Focus on Pediatrics Spring 2016

New Therapy for Those with Feeding Disorders Children’s Hospital Year-end Review CME: Anxiety and Mental Health

Vol. 28.1 Spring 2016

on Pediatrics

Faculty Fellows Boost Research

International Adoption Clinic: A Valuable Resource

Focus on Pediatrics is published quarterly

by Children’s Hospital of Greenville Health System.

Medical Editor Joseph L. Maurer, MD Managing Editor Lark Reynolds

FROM THE MEDICAL DIRECTOR

GHS Photographer AV Services Art Director GHS Creative Services Editorial Board Linda Baumbach, CAP Nichole Bryant, MD Sally Cade Kristi Coker, MSN, MHA, RN Jeanine Halva-Neubauer Jennifer Hudson, MD Emily Hughes Crissy Maynard, FAHP, CFRE Eric Nash Terri Negron, MN, RN Janine Sally, MS, CCC-SLP Robert Saul, MD Kerry Sease, MD, MPH If you would like your name added to or removed from our mailing list or have any comments, questions or suggestions, please send the appropriate information to: Marketing Services Greenville Health System 300 E. McBee Ave. Suite 200 Greenville, SC 29601 (864) 797-7544 The information contained in the Focus is for educational purposes only—it should not take the place of medical advice or diagnoses made by healthcare professionals.

All facilities and grounds of Greenville Health System are tobacco free.

“Greenville Health System” and GHS symbol design are trademarks of Greenville Health System. © 2016 Greenville Health System 16-0315

What Consumers Want from Health Care Now I recently saw survey results from a firm specializing in healthcare issues. Surveys from thousands of participants sought to determine what consumers want from health care. The results might surprise you!

Just a few years ago, I spoke with pediatricians who were sure their patient families would not visit in-store clinics staffed only by advanced practitioners. Data now show that 56% of consumers might go to retail clinics, and 42% would use email visits rather than drive to their medical home. Access and convenience rank far ahead of provider continuity and even more ahead of preferring treatment by a doctor instead of an advanced practitioner. Experience with our own MD360® urgent care clinics shows that many families will pay more to be seen sooner and drive past their medical home to do so.

Clearly, key determinants for those seeking medical care are changing. At GHS Children’s Hospital, we are changing, too, adding services that improve access.

four middle schools in underserved areas.

A pediatric nurse practitioner rotates through the schools, working with the school nurse.

When a student may need medical attention from a doctor, a telemedicine session is arranged with Dr. Sease without taking the child out of school.

Yet another, led by Drs. Carley Howard, Jeff Faust and George Haddad, allows access through the Internet for minor medical events. GHS SmartExam lets existing Children’s Hospital families obtain “asynchronous” assessments through a guided online interview. Parents complete medical history questions that are sent to one of our pediatricians or nurse practitioners for quick review and response, also by way of the Internet. Safeguards are in place to urge parents to contact their physician office directly if the problem exceeds the scope of this service.

Stay tuned to learn more about these offerings in upcoming issues of Focus on Pediatrics!

One, being tested by Pediatric Associates– Easley, places a psychologist in the office, along with a telemedicine unit connected with a child psychiatrist. Our aim is to increase access to behavioral health services.

Another, led by Kerry Sease, MD, MPH, puts telemedicine units directly into nurse offices at

William F. Schmidt III, MD, PhD

CONTENTS

Clinic Provides Direction for Adopting Families 2 The International Adoption Clinic at GHS Children’s Hospital provides comprehensive assessments for recently adopted children.

CME: Anxiety and Mental Health 10 Pediatricians can help identify anxiety disorders in children and teens in their early stages.

VitalStim Therapy

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VitalStim therapy helps young children with feeding disorders achieve a safe swallow more quickly.

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Ask the Faculty 22 How can busy pediatricians best incorporate child advocacy in their practice?

Departments What’s New 5 Gift for Complex Pediatric Care, New Helmet-fitting Program, Telehealth in the Delivery Room

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Year-end Snapshot 6 A Look at Children’s Hospital’s Numbers for FY 2015

Medical Staff Spotlight 7 Meet Our New Physicians

Clinical Research 8 Antibiotics in the NICU, Current EoE Research

Academic News 9 Clemson, Children’s Hospital Partner Through Faculty Fellows

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Quality Counts 15 Maximizing Safety for Patients in Your Practice

Celebrations 16 Accreditation and Philanthropic News

Case Study 18 Agenesis of Corpus Callosum

20 On the cover: Pam Jackson and her husband, Jonathan, found Children’s Hospital’s International Adoption Clinic to be a valuable resource when they first adopted their daughter Claire (right) from Russia in 2009, and again when they adopted Siri (left) and Narada (center) from Thailand in 2013 and 2015, respectively.

Cover and lead story photography by George Reynolds

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

LEAD STORY The International Adoption Clinic at Children’s Hospital of Greenville Health System (GHS) helps parents address the medical needs of their newly adopted children.

When Parents Opt to Adopt

When Jonathan and Pam Jackson adopted a baby girl from Russia in 2009, Pam thought it wouldn’t be much different from having a child of her own. They already had four biological children, so she was well-versed in parenting. But when she took her new daughter to the pediatrician’s office for the first time, she began to rethink that idea.

Top: Sue Jue, MD, sits with (from left) Siri, Narada and Claire Jackson.

Dr. Jue and her colleagues in Pediatric Infectious Disease helped Pam and Jonathan Jackson sort through the medical histories they received when they adopted each of the girls. Above: At a post-adoption visit, Dr. Jue performs a full physical examination and conducts blood work to check for protective antibodies.

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“Adopting a child from another country is completely different from having your own child, because there are so many things you don’t know,” Jackson remarked. “You show up at the pediatrician with this child who has this long, involved history, and the doctor’s trying to figure all of this out in a short time.”

A special program at GHS Children’s Hospital offers a solution for piecing together the complex puzzle of an internationally adopted child’s medical needs. The International Adoption Clinic, part of Children’s Hospital’s Division of Pediatric

Infectious Disease, offers pre-adoption consultation along with post-adoption assessment.

Sue Jue, MD, along with division colleague Robin LaCroix, MD, and medical director Joshua Brownlee, MD said their first contact with adopting parents often takes place before the child has even arrived in the U.S. “One of the things that parents are concerned about when they adopt a child is, is the child healthy?” Dr. Jue said. “In the preadoption consultation visit, we usually review the medical record that they receive from the child’s home country and can let parents know if there are any red flags or issues that might need to be addressed fairly quickly.”

Dr. Jue said they also can offer parents advice on immunizations they might need to get before traveling to pick up their child.

This pre-adoption consultation often helps address parent concerns and reassure them—or sometimes helps parents with the decision on whether to pursue the adoption.

First Stop on Arrival When the parents return to the U.S. with their child, the clinic’s physicians try to see the child within the first two weeks. At this visit, the physician will review the child’s immunization record as provided by the home country. Records and documents for some countries are more thorough and reliable than those from other countries, Dr. Jue noted.

to her pediatrician’s office, where Claire tested positive for tuberculosis. Like any parent, Jackson panicked. But Dr. LaCroix offered some insight.

“Apparently, the vaccine for tuberculosis used in Russia leaves a mark on the skin,” Jackson said. “So when Dr. LaCroix did her physical assessment of Claire, she saw that and said the reason her TB test returned positive was probably because she had received that immunization.”

After a chest X-ray confirmed that Claire did not have tuberculosis, Jackson’s fears were calmed.

“She kind of talked me off the cliff, because I was really stressed about it,” Jackson recalled.

After Jackson’s initial, almost accidental, visit to the clinic, she made sure it was her first stop the next time she adopted—this time from Thailand in 2013—and again when she adopted a second girl from Thailand in 2015. Both girls appeared to be underweight on U.S. growth charts. But at the adoption clinic, they did some digging into the numbers.

Jackson said, “They put in the time to get the Thailand growth charts, and then they brought them to me and showed me, and said, ‘This is actually OK, you don’t need to worry that they’re so small. They’re actually normal for that country, ’ ”

“If the child is an infant, a lot of times we’ll just start over with immunizations,” Dr. Jue said. “If they’re older, I’ll do blood work or antibody titers to see if they have a protective antibody based on the vaccines their records indicate they were given. Then I develop a catch-up immunization schedule for the children going forward.”

At this same visit, Dr. Jue screens the child for acquired congenital conditions such as HIV, syphilis, hepatitis B and tuberculosis, along with other conditions such as lead poisoning and parasitic infections such as giardia. Sometimes, medical records may indicate that the child already has been tested for some of these conditions, but Dr. Jue always repeats them.

“As a parent, I would want to be sure,” Dr. Jue emphasized.

Knowledge from Experience

Pam and Jonathan Jackson with their three adopted daughters, Claire, Narada and Siri (front, left to right) and two of their biological children, Keagan (far left, with friend Halee Bryant) and Jakob (far right).

Dr. Jue can certainly relate—she adopted a daughter from China nearly a decade ago, and she did all of those things for her own daughter.

All of the clinic’s doctors possess the extensive knowledge base to address parent concerns and dig into the appropriate research to find answers.

When Jackson visited after bringing her daughter Claire home from Russia, it was because she already had been

The International Adoption Clinic offers a solution for piecing together the complex puzzle of an internationally adopted child’s medical needs.

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Dr. Jue said they also can help the parent connect to other services or specialties if needed—for instance, if the child shows developmental delays or has a birth defect such as cleft palate.

Tracey Butcher, MD, a pediatrician with GHS’ Carolina Pediatrics of Greenville, said the clinic also is a valuable resource for physicians.

