S TA N D I N G B E H I N D O H I O ’ S C H I L D R E N
What has the Chapter done for YOU lately?
Members often wonder what the AAP is doing for them. Ohio In one word – PLENTY.
Here are some of the Chapter’s accomplishments in the past year:
William Knobeloch, MD, Ohio AAP Foundation Board member, makes friends with a dingo at the Columbus Zoo fundraiser.
$14,000 raised at Ohio AAP Foundation event
More than 150 people helped the Ohio AAP Foundation raise more than $14,000 at the 7th Annual Signature Fundraiser, “Lions, Literacy, and Lunch” on May 18 at the Columbus Zoo and Aquarium. The event featured three guest readers, raffle prizes, and a full day of family fun at the Zoo. New this year was the opportunity to bring foster families to the event. Sponsor donations provided tickets to over 40 foster children and par-
See Lions...on page 7
The Ohio AAP’s Second Annual Bike Helmet Safety Week, held May 6-10, reached millions in Ohio. John Sherman Elementary students (at right) took part in a bike rodeo. See story and more photos on pages 24 & 25.
• Bike Helmet Safety Awareness Week – Distributed more than 4,000 helmets; reached more than 12 million people with the campaign; had 60 groups in Ohio receive helmets representing 40% of Ohio counties.
• Continue to advocate Ohio Medicaid to make sure Ohio physicans will receive their enhanced reimbursements. • Established four MOC programs for members – Building Mental Wellness (BMW), Asthma, Injury Prevention, and Pound of Cure. • Distributed more than 150,000 books to Reach Out and Read
See Chapter...on page 10
In This Issue
• Sports Shorts - Performance Enhancing Substances
• Case Study: Spondylolysis H
• Health Plan Assistance Guide
• Tips for proper vaccine storage
Newsmagazine of the Ohio hio Chapter Chapter,r,, American Academy of Pediatrics
Update from the Statehouse
Ohio’s Medicaid expansion debate – Better than a movie! Fans of The West Wing or House of Cards can cancel their Netflix subscription, there is a way more entertaining show for you – Ohio’s Medicaid expansion debate. Over the last few months, Medicaid expansion has dominated the debate surrounding House Bill 59, the state operating budget. The Ohio House of Representatives removed expansion from Gov. John Kasich’s proposed budget in April; after the budget passed the House and moved to the Ohio Senate, President Keith Faber (R-Celina) immediately said his chamber would not add expansion back in. Legislative Democrats, healthcare provider organizations including the Ohio Chapter, patient advocates, and other groups have continued to press for expansion during committee hearings, at Statehouse rallies, and on editorial pages.
Following passage of the budget, the House began a series of informal hearings focused on Medicaid “reforms.” Most of the debate has centered on past initiatives including managed care, PCMH, and the welfare reforms of the mid 90s . Additionally, State Rep. Barbara Sears (RSylvania) has introduced a standalone measure (House Bill 176) which would allow Ohio Medicaid to expand coverage; Rep. Sears has been a leading voice in the Republican caucus for expansion. House Speaker William Batchelder (R-Medina) has said he wants to have a ’
Medicaid reform package passed by June 30, the same time frame as the state operating budget. We do anticipate that other reform packages will be introduced by conservative House Republicans who would seek to shift some populations off of the Medicaid rolls and increase personal responsibility requirements (drug testing, job seeking, etc.). Members who support this approach are opposed to House Bill 76, and vice versa.
Over in the Senate, State Senator Dave Burke (R-Marysville), a licensed pharmacist and leader on health-care issues, has said he will begin hearings as part of a Medicaid study committee. The Senate is set to pass the budget in early June, setting up a conference committee between the two chambers to resolve differences. The budget must be passed by June 30. At this point it is very unlikely that Medicaid expansion will find its way into the budget in conference committee, despite the fiscal impact it could have on state spending. Further, it is unclear what the legislature will be able to pass; despite controlling both chambers, legislative Republicans are very divided on this issue. It’s also important to highlight another budget issue outside of the expansion debate that has caught us all by surprise – chiropractors and concussions. Ohio’s landmark concussion law went into effect earlier this year. As you
know, after showing signs of a concussion a youth athlete must be removed from play and kept out for at least 24 hours, and only after they are cleared by a health-care professional. Nonphysicians must consult with a physician before clearing an athlete to return to play. A small provision slipped into the state operating budget by the House would allow chiropractors to clear athletes to return to play without consulting a physician. The Ohio AAP and other stakeholders have adamantly opposed this change, and continue to press legislative leaders to remove the provision. Thank you to all who have called or written their legislator on this issue! Daniel Hurley, Lobbyist Capitol Consulting Group
A Publication of the Ohio Chapter, American Academy of Pediatrics
President....Judith Romano, MD
President-Elect....Andrew Garner, MD, PhD Treasurer....Robert Murray, MD Delegates-at-large: Jill Fitch, MD Allison Brindle, MD Mike Gittelman, MD
Executive Director: Melissa Wervey Arnold
450 W. Wilson Bridge Road, Suite 215 Worthington, OH 43085 (614) 846-6258, (614) 846-4025 (fax)
Lobbyist: Dan Jones
Capitol Consulting Group 37 West Broad Street, Suite 820 Columbus, OH 43215 (614) 224-3855, (614) 224-3872 (fax)
Editor: Karen Kirk
(614) 846-6258 or (614) 486-3750
Ohio Pediatrics • Spring 2013
Reflecting on Chapter activities, accomplishments this year crease in efficiency. By using dedicated staff members working alongside our pediatrician volunteers, our successes have skyrocketed.
President Judy Romano, MD It’s hard to believe that my presidency is half over! I thought it appropriate to take this time to reflect on the activities of the past year. I hope you will pay particular attention to the article on Chapter accomplishments for members this year (see page 1). There has been so much activity it is impossible for me to highlight all of them, but I would like to share a few that demonstrate the Chapter’s commitment to children and to the pediatricians serving them. As you may recall, your leadership made a bold decision to revamp the organization of the Ohio AAP using what we now call the four pillars approach. The four pillars are Child Health, Pediatric Practice, Advocacy, and Operations. By using this model, we have successfully used process to dictate structure which I believe has resulted in an in-
A beautiful example is our activities around injury prevention. These include a Quality Improvement/Maintenance of Certification program; legislative advocacy which resulted in enactment of the Ohio concussion laws regarding return to play; and an extraordinary bike helmet safety initiative. The “Put a Lid on It” campaign, which developed the 2013 Bike Helmet Awareness Week, reached an estimated 12 million people. In addition 40% of Ohio counties had groups receiving free bike helmets. I applaud Michael Gittleman, MD, FAAP, and Sarah Denny, MD, FAAP, for their success and thank Hayley Southworth and Angela Krile for their hard work. Another change for the Chapter this year was the structure of the Executive Committee meetings. Using that time together to identify new topics and directions for the Chapter has proven fruitful. At the September 2012 Executive Committee meeting, two topics were identified and resulted in activities. One of these topics was adolescent issues which developed into a very successful Adolescent Vaccine Roundtable which was held in April. Attendance from key stakeholders around adolescent immunizations has resulted in the intent to
develop a Quality Improvement/ Maintenance of Certification Program. Another topic identified at that meeting was foster care. Jonathan Thackeray, MD, FAAP, took the lead and represented the Chapter in statewide discussions with the Attorney General. The result Is a specific recommendation for creating a standardized computer-based system to share medical Information for foster children – an action long desired by the Chapter! The Chapter recognizes the importance of engagement of our young physicians:
Congratulations to Allison Brindle, MD, FAAP, who received a Community Pediatrics Training Initiative Grant, and with Visiting Professor Lisa Chamberlain, MD, FAAP, developed an advocacy training collaborative for pediatric training programs – four programs participated representing half of the training programs in the state. I could go on with many more examples, but will close by saying that I am extremely thankful to all of our pediatrician volunteers and our dedicated staff, who have accomplished so much for the good of the children in Ohio. Judith T. Romano MD, FAAP Ohio AAP President
Ohio Pediatrics • Spring 2013
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empower students to take actions like starting breakfast programs and walking clubs. Community leaders, businesspeople and health professionals can also assist schools in providing opportunities.
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American College of Sports Medicine, American School Health Association, GENYOUth Foundation, National Dairy Council, The Wellness Impact: Enhancing Academic Through Healthy School Environment, March 2013. ÂŠ2013 National Dairy Council. Fuel Up is a service mark of National Dairy Council.
Ohio Pediatrics â€˘ Spring 2013
Case Study: Spondylolysis Editor’s note: The author of this case study is Drew Duerson, MD, is a Second Year Pediatric Resident at Nationwide Children’s Hospital, Columbus.
