1. Common pediatric issue: Deformational plagiocephaly (Positional skull deformity)
The incidence of deformational, non-synostotic, plagiocephaly has increased substantially in the past decade. It widely is accepted that this is a direct result of the American Academy of Pediatrics's "Back to Sleep" campaign of the early 90s, and several studies appear to confirm the significance of this finding.
The deformity may be present at birth but usually develops in the postnatal months. It may involve both but usually affects one side of the occiput. The typical clinical features (Figure 1) include occipital flattening with ipsilateral anterior ear displacement, and slight ipsilateral frontal bossing. In extreme cases, the nasal root may be displaced (slightly curved) away from the affected side. The critical issue is to distinguish this entity from craniosynostosis, which must be corrected surgically. It often is difficult to differentiate deformational plagiocephaly from lambdoidal synostosis on purely clinical grounds, and radiographic studies are required. In fact, lambdoidal synostosis is a rare cause of plagiocephaly; unicoronal synostosis is more common, and the features of this entity are distinguished readily from non-synostotic plagiocephaly in most cases. Table 1 summarizes distinguishing features of the various forms of plagiocephaly.
Often these findings are equivocal; however, actual brow retrusion is a finding that is not seen often in non-synostotic cases. Though it may appear inferiorly displaced or relatively retruded in the context of an asymmetric forehead, the boney brow actually is not posteriorly displaced in relation to the globe in deformational plagiocephaly. Nevertheless, while the diagnosis of deformational plagiocephaly usually is made safely on clinical grounds, some cases warrant the exclusion of synostosis by radiographic means. A formal multi-view skull series (PA, Lateral, R/L Oblique, Towne's) effectively can demonstrate suture patency in the major (sagittal, metopic, coronal and lambdoid) sutures. Also, the "harlequin" sign, which demonstrates the superiorly displaced sphenoid ridge in coronal synostosis, is absent. At times, the plain films may show equivocal findings; a CT scan then is indicated, or is done without plain films if a strong suspicion exists for craniosynostosis (classic head shape, sutural ridging, prematurely closed fontanel, etc.).
The etiology for deformational plagiocephaly is unknown, but thought to be related to prematurity, intrauterine restraint, twin pregnancy and/or postnatal positioning. The incidence is higher in boys, and the coincidence of torticollis often is observed. Classic muscular torticollis may contribute to plagiocephaly by limiting neck mobility, but also may contribute to facial asymmetry in the absence of skull flattening. The treatment is the same: physical therapy with surgical release in patients who fail conservative measures.
As the bones increase in stiffness, the capacity to resist external deformational forces increases, and the potential to correct these deformities with orthoses becomes more limited. It thus follows that an optimal window exists in which molding helmet therapy is efficacious: the earlier it is begun the more effective, but as the skull becomes less plastic the efficacy drops to insignificance. This window loosely is defined between ages 6 and 12 months. In other words, the best results are demonstrated when therapy is begun by about 6 months of age, and little change can be expected, with or without helmets, after 12 months.
Treatment of deformational plagiocephaly is not strictly an exercise in cosmesis. Evidence is emerging that demonstrates mandibular dysmorphology in these patients. It remains to be seen if treatment can minimize the prevalence of malocclusion or other pathology later in life for these children.
When treatment is pursued, it begins with conservative measures, or "counter-positioning" efforts. It simply refers to identification of habits that may be contributing to a constant, focal external force applied repeatedly. This information may be elicited from the parents or principle caregivers, with special attention to positioning and time spent in carseats, cribs, etc., as well as positioning of the baby during feeding, and the layout of the nursery (most of the stimuli may be located in a particular place). An effort then is made to position the child on his other side with rolled blankets, movement of sensory stimuli, rotation of feeding positions and other methods to minimize any preference for one particular position. This is not effective always, and in severe cases may not have sufficient effect. In these cases, helmet therapy is warranted.