Once the post-adoption visit is complete, Dr. Jue said they often will see the family one more time to go over blood work and test results. Then, armed with a customized vaccination schedule, the family returns to their chosen pediatrician.

“The needs of internationally adopted children are so much greater than those of a typical pediatric patient,” Dr. Butcher pointed out. “Each case is complex and unique, and depends on a number of factors, from the home country to the age and any present medical conditions. That amount of complexity and the time involved to gather that information are overwhelming for a general pediatrician.”

Jackson was thrilled to have discovered such a valuable resource in the International Adoption Clinic.

“If you’re going to adopt internationally, that is the first place you should go,” she stated. “They really put a lot of time into that clinic. I believe it’s their passion. I know that they’re spending far more time than they can bill for, because they care so much about these kids.”

The clinic sees internationally adopted children of any age— although Dr. Jue said most tend to be toddlers—from any country. Currently, the majority of the children come from China, Thailand, Russia, Ethiopia and Ghana.

To schedule an appointment for an international adoption evaluation, call (864) 454-5130.

Additional Services for Fostering and Adopting Families Other divisions within Children’s Hospital also offer services that are especially helpful to families who have adopted children or who provide foster homes. At the Center for Pediatric Sleep Disorders, Ford Shippey III, MD, MS, estimated that 5 percent of their patients have been adopted or in foster care.

“Children who have been in an institutionalized environment for many months or even years certainly can develop chronic sleep problems like insomnia, and they have many underlying mood and behavior issues that can affect sleep quality as well,” Dr. Shippey said. “While a child’s sleep issues may seem trivial on the surface, they can lead to significant household disruptions.”

Sometimes, adopted children may not have been screened for obstructive sleep apnea, a common condition that can cause behavior and attention issues. Dr. Shippey said oftentimes the treatment these children receive for their underlying sleep conditions at the center can have a significant impact on their daytime behavior, energy and ability to focus.

The center also can help wean foster children from unnecessary sleep medications in cases where they have been prescribed multiple medications.

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Children’s Hospital’s Child Advocacy Medical Program (CHAMP) performs assessments on every child removed from a home in Greenville County who is placed in a foster home.

These physicians examine the causes for the child’s removal and attempt to identify medical, developmental or mental health services the child may need.

“We try to make sure the child’s needs are identified at the very earliest point of his or her entry into the foster care system,” said Nancy Henderson, MD, the program’s medical director.

This equips the foster family to better understand the child and provide a stable environment until the child either returns home or is adopted. Dr. Henderson said CHAMP also holds a few lectures each year for foster parents to help them understand the complexities of a child who has been exposed to trauma.

WHAT’S NEW? Children’s Hospital of Greenville Health System (GHS) launches a neonatal telehealth program in Laurens and Pickens Counties, bicycle helmet-fitting program in northern Greenville County and announces a new center for children with complex health conditions.

Ferlauto Center for Complex Pediatric Care A $1 million gift from longtime GHS neonatal physician Jerry Ferlauto, MD, and wife Natalina will endow and grow an innovative program to help families cope with the complex needs of chronically ill children. The Ferlauto Center for Complex Pediatric Care will provide primary medical care, but will particularly emphasize care coordination, social services and nutrition services through a team-oriented, family-centered approach.

Technology advancement has allowed more and more children with complicated diagnoses to survive their condition and even be cared for at home instead of in the hospital. However, providing that care requires intensive support and close medical management to help ensure these children stay well.

The goal at the Ferlauto center is for the patient and family to see the same doctor every visit, so they don’t have to retell their story. The pediatrician will partner with a team of care coordinators, nurses, dietitians and social workers to ensure children receive the medical care and support needed to thrive.

Staff members also will assist families in coordinating visits with multiple specialists, when possible, in a single location.

Kent Jones, MD, who previously headed the Pediatric TEAM Center at Baptist Easley Hospital, of which GHS is half owner, serves as the center’s medical director. The center is located above the Center for Pediatric Medicine in Cross Creek Medical Park, and provides patients with convenient access to translators, social workers, nutritionists and psychologists. The center’s phone number is (864) 220-7270.

Camp Buddy for Diabetes GHS Children’s Hospital will launch a new day camp for children with type 1 diabetes in August. Camp Buddy will take place at the Kroc Center in Greenville from August 8-10 and will include activities such as swimming, rock climbing, sports, and arts and crafts. The camp is open to children ages 6 to 12 and runs from 9 a.m.-3 p.m. For more information, call (864) 454-1109.

Delivery Buddy Debuts Soon-to-be moms in Laurens and Pickens Counties now can enjoy the peace of mind offered by GHS Children’s Hospital’s telehealth program for newborns called Delivery Buddy. In the unlikely event that a baby experiences complications during or just after delivery, a neonatologist or neonatal nurse practitioner from GHS can log in to Delivery Buddy immediately through the system’s secure network.

The specialist will complete an assessment of the baby with the help of Delivery Buddy and on-site nurses and doctors. This program lets the specialist take part in the baby’s care right away by making recommendations as if at the bedside. Medical teams on each side of the screen can hear and see the newborn and interact with the family.

This telehealth program is the first of its kind in the Southeast for neonatal patients. It is offered at Laurens County Memorial Hospital and Baptist Easley, of which GHS is half owner.

Program Offers Bike Helmets A new helmet-fitting and educational intervention program with Safe Kids Upstate™, led by GHS Children’s Hospital, was launched at North Greenville Outpatient Center–Pediatrics in early 2016. Through the program, a properly fitting bicycle helmet will be provided to children who present to the clinic with an unintentional injury related to use of a wheeled instrument (e.g., bicycle, scooter, skateboard).

Residents and attending physicians will provide educational information to parents and caregivers on the importance of modeling safe behaviors and wearing helmets themselves when they ride. Program plans also include a follow-up study about the usage of the provided helmets and possible changes in risky behaviors following the intervention, with family consent. for more information, call (864) 455-9264.

Grief Support Group A new support group at Children’s Hospital offers fellowship for parents and caregivers of children who have died. The Parent Grief Support Group meets at Patewood Center (255 Enterprise Blvd.), Conference Room A/B. The group meets the second Wednesday monthly from 6:30 to 8 p.m. For more information, call (864) 436-3350 or (864) 455-5201.

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YEAR-END SNAPSHOT

GHS Children’s Hospital Snapshot:

Fiscal Year 2015 Total Philanthropic Revenue: $6,131,535

(Pediatric Therapies) • Saw 30 children in Laryngoscopic Clinic with Greenville ENT

$620,626

$2,258,527

Kidnetics® Collaborations

• Saw 92 children in Muscular Dystrophy Clinic with Pediatric Neurology $3,252,382

• Saw 120 children in the Pectus Program with Pediatric Surgery • Performed more than 300 Modified Barium Swallow Studies with GHS Radiology

Other Children’s Hospital Highlights Total Inpatient Days: 36,076 21,779: Bryan Neonatal Intensive Care Unit 3,868: Pediatrics–Infant/Child 3,819: Pediatrics–School Age/Adolescent 2,567: Pediatric Intensive Care Unit 2,465: Pediatric Hematology/Oncology 1,549: Pediatric Surgery 29: Children’s Emergency Center

Patient Visits and Discharges 4,432: Children’s Hospital Discharges 28,120: Emergency Room Visits 163,545: Pediatrics Specialty Visits 204,437: Pediatrics Primary Care Visits at GHSowned Practices

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• Safe Kids™ Upstate fitted more than 3,500 bicycle helmets in Greenville, Pickens and Oconee counties • Safe Kids Upstate trained 60 new Child Passenger Safety (CPS) technicians and two new CPS Instructors, and the coalition established two new permanent Car Seat Safety Inspection Stations in Greenville County • Help Me Grow provided 487 children between birth and age 5 with a free developmental screening • Pediatric Residency Program graduates posted a 100 percent pass rate on the board exam, for the fifth year in a row • Children’s Hospital faculty authored 54 peer-reviewed articles and book chapters

MEDICAL STAFF SPOTLIGHT Children’s Hospital of Greenville Health System (GHS) welcomes one new physician and announces three new medical directors.

Meet Our New Physicians General Pediatrics Sarah B. G. Hinton, MD, earned her medical degree from the University of South Carolina School of Medicine in Columbia. She completed her residency training in internal medicine-pediatrics at GHS, where she served as chief resident in 2013-14. Dr. Hinton is working at the Center for Pediatric Medicine. She can be reached at (864) 220-7270.

New Community Pediatricians We welcome the addition of three pediatricians to GHS-owned practices.

Dr. Bragg

Dr. Hefty

New Medical Directors R. Austin Raunikar, MD, was named senior medical director for Subspecialty Pediatrics, and Carley Howard, MD, was named senior medical director for Primary Care Pediatrics in November 2015.

Dr. Raunikar has served as a physician with the Division of Pediatric Cardiology since 1994. He recently served as chief of the GHS Medical Staff.

Dr. Howard completed her pediatrics residency at Children’s Hospital in 2008.

She started the GHS Pediatric Inpatient/ Nursery service and helped coordinate a pediatric urgent care clinic at AnMed Health’s Women’s and Children’s Hospital in Anderson, S.C. Dr. Howard also helped develop the new Delivery Buddy telehealth solution for neonatal resuscitation and PICU transfers (see p. 5).

Dr. Raunikar

Dr. Howard

Dr. Thomas

K. Leigh Bragg, MD, has joined Pediatric Associates–Easley.

She can be reached at (864) 855-0001.

