1. Common pediatric issue: Overuse injuries continue to increase among children
The recent explosion in the number if children participating in organized sports has led to a corresponding increase in the number of sports-related injuries. In general there are two broad categories of sports injuries: acute traumatic injury and overuse injury - also known as fatigue or repetitive stress injury. This article will focus on injuries that result from overuse.
Definition
Overuse injuries occur with repetitive application of sub-maximal stresses to otherwise normal tissues. Not all children who have this type of injury are athletes. Some children become symptomatic with overuse injuries primarily from daily activities. These children tend to have a low level of normal activities which predispose them to injury. They may be involved in an activity which results in either a large amount of event-specific training or activities that are repetitive.
Diagnosis
In the early stages of stress injury, inflammation leads to pain alone but can result in complete tissue failure in the late stages. Overuse injuries are not as common as acute injuries, but often require longer periods of activity restriction.
Overuse injuries can occur in a variety of tissues including bone, articular cartilage and growth cartilage. Growth tissues of the physis (growth plate) and the apophysis (tendon attachment site) are particularly susceptible to overuse injuries.
Growth cartilage is found in the ephiphyseal plate, the articular cartilage of the joint surface and at many of the insertion sites of muscle tendon units (apophyses). Overuse injury at each of these tissues is associated with its own specific condition and can occur throughout the skeletal system but is most common in the lower extremity.
Causative factors for overuse injuries can be categorized into intrinsic or extrinsic. Intrinsic factors are related to the athlete, such as limb alignment, growth, muscle tendon imbalance and underlying disease states. Extrinsic factors relate to training errors, environment and equipment.
Intrinsic factors
A host of anatomic factors can predispose to overuse injuries. In the lower extremity, leg length discrepancies and anatomical malalignment - such as anteversion of the hips, external and internal tibial torsion, excessive foot pronation or supination - can lead to chronic stress related to injuries in children that participate in demanding, repetitive use sports.
Growth also is a significant factor in the cause of overuse injuries in children. Reduced flexibility with age and growth, especially during the adolescent growth spurt, can lead to increases in stress on bone and joints. The longitudinal growth of bone advances more rapidly than that of the surrounding muscle tendon units. Resultant muscle tendon unit tightness can then contribute to overuse injuries such as patellofemoral stress syndrome. A major emphasis on the flexibility component of training can help athletes reduce their risk and severity of overuse injuries. The idea is to focus more on flexibility training and less on strength training or conditioning. Often times establishing the diagnosis of an overuse syndrome requires ruling out a previously unrecognized disease condition such as tarsal coalition, Legg Perthes disease or slipped capial femoral epiphysis. Radiographic evaluation is often more important to rule out these underlying disease states than it is in establishing the presence of an overuse injury.
Extrinsic factors
Training errors are by far the most common extrinsic factors that predispose to overuse injuries. The frequency, volume and intensity of training are all part of this equation. Injuries arise when the child is asked to do too much, too soon, and the musculoskeletal structures are unable to adapt in time to forestall injury. Inadequate recovery time between training sessions also can cause this type of injury. While overuse injuries can occur at any phase of an athlete's training, typically injuries are seen most often at the start of training and when a training program is accelerated to gear up for a specific high profile event. Children often suffer from what I call the "tournament effect." This occurs when a child has a weekend sports tournament with three to six games that results in a sudden increase in stress activities in a short time span, causing an overuse injury. While multiple games on a weekend are convenient for adult schedules, they are certainly a high-risk activity to many children.
There are also environmental and equipment factors that can lead to problems. Specifically, having equipment that is properly designed can help reduce the severity and frequency of overuse injuries. Shoe wear can have an important helpful effect in preventing overuse injuries with the appropriate amount of foot support and cushioning. Using a tennis shoe for cross country running can result in symptomatic foot, ankle or knee stress injury. Playing surface also can have an impact on the incidence of overuse injuries with harder, less forgiving surfaces such as concrete leading to an increase in these injuries.
Patient evaluation
The clinical evaluation of the childhood athlete requires a thorough history and physical examination. Specifics about the onset of symptoms in relationship to changes in training patterns, equipment and shoe wear can give important clues about possible overuse injuries. The physical examination needs to localize pain to specific anatomic locations differentiating diaphyseal bone pain, physeal area periarticular pain, joint pain and tendon or ligament attachment site pain.
Obviously joint range of motion and joint stability, as well as ability to fully weight bear and to perform specific stress induced activities such as hopping and jumping, need to be assessed. Lower extremity alignment also should be evaluated as a possible predisposing factor.
Common syndromes
Understanding the common specific overuse syndromes is helpful in identifying and determining treatment regimes.
