’ overall cognitive performance and has a negative impact on

attend 1.5 more days of school per year

score 17.5% higher

on standardized math tests

levels of alertness attention memory problem solving and math skills

OhioSchoolBreakfastChallenge.com It’s Important.

Brought to you by:

It’s Proven.

It’s Smart.

It’s Time.

Foundation Focus Splish, Splash, Stories Fundraiser to Raise Support for Ohio AAP Early Literacy Efforts Early literacy has long been a focus of the Ohio AAP’s Foundation Pillar, and the topic is receiving renewed attention following the Early Literacy Roundtable held on January 27, 2017 at the Ohio AAP Offices. More than 40 partners joined to discuss the future of Ohio AAP efforts in early literacy, including presentations by Ohio AAP members Greg Szumlas, MD, FAAP and John Hutton, MD, FAAP, and a webinar on the Kansas AAP program “Turn a Page, Touch a Mind.”

As a result of these presentations and discussions, the Ohio AAP has set a long-term goal of developing a coalition for early literacy in Ohio and sustainable early literacy support, including funding for books. To reach this goal, the Chapter will utilize the model of a targeted awareness month, similar to Bike Helmet Safety Awareness Month, to increase public and member knowledge on early literacy. Early Literacy Awareness Month has been tentatively set for March 2018, and a toolkit will be shared with all Ohio AAP members and partners in late 2017 for planning. During this month, Ohio AAP members will be asked to evaluate and increase their discussions on early literacy with families, an action that will hopefully provide a sustained increase in these discussions.

Other early literacy efforts will include the development of practice and community partnerships in at least five communities around the state that have been identified as kindergarten readiness improvement areas and support of Reach Out and Read practices as they pursue funding to provide books.

On June 11, 2017, the Ohio AAP will host the Summer Fundraiser to support these efforts. This year’s event, Splish,

www.ohioaap.org

Splash, Stories, will be held at COSI: Center of Science and Industry in Columbus and will provide attendees with a private experience in the Oceans exhibit. Based on real ocean exploration technology, guests will enter a research habitat and use real technology such as submersibles, sonar, and remote operated vehicles to explore the wonders of the worlds under the sea. Splish, Splash, Stories is an opportunity to provide your family and friends with an amazing memory, all while supporting Ohio’s most vulnerable children. Supporters may also donate tickets for foster families to attend the event – in 2016 the Ohio AAP and supporters brought 25 foster families to the Summer Fundraiser free of charge.

All proceeds will support the programs of the Foundation Pillar, including early literacy and injury prevention. Details and registration for tickets and sponsorships can be found at http://ohioaap.org/SummerFundraiser.

Ohio Pediatrics • Spring 2017

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Ramping Up for Bike Helmet Awareness Month The Ohio Chapter, American Academy of Pediatrics is ready for Bike Helmet Safety Awareness Month in May! The Chapter distributed more than 10,000 bicycle helmets to over 160 Jared Kusma helping at the ODOT partner organizations warehouse on Apr. 13. in April as part of the Put a Lid on It Program. Most helmets were housed at the Ohio Department of Transportation warehouse and others filled the Ohio AAP offices in north Columbus.

“We know that 75 percent of bike-related fatalities would be prevented with a helmet,” said Melissa Wervey Arnold, Chief Executive Officer of the Ohio AAP. “We are incredibly grateful for ODOT’s support of our Put a Lid on It campaign again this year. With their continued support, we will be able to supply more bike helmets to children this year – and save more lives – than ever before.”

The Put a Lid on It Team also delivered helmets and bike helmet safety materials to legislators in Columbus on Apr. 12, 2017.

To learn more about Bike Helmet Safety Awareness Week, visit the Put A Lid On It Facebook page at www.facebook. com/bikehelmetsafety or the Chapter website at www. ohioaap.org/putalidonit.

Left to right: Hayley Southworth, Melissa Wervey Arnold, Sarah Denny, MD, FAAP, Grace Castilli, Jenni Kusma, MD, Jared Kusma, and Amy Vagedes, DO.

Ohio AAP Announces Partnership with Popular School App The Ohio Chapter, American Academy of Pediatrics began a new partnership with the award-winning parenting mobile app, Bloomz, in Feb. 2017 to educate parents across the country on a variety of topics relevant to raising children.

Bloomz connects educators, activity centers, child care, and many other service providers in their kids’ world.

The partnership will consist of three initiatives: 1. A pilot program that will work with a select group of early childcare providers in the state of Ohio and collect data on knowledge, confidence, and families' change in behavior; 2. The creation of a content channel where all Bloomz users can find AAP's information and other relevant content; and 3. The availability of this content to all childcare providers and schools across the United States.

Through this partnership, Bloomz will share critical information about a wide range of topics including how to reduce sudden infant death syndrome (SIDS), constructive disciplining, screen-time management, and reading to children. The service is free, and will distinguish 18

Spring 2017 • Ohio Pediatrics

participating schools and childcare centers from others by providing a higher level of service to their parents and children.

“We look forward to using this innovative approach to reaching parents and helping them navigate the challenging world of parenting with important information they can use,” said Judy Romano, MD, FAAP, past president and project medical director at Ohio AAP. “Our ongoing success working with the Cardinal Health Foundation, training pediatricians nationwide on the importance of families connecting, nurturing, and making the most of every moment with their children, has led us to work with early childhood educators, too. The unique features and functions of the Bloomz platform will not only help us deliver content to parents, but also help childcare centers and schools engage better with them—and we all know that the best way to help kids reach their full potential is to have parents involved as early as possible.” www.ohioaap.org

A Legend Retires Antionette Parisi Eaton, MD, FAAP, retires after more than 60 years in pediatrics.

When a teenage Antoinette Parisi planned to become a nurse because she loved biology, it was an uncle, a pre-med student himself, who urged her to enter medical school.

“In the 1950’s, only about 6% of the physicians in the entire county were women,” said Dr. Antoinette Parisi Eaton in a recent interview. “Most women going into the medical field went into nursing, but my uncle really challenged me to study medicine.”

After a more than 60-year career in medicine, Dr. Eaton retired in January 2017, leaving behind a legacy of a passion for helping the country’s most vulnerable children and blazing a trail for women in pediatrics.

“When women were few in medicine, she was a role model,” said Ellen Buerk, MD, FAAP, past president of the Ohio Chapter, American Academy of Pediatrics. “Many of us felt authenticated because of the way she supported women physicians.”