Cary A. Hefty, MD, has joined GHS Pediatrics & Internal Medicine–Wade Hampton. She is trained in MedicinePediatrics. She can be reached at (864) 522-5000.

Jenny Thomas, MD, has joined Pediatric Associates– Spartanburg. She can be reached at (864) 582-8135.

Psychologist Joins Supportive Care Team Julie S. Jones, PsyD, has joined Children’s Hospital’s Supportive Care Team. Dr. Jones earned a master’s degree in clinical psychology from Eastern Kentucky University in Richmond. She completed a psychology residency at Cincinnati Children’s Hospital Medical Center. Dr. Jones earned her Doctor of Psychology from the Georgia School of Professional Psychology at Argosy University in Atlanta, where she majored in child psychology.

She can be reached at (864) 455-5129.

Joshua Brownlee, MD, assumed the role of medical director for the Division of Pediatric Infectious Disease. Dr. Brownlee has been part of this division since 2012 and has served as medical student (M3) clerkship director.

Dr. Brownlee

Dr. Kolarik Appointed As Reviewer Russ Kolarik, MD, director of GHS’ Medicine-Pediatrics Residency Program, has been selected to be a reviewer for the Journal of Graduate Medical Education. The peer-reviewed journal works to inform and engage the graduate medical education community to improve the quality of graduate medical education.

Dr. Kolarik has been actively involved with the Association for Program Directors in Internal Medicine. He served as president of the Med-Peds Program Directors Association in 2013-14.

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Dr. Saul Named Chair of Institutional Review Board Robert Saul, MD, was named Chairperson of GHS’ Institutional Review Board (Children’s Studies) in late 2015. He follows Bryce Nelson, MD, PhD, who had served in that capacity since 2011.

IRB-B reviews and approves any research studies involving children excluding Cancer Oncology Group studies, which are reviewed by the National Institutes of Health. Research is critical to advancing health care for children, yet appropriate safeguards must be followed to assure protection for this vulnerable population. Dr. Saul brings a long-standing career in pediatrics and genetics to his role on this important committee.

Girlology Co-founder Joins GHS Melisa Holmes, MD, co-founder of the nationally known, medical-based sexuality program for adolescent girls called Girlology, has joined GHS. Dr. Holmes helped develop the Girlology program while living in Charleston 12 years ago, with the goal of helping mothers and daughters start conversations about sensitive subjects that often need to be addressed during adolescence.

Dr. Holmes can be reached at Pediatric & Adolescent Gynecology, (864) 455-1600.

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

Antibiotic Use The Bryan Neonatal Intensive Care Unit (NICU) is taking part in the Vermont Oxford Network’s (VON) iNICQ 2016 collaborative, Choosing Antibiotics Wisely. The collaborative aims to improve patient safety and develop processes to optimize antibiotic use as a way to combat antibiotic resistance.

Across the country, overuse of antibiotics in the NICU and variations in prescribing practices have contributed to a growing danger of drug-resistant bacteria. As a result, the Centers for Disease Control and Prevention (CDC) designed hospital-based antibiotic stewardship programs to promote appropriate use of antibiotics. The CDC partnered with VON to develop iNICQ 2016.

The collaborative will focus on key components of antibiotic stewardship programs within the NICU. Center-level improvement teams will work to integrate evidence-based best practices and standardized protocols to reduce the overuse of antibiotics. Participating centers will have access to shared baseline data and key neonatology experts from Choosing Wisely in Neonatology, an initiative of the American Board of Internal Medicine Foundation.

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EoE Research The Division of Pediatric Gastroenterology has a number of ongoing studies related to eosinophilic esophagitis (EoE): • A prospective study examining the effects of secondhand cigarette smoke exposure on EoE symptoms and outcomes • A review of the long-term safety and efficacy of reslizumab in children and adolescents with EoE, which comprises 477 doses administered to 12 children over the course of seven years • An evaluation of treatment outcomes in pediatric EoE patients transitioning to adulthood • A multi-center growth trajectory study in pediatric patients with EoE • A study of the coexistence of inflammatory bowel disease among pediatric and adolescent patients with EoE For more information about these studies, call (864) 454-5125.

ACADEMIC NEWS Greenville Health System (GHS) and Clemson University (CU) have partnered to advance medical research.

Faculty Fellows Provide Boost for Pediatric Research As part of its research relationship with Clemson University, GHS partners with members of the CU faculty who serve as Faculty Fellows. These fellows shift their focus from their regular teaching duties at CU to develop and conduct research projects in their embedded departments at GHS. One of the first of these Faculty Fellows was Joel Williams, PhD, MPH, ATC, an associate professor in CU’s Department of Public Health Sciences, who is working with Bryce Nelson, MD, PhD, and Jonathan Markowitz, MD, MSCE, in the divisions of Pediatric Endocrinology and Pediatric Gastroenterology, respectively.

Dr. Williams is investigating how mobile technology can help patients manage medical conditions. He is studying how to best track pediatric diabetes and eosinophilic esophagitis (EoE) symptoms and flare-ups using mobile apps. While such apps already exist for pediatric diabetes, few are available for tracking EoE. For both conditions, monitoring symptoms and triggers in real time will provide critical information for immediate management and for guiding clinical decisions at follow-up.

“Faculty Fellows are producing research to improve the health of the community with their clinical partners,” said Windsor Sherrill, PhD, chief science officer at GHS. “Their research also will contribute to the rapidly expanding joint Clemson University and GHS collaborative research agenda.”

Recently, the Department of Pediatrics welcomed a second Faculty Fellow, Sarah Griffin, PhD. Dr. Griffin, who also works in CU’s Department of Public Health Sciences, will examine the effectiveness and costs of obesity prevention efforts associated with three initiatives at GHS Children’s Hospital—the Greenville Dr. Griffin Memorial Childcare Center, New Impact childhood weight-management program and GHS health clinics at four area middle schools.

Joel Williams, PhD, MPH, ATC (second from right), Faculty Fellow, discusses with Jonathan Markowitz, MD, MSCE, (right) and his team, the potential of using mobile technology to track symptoms in patients with eosinophilic esophagitis (EoE).

Dr. Griffin brings expertise in behavioral science, intervention design and delivery, and program evaluation. She plans to focus on novel ways to prevent and treat obesity through the influence of social and behavioral factors.

“With ever-increasing childhood obesity rates, it is vital that researchers develop evidence-based prevention practices and provide scholarship on the effectiveness of these practices,” Dr. Griffin said. “Healthy interventions that change weight-related behavior and prevent or treat obesity benefit everyone— children, their families, healthcare systems and the community as a whole.”

Graduates Score 100 Percent For the fifth consecutive year, 100 percent of GHS Children’s Hospital’s Pediatric Residency Program graduates passed the general pediatric certifying examination.

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CONTINUING MEDICAL EDUCATION

Addressing Anxiety and Mental Health in the Pediatric Population CME Credit Information To receive possible continuing medical education (CME) credit for this article, please complete the online Q&A that can be accessed on page 14.

Both physicians and nurses are eligible to test for the credit.

It is the policy of the GHS Continuing Medical Education Committee to ensure balance, independence, objectivity and scientific rigor in all its individually sponsored or jointly sponsored education activities. Article author Ben Jones, PsyD, has disclosed that he has no significant financial interest or relationship with any company that may be considered an actual or potential conflict of interest with this educational activity. The planning committee have listed no duality of interest with regard to potential relevant financial relationships for the FOCUS enduring activity.

The CME committee have listed no duality of interest with regard to potential relevant financial relationships for the FOCUS enduring activity with the exception of Sandra Weber, MD (Committee Chair), Grand Research Support–Eli-Lilly, NIH, and Pfizer and William A. Coleman, MD (OB/GYN), Consultant–Merck.

The Greenville Health System (GHS) designates this enduring activity for a maximum of 0.50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

The Greenville Health System is accredited by the South Carolina Medical Association to provide continuing medical education for physicians.

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Anxiety is a common, and often adaptive, part of childhood. As a function of normal development, children experience fear and anxiety in response to real or perceived threats. These fears typically reflect the child’s developmental phase.

Infants fear loss of physical support and unpredictable and sudden stimuli, while toddlers exhibit anxiety in response to strangers, separation from caregivers and loud noises. Young school-age children are fearful of darkness, monsters, animals and natural phenomena such as thunder.

As children grow older, anxieties shift to foci such as school performance, medical procedures, health, family discord and punishment. In adolescence, anxiety frequently is associated with social interaction and personal adequacy. For most children and adolescents, these commonly occurring anxieties do not markedly impede function or emotional well-being, and they require no intervention.

Other children, however, may manifest symptomatology suggestive of an anxiety disorder. Anxiety disorders have the

potential to affect family functioning, academic performance, self-esteem and peer relationships. Moreover, anxiety disorders often persist into adolescence and adulthood, where they are correlated with higher rates of depression, substance abuse and suicide.1 Because of the debilitating and potentially long-term consequences of anxiety disorders, it is imperative to identify and appropriately treat patients as early as possible.

Unfortunately, many children with anxiety disorders do not receive adequate assessment and treatment, possibly as a result of the internalizing nature of these disorders.

Prevalence Anxiety disorders are among the most frequently diagnosed and early emerging mental health disorders of childhood and adolescence. Because of differences among studied age groups, diagnostic systems and assessment instruments employed, there is notable variance in prevalence estimates across epidemiologic studies. However, prevalence rates for anxiety disorders in the youth population generally range between 15% and 20%, with most cases emerging before 12 years of age.2 The most commonly diagnosed disorders among children include separation anxiety disorder, specific phobias (e.g., animal type, blood-injection-injury type, situational type) and social phobia, with generalized anxiety disorder, panic disorder, agoraphobia and other anxiety disorders diagnosed less frequently.