Bone overuse: Stress fractures occur with less frequency than in adults but affect the same areas. The tibia, fibula metatarsals and posterior spinal elements (pars intra-articularis) are most frequently involved. Spondylosis (a stress fracture of the posterior spinal elements) is relatively common in children and should be ruled out in adolescents with significant lower back pain for more than three to five weeks. Athletes at high risk for this type of injury include gymnasts, football linemen and ballet dancers.
Simple radiographs of the spine, including oblique X-rays, may be negative in early cases of spondylolysis and may need special studies including technician 99 bone scan or a CT scan of the L4-S1 area. Spondylolysis treatment usually includes a brace for immobilization combined with hamstring stretching, abdominal strengthening and restriction of activities.
Lower extremity stress fractures in the early stages may be treated with activity restriction alone but in more advanced cases may require casting, non weight-bearing activity and, occasionally, surgical stabilization.
Plain radiographs are negative in the early stages of stress fracture.
Articular cartilage overuse: Shoulder impingement syndrome can result from throwing or other repetitive overhead activities. Often a relatively lax anterior shoulder capsule can make anterior joint subluxation and impingement more likely. Generally, these children do not have rotor cuff tears.
Treatment is aimed at stretching and strengthening. Rarely is surgical intervention useful in this age group.
Little league elbow is an overuse condition caused when growing children are involved in a high level of throwing activities. Symptoms include pain over the lateral aspect of the elbow, occasionally with loss of elbow extension.
X-rays usually are negative early. An MRI is helpful for diagnosis. In early stages, this condition is usually reversible. If left untreated, often-permanent cartilage and bone deterioration occurs leading to persistent pain and deformity.
Surgery occasionally is needed for debridement of the deteriorated joint cartilage.
Patellofemoral stress syndrome is the most common overuse injury of articular cartilage and occurs predominantly in the adolescent athlete. It is the most common cause of knee pain in adolescents. It is exacerbated with jumping and stair climbing. Factors contributing to this condition include the relative muscle, tendon and ligament imbalance around the patella and relative weakness of the vastus medialias obliqus muscle. Lower extremity malalignment can contribute to this condition, such as knock knees, severe flat feet and significant femoral rotational malalignment.
Physical findings include peri-patellar pain to palpitation. Presence of a knee effusion is rare and should be cause for investigating other conditions. X-rays are unremarkable and there is no restriction of range of motion. Symptomatic treatment is a rule. A physical therapy program for quadriceps stretching and strengthening exercises often is helpful. Patella stabilizing sleeves may be helpful symptomatically but not provide any proven benefit. Anti-inflammatory medications may be helpful for symptomatic relief as well. Often this can be a prolonged symptomatic problem with fluctuations in pain intensity, but it rarely needs any surgical attention.
Osteochondritis dissecans of the distal femoral area is thought to be associated with repetitive trauma to the area and may well be classified as an overuse condition. Osteochondritis results in deterioration and softening of the articular cartilage and underlying bone. Pain usually is deeply seated in the knee. Occasionally a knee joint effusion will be present. Usually the pain increases with activities. Radiographs are needed to confirm the lesion. Radiographs must include an inter-condylar notch view to best illustrate the lesion. Occasionally an MRI or bone scan can help with treatment recommendations.
If the lesion is not identified early it can lead to permanent pain and disability. There is an extremely favorable prognosis if lesions are identified and treated early. Initial stages of treatment include immobilization and non-bearing weight. More persistent lesions need more aggressive treatment including arthroscopic evaluation, intraarticular drilling and occasional fixation of the lesion with bone grafting.
Physeal (growth) cartilage overuse: Gymnasts wrist is a relatively common injury to the distal radius physeal area in high-level gymnasts because of the repeated excessive compression forces on the upper extremity. During gymnastics, the arm is being used for weight bearing activity which overwhelms the ability of the physis to continue normal growth. Wrist pain develops often, and there is swelling of the distal radius. Limitation of wrist dorsiflexion and tenderness about the distal radial physis is common once this condition has developed.
Early radiographic evaluation may be normal. In more advanced stages wrist radiographs show irregular widening of the distal radial physis. If significant physeal irregularity exists. Immediate and near complete rest is necessary until the symptoms have completely subsided.
If radiographs are negative, modification of activity levels until the area becomes pain free is adequate. Bracing or casting, and limitation of activity, can help reduce the pain.
Tendon and tendon attachment overuse: There are multiple traction apophysitis that occur in children, with Osgood-Schlatter disease or condition being the most common. The usual age at presentation is older than ten. Repetitive traction on the tibial tubercle apophysis is the cause. Patellar tendon attachment becomes irritated with overuse and becomes painful. This is more common in children that are active in sports but also can involve children at more normal activity levels.
Typical symptoms include pain isolated to the tibial tuberosity. Enlargement of the tibial tubercle is common. Radiographs of the knee are not diagnostic but can be helpful to rule out other conditions. Treatment involves activity modifications, use of ice and appropriate stretching exercises including quadriceps stretching. Non-steroidal anti-inflammatory medications can be helpful for symptomatic relief. The condition is self-limited and can vary quite a bit in intensity depending on the stage of growth as well as activity level. In most cases, some limitations of activities are helpful, but stopping all activity is unnecessary.
