1. Common pediatric issue:
Developmental Dysplasia of the Hip
There has been a transition in understanding developmental dysplasia of the hip (DDH). What previously was believed to be a congenital disorder now is understood to be a developmental disease. This has important implications as there are well-documented cases of infants with normal early examinations who go on to have DDH – it is not a missed diagnosis but the natural history of the disease.
Defining the problem
Dysplasia of the hip involves the relationship of the ball (femoral head) to the socket (acetabulum). The shape of the socket also is a part of the definition in that a shallow socket is the actual meaning of dysplasia. The relationship of the femoral head to the acetabulum can be described in a number of ways:
- Tightly reduced – the femoral head is well located within the socket.
- Loose/subluxatable – the femoral head has movement within the socket but cannot purposely dislocate the hip.
- Dislocatable – the femoral head is located within the socket but, during examination, the femoral head can be moved (dislocated) out of the socket.
- Dislocated – the femoral head lies outside of the socket. Most often during examination the femoral head can be reduced or put back into the socket. However, there also are times when it is fixed outside of the socket and cannot be reduced.
Risk factors identified
The risk factors of DDH include:
- First born.
- Female.
- Family history.
- Breech position in utero.
Of these risk factors, breech likely is most important and, therefore, the American Academy of Pediatrics recommends a screening ultrasound on all breech babies at 6 weeks of age. Ultrasounds obtained before six weeks may be too sensitive. They can create a clinically confusing picture with their hypersensitivity and may lead to overtreatment and very worried parents.
Examination
The evaluation of the patient for DDH is a sensitive task. A crying and struggling baby yields, at best, an imprecise exam and ensures missing any subtle laxity or even a dislocation. A soft examining table with blanket and a dark room that is either quiet or with baby-friendly background noise can help. If the baby takes a bottle or uses a pacifier this can also be very helpful to calm the infant.
Once the child is comfortable, check for any additional positional issues. Examine the back for any signs of spinal dysraphism all the way into the gluteal cleft. This is a good time to discuss all of the eponyms associated with DDH. I believe there are too many eponyms and unless one utilizes them on a day-to-day basis, it is best to just avoid them. Discuss what you see, including if the hip is lax/subluxates, dislocates, is dislocated but reduces, or is a fixed dislocation. The exam should be straight-forward when performed systematically.
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| Figure 1: Apparent femoral shortening | Galleazzi sign: With the baby on his or her back, hold the legs with the knees toward the ceiling and look for a difference in height in which femur appears shorter than the other. A difference is considered a positive Galleazzi sign and would raise a concern of a dislocation on the short side.
Barlow sign (a dislocatable hip): Gently push the hips posteriorly from the adducted position sensing any laxity or a dislocation (dislocatable – Barlow).
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| Figure 2: Barlow (Dislocatable) Ortelani (Reducible) | Ortelani sign (a reducible hip): Abduct the hips with a gentle push anteriorly to feel a reduction (reducible – Ortelani). It is important to do this gently as increased squeezing will inevitably upset the baby and make the rest of the exam more difficult.
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| Figure 3: Limited abduction | Abduction: In addition it is important to note the amount of abduction on both sides as asymmetry is a strong indicator of possible dislocation.
Thigh folds: Remove the diaper to examine the thigh folds and ensure they are generally symmetric. Often there can be minor differences but this is not the asymmetry that is of concern.
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| Figure 4: Negative Klisic test (left) Positive Klisic test (right) | Klisic's test: This is a useful facet of the exam that would identify a patient with bilateral fixed dislocations. As you could imagine, all of the previous tests could be negative in this situation. To perform this, place your middle finger on the greater trochanter bilaterally and the index finger on the anterior superior iliac spine. The line between the two fingers must point above the umbilicus. In bilateral fixed dislocations the lines will point lower as the greater trochanter is positioned higher.
Treatment options
The Pavlic harness has excellent results for treating subluxatable or dislocatable hip. It is utilized for six weeks and the ultrasound is repeated. It is possible that additional six-week intervals may be necessary for complete stabilization of the hip. For the dislocated reducible hip, or even the fixed dislocation, the harness also is utilized but with more caution. One must ensure that the hip has reduced within the first three weeks of treatment or further damage can ensue, which is coined Pavlic harness disease, with the posterior acetabulum worn away making subsequent treatment much harder. Failure of the Pavlic harness can be treated in a variety of ways. A recent study has implicated the abduction orthosis with success after a failed Pavlic harness. Arthogram, spica cast application and open reduction are possible treatment options.
A final word on hip clicks
When professor Ortelani first described the sensation of the hip moving in and out of the socket he used an Italian phrase to describe the clunking sensation one feels as the hip dislocates and reduces. Unfortunately, the translation of this into English came as a click. The soft clicks that often are felt when mobilizing a child's joints are not indicative of hip instability but are a normal finding in children. They are not the "clunk" that professor Ortelani described which must be further evaluated. Any patient with any concern of instability, dislocation, or an abnormal ultrasound showing pathologic laxity after 6 weeks of age necessitates further evaluation by a pediatric orthopedic surgeon.
Source: J. Channing Tassone, MD, sees patients in the Orthopedic Center at Children's Hospital of Wisconsin. He is an assistant professor of Orthopedic Surgery at the Medical College of Wisconsin and a member of Children's Specialty Group.