History: A 13-year-old female gymnast presents to clinic with insidious onset of low back pain. She states that the pain started about 3 months ago and has been steadily worsening ever since. She denies any specific injury that led to the onset of pain. The pain typically worsens with activity, especially those that require extension or rotation, and improves with rest. She reports no previous history of back pain. She denies neurological symptoms, such as radiating pain, numbness, tingling, or bowel or bladder incontinence. She denies night pain, fever, chills, or weight loss. She is currently a level 8 gymnast and practices approximately 15 hours per week. Physical Exam: She is a healthy appearing female in no acute distress. Examination of her back reveals mild lumbar hyperlordosis but no scoliosis, excessive thoracic kyphosis, or visible step-offs. She is tender to palpation at the L5 vertebrae with surrounding mild bilateral paraspinal muscle spasm. She has full range of motion in her lower back with the exception of extension, which causes her increased pain. She endorses pain with single-leg hyperextension, or the Stork test, bilaterally. FABER test is negative bilaterally. She denies radiating pain upon straight leg raise. She has full strength with hip, knee, and ankle flexion and extension. Her lower extremity sensation and reflexes are normal and symmetric, without evidence of clonus. Differential Diagnosis: Spondylolysis, Spondylolisthesis, Lumbar Strain/Mechanical Low Back Pain, Scheuermann’s Kyphosis, Herniated Disk, Spinous Process Apophysitis, Limbus Vertebra, Vertebral Fracture, Inflammatory Joint Disorder, Tumor, Infection Tests/Results: Screening AP and standing lateral radiographs of her lumbar spine were normal. Due to increased clinical suspicion of pathology, a SPECT scan was performed, which revealed increased tracer uptake in bilateral pars regions of the L5 vertebrae.
A limited, thin-cut axial CT was performed to further characterize the lesions. Bilateral spondylolytic defects of the pars interarticularis at L5 were revealed showing evidence of sclerotic margins, indicating chronicity. Final Diagnosis: Bilateral Spondylolysis of L5 Treatment: Once diagnosed with a spondylolysis, the patient was removed from her sporting activities and rested for 12 weeks. For comfort she was placed in a soft lumbar corset brace to be worn as needed. After her prolonged period of rest she was referred to physical therapy to focus on core strengthening and hamstring flexibility. She completed a total of six weeks of rehabilitation with the first, second, and last two weeks spent on flexion, extension, and functional activities, respectively. Follow-up after the completion of PT revealed that our patient had regained pain-free range of motion with improved strength and flexibility, and she was allowed to return to her sport without restrictions. She was advised to return for follow-up in one year, for a standing lateral lumbar spine radiograph, to ensure that progression to spondylolisthesis had not occurred. Discussion: Patients with spondylolysis will present to the office
See Case Study...on page 6
Ohio Pediatrics • Spring 2013
Case study...from page 5
complaining of acute or chronic low back pain. On physical exam, range of motion testing will discover pain mostly with extension. The Stork test is a special test used to identify spondylolytic defects. It is simply performed by having the patient stand on one leg while flexing the other to 90 degrees. The patient is then asked to hyperextend the back, with any resulting low back pain indicating a positive test. Other special tests used to evaluate low back pain should include FABER’s and the straight leg raise tests. The FABER’s test is performed to evaluate for sacroiliac joint dysfunction. It is completed by having the patient Flex, ABduct, and Externally Rotate their hip while the examiner provides posteriorly directed pressure to the knee and stabilizes the opposing hip. Pain elicited posterior on the contralateral side is considered a positive test. The straight leg raise is a sensitive test used to screen for an underlying herniated disk. With the patient supine the examiner lifts the patient’s leg to an angle of 30 to 70 degrees. Recreation of pain down the leg is considered a positive test; pain elicited by raising the opposing leg increases the specificity of this test. If the physical exam raises suspicion for spondylolysis, a radiographic workup is necessary. Included in this must be a standing lateral radiograph, as supine lateral films may miss a spondylolisthesis of less than 25%. While bilateral oblique views may reveal the traditional “Scotty dog collar,” they are not always performed secondary to the increased amount of radiation exposure. With a sensitivity of less than 50%, radiographs do not always detect a spondylolytic defect. In the presence of appropriate history (pre-teen or teen, prolonged period of pain, athlete competing in extension based activities) and exam (pain with extension, positive Stork test, spina bifida occulta on X-ray) advanced imaging is recommended. A single photon emission computed tomography (SPECT) scan looking for increased uptake in the areas causing pain can distinguish a bony source of pain. CT scans may be obtained to help clarify the lesion, using thin cuts limited to the positive areas on the SPECT scan to help guide prognosis and treatment. Treatment of these lesions is controversial. The length of activity restriction, bracing versus not bracing, types of braces used, the timing of rehabilitation, and
the physical therapy protocol followed can all vary. However, the focus of a treatment plan should always be pain relief for the patient, and this most often comes with rest. Using the CT scan as a guide, the length of relative rest can be short with pain-free advancement into rehab for chronic appearing lesions or up to 3 months of activity restriction for those that appear more acute or subacute. Bracing is typically considered when rest alone is not effective in alleviating the patient’s symptoms. Braces can range from soft lumbar corsets to rigid Boston braces and are often chosen based on physician preference. Lastly, it is also important to recognize the potential for bilateral spondylolyses to progress to spondylolisthesis, especially during the adolescent growth spurt, making annual screening standing lateral radiographs an important part of your overall treatment plan, until the patient reaches skeletal maturity. REFERENCES • Axelsson, P; Johnsson, R; Stromqvist, B. “Effect of lumbar orthosis
on intervertebral mobility.” Spine 1992;17:678-681 • Bernstein RM; Cozen H. Evaluation of Back Pain in Children and Adolescents. Am Fam Physician 2007 Dec 1;76(11):1669-1676 • Fischer A. "Spondylolysis in the Adolescent". OAFP 2011; 63(3):2829 • Gregg CD, Dean S, Schneiders AG. Variables associated with active spondylolysis. Physical Therapy in Sports 2009;10:121-124 • Luke A, Micheli LJ. Spondylolysis and Spondylolisthesis: Principles in Diagnosis and Management. International SportMed Journal 2000;1(4) • Sairyo K, Shinsuke K, et al. Athletes With Unilateral Spondylolysis Are at Risk of Stress Fracture at the Contralateral Pedicle and Pars Interarticularis – a Clinical and Biomechanical Study. The American Journal of Sports Medicine 2005;33(4):583-90 • Standaert CJ, Herring SA. Expert Opinion and Controversies in Sports and Musculoskeletal Medicine: The Diagnosis and Treatment of Spondylolysis in Adolescent Athletes. Archives of Physical Medicine and Rehabilitation 2007;88:537-40 • Wicker, Antony. Spondylolysis and spondylolisthesis in sports – FIMS Position Statement. International SportMed Journal 2008; 9(2):74-78 • Yamane T, Yoshida T, Mimatsu K. Early Diagnosis of Lumbar Spondylolysis by MRI. J Bone Joint Surg [Br] 1993;75-B:764-768 • Spondylolysis and Spondylolisthesis in Children and Adolescents: Diagnosis, Natural History, and Nonsurgical Management. J Am Acad Orthop Surg 2006; 14(7):417-424
Drew Duerson, MD Second Year Pediatric Resident Nationwide Children’s Hospital, Columbus
Ohio Pediatrics • Spring 2013
Lions...from page 1
ents who joined Ohio AAP and community members for lunch and activities. Shelley Robbins, RN, LNC-CSp, C.H.A.M.P. Coordinator for the Rocking Horse Center, was on hand during the event to speak about the “My Story” Foster Care program and to share the day with some of the foster families she assists. This program is very close to her heart, as she shared at the event. “I am not sure who quoted this but I have this on my wall in my office surrounded by tons of pictures of ‘my kids’ over the past 10 years. When the kids come to the Rocking Horse they come in to see if their picture is still there. I have even had children that are not involved in the foster system bring me pictures of themselves to place on my wall. I get to look at it every day and it helps keep me going for these children. It is simply ‘Every child has a story yet to be told,’” Robbins said. Other foundation initiatives were also introduced to the audience, including Injury Prevention and Obesity Prevention. William Knobeloch, MD, an Ohio AAP Foundation Board Member, discussed why he supports the Early Literacy program; see the Foundation Focus on page 9 for more information on exciting developments with this program. Guest readers included Dave Kaelin of the WNCI Morning Zoo radio show reading The Stinky Cheese Man, a zookeeper reading Brown Bear, Brown Bear, What Do You See? and Frankie Hejduk of the Columbus Crew reading Polar Bear, Polar Bear, What Do You Hear? Bob McElligott, Columbus
Current and past presidents, from left, Bill Cotton, MD, Gerry Tiberio, MD, Judy Romano, MD, Toni Eaton, MD, and Terry Barber, MD.