Bracing or casting is unnecessary except in the extreme case. Surgery is not indicated. Once the tibial tubercle apophysis is closed, symptoms should resolve. In most cases, enlargement of the tibial tubercle is permanent.
Sinding-Larsen-Johansson syndrome is also a traction apophysitis. The site of injury and pain is at the distal pole of the patella. It is significantly less common than Osgood-Schlatter and occurs between the ages of ten and thirteen. Symptoms often are exacerbated by running, jumping, stair climbing and kneeling.
Lateral radiographs of the knee show calcification of inferior pole of the patella in more advanced stages but are negative early. As in Osgood-Schlatter condition, symptomatic treatment is the rule. In both Osgood-Schlatter and Sinding-Larsen-Johansson syndrome, radiographic abnormality is not needed to establish the diagnosis. The diagnosis is based on clinical evaluation.
Other common traction apophysis include calcaneal apophysitis (Sever's), which is pain specifically over the posterior most aspect of the calcaneous and usually not on the plantar surface of the heel. Traction apophysitis also occur at the base of the fifth metatarsal, which is called Iseling's disease. There can be pain and swelling over this area. The radiographic appearance often is confused with a normal appearing apophysitis and a secondary growth center in this area. Again, symptomatic treatment for these conditions involves modification of activity and stretching exercises, and immobilization only is needed occasionally. Sometimes a hard pad as protection from blunt trauma to these painful swollen areas is helpful.
Chronic overuse injuries in children are becoming more common and no doubt are seen daily in the pediatricians' offices. The combination of basic understanding of musculoskeletal development and extremity physical examination can easily lead to early identification of most overuse syndromes. In most cases, overuse syndromes that are diagnosed early can be dealt with simply with activity modification, which can lead to resolution of symptoms and allow the child to continue participation, but at a reduced level. If unrecognized, overuse syndromes can lead to catastrophic failure or significant joint or physeal damage.
In summary, sports competition in children is healthy and should be encouraged when done in a reasonable and rational fashion. A well-organized athletic program can then provide a safe, wholesome environment where a child can enjoy his or her spare time.
Source: Roger Lyon, MD, sees patients in the Orthopedic Center at Children's Hospital of Wisconsin. He is an associate professor of Pediatrics (Orthopedics) 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. Effectively managing facial paralysis
Facial paralysis in the pediatric population can arise following resection of a tumor such as acoustic neuroma, following facial trauma or in utero. Mobius syndrome is the most common congenital cause of facial paralysis, and it results from arrested development of one or more cranial nerves.
Surgical treatments
Difficulties with eyelid closure and inability to smile are the most significant problems for children with facial paralysis. The most effective surgical options consist of either static or dynamic nerve transfers to replicate function of the lost muscles. Eyelid closure is best treated using a gold weight, since reconstruction of the orbicularis oculi muscle has not achieved a consistent degree of success.
Facial reanimation for smiling can be treated by static slings to stimulate symmetry or by local muscle transfer using either the masseter or temporalis muscles. The reconstructive technique that can achieve the greatest symmetry is free muscle transfer, since the muscle can be oriented to stimulate the pull of the contralateral side. Facial symmetry is difficult to achieve using local muscle transfer. Another advantage of free muscle transfer is that it can be innervated by a cross-facial nerve graft. When compared with a local muscle transfer, this graft provides increased spontaneity of smiling as it is innervated by a nerve that is not ordinarily associated with smiling.
Helping children smile
The preferred technique for facial reanimation to restore a patient's ability to smile begins with placement of a cross-facial nerve graft, harvested from the sural nerve in the leg. The entire length of the nerve, from just above the lateral malleolus to just below the popliteal fossa, usually is required. The buccal and zygomatic branches of the facial nerve are identified as they emerge from the anterior border of the parotid gland and traced distally until these nerve branches bifurcate. Two or three branches are chosen for anastomosis to the cross-facial nerve graft. Branches of the facial donor nerve are selected, preferable at a point where they bifurcate, leaving one limb of each nerve branch to innervate the normal facial musculature.
Should the bifurcation show a weaker and a stronger division, using the stronger division, using the stronger division for the cross-facial nerve graft is recommended. This selection will ensure better nerve regeneration and may slightly weaken the normal side, thereby improving symmetry once the reconstructed side regains function. The nerve is tunneled beneath the alar base and brought out temporarily through one nostril floor. The nerve is then passed toward the zygomatic arch and the preauricular region, where the nerve end is marked with a nonresorbable marker.
To facilitate a repeat dissection, it is important to note the exact location of the marker that designates the end of the cross-facial nerve graft.