For more information
Orthopedic Center
(414) 266-2414
To make an appointment
Central Scheduling
(414) 607-5280 or (877) 607-5280
2. Growing incidence of childhood autism can challenge primary care providers and families
Autism is a childhood onset disorder affecting the development of communication and social skills. As originally described in 1943 by Leo Kanner, a child psychiatrist at Johns Hopkins University, "children with autism have great difficulty relating in an ordinary way to people and situations from the beginning of life." Kanner stated that these children often exhibit "an anxiously obsessive desire for the maintenance of sameness and a limitation in the variety of spontaneous activity."
In recent years, public awareness of childhood autism has grown dramatically. In addition, there is evidence that the incidence of this condition is increasing but no clear explanations have been identified.
Symptoms
Symptoms of autism often are recognized between 15 and 24 months of age, and approximately one-third of children with autism experience a significant regression of language and social skills development in the second year of life.
Causes
Since this time period coincides with administration of Mumps, Measles and Rubella (MMR) vaccine (recommended at 15 months), childhood vaccines and thimerisol, a preservative used in multidose vials of MMR vaccine, were suspected of causing autism. However, very thorough research by a variety of scientific organizations and governmental agencies has found no causal link between MMR vaccine or thimerisol and autism (see the Institute of Medicine's report at www.iom.edu). Other avenues of research have identified a variety of differences in brain development and function, increased incidence of "autistic-like" features in relatives and immunological dysfunctions in autistic individuals, but no "unifying theory" has been identified. Research is further hampered because diagnosis of autism relies exclusively on observation and interpretation of developmental and behavioral patterns in children. There are no objective genetic or physiologic "markers" of this disorder.
Diagnostic evaluation
Children with autism develop in a very atypical manner. Although approximately 70 to 80 percent of autistic children also are cognitively delayed, they may show an unusual pattern of strengths and weaknesses. For example, extraordinary musical, numerical and artistic skills (so-called "savant skills") may occur in the context of general intellectual and social incapacity. In addition to autism (and its milder variant of pervasive developmental disorder – not otherwise specified or 'PDD-NOS'), medical providers should consider a number of other diagnostic possibilities. These include primary disorders of language development (developmental dysphasia or specific language impairment), moderate-to-severe mental retardation, Asperger's syndrome, and non-verbal learning disability. Rarely, children with auditory verbal agnosia (Landau-Kleffner syndrome) present with loss of established language skills and behavior changes including social unresponsiveness. Diagnosis of autism requires an overnight sleep EEG to identify a pattern of electrical status epilepticus of sleep. Atypical development, including autism, also may be associated with a variety of systemic and neurologic disorders including tuberous sclerosis, fragile X syndrome and other chromosome abnormalities, congenital or acquired brain malformations, and metabolic disorders. In adults and older children, studies using functional magnetic resonance imaging (fMRI) have identified deficits in function of the fusiform gyrus of the brain to be responsible for the poor visual-facial recognition ability of autistic patients. Recent research provides great promise that a new MRI scanning technology called "diffusion tensor weighted imaging" may help to identify the presence of abnormal neuronal tracks in the brains of autistic individuals.
Resources
For nearly 10 years, the ABC (Autism, Behavior and Communication disorders) Team at the Child Development Center of Children's Hospital of Wisconsin has been performing multidisciplinary diagnostic evaluations of children with learning, communication and socialization disorders. Children receive complete medical, developmental, non-verbal cognitive and speech-language evaluations scheduled over several days. The program's goal is to identify the child's strengths and abilities, as well as to characterize the nature of his or her difficulties before arriving at a diagnosis. Specialists use state-of-the-art genetic diagnostic studies, MRI brain scans and EEG evaluation as needed. Counseling and specific recommendations are provided to the parents for therapeutic and educational interventions to assist the child's development. Most importantly, specialists continue to follow the child's development over time to track progress and to refine the diagnostic impressions. In some instances, medications have been found to be very helpful in alleviating troubling symptoms of autism such as obsessive and perseverative behaviors, overwhelming anxiety, extreme mood instability, and self-abusive or aggressive behaviors.
The future
Children's Hospital of Wisconsin and the Department of Pediatrics at the Medical College of Wisconsin are considering developing a Center for the Study of Autism and Savant Syndrome to expand the scope of clinical and research activities in this field, using the newest diagnostic technologies available.
Source: Mark Simms, MD, MPH, is medical director of Child Development at Children's Hospital of Wisconsin. He is a professor and chief of Pediatrics (Child Development) at the Medical College of Wisconsin and a member of Children's Specialty Group.
For more information
Child Development Center
(414) 266-2928
To make an appointment
Central Scheduling
(414) 607-5280 or (877) 607-5280
3. Dermatology programs growing to meet demand
Staff changes improving patient access
While Nancy Esterly, MD, is set to retire Oct. 1, several new physicians have joined the Dermatology Department. Sheila Galbraith, MD, now is seeing patients at Children's Hospital of Wisconsin. She also is an assistant professor of Dermatology at the Medical College of Wisconsin. Galbraith joins Beth Drolet, MD, medical director of Dermatology at Children's Hospital and an associate professor of Dermatology at the Medical College, in providing specialized dermatology care to patients. In addition, two physicians, Kristi Holland, MD, and Victoria Barrio, MD, have started their Pediatric Dermatology Fellowships with the program. Jeanette Kirchner, RN, and Marcia Seefeldt, RN, are new registered nurses joining Ann Norton, RN, who has been with the team for a number of years. Joree Ruiz is the program's physician assistant and Valerie Lyon, MD, who sees patients at Children's Hospital of Wisconsin Clinics in Gurnee and Kenosha, is on call to see dermatology surgery patients. Lyon is an assistant clinical professor of Dermatology at the Medical College of Wisconsin.