A Columbus zookeeper reads to the children from “Brown Bear, Brown Bear, What Do You See?” Blue Jackets color analyst, returned for a second year as event emcee. McElligott was impressed by the Ohio AAP Foundation at last year’s Signature Fundraiser. “I thought you guys were great, and I really enjoyed myself,” McElligott said of his experience at Safety, Sandwiches, and Slapshots in August 2012. “I think the cause is worthwhile and you do great work. When you asked me to come back it was really a no-brainer.” Thanks to the generosity of attendees at the Ohio AAP’s Adolescent Immunization Expert Roundtable, raffle prizes for this year included an iPad mini, gift cards, and book gift sets for kids and adults. The Columbus Blue Jackets also donated a signed stick and puck that were awarded in the raffle.
Amy Sternstein, MD, discusses the Pound of Cure initiative.
Sponsor donations provided tickets to 40 foster children.
Thank You to Our Generous Sponsors:
$1,000 Level Sponsors • The Center for Cognitive and Behavioral Therapy • Nationwide Children’s Hospital $500 Level Sponsors • Accel Inc. • American Dairy Association Mideast • Andrew Garner, MD • Drs. Bill Cotton & Patty Davidson • Chuck Spencer, MD, & Pediatric Rheumatology * The Dave Thomas Foundation for Adoption • Edwin and Carol Hall • Judy Romano, MD • Krile Communications • Libby Ruppert, MD • Thad & Barbara Matta & family • William Knobeloch, MD Special Thank You to: • Frankie Hejduk, Columbus Crew Brand Ambassador • Dave Kaelin, Dave and Jimmy Morning Radio Show • Bob McElligott, color analyst for the Blue Jackets Radio Network • The Columbus Zoo & Aquarium • The Columbus Blue Jackets
Ohio Pediatrics • Spring 2013
Injury prevention by the numbers In the United States, a child or adolescent visits an emergency room once every second, and almost one-half of these visits are due to unintentional injuries. This accounts for an estimated cost of $4 billion per year.
In Ohio, the numbers of children from birth through 14 years old, are just as staggering:
166,032: The average number of children in Ohio
who are treated in Emergency Departments (ED) for unintentional injuries, annually.
3,274: The average number of children who are
admitted to a hospital for unintentional injuries in Ohio per year.
266: The average number of children who die from unintentional injuries in Ohio annually.
All of this leads to # 1. Unintentional Injuries are the number one cause of morbidity and mortality in children and adolescents. In fact, injuries cause more deaths to children less than one year of age than all diseases combined, including cancer, heart disease, and infectious diseases.
ers, decreased falls, and decreased home and auto passenger injuries. Pediatricians addressing the injury problem during office visits The Ohio Chapter, AAP conducted a membership survey in the fall of 2011 to determine the injury prevention anticipatory guidance at well-child visits per age for children younger than 12 months old in Ohio practices. This was later followed by observations of injury prevention documentation written in pediatrician’s charts. Injury prevention anticipatory guidance was documented less than half the time for all recommended topics. In the survey, physicians provided four common barriers to providing injury prevention anticipatory guidance at well-child visits: 1) Lack of time (80% of respondents reported) 2) Uninterested parents (29%) 3) No reimbursement (24%) 4) Lack of confidence in effective counseling (20%). Mike Gittelman, MD, Co-Principal Investigator for the Injury Prevention Learning Collaborative states “To address these barriers, the Ohio AAP launched the Injury Prevention Learning Collaborative in September 2012, which is highlighted by the development of a screening tool for use at each well-child visit to help pediatricians address age-appropriate injury prevention topics with families. These tools identify current high-risk behaviors and allow pediatricians to have needed discussions to prevent future injuries.” In addition to the screening tools, talking points are provided for each risky behavior to assure providers are comfortable with the anticipatory guidance they are asked to provide to families.
What is a pediatrician to do? Providing injury prevention anticipatory guidance at well-child visits has been shown to improve child and family functioning by changing the behavior of the family, and ultimately, reducing injuries. Bass and colleagues (Pediatrics, 1999) showed that injury prevention counseling during an office visit is associated with increased motor vehicle restraint use, safe home hot water temperature settings, the presence of smoke alarms in the house, and increased use of outlet cov-
How has this screening tool increased awareness for injury risk? To date, six practices throughout Ohio have participated in the Injury Prevention Learning Collaborative, and have gathered data on a monthly basis around whether providers addressed and documented injury prevention discussions with families at each of the well-child visits for children under 1 year of age. Prior to the start of learning collaborative, 45% of pediatricians documented that they addressed sleep safety See Numbers...on page 20
Ohio Pediatrics • Spring 2013
ffoundation oundation Pediatricians Pediatricians Standing Standing Behind Ohio’s Ohio’s Children Children
Foundation’s ea Foundation’s early rly liter literacy acy program provide pr rog ram continues to pr rro ovide books ocal pr practices actices books to llocal
focus each,, just like walking and craw wlin We want literacy wling. their children reach, skills to be just as impor tant.” or through throug the Foundation The grant that Drr.r Knobeloch applied ffor is being funded by the Ohio Depar tment of Health ealth (ODH).. ODH currently has a program called Help Me Grow, which primarily ser ves children ages 0-3 through early inter vention and home visits. “W We are keenly aaware ware that ages 0-3 are critical periods of brain development, and we understand that literacy and reading are key components to that development,” said Jessica Fosterr,r MD, ODH. “Children who are read to regularly and whose parents talk and interact with them on a regular basis are much more likely to come to school with good language skills and are ready to read. They are much more likely to grow into good readers throughout schooling.”
Children at last year’s year’s Foundation fundraiser, fundraiser,r,r Safety, Saffety etyy, y Sandwiches Sandw and Slapshots, listen to reading of Is Your Your Mama a Llama?
In 2012, the Ohio AAP Foundation continued to suppor t pediatricians in Ohio by providing them with new books to be used at well child visits through an evidence-based ear ly literacy program. Early Literacy grants were distributed to practices ffor or the th purchase of new and gently used books that were distributed to children throughout the state. Thanks to funding from the Ohio Depar tment of Health, by June of 2013 the Foundation will distribute more than 140,000 books to Ohio pediatricians.
“W We know that this investment in the Reach Out and Read program is an impor tant one,” said Drr.r Fosterr. “By suppor ting pediatricians and providing books to promote this efffor or t,, we’re suppor ting an impor tant par t of child brain development.” The Ohio AAP Foundation was established in 2000 to suppor t the Ohio AAP in advocating for for the physical health,, mental mental health,, saffety ety and education,, and prev p ention of cruelty of Ohio’s infants, ants,, children,, adolescents ERHXLIMVJEQMPMIWERHXSEHZERGIIHYGEXMSRERHVIWIEVGLXSFIRI½X infants,, children,, adolescents and their families.To le learn more, or donate, to the foundation, foundation,, visit v www w.ohioaap.orrg/foundation.
William Knobeloch, MD, the newest member of the Foundation Board and a big suppor ter of ear ly literacyy, recently applied plied ffor or an IEVP]PMXIVEG]KVERXJSVLMWTIHMEXVMGSJ½GIFIGEYWILIORS[WLS[ critical it is ffor or pediatricians to teach parents the impor tance of reading to their children. According to Drr.r Knobeloch, 88% of kids who are behind in school are actually capable of reading successfully; they’re simply not being exposed to language or books ear ly enough. “Pediatricians are in a unique position as a tr usted resource to parents of young children because we see them so often in the ½VWXXJIIEVW²WEMH(V/RSFIPSGL±;MXLXLI6IEGL3YXERH6IEH program, we can help make reading a milestone that parents help
Ohio Pediatrics • Spring 2013
Chapter...from page 1 programs in Ohio.
• Enacted Ohio concussion laws regarding return-to-play.
• Advocated for Medicaid expansion. • Sponsored Adolescent Vaccine Roundtable; discussions resulted in a Quality Improvement program to be initiated in the state. • Distributed more than 1,100 foster care bags with portable medical records. • Received $215,000 grant from the Centers for Disease Control and the Ohio Department of Health (ODH) to continue the Maximizing Office Based Immunization (MOBI) program. • Received a $7,500 grant from Honda for bike helmets.
• Received a $200,000 grant from ODH for early literacy books.
• Received a $340,000 grant for BMW and $212,000 for the obesity program from ODH, GRC and Medicaid. • Received a $60,000 grant for Injury Prevention from Emergency Medical Services for Children. • Received a $75,000 grant from CareSource for the Chapter’s asthma initiative.
• The Ohio AAP Pediatric Care Council put together a Health Plan Assistance Guide with a list of phone numbers of medical consultants and major Ohio insurers. (You can find a copy on page 21 in this issue.)
