July/August 2017 - Children's Health

July/August 2017

Children’s Health In This Issue: • Healthy Kids—Our Greatest Legacies • TCMS In Action • Luminary of Twin Cities Medicine

A FAC E O F A TOP M I N N E SOTA DE R M ATOL O GIST Recognized by physicians and nurses as one of the nation’s leading dermatologists, Charles E. Crutchfield III MD has received a significant list of honors including the Karis Humanitarian Award from the Mayo Clinic, 100 Most Influential Health Care Leaders in the State of Minnesota (Minnesota Medicine), and the First a Physician Award from the Twin Cities Medical Society, for positively impacting both organized medicine and improving the lives of people in our community. He has a private practice in Eagan and is the team dermatologist for the Minnesota Twins, Wild, Vikings and Timberwolves.

Dr. Crutchfield is a physician, teacher, author, inventor, entrepreneur, and philanthropist. He has several medical patents, has written a children’s book on sun protection, and writes a weekly newspaper health column.

Dr. Crutchfield regularly gives back to the Twin Cities community including sponsoring academic scholarships, camps for children, sponsoring programs for children with dyslexia, mentoring under-represented students from the University of Minnesota, and establishing a Dermatology lectureship at the University of Minnesota. As a professor, he teaches students at both Carleton College and the University of Minnesota Medical School. He lives in Mendota Heights with his wife Laurie, three beautiful children and two hairless cats.

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CONTENTS V O L U M E 1 9 , N O . 4 J U LY / A U G U S T 2 0 1 7

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IN THIS ISSUE

“Growing” our Children

By Peter J. Dehnel, M.D.

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PRESIDENT’S MESSAGE

The Future of TCMS

By Matthew A. Hunt, M.D.

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TCMS IN ACTION By Sue Schettle, CEO CHILDREN’S HEALTH

Page 32

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Colleague Interview: A Conversation with Phillip M. Kibort, M.D., MBA, VPMA/CMO

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SPONSORED CONTENT:

Identifying Toxic Stress in the Most Vulnerable Period, Birth to Three Years

By Maria Kroupina, Ph.D.

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Fetal Alcohol Spectrum Disorder: Alcohol, Assessment and Accessing Care

By Judith K. Eckerle, M.D., and Kimara Gustafson, M.D.

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Health Disparities in Minnesota’s Children

By Fatima Jiwa, MBChB

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Only Through Ongoing Partnership Can We Provide Sustainable, Accessible Obesity Services for Minnesota Children

By John D. Anderson, M.D., Megan K. Ellingson, MHA, and Nancy Hoyt Taff, MPH

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Youth Tobacco Prevention in Minnesota

By Grace Higgins, MPH

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Child and Adolescent Mental Health

By Michael F. Troy, Ph.D., LP

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SPONSORED CONTENT:

Page 5

Page 6

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Multiple Sclerosis and Other Demyelinating Diseases in Children

By Amanda Moen, M.D.

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In Memoriam

Environmental Health — Children’s Health in a Changing Climate

By Bruce Snyder, M.D.

July/August 2017

Approaching the Rising Tide of ACL Injuries in Children

By Brad Nelson, M.D. and Marc Tompkins, M.D.

Children’s Health In This Issue: • Healthy Kids—Our Greatest Legacies • TCMS In Action • Luminary of Twin Cities Medicine

Career Opportunities

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LUMINARY OF TWIN CITIES MEDICINE

Marjorie J. Hogan, M.D. Page 5

MetroDoctors

The Journal of the Twin Cities Medical Society

What is being done to ensure our children’s growth and development comes first.

Articles begin on page 6.

July/August 2017

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July/August Index to Advertisers

Doctors MetroDoctors

Clearway...............................................................21

THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

TCMS Officers

Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Thomas E. Kottke, M.D. Physician Co-editor Stephanie Misono, M.D. Physician Co-editor Robert R. Neal, Jr., M.D. Physician Co-editor Marvin S. Segal, M.D. Physician Co-editor Richard R. Sturgeon, M.D. Physician Co-editor Charles G. Terzian, M.D. Medical Student Co-editor Mac Garrett Managing Editor Nancy K. Bauer TCMS CEO Sue A. Schettle Production Manager Sheila A. Hatcher Advertising Representative Erica Nelson Cover Design by Annie Krapek MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413.

Crutchfield Dermatology.....................................

President: Matthew A. Hunt, M.D. President-elect: Thomas E. Kottke, M.D. Secretary: Andrea Hillerud, M.D. Treasurer: Nicholas J. Meyer, M.D. Past President: Carolyn A. McClain, M.D.

Inside Front Cover Entira Family Clinics .......................................30 Fairview Health Services .................................31

TCMS Executive Staff

HealthPartners Institute .......................................

Sue A. Schettle, Chief Executive Officer (612) 362-3799; sschettle@metrodoctors.com

Outside Back Cover

Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893; nbauer@metrodoctors.com

Kinder Village Child Care ..............................23 Lakeview Clinic .................................................31

Karen Peterson, BSN Executive Director, Honoring Choices Minnesota (612) 362-3704; kpeterson@metrodoctors.com

M Health .............................................................15 PrairieCare ...........................................................20

Lynn Betzold, Program Coordinator, Honoring Choices Minnesota (612) 362-3703; lbetzold@metrodoctors.com

PrairieCare PAL .................................................14

Grace Higgins, Project Coordinator, Physician Advocacy Network (612) 362-3706; ghiggins@metrodoctors.com

St. Cloud VA Medical Center ............................

Annie Krapek, Assistant Project Coordinator, Physician Advocacy Network (612) 362-3715; akrapek@metrodoctors.com

St. David Center .................................................. 2

Saint Therese.......................................................17 Inside Back Cover University of Minnesota..................................28 Uptown Dermatology & SkinSpa................29

To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of TCMS. Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com.

For advertising rates and space reservations, contact: Erica Nelson 4084 Jana Ave. NE St. Michael, MN 55376 phone: (763) 497-1778 fax: (763) 497-8810 e-mail: erica@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Nancy Bauer at (612) 623-2893.

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July/August 2017

MetroDoctors

The Journal of the Twin Cities Medical Society

IN THIS ISSUE...

“Growing” our Children

Welcome to the July/August edition of MetroDoctors. The theme of this edition is children’s health which, in many ways, is growing and developing as rapidly as children do.

This edition starts off with our traditional “Colleague Interview” with Phil Kibort, M.D. — Chief Medical Officer of Children’s Hospitals and Clinics of Minnesota. Dr. Kibort has served in a number of leadership positions at Children’s for the last 20 years and brings great perspective and a wealth of experience to this topic.

The issue of toxic stress in young lives is an emerging concern in the growth and development of children, with its effects actually extending into adulthood. Maria Kroupina, Ph.D. leads us through a discussion of this issue and the research that serves as the foundation for this topic. She leaves us, thankfully, with some resources and interventions that can be employed.

Fetal alcohol syndrome was recognized years ago as an important emerging concern for its life-long effect on neurodevelopmental outcomes. This issue has not been resolved as pointed out in the next article by Judith K. Eckerle, M.D. and Kimara Gustafson, M.D. In addition, Minnesota has one of the highest rates of alcohol use in women of childbearing age.

Fatima Jiwa, MBChB, raises an important challenge for those of us medical professionals who provide health care for children in this state — health disparities in Minnesota’s children. For a state that is seen as a leader in the health of its citizens, including children, there are substantial subpopulations that are not doing well.

Three important modifiable health outcomes in children and teens are taken up next. The successes of the Minnesota Partnership for Pediatric Obesity Care and Coverage are described by John Anderson, M.D., Nancy Taff, MPH and Megan Ellingson, MHA. Work on nicotine reduction and tobacco use in adolescents through the work of the Physician Advocacy Network is highlighted by Grace Higgins, MPH. Finally, the

By Peter J. Dehnel, M.D. Member, MetroDoctors Editorial Board

MetroDoctors

The Journal of the Twin Cities Medical Society

very important topic of child and adolescent mental health is reviewed by Michael Troy, Ph.D., LP. Sports participation is a very common activity for the majority of pediatric subjects.

Unfortunately, this is not always injury-free participation as many families come to experience. The topic of ACL health, injury, diagnosis and treatment is considered by Brad Nelson, M.D. and Marc Tompkins, M.D. A discussion of the diagnosis and treatment of demyelinating diseases, including early onset multiple sclerosis in children and teens, brings us to the leading edge of pediatric neurology — and the inclusion of new “biologic” disease-modifying medications. Amanda Moen, M.D., leads us through this very complex topic in a very clear and succinct manner.

The effects of climate change and increasing ambient temperatures in Minnesota on children’s health is reviewed

by Bruce Snyder, M.D., a member of TCMS’ Environmental Health Task Force. A myriad of health effects are seen ranging from increasing severity of asthma, to an increase in tick-borne diseases to storm-related anxiety and PTSD conditions.

Marv Segal, M.D. concludes this pediatric-based edition with his submission of this month’s “Luminary.” Marjorie Hogan, M.D., has tirelessly worked throughout her professional career to improve the lives of the patients and families she has served. In addition, she has been an excellent educator of students and residents, and has received numerous awards demonstrating her accomplishments in that capacity.

As the Editorial Board, we hope you thoroughly enjoy this issue of MetroDoctors. In fact, we hope this topic of children’s health actually “grows” on you and your professional interests.

If you have questions or comments, please contact Nancy Bauer at nbauer@metrodoctors.com.

July/August 2017

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President’s Message

The Future of TCMS MATTHEW A. HUNT, M.D.

CHANGE IS CONSTANT. Our local medical society landscape has continually changed over the decades. Our roots go back to the 19th century with the Ramsey and Hennepin Medical Societies, which then transformed to the East and West Metro Medical Societies, respectively. In 2010, these two societies merged to form the Twin Cities Medical Society. Over the last seven years as TCMS, how we have focused on and met the needs of our community has changed. Our initiatives to serve our community have become a major focus of our efforts with financial support from community partners now comprising over 40% of the budget. Honoring Choices, work on obesity and prediabetes, and the Physician Advocacy Network’s smoking and vaping education and policy engagement, are many of the ways we are creating an impact on our community.

At the same time, trends in physician employment and society engagement seem to be driving gradual declines in membership at TCMS. More and more physicians are employed by healthcare systems, and this employment may be filling a role that used to be served by TCMS. Additionally, as more and more physicians are employed, TCMS membership becomes a function of employment, i.e. TCMS engages systems rather than physicians to find members. The American Association of Medical Society Executives has studied these trends to help societies like ours remain relevant to our members and our communities. In 2015 they issued a report describing how medical societies can approach membership in this environment. Key points from this report emphasize that work such as advocacy, leadership development, networking, and physician wellness demonstrate value to physicians and their organizations. However, I am concerned that our relationship with the systems that both help fund and guide our initiatives inhibit our interaction with our physician members.

Through initiatives supported by our partners TCMS has been able to make a greater impact on our community. This support has been critical to maintaining the vitality of TCMS. Yet the work that makes me so proud may also be having negative impacts on the organization as a whole. I believe that a fundamental focus on our members is vital to our ongoing success. For that reason, we are looking for ways to focus on membership — particularly how we engage and support physicians as employment models change, and as our members’ concerns evolve.

In order for TCMS to continue to positively influence our community, we must continue to support the efforts of our members and engage the organizations around us that influence the health of residents of the Twin Cities and Minnesota. This means we cannot forget the physicians who work so diligently every day in our healthcare organizations, whether large or small. We must support each other in order for TCMS to continue to have the vitality we need to advance our strategic goals: public and community health, focused public policy advocacy, and supporting our community’s physicians. I am optimistic about our organization and the incredible work our members selflessly do to improve the community here in the Twin Cities.

I’m interested in your ideas. Feel free to contact me at huntx188@umn.edu.