The essential principles of molding helmet therapy are that the underlying cause (if present) of the deformation is identified and treated, cranial bones are "moldable" for a relatively short period of time, and relief of external deformational force usually is sufficient to correct the problem (i.e., normal skull shape will follow from unimpeded normal brain growth). In other words, molding helmets are likely to be helpful if started in patients by the age of 6 months who either do not respond to physical therapy (PT) for torticollis, for example, or have such severe deformity that even with PT they are unable to assume any position other than one which persistently focuses the pressure on the flat area. An example of this would be a particularly large flat area in the occiput. Conversely, if underlying torticollis is treated, and as the baby grows and begins to turn in bed, he or she will be less likely to limit his or her position, and the effect of focal deformational forces will be diminished. When these improvements are seen before the age of 6 months, the likelihood is that improvement will continue, provided adequate therapy (if necessary) is continued. If, on the other hand, minimal improvement is seen, a molding helmet could be initiated at the age of 6 months and progress followed on a monthly basis. When mobility limitations can be identified, but not rectified (as in severe torticollis), helmet therapy can be extremely effective in limiting the extent of deformity of the skull shape, if not necessarily facial changes associated with torticollis. The facial changes typically noted with plagiocephaly (anterior ear displacement, cheek bulk asymmetry, forehead asymmetry, etc.) usually improve significantly with correction of the skull deformity, regardless if helmet therapy is utilized.
Molding helmets must be worn 23 hours a day (removed for cleaning twice daily), especially while recumbent, and in general are of two types: passive and active. Passive orthoses prevent the deformational force, for example the bed, from continued transmission of external force to the flat area, and correction of head shape occurs strictly as a consequence of normal, unimpeded growth of the brain. Active devices actually exert forces on prominences to re-mold the cranial vault during growth. These are the more commonly encountered devices, marketed as D.O.C. band(TM), STARband(TM) or N~i.C. BAND(TM). They are FDA approved as a class II "cranial orthosis" and are indicated in the treatment of non-synostotic skull deformity in patients between the ages of 3 and 18 months. They require a trained orthotist for fitting and ongoing adjustments, and cost between $2,000 to $3,000 each. Most insurance companies do not reimburse this cost, though usually will pay for helmets as a part of a postoperative careplan (for example, when used in young babies with sagittal synostosis undergoing strip craniectomies). Moreover, in order to get the correct fit, a second helmet often is necessary to accommodate growth if the period of treatment is longer than about three months.
The availability of passive helmets in southeastern Wisconsin is limited at present, but interest is growing in the development of this alternative. Passive helmets differ in that they are not designed to exert pressure on the abnormal prominences. Rather, the helmet is custom made of a semi-rigid foam, made slightly large, and fitted to the individual by placement of adhesive-backed foam inserts in the flattened, or deficient areas, to maintain the fit. These foam inserts are changed and moved as necessary as the head shape normalizes. The cost is substantially less.
Surgical correction of skull deformity remains a rarely used alternative in cases of non-synostotic plagiocephaly, reserved only for the most severe deformities.
In summary, deformational plagiocephaly remains a commonly encountered phenomenon. The question of helmet therapy versus positional changes alone remains an important question.
2. Intoeing: Reassurance or referral
Variability in pediatric lower extremity rotational profiles is a constant source of concern for parents, grandparents, teachers and coaches. Many children are seen in pediatricians' offices with questions about intoeing and outtoeing. Families' concerns are often appeased by their pediatrician but many seek additional evaluation from an orthopedic specialist. Following is information that may help you address concerns.
Affirm the parent's concerns. They typically revolve around both the cosmetic appearance of a child's feet as well as his or her gait. Frequently, a child may be falling and tripping and the appearance of the feet is seen as the source of the problem.
Intoeing originates from the hip, tibia and foot and is defined by the rotational profile of the legs. An intoeing evaluation begins with watching the child walk. Often this is best done informally while taking the history. Watch for problems such as poor balance or weakness. Determine the foot progression angle. This describes the angle of the axis of the foot compared to the line of direction of gait. Examine the child for any pathologic neurologic findings such as increased tone, velocity dependent tone or pathologic reflexes. These are exceedingly rare in the evaluation of intoeing but are necessary to rule out an underlying condition.
Define the child's rotational profile. With the patient prone on the examination table, rotate the hips. As the ankles are rotated laterally, the hip internal rotates. Be sure to stabilize the pelvis with the contralateral hand while performing this part of the exam to get accurate measurements. Next, rotate the ankle medially to test external rotation of the hip. The relation of these numbers determines the amount of femoral anteversion. Children with significantly more internal (ankles lateral) than external (ankles medial) rotation at the hip have increased femoral anteversion, a cause of intoeing. The opposite rotational profile with increased external vs. internal rotation is consistent with outtoeing. This is less related to femoral anteversion but instead to tight muscles around the hip that are common in childhood (see Figure 1).