=SYFYMPH]SYVTEXMIRX VIPEXMSRWLMTWSREJSYRHEXMSR SJXVYWX7SHS[I Physicians across the country turn to ChildLab because we care about your patients as much as you do.
Adolescent immunization discussed at Roundtable
Forty experts gathered for the Ohio AAP Adolescent Immunization Expert Roundtable in April. Speakers provided background on the issue of adolescent immunizations in Ohio, as well as resources available, before attendees were invited to provide feedback as part of a focus group. The day began with an overview of the issue provided by Michael Brady, MD, Physician-in-Chief at Nationwide Children’s, and an infectious disease expert. Dr. Brady explained current regulations and issues facing four key adolescent vaccines, including TDap, Meningococcal, HPV, and Influenza. This was followed by an update on available resources by Tina Bickert, MA, Health Planning Administrator for the Ohio Department of Health. Following a panel discussion over lunch, attendees broke into two focus groups to provide their opinions on the adolescent immunization issue and the future of an Ohio AAP Quality Improvement program on this topic. Some interesting observations from the focus group included:
For a complete list of our pediatric laboratory tests and pathology services, visit www.childlab.com or call 800-934-6575.
• Parents who choose to vaccinate will also be those
See Roundtable...on page 23
Ohio Pediatrics • Spring 2013
Wave 2 of BMW coming to a close The 12 primary care practices participating in Wave 2 of the Building Mental Wellness (BMW) Learning Collaborative are nearing the end of their nearly eightmonth commitment to improving mental wellness within their practices. After months of data entry, action period calls and PDSA cycles, I am happy to share that this second group of practices will be completing the project in June. Just as in Wave 1, participating physicians received 25 Part IV MOC credits for their participation in the project. More importantly, these clinicians were given the opportunity to truly transform the way that mental health is addressed within their practice. On behalf of the BMW Project Team and the Chapter, I would like to thank and acknowledge the following practices: • Akron Children’s Hospital Pediatrics – Green • Children’s Health Clinic of Dayton
• Locust Pediatric Care Group (Akron)
• Oxford Pediatrics and Adolescents (Oxford, Brookville, Ross) • Partners in Pediatrics (Westlake) • The Pediatric Group (Piqua)
• Pediatric Associates, Inc. – Hilliard, Lewis Center, Whitehall, Pickerington • Pediatric Associates of Springfield • Wilmington Medical Associates
As mentioned in the last issue of Ohio Pediatrics, we
are currently in the planning phase of Wave 3 of the BMW Project. This wave of the project will take successful elements from the first two waves and incorporate them into a new format that will allow the project team to provide practices with more individualized learning. Additionally, we plan to allow providers to have the opportunity to “put their toes in the water” through a variety of online learning modules that will allow pediatric practitioners to commit to changes in their practice at a level that is comfortable and convenient for them. In another effort to help spread the project around the state, there will be four learning sessions to allow providers to learn a lot without travelling a lot. The learning session locations and times are tentatively scheduled for: • Oct. 12 – Toledo Museum of Art, Toledo
• Nov. 9 – Athens Community Center, Athens
• Feb. 22, 2014 – Cincinnati
• April 26, 2014 – Cleveland If you are interested in finding out additional information about the BMW Project, or if you would like to stay informed about the plans for the next wave of the project, please contact Sean O’Hanlon, BMW Project Manager, at firstname.lastname@example.org or (614) 846-6258. John Duby, MD BMW Medical Director
Immunization Conference: Keeping your vaccines, your community, and your bottom line healthy The recent introduction of the Affordable Care Act and changes to billing and coding practices has substantially impacted physicians, providers, health-care workers and the public alike. The 2013 Statewide Immunization Conference presented by immunizeohio.org – The Consortium for Healthy & Immunized Communities Inc. – focuses on effective strategies to
improve the systems for immunizing adults, teens and children. Topics will include: Immunization Update, Billing and Coding, Impact of Health Care Reform on Vaccine Payment and Delivery, New Recommendations in Storage and Handling, Vaccination of Pregnant Women, and more. Who should attend? Physicians, nurses, nurse practi-
tioners, office staff and public health professionals. The conference will be held Oct. 18, 2013 at the 100th Bomb Group Restaurant, 20920 Brookpark Rd., Cleveland, from 7:30 a.m. to 4:15 p.m. Cost: $75 (nonphysician); $85 (physician). Registration opens July 1 and closes on Oct. 1. For more information visit www.immunizeohio.org.
Ohio Pediatrics • Spring 2013
Ohio AAP's asthma program: Improvement for pediatricians and their patients Editor’s Note: The following article appeared in the March issue of “To Your Health” in The Columbus Dispatch. It is reprinted with permission. By Misti Crane The Columbus Dispatch
Ohio pediatricians working together to keep young asthma patients well have seen significant improvements, prompting more doctors to join the effort. The Ohio Chapter of the American Academy of Pediatrics’ project is part of a national effort to improve quality of life and keep kids in school and out of the hospital. The last round of the project in Ohio, which ran from September 2011 to October 2012, concluded with a significant cut in missed school days, missed work days for parents, and urgent-care and emergencydepartment visits. The academy evaluates “optimal care” using a number of factors and has reported that the medical practices are seeing good results. From September to August, the practices went from delivering “optimal care” from 50% of the time to 80% of the time. Starting in March, more pediatricians have joined a new round of the project. In all, 42 practices are involved. To improve care, doctors follow certain guidelines for identifying and caring for asthma patients, including finding the best medication to keep the disease under control and limit flare-ups. Elizabeth Dawson, the director of education at the Ohio Chapter and the project’s leader, said the most important thing participants are doing is creating “asthma action plans” for patients. The plans detail the optimal care for each child based on his or her circumstances. Some children have particular problems with seasonal allergies, for instance, while others have asthma typically aggravated by exercise. Parents are encouraged to keep a diary that tracks asthma attacks to try to better
identify triggers, she said.
William Long, MD, who works at Pediatric Associates of Pickerington, said this project gives doctors concrete goals and measurements, which have made a difference. At his practice, more time is now devoted to patient education, and there is more focus on spirometry tests, which measure lung function, Dr. Long said. He said he was surprised to learn that at the beginning of the project, his practice met all the best standards with 17 percent of patients. Now, it’s 80 percent. For Zion Fitzgerald, a 13-year-old from Reynoldsburg who goes to Long’s practice, good asthma control has meant taking oral medications every night. When Zion was younger, he relied on an inhaler and had frequent and frightening asthma attacks. A few times, his parents had to call an ambulance, said his father, Garvin Wilson. Now, he has an inhaler for emergencies but doesn’t have to use it often. Dr. Jerry Tiberio, who practices at Muskingum Valley Health Center in Zanesville, said that participation has prompted better education of doctors and nurses. One area that requires vigilance is making sure children understand how to use their inhalers. “I think most parents want to do what’s right for the children, but sometimes it just doesn’t play out,” Tiberio said. Dr. Suzanne Gunter, a Brown County pediatrician, recently joined the quality-improvement effort and said her practice will benefit from standardizing asthma care for kids. “This puts it in a more-structured form so people don’t fall through the cracks,” she said.
Ohio Pediatrics • Spring 2013
GUIDELINES FOR PHYSICIANS
Performance Enhancing Substances
A performance enhancing substance (PES) is any substance taken in non-pharmacologic doses specifically for the purpose of improving sports performance. This includes substances taken in supratherapeutic doses or without therapeutic indication, those taken for weight gain or weight loss, those used to increase oxygen carrying capacity, and any agent used to mask detection of, or minimize, the side effects of another PES. Examples include anabolic androgenic steroids (AAS), steroid precursors or prohormones, human growth hormone (hGH), creatine, stimulants such as ephedrine and caffeine, erythropoietin (EPO), diuretics, laxatives and nutritional supplements. This article will focus on the more commonly used substances in the pediatric population. Epidemiology Boys are 2-3 times more likely to use PES than girls and those that use alcohol, tobacco and other illicit drugs are also more likely to use PES. PES use is more common in athletes than in non-athletes, especially those involved in sports that rely mostly on strength, power and speed. However an estimated 3040% of adolescents that use PES do not participate in a school sport, but instead take them to improve their physical appearance and self-esteem. Usually these substances are acquired from a physician, health food stores, at the gym, or the Internet. Prevalence rates vary somewhat from study to study but in general show: Anabolic Adnrogenic Steroids 4-6% of adolescent boys 1-3% of adolescent girls 1.5% of junior high students
Creatine or other protein supplement 11-35% of adolescent boys 30-40% of college athlete
Nutritional Supplements Up to 58% of high school athletes; Up to 88% of college athletes
AAS and Steroid precursors AAS are synthetic testosterone derivatives taken orally, transdermally, or by injection that have anabolic and anti-catabolic, as well as emotional effects, which promote muscle building. They are classified as schedule 3 controlled substances. AAS have been shown to increase strength and lean body mass through muscle hypertrophy as well as the formation of new muscle fibers. They also have numerous adverse effects which involve nearly every body system (see table at right). Steroid precursors or prohormones are testosterone precursors taken in an attempt to increase testosterone levels and achieve effects similar to AAS. Studies have shown that they do neither. They do, however, have many of the same side effects as AAS. Stimulants The stimulants most commonly used as PES are ephedrine and caffeine. Ephedrine is the active ingredient of the herb ephedra, which was banned by the FDA in 2004 after being linked to numerous deaths. Ephedrine, however, is still accessible in over-the-counter cold medicines. These substances work as PES by increasing heart rate, contractility and blood pressure, increasing central nervous system stimulation and decreasing the perception of exertion during activity. Caffeine, especially, has been shown to increase performance in endurance sports although its influence on shorter bursts of activity is less conclusive and it may even impair functioning at higher doses. Stimulants can produce numerous adverse effects including arrhythmias, diuresis, increased core body temperature, tremors, anxiety and seizures.