Because somatic symptoms are so prevalent across anxiety disorders, the first professional sought out by the parents of a child with anxiety often is the pediatrician or primary care physician. Children may present with recurrent headaches or abdominal pain that parents, understandably, attribute to a medical issue and seek treatment for. It has been estimated that in pediatric primary care settings, at least 17% of patients meet criteria for one or more anxiety disorder diagnoses.1 Additionally, physicians in pediatric specialty practices treating children and adolescents with significant chronic illnesses (e.g., cancer, epilepsy, cystic fibrosis, spina bifida) may encounter numerous patients with anxiety disorders, with some estimates indicating prevalence rates of 25-67%. 3,4 Whether increased healthcare use results from symptoms of anxiety or a chronic medical condition, physicians and other healthcare providers are in a key position to identify children potentially in need of treatment for anxiety.

Assessment of Anxiety When complaints such as chronic nausea or headache do not have an apparent physiologic etiology (e.g., atrial tachycardia, hyperthyroidism, asthma) and anxiety is suspected, the physician should screen for other symptoms and assess severity and duration. Symptoms associated with anxiety can be diverse, but fall into three general categories: motoric, physiologic and subjective responses.

Motor symptoms can include trembling, stuttering, tics and postural rigidity. Tachycardia, increased perspiration, respiratory changes, nausea and vomiting often comprise the physiologic response, while the psychologic distress associated with the subjective response may be characterized by thoughts or images of incompetence, monsters, failure, abandonment, injury or death.

The differentiation between normal and pathologic anxiety can be particularly difficult with youth because, as noted, fears and anxieties are ubiquitous among children and adolescents.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) establishes diagnostic criteria for each of the anxiety disorders to assist in determining whether the symptoms reach the threshold of a disorder or are subclinical.

The criteria specify what symptoms must be present, minimum symptom count and duration of symptoms. The criteria also specify that some symptoms or responses must be excessive or intense in their severity and that the anxious responses are disproportionate to the stressor (a determination made by the clinician). Because symptoms of anxiety may present differently in children versus adults, the DSM qualifies some features of the core criteria, or modifies duration or symptom count necessary to meet the threshold for diagnosis.

A significant challenge to the diagnostic process is the fact that children, particularly at the younger ages, often lack the language and cognitive capabilities necessary for describing physiologic responses and articulating their thoughts and emotions. Therefore it is helpful to gather information from multiple sources (child, caregiver and teacher) and use multimodal assessment. Many diagnostic questionnaires and structured interviews are based on DSM criteria that, when taken together with the results of a clinical interview and observations, are useful in determining if the child’s symptoms are clinically significant.

Because of the debilitating and potentially long-term consequences of anxiety disorders, it is imperative to identify and appropriately treat patients as early as possible.

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rotate around the child’s anxiety, but considerable stress and discord among family members also can result, particularly if caregivers disagree about how to respond to the child’s symptoms. In general, impaired functioning in one or more domains and persistent avoidance of a feared stimulus are strong indicators of an anxiety disorder.

While somatic symptoms and impaired functioning may be the most outward manifestations of anxiety, anxiety-provoking thinking is one of the hallmarks of anxiety disorders. Such thinking is referred to as negative, distorted or irrational thinking, with the central tenet being that these thoughts are maladaptive and generate anxiety.

An exploration of the patient’s thought processes can help discriminate between subclinical anxiety and an anxiety disorder. Some thinking patterns characteristic of anxiety disorders include all-or-nothing thinking, catastrophizing, unreasonably negative self-labeling, and dismissing positive attributes and accomplishments. Children also may engage in “mind reading” and have a pessimistic outlook regarding future events and their ability to make changes to how they interact with the world around them.

Another important determinant is the degree to which anxiety impairs functioning. Most children (and adults) prefer to avoid situations that evoke anxiety, but are usually able to place themselves in the situation and function with minimal anxietyrelated impairment. In contrast, children and adolescents with anxiety disorders will avoid stressors whenever possible despite the consequences or else endure them with intense anxiety.

School is a domain where children often experience anxiety, either as a result of performance-related concerns or in response to the social milieu. While these issues concern nearly all children to varying degrees, some experience such intense anxiety that they miss substantial amounts of school because of avoidance and suffer falling grades. Likewise, anxiety in social situations may result in children avoiding interaction, crying or refusing to speak when called on in class, and avoiding school or other activities entirely.

Functioning across domains can be affected by phobic avoidance of the feared stimulus. For example, phobias associated with storms or insects may prohibit the child from leaving the indoors, thus interfering with socialization, play, travel and other activities. Family functioning also can be negatively affected by a child’s anxiety. It is not uncommon to see families change their routines and lifestyle to minimize the child’s symptoms, which can have the unintended consequence of enabling further avoidance. Not only can family life come to

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As noted, younger children often are unable to describe their thinking patterns, complicating the assessment process. Schoolage children and adolescents are better equipped to identify and verbalize their thinking, though they may struggle to do so retrospectively. Another challenge to an examination of the child’s thinking is that young patients do not always recognize that their anxiety is excessive or that their beliefs are irrational.

A child with persistent anxiety may not identify his or her thinking as particularly anxiety-provoking because, for that child, excessively negative thinking is the norm.

Treatment of Anxiety Treatment of anxiety disorders typically consists of counseling and/or pharmacotherapy, with each treatment modality possessing its own strengths. The use of medication may confer results more quickly (particularly for patients whose anxiety is very intense), whereas the goal of counseling is to guide the patient toward developing the skills necessary to better manage anxiety throughout life.

The strongest research on efficacy of medication has been directed toward the selective serotonin uptake inhibitors (SSRIs). In a five-center trial initiated by the National Institute of Mental Health, fluvoxamine was superior to placebo in treating separation anxiety disorder, social anxiety disorder and generalized anxiety disorder5 in the pediatric population.

Studies of sertraline,6 escitalopram7 and fluoxetine8 also have yielded results suggesting they are effective in treating anxiety in childhood and adolescence.

The SSRIs generally are well-tolerated, with the most common side effects being gastrointestinal upset and sleep disturbance.

By way of comparison, minimal evidence supports the use of tricyclic antidepressants or benzodiazepine as first-line medications in treating anxiety in patients under 18 years of age.5 Of the evidence-based talk therapies, cognitive-behavioral therapy (CBT) likely has the largest body of empirically based support. Research indicates that CBT is an effective form of treatment for as many as 70% of clinically anxious children.9, 10 There are several cognitive-behavioral treatment strategies, including exposure-based techniques, contingency management and modeling. Graduated exposure, systematic desensitization and flooding constitute the exposure-based interventions. In graduated exposure, the patient and therapist generate a list of anxiety-provoking stimuli and arrange them hierarchically, with the most feared stimulus at the top. The patient then approaches each stimulus sequentially, moving up the hierarchy once anxiety has decreased.

Systematic desensitization is similar to graduated exposure in that an anxiety hierarchy is constructed, but exposure to the feared stimulus is paired with relaxation training conducted before exposure. Relaxation training may include breathing exercises, progressive muscle relaxation and imagery. When working with younger children who cannot effectively use relaxation techniques, alternatives such as reading, game playing and other forms of distraction may be substituted. The underlying objective is to induce an anxiety-antagonistic state in the presence of an anxiety-producing stimulus.

Flooding involves prolonged and repeated exposure to the anxiety-provoking stimulus. This variant is typically paired with response prevention (not allowing the child to flee the stressor) and has the potential to create more stress than other exposure-based interventions.

Other strategies include contingency management—which involves modifying antecedents and consequent events through reinforcement, shaping, extinction and punishment, and is typically combined with graduated exposure—and modeling,

With effective treatment, somatic symptoms can be reduced and the child can learn to manage anxiety effectively, potentially avoiding severe and longterm consequences.

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where the child observes a model approach and cope with an anxiety-provoking situation. Modeling can be done via direct observation, video or with the child participating with a model.

Cognitive strategies are central to CBT and are directed toward the maladaptive thought patterns associated with anxiety disorders. Children often will overestimate the potential threat posed by an anxiety-provoking stimulus, assume that a negative outcome is inevitable and feel inadequate to the task at hand. Negative self-perception is common, particularly regarding the ability to manage stressful situations.

The cognitive strategies of CBT focus on modifying the patient’s thinking to minimize anxiety-provoking thought patterns. This tactic is accomplished by working with the child to help him or her develop the ability to challenge negative selfappraisal, predictions of failure and overestimates of potential threat. In this way, the patient is guided toward the ability to self-generate more objective thinking that does not exaggerate potential threats or perpetuate overly negative self-appraisal.

The particular treatment techniques may vary by the patient’s age, symptoms and severity; and while CBT and pharmacotherapy may be used as monotherapies, research suggests the most favorable treatment outcomes are attained through their combination.6

Conclusion

References 1

Chavira DA, Stein MB, Bailey K, Stein MT. Child anxiety in primary care: prevalent but untreated. Depress Anxiety. 2004; 20:155-164.

2 Beesdo K, Knappe, S, Pine, D. Anxiety and anxiety disorders in children and adolescents: developmental issues and implications for DSM-V. Psychiatr Clin North Am. 2009; 32(3):483-524.

3 Goodwin RD, Messineo K, Bregante A, Hoven CW, Kairam R. Prevalence of probable mental disorders among pediatric asthma patients in an inner-city clinic. J Asthma. 2005; 42:643-647.