Dr. Eaton’s parents immigrated to the U.S. from Italy and had four children while living in Youngstown, Ohio. Her parents valued education and were very supportive when she decided to go to medical school. After graduating from the Woman’s Medical College of Pennsylvania, now Drexel University College of Medicine, in 1956, Dr. Eaton completed a rotating internship at Youngstown Hospital. She then applied, and was accepted, to the pediatric residency program at what is now Nationwide Children’s Hospital in Columbus. It was during that time, when she served as chief resident, she married her husband, Samuel Eaton, and had her first child.

“In that era, there was no maternity leave provided,” said Dr. Eaton. “Had I not saved vacation and meeting time, I would have had to extend my residency.”

Dr. Eaton during her time as AAP President Photo Courtesy: Nationwide Children’s Hospital/ Donn Young

www.ohioaap.org

Dr. Eaton’s career continued at Nationwide Children’s Hospital where she served initially as Director of the Birth Defects Center and Chief of the Handicapped Children’s Section, along with teaching as a professor of pediatrics at the Ohio State University. In

1974, she was recruited to the Ohio Department of Health (ODH) to serve as Chief of the Division of Maternal and Child Health.

“It was really during my time at the State Health Department that I became very involved and Photo Courtesy: Nationwide Children’s Hospital enamored with legislative advocacy,” said Dr. Eaton.

“A lot of my later career was focused on legislative advocacy.”

Over the years, she provided legislative testimony on countless issues impacting Ohio’s children and physicians, including advocating for special needs children. She also helped other physicians see the importance of advocacy.

“Toni taught us how to advocate for children. She showed us how to speak to elected representatives and Senators, how to advocate for issues, how to testify at the Statehouse,” said Dr. Buerk.

Dr. Eaton returned to Nationwide Children’s Hospital after her tenure at ODH. Her dedication often impressed colleagues.

“When the president of the American Academy of Pediatrics came to Nationwide Children’s Hospital, she was there to guide and host his visit even though she had awakened that morning with acute appendicitis,” said Dr. Buerk. “She was on the operating table by noon of that day once her duties as host were completed.”

“Toni’s academic office was next to mine for many years and each morning I’d hear her get settled into her office, and spray and comb her lovely auburn hair into submission. When that was done, she was ready to take on the world,” said Elizabeth Spencer Ruppert, MD, FAAP, past president of the Ohio AAP. “What a wonderful person, a terrific administrator and a top-notch pediatrician.”

During her busy career, she also made time for involvement with the American Academy of Pediatrics and the state Chapter. She served as the Chapter’s president from 19831989 and as the national Academy’s first female president in 1990-91. ... continued on page 30 Ohio Pediatrics • Spring 2017

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A Deeper Dive

Column Coordinators Greg Walker, MD, FAAP & Jaclyn Bjelac, MD, FAAP

Prenatal Exposure to Respiratory Syncytial Virus Found to Alter Postnatal Immunity Vertical transmission may explain multiple childhood conditions Giovanni Piedimonte, MD, FAAP Building on previous findings that maternal-to-fetal transfer of the respiratory syncytial virus (RSV) predisposes babies to airway hyperreactivity, my colleagues and I at Cleveland Clinic Children’s have now confirmed that in acute maternal RSV infection, the virus traverses the placenta, modifying immune response after birth.

Our results, recently published in PLoS One, demonstrate that maternal RSV infection alters postnatal offspring immunity, resulting in airway lymphocyte and cytokine profiles that are significantly different from that of a RSV-naïve host during a first postnatal RSV lower respiratory tract infection.

The most significant effects measured after primary early life infection were a sharp increase in CD3+CD4-CD8- T cells, combined with virtual suppression of the production of key Th1-type cytokines like IFN-γ and IL-2; a large increase in the expression of the prototypical neurotrophin NGF; and increased pre- and post-synaptic reactivity of the airways combined with intrinsic hypercontractility of the smooth muscle, delaying its return to resting tone.

These changes persisted — albeit to a lesser degree — after secondary reinfection and might provide a plausible explanation to the development of chronic airway dysfunction and asthma in a subpopulation of children with history of RSV infections in infancy.

Suspicions confirmed Although our studies were performed in rat models, reports of cross-placenta viral transmission in humans have begun to surface.

Indeed, most of what is known today about intrauterine infections derives from studies originally performed in rats, because the rat placenta has many similarities with the human one.

The possibility that viruses that give people the common cold can get into the bloodstream, cross the placenta and reach the fetus should not be surprising. I’ve suspected this for several years.

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Spring 2017 • Ohio Pediatrics

Look at the Zika virus, which causes kids to be born with microcephaly. It is not bad luck — they are infected with the virus in utero. Indeed, many more congenital abnormalities and chronic health issues may originate from previously undetected infections acquired in utero.

Viral infection might have more important consequences when the mother is in the first trimester of pregnancy, prior to development of the fetal immune system. The immune system develops during the second part of pregnancy by recognizing proteins already present in the fetus. If, during the process, there are proteins that don’t belong, the immune system will still recognize them as self. If the baby is reinfected with the same virus during the first months of life, it will not be able to fight the infection effectively because the immune system has been programmed not to respond.

Protecting newborns These findings underscore the importance of avoiding respiratory infections during early pregnancy, particularly when this coincides with the epidemic peak of RSV that usually spans from October-November to March-April in most of the United States. Because this is difficult in most situations, particularly for pregnant women with young children at home, we suggest instituting another layer of protection.

Tip of the iceberg?

Now that the technology to detect infections has become much more sensitive and specific, such as the RSV detection by PCR, we expect other vertically transmitted infections to surface as determinants of postnatal diseases.

I suspect there are more diseases and conditions affecting newborns and evolving in adult life that may be due to situations that occur in pregnancy. This adds to the hypothesis that the nine months we are in utero are the most important in determining what will happen medically to us during the rest of our lives.

Dr. Giovanni Piedimonte is a pediatric pulmonologist and chairman of Cleveland Clinic Children’s. www.ohioaap.org

From the Lawyer: HIPAA Confidentiality When Texting or Using a Cell Phone Gil Gradisir Most medical professionals use their personal mobile devices in support of their medical practice.

Unfortunately, this creates a considerable risk of protected health information (PHI) being accessed by unauthorized personnel. Most messaging apps have no log-in or logoff requirements and, if a mobile device is lost or stolen, there is a significant risk that messages containing PHI could be compromised.