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July/August 2017

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The Journal of the Twin Cities Medical Society

TCMS IN ACTION SUE A. SCHETTLE, CEO

Rep. Erin Murphy Attends TCMS Board Meeting

Rep. Erin Murphy, (DFL 64A), took time away from her busy schedule to meet with the TCMS Board members on May 15, 2017. As a candidate for Governor, Rep. Murphy described her “Vision for Minnesota” and responded to questions regarding the legislative session. Rep. Matt Dean, (R 38B), also a gubernatorial candidate, has been invited to attend the July meeting of the TCMS Board.

Member Highlights

Physicians serve as persuasive messengers when advocating for healthy policy and Edina proved once again just how powerful their voices truly are. TCMS would like to congratulate Dr. Caleb Schultz, a member of the TCMS Board and Physician Advocacy Network, for his leadership on Edina’s Tobacco 21 effort with the support of local partner organizations and members of Minnesotans for a Smoke-Free Generation. As a member of Edina’s Community Health Commission, Dr. Schultz leveraged that role to garner significant interest in the issue of raising the tobacco purchasing age to 21. Mayor Hovland and the council expressed their gratitude to Dr. Schultz MetroDoctors

and the Community Health Commission for bringing this issue to the council, a policy option they would not have otherwise been aware of. We hope to see physician advocates like Dr. Schultz leading these efforts as momentum continues to grow across the state.

TCMS would also like to congratulate Alex Feng, a TCMS member and University of Minnesota medical student for his role in the recent updates to Minneapolis’ parks smoking ban that went into effect on May 8. The new policy prohibits the use of all commercial tobacco products including e-cigarettes and smokeless tobacco on any land owned by the Minneapolis Park Board. Alex testified at the public hearing in March along with community advocates from Breathe Free North, Association for NonSmokers-Minnesota and other partner organizations. This is a huge victory toward eliminating the norm of commercial tobacco use of all kinds in our communities.

If you are interested in considering a policy like Tobacco 21 or updated smoking bans in your own community, visit the Physician Advocacy Network’s website to find out more www.panmn. org.

The Convenings

Northfield, MN was the site of the May 2017 Convenings where over 400 people packed St. Dominic’s Church.

MPR’s Cathy Wurzer, was the host and emcee for the evening and brought the message of “Dying Well” to the audience. Special music and a guest reader of passages from Bruce Kramer’s book, We Know How This Ends, contributed to the success of the evening. Honoring Choices MN assisted the Northfield community in preparing for this event by working with their local Advance Care Planning coalition. A combined Fairbault/Owatanna audience will be held in June, our sixth site, for The Convenings. Reconvenings will happen later this year.

Senior Physicians Association

Bruce Snyder, M.D. was the guest speaker at the May meeting of the Senior Physicians Association, where he discussed how “Climate is Changing the Face of Disease.” The next SPA luncheon is scheduled for October 10, 2017 with MDH Commissioner, Edward Ehlinger, M.D., the featured speaker.

Twin Cities Physician Social

TCMS was proud to co-host with the Minnesota Medical Association the Twin Cities Physician Social, held on May 23, 2017 at Monster Brewing with tours of the adjacent LeafLine Labs.

The Journal of the Twin Cities Medical Society

Drs. Eugene Ollila, SPA President (right), Bruce Snyder, guest speaker, and Nancy Bauer, Associate Director, TCMS.

July/August 2017

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Children’s Health

Colleague Interview: A Conversation with Phillip M. Kibort, M.D., MBA, VPMA/CMO

P

hillip M. Kibort, M.D. has served as the Vice President Medical Affairs/Chief Medical Officer at Children’s Hospitals and Clinics of Minnesota since 2001 and is the President, Children’s Services, Inc. A board certified pediatrician, Dr. Kibort received his medical degree from the University of Minnesota and completed a pediatric residency at the University of Minnesota followed by a fellowship in pediatric gastroenterology at UCLA. In addition, Dr. Kibort obtained an MBA from the University of St. Thomas. He is a member of the American Academy of Physician Executives and was named one of the Top 100 Healthcare Executives in Minnesota in Minnesota Physician, August 2008. Dr. Kibort holds a teaching appointment at the University of St. Thomas Physician Leadership College with a focus on Quality and Performance Improvement/Safety.

You have served in senior healthcare leadership positions at Children’s Hospital for over 20 years. In your opinion, what has been the biggest change in caring for kids?

It’s hard to pick just one, but if I had to summarize I’d say immunizations, technology of imaging and genomics have been the biggest innovations we’ve seen these past 20-40 years.

With regard to immunizations, we can actually see the impact when parents do not immunize their kids and we get moderate epidemics such as the measles outbreak happening now in Minnesota.

Imaging technology has also vastly improved our ability to diagnose while doing so with far less pain and radiation. And genomics presents the ability to conduct precision medicine. I believe it will be a major game changer in how we treat and care for children in the future.

How has telehealth changed your care delivery model — goals, logistics, finances, what’s next on the horizon?

I still believe that we are in the infancy of our ability to conduct medicine via telehealth. Many entities have goals and logistics to expand their telehealth offerings, but aren’t sure how it will work or be paid for. While I do see a phenomenal future for it, finances remain a problem. For instance, how do two separate models of care, the traditional and the new telehealth, co-exist 6

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at the same time? This has (and will continue to have) a great impact on health care. The ability to see a rash, the ability to see a patient and have a discussion with them (without them having to come into the office or hospital) will greatly change, and possibly improve, how we are able to care for patients.

What is the role of the “general” pediatrician in the ever-changing health care delivery model?

I think the role of the general pediatrician is evolving every day in care delivery. For one, I foresee more primary care in pediatrics being done by advanced practice nurses who can take care of at least 85% of what a general pediatrician does. At the same time, the other 15% of the kids we see are much more complex, and may have pathophysiology that is more difficult to interpret, and those cases require more education and direct work with a pediatrician.

As a whole, I see pediatricians being the leader of the care team while utilizing an entire care team to help take care of our country’s children.

What issues do you see with future pediatric clinic workforce from a supply-demand perspective?

I believe the number of general pediatricians will remain strong, especially in light of working with advanced practice clinicians.

At the same time, the subspecialty demand continues to grow and the supply is not keeping up. Pediatric subspecialties do not MetroDoctors

The Journal of the Twin Cities Medical Society

get paid as well as adult subspecialties, so there is less desire to enter into them. If we changed our model of care and focused more on primary care than specialists (like they do in Europe), then demand might decrease. In Europe, the ratio of primary to specialists is 2:1. In America it is 1:2.

How is Children’s seeking to collaborate with other pediatric entities within the state, and is there any likelihood of a more strongly consolidated pediatric organization or institution in the future?

The future of pediatric care has never been more promising and our region is blessed with outstanding resources for pediatric care.

However, we at Children’s believe there is a difference between the best available care and the best possible care. One path to the best possible is greater collaboration among the multiple systems and clinical groups that treat our region’s kids. If we had more coordination and collaboration we could unleash a cascade of benefits such as better experiences, faster access to innovative treatments, better outcomes at lower costs and better allocation of capital to underfunded areas like mental/behavioral health.

We’ll continue to lead the way for kids, but partners from the community, government and adult systems will be key.

What is Children’s doing to enhance healthy lifestyles for children and teens, and what more can be done?

Children’s Minnesota is committed to providing evidence-based medicine when it comes to issues of eating and exercise, as well as understanding how toxic stress can affect a young child’s cognitive behavior. We have worked with partners such as HealthPartners, and the metro area’s Children on Obesity and Mental Health Coalition trying to educate the community both at the clinician level as well as the public level. We take great pride in advocating on behalf of all children and stand by that mission daily.

In light of striking ongoing pediatric care improvements in morbidity and mortality, how will surviving and healthier children be cared for in a collaborative sense when they become adults (e.g. congenital heart disease, cancer)?

We have been blessed by the fact that diseases that years ago were death sentences during childhood, such as heart disease, cancer and cystic fibrosis are now at the point where patients are living well into full adulthood. This is sort of a paradox because we believe that pediatricians and pediatric subspecialists should take care of children because they are not little adults, and that the adult clinicians should be providing care for the adult patients. At the same time, if the adult clinician doesn’t have any knowledge or care experience in congenital heart disease, or certain cancers, then it may be that the pediatric subspecialist should continue that work into adulthood. At a minimum, we must partner with the adult systems to make sure that the total patient (not just the disease MetroDoctors

The Journal of the Twin Cities Medical Society

itself ) is being cared for. Children’s Minnesota does provide care for adults with congenital heart disease, as well as young adults (20-30) with cancer, since the protocols in pediatric cancer seem to do better than those in adults.

What are a few of the imminent changes in health care from a regional or national perspective? What should practicing providers be doing/thinking about now to be ready for changes coming down the pike over the next 5-10 years?

The biggest issue for imminent change is that the ability for free standing children’s hospitals to survive is becoming more and more difficult. There used to be 40+ free standing children’s hospitals in the country and now we are in the low 30s. The economics of the world is partly to blame and it is somewhat concerning because once a pediatric entity becomes part of an adult system, children seldom become the main focus of that system because they don’t generate the largest spend. With that in mind, I believe that practicing clinicians should be focused on population health, precision medicine, and how to utilize the technologies that millennials, (as well as the next generation), are and will be using.

How has the ACA and Medicaid expansion in Minnesota affected operations at Children’s, and what is likely to change if the ACA is substantially altered or replaced?

In regards to Medicaid and ACA, in my career, Medicaid percentages of children’s hospitals patients have gone from 15% to almost 45%. For every percentage that it goes up, Children’s Minnesota stands to lose $3-4 million dollars on an annual basis.

Our philosophy has always been that we will provide care for children, regardless of their ability to pay, but it is getting harder and harder to do so. Society can be judged on how it takes care of its children and its elderly, and its disabled. If dollars for their care continues to decrease, we will be facing many more difficulties. As a society we tend to spend much less on social services than Europeans do, and they are the ones with better outcomes.

Perhaps this is an area we ought to be focusing on.

As you reflect on your career, what has been your biggest accomplishment, and/or given you the most joy?

I can’t really say what my biggest accomplishment is. But I will say this, knowing that I started as a student at the place I wanted to work (Children’s) and that I have been able to work here for over 40 years is an amazing journey.

The most joy I have received is knowing that we have helped so many children get healthier and be comforted. Children’s Minnesota is a wonderful institution, with phenomenal outcomes, but most importantly, it has been consistent with its mission to champion the special needs of children from the day it opened.

I look forward to it continuing to be one of the top children’s hospitals in the country.

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Sponsored Content

Identifying Toxic Stress in the Most Vulnerable Period, Birth to Three Years Contributed by Maria Kroupina, Ph.D. During the first years of life, the human brain is in its most plastic and sensitive period, making it vulnerable to environmental factors, including toxic stress. Research from human and animal models has aided researchers in proposing three different categories of stress affecting children. The first, labeled positive stress, applies to a physiological state that is mild and brief.

Experiences such as getting an immunization or dealing with frustration or a child’s first day of daycare could all lead to positive stress. Positive stress can actually be beneficial to children, given that it provides opportunities to learn and practice healthy methods of dealing with everyday stress.

The second category of stress is tolerable stress. While similar to positive stress, these experiences are considered non-normative and present a greater magnitude of threat.

Experiences such as serious illness, death of a family member, or a natural disaster would be classified as tolerable as long as they are experienced in conjunction with a supportive relationship that aids the child in coping with the stressful experience and thus reducing the physiological stress response.

The third and most harmful classification is toxic stress. Toxic stress is caused by an experience(s) that produces frequent, strong, and prolonged activations of the body’s stress response systems in the absence of the protection of a supportive adult relationship. These types of stressors can range from child abuse to maternal depression. Toxic stress affects metabolic systems, brain circuitry, and a child’s overall mental health. This is especially true between birth and three years of age. Supportive relationships can protect against 8

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the impact of this stress and are classified as relationships from which a child can seek help from a caring and responsive adult who can help the child’s stress system return to baseline. These relationships are considered “buffers” because they can provide some insulation between the child and the stressful experience. While it is not always easy to identify toxic stress, it is incredibly important to do so. The effects of toxic stress experienced in early childhood can often last a lifetime.