Figure 1: Normal external/internal hip examinations as well as alterations consistent with increased external rotation (outtoeing) and increased femoral anteversion (intoeing).
Evaluate the foot thigh angle which defines the amount of tibial torsion. With the child remaining prone, place the foot into its neutral position and visualize a line down the longitudinal axis of the thigh. Imagine a second line down the long axis of the foot. The relation of these two lines defines the type (neutral, internal or external) and degree of tibial torsion. This is the second possible source of intoeing or outtoeing (see Figure 2).
Figure 2: Examination of foot thigh angle: neutral vs. internal tibial torsion.
The final step is the foot evaluation. With the patient remaining in the prone position, examine the lateral border of the foot. Place your finger along the lateral border of the heel toward the forefoot. The lateral border should be a straight line from the heel to the small toe. Any deviation of the forefoot is metatarsus adductus, the third source of intoeing (see Figure 3).
Figure 3: Examination of a child's foot: normal, mild, and more significant metatarsus adductus.
It is worth mentioning that of the three causes of intoeing, metatarsus adductus is the one that, in severe, rigid cases can benefit from early intervention through casting. Although rare, it is important to always keep in mind the more serious causes of intoeing. During the evaluation, be sure to rule out static encephalopathy, mild tibial deficiencies, Blount's disease, skeletal dysplasias and metabolic bone disease. Children with these conditions require further orthopedic evaluation.
Armed with the components of the rotational profile and having ruled out any underlying condition, it is likely that the most difficult part of the visit is about to take place. It often is challenging to explain the examination results to parents and help them understand that intoeing and outtoeing is normal and they should not worry. In my discussions with parents, I explain the three sources of intoeing and show them the source or combination of sources for their child's condition. I find it is easier to involve parents in the exam and tell them that the details and finding will be explained once the full exam is completed. I then explain that intoeing is purely a cosmetic issue. I acknowledge their child probably does trip and fall but this is a normal part of learning to walk and run. The child's coordination will increase over time and intoeing generally is not the source of the problem. The next hurdle is to help parents to understand that treatment is not necessary.
It is important to comment on all of the various interventions the parents may have been told their child needs including braces, special shoes, physical therapy, sitting position parental instruction and countless others. State that these have absolutely no impact on intoeing. Explain the only way to change the direction of their child's foot – certainly a way you don't recommend – is with surgery on the affected bone (femur or tibia) that includes cutting the bone, turning the bone and using metal plates and screws to fix the bone. I use these exact words to help emphasize the significance of the surgical intervention. The parents uniformly are relieved that their child does not need this surgical intervention.
Finally, describe to the parents what the future holds for their child. It is appropriate to explain that intoeing will become less prominent over time. Encourage them not to watch too closely because they likely will not notice the changes. You might suggest pictures at each birthday as one way to monitor change.
The final rotational profile generally is reached at 8 to 9 years of age. At that point, if parents are concerned their child is emotionally distraught about the direction of his or her feet, it then would be appropriate to discuss possible surgical interventions.
Parents also should be aware of two additional points. First, everyone is built differently and it is possible that at maturity a child may intoe or outtoe and that is normal. Second, many of the fastest Olympic-level runners in the world are intoers and this condition obviously doesn't adversely impact them.
The clinic is run by two certified physician's assistants both with several years of pediatric orthopedic experience and specific training in these conditions. Appointments include assessment and parent/family education. In-clinic radiologic services are available if needed. If treatment is required, an orthopedic surgeon is consulted. Parental reassurance is all that often is needed for many of these common issues.
3. Download CSG Pocket Directory to your PDA
You now can download the Children's Specialty Group (CSG) Pocket Directory to your PDA. Please refer to the instructions below on how to create the download. The downloadable version of the Pocket Directory will be updated as physician, nurse practitioner and program changes are made.
To download the CSG Pocket Directory, create a custom AvantGo channel:
- Point your browser to https://my.avantgo.com/home/ and sign into your AvantGo account, or create one if you do not yet use this free service.