Whether your texting of patient information violates HIPAA depends on the content of the text message, who receives the message, and the mechanisms established to ensure the integrity of the PHI. First, some background is necessary.

Text messages create and transmit information. Where this information includes electronic protected health information (ePHI) two questions arise.

The first is, does the information being transmitted, in fact, contain PHI? If the answer is yes, then the second question is, does your phone’s ePHI system meet the same privacy and security standards as the full electronic health records (EHR) system maintained on hospital and other provider servers? If the answer to the second question is no, then texting PHI is prohibited. To comply with the technical safeguards of the HIPAA Security Rules, a mobile device must meet the following requirements: • Access to PHI must be limited to authorized users who require the information to do their jobs.

• A system must be implemented to monitor the activity of authorized users who access PHI. • Those with authorization to access PHI must authenticate their identities with a unique, centrallyissued username and PIN. • Policies and procedures must be introduced to prevent PHI from being inappropriately altered or destroyed.

• Data transmitted beyond an organization´s internal firewall should be encrypted to make it unusable if it is intercepted in transit.

Unfortunately, text messaging of ePHI over a commercial network (like Verizon or ATT) rarely meets these requirements. Moreover, commercial text messaging services also offer little protection from the most significant danger to the privacy of texted ePHI: the risk of your text going to an unintended recipient.

The latest rules presume that any unauthorized disclosure is a breach and requires reporting to the HHS Office of Civil Rights (“OCR”) unless there is a documented low probability that the unauthorized transmission resulted www.ohioaap.org

in the compromise of a patient’s privacy. The OCR rules enumerate those factors used to evaluate the probability of compromise, which are: the type and amount of PHI being transmitted; whether the PHI was actually viewed by an unauthorized recipient; the identity of the unintended recipient; whether the recipient provided assurances that the information has been destroyed; and whether the risk to the PHI has been mitigated.

The obvious take-away is to immediately follow up with the unintended recipient and request that the text be deleted and to implement whatever remedies are needed to preclude a similar event reoccurring. Another concern is the potential for loss of a medical record. Let’s say a physician sends an order via text in response to a nurse’s text about a patient’s condition. That brief exchange—the nurse’s message and the doctor’s texted reply—become ePHI which must be made part of the patient’s medical record. Unless a text messaging application integrates with an EMR system and associates the exchange with the correct patient record, all parties are at risk if those two texts do not become part of the EMR. Concerns over text messaging extend beyond HIPAA compliance. The Joint Commission for Physician Accreditation has stated it is not acceptable to text patient orders to hospitals or other health care providers. The Commission highlighted authentication and hospital record recording as primary issues with texting.

Solutions First, determine the extent to which text messaging is used by your partners, nurses and other providers. Next, develop appropriate policies and training to prevent the inappropriate use of text messaging services. Although text messaging services available through your mobile provider are unlikely to meet the privacy or security requirements mandated by HIPAA, commercial options are available that do. They use secure attachments and require the recipient to authenticate with a password before viewing the text.

Commercial services can also provide email services that comply with HIPAA requirements.

Look for platforms that permit you to control the lifespan of a message so that the message automatically deletes from a mobile device within a defined time period. The better texting apps allow users to integrate their EHRs with the secure texting program, permitting users both to attach information and to add information to the EHR. If you decide to use a secure texting platform, keep in mind the three requirements of confidentiality, integrity, and availability.

Gil Gradisir and Jack D’Aurora are legal contributors to Ohio Pediatrics. You may send legal questions for consideration in an upcoming issue to jdaurora@behallaw. com or ggradisar@behallaw.com.

Ohio Pediatrics • Spring 2017

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Thank You, Heather!

April 2017 marks the 10year anniversary of Ohio AAP team member, Heather (Hall) Maciejewski. A familiar name and face to most members, Heather has been a steadfast leader in various Ohio AAP programs in her tenure. Heather’s hallmark accomplishment has been her Quality Improvement work, but she also has lead the following initiatives: • Early Literacy (Reach Out and Read Ohio) • Ohio AAP Foundation • Quality Improvement Manual • Planning, Implementation and Performance (PIP) Committee Heather is quick to recall institutional knowledge and her affectionate nickname “eagle eye” speaks to her proficient editing skills!

On behalf of the Ohio AAP Board of Directors and staff, thank you for 10 years, Heather. We look forward to many more to come!

Coming Soon to the Parenting at Mealtime and Playtime App!

On March 1, 2017, the Parenting at Mealtime and Playtime team held a video shoot that involved 11 families, 20 kids of all ages, and a lot of fun! The videos will used on on the Parenting at Mealtime and Playtime mobile app to demonstrate nutrition and play tips to parents. Download the app now to be the first to see the videos. Search “Parenting at Meal and Playtime” in the Apple store or on

I choose to put my family first.

I CHOOSE BUCKEYE HEALTH PLAN. Buckeye Health Plan offers help with finding a doctor, transportation to appointments and Start Smart for Your Baby® for new moms. I can earn rewards for trying to stay healthy.

I choose Buckeye Health Plan.

1-866-246-4358 BuckeyeHealthPlan.com ©2017 Buckeye Health Plan. All rights reserved.

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Spring 2017 • Ohio Pediatrics

www.ohioaap.org

Sports Shorts

GUIDELINES FOR PEDIATRICIANS

Sports Specialization and Burnout Steven Cuff, MD, FAAP Nationwide Children’s Hospital Over 60 million kids between the ages of 6-18 participate in organized sports in the U.S., a number that continues to increase each year. As athletes and parents try to gain an edge over the competition, many will attempt to specialize in a single sport at an early age. The question is, though, is early sports specialization helpful or harmful?

Sports specialization, which can be defined as intense, year round training in a single sport, with the exclusion of other sports, first gained popularity in Eastern European development programs for young athletes. It’s often thought that early specialization will lead to improved skill acquisition through the accumulation of practice hours, exposure to increased resources and more elite coaching, easier access to travel and club teams and attention from college recruiters and professional scouts. Additionally, this idea had been reinforced through profiles of athletes who have achieved tremendous success at a young age-LeBron James in basketball, Venus and Serena Williams in tennis and countless U.S. Olympians.

For some activities like gymnastics, figure skating, swimming, diving, and dance, early specialization may indeed be beneficial because peak performance in these sports typically occurs in adolescence/early adulthood or before physical development is complete. Muscle bulk is relatively less important and large physical size may be detrimental.