Effects of Toxic Stress

Extant research indicates that toxic stress can have both short- and long-term effects on a child. Toxic stress can lead to disturbances in the regulation of the body’s stress-sensitive systems, which results in the circulation of stress hormones becoming either chronically excessive or chronically deficient. The plasticity of the

developing brain allows toxic stress to have dramatic neurological effects on children in their first three years of life. Early toxic stress can have the most detrimental effect on three regions of the brain. Significant early stress can trigger hypertrophy of the amygdala, a region of the brain critical in activating the physiological stress response, and result in a chronically activated stress response system.1 While the amygdala plays a role in turning on the physiological stress system, the hippocampus normally turns off elevated cortisol levels. Chronic stress, however, diminishes its capacity to do so. This damage to the hippocampus also impairs memory and its mood-related functions.2 The third brain region most sensitive to toxic stress is the prefrontal cortex. Elevated cortisol (a product of toxic stress) changes the connectivity in the prefrontal cortex, which in turn hinders its ability to inhibit an overactive amygdala.3 These neurological changes can have long-term effects on a child’s physiological, cognitive, and social development. An individual’s response to toxic stress will vary due to genetic predisposition, availability of supportive relationships, and the duration, intensity, timing, and context of the stressful experience.

Buffering the Impact

While it is not yet understood how toxic stress will specifically affect individual children, extensive research findings stress the importance of a supportive relationship.

Stress does not become toxic if children have a supportive relationship from which they can seek comfort. Children without this optimal buffering are at a much higher risk for experiencing toxic stress. Almost

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all children form attachment relationships with their caregivers, but the quality of these relationships can vary dramatically.

Attachment relationships are driven by biological need and form in the first year of a child’s life. Secure attachment relationships are the most effective at protecting a child from a stressful experience and occur in the presence of consistent caregiving, when the adult has reliably been able to meet the needs of the child.

Having this supportive relationship in times of stress can have a profound insulating effect on children both psychologically and biologically. In a series of studies,4

Interventions

While children in the first three years of life are more vulnerable to toxic stress, they are also more sensitive to the positive impact of early interventions. Evidencebased interventions are even available for children from newborn to three years of age. These interventions focus on building buffering relationships and have shown positive impacts on children’s neurodevelopment and long-term mental health.

Programs shown to provide neurological benefits for young children include Child Parent Psychotherapy (CPP)5 and Attachment Bio-Behavioral Catch-Up

While children in the first three years of life are more vulnerable to toxic stress, they are also more sensitive to the positive impact of early interventions.

children who were exposed to stressful situations such as receiving an immunization, being approached by a loud robot, or meeting a clown did not show the expected elevated cortisol levels if they were in the company of an adult with whom they had a secure emotional relationship. Children with insecurely attached relationships who were exposed to these same conditions did show a high stress response.

Unfortunately, some children due to multiple risk factors, such as high parental stress or psychopathy, multiple foster care placements, or neglect or abuse in their family, do not form optimal attachment relationships. Children with a history of experiencing less-than-optimal buffering relationships show more self-regulation challenges, including sleep, eating, and emotion regulation issues. Children who have experienced other risk factors such as premature birth, prenatal drug exposure, or compromised health status have also been found to be more sensitive to the effects of the quality of buffering relationships.

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(ABC),6 both of which are available in Minnesota. Designed for children who have experienced past trauma, CPP focuses on strengthening the primary caregiving relationship. The ABC intervention program is aimed at first-time mothers as well as children experiencing foster care and adoption.

Pediatricians may not always be aware of the interventions available or may believe they should wait until a child is older before making a referral. A mental health referral for children as young as 3 or 6 months may seem novel. Toxic stress, however, as identified by the American Academy of Pediatrics, poses significant risks to the health and normal development of very young children. Any child who appears to be at risk for toxic stress needs to receive a referral to a specialist for treatment.

Early Mental Health Care

Early identification and intervention is critical to preventing the long-term negative impact of toxic stress. University of Minnesota Health pediatric specialists in

The Journal of the Twin Cities Medical Society

toxic stress focus on translating this research into clinical programs. Our new Birth to Three program provides evaluations and evidence-based interventions for young children who have experienced or are at risk of experiencing toxic stress.

We also offer consultations and training courses for medical providers. Providers who would like to refer a patient can contact us at 612-365-6777. If you need additional information or wish to receive a training course, please contact us through our University of Minnesota Medical School website: www.pediatrics.umn.edu/ divisions/global-pediatrics/mental-healthclinical-program. If a parent or provider has questions or concerns about a child’s development, contact Minnesota Help Me Grow: call 1-866-693-GROW (4769) or go to helpmegrowmn.org. To find an early mental health specialist in Minnesota, please visit https://edocs.dhs.state.mn.us/ lfserver/Public/DHS-5448D-ENG. Dr. Maria Kroupina is a clinical child psychologist who is currently an Associate Professor in the Department of Pediatrics, Division of Global Pediatrics at University of Minnesota Medical School. She is the director of the University of Minnesota Health Birth to Three program, which is aimed at identifying children with a history of early adversity and toxic stress in order to provide early intervention. The development of this program is funded by the Masonic Children’s Fund.

References 1.

National Scientific Council on the Developing Child (2010). Persistent Fear and Anxiety Can Affect Young Children’s Learning and Development: Working Paper No. 9. Retrieved from www.developingchild.harvard.edu.

2.

National Scientific Council on the Developing Child (2005/2014). Excessive Stress Disrupts the Architecture of the Developing Brain: Working Paper No. 3. Updated Edition. Retrieved from www.developingchild.harvard.edu.

3.

Boyce WT, Ellis BJ. Biological sensitivity to context: I. An evolutionary-developmental theory of the origins and functions of stress reactivity. Dev Psychopathol. 2005;17(2):271– 301pmid:16761546.

4.

Gunnar MR, Donzella B. Social regulation of the cortisol levels in early human development. Psychoneuroendocrinology. 2002;27(12):199–220.

5.

“Child-Parent Psychotherapy (CPP).” California Evidence-Based Clearinghouse. California Evidence-Based Clearinghouse for Child Welfare, May 2015. Web. 10 Apr. 2017.

6.

“About ABC.” Infant Caregiver Project. University of Delaware, 2013. Web. 10 Apr. 2017.

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Children’s Health

Fetal Alcohol Spectrum Disorder: Alcohol, Assessment and Accessing Care

L

ike most adoptees who arrived to the USA in the wave of international adoption in the 1970s and 80s, we were young, healthy and came from areas of low resources. We were welcomed into the arms of U.S. families who were charged with providing for our physical and developmental needs.

The Adoption Medicine Clinic (AMC) at the University of Minnesota was founded in 1986 to help guide adoptive families through research, advocacy and clinical care.

Over the past few decades a dramatically different and more complex adoption landscape has emerged and many children in the domestic and international adoption system have more complex medical or social needs.

Some children have histories of prenatal drug and alcohol exposures. In response, AMC expanded from international adoption to also assess domestic and foster care children.

The clinic has a special focus area to assess children (adopted or with biological family) with prenatal exposures.

We both are now physicians practicing at AMC and have additional training from programs like the Minnesota Organization of Fetal Alcohol Syndrome (MOFAS) and the CDC. One of our goals is to provide prenatally exposed children with a clear, comprehensive assessment of their medical, emotional and developmental needs in order to provide accurate diagnoses and help them move forward on the right path.

What is FASD? Fetal Alcohol Spectrum Disorders (FASD) is an umbrella term that describes the range of effects that can occur in an individual who has been exposed to alcohol during

By Judith K. Eckerle, M.D., and Kimara Gustafson, M.D.

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July/August 2017

Kimara Gustafson, M.D.

Judith K. Eckerle, M.D.

the pregnancy. These effects can include physical, mental, behavioral, and learning disabilities with lifelong implications. Historically, the most recognized type is Fetal Alcohol Syndrome (FAS), but there are subtypes, such as Alcohol-Related Neurodevelopmental Disorder (ARND) and partial FAS (pFAS). These lesser known subtypes actually account for the majority of the diagnosed individuals on the spectrum.

There are four main diagnostic criteria for FASD. These include: 1. Growth deficiency: Height or weight <10th percentile at any time in the person’s life.

2. Characteristic facial features: small palpebral fissures, thin upper lip, smooth philtrum.

3. Central Nervous System damage (structural, neurological, and/or functional abnormalities or impairments) a. Microcephaly b. Structural brain abnormalities c. Neurological clinical features (i.e. seizures, spasticity, tremors) d. Impairment in three functional domains (neuropsychology evaluation)

4.

Known prenatal alcohol exposure: This can include documented alcohol exposure, parental report, first-hand observer account.

Additionally, there are minor criteria, which may further support the diagnosis: • Clinodactyly — incurving of the 5th fingers • “Railroad track” ears or other ear deformities • Epicanthal folds • Palmar crease abnormalities • Pronation/supination limitations • Cleft lip and/or palate What is the Diagnostic Process Like for an FASD Evaluation?

There is no single test or physical finding that can make the diagnosis of FASD so the diagnosis is somewhat of an art form: defining the major criteria, looking for other risks or minor criteria and excluding other comorbidities and complicating factors. It is common for individuals with FASD to carry diagnoses of ADHD, Oppositional Defiant Disorder, or Reactive Attachment Disorder.

While there can certainly be concurrent issues, finding the accurate diagnosis is needed

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to fully help the individual get the appropriate care and treatment needed.

Our diagnostic process consists of a medical evaluation, developmental screening (OT, PT and/or speech evaluation), and a (neuro)psychological evaluation to assess the functional brain domains. As a medical professional, our job is to ensure that the child’s medical health is optimized, e.g., ongoing chronic constipation, developmental delays, sensory issues, sleep disturbances, feeding problems, precocious puberty or headaches can complicate a child’s ability to learn or focus.

Other genetic causes of developmental/ behavioral issues also need to be ruled out as there can be organic causes or mimics of FASD: Fragile X, chromosomal duplications/deletions or other syndromes such as neurofibromatosis Type 1, Velocardiofacial syndrome etc. have all been diagnosed during our FASD evaluation process. Given our population’s history of often poor or unknown prenatal care and early life adversity (such as malnutrition and/or neglect), we also test for thyroid issues, infectious diseases, vitamin D and iron deficiencies.

Further referrals are made if other testing or evaluation is needed from other specialists.

What is the Prevalence of Alcohol Use and of FASD? In 2013, the prevalence of alcohol use among women in Minnesota of childbearing age (18-44 years) was the highest of any state in the U.S. (64% for any use and 21.9% for binge drinking–BRFSS data) In the upper Midwest region, nearly ¼ of women of childbearing age exhibit some binge drinking behavior, 1 in 10 pregnant women reported some alcohol use and 1 in 33 reported binge drinking in the past 30 days.1 It is estimated that in Minnesota, 7,061 infants are born each year with prenatal alcohol exposure. Nationally, the prevalence for FASD (the spectrum) may be has high as 2 to 5 per 100 school children (or 2% to 5% of the population).2 What is the Associated Cost of FASD? It is estimated that the cost to the United States for FAS is over $4 billion annually.3 These FAS cost estimates are based on the FAS diagnosis, and mostly do not include

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the related subtypes so the cost estimate is very likely a severe underestimation of the financial cost of this disorder.

How do We Treat FASD? While research experts are working on a biomarker and nutritional interventions for FASD, currently there is no single test for diagnosis, and unfortunately no current cure for this widespread issue. Once the prenatal alcohol exposure impacts the developing brain, these effects are considered static. Because so many of these kids “look normal” it can be difficult for people to understand the underlying brain damage. Understanding their strengths and weaknesses can minimize or fully prevent some of the common associated secondary disabilities such as: • Mental health problems • “Disruptive” school behavior • Difficulty with law enforcement, chemical dependency • Employment problems However, with a correct diagnosis early on in life, the right support systems can be accessed. “Protective factors” include:4 • Diagnosis before 6 years of age • Loving, nurturing, nonviolent and stable home environment before the school years • Access to special education and social services Summary “Of all the substances including cocaine, heroin, and marijuana, alcohol produces by far the most serious neurobehavioral effects in the fetus resulting in the life-long permanent disorders of memory function, impulse control and judgment.” – IOM Report to Congress, 1996.