Following nine to 12 months, the marked end of the nerve graft is dissected. A segment of the nerve is submitted for frozen section analysis to evaluate for myelinated axons. If the analysis reveals viable nerve regeneration, the surgery is performed utilizing free muscle transfer. The ipsilateral gracilis muscle is used, tailoring the length of muscle harvested to match the distance from the zygomatic arch to the upper and lower lips. The obturator nerve is harvested to the level of the inguinal ligament, thereby ensuring adequate nerve length at the time of the final nerve anastomosis. The muscle is harvested and set into a subcutaneous flap, making an effort to stimulate the contralateral nasolabial fold as the muscle is tightened to elevate the upper lip. Neurovascular anastomosis is then performed, preferably anastomosing the vessels of the flap to the facial nerve and artery and suturing the nerve to the gracilis with the cross-facial nerve graft (See Figure 1). The proximal end of the muscle then is secured to its origin along the zygomatic arch. Reinnervation of the transferred muscle generally requires four to nine months.
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| Figure 1: Schematic representation of the gracilis muscle placed from its origin at the zygomatic arch to its new location at the lateral commissure of the mouth. The inset shows he anastomosis of the nerve to the gracilis and to the cross-facial nerve graft. Vascular anastomosis is made to the facial vein and artery. |
A 9-year-old girl who presented with left unilateral facial paralysis was treated surgically (See Figure 2A). A second photograph, taken one year following facial reanimation using free gracilis muscle transfer, demonstrates that the patient has achieved excellent symmetry between the right and left sides of the face when smiling (See Figure 2B). Achieving a symmetric smile was further enhanced by a biofeedback program, initiated soon after the first signs of facial reanimation were observed.
Source: Arun Gosain, MD, sees patients in the Craniofacial, Plastic and Reconstructive Surgery Clinic at Children's Hospital of Wisconsin. He is a professor of Plastic Surgery at the Medical College of Wisconsin and a member of Children's Specialty Group.
For more information:
Craniofacial, Plastic and Reconstructive Surgery
(414) 266-2825
To make an appointment:
Central Scheduling
(414) 607-5280 or (877) 607-5280
3. Epilepsy surgery: Early intervention is critical
Epilepsy, or recurrent, unprovoked seizures, affects 0.5 to 1 percent of the population, with the most frequent incidence being in childhood. Every year approximately 25,000 to 40,000 children in the United States experience their first seizure that is not associated with a febrile illness or head trauma. Thirty to 65 percent of these children go on to have a second unprovoked seizure within the first year. The etiologies for the recurrent seizures encompass two broad categories - genetically determined epilepsy syndromes and substrate-based epilepsy syndromes.
Early intervention is key
Young infants and children have specific vulnerabilities to the cognitive and behavioral consequences of even brief, recurrent seizures. Recent animal studies document that immature brains appear to develop spontaneous seizures more readily than mature brains when presented with seizure producing irritants. They quickly become "programmed" to excitability and continued seizures. In addition, even in children whose epilepsy is well controlled, the non-medical consequences of their epilepsy are profound - anxiety and depression; lack of similar academic achievement when compared with matched peers; discrepancy in employment and income when compared with peers. In men, they are less likely to marry. It is recognized that some of these consequences may be the result of the underlying cause of their epilepsy syndrome, but neuropsychologists also have documented a decline in cognitive and behavioral function in those patients with intractable epilepsy.
One recent study indicated that it took 20 years for a patient with intractable epilepsy to be referred to a tertiary epilepsy center for surgery evaluation. The majority of adult patients with epilepsy had their onset of epilepsy in infancy or childhood. Early intervention might prevent many adult epilepsy cases.
Surgery is not a last resort
Epilepsy surgery never should be considered a treatment of last resort. Tt can be life-saving and should be considered early in the child's course of treatment. This is particularly true in these conditions:
- Children with lesional localiazation related to epilepsy, for example presence of a tumor, tubor or other structural lesion, whether or not controlled with antiepileptic drugs (AEDs).
- Children with catastrophic epilepsies where the continuation of the epileptic encephalopathy and clinical seizures will result in substantial morbidity in terms of development and quality of life. Examples include patients with:
- Infantile spasms and an underlying malformation of cortical development.
- Sturge-Weber syndrome with progressive hemiparesis and intractable seizures.
- Rasmussen's syndrome with progressive encephalopathy, seizures and hemiparesis.
- Malformations of cortical development, including hemimegalencephaly.
- Perinatal infarctions, such as middle cerebral artery infarctions, with concomitant porencephalic cyst formation.
Other candidates for epilepsy surgery include children with:
- Nonlesional localization related epilepsy who have failed two to three standard AEDs. If a patient fails one AED, the chance of a second AED controlling the seizure is only 10 percent.