4 Dufton LM, Dunn MJ, Compas, BF. Anxiety and somatic complaints in children with recurrent abdominal pain and anxiety disorders. J Pediatr Psychol. 2009; 34(2):176-186 5 The research unit on pediatric psychopharmacology anxiety study group. Fluvoxamine for the treatment of anxiety disorders in children and adolescents. N Engl J Med. 2001; 344:1279-1285.

6 Walkup JT et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. N Engl J Med. 2008; 359:2753-2766.

7 Isolan L, Pheula G, Salum GA, Oswald S, Rohde LA, Manfro GG. An openlabel trial of escitalopram in children and adolescent with social anxiety disorder. J Child Adol Psychopharm. 2008; 17:751-760.

8 Birmaher B, Axelson DA, Monk K, Kalas C, Clark DB, Ehmann M, Bridge J, Heo J, Brent DA. Fluoxetine in the treatment of childhood anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2003; 42(4):415-423.

9 Ollendick TH, King N. Empirically supported treatments for children with phobic and anxiety disorders: current status. J Clin Child Psychol. 1998; 27:156-167.

10 Kendall P. Treating anxiety disorders in children: results of a randomized clinical trial. J Consult Clin Psychol. 1994; 62:100-110.

Article author Ben Jones, PsyD, is a pediatric psychologist with the BI-LO Charities Children’s Cancer Center at Children’s Hospital.

Anxiety disorders are the most common type of psychiatric disorders among children and adolescents, causing significant distress and impairment in family, academic and social functioning. These disorders not only persist into adulthood, but also are predictive of other psychiatric and substance abuse issues.

While efficacious treatments for anxiety disorders exist, many children and adolescents with anxiety disorders go unidentified and, consequently, untreated. Somatic complaints are common to anxiety disorders, which may result in children and adolescents presenting initially to the pediatrician or PCP. This scenario presents individuals working in the healthcare field with an opportunity to screen for anxiety disorders and treat or refer the patient appropriately.

With effective treatment, somatic symptoms can be reduced and the child can learn to manage anxiety effectively, potentially avoiding severe and long-term consequences.

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

GHS Children’s Hospital Physician Directory For admission to Children’s Hospital: (864) 455-0000 Phone Fax William F. Schmidt III, MD, PhD 455-8401 455-3884 Medical Director; Chairman, Department of Pediatrics Adolescent Bariatric Surgery Eric S. Bour, MD 676-1072 676-0729 Adolescent Medicine Michael F. Guyton Jr., MD 220-7270 241-9211 Allergy, Immunology and Asthma Charles W. Greene Jr., MD 675-5000 675-5005 James L. Kuhlen Jr., MD 675-5000 675-5005 John M. Pulcini, MD 675-5000 675-5005 Ambulatory Pediatrics/Center for Pediatric Medicine (Medicaid) J. Blakely Amati, MD 220-7270 241-9211 Jessica P. Boyd, MD 220-7270 241-9211 Britni M. Bradshaw, MD 455-9261 455-9264 Elizabeth W. Burton, MD 220-7270 241-9211 Rachael D. Davis, MD 220-7270 241-9211 Janelle E. Godlewski, MD 220-7270 241-9211 Jill D. Golden, MD 220-7270 241-9211 Lochrane Grant, MD 220-7270 241-9211 Matthew P. Grisham, MD 220-7270 241-9211 Michael F. Guyton Jr, MD 220-7270 241-9211 Sarah B. G. Hinton, MD 220-7270 241-9211 Sara E. Ryder, MD 220-7270 241-9211 Robert A. Saul, MD 220-7270 241-9211 Kerry K. Sease, MD, MPH 220-7270 241-9211 Cady F. Williams, MD 220-7270 241-9211 Anesthesiology Carlos L. Bracale, MD 242-4602 242-0129 Michael G. Danekas, MD 242-4602 242-0129 Lauren H. Doar, MD 242-4602 242-0129 John P. Kim, MD 242-4602 242-0129 Richard F. Knox, MD 242-4602 242-0129 Laura H. Leduc, MD 242-4602 242-0129 Steven W. Samoya, MD 242-4602 242-0129 Matthew R. Vana, MD 242-4602 242-0129 Randall D. Wilhoit III, MD 242-4602 242-0129 Cardiology Benjamin S. Horne III, MD 454-5120 241-9202 Jon F. Lucas, MD 454-5120 241-9202 David G. Malpass, MD 454-5120 241-9202 Manisha S. Patel, MD 454-5120 241-9202 R. Austin Raunikar, MD 454-5120 241-9202 Child Advocacy Medical Program Mary-Fran R. Crosswell, MD 335-5288 331-0565 Nancy A. Henderson, MD 335-5288 331-0565 Critical Care Michael G. Avant, MD 455-7146 455-5380 Eric L. Berning, MD 455-7146 455-5380 Christina M. Goben, MD 455-7146 455-5380 Darryl R. Gwyn, MD 455-7146 455-5380 Robert S. Seigler, MD 455-7146 455-5380

Phone Fax Developmental-Behavioral Peds/Gardner Center for Developing Minds James H. Beard Jr., MD 454-5115 241-9205 Tara A. Cancellaro, MD 454-5115 241-9205 Gerald J. Ferlauto, MD 454-5115 241-9205 Desmond P. Kelly, MD 454-5115 241-9205 Nancy R. Powers, MD 454-5115 241-9205 Victoria L. Sheppard-LaBrecque, MD 454-5115 241-9205 John E. Williams, MD 454-5115 241-9205 Emergency Medicine Elizabeth L. Foxworth, MD 455-6016 455-6199 Jacqueline J. Granger, MD 455-6016 455-6199 Alison M. Jones, MD 455-6016 455-6199 Patrick J. Maloney, MD 455-6016 455-6199 Matthew B. Neal, MD 455-6016 455-6199 Kevin A. Polley, MD 455-6016 455-6199 John D. Wilson Jr., MD 455-6016 455-6199 Endocrinology James A. Amrhein, MD 454-5100 241-9238 Elaine A. Apperson, MD 454-5100 241-9238 Bryce A. Nelson, MD, PhD 454-5100 241-9238 Ferlauto Center for Complex Pediatric Care W. Kent Jones, MD 220-7270 241-9211 Gastroenterology Liz D. Dancel, MD 454-5125 241-9201 Michael J. Dougherty, DO 454-5125 241-9201 Emily N. Kevan, MD 454-5125 241-9201 Jonathan E. Markowitz, MD, MSCE 454-5125 241-9201 Colston F. McEvoy, MD 454-5125 241-9201 Genetics David B. Everman, MD 250-7944 250-9582 R. Curtis Rogers, MD 250-7944 250-9582 Gynecology Melisa M. Holmes, MD 455-1600 455-2805 Benjie B. Mills, MD 455-1600 455-2805 Hematology/Oncology / BI-LO Charities Children’s Cancer Center Nichole L. Bryant, MD 455-8898 241-9237 Rebecca P. Cook, MD 455-8898 241-9237 Cristina E. Fernandes, MD 455-8898 241-9237 Leslie E. Gilbert, MD, MSCI 455-8898 241-9237 Aniket Saha, MD, MSCI, MS 455-8898 241-9237 William F. Schmidt III, MD, PhD 455-8898 241-9237 Infectious Disease Joshua W. Brownlee, MD 454-5130 241-9202 Sue J. Jue, MD 454-5130 241-9202 Robin N. LaCroix, MD 454-5130 241-9202 Inpatient Pediatrics Greenville April O. Buchanan, MD 455-8401 455-3884 Karen Eastburn, DO, MS 455-8401 455-3884 Jeffrey A. Gerac, MD 455-4411 455-4480 Matthew P. Grisham, MD 455-8401 455-3884 Amanda G. Hartke, MD, PhD 455-8401 455-3884 Russ C. Kolarik, MD 455-7844 455-3884 Elizabeth S. Tyson, MD 455-8401 455-3884

Continued on back

Phone Greer Matthew N. Hindman, MD 455-4411 Anderson Callie C. Barnwell, MD 454-5612 Sara M. Clark, MD 454-5612 Carley M. Howard, MD 454-5612 Ann Marie Patterson, MD 454-5612 Allison B. Ranck, MD 454-5612 Senthuran Ravindran, MD 454-5612 Silvia Y. Rho, MD 454-5612 Elizabeth A. Shirley, MD 454-5612 Miranda L. Worster, MD 454-5612 Minor Care Children’s Hospital After-hours Care (Greenville) Staffed by current GHS pediatricians 271-3681 Children’s Hospital Spartanburg Night Clinic George C. Haddad Jr., MD 804-6998 Neonatology/Bryan Neonatal Intensive Care Unit India C. Chandler, MD 455-7939 Benton E. Cofer, MD 455-7939 Nicole A. Cothran, MD 455-7939 J. Thomas Cox, MD 455-7939 R. Catrinel Marinescu, MD 455-7939 Bryan L. Ohning, MD, PhD 455-7939 Jeffrey M. Ruggieri, MD 455-7939 Michael S. Stewart, MD 455-7939 M. Whitson Walker, MD, MS 455-7939 Nephrology & Hypertension Franklin G. Boineau, MD 454-5105 T. Matthew Eison, MD 454-5105 Scott W. Walters, MD 454-5105 Neurology Emily T. Foster, MD 454-5110 Addie S. Hunnicutt, MD 454-5110 Augusto Morales, MD 454-5110 William C. Taft, MD, PhD 454-5110 Neurosurgery E. Christopher Troup, MD 797-7440 Newborn Services Jennifer A. Hudson, MD 455-3512 Rebecca P. Wright, MD 455-3512 Ophthalmology Alison S. Smith, MD 454-5540 Janette E. White, MD 454-5540 Orthopaedic Oncology Scott E. Porter, MD, MBA 797-7060 Orthopaedic Surgery Michael L. Beckish, MD 797-7060 Christopher C. Bray, MD 797-7060 Edward W. Bray III, MD 797-7060

Fax 455-4480 454-5121 454-5121 454-5121 454-5121 454-5121 454-5121 454-5121 454-5121 454-5121

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ghschildrens.org 16-0315 Revised 4/16

QUALITY COUNTS

How Safe Are Patients in Your Practice? lights and TVs should be safely secured. Glove boxes and sharps containers should be positioned out of children’s reach.