The first step in tackling FASD is prevention. We know that this can be prevented by completely abstaining from any alcohol use during pregnancy. There is no known safe amount of alcohol during pregnancy and all types of alcohol can be equally detrimental, whether it is a glass of wine, a shot of liquor or a beer. It is also recommended that women who are trying to get pregnant consider abstaining from significant alcohol use as they may consume after conception but prior to knowing their pregnancy status.

If a woman does consume alcohol during the pregnancy, one can counsel that it is

The Journal of the Twin Cities Medical Society

never too late to stop drinking. As we know that brain growth is continuous throughout the pregnancy, the earlier a woman stops drinking, the serious effects from the alcohol exposure may be minimized.

Finally, if you suspect a child has had prenatal alcohol exposure, the best thing you can do is seek out a comprehensive FASD clinic that can help you do a full assessment of the child. The earlier a correct diagnosis can be made, the more likely the child will reach their fullest potential.

Judith K. Eckerle, M.D., is the Medical Director of the Adoption Medicine Clinic (AMC) at the University of Minnesota. Dr. Eckerle helps families pre and post adoption with consultation, referral and clinical services. She was trained at the Medical College of Wisconsin, Weill Cornell Medical Center (NY, NY) and the University of Minnesota’s Center for NeuroBehavioral Development. She is active personally and professionally in adoption and FASD education and advocacy worldwide. She was adopted at 6 months old and grew up in Minnesota. https://adoption.umn.edu/ Office phone, 612-624-1164, ecke0056@umn.edu.

Kimara Gustafson, M.D., is an Adjunct Assistant Professor of Pediatrics in the Division of Global Pediatrics and the Division of Pediatric Emergency Medicine at the University of Minnesota Masonic Children’s Hospital.

Dr. Gustafson sees children for Fetal Alcohol Spectrum Disorder medical evaluations, as well as domestic, internationally adopted, and foster care children in the Adoption Medicine Clinic. She completed her medical school and pediatric residency training at the University of Minnesota. She was adopted at 7 months old and grew up in New York.

(Endnotes) 1.

Centers for Disease Control and Prevention (2017). Fetal Alcohol Spectrum Disorders (FASDs):Data and Statistics. https://www.cdc. gov/ncbddd/fasd/data.html.

2.

CDC. Alcohol Use and Binge Drinking Among Women of Childbearing Age–United States, 2011–2013. MMWR Morbidity and Mortality Weekly Report 2015; 64 (37): 1042- 1046.

3.

Lupton, C., Burd, L. and Harwood, R. (2004), Cost of fetal alcohol spectrum disorders.

American Journal of Medical Genetics, 127C: 42–50.

4.

Centers for Disease Control and Prevention (2017). Fetal Alcohol Spectrum Disorders (FASDs): Facts about FASDs. https://www.cdc. gov/ncbddd/fasd/facts.html#References.

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Children’s Health

Health Disparities in Minnesota’s Children

T

he World Health Organization (WHO) defines health as a state of complete physical, mental and social well-being, and not merely the absence of disease. A lofty goal for any population.

Minnesota, the land of 1.28 million children under age 18, is regarded as one of the healthiest and best places for children to grow up — unless they live in certain zip codes or are of a certain race.

As a pediatrician, my patients include newborns to young adults in college. Let us look at just a few of the disparities and inequities that are present in every age group. Health disparities are differences in health status based on social or demographic factors such as race, gender, income or geographic region.

Our Youngest Patients: Infants

The infant mortality rate is a common measure of health status in a society. Minnesota ranked 11 of all states in 2016 with 4.6 deaths out of 1,000 live births. Why is it that white babies die at a rate of 4.3 out of 1,000 but black and American Indian babies die at more than double that rate in Minnesota?

Some of the disparity may be laid at the door of social determinants of health, the conditions in which people are born, grow, live, work and age, that are shaped by the distribution of money, power and resources.

Even if those factors are controlled for, disparities exist and race has been identified as an independent factor.

The American Public Health Association (APHA) defines health equity to mean

for MN, for example, outlines a number of recommendations to reduce the overall infant mortality rate and to reduce the racial and ethnic disparities in infant death rates in partnership with the residents of Minnesota.

The Children of Minnesota

everyone has the opportunity to attain the highest level of health. It entails special efforts to improve the health of those who have experienced social or economic disadvantage.

The Minnesota Department of Health’s Infant Mortality Reduction Plan

If data is not collected, disparities will not be determined and equity will not be attained. Minnesota Community Measurement recently released their first annual Health Equity of Care Report. Differences in rates of screening for adolescent mental health, overweight counseling in children and pediatric asthma control were found related to race, ethnicity, preferred language and country of origin.

Here are Some of Their Findings: American Indian or Alaskan Native and

MN Child Population by Race, 2015 2 or more race groups, 5%

Asian 6%

Black, 8%

Hispanic/Latino, 9%

American Indian and Alaskan Native, 1%

White, 71% Native Hawaiian and Pacific Islander, 0.50%

Source: kidscount.org

By Fatima Jiwa, MBChB

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Determinants of Health Social & Economic Factors, 40%

Physical Environment, 10%

worse in the above demographics if they also had Medicaid insurance. Being poor compounds the effect of race, but being rich does not negate the effect of race.

Adolescents of Minnesota

Genes & Biology, 10%

Clinical Care, 10%

Health Behaviors, 30%

Black/African Americans were across the board worse off than all other races in the measures studied.

Disparities were also significant in Hispanic populations and in those who were born in or prefer to speak the native languages of Laos, Somalia and Mexico.

Patients in greater Minnesota overall had poorer health outcomes than metro area patients.

Not surprisingly, the outcomes were

Another report that showcases child health disparities is the Minnesota Student Survey, a triennial, anonymous, statewide, school-based survey conducted to gain insights into the world of students and their experiences.

Within the questionnaire, lesbian, gay, bisexual and questioning adolescents were self-identified and surveyed in 2013.

On nearly every measure assessed, LGBQ youth had consistently worse experiences and outcomes compared to their straight peers. Most alarming was their mental health status.

These are the Numbers: Bisexual students were 2.5 to 3 times more likely to report being treated for a mental health problem than their straight peers.

Over half of LGB females reported harming themselves in the past 12 months

versus less than a fifth of straight females.

The rates of suicidal ideation were similar to reports of self harm.

One in five bisexual females reported a suicide attempt in the last year, compared to less than 1 in 20 of straight females.

The 2013 survey did not have any questions on gender identity. Transgender youth were effectively invisible in this survey.

What Can We Do?

Factors contributing to health inequities include income, education, occupation, race/ethnicity, gender, gender identity, sexual identity, immigration status, country of origin just to name a few.

How can physicians and medical groups help promote equity and decrease disparities? How can we combat the effects of social determinants of health and structural racism? How can we understand the challenges of our healthy, unique patients?

(Continued on page 14)

Table 2 and Figure 2: Infant Mortality Rate by Race/Ethnicity of Mother Minnesota 1993-2012 (BirthYear) Birth Year* 1993-1997 1998-2002 2003-2007 2008-2012

African American Deaths Births IMR 209 14,969 14.0 241 21,330 11.3 286 29,831 9.6 308 33,633 9.2

American Indian Deaths Births IMR 87 5,579 15.6 65 6,160 10.6 76 7,129 10.7 66 7,225 9.1

Deaths 94 110 102 112

Asian Births 12,972 16,873 21,856 25,192

IMR 7.2 6.5 4.7 4.4

Hispanic (can be any race) Deaths Births IMR 70 9,963 7.0 124 19,333 6.4 119 27,641 4.3 133 25,870 5.1

Deaths 1,675 1,419 1,236 1,124

White Births 283,474 285,748 278,898 262,168

IMR 5.9 5.0 4.4 4.3

18.0 16.0

Rate per 1,000 Births

14.0 12.0

African American

10.0

American Indian

8.0

Asian

6.0

Hispanic^

4.0

White

2.0 0.0 1993-1997

1998-2002

2003-2007

2008-2012

Birth Year

Source: Minnesota Department of Health, Center for Health Statistics ^Can be any race

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Children’s Health Health Disparities in Minnesota Children (Continued from page 13) Your Link to Mental Health Resources

mnpsychconsult.com onsult on lt.com

calling PAL

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July/August 2017

Here are some suggestions: 1. Gather data consistently. If it can be measured, it can be managed. Partner with Minnesota Community Measurement and collect and submit the data.

2. Examine our own implicit biases.

Harvard Implicit Bias tests are an eye opening tool that can help us determine our own unconscious biases and make them more conscious.

When faced with a patient we have little in common with, taking that deep breath and actively leaning in to the conversation, will remind us of the empathy that being in healthcare requires and will improve our understanding so that unseen barriers become more visible and stereotypes are not perpetuated.

An implicit bias education series presented by Dr. Stephen Nelson, is posted on the Minnesota Medical Association website at: https://www. mnmed.org/resources/Education/ Online-Education-CME. 3. Be mindful of language that is used and avoid binary choices in questionnaires. Youth may be male, female, transgender or non conforming. Parents may be identified as guardians instead of mother/father duos.

4. Examine your group’s policies and processes for structural racism.

A Health Equity Timeout, as coined by Dr. Lyn Hassan-Jones, is taking that opportunity before a policy or process is passed to actively examine how our most vulnerable or needy patients will be affected. The Minnesota Commissioner of Health, Dr. Ehlinger, has instituted a “health in all policies” approach at the Capitol, an example of which is the recent raise in minimum wage. This will positively impact the health of our poorest children.

5. Become informed and more involved in what is happening in our local communities. We are busy in the

healthcare world, but are also a part of our civic communities.

• Minnesota Doctors for Health Equity is a grassroots organization that is active at the Capitol and in forging relationships with community organizations to promote health equity for all. https://www.mdhealthequity. com/ • The Minnesota Medical Association and Minnesota Chapter of the American Academy of Pediatrics convene physician work groups to address health disparities and improving health equity in practice.

Minnesota Medical Association: https://www.mnmed.org/ about-us/committees-task-forces/ Health-Equity-Advisory-Group • Minnesota Chapter of the American Academy of Pediatrics: http://mnaap.org/disparities.htm A society only does as well as its most vulnerable and disadvantaged member.

How can we as physicians, who have been charged with the physical and mental wellbeing of our patients, not be active in striving for health equity?

Fatima Jiwa, MBChB, is a graduate of the University of Wales, College of Medicine and the Pediatric Residency Program at the University of Minnesota. She is a general pediatrician at Partners in Pediatrics, Children’s Minnesota at their Rogers site. She has been active in the Minnesota Medical Association as a trustee for six years and prior to that on the Committee for Minority and Cross Cultural Affairs. She is passionate about equity and is currently co-chair of the MMA Health Equity Advisory Group. She can be reached at: fjiwa@pipstop.com.

Sources 1.

Kids Count Data Center 2.

Minnesota Center for Health Statistics 3.

World Health Organization 4.

Centers for Disease Control 5.

National Information Center on Health Services Research and Health Care Technology 6.

American Public Health Association 7.

Minnesota Community Measurement 8.

Harvard Implicit Bias Test 9.

Rainbow Health Initiative 10. Minnesota Student Survey

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is for children.

Innovative pediatric care.

University of Minnesota Health leads the way in children’s healthcare.

Inspired by the need to explore and develop, we’re committed to bringing breakthrough treatment options to kids. Refer your patients to us for expert pediatric care that’s always at the forefront of research and technology.