- Click the "My Account" tab in the right-hand column.
- Under Subscriptions, click "Create a custom channel."
- Title the channel as you wish (e.g. "CSG Pocket Directory"). In the Location field, enter: http://www.mcw.edu/CSGPocket/index.asp
- Under "Channel Size," set the link depth to 3, and select "Yes" next to Include Images.
- Click "Save Channel" at the bottom of the page.
Be aware that refinements to the database and appearance of the pages are ongoing. For technical issues, contact Mike Sauer at (414) 456-4749 or msauer@mail.mcw.edu. If you have suggestions or comments, contact Nancy Paffel at (414) 266-6556 or csg@chw.org. Your feedback is appreciated.
4. Member news
New appointment: Kevin J. Kelly, MD, has been appointed associate dean of Clinical Affairs at the Medical College of Wisconsin. Kelly continues to serve as medical director of the Asthma & Allergy Clinic at Children's Hospital of Wisconsin and chairman of Children's Specialty Group. He is a professor of Pediatrics at the Medical College of Wisconsin.
Membership accepted: Calvin B. William, MD, PhD, a specialist in Rheumatology at Children's Hospital of Wisconsin and associate professor of Pediatrics and Chief of Pediatrics (Rheumatology) at the Medical College of Wisconsin, has been elected to membership in the Society for Pediatric Research.
Hospitalist program planned at Condell Hospital: In 2004, a hospitalist program will begin at Condell Hospital in Libertyville, Ill. The program, seven days a week, 24 hours a day, will include four pediatricians who will provide daily care on the 18-bed pediatric unit. Akarim Shaltooni, MD, will direct the program.
Pediatric hospitalizations study released: Glenn Flores, MD, FAAP, associate professor of Pediatrics, Epidemiology and Health Policy, Medical College of Wisconsin, participated in a study of pediatric hospitalizations. Flores also is director of Community Outcomes in Pediatrics and associate director of the Center for the Advancement of Urban Children, a joint program of Children's Hospital of Wisconsin and the Department of Pediatrics at the Medical College.
According to the study released Nov. 3 in the Journal of Pediatrics, thousands of unnecessary pediatric hospitalizations could be avoided and $100 million dollars could be saved each year if parents were better educated about their children's health problems. The medical diagnoses most likely to be associated with avoidable hospitalizations in children include asthma, dehydration, gastroenteritis, pneumonia, seizure disorders and skin infections. These conditions accounted for 90 percent of admissions.
The study authors define avoidable hospitalizations as including conditions whose onset can be prevented (such as through immunization), acute illnesses that could be controlled in ambulatory settings (such as a urinary tract infection) and chronic diseases that can be managed in outpatient settings (such as asthma).
The most frequently cited reasons for avoidable hospitalizations included:
- Parents' failure to pay greater attention to medication-related issues.
- Parents' failure to take adequate preventive measures, such as removing dust or a pet from the home of a child with asthma.
- Physicians' failure to provide adequate information regarding a child's condition.
- Delayed or no follow-up on outpatient visits for a child's condition.
IBD study released: Subra Kugathasan, MD, a specialist in the Gastroenterology Center at Children's Hospital of Wisconsin and an associate professor of Pediatrics at the Medical College of Wisconsin, led a research study that appears in the October issue of Journal of Pediatrics. This was the first study of pediatric inflammatory bowel disease (IBD) in large, defined, ethnically diverse North American populations and was designed to provide a clearer picture of who this disease strikes and offer clues about its cause. The data suggest that IBD is an equal opportunity condition afflicting all populations within the region. Among children in Wisconsin, new diagnoses of IBD are equally distributed throughout all populations, including minority groups previously felt to be at lower risk for the disease.
5. Burn program takes a team approach
While just less than 10 percent of trauma patients at Children's Hospital of Wisconsin present with burns, this small number of children need a large amount of care. To treat patients with burns, the Children's Hospital Trauma Service includes a Burn Program.
The number of burn patients treated at Children's Hospital is on the rise. In 2001, 82 children with burns were admitted to the hospital, up from between 50 and 60 a year in the early 1990s. Additionally, more than 200 outpatient burn cases are handled annually through the hospital's Emergency Department/Trauma Center (ED/TC) and there are 500 outpatient visits to the Burn Clinic.