Hand hygiene opportunities, whether waterless hand gel dispensers or sinks, should be easily accessible and consistently used. The Centers for Disease Control and Prevention and the World Health Organization both recommend five indications for hand hygiene around a patient encounter:

In late 1999, the Institute of Medicine brought issues of patient safety to the forefront of public attention, and Congress subsequently established the Agency for Healthcare Research and Quality. The agency was tasked with developing evidencebased strategies and tools the medical system could implement to build a patient-safety infrastructure.

A number of interventions have become available to practices and hospitals to help systematically address patient-safety events. The goal of all these interventions is Zero Harm.

These tools and strategies can be applied in a variety of ways, but the key is building healthcare teams that focus on communication and accuracy, reducing the chance of medication, vital sign or weight errors.

Optimized communication to the physician about patient concerns or complaints helps ensure that all information needed to diagnose and treat conditions is available as care decisions are made.

Patient simulation training can help caregivers learn procedures and demonstrate proficiency before the procedure is performed on an actual patient. Examples of this model of training include learning and demonstrating proficiency with patient blood draws, injections and suture removal.

The physical environment for healthcare delivery also has been identified as important for patient safety. Waiting rooms, exam rooms and patient care areas should be checked carefully for cleanliness and safety risks. Processes for daily cleaning of toys and environmental surfaces should be implemented. Outlets,

• • • • •

When entering the room and before patient contact Before examining a patient After examining a patient After any exposure to a body fluid such as saliva or urine After leaving the exam room or patient room

Medication errors continue to be a significant contributor to patient harm. The list of patient-reported medications and dosages should be reviewed initially and again each time new prescriptions are given to check for drug-to-drug interactions.

If the EMR does not provide dosage calculations to facilitate e-prescribing, a process should be established to allow the prescriber to confirm that dosing is accurate.

As a safety net to avoid ordering and administering errors with vaccines, nursing staff should review the patient’s vaccine history and compare it directly to ordered vaccines and also to vaccine recommendations for the patient’s age group.

An intentional focus on education and a commitment to performing tasks in a consistent process will lead to a decrease in medical errors.

Finally, it is important to patient safety, both in a practice and in the hospital, that the environment be one in which reporting of errors is encouraged, and processes are in place to systematically review the circumstances around errors to prevent a recurrence.

Article author Robin LaCroix, MD, is vice chair of Medical Staff Affairs for Children’s Hospital of Greenville Health System (GHS) and a Pediatric Infectious Disease physician at GHS.

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CELEBRATIONS

Children’s Hospital of Greenville Health System (GHS) has many reasons to celebrate!

Day Hospital Named for Clement’s Kindness Founders In March, GHS Children’s Hospital announced that its children’s day hospital at the BI-LO Charities Children’s Cancer Center would be named in honor of Knox and Priscilla Haynsworth, founders of Clement’s Kindness Fund for the Children.

Since 2002, Clement’s Kindness has given approximately $800,000 in financial assistance to patients and families of the children’s cancer center, and provided more than $1.2 million in support of the center’s programs and facilities.

Recent renovations to the hospital, made possible by Clement’s Kindness, include the addition of child-friendly equipment, more comfortable and adaptable infusion chairs, new décor for the suite, a built-in fish tank, and distraction technologies such as tablets, TVs and headphones.

‘Positive Exposure’ Exhibit Opens A new photo exhibit outside of the Pediatric Intensive Care Unit at Greenville Memorial Hospital showcases the beauty of specialneeds children.

Renowned fashion photographer Rick Guidotti visited the Wonder Center, GHS’ child care facility for children with special needs, in spring 2015 to take photos of the children.

The exhibit, titled “Positive Exposure,” debuted in November 2015. Families attended an opening reception where Guidotti cut the ribbon for the new exhibit. At the reception, one mother commented, “Now people can see my child as I see her.”

Gresham Retires After 25 Years with GHS

Above: William F. Schmidt III, MD, PhD, unveils the plaque honoring Knox and Priscilla Haynsworth at the Haynsworth Day Hospital in the BI-LO Charities Children’s Cancer Center. Right: A gift from Clement’s Kindness funded renovations to the day hospital to make it a more comfortable, child-friendly space.

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Steve Gresham, who served for 26 years in various administrative roles with GHS, including the last five years with Children’s Hospital, retired in early 2016. Gresham first joined GHS in 1990 as administrative director for GHS cancer services. Since that time, he has served as service line administrator over a number of areas, including orthopaedics, trauma, sports medicine and neurodiagnostics.

Gresham was a charter member of the Association of Cancer Executives and the Society of Air Force Medical Service Corps Officers.

CELEBRATIONS

Mini-circus Visits Children’s Hospital

Clemson Students Raise Record Amount

While Ringling Bros. and Barnum & Bailey Circus was in Greenville in early February, they brought a mini-circus to GHS’ Children’s Hospital to entertain the patients there. In addition, the organization donated $10,000 to Children’s Hospital.

Students at Clemson University raised a record $71,027.82 in their annual Clemson Miracle Dance Marathon, February 13.

Those funds will benefit Safe Kids™ Upstate in Pickens and Oconee counties.

The money will fund Child Life Services, which provides activities and programs that reduce the stress of healthcare experiences for patients at Children’s Hospital.

Dance marathons take place at schools throughout the U.S. as a fundraiser for the Children’s Miracle Network. Clemson’s total was the most ever raised by any of the six local schools that hold Dance Marathons for Children’s Hospital.

Cystic Fibrosis Center News Cystic Fibrosis Program Achieves Core Center Status

2015 Virtual Toy Drive Tops $65,000 The 2015 Virtual Toy Drive Campaign, sponsored by WYFF 4, raised $65,044.38 for GHS Children’s Hospital patients and families. Those funds will help purchase items to enhance the care and quality of life for children while they are hospitalized, such as art supplies, books and DVDs, clothing and distraction items.

Monies raised enabled the purchase of 31 crib mobiles created specifically for the medical setting. These mobiles stimulate emotional, psychological and physical development in our youngest Children’s Hospital patients when they must be in the hospital for an extended time.

Although the 2015 campaign has ended, the Virtual Toy Drive website is available year-round for those who want to donate, and the 2016 campaign already has begun!

The Division of Pediatric Pulmonology’s Cystic Fibrosis (CF) Center at GHS Children’s Hospital was designated a core center by the Cystic Fibrosis Foundation. This recognizes the growth and development of the CF Center and the continued excellent care offered by the multidisciplinary CF team of healthcare providers, nutritionists, social workers, respiratory therapists and others. The CF Center currently cares for approximately 75 patients.

With this recognition will come increased support from the CF Foundation, as well as goals to expand many current services and develop more clinical research related to CF. Developing an adult CF program also is a priority.

Foundation Helps Patients with Cystic Fibrosis Clemson football coach Dabo Swinney’s All In Team Foundation awarded a $5,000 grant to Children’s Hospital’s Cystic Fibrosis Center, enabling the purchase of a special stationary bicycle for patients.

The bicycle is part of a new inpatient exercise program at the center. Exercise helps patients with cystic fibrosis clear their airways of fluid and is particularly important while patients are hospitalized with lung infections. Exercise also decreases stress and leads to improved overall health as a result of better conditioning and fitness.

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CASE STUDY

Agenesis of Corpus Callosum

A newborn infant with history of agenesis of corpus callosum (ACC), visualized via prenatal ultrasound, presented to Children’s Hospital of Greenville Health System (GHS) on day of life 5 after being found to be hypothermic at her primary care physician (PCP).

In the Newborn Nursery after delivery, the patient was found to have poor weight gain and hyperbilirubinemia requiring phototherapy. In addition, an MRI confirmed ACC, and echocardiogram, looking for midline cardiac defects, was normal. Serial blood sugars were measured because the patient was small for gestational age, and the numbers were stable. She was discharged home with PCP follow-up day after discharge.

At hospital follow-up, the patient was noted to have a 94 F body temperature that was resistant to radiant warming.

Subsequently, she was admitted to GHS Children’s Hospital for further evaluation and treatment of temperature instability.

Review of the mother’s medical records showed that the mother had negative microbial serologies and GBS status.

However, because of hypothermia resistant to radiant therapy, sepsis evaluation was initiated, including CSF, blood, and

18

urine studies and cultures. Empiric antibiotics of ampicillin and cefotaxime were initiated to cover likely organisms and minimize side-effect profile.

The mother reported that the patient had been feeding well with good urine output. Although she had been stooling well, her stools had not transitioned past meconium. As a result of dehydration on exam, electrolytes were obtained, and the patient was started on maintenance intravenous fluids.

Initial lab evaluation revealed hyperbilirubinemia, hypoglycemia and macrocytosis. The patient received phototherapy until hyperbilirubinemia resolved, and her antibiotic therapies were continued until specimen cultures were negative for at least 48 hours. Throughout admission, she displayed proper weight gain and showed improving ability to tolerate oral feeds.