- Generalized or multifocal epilepsies in whom the clinical presentation, seizure symptomatology, EEG findings, MRI scan of the brain or other tests strongly suggest a single focal generator for the epileptic condition.
- Intractable generalized epilepsy who have tonic/atonic seizures may be candidates for corpus callosotomy.
Following are the most important questions to ask before considering a presurgical evaluation for the child:
- Is this an epileptic syndrome with a poor prognosis for remission?
- Will the continuation of the epileptic seizures have a significant impact on the child's ultimate development or quality of life?
- Have the seizures been refractory to at least two AEDs?
- Can the epileptogenic zone be localized using EEG data and neuroimaging?
- Can the epileptogenic zone be resected without unacceptable neurologic deficits?
The type of epilepsy surgery performed depends on the localization of the epileptogenic zone. Some of the more common surgical procedures include:
- Temporal lobectomy with amgydalohippocampectomy.
- Focal cortical resection.
- Hemispherectomy.
- Corpus callosotomy.
In young infants and children, an entire hemisphere can be removed with relative impunity. The patients who are candidates for hemispherectomy already have a significant hemiparesis, based on the extent of the lesion that requires resection. These children have a significant capacity to transfer functions to the remaining hemisphere, including the bulk of the motor function - as there is considerable bilaterality in motor function, save for hand function - speech and language, and memory. These functions do "crowd" themselves into a single hemisphere, but the benefits of having a significant reduction in seizure burden or being seizure free outweigh some of these "costs."
Managing pediatric epilepsy
Epilepsy in infants and children differs from adult epilepsy in several areas: seizure symptomotology, EEG characteristics and seizure development/propagation, which reflect the developmental stages of the immature brain. In addition, the underlying substrates of epilepsy are very different, with the most common eitiologies being either genetic or remote central nervous system (CNS) lesions. The etiologic differences have resulted in uniquely pediatric epilepsy syndromes. Some of the epilepsy syndromes are catastrophic and malignant; others are idiopathic, age-limited and probably genetically predetermined. Epilepsy syndromes require a comprehensive compilation of data, including seizure types, age of onset, neurological exam, family history, EEG data and neuroimaging results.
Genetically determined cases
Of the genetically determined epilepsy syndromes, the majority are benign, self-limited and can go into remission. The most common epilepsy syndrome of childhood is benign rolandic epilepsy. In some studies, this epilepsy syndrome accounts for 25 percent of all childhood epilepsy. It is genetically determined, probably autosomal dominant with variable penetrance and age-limited expression. Children with this syndrome typically enjoy normal growth and development. The seizure description is classically defined by sensorimotor symptoms and convulsive activity in the face, arm or leg, with associated drooling (hypersalivation) and speech arrest. There may be secondary generalization. The seizure frequency varies, but usually seizures are rare and precipitated by sleep deprivation. The seizures are predominantly nocturnal, occurring in the early morning hours prior to awakening or soon after falling asleep, therefore the interictal awake EEG can be normal. With drowsiness and sleep, there is activation of central-temporal spikes. The most important fact about this epilepsy syndrome is that it is outgrown in all patients by the time of adolescence. Treatment with AEDs does not appear to alter prognosis. In fact, AEDs seldom are used in patients with rare seizures. Medication may be indicated for those patients who are experiencing more frequent seizures that disrupt sleep, school performance or psychosocial well being.
Substrate-based cases
Catastrophic epilepsy syndromes generally are found in infants and young children. This is due, in large part, to significant CNS pathology typically associated with these syndromes, as well as to the immaturity of the brain with its unique vulnerabilities. In the context of an ongoing epileptic encephalopathy, the immature brain, at least theoretically, can undergo aberrant apoptosis (cell death) and synaptogenesis (synapse formation). The comorbidities associated with these catastrophic epilepsies include neurological abnormalities, developmental delays, cognitive impairments and behavioral difficulties. If the seizures and ongoing epileptic encephalopathy can be stopped, whether with medication or epilepsy surgery, clinicians recognize that windows of "developmental opportunity" occur. The result is developmental gains that would not have been seen if the ongoing epileptic encephalopathy had persisted.
A classic example of this is infantile spasms. Any physician who has treated a child with infantile spasms has observed the developmental plateauing and regression that classically accompanies this epilepsy syndrome. If the infantile spasms can be stopped and the EEG normalized, such as with adrenocorticotropic hormone (ACTH) therapy, the child will begin to make developmental gains. Thirty to 40 percent of children with intractable infantile spasms, however, go on to develop Lennox-Gastaut syndrome, an intractable generalized epilepsy syndrome associated with multiple seizure types (atonic, tonic, myoclonic, atypical absense and generalized tonic-clonic seizures) and significant cognitive impairments. Approximately 17 percent of these children have identifiable lesions on neuroimaging, making them potential candidates for epilepsy surgery. Infants and young children with catastrophic epilepsies and identifiable lesions on neuroimaging certainly should be at the top of our list for surgical intervention.