Proper treatment of pediatric burns requires aggressive early wound care as well as long-term multidisciplinary care management that may continue for several years to ensure the child's injuries heal properly with the optimal outcome. Children with burns are best cared for by a team of pediatric specialists. Children's Hospital is a Level I trauma center and offers a full range of specialized resources necessary to treat children of all ages with burns, including a medical transport team, inpatient critical and acute care units, an inpatient multidisciplinary burn care team, and a weekly burn clinic that provides comprehensive follow-up care.
The Children's Hospital multidisciplinary trauma team oversees the care of children burned seriously enough to be admitted to the hospital. Children with less serious burns are treated in the ED/TC and released. For all burn patients, the Children's Hospital burn clinic provides follow-up care by specially trained physician assistants and nurses. In 2003, the clinic had nearly 500 visits.
The Children's Hospital burn team includes pediatric specialists from many different disciplines, including pediatric surgeons who coordinate the children's care, anesthesiologists who specialize in pain management to keep children as comfortable as possible, plastic surgeon consultants who perform any needed reconstructive or cosmetic surgery, and critical care physicians working in the state-of-the-art Pediatric Intensive Care Unit.
The burn team also includes pediatric nurses with special burn training, child life specialists who help children and their families prepare for treatments by talking through their questions and fears, and social workers who help families gain access to resources and support services at the hospital and in the community. In addition, nutritionists design diets rich in protein and calories to enhance wound healing and help children recover faster, physical and occupational therapists rehabilitate children and provide scar management, and psychologists support children and families dealing with a trauma and any long-term effects.
Pediatric burns are different from adult burns
Children's skin is different than that of adults, and children's burns differ as well. Because a child's skin is thinner, the same temperature or contact, for the same amount of time, will cause a much deeper burn on a child than an adult. The causes of children's burns also differ. The most common burns in children are from fire and thermal burns caused by scalds. Children's Hospital treats all types of pediatric burns, including electrical burns, inhalation burns and chemical scalds.
The main concerns following burn injury are infection and mobility-limiting scarring. In severe cases – where more than 10 percent of the body is burned – acute dehydration and shock can develop.
A focus on minimizing pain
Mitigating pain for children with burns is a high priority for the staff at Children's Hospital who strive to provide "pain-free" burn care. They perform initial burn care, including debridement, with a pediatric anesthesiologist who sedates the child. To help increase the child's sense of safety, debridement is done in a special procedure room, not in the child's hospital bed or room. As the child's wounds heal, the amount of sedation is decreased. Children's Hospital also is using new, innovative, temporary biologic dressings to minimize painful procedures and facilitate wound healing.
Burn clinic provides ongoing follow-up care
Before leaving the hospital, burn patients and their families are taught to care for the healing burns and scars. They are asked to return for progress checks at the weekly burn clinic, which also is available to pediatric burn victims discharged from other hospitals, treated and released by another hospital's emergency room or referred by a family practice physician or pediatrician. In the clinic, a child life specialist uses distraction techniques to help children cope with dressing changes and other procedures.
Clinic appointments can last up to one hour as each specialist involved in a child's care meets with the patient. This helps the burn team work together to plan the child's care and saves families from having to schedule separate appointments.
For more information
Burn Clinic
(414) 266-6420
To make an appointment
Central Scheduling
(414) 607-5280 or (877) 607-5280
6. Controlled carbohydrate nutrition: fad or fact?
Usually, the word "fad" means "a fashion that is taken up for a short period of time; a craze," but when followed by the word "diet," fad implies a meal plan that is extreme, ridiculous, unscientific and potentially dangerous, administrated by quacks out to make a buck. The shelves in any bookstore are filled with books selling unusual weight-loss plans of dubious value. Currently, the most popular of these is the Atkins Diet, which has remained on the national best-seller list for years. But Atkins appears to be breaking out of the fad diet ghetto. In the last couple of years, scientific studies have been undertaken and published evaluating the Atkins diet, and some prominent physicians now either are openly advocating it, or at least admitting that it's not as bad as originally thought. In its shadow, other plans that focus on carbohydrates also have been gaining popularity. A recent study reported that one in six Americans is following a plan that restricts carbohydrates in one form or another. So what's the skinny on low-carb diets?