Nutritional Supplements The term nutritional supplement generally refers to substances such as protein/amino acid preparations, trace elements, vitamins, minerals and herbal preparations. Creatine, a complex, non-essential amino acid, is the most popular supplement used as a PES. It is thought to increase muscle mass and strength, shorten recovery times during workouts and increase training load overall. It does appear to improve strength and performance in short-duration, anaerobic events but has little effect on endurance activities. Also, up to 30% of people seem to be “non-responders” to creatine, likely because they have already maximized creatine stores in the body through dietary
Side effects of Anabolic Androgenic Steroids (AAS) Cardiovascular • Increased LDL • Decresed HDL • Thrombus formation • Coronary vasospasm • Hypertension
Hepatic • Elevated LFTs • Cholestasis • Hepatocellular adenomas
Reproductive/Endocrine Males • Testicular atrophy • Decrease spermatogenesis • Gynecomastia • High pitched voice Females • Amenorrhea • Breast tissue atrophy • Deepened voice • Clitoromegaly • Hirsutism
Infectious • Soft tissue & muscular abscesses • HIV/Hepatitis risk Musculoskeletal • Increased likelihood of tendon rupture • Physeal arrest Dermatologic • Severe acne • Striae • Premature balding Psychiatric • Mood swings • Hypomania • Mania • Depression • Decreased libido • Aggression • Addiction • Withdrawal
intake. Commonly reported side effects include weight gain through water retention, muscle cramps, diarrhea and rarely impaired renal function. The larger problem with nutritional supplements is that they are not regulated by the FDA. This means that manufacturers do not have to prove the safety or efficacy of their products. Multiple studies have shown that stated ingredients are often missing or present at levels much higher than what has been reported on the label. Also, steroids and stimulants have been shown to be present in up to 25% of nutritional supplements. Prevention Drug testing is widely used as a deterrent at the collegiate, professional and amateur elite levels of sports but is more problematic in the school-aged population because of time constraints, high cost, and a relatively low yield of positive tests which occurs for a variety of reasons. On the other hand, education, in the form of interactive classroom and training activities led by coaches and peer leaders that teach kids about the side effects of PES and ways to reject offers to use them, have been shown to decrease the reported use of these substances. Other tips for physicians in dealing with the use of PES • Encourage discussion of PES during yearly pre-participation exams. • Be honest – Acknowledge that some PES do work, but emphasize that many of these gains are incremental improvements that may help elite athletes much more than the typical school-aged athlete. • Discuss the side effects that are most likely to have an immediate impact on the adolescent’s appearance or performance. • Screen for use of other substances (alcohol, tobacco, illicit drugs). • Describe alternative ways to improve performance - nutrition or utilizing a certified strength and conditioning coach.
Ohio Pediatrics • Spring 2013
GUIDELINES FOR PARENTS
Performance Enhancing Substances
A performance enhancing substance (PES) is any substance used in a way in which it wasn’t intended or prescribed, specifically for the purpose of improving sports performance. This includes substances taken in higher than normal doses or without a true medical reason, those used to gain or lose weight, those taken to help the body use oxygen more efficiently, and any agent used to cover up the use of, or minimize, the side effects of another PES. Examples include steroids, human growth hormone (hGH), creatine, stimulants such as ephedrine and caffeine, erythropoietin (EPO), water pills, laxatives and nutritional supplements.
WHO IS MOST LIKELY TO USE PES? • Boys more than girls • Kids that use alcohol, tobacco and other drugs • Athletes more than non-athletes • Football, baseball and basketball players, gymnasts, wrestlers, weightlifters and track athletes • Kids that are trying to improve their physical appearance WHERE DO KIDS GET PES? • From their physician • At the gym • On the internet • Health food stores
HOW DO THEY WORK? Most PES are taken to build muscle and increase strength. Steroids, hGH and creatine have all been shown to improve strength to varying degrees in studies of adults. Stimulants and steroids can also increase energy levels, allowing for more frequent, prolonged or intense workouts. hGH and creatine have been shown to increase athletic performance in short-duration exercise such as sprints, while stimulants tend to help more with endurance events. WHAT’S THE DOWNSIDE TO USING PES?
Many of these substances are illegal if obtained without a prescription from a doctor, and all have potential side effects, some more dangerous than others. The Ohio High School Athletic Association (OHSAA) policy states that students using PES will be ineligible for competition.
WHAT TO LOOK FOR IF YOU SUSPECT YOUR CHILD IS USING PERFORMING ENHANCING SUBSTANCES
• Rapid gain in strength or muscle bulk • Severe acne on the face, chest and back • Premature balding • Stretch marks • Growth of breast tissue, shrunken testicles, highpitched voice (boys) • Menstrual irregularity, deepened voice, excess hair growth, loss of breast tissue (girls) • Mood swings/aggressive behavior/depression
What about supplements? Many times nutritional supplements are thought to be safe because of their name. Unfortunately, these substances are not regulated by the FDA and therefore little is known about the actual ingredients they contain. Oftentimes supplements list misleading information on their labels and lack some or all of the stated ingredients. Studies have shown supplements are sometimes contaminated with steroids or stimulants. Prevention Most states, including Ohio, do not test for PES at the high school level and below because it is expensive and relatively few positive tests are found. If you are concerned that your child may be using PES, explain the negative effects that can result, emphasizing disqualification from sport and the adverse effects to physical appearance. If the child is actively trying to improve performance, make an appointment with a registered dietician to discuss proper nutrition or to have him/her work with a certified strength and conditioning coach to make sure workouts are structured in the most beneficial way.
This information is available on the Ohio AAP website www.ohioaap.org
Author: Steven Cuff, MD, Nationwide Children’s Hospital Sports Medicine
Ohio Pediatrics • Spring 2013
District V Report
Facing warm weather challenges Have you ever thought about how the imminent change of weather in our temperate climate affects your practice?
Does the focus of your patient discussion change from fever and influenza to anticipatory guidance about the events of summer? I would propose that it should, Marilyn Bull, MD and that you might like to consider some of the risks and hazards that will accompany our children as they venture out into the world in the weeks and months ahead. First, the vehicle miles traveled will increase significantly and it is important to provide the anticipatory guidance that infants and young children should ride rear facing in car seats to the highest weight or height allowed by the manufacturer of a convertible seat (usually 35-40 pounds). Just having a medical caregiver say, “Children are 500% less likely to die or have serious injury in the second year of life when rear facing than forward facing” can make a huge difference to a parent. Using seats with full harnesses as long as possible and booster seats to 4’9” is also important advice, and do not forget the teens behind the wheel and urging parent involvement in the early driving experiences. Deaths and injuries in and around cars including backovers as toddlers become mobile, and hyperthermia/heat stroke when children are forgotten or “left for just a minute” in cars also escalate in summer months. Do you know that the temperature in even a partially closed vehicle can reach 125 degrees Fahrenheit in minutes? This is also the season for opening pools and going to the beach. Parents must ensure close “touch supervision” in the pool and use of personal floatation devices whenever in or near the water. Avoidance of the tragedy of a drowning, or near-drowning, is something for which you most likely will not be thanked, but about which only you will know when the counseling has been provided.