In addition to the known catastrophic epilepsy syndromes of infancy and childhood, children with symptomatic localization related epilepsy syndromes also are much less likely to go into remission and achieve withdrawal of their antiepileptic medication. The facts are:
- Sixty percent of children with epilepsy will have their epilepsy come under full control with the initial antiepileptic medication that is prescribed.
- Of the 40 percent whose seizures persist, only an additional 10 percent will achieve complete seizure control with the second appropriately chosen antiepileptic medication.
- The remaining 30 percent constitute the intractable or "difficult to control" epilepsy group.
Children with intractable seizures should be referred to a tertiary epilepsy center, such as Children's Hospital of Wisconsin, for a complete evaluation. Some may have the wrong diagnosis - such as a movement disorder or cardiac arrhythmia; others may be on an inappropriate antiepileptic medication for their specific epilepsy syndrome (for example, children with absence seizures will have an exacerbation of their epilepsy when treated with crabamazepine or oxcarbazepine); and others may be suitable candidates for epilepsy surgery or other epilepsy therapies.
In summary, the most important determinant of therapeutic options and prognosis in a pediatric patient with epilepsy is the ability to determine a specific epilepsy syndrome. If the epilepsy syndrome is genetically based with an early age of onset, the prognosis generally is favorable for remission. On the other hand, if the epilepsy syndrome is "substrate-based" (i.e. remote CNS lesion) the prognosis is less likely for remission. Patients with intractable epilepsy (failure of three AEDs) should be referred early to a tertiary epilepsy center for evaluation.
Source: Mary L. Zupanc, MD, is medical director of Neurology and leads the Pediatric Epilepsy Center at Children's Hospital of Wisconsin. She is a professor and chief of Pediatric Neurology at the Medical College of Wisconsin and a member of Children's Specialty Group.
For more information:
Neurology Clinic and Pediatric Epilepsy Center
(414) 266-2831
To make an appointment:
Central Scheduling
(414) 607-5280 or (877) 607-5280
4. Tips for managing first unprovoked seizure
Every year, approximately 25,000 to 40,000 children in the United States experience a first seizure that is not associated with a febrile illness or head injury. However, only 29 to 65 percent of those children are likely to have a seizure recurrence within the first year after the initial seizure, and only 10 percent are likely to have multiple seizures. These statistics might lead the primary care provider to question: How should that first seizure be managed? What tests, if any, need to be done for the child? Should medication be started? If no, what other interventions should be employed?
Evaluation
The first seizure may be a complex partial seizure, a primary or secondarily generalized tonic-clonic seizure, or a tonic seizure. The most immediate need is to obtain a detailed history and physical/neurologic exam to establish that a seizure occurred, verify that this was indeed the first seizure, and determine whether there were any provoking factors for the seizure, such as hypoglycemia, toxic ingestion, trauma or infection. Laboratory testing is not recommended in children who are older than 6 months, who have returned to baseline after the seizure and have no history of symptoms for the seizure. If there is a possibility of drug or toxin exposure, a toxicology screen is recommended. In addition, a lumbar puncture has not been found to be valuable in a first unprovoked seizure, unless there is concern about the possibility of meningitis or encephalitis. However, because an infant may not have the typical signs and symptoms of meningitis or encephalitis, a lumbar puncture should be considered in a child who is less than 18 months of age.
Since electroencephalograms (EEG) may be helpful in determining the type of seizure, the presence of an epilepsy syndrome and the risk of seizure recurrence, it generally is recommended that a child who has had an unprovoked seizure have an EEG performed as part of his or her evaluation. However, there is not immediate urgency to have the EEG done. In fact, transitory postictal slowing can commonly occur after a seizure, which usually resolves in 24 to 48 hours. Since the presence of this slowing needs to be evaluated cautiously, it is more advantageous to have an EEG performed at least 48 hours after the seizure. It is important that the EEG be done both during the awake and sleep phases, since some abnormalities don't present until the child is asleep.
Although neuroimaging abnormalities may be seen in children with a first unprovoked seizure, generally these abnormalities don't impact the immediate management decision. Therefore, routine neuroimaging after a first unprovoked seizure is not recommended in circumstances where there is the possibility of a serious structural lesion that might require emergent intervention. When neuroimaging is indicated, the preferred method is magnetic resonance imaging (MRI), which is more likely to demonstrate subtle abnormalities. The presence of a postictal focal deficit that is not resolving quickly or a failure to return to baseline within several hours after the seizure might indicate the possibility of a serious condition requiring urgent intervention and necessitate an emergent MRI. In addition, a nonurgent MRI should be considered in a child who meets one of more of the following criteria:
- Has a significant cognitive or motor impairment.
- Has abnormalities on neurologic exam that have no obvious cause.