To better meet patient needs, physicians and staff continue to work to improve wait times and time to next appointment. Currently, there is a three to six week wait for new patients.
New clinics and programs added to address unique pediatric needs
Each week, Drolet, Galbraith and Ruiz schedule multiple general dermatology clinics. In addition, Lyon holds a dermatology surgery clinic.
A specialized laser clinic is available on a weekly basis for the treatment of children and adults with hemangiomas, port-wine stains, pyogenic granulomas, spider angiomas and telangiectasia using the Candela SPLT 1 pulsed dye laser, Candela Sclero-plus laser, and Candela V-beam. In addition, a pediatric laser clinic for cases involving general anesthesia is held monthly. Drolet and Linda Rabinowitz, MD, an associate clinical professor of Pediatrics at the Medical College of Wisconsin, hold clinics that focus on the treatment of infants and children with large or facial port-wine stains using general anesthesia in day surgery.
A relatively new service, the Hemangioma of Infancy Clinic, is designed to improve education and treatment of infants who have hemangiomas. In addition, the Vascular Anomalies Clinic, a multidisciplinary physician specialist group, was formed out of the need to serve infants, children and adults with complex vascular anomalies and tumors. It includes Plastic Surgery, ENT Surgery, Interventional Radiology, General Surgery, Oculoplastics and Oncology. Specialized nursing, support groups and educational material also are included in this clinic. Ancillary services such as nursing and wound care, laser, diagnostic ultrasound, pain management and physical therapy are available. This is the only program of its type in Wisconsin.
Research important to patient care
Physicians in the program collaborate with one another and with pediatric specialists across the country and throughout the world to conduct research to provide new and innovative treatments for children. Areas of study include the hemangioma of infancy, cutaneous signs of neural tube dysraphism and mastocytosis.
Recent publications, presentations highlight expertise of physicians
In addition to caring for patients and conducting research, dermatology specialists collaborate with peers in their field and other pediatric subspecialists to write and publish articles and to make presentations at regional and national conferences. For a list of presentations and publications, call (414) 805-5304.
For more information
Dermatology Office: (414) 805-5304
Dermatology Clinic: (414) 266-6430
To make an appointment
Central Scheduling
(414) 607-5280 or (877) 607-5280
Vascular Anomalies: Ann Norton, RN, at pager (414) 907-3926 or anorton@chw.org
Laser Clinic: Linda Rabinowitz, MD, at (414) 266-6842
Vascular Anomalies Clinic
Director: Beth Drolet, MD
Nurse coordinator: Ann Norton, RN
Multidisciplinary physician specialists:
Arun Gosain, MD, and John Jensen, MD – Plastic and Reconstructive Surgery
Joseph Kerschner, MD – ENT Surgery
Robert Wells, MD – Interventional Radiology
John Aiken, MD – General Surgery
Jerold Harris, MD – Oculoplastics
Meg Browning, MD, and James Casper, MD – Oncology
Esterly, leader in pediatric dermatology clinical care and training, retiring Oct. 1
Nancy B. Esterly, MD, nationally known for her leadership in clinical work and resident training in pediatric dermatology, is retiring Oct. 1 from her practice of 17 years at Children's Hospital of Wisconsin. Esterly will maintain her faculty position as professor of Dermatology at the Medical College of Wisconsin.
Esterly's clinical interests include genetic diseases of the skin, hair and nails, as well as cutaneous infections, neonatal problems and vascular lesions. She was the first to define the clinical characteristics of several newborn skin disorders such as transient neonatal pustular melanosis, a disease characterized by pus-secreting blisters.
"When Dr. Esterly came to town it was like a tornado hit," said Thomas Dunigan, MD, president of Children's Medical Group. Dunigan previously was a pediatrician in private practice and referred patients to Esterly. "Her excitement about taking care of children and their parents prompted mothers to call me at my office thanking me for sending their child to her. She treated referring pediatricians with respect and warmth, even when we sent her cases that were 'difficult to us' but snap-finger simple for her. To have such a world-renowned specialist in easy reach was wonderful. I think mostly what I have missed of her since I left clinical practice is best summed up by her enthusiasm – enthusiasm for children, their parents, her colleagues and her trainees. There simply will be a drop in the general energy of the medical community with her retirement."
Prior to joining Children's Hospital and the Medical College in 1987, Esterly was professor of Pediatrics and Dermatology at Northwestern University Medical School where she was named editor of Pediatric Dermatology in 1983.
Esterly received the Society of Pediatric Dermatology's first Lifetime Achievement Award at the society's annual meeting in 1998. She is a charter member of the organization and helped create and edit the society's journal, Pediatric Dermatology. The award recognized Esterly's commitment to the education and training of pediatric dermatology residents. In 1991, she received the Alvin H. Jacobs Award, the highest award bestowed by the American Academy of Pediatrics for contributions to the field of dermatology. She has published nearly 300 original articles, 78 book chapters and is co-editor of two major pediatric dermatology texts, Textbook of Neonatal Dermatology and Handbook of Genetic Skin Disorders.
"One of Dr. Esterly's greatest assets is her aptitude for mentorship. She has this remarkable and unique ability to care for patients, teach dermatology and pediatrics, and inspire literally hundreds of young physicians," said Beth Drolet, MD, a pediatric dermatologist who has worked with Esterly at Children's Hospital for the last 11 years. "She has a thirst for knowledge. Even with her national reputation as the mother of pediatric dermatology, she was constantly asking and listening to other opinions and ideas. The field of pediatric dermatology would not exist in its current form without her contributions and the contributions of those she trained."