Cycling is wonderful exercise for our youth and reminding parents and young people that 70% of bike fatalities occur from head injuries and that bike helmets worn correctly are 85% effective for prevention of head injury is another important message. Helmet use starting with tricycles to establish consistency of behavior is also important to emphasize. Anticipatory guidance is expected, appreciated and heeded by families and caregivers. The concern of a pediatrician is a strong and effective message. Resources to help you provide the best messages possible are found in Bright Futures, Healthychildren.org and at AAP.org. I leave you with a reminder to watch for the announcements about the upcoming registration for the AAP National Conference and Exhibition (NCE) 2013. The kickoff event will be a Peds 21 pre-conference program on Oct. 25, which will address the critical topic of Early Brain and Child Development. This, and a packed NCE Program, are not to be missed. Marilyn Bull, MD District V Chair
CATCH Grant recipients
The following Ohio physicians have been awarded 2013 CATCH Planning Grants: • Patricia Gabbe, MD, Nationwide Children’s, Columbus. Project: “The Children of MOMS2B” • Gregg Kottyan, MD, and Leah Kottyan, PhD, Blue Ash. Project: “Avondale Moves!” • Orville Bignall, II, MD, Cincinnati. Project: “Empowering Fathers as Child Health Advocates” The CATCH Planning, Implementation, and Resident Grants “Call for Proposals” is now open. The deadline for submission is July 31, 2013 at 2 p.m. CDT. For more information and assistance, contact Heng Wang, MD, PhD, State CATCH facilitator, at email@example.com.
Ohio Pediatrics • Spring 2013
‘Breastfest 2013’ suggests engaging pharmacists in breastfeeding discussions As new Chapter Breastfeeding Coordinators (CBC) we appreciated an invitation from the organizing committee of the Ohio Lactation Consultants Association (OLCA) to participate in their annual meeting “Breastfest 2013,” held in Dublin, Ohio, March 15-16. We used this terrific opportunity to meet each other in person for the first time, to network, and to showcase the AAP and its Section on Breastfeeding. The conference included several great presentations. Arthur James, MD, Co-Chair of the Ohio Collaborative to Prevent Infant Mortality (Ohio Department of Health) gave a “wake up call” talk about
Ohio’s Infant Mortality Rate (IMR), which is disturbingly high at 7.9 per 1,000 live births (national average 6.05), up from 7.7, and with a worrisome racial disparity (African-American IMR 15.8). Breastfeeding promotion is Sarah Riddle, MD, IBCLC, Tara Williams, MD, one of several strate- and Lydia Furman, MD, at the Ohio gies being actively Lactation Consultants Association annual pursued. Roger Edwards, MD, spoke about enpharmacists prior to hearing this gaging pharmacists in the breastgreat presentation. feeding discussion, and it opened up a whole new arena for particiWe talked about our role as CBCs pants to consider. None of us had in supporting breastfeeding in even thought about a role for Ohio. We displayed a poster describing activities and initiatives of the Section on Breastfeeding, CBC duties, and information on the AAP’s online breastfeeding curriculum. We received a great reception with an invitation to return next year.
40thAnnualPediatricsforthePracticingPhysicianSymposium Program Supported by: The University of Toledo, College of Medicine and Life Sciences Department of Pediatrics Mercy Children’s Hospital, Toledo Children’s Hospital and The Ohio Chapter of the American Academy of Pediatrics
Friday, September 27, 2013 7:30am - 4:30pm and Saturday, September 28, 2013 8:00am - 1:00pm Location: Hilton Garden Inn-Levis Commons, Perrysburg, OH For more information, go to Website:
cme.utoledo.edu or call 419-383-4237
Laurie Nomsen-Rivers, MD, spoke on delayed onset of lactogenesis with up-to-date scientific data. Breakout sessions included: “Ethics, Marketing and the WHO Code,” and “Treatment of Tongue Tie,” and challenges of breastfeeding for first-time mothers. The final presentation was given by Tina Carderelli the Indiana Perinatal Network Breastfeeding Coordinator, who has been an active agent of change in Indiana. For details go to OLCA website (http://www. ohio-olca.org/ contrib/confconfhome.shtml). Sarah Riddle, MD, Tara Williams, MD, and Lydia Furman, MD
Ohio Pediatrics • Spring 2013
Earn 20 points toward your Part II MOC requirement at Annual Meeting On Saturday, Sept. 21 at the Ohio AAP Annual Meeting 2013, you can earn 20 points toward your Part II MOC requirement while receiving expert instruction in the area of sports medicine. Kelsey Logan, MD, FAAP, will lead an interactive group session where you will not only answer the questions of the sports medicine self-assessment, but also have the opportunity to ask questions and hear more details about the resources used to complete the assessment. This session is scheduled from 10:30 a.m. – 12:30 p.m. on Saturday; all participants will receive copies of the resources in advance, and you will need to bring your laptop.
“Annual Meeting is an investment of time that I happily make each year…not only for the continuing educational opportunities, but for the networking with colleagues throughout the state, the chance to hear about upcoming trends in our profession and the opportunity to meet and talk with like-minded professionals who offer diverse perspectives on issues that we face each and every day.” – Allison Brindle, MD, Ohio AAP Young Physician
Attendees will receive an additional 10 CME credits just for this session, 7.5 credits are available for the rest of Annual Meeting.
Pre-Annual Meeting Advocacy Workshop at the new Ohio AAP Chapter office in North Columbus on Sept. 19.
Annual Meeting will be held Sept. 20-21 at the Columbus Sheraton Hotel on Capitol Square, with a
Other topics and events that will be featured during Annual Meeting include:
See Annual Meeting...on page 27
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Ohio Pediatrics • Spring 2013
Drowning incidents on the rise As what seems to me to be the longest, coldest, wettest, grayest winter of all times, finally draws to a close, there is a hint of warmth and sunshine in the air. And with that warmth and sunshine, sadly will also come the predictable increase in drowning and near drowning incidents around Ohio and nationwide. In Ohio, drowning is the 2nd leading cause of injury death in young children, with an average of 34 Ohio children ages 1-19 dying from drowning every year. The summer months, May-August see a 119% increase in drowning deaths among Ohio youth. Knowing these trends, we should be increasing our water safety discussions at well-child visits throughout the summer.
By age: • < 1: most of the drowning deaths in infants occur in the home: bathtubs, toilets, buckets. • 1-4: Drowning is the leading cause of injury death in children ages 1-4, most commonly drowning in swimming pools. • Adolescents: most likely to drown in natural bodies of water, and these drowning deaths often involve substance abuse. Who is at risk? Nearly 80% of drowning deaths occur in males. From ages 0-4 years, white males had the highest rate of drowning deaths, but from 5-14 the drowning fatality rate in African American males is almost three times that of white children. These deaths are PREVENTABLE! • Installation of four-sided fencing is the only environmental prevention proven to be effective in toddler drowning. • Most toddlers enter a pool from their home through an unprotected side of the pool. • Four-sided fencing is associated with a >50% decrease in pool immersion injuries,
AAP recommendations for newborn to 5 years • Never leave a child alone near a bathtub, pool, water bucket, even open toilets. • Residential pools should be surrounded by a foursided fence. • Pool covers are not a substitute for four-sided fencing. • “Touch supervision” is recommended for infants or children while around water. • Parents should inquire about exposure to water and water-related activities for out-of-home child care. • Do not use flotation devices as a substitute for supervision or in place of life preservers. • Keep rescue equipment and a telephone by the pool. • All parents, caregivers, and pool owners should learn CPR. • Swimming lessons are not developmentally appropriate until age 4. • Use approved flotation devices when riding in a boat, or when at risk of falling into water. AAP recommendations for 5-12 years • Teach children to swim but realize limitations. • Teach children to never swim alone or without adult supervision. • Be aware of underwater hazards – feet first, first time. • Use approved flotation devices when riding in a boat or when at risk of falling into water. • Recognize drowning risks during the cold seasons. • Constant supervision is needed for children with seizure disorder. AAP recommendations for adolescents • Counsel about the dangers of alcohol use during aquatic activities. • Be aware of underwater hazards – feet first, first time. • Use approved flotation devices when riding in a boat. • Teens should learn CPR. Sarah Denny, MD, Co-Chair Injury Prevention Committee
Ohio Pediatrics • Spring 2013
Obesity management improves with Pound of Cure Learning Collaborative As a pediatrician, how do you define success when it comes to your overweight or obese patients? Is success defined by tangible outcome measures such as weight loss, a decrease in body mass index (BMI), or a decrease in the child’s blood pressure? Or do you define success by the increased knowledge a family has about the importance of eating breakfast or getting enough sleep?
The providers who are participating in the Pound of Cure Learning Collaborative unanimously said they have changed the way they define success in weight management since starting the collaborative either in January 2012 or July 2012. Now, definitions of success for these providers, include: • Having a patient attempt a lifestyle change because they have learned about nutrition and understand why past behaviors have been unhealthy. • No weight gain, or slower weight gain, especially for children who are growing in height and can grow into their current weight. • Applying new behavior changes. • Parental understanding of potential adverse effects of overweight status, and their willingness to address the problem. “The Pound of Cure project takes the overwhelming task of managing obesity and makes it manageable. The Pound of Cure toolkit provides a system for identifying problematic habits and pairs
each area of concern with specific patient education handouts to evoke lifestyle change. This practical approach has resulted in much healthier lifestyles for my overweight and obese patients, and has even trickled down to improved habits for my healthy weight patients,” wrote one current Pound of Cure provider in an anonymous survey.