- Has a seizure with focal onset without an EEG pattern associated with benign partial epilepsy of childhood (Rolandic epilepsy) or primary generalized epilepsy.
- Is under a year of age.
In these circumstances the presence of abnormal MRI findings might have an impact on recommendations for long-term management of seizures.
Intervention
The decision on whether to intervene with medication for a first provoked seizure needs to be made on the basis of multiple factors including the risk of seizure and the risks of side effects from antiepileptic medications (AED). Although treatment with AEDs decreased the risk of seizure recurrence in combined adult/pediatric studies, there is no significant evidence to support that treatment with an AED after a second - rather than first - seizure has any impact on the chance for long-term seizure remission. In addition, AED therapy carries the risk of physical, psychosocial, behavioral and cognitive side effects that have the potential for affecting the quality of life of a child. Therefore, the decision to initiate AED therapy should be based on the risk-benefit ratio for seizure recurrence and AED therapy side effects and should be individualized and based on a mutual discussion between the health care provider and patient and family.
Children whose first unprovoked seizure is prolonged (greater than 30 minutes) are not at risk for seizure recurrence. However, they are more likely to have another prolonged seizure (if seizures recur) than children who did not have a prolonged seizure initially. Therefore, the family of children who present initially with a prolonged seizure should be prescribed and instructed on the use of rectal diazepam gel (Diastat). Diazepam gel is given rectally for seizures that have not spontaneously resolved after five minutes. It has been effective in stopping a prolonged seizure or repetitive seizures in approximately 80 percent of patients.
Regardless of whether an AED is started, the family needs education on emergent intervention should a second seizure occur (See Table 1). The goal of emergent care during a seizure is to protect the child from injury and to provide timely access to emergency medical services are prolonged. The family and child also should receive instruction on activities - for example, climbing, unsupervised swimming, biking/skateboarding without a helmet, driving - that are best to avoid at least until a pattern for seizure recurrence has been established.
Summary
In a child with a first unprovoked seizure, it is strongly recommended that a nonurgent EEG be performed to aid in classifying the seizure type and epilepsy syndrome and to provide information that may aid in predicting risk for seizure recurrence. Other lab work-studies, including a lumbar puncture and neuroimaging studies need only be done if the tests can provide information on a potentially treatable cause for the seizure.
Since the risk of seizure recurrence - especially the risk of multiple seizure recurrence - is relatively low and because of the potential side effects from antiepileptic medications, it is generally felt that antiepileptic medication therapy does not need to be initiated after a first unprovoked seizure. Education on seizure first aid and activities to avoid or decrease the risk or injury during a seizure is valuable to help allay the fears of the child and family and to promote their understanding of seizures.
Source: Rhonda Roell Werner, RN, BSN, MS, is a clinical nurse specialist in the Pediatric Epilepsy Center at Children's Hospital of Wisconsin.
For more information:
Neurology Clinic and Pediatric Epilepsy Center
(414) 266-2831
To make an appointment:
Central Scheduling
(414) 607-5280 or (877) 607-5280
Table 1: Caring for a Child During a Seizure
What to do for a tonic-clonic seizure:
- Keep calm. You cannot stop a seizure.
- Help your child lie down.
- Gently roll your child onto one side. This helps saliva drain from his or her mouth.
- After the seizure, your child may throw up. Keep your child lying on his or her side so saliva and vomit can drain from the mouth.
- Loosen your child's collar and put something flat and soft under the head.
- Clear the area of hard, sharp or hot objects that may harm your child. You also may gently pull your child to a safe area.
- If your child wears eyeglasses, remove them.
- Do not try to hold your child or stop his or her movements.
- Do not force anything between your child's teeth. The child will not swallow his or her tongue. Forcing something between the teeth could hurt your child.
- Stay with your child until the seizure is over.
- Let your child rest after the seizure.
- Do not worry if breathing stops for a few seconds during the seizure. Breathing should return as soon as the seizure is over. If your child does not start breathing again, start CPR.
- Watch your child during the seizure. Time the seizure. Write down which parts of the body were moving during the seizure. Note unusual movements or behavior that happened just before the seizure.
- After your child rests, ask what he or she remembers about the seizure.
- Call your child's doctor to report that a seizure occurred.
What to do for a complex partial seizure:
- Keep calm. You cannot stop a seizure.
- Stay with your child until he or she is fully awake. Do not try to hold your child or stop his or her movements. Remove harmful objects that are near your child or stand in front of the dangerous areas such as a stairway. If needed, gently lead your child away from dangerous areas.
- Your child may not hear you or may not be aware of what he or she is doing.
- If the seizure becomes a tonic-clonic seizure, follow the directions for that type of seizure.
- Write down how long the seizure lasts and what your child did.
- After your child rests, ask what he or she remembers about the seizure.
- Call your child's doctor to report that a seizure occurred.
Call 911 right away if:
- The seizure lasts longer than five minutes.