Unfortunately, evidence supporting the benefit of early specialization in most other sports is lacking. First of all, the odds of making it to the next level are infinitesimally small.

Fewer than 10% of high school athletes will play in college and less than 2% will be drafted by professional leagues. The outlook is even more bleak when looking at younger athletes.

Tens of millions of young athletes play football, basketball, soccer, and baseball, but only a few thousand total positions are available in those sports’ professional leagues in this country.

Furthermore, there are many studies showing that early diversification and later specialization (playing many different sports as a child before choosing one sport to focus on later in adolescence) is more likely to lead to success www.ohioaap.org

at the college or professional level. Most college athletes report that their first organized sports participation was in a sport other than the one they played in college. Elite athletes are actually more likely to begin intense training at a later age when compared to near-elite athletes. Early diversification also tends to lead to the development of a wider range of fundamental motor skills, fewer injuries and more enjoyment of and longevity in sport.

Finally, there is evidence that not only is early specialization not beneficial for most sports, but in many cases it can actually be harmful. Early specialization has been linked to delayed growth and maturation, is associated with a higher rate of overuse injury, and can lead to social isolation and burnout.

Burnout refers to a series of psychological, physiologic and hormonal changes that result in decreased sports performance. Potential triggers include a heavy training load without adequate recovery, monotony of training, an excessive number of competitions and the perception that the athlete cannot meet the demands of the sport. It’s more common in athletes who have low self-esteem, are perfectionists, have a need to please others, suffer from anxiety, and have little control over decision making when it comes to their sport.

Symptoms of burnout include: • Poor sleep • Exhaustion • Weight loss • Muscle soreness • Decreased performance • Feeling depressed • Losing enjoyment from playing sports Sometimes kids lose enjoyment in sports they once loved for a variety of reasons. Their interests may change or they may just want to spend more time with friends. But, it’s also possible that they are practicing and playing too much, feeling overwhelmed or feeling pressure from coaches or parents to excel. If you suspect burnout, be sure to bring this up with your patients as they may be reluctant to initiate such a discussion, especially in front of a parent.

This handout is also available for download at OhioAAP.org.

Ohio Pediatrics • Spring 2017

23

Sports Shorts

GUIDELINES FOR PARENTS

Sports Specialization and Burnout Steven Cuff, MD, FAAP Nationwide Children’s Hospital

Over 60 million kids between the ages of 6-18 participate in organized sports in the U.S., a number that continues to increase each year. As athletes and parents try to gain an edge over the competition, many will attempt to specialize in a single sport at an early age. The question is, though, is early sports specialization helpful or harmful?

Sports specialization, defined as intense, year round training in a single sport, with the exclusion of other sports, first gained popularity in Eastern European development programs for young athletes. This theory has likely been reinforced through profiles of athletes who have achieved tremendous success at a young age-LeBron James in basketball, Venus and Serena Williams in tennis and countless U.S. Olympians.

For some activities like gymnastics, figure skating, swimming, diving, and dance, early specialization may indeed be beneficial because peak performance in these sports typically occurs in adolescence/early adulthood or before physical development is complete. Muscle bulk is relatively less important and large physical size may be detrimental.

Unfortunately, there isn’t much to show that early specialization in most other sports is constructive. To start with, the odds of a child making a living playing sports are extremely low. Fewer than 10% of high schoolers will play in college and less than 2% will be drafted by professional leagues. The outlook is even worse for younger athletes. Tens of millions of kids play football, basketball, soccer, and baseball, but only a few thousand total positions are available in those sports’ professional leagues in the U.S. Furthermore, there are many studies showing that playing many different sports as a child before choosing one sport to focus on later in adolescence is more likely to lead to success at the college or professional level. Most college athletes report that their first organized sports participation was in a sport other than the one they played in college. Elite athletes are actually more likely to begin intense training at a later age when compared to near-elite athletes. This early diversification also tends to lead to the development of a wider range of fundamental motor skills, fewer injuries and more enjoyment of and longevity in sport.

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Finally, not only is early specialization not beneficial for most sports, in many cases it can actually be harmful.

Early specialization has been linked to delayed growth and maturation, is associated with a higher rate of overuse injury, and can lead to social isolation and burnout.

Burnout refers to a series of psychological, physiologic and hormonal changes that result in decreased sports performance.

Burnout symptoms include: • Poor sleep • Decreased performance • Exhaustion • Feeling depressed • Weight loss • Losing enjoyment from playing • Muscle soreness sports Risk factors for burnout Training factors: - Heavy training load without adequate rest - Repetitive or boring training - Too many intense competitions - Negative feedback from coaches/parents Characteristics in the athlete: - Feel like they can’t meet the demands of their sport - Low self-esteem - Perfectionists - Need to please others - Anxiety - Little control over decision making in their sport Studies have shown that of the top 10 reasons kids play sports, #1 is to have fun. Winning is way down at #8 on the list. There are no hard and fast rules about sports participation when it comes to how early, how many, and how often, but here are some guidelines to help parents: •

• •

Preschool should be a time for free play and learning motor skills like running, jumping, throwing and catching.

Vision, attention span and the ability to understand competition are not fully developed in these kids so highly competitive sports should be avoided.

As kids get older, a good rule of thumb is that they should not practice more hours per week in sports than their age.

Let kids determine which sports they play and how much.

It’s good to expose them to a bunch of sports early on, but as they get older let them choose what they like and never pressure them into continuing a sport they no longer enjoy. www.ohioaap.org

District V News Richard Tuck, MD, FAAP District V Chair

AAP Speaking Out For Children and You Be First, Be Right, Be Credible!

As each of you know and now experience everyday, the needs and issues of children are threatened in many ways.

Your AAP is aggressively and forcefully responding to these challenges on a real time basis with timely media releases and by building coalitions. Our AAP CEO, Karen Remley, has embedded her mantra to respond to these issues: Be First, Be Right, Be Credible!

The AAP has developed a rapid response communication team coordinated and championed by Mark DelMonte, JD. Our current AAP President, Fernando Stein, MD, FAAP, has led our rapid responses, along with Karen Remley, MD, FAAP. These responses are firmly evidence based and evidence informed, supported by AAP policy. In addition, AAP member expertise is identified and utilized whenever possible. This enables us to stand up and speak for children with credible authority.