"Having been partially trained in Illinois, where Dr. Esterly previously was located, I was very aware of her national reputation in pediatric dermatology and was very excited when she arrived in Milwaukee," said Catherine (Kitty) Slota-Varma, a pediatrician in Milwaukee and past-president of the medical staff at Children's Hospital. "It has been invaluable to have been able to tap into Dr. Esterly's vast knowledge and experience when we were faced with unusual dermatologic cases in our practice. Not only was her diagnostic ability outstanding but her knowledge about systemic manifestations of dermatology disease were thorough and complete. With her help, we have been able to provide high quality care to our pediatric patients affected by dermatology conditions."
Slota-Varma also noted that Esterly led efforts to have the Dermatology Department participate in clinical trials for new medications and was responsible for positioning the program on the leading edge of research efforts. While research was important, her clinical care also was highly valued.
"Parents referred to Dr. Esterly's clinic have been uniformly pleased with their consultations and especially for rare conditions, they have been provided with excellent resources and information," said Slota-Varma. "Dr. Esterly will be greatly missed – she has helped countless patients and has educated so many, among them students, residents and primary care pediatricians. We are so grateful for the knowledge she has imparted and for her years of dedication to providing extraordinary patient care."
4. The essentials of enteral feeding tube management
An increasing number of children are receiving feeding tubes as part of their course of treatment. As a primary care provider, it is important for you to be aware of the type of tube your patient has as well as possible complications related to the placement and management of the tube. Following is a guide to enteral tubes and proper management.
Types of tubes
A gastrostomy tube (g-tube) is a tube that is placed through a surgically created opening in the stomach. If placed by the PEG (Percutaneous Endoscopic Gastrostomy) method, it must remain in place for 4 to 6 months to allow time for the stomach to adhere to the abdominal wall. If the tube was placed as an "open surgical tube" (Stamm procedure) the stomach is brought up to the abdominal wall and sutured in place. The original tube can be changed in four to six weeks. If a newly placed g-tube falls out, parent and caregivers should not put the tube back in. During the day, instruct the family to contact their GI/Surgery nurse, or call (414) 266-2850. If the tube comes out after 4 p.m., contact the surgeon on call at (414) 266-2000.
A gastro/jejunostomy tube (j-tube) is a g-tube with a smaller bore tube that continues on into the small intestine. This allows for decompression of the stomach and feeding access into the small intestine. In the event the j-tube portion becomes clogged, the parent should attempt to unclog using 5cc and 10cc syringes filled with carbonated water. The caregiver should use the push and pull method to irrigate the tube. If the tube cannot be unclogged, or if the j-tube becomes completely dislodged, the family can contact the Radiology Department at Children's Hospital weekdays at (414) 266-3648 to arrange a time to have it replaced. If the clog occurs after hours or on the weekend, the child should be fed through the g-tube. If this is not an option, children should be brought to the Children's Hospital Emergency Department/Trauma Center if the child:
- Is younger than 6 months of age.
- Is 6 to 12 months of age and has had no feeding in more than 6 hours.
- Is 12 months or older and has had no feeding in more than 12 hours.
- Has special instructions by his/her physician stating he/she cannot go without fluids for any given period of time.
Low-profile devices ("buttons") usually are placed after the appropriate waiting time based on the original placement. Buttons can be used for gastric or jejunal feedings. In addition, buttons can be used for antegrade enemas if placed in the large bowel. A button can be replaced with the same size button if performed promptly. If unable to replace the button, a foley tube of a smaller caliber can be temporarily placed and used for feeding until the patient can have the tube replaced.
Caring for the tube
Regardless of the type of tube, all sites should be cleaned daily with soap and water. Caregivers can use a half-strength solution of hydrogen peroxide to assist in breaking down any dry drainage. Gauze dressings are not needed.
Common problems, causes and solutions
If leakage is present around the tube site, assess the space between the bar/disc of tube and abdomen for snugness. In addition, if the tube has a water balloon, the volume should be checked to ensure it is filled correctly. If fluid level is low, re-instill the correct amount of saline, sterile or bottled water. If the stoma tract appears too large for the tube, secure the tube using a bolster dressing or any other secure method to decrease side-to-side movement of the tube.
Skin Problems
Granulation tissue is the most common problem with the tube site. Granulation tissue is the pink, moist tissue that can build up around the tract site as well as inside the tract. It can start out as a small – and develop to a large – "blister-like" growth in a short time. This tissue often will have yellow/tan/green drainage. This is a normal response and should not be treated with antibiotics. If the tissue is small it can be treated with a topical steroid such as Triamcinolone 0.5% applied three times per day for up to two weeks. Parents should not apply topical steroids to healthy skin and should stop using if problem persists. In some cases a large or persistent granuloma may need to be cauterized. This is done using silver nitrate sticks. Apply the medicated part of the stick to the granuloma. The area treated will turn white. Blot off any dripping that may occur as silver nitrate will stain healthy skin. This should be done daily or every other day until the granuloma completely sloughs off.
Red, irritated tube sites are most commonly related to dampness and/or gastric leakage due to an unstable tube. Assess tube stability as previously discussed. Use Stomahesive powder to absorb the moisture. Any topical protective creams can be used as barriers on the irritated skin (Sensicare, Desitin or Triple Paste). If tiny red bumps are present around the site, most likely a skin yeast infection has developed and the patient also should be assessed for oral thrush and/or a perineal yeast rash. Secure the site and treat with topical antifungal. If the area is moist, treat it with a powder antifungal. Use a cream if the area is dry.