We see patients at four convenient clinic locations and University of Minnesota Masonic Children’s Hospital, named the top children’s hospital in the metro area for 2016-17.*

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Children’s Health

Only Through Ongoing Partnership Can We Provide Sustainable, Accessible Obesity Services for Minnesota Children

O

ne out of every four Minnesota children is overweight or obese (National Survey of Children’s Health, 2012). For children living in lower income households or who are ethnic minorities, the likelihood of being overweight or obese is much higher. In the short term, these children face possible struggles with type 2 diabetes, hypertension, and lower self-esteem. They also risk complications in adulthood that include coronary heart disease, stroke, and depression. The direct and indirect economic costs of obesity in Minnesota add up to $2.8 billion.

Impacting obesity on a large scale will require continued diverse public health strategies aimed at prevention.

In the meantime, the over 25% of Minnesota children who are overweight or obese need effective services to help them avoid the downstream health consequences of this condition. The traditional medical model is generally ineffective at impacting obesity for individuals and families. Episodic clinicbased visits are not enough to help most families make and sustain the necessary healthy behavioral changes in nutrition and physical activity. The populations at the most risk for obesity often face additional barriers such as food insecurity and inconsistent availability of safe space for physical activity.

By John D. Anderson, M.D., Megan K. Ellingson, MHA, and Nancy Hoyt Taff, MPH

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John D. Anderson, M.D.

Megan K. Ellingson, MHA

Thankfully, in recent years we have witnessed a growing body of literature on this subject that offers increasingly clear management guidance. Recommendation statements from the American Academy of Pediatrics (2007), the United States Preventive Services Task Force (USPSTF) (2010), and the Institute for Clinical Systems Improvement (2013), along with more recent studies, all point toward intensive behavioral interventions as a mainstay of effective childhood obesity treatment. These interventions incorporate nutritional, physical activity, and behavioral change elements, and they often demonstrate health benefits not only for participating children, but also for their parents and other family members.

The YWCA’s Strong Fast Fit program in Minneapolis is a clear example.

Over 12 months, youth participants receive regular nutrition education, and twice weekly physical activity. Parents are

Nancy Hoyt Taff, MPH

engaged in the program, and the whole family receives a YWCA membership.

Results show that the average participant achieves a 3% decrease in body mass index percentile.

Making these types of evidencebased services accessible on a broad scale is a challenging but worthwhile goal and requires two things: building capacity in communities that do not already have these services by assembling the necessary personnel, resources, and expertise, and sustainable funding streams to support childhood obesity services. As these services are evidence-based, USPSTF recommended, and therefore mandated covered services, partnering with health care payers to provide reimbursement represents a natural solution for ensuring financial sustainability.

In 2012, the Minnesota Partnership for Pediatric Obesity Care and Coverage (MPPOCC) was established. The partnership’s mission is to improve pediatric

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obesity care and insurance coverage by developing referral pathways and ensuring reimbursement for evidence-based services. The intent is that improved coverage will sustain existing services and programs and expand access for other providers statewide to begin providing similar childhood obesity interventions.

Convened by the Minnesota Council of Health Plans and the Minnesota Chapter of the American Academy of Pediatrics, MPPOCC also includes numerous other stakeholders including representation from state and local public health departments, the Department of Human Services (DHS), health care providers, and community service providers. Funded through SHIP (Statewide Health Improvement Partnership) grants administered by the Minneapolis and Hennepin County Health Departments, MPPOCC contributes to SHIP’s impressive impacts in Minnesota. SHIP plays a role in Minnesota being the only state in the region with an obesity rate under 30% (26%, compared to 30-32% in neighboring states). SHIP efforts support healthy policies and environments in schools, childcare facilities, workplaces, health care, and communities.

MPPOCCs early efforts focused on exploring reimbursement for clinicbased childhood obesity services. While specific coverage under each plan varies, all plans are required to cover the service intensity outlined in the USPSTF recommendation (at least 25 hours over six months). In a January 2015 webinar and fact sheet, MPPOCC presented clear guidance for clinic-based providers to access coverage for their services. Additional early accomplishments for MPPOCC included adopting and promoting the 5-2-1-0 counseling strategy, supporting childhood obesity measures for the Minnesota Community Measurement program, and achieving consensus on key evidence-based outcome measures to assess the effectiveness of childhood obesity services.

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Over the last two years MPPOCC has pivoted, directing its focus on promoting best practices and advocating for reimbursement for community-based pediatric obesity services. These intensive behavioral interventions, offered within the neighborhoods where families live, are a necessary complement to the services children and families receive in their clinics. Yet because these services are only intermittently available, and began as short-term, grant-funded offerings outside the traditional health care system, there exists little infrastructure around them accessing ongoing reimbursement. Establishing new approaches and systems to support these services presents significant challenges.

In late 2015, the advocacy efforts of MPPOCC and other organizations led to a significant change and new opportunity. DHS altered its rules around billing for community health worker (CHW) services for medical assistance recipients.

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These changes included: “pediatric obesity” was added as an example of covered CHW services, covered hours per month per participant increased from 4 to 12, and the “standardized curriculum” requirement for CHW services was removed. The training and background of CHWs makes them an excellent fit to lead and facilitate community-based obesity services. DHS’s policy change meant that with CHWs administering their services, community-based providers could now explore reimbursement.

Currently, MPPOCC helps service providers utilize this new CHW coverage opportunity. MPPOCC’s new learning collaborative includes public health representatives, healthcare payers, and community organizations already providing intensive pediatric obesity services. The learning collaborative consolidates and disseminates best practices, articulating the content and structure (Continued on page 18)

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Children’s Health Obesity Services for Minnesota Children (Continued from page 17)

of community-based childhood obesity interventions. It is also a forum for developing and sharing knowledge, skills, and tools to help community providers obtain reimbursement for their services.

The learning collaborative is currently recruiting greater Minnesota organizations and seeking to understand their unique technical assistance needs in adopting these practices. As learning collaborative members implement new practices, MPPOCC will continue to explore additional policy approaches that enhance childhood obesity services and their sustainability. MPPOCC’s current goals and recommendations are summarized in a January 2017 webinar (posted in a toolkit on the Minnesota Chapter of the American Academy of Pediatrics website).

What will it take to maintain Minnesota’s current momentum, and see continued progress on reducing obesity rates? Ongoing investment in obesity prevention will be vital, including strategies that support healthier food choices and regular physical activity in environments where Minnesotans live, work, and play. But an effective approach to this problem must also include comprehensive strategies for improving the health of children who are already

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July/August 2017

overweight or obese. These children all deserve access to effective, intensive behavioral interventions, with service providers working in close collaboration with the child’s medical home. Consistently tracking the outcomes and effectiveness of community-based services will lead to ongoing service improvements. For communities that do not yet offer these services, local agencies can build capacity through collaboration with other organizations, and by utilizing the proven care and coverage models of others. As these services become more prevalent it will also be important to expand awareness among clinical providers, and develop consistent referral pathways.

Achieving these goals will require that individuals from varied sectors — healthcare providers, public health agencies, healthcare payers, community organizations, private industry, and citizens — choose to share ownership of this pervasive health issue of childhood obesity. With ongoing and improved collaboration, new and innovative solutions await. Along the way, MPPOCC looks to continue to convene these key stakeholders to advance the implementation of best practices in pediatric obesity care, as well as support policies and develop mechanisms for coverage. Together, Minnesotans can lead the way in making effective and financially sustainable childhood obesity resources accessible for all families who need them.

Together program. Dr. Anderson is an assistant professor for the University of Minnesota Pediatric Residency Program and is a co-chair of the Minnesota Partnership for Pediatric Obesity Care and Coverage (MPPOCC). Prior to working at Hennepin County Medical Center, he obtained his BA in Biology at Macalester College, completed medical school at the University of California, San Francisco and completed his pediatric residency and a chief resident year at the University of Minnesota.

John Anderson, M.D. is a general pediatrician at Hennepin County Medical Center (HCMC) and a fellow of the American Academy of Pediatrics. For the past six years he has served as medical director for HCMC’s Taking Steps Together program, a nutrition and healthy lifestyle course for families addressing childhood obesity.

Witnessing the challenges of addressing childhood obesity within the primary care clinic environment motivated him to join and help develop the Taking Steps

Nancy Hoyt Taff, MPH, has her Masters of Public Health, specializing in federal and state public health policies and programs.

She has worked at non-profit, city, and county public health agencies on programs to promote and improve community health.

As Public Health Program Manager at HealthPartners, Nancy builds partnerships with community organizations and local governments to enhance the experience, care and health of members, patients and communities.

Megan Ellingson, MHA (Owner, Ellingson Health Consulting; Co-Owner, CHW Solutions): Megan’s expertise is in collaborative planning and implementation to address health issues requiring both clinic and community approaches. Her work also focuses on helping organizations utilize Community Health Workers. Her experience includes serving as a Health Policy and Program Coordinator at the Minneapolis Health Department, and as a Department Manager in women’s services and pastoral care at Intermountain Health Care. Her direct patient care experience includes serving as a Patient Advocate and Clinical Services Coordinator at a California community clinic, as a Care Guide in late-life supportive care at Allina Health, and as a hospice volunteer. Megan has a BA in Human Biology/Medical Anthropology from Stanford University and an MHA in Healthcare Administration/Financial Management from the University of North Carolina, Chapel Hill. She completed her Administrative Fellowship at Intermountain Health Care in Salt Lake City, Utah.

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Youth Tobacco Prevention in Minnesota

Y

outh tobacco prevention is a continually evolving landscape thanks to the tobacco industry’s relentless creative drive to recruit lifelong customers. With the introduction of e-cigarettes onto the U.S. market in 2007, the tobacco industry expanded the realm of possibilities for circumventing years of polished public health messaging about the risks of cigarette smoking. E-cigarettes and flavored tobacco products continue to pose challenges to the public health community when it comes to keeping youth smoking initiation rates down. Tobacco use is still a problem for Minnesota communities and physician advocacy is essential in supporting policies to protect our youth from a lifetime of tobacco addiction. That’s why the Physician Advocacy Network (PAN), a project of Twin Cities Medical Society, prioritizes policies that put youth first. We support restricting the sale of menthol, fruit and candy flavored tobacco products, keeping the price of tobacco high, continuing to regulate e-cigarettes, and raising the tobacco sales age to 21.

Minneapolis, St. Paul and Shoreview have all taken bold steps to prevent youth tobacco use by restricting the sale of flavored tobacco products to adult-only tobacco shops. Nationally, 70% of all current youth tobacco users have used at least one flavored tobacco product in the past 30 days.1 Recent research also found that youth are six times more interested in trying menthol, candy or fruit e-cigarettes than trying a tobacco e-cigarette.2 There is still a lot of work to do across the state when it comes to regulating flavored tobacco products which is why PAN has

By Grace Higgins, MPH

MetroDoctors

chosen this hi as a policy li priority i i in i 201 2017.

We continue to support local efforts across Minnesota to update ordinances to restrict the sale of flavored tobacco as well as supporting advocates in the Twin Cities to update their existing flavor restrictions to include menthol flavored tobacco products.

The inclusion of menthol flavored tobacco products in flavor restrictions is an overdue policy update that continues to provoke resistance from the tobacco industry across the country. Canada and the European Union recently enacted menthol bans, recognizing the role that menthol flavoring plays in making it easier to start and harder to quit by masking the harsh taste of tobacco. While the Family Smoking Prevention and Control Act of 2009 banned all other characterizing cigarette flavors in the U.S., including fruit, candy and clove flavors, menthols were left out of the ban. In the United States, the tobacco industry has targeted youth, African Americans and the LGBTQ community, resulting in significantly higher menthol use rates among these populations. An alarming 71% of African American youth smokers, 70% of LGBTQ youth smokers

The Journal of the Twin Cities Medical Society

and 44% of all Minnesota high school smokers use menthol cigarettes.3 If menthol flavored tobacco were banned in the U.S., up to 300,000 lives would be saved over the next 40 years, one third of which would be African Americans.4 It’s time to update our policies to acknowledge the harms of menthol tobacco and prioritize health equity.