The epidemic of pediatric and adolescent overweight
Of course alternative nutritional approaches become more visible as people recognize the epidemic increases in obesity and obesity-related disease. According to the National Health and Nutrition Examination Surveys (NHANES), about 23 percent of American children are above the 85th percentile for Body Mass Index (BMI), and 10.5 percent are above the 95th percentile. Not only is the average child becoming heavier, but the heaviest also are becoming even more overweight. Non-insulin dependant (Type 2) diabetes has become an epidemic in the adolescent population. Type 2 diabetes in young adults and children was nearly unheard of in previous generations, however it now comprises up to 50 percent of new diabetes cases in some pediatric centers. Pediatric hypertension also is increasing in concordance with increase in BMI. Non-alcoholic fatty liver and steatorrheic hepatitis is becoming more commonly diagnosed. With all these increasing risk factors taken together, it is hypothesized that the generation that now are teenagers may be the first generation in American history that has a lower life expectancy than the one preceding it.
So where did we go wrong?
Pundits argue that we live in an "obesogenic culture," where sedentary activity is increased, super-sizing is encouraged and the commercial airwaves are littered with junk foods being sold to children. But some low-carb experts also put the blame squarely back on the medical establishment. They argue that the obesity epidemic began at the same time that fat reduction became most popular. By replacing fats with simple sugars and processed carbohydrates, the argument goes, we actually have contributed to the obesity epidemic in our attempt to fight it. Carbohydrates increase insulin levels, and insulin is a lipogenic hormone that causes fat to be deposited into the body. Also, insulin spikes caused by sugar intake cause reactive hypoglycemia, which leads to increase in appetite and further carb craving. By cutting fat, we became fatter than ever.
The popular low-carbohydrate meal plans tend to fall into three main categories:
Ketogenic diets are the most carbohydrate-restricted plans. In these plans, carbohydrate is restricted to the point where the body is forced to utilize fatty acids as the primary energy sources, resulting in circulating ketones in the blood. Popular examples of ketogenic diets include the Atkins Diet, Protein Power and the South Beach Diet
Glycemic index-based diets focus not on the amount, but the type of carbohydrates. The glycemic is an experimentally derived value that measures the insulin response to ingested foods. The greater the insulin response, the higher the glycemic index. In general, the more processing a carbohydrate source goes through, the higher its glycemic index. White bread is higher than wheat bread; stone cut oats are lower than instant oatmeal. The nuts and meats have the lowest glycemic index of all, barely generating an insulin response. Plans that focus on glycemic index include Sugar Busters, the Zone, Syndrome X and The Glucose Revolution.
Timing based diets focus not on the amount of carbohydrates nor the type, but they depend on when the carbohydrate is eaten, or with what they are eaten. For example, Suzanne Sommers claims that you can eat any fat source or any carb source you like as long as you don't eat them together. The Carbohydrate Addicts Diet suggests that as long as you eat all your carbohydrates within one hour, you'll be fine.
The ketogenic diets have come under the most scrutiny from the mainstream medical community. The most popular of these is the Atkins Diet. Atkins recommends a three-phase approach; induction, ongoing weight loss and maintenance. In the induction phase, carbohydrate intake is restricted to less than 20 grams/day. This is continued for two weeks and then carbohydrate consumption is increased to 40 grams/day (ongoing weight loss) until a desired weight is reached. At this point, carbohydrate consumption is increased by 5-10 grams per day until weight maintenance is reached.
The Atkins Diet has come under intense scrutiny because of its reliance on fat and protein as an energy source. Critics argue that followers of Atkins will increase their cardiovascular risk as measured by serum cholesterol and put themselves at risk for renal disease, gallstones and colon cancer. They argue that the Atkins Diet is a low-calorie diet in low-carb clothing meaning people eat less because they are bored or don't feel well, and carbohydrates have nothing to do with it.