A stomal infection should be suspected when fever, localized erythema, edema, pus and/or pain is present. The practitioner can consider a topical or systemic antibiotic and encourage frequent dressing changes.
Resources
Each year, more than 1,500 children who have feeding tubes placed for nutritional support are seen at Children's Hospital of Wisconsin. To meet the needs of this growing population, the Gastroenterology Center and the Surgery Clinic at Children's Hospital worked together to create a team of nurses referred to as the G-tube Care Team. These specially trained nurses are available to manage, troubleshoot and treat the various complications that can arise. In addition, they are available to provide training to medical staff and community personnel related to care and management of a child with a feeding tube. The goal is to help families become independent in managing issues related to their child's enteral feeding needs.
If your patient receives medical care at Children's Hospital, he or she will have a nurse to contact when problems arise. However, if the family is unsure, or if your patient does not receive his or her care at Children's Hospital, a G-tube Care Team member is available to assist the child and the family. We can identify their primary GI/Surgery nurse or, if they do not have one, assistance can be provided in collaboration with the referring physician.
Source: Deborah Wallner, RN, is a nurse clinician in the Gastroenterology Center at Children's Hospital of Wisconsin.
For more information
A G-tube Care Team nurse is available on call from 8 a.m. to 4 p.m. Monday – Friday at (414) 266-2000.
Non-urgent, after-hours messages can be left on the Gastroenterology Center voice mail at (414) 266-2850.
To make an appointment
Central Scheduling
(414) 607-5280 or (877) 607-5280
5. Information you can use: Diabetes patient at-home guidelines when sick
The following information is provided to our patients and you may want to take this into account as you counsel your diabetes patients. If you have questions, call (414) 266-2000.
Following are key points for your diabetes patients to remember when they are sick. These guidelines are only for patients on multiple daily dosing using Humalog or Novolog with Lantus or Ultralente insulins. If you have patients on NPH insulin, please consult a diabetes specialist for sick-day guidelines.
1. Never skip a basal (long-acting) insulin dose even if your child is not eating. Basal insulin (Latus/ glargine and Ultralente) helps to:
- Push sugar into the cells.
- Stop the liver from making sugar.
- Stop the liver from making ketones.
2. It's more important to drink than eat.
- You need 3 to 4 ounces (about 1⁄2 cup) of liquids per hour during the day. More is better, but take it slowly. If your child cannot eat, refer to the chart for guidelines.
3. If your child is sick enough to stay at home, you must check:
- Blood sugar every 1 to 2 hours.
- Urine for ketones every time you go to the bathroom.
4. Know when to seek help.Never leave a child or teen at home alone throwing up or unable to check blood sugar every 1 to 2 hours.
- If your child's blood sugar is above 250 or less than 80, he or she can't stop throwing up, or has moderate or large ketones, call the Children's Hospital of Wisconsin Diabetes emergency number at (414) 266-2000 or go to the local emergency department.
Insulin tips
If your child needs an extra dose of fast-acting insulin use your normal correction dose guideline to lower a blood sugar. The correction dose of fast acting insulin can be given every 1 to 2 hours until blood sugar is under 250 or urine ketones are negative. Remember, fast-acting insulin types are:
- Humalog (lispro) insulin.
- Novolog (Aspart) insulin.
A correction dose is based on insulin sensitivity. The younger the child, the more sensitive the child is to insulin. Anyone who is on a multiple daily dosing regimen will have a correction dose they use at home. The following are some examples:
- 0.5 units of Humalog will drop the blood sugar level 150 points.
- 0.5 units of Humalog will drop the blood sugar level 50 points.
- 1.0 units of Novolog will drop the blood sugar level 50 points.
- 1.0 units of Novolog will drop the blood sugar level 30 points.
Pointers:
- Call your child's doctor or diabetes specialist if your blood sugar and ketones are not improving after giving 2 extra doses.
- If your child starts vomiting, call his or her doctor and go to the emergency room.
- If you have given extra insulin during the day, you will need to check blood sugar at night at Midnight and 3 a.m.
Night checks
You must check your blood sugar at night (one to two hours after dose and at 2 a.m. or 3 a.m.). If blood sugars are running low or if ketones are present, you must check at night.
When to call a diabetes specialist
Call your local diabetes specialist or the Diabetes Clinic at Children's Hospital, at (414) 266-2000, if the following occurs:
- Unable to drink or are throwing up.
- Ketones are moderate or large.
- Unsure of what to do.
Special notes about Diabetic Ketoacidosis (DKA):
DKA occurs in Type 1 diabetes. The acid level (ketones) in the blood go so high the internal organs are in danger and your child becomes very dehydrated. This should not occur after diagnosis if proper attention is paid to management of blood sugar, insulin administration and ketone levels. The most common reason for DKA is missed insulin injections.
Following are several reminders regarding DKA:
- DKA means the diabetes is poorly controlled and your child is severely dehydrated. You may need to go to an emergency department or hospital.
- DKA develops over time and can almost always be avoided.
- DKA can be life threatening.
- A child with diabetes does not get sick more often than a person without diabetes.
- If a child is sick, it does not mean the diabetes condition necessarily will be impacted.
- Just having ketones is not DKA, but you may be close.
- Ketones mean the body needs more insulin and/or fluids. If needed, use your sick day guidelines and call for advice.