Keeping tobacco prices high is another strategy that has proven effective to prevent youth access to tobacco. We know that every 10% increase in tobacco prices yields a 5% drop in youth smoking rates.5 Since the tobacco tax increase in Minnesota in 2013 we have witnessed these benefits in our state. The smoking rate among 18 to 24-year-olds in Minnesota dropped from 22% in 2010 to 15% in 2014.6 The benefits of preventing youth smoking initiation and encouraging adults to quit brought by price increases saves the state billions in long-term health expenses.7 Despite the evidence that keeping tobacco taxes high works to promote the health of our communities and that the policy is supported by 64% of Minnesotans, we saw the inclusion of tax cuts that benefit the tobacco industry yet again this past legislative session. We must continue to advocate against policies like this and support tax increases on all tobacco products, including e-cigarettes.

E-cigarettes, or vapes, are the latest but certainly not the last nicotine delivery innovation from the tobacco industry.

While conventional cigarette use continues to decline in Minnesota, e-cigarette use among youth is now more than double conventional cigarette use.8 The vaping industry markets their products as smoking (Continued on page 20)

July/August 2017

19

Children’s Health Youth Tobacco Prevention (Continued from page 19)

cessation tools, however quality evidence to support these claims does not yet exist and they are not an FDA-approved smoking cessation device.9 The recent Surgeon General’s Report on e-cigarettes and young people also highlights the strong association between e-cigarette use and other tobacco products. These products market heavily towards youth with candy and fruit flavored liquid nicotine and eye-catching products and ad campaigns.

E-cigarettes also pollute indoor air and the long-term health effects of exposure to secondhand e-cigarette smoke are still largely unknown.10 Minneapolis recently updated their smoke-free parks policy to include e-cigarettes and while many communities have taken initiative to include these products in clean indoor air policies; 50% of Minnesotans are still not covered.

We support expanding these policies across the state and continuing to update smokefree parks and campus policies.

In May, Edina became the first community in Minnesota to tackle raising the tobacco sales age to 21, following in the footsteps of California, Hawaii and more than 210 localities nationwide. The ordinance passed unanimously in a demonstration of public health leadership from the city council members and Edina’s Community Health Commission led by TCMS board member Dr. Caleb Schultz. The PAN is excited to support other localities around the state that continue to move forward on this policy. Almost 90% of adult smokers start smoking before age 18 and increasing the age from 18 to 21 limits the availability of tobacco to high school students within their social networks.11 Further, a 2014 survey found this policy is supported by 75% of adults in the United States.12 This policy will have a lasting impact on youth smoking initiation rates in Minnesota and physician advocates are a key component of these efforts.

The Physician Advocacy Network supports our partners across the state to pass these evidence-based tobacco control policies to protect our youth from a lifetime of addiction. We know these policies are effective and we know that lawmakers value the expertise that physicians bring 20

July/August 2017

to the discussion on tobacco control. For more information on getting involved in these efforts, join our mailing list to receive research and news updates or sign up for action alerts to stay up-to-date on advocacy efforts in your community. Visit www. panmn.org or contact Grace Higgins at ghiggins@metrodoctors.com.

Grace Higgins, MPH, is the project coordinator for the Physician Advocacy Network (PAN) of Twin Cities Medical Society. As the PAN project coordinator Grace develops educational presentations to increase physician awareness and engagement in local advocacy around e-cigarettes, menthols and other trending tobacco products. Grace holds a Masters of Public Health from Simon Fraser University and previously worked as the Project Coordinator for a community health initiative in Vancouver, British Columbia focused on utilizing regional survey data to improve local health programs and policies.

References: 1.

Centers for Disease Control and Prevention (2015). Youth and Tobacco Use. Retrieved from https://www.cdc.gov/tobacco/data_statistics/ fact_sheets/youth_data/tobacco_use/.

2.

Pepper, J.K., Ribisl, K.M., Brewer, N.T. (2016).

Adolescents’ interest in trying flavoured e-cigarettes. Tobacco Control. Retrieved from http://tobaccocontrol.bmj.com/content/ early/2016/09/15/tobaccocontrol-2016-053174.

3.

National Youth Advocacy Coalition. Coming Out about Smoking: A Report from the National LGBTQ Young Adult Tobacco Project.

2010.

4.

Minnesota Adult Tobacco Survey (2014).

Chaloupka FJ, et al. The impact of price on 5. youth tobacco use. Smoking and Tobacco Control Monograph, No. 14. 2001.

6.

ClearWay MinnesotaSM, Minnesota Department of Health. Minnesota Adult Tobacco Survey: Tobacco Use in Minnesota, 2014 Update. 2015.

Campaign for Tobacco-Free Kids. New Rev7. enues, Public Health Benefits & Cost Savings From a $1.50 Cigarette Tax Increase in Minnesota. 2013.

8.

Minnesota Student Survey (2016). Minnesota Department of Health.

9.

Hartmann-Boyce, J et al. (2016). Electronic Cigarettes for Smoking Cessation (A Review).

Cochrane Database of Systematic Reviews, 9.

10. Grana R, et al. E-cigarettes: A scientific review.

Circulation. 2014.

11. U.S. Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 2 Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. 2012.

12. King BA et al. Attitudes Toward Raising the Minimum Age of Sale for Tobacco Among U.S. Adults. Am J Prev Med. 2015.

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The Journal of the Twin Cities Medical Society

The tobacco industry will stop at nothing to addict teenagers to smoking.

Adding flavors like menthol make it easier for kids to start and harder for them to quit.

Currently, 71 percent of African American youth smokers smoke menthol.

But if kids donâ&#x20AC;&#x2122;t start, smoking stops. Learn how we can all help at stopthestartmn.com.

Children’s Health

Child and Adolescent Mental Health

T

his article is being written in May, “Mental Health Month,” and, in fact, the first draft is being submitted on “National Children’s Mental Health Awareness Day.” The month of May is a time for the community of mental health providers, advocates, and concerned families to build greater awareness about mental health issues, break down stigma, and lend support and hope to those of us who deal with mental health issues in our own lives or the lives of our children. While I find myself grateful for this much needed focus, I also hope for a time when we don’t have a special month for mental health. A time when such special recognition would seem no more necessary than a month dedicated to raising awareness of the importance of overall physical health. We assume that flu will lead to missed time at school or work; we know that cancer will require treatment; and we recognize that continued lack of treatment of high blood pressure could result in a stroke or heart attack. And yet, despite equally compelling evidence, we often fail to recognize that emotional and behavioral problems have a direct and profound impact on current and future well-being.

While we have much more work yet to do, society is increasingly recognizing that mental health care is health care.

This understanding is being validated by a growing body of research that speaks to the powerful interaction of biological, psychological and social factors on the developing brain, gene expression and overall health.

We know, for example, that significant and sustained adversity early in life contributes to a wide range of behavioral, learning and

By Michael F. Troy, Ph.D., LP

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July/August 2017

health problems throughout development.

There’s an abundance of scientific evidence linking behavioral disorders of childhood to poor physical health throughout the lifespan. Consequently, monitoring risk and responding with appropriate evaluation and treatment for emotional, behavioral and developmental problems is as important as it is for medical problems. Indeed, these domains quite often lead to final common pathways of increased risk and compromised quality of life.

Recent data from the CDC estimates that 13% of children between 8 and 15 years of age in the United States meet the criteria for a clinically significant mental health disorder (Merikangas, He, Brody et al., 2010).

If the threshold for measurement is expanded to include all emotional, behavioral, and developmental conditions likely to benefit from clinical intervention, these rates are closer to 20% of children 2 – 5 years old and about 25% of youth 8 – 17 years old (Egger & Angold, 2006).

Yet, fewer than half of children and adolescents who need mental health interventions receive them (e.g., Costello, He, Sampson, Kessler, & Merikangas, 2014).

When children do receive psychological care, the cost of appropriate intervention is often prohibitive, and insurance coverage varies widely. Until recently, most health insurance policies placed restrictive limits on reimbursement of mental health coverage. The availability of effective therapies and treatments is significant only if infants, children, and adolescents are able to take advantage of them.

An effective system of comprehensive assessment and intervention should be anchored within common developmental settings including primary care. It should

provide support for youth with emerging mental health issues, anticipate the needs of children at high risk for compromised functioning, and make effective treatment of clinically significant disorders easily available. Such a system would also allow families to directly access appropriate and effective mental health services, emphasize preventive care for high-risk children and families, and value cultural context and cultural competence across these settings. Proposals such as this lay the groundwork for resource allocation and policy implementation that would have longstanding consequences for the well-being of countless children (Tolan and Dodge, 2005).

The recent emphasis on early childhood development and mental health services is of particular importance for medical providers as primary care providers can reasonably be thought of as the developmental sentinels of our society. Long before our children come into contact with the school system, parents and their infants are likely to see

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The Journal of the Twin Cities Medical Society

their primary care provider. As compellingly documented by researchers in programs such as the University of Minnesota’s Institute of Child Development and the Harvard Center on the Developing Child, the science of early childhood development makes clear that the foundation for mental health is built early in life and in the social context of caregiving relationships (National Scientific Council on the Developing Child, 2012). The neurodevelopmental sensitive period of these early years represents not only a time of significant vulnerability, but also of greatest opportunity to build healthy brains and robust mental health.

Adolescence is another developmental period receiving renewed focus from the fields of developmental neuroscience and mental health. From a pediatric perspective, adolescence is often seen as a late stage in the larger developmental arc from infancy to adulthood. From an adult medical perspective, it is generally seen as the starting point of adult development. Both these perspectives tend to underappreciate the full and distinctive arc of adolescent development itself. Adolescents at risk for major psychopathology may accelerate into significant and disabling symptoms. For those at risk for maladaptive personality patterns, adolescence represents a period of consolidating symptom patterns, especially those most relevant to interpersonal functioning. By understanding the distinctive social, emotional, and neurological changes that define this critical period of development, we equip ourselves to ameliorate suffering that might otherwise cause pain and distress through adulthood.

While society still has a long way to go, I am hopeful that increasingly we are viewing and valuing mental health in a more enlightened way. The pediatric health care community is investing in more intensive and robust screening methods to identify potential issues earlier, as well as advancing models for delivering care that integrates mental health services into medical settings.

I embrace this momentum, while also recognizing that much more work needs to be done before we no longer need a single month devoted to mental health. What will that look like? Children who struggle with depression, for example, will be treated with

MetroDoctors

the same understanding, compassion, and support as those with cancer. Healthcare systems and insurers will view physical and mental health services as equal contributors to the developmental well-being of all of our community’s youth. And families will be able to access mental health services as readily as any other essential health care service.

Michael Troy, Ph.D., has been a clinical psychologist at Children’s Hospital of Minnesota since 1988. Currently, he is Medical Director of Behavioral Health Services and Associate Medical Director of Children’s Neuroscience Institute. Michael received his undergraduate degree from Lawrence University and his Ph.D. in Clinical Psychology from the University of Minnesota. He completed his internship and fellowship at Hennepin County Medical Center. His clinical and academic interests include diagnostic classification issues in developmental psychopathology, neurodevelopment, models of therapeutic assessment, and teaching child clinical psychology as part of community and medical education programs. He is co-author of the book, “Disorders of Childhood: Development and Psychopathology” (3ed).

References: 1.

Costello, E.J., He, J., Sampson, N.A., Kessler, R.C., and Merikangas, K.R. (2014). Services for adolescents with psychiatric disorders: 12-month data from the national Comorbidity Survey-Adolescent. Psychiatric Services, 65, 359-366.

2.

Egger, H., & Angold, A. (2006). Common emotional and behavioral disorders in preschool children: presentation, nosology, and epidemiology. Child Psychiatry and Psychology, 47, 313-337.

3.