Specific recent examples of our AAP response to challenges on a real time basis: After several anti-immigration focused orders were issued in late January, the Academy swiftly took action by issuing a press statement consistent with our mission. Dr. Stein firmly stated: “We urge President Trump and his Administration to ensure that children and families who are fleeing violence and adversity can continue to seek refuge in our country.”

A policy statement was released on 3/13/17: “Detention of Immigrant Children.” This powerful statement clearly defined the issue of detention of immigrant families and children. It also makes specific recommendations that pediatricians can take, as we have the opportunity, to advocate for systems and policies that mitigate trauma and protect the health and well-being of vulnerable immigrant children.

Opposition to immunizations continues to be an area of challenge. The AAP has and will continue to rapidly and forcefully respond when the antivaxers and misinformed provide uninformed views. In February, the AAP joined with 350 medical, professional, and advocacy organizations drafting a letter to President Trump expressing “unequivocal support” for the safety of vaccines. The 28 page letter cited more than 40 studies on vaccine safety and effectiveness.

The letter states “Vaccines have been part of the fabric of our society for decades and are one of the most significant medical innovations of our time… Put simply: Vaccines are 25

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safe. Vaccines are effective.

Vaccines save lives.”

The Department of Justice and Education issued recent guidance that eliminated protections for transgender youth in public schools, no longer allowing them to use restrooms corresponding with their gender identity.

In response, the Academy immediately responded stating strong opposition to the policy, urging children be supported through policies enacted at the state and federal levels. An NBC news article covered the AAP response and pediatrician perspective, outlining the negative mental and physical consequences these policies have on transgender youth.

Reaching out for you was also exemplified on 2/28/17, when chapter leaders from all 50 states traveled to Washington to urge Congress to protect children’s health coverage. During this Friends of Children sponsored fly-in, Bill Cotton, MD, FAAP, from the Ohio Chapter, met with congressional offices following training, facilitated by Academy leaders and legislative staff, focused on advocacy on the pressing issue of children’s health care coverage. Maintaining Medicaid and CHIP coverage at current levels is the highest priority. Health system reform will remain a major focus of our national AAP and Ohio Chapter work for the indeterminate future.

The AAP has joined others speaking out in strong opposition to the ACA Replacement bill. This has brought the family of medicine (AAP, AAFP, ACP, ACOG, AOA) together as never before, uniting over 500,000 physicians, in opposition to the bill! This is critical and timely as we face potential major disruptions in Medicaid for children as we currently know it.

A new opportunity for you to stay abreast with current issues is “AAP Daily Briefing.” This is an exclusive daily news briefing available on the internet. This benefit is available only to AAP members.

Think about what you can do and say at every opportunity as we advance the agenda for children, founded in our Mission and Vision statements. We are firmly committed to the role and mission of the AAP in order to attain optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults.

As you continue your advocacy whenever and wherever you can, look to your AAP to continue to BE FIRST, BE RIGHT, BE CREDIBLE ! www.ohioaap.org

The Importance of Lived Experience Hearing first-hand how sharing real-life perspectives, strategies, and resources can change the lives of autistic people and their families.

To read Kelli’s entire story, visit OhioAAP.org/kellis-story Written by Kelli Yeagley, OCALI Several years have passed since I first discovered that I have an autistic neurology. Like many autistic women, my path did not begin with a diagnosis in childhood, though I always knew that I had what my family and now-husband once called “sensitivities.” Growing up in an under-resourced and underserved community in the late 1980s - 90s, information about autism, disability, and mental health wasn’t widely available. Any challenges that I had ever experienced were generally attributed to being born two-months premature, so we did what many people choose to do — ignore the little things and adapt to others.

As a child, if I had my way, I would have spent my days floating in a swimming pool, surrounded by glittering sea life. My family thought it was because I had developed a keen interest in all things mermaids and marine biology, but it was also because being in the water was the only place I ever felt my body truly relax. It was something I could point to, even though I didn’t have the words to describe what was happening, and say this makes me feel better.

I couldn’t distinguish between what I perceived my voice to be and what everyone else called an “inside voice,” so it became increasingly difficult to participate in conversations without becoming consumed by intense anxiety. Though I had always experienced unexplained stomach pain from a young age, it was when my stomachaches appeared linked to anxiety that my parents became concerned. Doctors who treated me dismissed them as the result of my food preferences, lots of salty and sweet, with very little else (my favorites were chips and ice cream).

I only started to re-examine things after I graduated from high school and began to experience escalating panic attacks.

I kept telling myself that if I only tried a little harder, things would fall into place. After being referred by the counselor to a psychiatrist for what I thought was typical twenty-something anxiety, an assessment eventually lead me to a diagnosis of Bipolar Disorder II and down the long and winding road of medication trial and error. Over several months, I had a series of conversations with my doctor which led to an autism assessment and ultimately a formal diagnosis.

I looked for answers to my mounting questions where I had always been most comfortable — books and the internet. But to my surprise, what I was seeking couldn’t be found in a textbook or research paper. While statistics and figures were 26

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great, what was most helpful for the day-today came from connecting with people with lived experience.

It was lifechanging to find out that my family and I are not alone in our experiences. I now had people who really saw me for who I am. As I continued to learn more about what it meant to better care for myself as an autistic adult, people kindly shared their own experiences so that I might adapt strategies that I found useful and I shared those I found most helpful.

Personally and professionally, I have been fortunate to share parts of my story with others. Currently, I focus much of my work on developing resources, tools, and trainings for autistic people, our families, and those who work alongside us in professional or other supportive roles. As a staff member at OCALI, I contributed to an innovative online learning tool - ASD Strategies in Action. It is a video-based training series about autism spectrum disorder, based on evidence-based strategies with strategies for different stages of life and across settings. It combines research with reallife experiences and features the perspectives of autistic people, our families, as well as those of the educators and professionals who have worked with us along the way.

After years of navigating doctors offices, hospitals, and other medical facilities, I have come to understand the important role that medical professionals play in each of our lives. Our physical, mental, and emotional health and wellbeing are so deeply interconnected. It is my hope that doctors, nurses, and related professionals use ASD Strategies in Action as one of the resources that you refer to families, schools, and neighborhood communities to create a welcoming and informative space around the topic of autism. As a possible training tool for your own practices, it can also support your ongoing efforts to become more inclusive, accessible, and ...continued on page 31 www.ohioaap.org

Which Milk Should My Patients be Drinking?