- A sweet smell to the breath usually means ketones.
- Heavy breathing usually is a late sign of DKA. Go immediately to the local emergency department.
Diabetes self-management is the most effective approach with patients and families. Join us in advocating and empowering our patients to take control of their diabetes.
Source: Elaine Parton is a pediatric nurse practitioner with the Diabetes Clinic at Children's Hospital of Wisconsin and the Diabetes Department at the Medical College of Wisconsin.
Kate Holzum, RN, BSN, CDE, is the lead nurse clinician for the Diabetes Clinic at Children's Hospital of Wisconsin.
The Children's Hospital diabetes self management education program has continued to be recognized by the American Diabetes Association in accordance with the national standards for diabetes self management education programs.
Diabetes Patient At-home Guidelines When Sick
For more information
Diabetes and Endocrine Center
(414) 266-3380
To make an appointment
Central Scheduling
(414) 607-5280 or (877) 607-5280
6. Bone and Marrow Transplant Program achieves status among national leaders
The Blood and Marrow Transplant (BMT) Program in the Cancer and Blood Disorders Center at Children's Hospital of Wisconsin uses cells from a donor's blood or marrow to treat a wide range of hematology (blood) conditions and cancers in children. One of the largest and most successful programs of its kind in the United States, the BMT Program specializes in using mismatched or unrelated donors. Children's Hospital is among an elite group of pediatric hospitals that offer these type of transplants with good success. Since its inception, more than 630 transplants have been performed at Children's Hospital.
The BMT Program at Children's Hospital has some of the highest documented transplant success rate worldwide for treating aplastic anemia using unrelated donors. In addition, the program achieved the third highest survival rate in the country for overall blood and marrow transplants, according to the National Marrow Donor Program (2004).
For more information
David Margolis, MD, program director, Blood and Marrow Transplant Program, Children's Hospital of Wisconsin, and associate professor of Pediatrics (Hematology/Oncology) at the Medical College of Wisconsin, can be reached at (414) 456-4154.
Blood and Marrow Transplant Program (414) 266-2420.
To make an appointment
Central Scheduling
(414) 607-5280 or (877) 607-5280
7. Resident alumni focus: Hartland pediatrician calls on Children's Hospital expertise to treat a variety of illnesses, injuries
Pediatrician Karen Zorek, MD, says her time at Children's Hospital of Wisconsin provided her with marvelous training that applies directly to the needs of the children she sees today in her practice. She also continues to draw on the expertise of the members of Children's Specialty Group for consultation and other support for her patients.
Zorek received her medical degree from Rush Presbyterian St. Luke's Medical Center in Chicago. She completed her residency in Pediatrics at Children's Hospital in 1996 and then served as chief resident until 1997. Since that time, Zorek has practiced in Hartland, Wis., at Wilkinson Medical Clinic, a multispecialty group that includes nine pediatricians. Four pediatricians practice at her location in Hartland, and five see patients at a clinic in Oconomowoc, Wis.
The pediatricians at Wilkinson Medical Clinic treat children from birth through college age for normal growth and development issues, well checkups and acute care. Some of the typical chronic illnesses treated at the clinic include asthma, constipation, obesity and acne. The clinic has the ability to place intravenous lines, administer medications through nebulizers, and take and read laboratory tests and X-rays – so the staff diagnose and treat many patients that might normally need to be seen in an urgent care or emergency room.
Zorek and her colleagues also routinely deal with school learning and socialization issues, pre-teen and teen self-image problems, family alcohol or drug abuse that affects children, and middle and high school students experimenting with drugs.
"These can be challenging issues for pediatricians to help children and their families manage and overcome," Zorek said. "In particular, we have a growing number of children with psychosocial issues. We value resources that can help provide psychological evaluations and treatment recommendations."
The pediatricians at Wilkinson Medical Clinic refer patients to Children's Hospital for a variety of illnesses and injuries. These include allergy testing, complicated constipation cases, diabetes, neonatal hypertension, chronic headaches, seizures, endocrine problems, cardiology issues and infectious disease support.
According to Zorek, the specialists at the hospital are easily accessible and willing to provide a second opinion and other support.
"Many of the pediatricians and subspecialists are available to answer questions over the phone when we have issues that are concerning. It is so nice to pick up the phone and have an unconditional opinion waiting on the other end," she said. "Pediatric information changes rapidly, and it is impossible to stay abreast of all the updates. It is extremely helpful to get the most recent recommendations with just a simple phone call."
The training Zorek received at Children's Hospital prepared her for both the routine and the extraordinary.
"Children's Hospital pulls from a huge population of children, so residents are exposed to families who use the facility for everyday care as well as extremely rare cases. This diversity helped prepare me for the common pediatric issues that make up the majority of my practice as well as cases where I need to consult a specialist," she said.
Zorek speaks highly of the time she spent at the Downtown Health Center in Milwaukee working with Children's Specialty Group physicians.
"The staff at the center are wonderful clinicians and great role models," she said. "They taught me a lot about dealing with cases that don't necessarily fit into one specialty – how to sort out the issues and figure out where to go to get patients the help they need. Dr. Al Pomeranz in particular has been an amazing resource about common pediatric issues."
Serving as chief resident was a valuable learning experience for Zorek as well.
"It's one thing to learn material and another to learn it well enough to teach it. As chief resident I was exposed to so many learning opportunities that impacted me dramatically."
Zorek stays connected to Children's Hospital and the Medical College of Wisconsin by taking part in continuing medical education programs offered by the organizations.