Merikangas, K.R., He, J., Swanson, S.A., Avenevoli, S. Cui, L., Benjet, C., Georgiadis, K., & Swendsen, J. (2010). Lifetime prevalence of mental disorders in U.S. adolescents: Results from the National Comorbidity StudyAdolescent Supplement (NCA-A). Journal of the American Academy of Child & Adolescent Psychiatry, 49, 980-989.

4.

Tolan, P.H. & Titus, J.A. (2009). Therapeutic jurisprudence in juvenile justice. In B.L. Bottoms, C.J. Najdowski, & G.S. Goodman (Eds.), Children as victims and offenders: Psychological science and the law (pp. 313-333). New York, NY: Guilford Press.

5.

National Scientific Council on the Developing Child. (2008/2012). Establishing a Level Foundation for Life: Mental Health Begins in Early Childhood: Working Paper No. 6. Updated Edition. Retrieved from www.developingchild. harvard.edu.

The Journal of the Twin Cities Medical Society

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Approaching the Rising Tide of ACL Injuries in Children Contributed by Brad Nelson, M.D. and Marc Tompkins, M.D.

Clinical Vignette:

An 11-year-old male football player presented after injuring his left knee in practice. He felt a pop and had swelling.

His physical examination demonstrated increased anterior translation and his MRI revealed a torn anterior cruciate ligament (Fig. 1). The athlete and his parents were initially told that the child was too young for surgery so he started physical therapy and was given a brace. The athlete continued to have feelings of knee instability and pain. We met with the child and family and discussed ACL reconstruction using the patient’s own hamstring tendons. He underwent surgery with a technique to minimize growth disturbance (Fig. 2 and 3). Following 9 months of rehabilitation, the athlete returned to sports with a brace.

Tears of the anterior cruciate ligament (ACL) in the knee are common, especially in people who participate in sports. An estimated 100,000 ACL surgeries are performed each year in the United States alone. An ACL tear can significantly impair the function of the knee and increases the risk of arthritis later in life — especially if the injury occurs in childhood. Surgery may not reduce the risk of arthritis, but it can help prevent further injury and allow patients to return to their usual activities.

Injury and Diagnosis

Most ACL injuries occur during activities that involve pivoting or side-to-side movement. These injuries are seen in sports such as football, soccer and basketball.

Typically, the knee is twisted, and most patients feel a pop in the knee followed by pain and swelling. Once the pain and swelling improve, patients generally can 24

July/August 2017

Brad Nelson, M.D.

Marc Tompkins, M.D.

walk and perform daily activities with minimal pain.

ACL tears are diagnosed using a combination of physical examination and magnetic resonance imaging (MRI). On examination, the affected knee feels looser than the other knee. Torn ACL fibers are usually visible on MRI.

bone. Rebuilding the ACL can be done using tendons from the patient or a cadaver donor. Patients can return home the same day following surgery.

Rehabilitation is a critical part of the healing process. Initially, the focus is on bending and straightening the knee and activating the leg muscles. Once the patient is walking well, the focus shifts to building strength and balance. It is usually at least 6 to 12 months before patients can return to sports or other athletic activities.

Treatment and Rehabilitation

Not all ACL tears require surgery. The decision to have surgery depends on the patient and his or her activity goals. In general, surgery is recommended if patients feel that their knee is unstable or if they wish to return to activities such as sports that involve pivoting.

In most cases, it is not possible to repair the ACL, so surgery involves rebuilding it. In children who are still growing, different techniques are used in order to avoid damaging growing portions of the

Increasing Incidence in Children

Physicians have suspected that more ACL injuries are occurring, especially in children, however there is limited data to support that notion. Researchers from TRIA Orthopedic Center, the University of Minnesota, and HealthPartners Institute recently published a study in the journal Pediatrics. We identified the number of

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The Journal of the Twin Cities Medical Society

ACL injuries per year in patients younger than 18 in the HealthPartners insurance database and compared it with the number of children enrolled in the database per year. Doing so allowed us to follow the incidence of ACL injury in children for 20 years; we found that, in fact, its incidence has risen each year. In terms of gender, we found that girls have a higher rate of ACL injuries than boys, but are surpassed by boys in the 17- and 18-year-old age group.

To our knowledge, this study was the first to show that the incidence of ACL tears treated both operatively and nonoperatively has increased in recent years.

We did not study why the injuries are increasing, however many theories have been suggested. One potential cause is yearround sports specialization at an earlier age. Instead of getting cross training from multiple different sports and, therefore, input from different neuromuscular patterns, young athletes are doing the same thing repetitively. Eventually, this leads to fatigue and an increased risk of injury, including that of the ACL. Another potential cause is that children play sports with more intensity and force than did children 20 years ago, which may increase the risk of injury. Perhaps more children are playing sports that put them at risk for ACL injury. Lastly, the rates may be increasing because we are getting better as a medical community at diagnosing ACL injury.

Prevention

We hope that this study will increase awareness of ACL tears in the pediatric population, which will help foster discussion about how changes in pediatric

athletic participation over the past 20 years may be behind the trend we identified.

It should also encourage a dialog about how we might prevent these injuries with prevention programs or athletic participation guidelines in the pediatric population.

Education and awareness of the rising incidence is the place to start in reducing these injuries. We do not know for sure, but many experts think that reducing early sports specialization and overtraining would be beneficial. Also, programs have been developed to help with neuromuscular training for athletes before and during a season to reduce the risk of ACL injury; more use of these programs may also reduce the incidence.

The Future

Reducing the impact of ACL injury requires better means of preventing injury, enhanced surgical techniques, improved postoperative management and analysis of rehabilitation progress. ACL prevention programs are developing and should continue to improve. Beyond physical programs, understanding what puts children at risk for ACL injury, such as early sports specialization, and learning how much is too much may also aid in prevention.

Our patient reported functional outcomes data are currently published on our website. As we continue to grow this database, we plan to use the information to guide patients and parents’ decisions and expectations post ACL reconstruction based on patient-specific criteria including age, gender, and co-morbidities.

In terms of enhanced surgical technique, the most exciting thing on the horizon is the possibility of ACL repair

Fig. 1

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The Journal of the Twin Cities Medical Society

Fig. 2

in which no additional tissues are needed to rebuild the ACL. This would enable maintenance of the ACL in a much more normal anatomic state. Postoperative management of ACLs has perhaps made the greatest strides in the past two decades, as we are always getting better at assessing rehabilitation progress. New technology and a better understanding of the key components of rehabilitation will continue to improve our ability to manage ACL injury.

Conclusions

ACL injuries, which are clearly on the rise in the pediatric population, have a significant impact on the lives of patients and their families. Awareness of this increase is key to efforts to identify causes and reverse the trend. In the meantime, we are working to improve our care for patients with ACL injuries.

Brad Nelson, M.D., is a fellowship trained orthopaedic surgeon specializing in sports medicine. He serves as the Medical Director of the TRIA Research & Education Institute and the Medical Director of University of Minnesota Athletics while also serving as the Team Physician for the Minnesota Wild. He received his medical degree from the University of Minnesota Medical School.

Marc Tompkins, M.D., is an academic orthopaedic sports medicine surgeon. As a sports medicine physician, he’s provided sideline care to all levels of athletes, including professional, collegiate, high school, and major annual events. He received his medical degree from the University of Nebraska Medical Center.

Fig. 3

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Children’s Health

Multiple Sclerosis and Other Demyelinating Diseases in Children

M

ultiple Sclerosis (MS) is a neurologic disorder in which the white matter of the central nervous system is injured by an inflammatory process termed “demyelination.” MS is typically associated with Caucasian women in their 20s and 30s. However, MS symptoms start before age 16 in up to 10% of patients. MS is just one demyelinating disorder that affects children. Because demyelinating conditions are treatable, early recognition and diagnosis improves outcomes. This article serves as an introduction to pediatric demyelinating disorders.

Classification:

Pediatric demyelinating disorders are characterized based on location, pattern, time course, and underlying cause. A combination of terms may be applied to a single demyelinating event to provide the most accurate diagnosis. Demyelinating disorders generally present as acute loss of the neurologic function with onset of symptoms over hours to days followed by improvement over days to weeks.

Diagnosis:

Early and accurate diagnosis is important for long-term prognosis.

Differentiation between demyelinating conditions is possible by obtaining a detailed history and customized evaluations. Testing generally includes magnetic resonance imaging (MRI), lumbar puncture and blood work. Evaluations may identify alternative neurologic diagnosis or confirm a demyelinating process. Imaging often identifies lesions that are asymptomatic in addition to those that were predicted by symptoms, and the appearance of lesions can help differentiate between diagnoses.

Types of Pediatric Demyelinating Disorders

There are two major demyelinating events which are referred to by location involved.

1. Optic Neuritis (ON) presents as acute vision loss secondary to demyelination of the optic nerve. ON can be easily missed in young children who often don’t report their symptoms.

Children with bilateral eye involvement are more easily recognized due to change in visual behaviors.

By Amanda Moen, M.D.

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July/August 2017

2. Transverse myelitis (TM) occurs when demyelination involves the spinal cord. Symptoms may include weakness or paralysis, sensory changes, and bowel or bladder dysfunction in an otherwise toilet trained child.

Both ON and TM can occur as isolated one-time events, or as part of another demyelinating condition.

There are three pediatric demyelinating disorders in which pattern of demyelination and time course determine diagnosis.

1. Acute Disseminated Encephalomyelitis (ADEM) is often post-infectious, and presents with encephalopathy, headaches, and focal neurological symptoms. Imaging shows multifocal, fluffy-appearing demyelinating lesions of the brain which often involve the thalamus or basal ganglia. Patients with ADEM may present with concurrent ON or TM. Typically, ADEM is a monophasic, one-time event. However, for 1020% of patients, ADEM is the first demyelinating event of relapsing-remitting MS. 2. Neuromyelitis Optica (NMO) is a demyelinating condition that was previously thought to be a severe form of MS. Patients with NMO present with ON, TM, or brainstem symptoms such as intractable vomiting. ON and TM may occur simultaneously or sequentially, and relapses are common.

NMO is caused by anti-aquaporin-4-antibodies which can be detected in blood or cerebrospinal fluid. Early diagnosis is crucial, and even with treatment the risk of permanent vision loss and paralysis is higher than in other demyelinating conditions.

3. Multiple Sclerosis (MS) is a relapsing and remitting condition

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The Journal of the Twin Cities Medical Society

with a high risk of developing a lifelong disability. Symptoms vary widely depending on the area of the central nervous system affected. Events of ON or TM are common in MS. Demyelinating lesions of the brain and brainstem may cause weakness, cranial nerve dysfunction, incoordination, or sensory changes. A diagnosis of MS requires evidence of multiple events in “time” and “space.” Diagnosis can be made using either clinical or radiographic criteria, either with two events occurring at least 30 days apart involving two different areas of the central nervous system, or one event and an MRI that meets specific diagnostic criteria. The term clinically isolated syndrome (CIS) is used for patients with one clinical event who do not meet criteria for MS diagnosis, but are anticipated to have future demyelinating events. MS has been diagnosed in children as young as 3-4 years old, and younger patients often initially present with ADEM.

Cases:

1. A 3-year-old boy presented with confusion and fever two weeks after a respiratory illness. He developed rapidly progressive facial weakness and flaccid quadriplegia. Imaging confirmed a diagnosis of ADEM with associated TM. He was treated with IV steroids, plasmapheresis and inpatient rehabilitation. At discharge, he was able to walk with minimal assistance.

Treatment:

Treatment can be divided into three phases: treatment of acute demyelinating events, prevention of relapses, and management of residual symptoms.

Treatment of acute events aims to reduce the inflammation and speed up recovery. First-line treatment is intravenous steroids; in MS and idiopathic ON, steroids do not change overall outcome but do decrease recovery time. Second-line therapies, intravenous immunoglobulins (IVIG) and plasmapheresis, are reserved for severe cases with high risk of disability. Plasmapheresis, a process similar to dialysis, removes antibodies and inflammatory molecules from the blood. Long-term outcomes vary based on underlying cause, time to treatment, and severity of the demyelinating event.