A Pound of Cure is a training program for obesity counseling in primary care. Training and resources are offered to clinicians to aid them in evaluating, interviewing, educating, tracking, and following up with overweight and obese children and their families. Wave One of the Learning Collaborative launched in January 2012 and half of the practices registered for Wave One, continued to participate in Wave Two of the collaborative, which launched six months later. Wave One was targeted at patients 211 years old identified as overweight or obese at well-child visits. Wave Two added patients 1218 years old, to provide continuity of care throughout all ages. While clinicians have refined their definition of success for their patients, they have made progress toward the outcome measures to ensure their patients are meeting their goals along the way. Providers have been expected to measure BMI at each visit, as well as take it one step further and document an overweight (>85th BMI percentile) or obesity (>95th BMI percentile) diagnosis. During the collaborative, providers have
consistently documented BMI in the patient’s chart above the goal of 90% of the time. Actually documenting overweight or obese in the chart has been more sporadic for the providers, but is improving toward consistently measuring around the 90% goal line. Documenting blood pressure at initial and follow-up visits has also constantly been measured at 100% during the collaborative, however documenting blood pressure category (normal-tensive, pre-hypertensive, or hypertensive) has steadily increased from less than 10% of patients at the start of each wave of the collaborative, to 100% at the end of the collaborative. Project Manager, Samantha Anzeljc, PhD, explained, “Without identifying the child’s blood pressure as either pre-hypertensive, or hypertensive, it is difficult to recommend a treatment plan, or difficult for parents and children to understand why an elevated blood pressure is a concern for the child’s health.” The development of a blood pressure slide rule tool has been instrumental in aiding practices in increasing their diagnosis of hypertension or pre-hypertension. Melissa King, MD, from Children’s Health Clinic in Dayton recently said, “these tools have allowed us to identify those risk factors more accurately; they have been a valuable tool for us, and our families.”
See Pound...on page 23
Ohio Pediatrics • Spring 2013
Numbers...from page 8
with parents of newborns, 38% addressed sleep safety with parents of 2-month olds, and 39% with parents of 4-month olds. This is comparable to the information from the 2011 Ohio AAP survey comparing reported discussion versus documented discussion, as outlined in Figure 1 below. Six months later, 82%, 86%, and 89% of pediatricians in the collaborative addressed and documented sleep safety with parents at the newborn, 2-month and 4-month well-child visits respectively. This increase in discussion is believed to reduce the incidence of infant death due to suffocation. Figure 1: Reported vs. Documented Injury Prevention Anticipatory Guidance Discussions for Children <1 Year at Well-Child Visits
Similar increases in discussion of car safety, fire/burn safety, family interactions, supervision, fall prevention, water safety, choking prevention, unintentional ingestions, home safety, and play safety have occurred, although not all to the same extent. “The injury prevention tool has been successfully used in primary care practices. It works to determine specific high-risk behaviors so that the pediatrician can concentrate only on those issues families screened at risk; enabling them to maximize their time with the family,” Dr. Gittelman says. What’s next? The pilot phase of the Injury Prevention Learning Collaborative is wrapping up this month, with plans to launch a second phase in October. This phase will condense the screening tool and allow the project team to determine changes made by families in response to recommendations made by their pediatrician. For more information, please see the article at right.
Participate in Phase Two of the Injury Prevention Learning Collaborative
Former United States Surgeon General C. Everett Koop, MD, once said “If a disease were killing our children in the same proportions as injury, we would be outraged and demand this killer be stopped.” Join the Ohio AAP in reducing the risk of injury to children from birth to 1 year old by participating in the Injury Prevention Learning Collaborative. Mark your calendar to attend the day long learning session in Columbus on Friday, Oct. 18, 2013. At this learning session, you will be trained in the use of the screening tools that will be given to parents during well-child visits, and the corresponding talking points for each section of the screening tool. Providers will also receive training in quality improvement topics to help them make changes within the practice to be successful. Benefits to participating in the Injury Prevention Learning Collaborative include: 1) Participating pediatricians will receive 25 Part IV Maintenance of Certification credits as approved by the American Board of Pediatrics. 2) Each practice will receive tools and talking points to address injury prevention issues for children less than 1 year of age that will maximize time spent with families. 3) Each practice will potentially receive $1,000 stipend for participating, depending on grant funding for the collaborative. For more information, contact Sean O’Hanlon at firstname.lastname@example.org, or (614) 846-6258.
Ohio Pediatrics • Spring 2013
Health Plan Assistance Guide
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Ohio Pediatrics • Spring 2013
Proper vaccine handling and storage is important
Proper vaccine storage and handling is of the utmost importance to ensure that vaccines retain their efficacy and that patients receive the best possible protection against vaccine-preventable diseases. Unfortunately, proper vaccine storage and handling can sometimes be challenging for physician offices. These challenges were recently noted in a report released by the U.S. Department of Health and Human Services (HHS) Office of the Inspector General (OIG) this past summer, after the OIG had undertaken a study to assess the vaccine management of Vaccines for Children (VFC) providers. The report, titled “Vaccines for Children Program: Vulnerabilities in Vaccine Management,” described some vaccine management practices that increase the chance that an ineffective vaccine may be administered to a patient. The OIG study showed that the VFC vaccines stored by 76% of the 45 selected providers were exposed to inappropriate temperatures for at least five cumulative hours during a two-week time period. Exposure to inappropriate temperatures can reduce vaccine potency, increasing the chance the patient will not develop protective antibodies against the vaccine-preventable disease for which the vaccine was administered. Thirteen providers stored expired vaccines together with nonexpired vaccines, increasing the risk of mistaken administration of expired vaccines. To read the full report, go to: https://oig.hhs.gov/oei/ reports/oei-04-10-00430.pdf. While the OIG report only addressed the storage and handling of VFC vaccines, non-VFC or private stock vaccines would likely be similarly affected since VFC and non-VFC vaccines are usually stored and handled in a similar manner. All vaccine providers and their office staff that handle or administer vaccine should be aware of proper vaccine storage and handling procedures. Physician offices should have internal policies that safeguard the efficacy of all vaccines, both VFC and private stock. Since the issuance of the OIG report, the Centers for Disease Control and Prevention (CDC) has worked to help providers assure that vaccines are effectively stored and handled. CDC has updated the Vaccine Storage and Handling Toolkit as a tool for VFC and non-VFC healthcare providers to assimilate new vaccine storage and handling standards and updated VFC protocols and requirements for all VFC providers to assure vaccines are managed effectively. The Ohio Department of Health (ODH) has also updated policies and practices to work more closely with VFC providers and community partners to improve vaccine storage and handling procedures. The Immunization Program provides a variety of services to VFC vaccine providers, including vaccine administration, storage and handling education,
Tips for proper vaccine storage
1. Designate primary and secondary vaccine coordinators in the office to manage daily vaccine monitoring, storage, ordering, etc. 2. Download and review the CDC’s Vaccine Storage and Handling Toolkit at http://www.cdc.gov/vaccines/recs/storage/toolkit/ default.htm.
3. Store vaccines with adequate space for air circulation in the storage unit; never store vaccines in the door or drawers of the refrigerator. Use appropriate refrigerators for vaccine storage; never use a dormitory-style refrigerator.
4. Use a certified, continuousreading thermometer to monitor storage temperatures. 5. Record storage temperatures twice daily each day that the office is open, on a paper log.
6. If storage temperatures go out of range, immediately contact vaccine manufacturers to determine whether or not the vaccine is still viable. 7. Utilize proper vaccine rotation so that short dated vaccines are used first and immediately remove expired vaccines from the storage unit.
8. Set target storage temperatures for vaccines in refrigerators at 40°F. This will help to assure that refrigerated vaccines will not be exposed to temperatures below 35°F.
See Vaccines...on page 23
Ohio Pediatrics • Spring 2013
Vaccines...from page 22
technical assistance and quality assurance. The materials that have been developed are posted on the ODH website and non-VFC providers are welcome to review them as well for guidance in developing office policies and procedures for their non-VFC vaccine. ODH’s Vaccine Handling and Wastage Policy provides a framework for appropriate vaccine management and prevention of VFC vaccine wastage. The policy, along with a variety of other resources for safe vaccine storage, handling and administration can be found on ODH’s website, http://www.odh.ohio.gov, under the Immunization Program – Vaccines for Children and can be used by both VFC and non-VFC providers to guide the development of office policies and procedures for handling and administration of all vaccine, both VFC and private stock. It is recommended that all vaccine providers record vaccine storage unit temperatures twice a day for each day that the office is open, including the VFC providers who use ODH-provided, continuous-reading temperature data loggers. If vaccine storage temperatures deviate from the recommended range, immediate action must be taken to restore appropriate storage temperature or relocate vaccine to a properly functioning storage unit. Roundtable...from page 10
who have had a personal experience with the disease. • The biggest problem is getting adolescents into the doctor’s office. There is also the case of missed opportunities in giving vaccines when a teen does comes in for a sick visit. • Teenagers are given the option to make vaccine decisions, and that shouldn’t be the case. • Establishing a rapport with the child seems to ease fears and increase buy in.