"These educational opportunities strengthen my skills as a pediatrician and allow me to stay in contact with the specialists I rely on to help care for my patients," she said.
8. Provider changes
Additions:
Anesthesiology
Jaya L. Varadarajan, MD, is a pediatric anesthesiologist at Children's Hospital of Wisconsin and an assistant professor of Anesthesiology at the Medical College of Wisconsin.
Medical School: Bangalore University Medical College (India).
Fellowships: Michigan State University (East Lansing, Mich.), Electrophysiology and Neuro Ophthalmology and the Medical College of Wisconsin (Milwaukee, Wis.), Anesthesia-Pain Management and Pediatric Anesthesiology.
Board Certification: Anesthesiology.
Cardiology
Michael G. Earing, MD, is a pediatric cardiologist at Children's Hospital of Wisconsin and an assistant professor of Pediatrics (Cardiology) at the Medical College of Wisconsin.
Medical School: Rush Medical College (Chicago, Ill.).
Fellowship: Mayo Medical School (Rochester, Minn.), Pediatric Cardiology.
Board Certifications: Pediatrics and Internal Medicine.
Critical Care
Jennifer A. McArthur, DO, is a pediatric critical care specialist at Children's Hospital of Wisconsin and an assistant professor of Pediatrics (Critical Care) at the Medical College of Wisconsin.
Medical School: Kirksville College of Osteopathic Medicine (Kirksville, Mo.).
Residency: University of Iowa (Iowa City, Iowa), Pediatrics.
Fellowship: St. Jude Children's Research Hospital (Memphis, Tenn.), Pediatric Hematology/Oncology and LeBonheur Children's Medical Center (Memphis, Tenn.), Pediatric Critical Care.
Board Certification: Pediatrics and Pediatric Critical Care.
Endocrinology
Saroj Nimkarn, MD, FAAP, is a pediatric endocrinologist at Children's Hospital of Wisconsin and an assistant professor of Pediatrics (Endocrinology) at the Medical College of Wisconsin.
Medical School: Mahidol University (Bangkok, Thailand).
Fellowship: Cornell University (New York, N.Y.), Pediatric Endocrinology.
Board Certifications: Pediatrics and Pediatric Endocrinology.
Gastroenterology
Adrian Miranda, MD, is a pediatric gastroenterologist at Children's Hospital of Wisconsin and an assistant professor of Pediatrics (Gastro-enterology) at the Medical College of Wisconsin.
Medical School: Medical College of Wisconsin (Milwaukee, Wis.).
Residency: Medical College of Wisconsin (Milwaukee, Wis.) Pediatrics.
Fellowship: Medical College of Wisconsin (Milwaukee, Wis.) Pediatric Gastroenterology.
Richard J. Noel, MD, PhD, pediatric gastroenterologist at Children's Hospital of Wisconsin, joined the department of Pediatrics (Gastro-enterology) at the Medical College of Wisconsin as an assistant professor.
Medical School: University of Southwestern Texas (Dallas, Texas).
Doctor of Philosophy Degree: University of Southwestern Texas (Dallas Texas).
Fellowship: Children's Hospital Medical Center (Cincinnati, Ohio), Pediatric Gastroenterology.
Board Certification: Pediatrics.
Hematology/Oncology
Julie Talano, MD, is a pediatric hematology/oncology specialist at Children's Hospital of Wisconsin and an assistant professor of Pediatrics (Hematology/Oncology) at the Medical College of Wisconsin.
Medical School: Northwestern University Medical School (Evanston, Ill.).
Residency: Children's Memorial Hospital (Chicago, Ill.), Pediatrics.
Fellowship: Medical College of Wisconsin (Milwaukee, Wis.), Pediatric Hematology/Oncology.
Board Certification: Pediatrics.
Hospitalist Program
Jennifer L. Perry, MD, is a pediatric hospitalist at Children's Hospital of Wisconsin and an instructor of Pediatrics (General Pediatrics) at the Medical College of Wisconsin.
Medical School: Wayne State University (Detroit, Mich.).
Residency: Children's Hospital Medical Center (Cincinnati, Ohio), Pediatrics.
Emily M. Densmore, MD, is a pediatric hospitalist at Children's Hospital of Wisconsin and an assistant professor of Pediatrics (General Pediatrics) at the Medical College of Wisconsin.
Medical School: University of Illinois (Peoria, Ill.).
Residency: Medical College of Wisconsin (Milwaukee, Wis.), Pediatrics.
Michael C. Weisgerber, MD, is a pediatric hospitalist at Children's Hospital of Wisconsin and an assistant professor of Pediatrics (General Pediatrics) at the Medical College of Wisconsin.
Medical School: Medical College of Wisconsin (Milwaukee, Wis.).
Residency: Medical College of Georgia (Augusta, Ga.).
Fellowship: Medical College of Wisconsin (Milwaukee, Wis.), Pediatrics.
Board Certification: Pediatrics.
Neonatology
Neil P. Mulrooney, MD, is a pediatric neonatologist at Children's Hospital of Wisconsin and an assistant professor of Pediatrics (Neonatology) at the Medical College of Wisconsin.
Medical School: University of Minnesota (Minneapolis, Minn).
Residency: Cincinnati General Hospital (Cincinnati, Ohio), Pediatrics.
Fellowship: Cincinnati General Hospital (Cincinnati, Ohio), Neonatology.
Board Certification: Pediatrics.