For patients with MS or NMO, long-term treatment with disease-specific medications is used to modify the disease course and prevent relapses. Unfortunately, no Food and Drug Administration-approved therapies exist for NMO. However, because NMO is antibody-mediated, off-label treatments are used to suppress antibody production. A number of Food and Drug Administration-approved medications exist for adults with MS and show promise in reducing relapse rate and disability in children with MS. These treatments should be overseen by a pediatric neurologist with experience in treating demyelinating diseases.

Many children with demyelinating diseases have incomplete recovery. They experience ongoing symptoms ranging from learning and cognition to motor, sensory, urinary, or visual symptoms.

Individualized treatment plans include neuropsychological testing, medical treatments, rehabilitation therapies, and assistive devices.

Addressing residual symptoms proactively reduces symptom impact on daily function.

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The Journal of the Twin Cities Medical Society

Image 1: MRI brain revealed multifocal lesions with a “fluffy” appearance, and spine showed a longitudinally extensive lesion from C2 to T10.

2. A 16-year-old young man presented with incoordination and recurrent falls. He was found to have severe decreased sensation in all extremities. He reported a prior episode of decreased vision in his left eye lasting several weeks consistent with ON. Imaging confirmed relapsing remitting MS presenting with TM. He improved quickly after IV steroids and rehabilitation services, but has not recovered completely. He was subsequently started on Food and Drug Administrationapproved therapy for MS to reduce relapse rate.

Image 2: MRI showed multiple lesions within the brain and spine. Brain lesions radiating from the lateral ventricles forming “Dawson’s fingers” is a classic pattern seen in MS.

(Continued on page 28)

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Children’s Health Demyelinating Diseases in Children (Continued from page 27)

3. An 8-year old girl presented with lower back pain, followed rapidly by inability to walk or urinate. She was diagnosed with TM and treated with steroids and plasmapheresis. She had a complete recovery. Six month later, she presented with acute monocular vision loss and was diagnosed with ON. Treatment with steroids and plasmapheresis was repeated. She

Image 3: MRI spine showed a longitudinally extensive lesion with severe swelling from C2 to T9; follow-up MRI brain and orbits confirmed a new right ON.

Children’s Orthopaedic Trauma Summit:

remains blind in her right eye. Antibody testing confirmed NMO diagnosis. Treatment with rituximab was started to prevent future relapses.

Conclusions:

Pediatric demyelinating diseases are relatively uncommon. Any child presenting with new neurologic symptoms such as vision loss, weakness or paralysis, sensory changes, or incoordination should be urgently evaluated by a child neurologist. Early diagnosis and intervention of demyelinating diseases can significantly impact recovery time and long-term outcome. We welcome your questions and referrals.

Amanda Moen, M.D., is a pediatric neurologist at Gillette Children's Specialty Healthcare. She received her medical degree from the University of Iowa’s Carver College of Medicine and completed a Pediatric residency and a Child Neurology residency at The Children’s Hospital of Colorado. Her professional interests include neuroimmunology, including pediatric MS and other demyelinating diseases, as well as autoimmune encephalitis, such as NMDA receptor encephalitis, and autoimmune epilepsy.

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Environmental Health — Children’s Health in a Changing Climate

M

innesotans celebrate Spring and Summer — our warm seasons mean a lot to us here in cold country. Of course winters in recent decades aren’t as cold, or as long.

Our changing climate means that Minnesota’s average temperature is rising ½ degree F per decade and winter temps are up a full degree per decade since the 70s. Warming trends are reflected in our growing and pollen seasons, now about a month longer than in the late 90s. As a result, the incidence and prevalence of allergies and asthma are steadily rising.

We can expect more days over 90o with higher dew points. Higher temperatures increase ozone concentrations especially in communities located near industrial areas.

Climate change means more wildfires that generate toxic micro-particulates that are widely dispersed.

These developments disproportionately affect children’s health.(1) Children spend more time outdoors, have higher respiratory and metabolic rates. Their developing brains and bodies are more sensitive to the effects of environmental stresses and toxins. It has been estimated that 90% of the global disease burden related to climate change is borne by children under age 5. Tick populations are up throughout Minnesota and not surprisingly so are the incidence of Lyme Disease and other vector-borne infections.(2) Boys ages 5-9 are the highest risk group for Lyme disease (MDH).

Extreme rain events (>6” of rain over >1,000 sq mi) are becoming more frequent in Minnesota(3) and wash chemical

pollutants, garbage, human and animal wastes (from overwhelmed septic systems, treatment plants and large manure ponds) into surface waters sharply raising the risk of diarrheal illnesses. Indoor mold contributes to respiratory infections. Children are more vulnerable to trauma, drownings or displacement from families. Anxiety disorders, depression and PTSD are common in children who have experienced weather disasters. Resumption of school may be delayed for weeks to months.

Physicians can help in a number of ways: by working with local health

departments to review emergency plans in light of weather extremes; helping educate elected officials and communities about the health effects of our changing climate; and advocating for sustainability planning.

For more information, see reference 1.

References: 1.

Special Focus: Climate Change and Children; http://climatehealthconnect.org/wp-content/ uploads/2016/09/Children.pdf.

2.

Disease Risk in a Dynamic Environment: The Spread of Tick-Borne Pathogens in Minnesota, USA; Robinson, S et al.; EcoHealth DOI: 10.1007/s10393-014-0979-y.

3.

MN DNR Climate Summaries; http://www.dnr. state.mn.us/climate/summaries_and_publications/mega_rain_events.htm.

By Bruce Snyder, M.D.

MetroDoctors

The Journal of the Twin Cities Medical Society

July/August 2017

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In Memoriam ARNOLD (ARNE) ANDERSON, JR., M.D., pediatrician, passed away on May 8, 2017. He was a founding member of St. Louis Park Medical Center/Park Nicollet Medical Center, serving as its CEO and Board President. He also established Teenage Medical Service (TAMS) and Children’s Health Center. He served as the first CEO and Chief Medical Director of Mpls. Children’s Hospital. Dr. Anderson joined the medical society in 1949.

EKREN GOZUM, M.D., passed away on May 12, 2017. He was a head and neck surgeon in private practice at Fairview Southdale Hospital. Dr. Gozum joined the medical society in 1966.

DARYL J. BATALDEN, M.D. passed away on May 19, 2017. A general surgeon, Dr. Batalden was a founding member of Specialists in General Surgery. He served on the Board of Hennepin County Medical Society from 1987-91.

ROBERT “BUD” PREMER, M.D., former Chief of Orthopedics at the VA Hospital, passed away on April 13, 2017.

He was the founding chair of Physicians

CAREER OPPORTUNITIES

30

July/August 2017

Serving Physicians and the Board of The Retreat in Wayzata. Dr. Premer joined the medical society in 1988.

JOHN JERRY RAICH, M.D., passed away on April 1, 2017. Dr. Raich practiced Pathology at Fairview Hospitals for 40 years. He joined the medical society in 1966.

ALAN T. HIRSCH, M.D., passed away unexpectedly in April 2017. He served as a Professor of Medicine and Director of the Vascular Medicine Program of the Lillehei Heart Institute at the University of Minnesota.

OTHILD M. SCHWARTZKOPFF, M.D., a pediatrician, passed away on May 23, 2017. Dr. Schwartzkopff practiced medicine in Germany, Canada and the U.S. She retired from Physicians Clinic in St. Paul. She joined the medical society in 1970.

See Additional Career Opportunities on page 31.

MetroDoctors

The Journal of the Twin Cities Medical Society

CAREER OPPORTUNITIES

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MetroDoctors

The Journal of the Twin Cities Medical Society

July/August 2017

31

LUMINARY of Twin Cities Medicine

By Marvin S. Segal, M.D.

MARJORIE J. HOGAN, M.D.

What a wonderful testament it is for our profession to have one of our own effectively combine time-honored caring clinical practices with today’s modern social technological activities. Let’s explore those complementary undertakings as employed by our Luminary.

Dr. Marjorie Hogan was born in Minneapolis where she’s spent virtually her entire life, save for four years of medical school at Stanford University. Her Phi Beta Kappa undergraduate time and Pediatric residency were both at our U of M where she’s remained affiliated for nearly 35 years as an integral part of her alma mater’s faculty.

An ambulatory fellowship at Minneapolis Children’s Hospital was followed by 11 years as a clinic staff pediatrician at that facility. Subsequently, she practiced at Hennepin County Medical Center (HCMC) where she has continued to serve in a clinical leadership role. She has been the long-standing Director of Pediatric Medical Education at HCMC, and has steadily climbed the U of M academic ladder to her present rank of full Professor. Marjorie’s designation as a Master Teacher has been accompanied by numerous Outstanding and Distinguished Teaching Awards from her students, residents and peers, plus a Guiding Light Achievement Award in Medical Education from HCMC. As to why Dr. Hogan chose the medical specialties of Pediatrics and Adolescent Medicine (Ephebiatrics), she answers, “I loved being around kids and teenagers — they are exciting, malleable and offer a ‘blank slate’ opportunity to really make an impression” . . . and, quite an impression she has made!

Along with the standard practice of Pediatrics, she has been deeply involved in patient education as the established chair of that HCMC committee. Dr. Hogan has been an advocate in the realms of child abuse/maltreatment/neglect and violence prevention via a variety of local and national channels including the Crisis Nursery, a Governor’s Task Force and numerous publication editorial/review positions. Even though teaching and administrative responsibilities have occupied much of her time, direct patient care has always been, “my number one passion.”

Dr. Hogan has embraced, utilized and taught the powers of contemporary print, TV and social media in her everyday professional activities and in her leadership roles with the American Academy of Pediatrics. The on-line pursuits of social media allow for the sharing of information and ideas, are 32

July/August 2017

generally welcomed by the youth of today and afford opportunities to impart meaningful messages regarding issues in the areas of substance abuse, sexual matters, obesity and other counter-productive lifestyle matters — addressing both their dangers and the benefits of corrective actions.

She strongly believes that being the parent of four children (and now grandchildren) has greatly aided her ability to serve her patients and their parents. She states, “We learned so much from our kids who taught us to allow those flexible youngsters to become ‘themselves’ in their own individual fashion.” Dr. Marjorie relates, as an example of a result of her successful application of those guiding principles, the story of a minority family she has actually followed for 35 years who dealt with the difficult trials of congenital heart disease in one of three children . . . “today, children from that wonderful home are now thriving and doing beautifully as adults.” The understanding care and parenting of today’s children foreshadow tomorrow’s societal outcomes.

One might think that Dr. Marjorie would be exhausted from the rigors of her full professional life. But no, she and her physician husband travel, cycle, cook, garden and regularly volunteer their precious time to aid adults and children newly learning our language.

Our Luminary — an old fashioned doc applying up-to-date technological approaches — was awarded the Gold Headed Cane for Lifetime Achievement by her U of M Pediatric Department colleagues. The Gold Cane is a symbol of excellence and preeminence among physicians who are recognized as “The Physician’s Physician.” That she truly is!

This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine.

Please forward names of physicians you would like considered for this recognition to Nancy Bauer, Managing Editor, nbauer@metrodoctors.com.

MetroDoctors

The Journal of the Twin Cities Medical Society

Stabilizing ACL injury rates in children Approximately 100,000 anterior cruciate ligament (ACL) surgeries are performed in the U.S. each year. Physicians at TRIA and researchers at HealthPartners Institute are partnering to study the ever-increasing incidence rate of ACL injuries in children.

HealthPartners Institute is one of the largest medical research and education centers in the Midwest.

As part of an integrated health care organization that includes hospitals, clinics and a health plan, our teams are helping transform health care across the nation.

450+ TRIA Marc Tompkins, MD Orthopedic Surgeon Brad Nelson, MD Orthopedic Surgeon

ACTIVE RESEARCH STUDIES EACH YEAR