Emia Oppenheim, PhD, RD, LD The 2015 dietary guidelines promote “fat-free or low-fat dairy, including milk, yogurt, cheese, and/or fortified soy beverages.”

Current Women, Infants, and Children (WIC) program rules allow whole milk only for children till they are two years old.

However, there is increasing data suggesting that for optimal weight, and Vitamin D and Calcium absorption, whole milk should be consumed across the lifespan. The recommendation to reduce milk fat intake largely began in the 70’s and 80’s with the work of Ancel Keys, who recognized that countries with rising heart disease rates had diets high in saturated fat, a type of fat found in milk fat.

We now know that the relationship between heart disease or other chronic diseases and diet is more complicated than one dietary component. Heart disease is also associated with education, income, sedentary activity, stress and physical activity, which are also correlated with dietary patterns. The recommendation to keep dietary milk fat low persists, in part, because of the rise in obesity among all ages and the reduced calories that low-fat products should provide. However, for over a decade research has been refuting these assumptions.

Many compelling studies and meta analyses have explored the association between dietary fat and weight. Many diet recall studies demonstrate that high low-fat dairy intakes at baseline are associated with a higher risk of central obesity, whereas a high intake of dairy fat was associated with a lower risk of central obesity. In a study among thousands of nurses, high fat dairy intake was associated with a lower risk for obesity and diabetes. Studies have also dispelled the association between dairy fat and heart disease, documenting that high levels of dairy fat intake do not increase a person’s risk for CVD, coronary heart disease or strokes.

These associations have been found not only in adults but across many different age groups. A large 2005 prospective study in adolescents demonstrated that among more than 12,000 adolescents, skim and 1% milk consumptions, but not dairy fat, were associated with weight gain. Another study at the University of Virginia, demonstrated that children ages 2-4 drinking skim milk were more likely to become obese or overweight, than those consuming whole milk or whole milk products. Author Dr. Deboer was quoted as saying “Our original hypothesis was that children who drank highfat milk, either whole milk or 2 percent would be heavier because they were consuming more saturated fat calories…

We were really surprised when we looked at the data and it was very www.ohioaap.org

clear that within every ethnicity and every socioeconomic stratum, that it was actually the opposite, that children who drank skim milk and 1 percent were heavier than those who drank 2 percent and whole.”

In addition to positive associations with obesity and overweight risk in children, low fat milk is also associated with lower Vitamin D absorption. Two recent studies indicate that children under 5 consuming whole milk have better Vit D status (with lower volume of milk consumption), which is important for healthy development and sufficient calcium absorption.

What are the possible causes between full fat dairy and lower weight? There are many theories. It is possible that higher dairy fat provides greater satiety, leading to lower caloric intakes and stable weights. It has been suggested that eliminating high fat dairy products, like full-fat aged cheeses or full-fat yogurts, leads to a lower intake of fermented products. Fermented products have been shown to help maintain a healthy insulin response. Reducing these products in the diet may alter insulin metabolism, thereby increasing adiposity risk. Additionally, some have written about bioactive components in full fat milk that help with weight maintenance, these components segregate with milk fat and are eliminated when the fat is removed. Finally, some theorize that when people choose low fat milk products, especially adolescents, they lower their milk consumption overall (because of low-fat milk’s decreased palatability) and increase their sugar sweetened beverage intake, resulting in higher overall caloric intakes. These are biologically plausible ideas, but none have been clearly demonstrated and no causal data has been published for this issue.

How does this all translate into practice? Perhaps it is time to rethink the low-fat recommendation since there is conflicting data, and numerous confounders that make these studies difficult to do, let alone interpret. More rigorous studies are clearly needed, but perhaps until then low-fat milk should be limited to those children already who are overweight or obese, have rising BMI trajectories or a family history of obesity.

References available upon request.

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Breast Milk is Nature’s Perfect Food It Gives Babies the Healthiest Start to Life Did you know 60% of mothers do not reach their own breastfeeding goals?

Mothers’ milk boosts a baby’s immune system, reducing the risk of many illnesses, asthma, ear infections, childhood cancers and sudden infant death syndrome (SIDS).

Breastfeeding also helps reduce infant mortality which is a crisis in our community. In fact, it’s estimated that more than 900 infant lives per year could be saved in the U.S. if 90% of mothers exclusively breastfed for 6 months, or an estimated 32 Ohio infant lives saved per year.

The American Academy of Pediatrics (AAP) recommends that infants are breastfed exclusively for the first 6 months and that breastfeeding continues with the addition of complementary foods for at least 12 months, and as long thereafter as both mother and baby desire.

The Ten Steps to Successful Breastfeeding have many areas where pediatricians play an important role.

1. Have a written breastfeeding policy that is routinely communicated to all healthcare and staff. (If you are on your hospital’s newborn team or task force, you may be asked to participate in creating this policy. The AAP can help you with this.)

2. Train all staff in skills necessary to implement the policy. (If you are on staff at a Baby Friendly Hospital, you will be provided with a minimum of 3 hours training on breastfeeding!)

3. Inform all pregnant women about the benefits and management of breastfeeding. (How many pregnant women visit your office every week?)

4. Help mothers initiate breastfeeding within one hour of birth by placing babies skin-to-skin. (You can talk about this in prenatal visits to prepare all moms for this important event post-partum, even if she chooses not to breastfeed – colostrum is the First Immunization – AAP Poster available!)

5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants. (You can learn how to help mothers breastfeed and how to get pumps if separated, with resources listed below.)

6. Give newborns no food or drink other than breastmilk unless medically indicated. (You can help guide staff to 28

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only give supplementation for medical indications.)

7. Practice rooming-in – that is, allow mothers and infants to remain together 24 hours per day. (You can round in the rooms to do your exam, and teach the parents about what to expect with breastfeeding.)

8. Encourage breastfeeding on demand. (You can help teach parents feeding cues, so they know when it is time to feed again [frequently in the early weeks!], not just watching the clock - as well as when to expect growth spurts) 9. Give no artificial nipples or pacifiers to breastfeeding infants.

(You can reinforce this prenatally and postnatally until breastfeeding is well established.)

10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital. (You can encourage mothers after hospital discharge to get breastfeeding support through WIC, lactation professionals, La Leche League and support groups to help them reach their breastfeeding goals.)

For more information on breastfeeding rates in Ohio, how you can help your new moms, and opportunities for CME and MOC Part II and IV on this topic, go to http://ohioaap. org/breastfeeding.