Neurology
Catherine M. Amlie-Lefond, MD, is a pediatric neurologist at Children's Hospital of Wisconsin and an assistant professor of Neurology at the Medical College of Wisconsin.
Medical School: University of California (Los Angeles, Calif.).
Residency: University of Colorado (Denver, Colo.), Pediatrics and Child Neurology.
Fellowship: University of Colorado (Denver, Colo.), Neurovirology.
Board Certification: Pediatrics and Neurology-Psychiatry.
Pathology
Lucile B. Tennant, MD, is a pathologist at Children's Hospital of Wisconsin and an assistant professor of Pathology at the Medical College of Wisconsin.
Medical School: University of Southwestern Texas (Dallas, Texas).
Residency: University of Texas (Houston, Texas), Pathology
Fellowship: Children's Hospital Medical Center-Harvard Medical School (Boston, Mass.), Pediatric Pathology.
Board Certification: Pediatric Pathology and Pathology.
Psychiatry
Alexander M. Scharko, MD, is a pediatric psychiatrist at Children's Hospital of Wisconsin and an assistant professor of Psychiatry at the Medical College of Wisconsin.
Medical School: University of Wisconsin (Madison, Wis.).
Residency: University of Wisconsin (Madison, Wis.), Psychiatry.
Fellowship: University of Wisconsin (Madison, Wis.), Child Psychiatry.
Post Doctoral Fellow: Johns Hopkins University School of Medicine (Baltimore, Md.), Child Psychiatry.
Board Certification: Psychiatry and Neurology.
Departures:
Arnold Slyper, MD, Endocrinology
Tseghai Berhe, MD, Endocrinology
Edward Guillery, MD, Nephrology
Endocrinology note
We wish to thank Arnold Slyper, MD, and Tseghai Berhe, MD, for their commitment and service to Children's Hospital of Wisconsin. Slyper had been a member of the Endocrinology staff since September 1990 and Berhe joined the group in July 2003 after completing his fellowship in Pediatric Endocrinology at Georgetown University. Best wishes to both physicians in their new endeavors.
Nephrology note
We would like to thank Edward Guillery, MD, for his dedication and service to Children's Hospital of Wisconsin, Children's Hospital of Wisconsin Clinics-Fox Valley and the Medical College of Wisconsin. Guillery saw patients in the pediatric nephrology clinic at Children's Hospital of Wisconsin Clinics-Fox Valley. In July he left to take a position in Oregon. We wish him the best in his new position.
To schedule a patient in pediatric nephrology, call Children's Hospital of Wisconsin Central Scheduling at (877) 607-5280. To reach the pediatric nephrology office, please call (414) 456-4180.
9. Fetal Concerns Program expands to serve northern Illinois families
Each year in the United States, 150,000 babies are born with some type of birth defect. This means that one out of every 28 babies will be diagnosed with an abnormality. To respond to the needs of this special population, the Fetal Concerns Program was first introduced in 2000 as a cooperative effort of Children's Hospital of Wisconsin, Froedtert and Medical College. The program now has expanded in cooperation with the Evanston Northwestern Healthcare Maternal-Fetal Medicine Group to serve families in northern Illinois.
The Fetal Concerns Program provides care for women whose pregnancies are complicated by concerns of fetal abnormalities. Services include: early education and prevention of birth defects; fetal diagnosis of birth defects; prenatal counseling with a neonatologist; consultation with a maternal fetal specialist and pediatric and surgical specialists; obstetrical management and delivery; and family support services. Since its inception, more than 450 families from throughout Wisconsin, Illinois, Alabama, Kansas, New Mexico, Colorado and Michigan have benefited from the comprehensive support provided by this program.
The northern Illinois Fetal Concerns Program, based at Children's Hospital of Wisconsin Clinics-Gurnee, now offers the same vital services as the Milwaukee-based program. The expansion of services includes the appointment of Scott McGregor, MD (Maternal-Fetal Medicine Group), medical director, and Teresa Godfrey, RN, MSN, nurse clinician.
The Fetal Concerns Program was developed by Steven R. Leuthner, MD, and Thomas Wigton, MD. Leuthner is a neonatologist at Children's Hospital of Wisconsin and an associate professor of Pediatrics (Neonatology and Bioethics) at the Medical College of Wisconsin. Wigton is a perinatologist at Froedtert Hospital and an associate professor of Obstetrics and Gynecology at the Medical College.
"Families who enter the Fetal Concerns Program will have one person – a familiar face, the Fetal Concerns Nurse – to help them through an incredibly stressful time," said Leuthner. "We begin coordinating their care at the time of prenatal diagnosis and help them understand the diagnosis as well as refer them to the appropriate specialists to care for their child."
Some of the specialists a family may see, depending on the diagnosis, can include: geneticists, surgeons, cardiologists and cardiothoracic surgeons, nephrologists, neurologists, orthopedic surgeons and cleft lip and palate specialists.
"Parents are empowered because they become informed participants in the plan of care for the remainder of the pregnancy, delivery and care of the infant after birth," said Leuthner.
"We help parents work through the grief of the loss of a normal pregnancy while also decreasing their anxiety about the care their child will require at birth."
There is no change for the Fetal Concerns Program. Referrals come from community-based obstetricians who have seen an area of concern on a routine ultrasound. Other referrals come from family physicians, nurse midwives or the families themselves. The program is designed to be a resource to provide the best care available to those families whose babies will be born with complications.
To refer a patient or learn more about the northern Illinois Fetal Concerns Program, call Teresa Godfrey at (847) 662-4380. (Milwaukee: call (414) 805-4776.) |