Personal experience using the Atkins Diet in teenagers
When I started treating obesity in teenagers in the late 1990s, I was becoming frustrated with our lack of success. Many kids only lost a small amount of weight, and most gained it back and disappeared from the program. I'd been hearing a lot about Atkins, so I performed a literature search and was shocked to find that, although the first Atkins book was published in 1972, I could find no study about the diet in either the pediatric or adult literature. Nothing pro; nothing con. Nothing. With the help of my research mentor, Marc S. Jacobson, MD, at Schneider Children's Hospital in New Hyde Park, I designed a research protocol to test the Atkins Diet against the more traditional diet we were using, in a randomized controlled trial. Both groups were given meal plans based on "The Stoplight Diet," described in a book by Epstein and Squires, in which foods are divided into red, yellow and green light categories, depending on appropriateness to the prescribed diet. For the ketogenic group, we used two weeks of induction and 10 weeks of ongoing weight-loss, followed by a maintenance program based on glycemic index. For the control group, we used a standard diet with 20-30 percent of calories coming from fat for the duration of the trial.
The results were startling. After 12 weeks, the ketogenic group lost twice as much weight, even though they ate one-third more calories (1,800 to 1,200 kcal/day) as the other group. Even more surprising was that, although the ketogenic group ate almost 1,000 mg of cholesterol per day (only 300 mg/day is recommended), and although they ate 60 percent of energy from fat, their lipid profiles almost invariably improved. The biggest effect was seen in serum trigylcerides, which were cut in half and significantly improved compared to the control group. HDL and non-HDL cholesterol also showed improvement compared to the low-fat control. After one year, seven of the 12 ketogenic patients continued to be followed in our clinic. All had maintained BMI improvement and none had significant side effects. The results of this trial were published in the March 2003 issue of the Journal of Pediatrics.
Although our research experience shows success with low carbohydrate diets, it is important to remember that one size does not fit all. Most children and adolescents can lose weight and improve their health profile by simply cutting down on sweetened beverages and junk food, and increasing exercise. Always work within the preference of the child or family. If they tell you they can't live without their pasta, try to find a plan that will incorporate pasta. Teenagers in the control arm of our trial lost weight, too, so there may be more than one way to improve your patient's health. Present any meal plan as a lifestyle change, not a "diet," which one goes on and off. Give specific recommendations, develop practice menus and troubleshoot before, not after, parties or holidays. Treating obesity is one of the more challenging areas in the field of pediatrics, but with a knowledge of nutritional alternatives, you and your patients can experience success.
To refer a patient
NEW Kids Program
(414) 266-6917
To make an appointment
Central Scheduling
(414) 607-5280 or (877) 607-5280
7. Advanced practice nurses: Partners in practice
Physicians recognized the value of partnering with nurse practitioners and clinical nurse specialists long before Children's Specialty Group existed. The first pediatric nurse practitioners to work within Children's Hospital of Wisconsin did so with the pediatric oncologists in the 1980s. Since that time the success of the role in terms of excellent outcomes for children, families and for physicians practicing in academic medicine, led to the current reality of over 85 advanced practice nurses (APNs) practicing within the system. Today most Children's Specialty Group practices have more than one APN with the largest group practice of APNs, (eight) working in the Hematology, Oncology, Blood and Marrow Transplant (HOT) Program.
APNs hold a master's degree in Nursing, are certified in their specialty and those who are nurse practitioners hold advanced practice nurse prescriber licenses in the state of Wisconsin. Advanced practice nurse is a broad title referring to both nurse practitioners and clinical nurse specialists. APNs work collaboratively with CSG physicians and colleagues from Children's Hospital to plan and provide excellent, individualized, holistic care to children and families.
As partners in specialty practices, APNs help ensure there are sufficient care providers to keep the wait time from referral to actual appointment at a minimum. APNs not only manage a subset of what traditionally is thought of as medicine, but are uniquely prepared to incorporate knowledge of nursing science, growth and development, families and of chronicity into the plan of care they create for a child and their family. APNs have taken the lead in developing clinics designed to meet the special needs of children living with chronic health conditions. Examples of such clinics include the Headache Clinic (Neurology), the Constipation Clinic (GI) and the HOT Long-term Follow-up Clinic. For example, the Long-term Follow-up Clinic was the brainchild of APNs and is designed to help children and families with the aftereffects of intensive chemotherapy and bone marrow transplant, including everything from physical growth to success in school.
APNs are partnering with physicians not only to provide direct care but also engage in program development, create and provide education to clinic and hospital staff and children and families, and engage in quality improvement and research with multidisciplinary colleagues.