Contributors: Julie Ware, MD, MPH, IBCLC, Center for Breastfeeding Medicine, Cincinnati Children’s Hospital Medical Center Michelle Allison, MS, RD, LD, CLC, State WIC Breastfeeding Coordinator, Ohio Department of Health Esther S. Gillett, MS, RD, LD, IBCLC, Breastfeeding Coordinator/Peer Supervisor, Franklin County WIC www.ohioaap.org

Burn Care in the Office Setting

Mashayla Colwell, Shriners Hosptials for Children Cincinnati The most frequent burns seen in the office setting are scalds and contact burns. First and second degree burns from coffee and tea spill scalds and scalds from noodles are very common.

Contact burns occur when the child grabs a straight/curling iron, or touches fireplace doors, oven doors, and more.

For all thermal burns, remove affected clothing and cool the area with cool running water for at least two minutes. Avoid applying an ice pack. Ice will cause vasoconstriction, decreasing the blood flow to the wound, potentially worsening the injury.

Referral to a pediatric burn center is ideal for treatment of these second degree burns. However, initial treatment in the office or emergency room setting should be washing the burn with mild soap and water, and applying a dressing with antibiotic ointment. No antibiotic prescription is necessary.

Pain can be treated with acetaminophen. Parents should premedicate the child about 30 minutes before cleaning the burn, and as often as recommended for break through pain.

In the past, using topical silver sulfadiazine was the traditional treatment for minor burns; however research has shown that

Pediatrician’s Guide to the Early Identification of Children at Risk for Dyslexia

Christine Johnson, MA/CCC-SLP/Nationwide Children’s Hospital.

Failure to detect the early signs of dyslexia can be devastating to a child. Children with dyslexia face educational challenges throughout their academic lifetime, including the efficient acquisition of reading, writing and spelling skills. Students who struggle to read and write are in a state of academic and emotional vulnerability. Prevalence rates of dyslexia are as many as one in five children (IDA, 2010) or as few as one in ten (Shaywitz, 1998). Additionally, there are many internalizing disorders and symptoms that often co-occur with dyslexia.

Children with dyslexia carry a significant risk of comorbid psychiatric disorders that appear in early childhood and can persist into adulthood. Research indicates that between 25-40% of people with dyslexia have ADHD and affective disorders including anxiety, depression, low self-esteem, and suicidal ideation (Wilcutt & Pennington, 2000a, 2000b).

ADHD is the psychiatric disorder most frequently associated with dyslexia; ADHD symptoms have been associated with an increased risk of suicidality (Balazs, 2014).

Pediatricians can play a vital role in making proper early referrals by identifying risk factors and characteristics of dyslexia. Pediatricians should use the following suggested screening questions: • Is there a family history of dyslexia or reading, writing, or spelling difficulties? www.ohioaap.org

sulfadiazine slows healing in minor first and second-degree burns, and is not recommended.

If referral to an ABA-verified burn center is not an option, parents should be instructed to wash the burn twice daily with mild soap water, and apply a new clean dressing using antibiotic ointment on the burn. A follow-up appointment should be scheduled in a week to see how the burn is healing.

If the burn is not healing as expected, referral to a pediatric burn center is absolutely critical. Deep second degree or third degree burn requires the special attention and skills available at an ABA-verified burn center.

Once the burn has healed, instruct parents to moisturize the healed area several times a day with lotion to avoid potential discoloration and scarring. When outdoors, a 30 SPF sunscreen should be applied to the healed area frequently for 12 to 18 months following initial injury.

If you have any questions about burn care or need to schedule an appointment for the family, the physicians and nurses at Shriners Hospitals for Children—Cincinnati are always here to answer your questions. Call us at 866-947-7840 24/7, or visit our website at www.shrinershospitalcincinnati.org.

• •

Is there a history of speech/language delay?

Is there a history of ADHD or other affective disorders such as anxiety or depression?

In Pre-School: • Does your child have difficulty learning common nursery rhymes?

• Does your child have difficulties with learning the alphabet or phonics (letter/sound correspondence)?

• Can your child rhyme words? (Give me a word that rhymes with “mop”) • Does your child know the letters in his/her own name?

In Kindergarten: • Does your child have difficulties identifying sounds in words (eg. “What sound do you hear at the beginning of ‘map’?” or “What sound do you hear at the end of ‘dog’?”)

• Can your child put sounds together to create a word? (m-o-p=mop) • Can your child tell what sounds he hears in words? (What sounds do you hear in “bat”?=/b/, /a/, /t/) • Does your child have difficulties with handwriting?

• Does your child have difficulty memorizing?

• Does your child have difficulties pronouncing words? (pacific/specific, renember/remember, pasgetti/ spaghetti) • Does your child avoid reading or complain about how difficult reading is?

• Does your child have difficulty reading simple one syllable (consonant/vowel/consonant [CVC]) words such as (map, hat, big, etc.)

Get much more informaiton at http://ohioaap.org/dyslexia.

Ohio Pediatrics • Spring 2017

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Eaton ... from page 19 “I felt very supported during my candidacy for president of the Academy. I really felt a lot of support, there were many male leaders who were just as eager to have a female president,” said Dr. Eaton.

“She remains an icon in pediatrics and especially for women in pediatrics,” said Gerald Tiberio, MD, FAAP, past president of the Ohio AAP. “Her presence at meetings included great ideas, watchful words, and simple humility. Writing about Toni is an honor and a privilege. Words can’t describe, but know that she is woven into the very fabric of pediatrics.”

Dr. Eaton served on many national AAP, Ohio Chapter and State committees and sections. She was Interim Dean of the School of Public Health at Ohio State University from 1997 to 1999. She also served as interim medical director at Nationwide Children’s Hospital and Chair of the Department of Pediatrics at Ohio State University. She authored and coauthored too many articles to list. Over the years, she also took time out to mentor other physicians, especially women.

“I have been the grateful recipient of mentoring by Toni for my entire career,” said Judy Romano, MD, FAAP, past president of the Ohio AAP. “Here was someone who managed

Abuse ...from page 8 As pediatricians we play an important role in recognizing and identifying possible child abuse and neglect. Early identification of abuse or neglect with subsequent intervention is important to help ensure children’s safety, mitigate toxic stress, and potentially save a life4. By knowing risk factors for abuse in combination with suspicious exam findings, hopefully we can overcome the non-specificity and normalcy of childhood injuries to identify potential victims in our practice.