However, the patient continued to have hypoglycemia with weaning of intravenous fluids, requiring multiple dextrose infusions for correction. Critical serologic samples to test for causes of hypoglycemia were attempted, but could not be obtained. Because of her history of ACC and refractory hypoglycemia, thyroid function was assessed because of concern for possible hypopituitarism.

Thyroid-stimulating hormone (TSH) was found to be profoundly low at 0.056, with expected value for gestational age and day of life to be 1.3-16. At this point, Pediatric Endocrinology was consulted. Given the presence of refractory hypoglycemia and hypothyroidism, the patient was presumptively treated as having adrenal insufficiency secondary to ACTH deficiency, resulting in her hypoglycemia. Unfortunately, a cortisol level could not be obtained; thus, she was started empirically on a loading dose of hydrocortisone, followed by maintenance therapy.

Throughout most of her admission, the patient required an isolette to maintain proper temperatures. This was thought to be secondary to hypothyroidism, possible growth hormone deficiency or a hypothalamic abnormality. We were able to successfully wean her from a radiant warmer on day of discharge.

Her non-anemic macrocytosis continued throughout most of her admission. This was discussed with Pediatric Hematology/ Oncology, who stated the belief that it was physiologic. In fact, patient was close to being polycythemic, and we were reassured by normal reticulocyte count. By time of discharge, her CBC normalized.

Because of the patient’s agenesis of the corpus callosum, Pediatric Neurosurgery was consulted and met with patient’s family, along with providing recommendations to the care team.

A renal ultrasound was performed to assess for associated anomalies, and it was normal. MRI with pituitary protocol was attained, but was unable to visualize the pituitary gland.

As an outpatient, patient required Pediatric Ophthalmology exam to rule out septo-optic dysplasia (SOD). This exam showed immaturity of optic nerves, and she will need to be assessed continually. Concern for developmental delay prompted referral to Neonatal Development Clinic and associated therapies.

Two days before discharge, the patient was able to maintain proper blood glucose without need for intravenous fluids. Her TSH improved dramatically after hydrocortisone was started, thus negating the need for thyroid replacement. Her thyroid function completely normalized by 1 month of life. She was discharged home directly to Pediatric Endocrinology where, at some future time, she would undergo ACTH stimulation testing.

Patients affected by ACC can express a wide range of phenotypical characteristics, from severe intellectual/ neurologic abnormalities to asymptomatic. Traditionally, its symptomatology has been related to the “company it keeps.”

If isolated, the patient can possibly be asymptomatic, but ACC often is associated with other brain anomalies caused by defects in cell migration. Furthermore, there is a genetic component in many cases, and it has been associated with specific chromosomal (trisomy 8 and 18) and metabolic disorders.

One recognized disorder typically associated with ACC is Aicardi syndrome, which also includes optic anomalies and infantile spams, and typically affects females. These patients’ seizures usually are resistant to anticonvulsants. Optic findings include retinal pits/lacuna and coloboma of optic disc. Almost universally, these patients have severe intellectual disability and many have hemivertebrae.

An additional possible finding with ACC is pituitary hypoplasia.

This also can be associated with midfacial anomalies or solitary maxillary central incisor, and the hormonal deficiency can be isolated or clustered. Furthermore, pituitary hypoplasia or agenesis can be seen in accompaniment with hypothalamic hamartoblastoma, polydactyly, nail dysplasia, bifid epiglottis, imperforate anus, and anomalies of the heart, lungs, and kidneys. MRI is the best imaging study to assess for presence of pituitary, and hormonal function testing is available to determine specific deficiencies. As in this case, hormonal deficiencies may make the patient symptomatic prior to the newborn screening resulting.

In cases such as the patient’s, SOD should be considered.

Diagnosis is based on the presence of two out of three of the following: optic nerve hypoplasia, midline forebrain defects and pituitary hypoplasia with variable hypopituitarism. One-third of these patients present with all three findings, with bilateral optic nerve hypoplasia being much more common than unilateral.

With SOD, no genetic mutation is typically identifiable. Care, as was the case with this patient, generally is supportive with physical therapies and hormone replacement.

Recommended Reading Kliegman R, Stanton B, St. Geme JW, Schor NF, Behrman RE. Nelson textbook of pediatrics. 20th ed. Elsevier; 2015.

Patra KP, Dariya V, Thomas W, et al. Index of suspicion: Case 1: Leg cramps, hand spasms, diarrhea, and substantial weight loss in a 12 year old: Case 2: Hypothermia, hypoglycemia, and hyperbilirubinemia in a neonate: Case 3: Recurrent fevers, abdominal pain, and cervical lymphadenopathy in a 7 year old. Pediatr Rev. 2011;32(7):299-305.

Rapaport R,. Pediatric endocrinology. Philadelphia, Pa.: Saunders; 2011.

Sankararaman S, LaFrance D, Matthews M, et al. Index of suspicion. case 1: Round opacity on chest radiograph, cough, and fever in a child. case 2: Groin pain and limp in a 10-year-old. case 3: Focal neurologic signs in the presence of sickle cell disease. case 4: Hypoglycemia and microphallus in an infant. Pediatr Rev. 2011;32(9):389-396.

Article author Nicholas Kelley, MD, is a third-year Pediatric resident at GHS Children’s Hospital. His article is written under faculty direction of Bryce Nelson, MD, PhD, medical director of the Division of Pediatric Endocrinology at Children’s Hospital.

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SPECIAL PROGRAM

New Feeding Therapy Speeds Progress

Landyn Clark was born with a number of birth defects, and spent his first 18 months eating and breathing with help from a feeding tube and a trach tube and ventilator. He first started speech and feeding therapy at 8 months old.

“Never in a million years did I think this process of learning to eat by mouth would take almost four years,” said mother Mackenzie Clark. “People can’t imagine the long process and the many stages it takes to get a child to even put food into his mouth, let alone chew and swallow safely.”

After two years of therapy, as Mackenzie began to feel like the progress was plateauing, Beth Clark (no relation), supervisor of Speech Therapy for Children’s Hospital of Greenville Health System’s (GHS) Kidnetics® program, suggested VitalStim, a therapy that was just beginning to be used in the U.S. for pediatric patients with feeding and swallowing difficulties.

Above: Landyn Clark smiles during a session of VitalStim at Kidnetics. Right: For his first 18 months, Landyn needed a feeding tube and a trach and ventilator.

“VitalStim is neuromuscular electrical stimulation,” Clark explained. “It gives a very small electrical impulse through electrodes to the muscle it’s placed on, and it stimulates and contracts the muscle to strengthen it.”

Once the muscle is stimulated, Clark said, the patient goes through traditional feeding therapy and exercises. She likened it to adding weights to your routine at the gym, instead of just doing repetitions.

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“With VitalStim, you have muscle strengthening and toning, and faster response,” Clark said. “In cases that typically would take six to 12 months to improve with traditional therapy approaches, this gives us an added tool so that we can speed up the progress and get them safer on foods and liquids more quickly.”

With feeding and swallowing difficulties, that “safe” level is particularly important. Children who are unsafe when eating or drinking are at a greater risk of choking, but also may end up with traces of food in the trachea, vocal folds or even the lungs.

“If there are tiny traces that continue to go into their lungs, it makes them at risk for chronic respiratory infections, chronic ear infections and recurrent pneumonia,” Clark noted. “And because most of our children already are compromised, we don’t want them to have those recurrent illnesses.”

The more quickly a therapy can help patients achieve a safe swallow, the better their overall health will be.

“I’ve done feeding therapy for about 11 years, and I would make progress with the traditional approaches, but VitalStim has helped me really progress some of the kids faster,” Clark said.

“It’s been really exciting.”

Landyn (right) plays with younger brother Eli at their home in Mauldin in March of this year. Thanks to VitalStim, he now is able to be active, talk and eat more safely.

he would tolerate it. To demonstrate the VitalStim therapy and prepare Landyn for it, together they put stickers on the faces of his favorite Thomas the Train toys.

Progress That’s Not Hard to Swallow Mackenzie and Landyn were excited, too. Landyn now is able to chew and swallow food, tolerate different textures in his mouth, and even eat delicacies like salmon and steak.

“We saw a huge transformation after the VitalStim with his eating, and even his oral motor movements improved for better sound production,” Mackenzie said. “He still has some issues, but now he’s able to protect his airway so that if he can’t tolerate something, he’ll spit it out instead of losing control of the food or liquid in his mouth and possibly aspirating on it.”

Mackenzie attributed a large part of their success with VitalStim to Clark and her dedication and patience. Because of Landyn’s extensive time in the hospital as an infant and toddler, he was extremely apprehensive of his therapy at first.

“When we first started speech therapy, Beth would come in and meet with Landyn, and just the sight of the purple gloves would make him shut down,” Mackenzie recalled. “It took several sessions for him to even open up to Beth and allow her hands to touch his face.”

Mackenzie said Clark would challenge Landyn and make demands of him, yet keep it playful and give him toys so that

“I just cannot say enough about the time and patience she put in with Landyn and me,” Mackenzie emphasized. “She really took the time to explain things to me and demonstrate them to both of us. It’s very scary for children who have been through everything that Landyn has, to add one more thing.”

Clark and two other Kidnetics therapists are certified to provide VitalStim therapy. Clark said patients generally receive VitalStim in conjunction with traditional exercises and feeding therapy approaches in two or three hourlong sessions a week.

VitalStim is available to any baby (term or older) or young child who demonstrates difficulty taking a bottle or eating safely.

For more information about VitalStim, call Kidnetics at (864) 331-1350.