Nearly three years ago Children's Hospital had the foresight to create the department of Advanced Practice Nursing to ensure that APNs have the support and development needed to practice successfully within Children's Hospital and Health System.
8. Safety news: Please share this information with your patient families. LATCH: The newest child safety seat installation system
When it comes to your child's safety seat, do you know the difference between installing with LATCH and installing with a safety belt? Can you tell the difference between a lower anchor and a top tether anchor? Well, if your answers are "no," you are not alone. Many caregivers are confused when it comes to the mechanics of installing child safety seats.
According to the National SAFE KIDS Campaign, more than 80 percent of child safety seats continue to be used incorrectly, and there are an average of three mistakes made with each one. That's one reason why motor vehicle crashes remain the leading cause of injury-related death among children ages 14 and under, killing nearly 1,700 children each year and injuring another 228,000 more.
The federal government and manufacturers continue to do their part to help parents "get it right" by simplifying child safety seat installation. LATCH – Lower Anchors and Tethers for Children, is a system designed to make child safety seat installation easier without using seat belts. All new car seats and new vehicles are equipped with LATCH.
Although LATCH can make installation simpler for parents and caregivers, it does not completely solve the problem of incorrect use. Education on the correct selection and use of child safety seats, as well as proper instructions for installation with LATCH, is still a critical component. Whether a car seat is being installed using LATCH or the seat belt, it is important to read the owner's manual of the vehicle and the car seat to ensure a proper installation.
To find out more about the LATCH installation system or to locate a SAFE KIDS child safety seat inspection station or checkup event in your area, parents and caregivers can visit www.safekids.org.
Source: Bridget Clementi, coordinator of SAFE KIDS Wisconsin Coalition, can be reached at (414) 390-2177. Children's Health Education Center, a member of Children's Hospital and Health System, is the lead agency for SAFE KIDS Wisconsin.
9. New Children's Specialty Group members
Alan N. Mayer, MD, PhD, sees patients in the Gastroenterology Center at Children's Hospital of Wisconsin and is an associate professor of Pediatrics (Gastroenterology) at the Medical College of Wisconsin. Mayer earned his medical degree from Cornell University Medical College and has a Doctor of Philosophy degree from Cornell University Graduate School of Medical Sciences in New York. He completed his pediatric residency at Children's Hospital of Philadelphia and fellowships in pediatric gastroenterology and nutrition at Children's Hospital, Massachusetts General Hospital and Harvard Medical School, Boston, combined program. He is board certified in Pediatrics and Pediatric Gastroenterology.
Mayer previously was an assistant professor at Harvard Medical School and in his new role with the Medical College of Wisconsin, he will spearhead the development of a research program focused on the developmental biology of the gastrointestinal system. He has identified a variety of genes that impact on GI development in a zebra-fish model. Mayer currently is funded by an National Institute of Health (NIH) young investigator award and is generally regarded as one of the most promising young investigators in the pediatric GI community. During the next year, Children's Specialty Group will recruit an additional basic scientist (PhD) as a faculty member to support the GI developmental biology program.
Robert J. Perzacki, MD, sees patients in the Child and Adolescent Psychiatry Center at Children's Hospital and is an assistant professor of Psychiatry at the Medical College of Wisconsin. He earned his medical degree from the Medical College of Wisconsin, Milwaukee, and completed his residency at Menninger School of Psychiatry, Topeka, Kan. He is board certified in Psychiatric and Neurology.
Jennifer A. Niskala, PhD, sees patients in the Child and Adolescent Psychiatry Center at Children's Hospital and is an assistant professor of Psychiatry at the Medical College of Wisconsin. She has a Doctor of Philosophy degree from the University of Texas, Dallas and completed her residency at Children's Medical Center, Dallas, in Pediatric Neuropsychology.
Abdelkarim Shaltooni, MD, is an assistant professor of Pediatrics at the Medical College of Wisconsin. He serves as the director of Pediatric Hospitalists at Condell Medical Center, Libertyville, Ill. He earned his medical degree at Pavia University, Italy, and completed his residency in Pediatrics at Christ Medical Center, Oak Lawn, Ill. He is board certified in Pediatrics. |