Sources 1. Sugar, N. F. (1999). Bruises in Infants and Toddlers.

Archives of Pediatrics & Adolescent Medicine, 153(4), 399. doi:10.1001/archpedi.153.4.399 2. National Center for Injury Prevention and Control, Division of Violence Prevention. (2014). Child Maltreatment: Facts at a Glance. Retrieved from https://www.cdc.gov/ violenceprevention/pdf/childmaltreatment-facts-at-aglance.pdf 3. Lindberg, D. M., Beaty, B., Juarez-Colunga, E., Wood, J. N., & Runyan, D. K. (2015). Testing for Abuse in Children With Sentinel Injuries. Pediatrics, 136(5), 831-838. doi:10.1542/ peds.2015-1487

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to be the top pediatrician in the country AND a mother AND a wife. Those credentials were a rare commodity 30 years ago. She became my mentor, my friend and someone I have come to rely on in every stage of my career.”

Dr. Eaton and her husband, Samuel, had four children. It is no surprise to many that three went into medicine and one went into law. But, Dr. Eaton didn’t push her children in that direction.

“Whatever career path they chose, I wanted to be supportive of their choice,” she said. “And certainly, when they decided to choose medicine, my focus was just to support them and not discourage them. That was so important to me. It didn’t matter how many degrees they had but that they should be kind to other people.”

After decades of hard work and little free time, Dr. Eaton is sure of at least a few things she’ll do in retirement.

“I have a lot of boxes of memorabilia – plaques and photos – and will hopefully organize them!” she said. “And of course, I’ll do some reading and maybe some traveling.”

4. Christian, C. W. (2015). The Evaluation of Suspected Child Physical Abuse. Pediatrics, 135(5). doi:10.1542/peds.20150356 5. Letson, M. M., Cooper, J. N., Deans, K. J., Scribano, P. V., Makoroff, K. L., Feldman, K. W., & Berger, R. P. (2016). Prior opportunities to identify abuse in children with abusive head trauma. Child Abuse & Neglect, 60, 36-45. doi:10.1016/j. chiabu.2016.09.001 6. National Center for Injury Prevention and Control, Division of Violence Prevention. (2016). Child Abuse and Neglect: Risk and Protective Factors. Retrieved from https:// www.cdc.gov/violenceprevention/childmaltreatment/ riskprotectivefactors.html

www.ohioaap.org

Ohio AAP Welcomes New Members Haithem Elhadi Babiker Chelsea Bitler MS Sarah Castiglia, DO Eileen Ciccia, MD Emily Cooperstein, MD, FAAP Laura D’Addese, MD, FAAP Nicolas Delacruz Kari Gali, DNP, CPNP Kaitlyn Garcia Karolin Ginting Angela Harris, MD, FAAP

Catherine Hart, MD, FAAP Allison Haupt Laurie Holubeck, MD, FAAP Hyunju Im, MD, FAAP Bilquis Khan, MD, FAAP Reeti Kumar, MD, FAAP Colette Libertin, CPNP Lauren Lindle, MD, FAAP Jason Rodriguez, OMS Ines Cuebas Rolon, MD, FAAP Regina Rosace, MD, FAAP

Lived Experience ... from page 26 effective in your support of autistic and disabled people and our families as you continue your invaluable work.

Author’s Note: A statement on identity-first vs. person-first language: The author chooses to use identity first language as in “autistic person” or “disabled person” vs. “person with autism.” For more on this please visit http:// autisticadvocacy.org/home/about-asan/ identity-first-language/ ASD Strategies in Action are divided into four courses: Many Faces of Autism, Toddler & Preschool Age, School Age, and Transition Age. All of the courses are available at no cost for all Ohioans, and the age-based coursework is available via subscription for those who reside outside of Ohio. ASD Strategies in Action was developed by OCALI (www.ocali. org) in consultation with a blue-ribbon panel of internationally-recognized experts. The project was funded under the leadership of the Ohio Department of Developmental Disabilities in collaboration with the Ohio Department of Education and the Governor’s Office of Health Transformation. For more information, visit www.autismstrategies.org.

www.ohioaap.org

Kaitlin Rubinic Gretchen Schaub Valerie Senko PA-C Hevil Shah, MD, MPH, FAAP Jason Tatka, DO, FAAP Cagri Yildirim Toruner, MD, FAAP Charu Venkatesan, MD, PhD Elisabeth Whipkey Vickie Zurcher, MD, FAAP

TeamHealth is looking for Pediatric/Emergency Medicine Physicians to join our team at Dayton Children’s ED, urgent care, and new Freestanding ED. Perks of this opportunity: • Annual volumes ranging from 80,000 at the main ED and 14,000 at the new Freestanding ED • Physician coverage ranging from 24 hrs/day to 63 hrs/day • Great APC support & dedicated back-up specialties • Resources to be an exceptional clinician with a balanced clinical workload • Employee Practice model • Competitive compensation, benefits, and PLI coverage Qualifications: • Fellowship trained PEM physicians are preferred • EM trained physicians with extensive pediatric experience will be considered Contact:Tiffany Oster, Physician Recruiter, at tiffany_oster@teamhealth.com or (954) 377-3064.

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Ohio Chapter, American Academy of Pediatrics 94 Northwoods Blvd. Ste. A Columbus, Ohio 43235-4721

Calendar of Events April 28, 2017 • Executive/Expert Roundtable Ohio AAP Offices, Columbus May 11, 2017 • Parenting at Mealtime and Playtime Regional Training Columbus June 11, 2017 • Splish, Splash, Stories! Literacy Fundraiser Downtown Columbus July 18, 2017 • Executive Retreat Ohio AAP Offices, Columbus July 28, 2017 • Glow Ball Glow-in-the-Dark Golf Fundraiser Galena October 3, 2017 • Planning, Implementation and Performance (PIP) Committee Meeting Ohio AAP Offices, Columbus October 27-28, 2017 • Annual Meeting Dublin

Dues Disclosure Statement Dues remitted to the Ohio Chapter are not deductible as a charitable contribution, but may be deducted as an ordinary and necessary business expense. However, $40 of the dues is not deductible as a business expense because of the Chapter’s lobbying activity. Please consult your tax advisor for specific information.

This statement is in reference to fellows, associate fellows and subspecialty fellows. No portion of candidate fellows nor post-residency fellows dues is used for lobbying.