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A S K T H E FAC U LT Y

Incorporating Child Advocacy Q: How can busy pediatricians best incorporate child advocacy into their practice?

doctor noted, “It was more or less thought that if a child was handicapped, he probably wasn’t educable. And that’s wrong.”

A: As a pediatrician, you already advocate for children one at a time in your office or hospital practice. Any time you treat an illness or educate a parent or school personnel, you are collaborating for the well-being of a child.

When considering child advocacy, first and foremost, pay attention to the issues that most engage you. It may be childhood obesity, cyber bullying, vaccine hesitancy, alcoholrelated fatalities, teen use of commercial tanning beds, access to mental health services or that toddler you saw with liquid nicotine poisoning. You must focus your time and energy to be effective.

Implementing thoughtful office- and hospital-based programs can extend additional benefits to many families in your practice. Examples of interventions include using the Edinburgh screen for maternal depression, working with a P&T committee to reduce medication errors, and collaborating with your partners and office staff to better counsel teens about e-cigarette use and risks.

Next, collaborate. Think of colleagues, community leaders, a board or organization that may share your passion. Working in partnership brings diverse skills and perspectives to the table, and it builds strength through increased numbers.

Greenville has a strong tradition of physicians advocating for children. Leslie Meyer, MD, of Shriners Hospital for Children took a step beyond providing surgical care for his patients with traumatic amputations and successfully lobbied the lawn mower industry to make safety changes to riding mowers.

Children do not vote or have a voice in government or industry.

Legislative advocacy is a natural avenue for pediatricians, and they, as experts in child health, have immediate credibility with legislators. Legislators must handle myriad topics and often welcome pediatricians’ expertise.

Dr. Meyer collaborated with community leaders and founded the Meyer Center in 1954, which has been helping children with disabilities reach their potential for over 60 years. The late

South Carolina faces many issues in which a physician’s experience and opinions are valuable resources, such as an outdated child passenger restraint law and a need for policies

Pediatrics, Medicine-Pediatrics and Family Medicine residents and faculty from GHS, University of South Carolina and Medical University of South Carolina attended Legislative Advocacy Day at the State House in Columbia on January 20. GHS Child Advocacy staff, Institute for Child Success leaders and some medical students also attended.

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Pediatric Specialty Services

that help kinship care families meet the needs of the children in their care.

Some other suggestions that can help you move toward a greater role in legislative advocacy include the following: • Sign up for timely legislative updates from the SC Children’s Hospital Collaborative • Take 15 minutes to enter your legislators’ contact information into your cellphone • Become an AAP Key Contact and contact your senator or representative at critical times in federal legislation • Illustrate your case with the story of a patient or child • Join us next winter for the annual Child Advocacy Grand Rounds at Greenville Health System or for Child Advocacy Day in Columbia, jointly sponsored by the Institute for Child Success and GHS Children’s Hospital • Attend the annual national AAP Legislative Conference in Washington, D.C., for your next CME meeting and learn from the experts Your education, training and years of experience add up to a unique opportunity to find ways to act as a child advocate. You do not always have to commit a large amount of time to make a difference in this role. Your level of involvement advocating for children is likely to vary throughout your professional career.

Your efforts may involve focused initiatives within your medical practice, accepting an invitation to speak at a school or lending your strength to a larger community collaboration. Find the issues that ignite you, consider and act. It will take some work, but can be one of the most fulfilling aspects of your career in pediatrics.

Recommended Reading American Academy of Pediatrics Key Contact Program. http://www.federaladvocacy.aap.org/resources

William F. Schmidt III, MD, PhD_______________________________ (864) 455-8401 Medical Director; Chairman, Department of Pediatrics Matthew P. Grisham, MD __________________________________________ 455-7895 Pediatric Residency Program Director Russ C. Kolarik, MD _______________________________________________ 455-7844 Medicine-Pediatrics Residency Program Director Desmond P. Kelly, MD _____________________________________________ 454-5115 Developmental-Behavioral Fellowship Program Director Adolescent Pediatrics ______________________________________________ 220-7270 Allergy and Immunology ___________________________________________ 675-5000 Ambulatory Pediatrics _____________________________________________ 220-7270 Cardiology _______________________________________________________ 454-5120 Child Advocacy Medical Program____________________________________ 335-5288 Critical Care ______________________________________________________ 455-7146 Developmental-Behavioral Pediatrics _________________________________ 454-5115 Emergency Pediatrics ______________________________________________ 455-6016 Endocrinology ____________________________________________________ 454-5100 Gastroenterology__________________________________________________ 454-5125 Genetics _________________________________________________________ 250-7944 Hematology/Oncology ____________________________________________ 455-8898 Infectious Disease _________________________________________________ 454-5130 Minor Care (Spartanburg Night Clinic) _______________________________ 804-6998 Children’s Hospital After-Hours Care ______________________________ 271-3681 Neonatology _____________________________________________________ 455-7939 Nephrology & Hypertension ________________________________________ 454-5105 Neurology________________________________________________________ 454-5110 Neurosurgery _____________________________________________________ 797-7440 Newborn Services _________________________________________________ 455-3512 Ophthalmology ___________________________________________________ 454-5540 Orthopaedic Oncology _____________________________________________ 797-7060 Orthopaedic Surgery_______________________________________________ 797-7060 Plastic Surgery ____________________________________________________ 454-4570 Pulmonology _____________________________________________________ 454-5530 Radiology ________________________________________________________ 455-7107 Rheumatology ____________________________________________________ 454-5004 Sleep Medicine ___________________________________________________ 454-5660 Supportive Care Team (formerly Palliative Care) _______________________ 455-5129 Surgery __________________________________________________________ 797-7400 Urgent Care (Anderson) ___________________________________________ 512-6544 Urology __________________________________________________________ 454-5135

Children’s Hospital Programs BI-LO Charities Children’s Cancer Center _____________________________ 455-8898 Bryan Neonatal Intensive Care Unit __________________________________ 455-7939 Child Life ________________________________________________________ 455-7846 Children’s Advocacy Program _______________________________________ 454-1100 Cystic Fibrosis Clinic _______________________________________________ 454-5530 Family Connection ________________________________________________ 331-1340 Ferlauto Center for Pediatric Care____________________________________ 220-7270 Gardner Center for Developing Minds ________________________________ 454-5115 Infant Apnea Program _____________________________________________ 455-3913 International Adoptee Clinic ________________________________________ 454-5130 Kidnetics® (pediatric therapies) _____________________________________ 331-1350 Neonatal Developmental Follow-up Services __________________________ 331-1333 New Impact (weight management) ____________________________ 675-FITT (3488) Office of Philanthropy & Partnership/CMN ___________________________ 797-7735 Pastoral Care _____________________________________________________ 455-7942 Pediatric HIV Clinic ________________________________________________ 454-5130 Safe Kids™ Upstate _______________________________________________ 454-1100 Wonder Center ___________________________________________________ 331-1380 Day treatment for medically fragile children

For admission to Children’s Hospital: (864) 455-0000 Satcher D, Kaczorowski J, Topa D. The Expanding role of the Pediatrician in Improving Child Health in the 21st Century. Pediatrics. 2005:115(3): 1124-1128.

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

Neonatal Transport _________________________________ (864) 455-7165

Shah SI, Brumberg HL. Advocating for Advocacy in Pediatrics: Supporting Lifelong Career Trajectories. Pediatrics. 2014:134(6): 1523-1527.

To reach a Children’s Hospital doctor or program, call 1-800-4RBUDDY.

South Carolina Children’s Hospital Collaborative. http://www.scchildrenshospitals.org michaelm@musc.org

Anderson

Spartanburg

Cardiology Endocrinology Hematology/Oncology Nephrology & Hypertension Neurosurgery

(864) 573-8732 Cardiology Developmental-Behavioral Endocrinology Gastroenterology Hematology/Oncology Kidnetics Nephrology & Hypertension Neurology Neurosurgery Pulmonology Sleep Medicine Urology

Article author Lochrane Grant, MD, FAAP, is a pediatrician at GHS’ Center for Pediatric Medicine, part of Children’s Hospital.

Pediatric Outpatient Service Locations Call the appropriate Greenville number above for an appointment.

Greenwood Cardiology Surgery

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Non-Profit Org. U.S. Postage PAID Greenville SC Permit No. 842 701 Grove Road Greenville, SC 29605-5601 Change Service Requested

GHS Vision Transform health care for the benefit of the people and communities we serve.

GHS Mission Heal compassionately. Teach Innovatively.

Improve constantly.

GHS Values Together we serve with integrity, respect, trust and openness.

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

New Spartanburg Outpatient Center Opens Local political leaders joined leaders and staff from GHS Children’s Hospital and members of the Spartanburg community at a grand opening ceremony for Children’s Hospital Outpatient Center–Spartanburg in November 2015. The 24,000-square-foot facility houses pediatric specialty practices along with Pediatric Associates–Spartanburg and Kidnetics® (pediatric therapies).

While these three entities have been operating separately in Spartanburg for some time, the new outpatient center combines the offerings under one roof, setting up a convenient one-stop shop for pediatric patients and their parents in the Spartanburg community.

“We want to do more than just provide medical services in the Spartanburg community,” said William Schmidt III, MD, PhD, medical director of Children’s Hospital, at the event. “We want to be part of your community. We’re very proud of this center. We hope that it makes Spartanburg feel proud. We want to be here for a long time.”

Exam rooms and common areas in the center feature photographic murals of scenes from around the Spartanburg area. Photos were selected by center staff.

External windows have a privacy screen that features Buddy the Bear with a variety of undersea creatures.

The facility is located at 249 N. Grove Medical Park Drive.

Visit our website: ghschildrens.org

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