The focus group comments will be used to design a QI Program to address the issues of adolescent immunization. For more information, please contact Elizabeth Dawson at edawson@ohioaap. org or (614) 846-6258.
The ODH provided data loggers for VFC providers are programmed to read temperatures every 30 minutes and then trigger a red light alarm if temperatures are out of range for three consecutive readings. When VFC providers check temperatures twice daily, data loggers should be observed for at least 20 seconds to ensure the light is flashing green and the red alarm light has not been triggered. If the red light alarm is flashing, the VFC provider must contact the ODH Immunization Program immediately at (800) 282-0546. The Immunization telephone number is staffed Monday – Friday, 8 a.m. – 5 p.m. by employees trained to assist with vaccine storage and handling questions and concerns. ODH should always be notified when VFC vaccine has been exposed to a cold chain failure. Taking these simple steps to ensure appropriate vaccine storage and handling will reduce the risk of administering nonviable vaccine. For additional information regarding vaccine administration or storage and handling, visit the CDC’s vaccine page at http:// www.cdc.gov/vaccines or call the ODH Immunization Program at (800) 282-0546.
Pound...from page 19
With the collaborative coming to a close, each practice plans to continue using the Pound of Cure materials, although many practices are adapting the visit structures to suit their practice needs. The majority of providers have discussed expanding the identification of overweight or obese patients to all patient visits, not just wellchild visits. Another survey provider wrote, “The Pound of Cure handouts and tools are essential for helping families with age appropriate health living strategies. The tools are a one-stop-shop for information on a very large variety of areas of interest or educational need. There is something of value for everyone. These tools are an essential starting point for any general pediatric practice.” The Project Team congratulates the five practices who have participated in both waves: Ashtabula County Health Department; Child and Adolescent Specialty Care of Dayton, Pediatric Associates, Inc; Wheeling Hospital Center for Pediatrics; and Wilmington Medical Associates; as well as the five practices that participated in Wave Two: Children’s Health Clinic; Cleveland Clinic Twinsburg; Kunz Medical; Pediatrics of Massillon; and Toledo Children’s Primary Care.
Ohio Pediatrics • Spring 2013
Bike Helmet Safety Awareness Week reaches 12 million people in Ohio The Second Annual 2013 Ohio AAP Bike Helmet Safety Awareness Week was held May 6-10. During this week it is estimated that more than 12 million people in Ohio were reached with the message of bike helmet safety. Media outlets throughout the state featured Drs. Michael Gittelman and Sarah Denny, co-chairs of the Injury Prevention Committee, prominently during this week.
Ohio News Network Radio spoke with Dr. Gittelman regarding a recent patient he treated following a bicycle accident. "Just last week I had a patient who tried to do a trick, landed on their head, had significant injury and is probably going to die," he said. "This is something that can happen to anybody and is something that is easily preventable." This story was also featured on WLWT-TV in Cincinnati, where Dr. Gittelman’s advocacy for state-wide legislation was highlighted. “Helmets can reduce the risk of injury by 85%, but right now only 20% of children in Ohio wear one when riding.”
Sarah Denny, MD, co-chair of the Injury Prevention Committee, spoke to 500 students at Hawthorne Elementary School in Westerville, after one of their classmates was injured while riding without a helmet.
Dr. Denny appeared at two school assemblies to highlight Bike Helmet Safety this year. On May 3 at Hawthorne Elementary in Westerville, she spoke to over 500 students after one of their classmates was injured while riding without a helmet. Thanks to
Sugar Grove, Ohio, joined in the Ohio AAP’s Bike Helmet Safety Awareness Week. More than 12 million people in the state were reached with the message of bike helmet safety.
A young bike rider waits patiently as she gets fitted for her bike helmet at Lincoln Community Center in Troy.
Ohio Pediatrics • Spring 2013
funding from the Ohio AAP Foundation, the “Put A Lid On It” Program was able to provide a helmet to every student in need at this school, totaling over 350 helmets. On May 9, Dr. Denny was on hand to speak to students in Cleveland’s Oliver H. Perry Elementary School as part of a safety assembly featuring former governor and senator George Voinovich. The senator explained that he didn’t always wear a helmet when riding his bike, but he now understands the importance of protecting his brain, and he challenged the students to do the same. Over 100 helmets were provided to this school. Dr. Denny also appeared on WCOL’s “Woody and The Wake-Up Call” morning radio show, NBC 4’s Daytime Columbus, and the Innerphase Video Productions “Safety First” show. “We know from studies that kids are more likely to wear their helmet if their parent and if their friends are wearing helmets,” Dr. Denny told Gail Hogan on Daytime Columbus. “If you think about it as a parent, you are a role model and if you are not wearing a helmet, get into a bike accident, and get a traumatic brain injury, that would take a huge toll on your family as well. There are multiple reasons for parents and children alike to wear their helmets.” The program also received national attention in The Wall Street Journal on May 1. For more information on how you can get involved in Bike Helmet Safety Awareness, or the “Put a Lid on It” Program, please contact Hayley Southworth at hsouthworth@ ohioaap.org or (614) 846-6258.
A safety assembly at Oliver H. Perry Elementary School in Cleveland featured former governor and senator George V. Voinovich. He challenged the students to wear their helmets to protect their brain. The Ohio State Medical Center held a Healthy Kids event at the Hilltop YMCA. They featured a table devoted to the importance of wearing a helmet when riding a bike, skateboard, or scooter.
John Sherman Elementary, part of Mansfield City Schools, held a bike rodeo. The rodeo was organized by Physical Education teacher Maggie Voedisch. Ohio AAP staff member Hayley Southworth, right, measures a Pickaway County youngster to get the appropriate size helmet for him. The event was part of the YMCA’s bike helmet safety week.
Ohio Pediatrics • Spring 2013
foundation Pediatricians Standing Behind Ohioâ€™s Children
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Ohio Pediatrics â€˘ Spring 2013
Annual Meeting...from page 17
Dr. Mahan wins Palmer Award
• Concussions: The Law, the Logic and the Logistics • The Role of the Pediatrician in School Violence: A Case Study • MRSA Update: New Trends and Treatment Strategies
• Technology in Medicine: What is in the Future for Our Practices? • 3rd Annual Casino Night: Ohio AAP Foundation Fundraiser
• Poster presentations from across the state • Speed Mentoring from pediatricians of all backgrounds
For more details and to register, please visit: http://www.ohioaap. org/pediatrician-education/2013annual-meeting. For conference questions, please contact Elizabeth Dawson at email@example.com or call (614) 846-6258.
John D. Mahan, Jr., MD, program director for Pediatrics and Pediatric Nephrology at Nationwide Children’s Hospital/Ohio State University received the 2013 Parker J. Palmer Courage to Teach Award, which honors program directors who find in-novative ways to teach residents and to provide quality health care. The award is presented by the Accredita-tion Council for Graduate Medical
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Ohio Pediatrics • Spring 2013
Ohio Chapter American Academy of Pediatrics 450 W. Wilson Bridge Rd. Suite 215 Worthington, OH 43085
Calendar of Events
The Ohio AAP announces the following meetings and events.
Sept. 19-21 – 2013 Ohio AAP Annual Meeting
Sheraton Columbus Hotel at Capitol Square
A few of the topics to be discussed: – Concussions: The Law, the Logic, and the Logistics – The Role of the Pediatrician in School Violence – MOC Part II: Complete Your Requirements
Visit our website for more details www.ohioaap.org
Building Mental Wellness Wave 3 Learning Session
Toledo Museum of Art Toledo, OH
Injury Prevention Learning Session
New Chapter office, 94 A Northwoods Blvd. Columbus, OH
Building Mental Wellness Wave 3 Learning Session
Athens Community Center Athens, OH
PRESORTED STANDARD Permit No. 156 U.S. Postage PAID DUBLIN, OH
Dues disclosure statement
Dues remitted to the Ohio Chapter are not deductible as a charitable contribution, but may be deducted as an ordinary and necessary business expense. However, $40 of the dues is not deductible as a business expense because of the Chapter’s lobbying activity. Please consult your tax adviser for specific information. This statement is in reference to fellows, associate fellows and subspecialty fellows.
No portion of the candidate fellows nor post residency fellows dues is used for lobbying activity.