- There is one seizure after another and your child does not wake up in between.
- Your child is hurt during the seizures.
- You child has difficulty breathing.
- Your child's color remains blue after the seizure is over. Start CPR if needed.
- The seizure occurs in the water (such as a swimming pool or bathtub).
- You do not know when the seizure started.
- Your child never has had this type of seizure before.
Adapted from "Caring for a Child During a Seizure," Maxishare (2003).
5. Treating major depression in children and adolescents
Depression is a relatively common condition occurring in up to 2 percent of children and 8 percent of adolescents. Major depression is a well-validated research-defined condition in which the prominent symptom is depressed mood. In children, irritable mood can serve as a proxy for depressed mood. In addition to depressed (or irritable) mood or loss of interest or pleasure, four additional symptoms are typical. The mnemonic SIGECAPS (see Table 1) can assist you in remembering the signs and symptoms of major depression. Typically, patients with depression have disturbed sleep with middle and terminal insomnia and decreased appetite with weight loss or failure to gain appropriate weight. With a condition referred to as atypical depression, patients sleep and eat excessively. A craving for carbohydrates is common.
Table 1: Signs and symptoms of depression
S - Sleep disturbance (usually decreased, can be increased).
I - Interests (decreased, for usual activities).
G - Guilt (excessive or inappropriate).
E - Energy (decreased).
C - Concentration problems.
A - Appetite change (usually decreased, can be increased).
P - Pleasure (decreased).
S - Suicidal thoughts or actions.
Causes
The cause of depression is unknown. The catch phrase "chemical imbalance" often is used to help explain that this is a medical illness with specific brain chemistry abnormalities. Psychosocial stressors commonly are involved in the precipitation of a depressive episode. Genetics also plays a role. People with affected family members are at increased risk to develop depression. Sporadic (nonfamilial) cases also are common. Depression affects all races and socioeconomic groups. The World Health Organization estimates that depression will be the No. 1 cause of morbidity throughout the world in the 21st century.
Treatment: Medication studies
In the last year, controversies have arisen regarding the treatment of depression. The controversy is related to the recent studies of Selective Serotonin Reuptake Inhibitors (SSRIs) for Food and Drug Administration pediatric exclusivity. The results of these studies have been disappointing. Seven of the eight SSRIs have had large industry-sponsored trials. Of these only fluoxetine was found to be both safe and efficacious. The other six were found to be no better than placebo. These findings do not mean that the medications do not work in specific patients. One reason for the inability to differentiate their effects from a placebo was that there were large placebo response rates in all of these studies. This made separation of a medication-specific effect from a placebo response difficult.
Safety issues arose with two of the medications studied. Paroxetine (Paxil) and venlafaxine (Effexor) both were found to increase the risk for developing suicidal thoughts. This increase was approximately 2 percent for the medication-treated groups. The overall incidence of this for both placebo and these two medications was in the low single digits. Due to these findings, our physicians - consistent with the FDA - are recommending that new pediatric patients not be started on these agents.
Unfortunately, we are not able to determine in advance which medication might work in which individual patient. In clinical practice all of these kedications are effective in some patients. Antidepressants should be given adequate trials before switching or discontinuing. An adequate trial period is six weeks at therapeutic doses. Serious side effects are the major reason to stop a medication before an adequate trial has been completed.
Treatment: Medication selection
Medication selection should be based upon a variety of criteria. The first would be an efficacy difference. Until the last year or so, no one would have thought this was a factor with SSRIs. Given the current state of knowledge, fluoxetine has an advantage in that it is FDA-approved for children and adolescents. Sertraline (Zoloft), citalopram (Celexa), and possibly escitalopram (Lexapro) and bupropion (Wellbutrin), also should be considered.
Secondary criteria for medication selection is effectiveness data. This information could include knowledge of the patient of family members prior response to specific medications. There also are minor differences in side effect profiles and drug-to-drug interactions that may impact your choice in patients on multiple medications. However, there are common side effects for SSRIs. These include: gastrointestinal distress, sexual dysfunction (adolescents), activation, akathisia and, occasionally, precipitation of mania.
Treatment: Psychotherapy
Psychotherapy is another potential treatment for depression. Many therapies have been used for the treatment of depression in children and adolescents. As with adults, the evidence supports certain therapies more than others. Cognitive-behavioral therapy, interpersonal therapy and dialectic behavioral therapy all show promise. In referring patients for therapy, families should familiarize themselves with types of approaches various therapists use in their treatment. Parents should be directed to shop around until they find a therapist who uses one of the above approaches. The combination of psychotherapy and antidepressants has been studied to a small extent in pediatrics and holds promise for the treatment of depression.
Suicide and suicidal thoughts and behavior are common in depressed patients. Somewhat obviously, discussing suicidal thoughts is important when dealing with depressed patients. There is no evidence that discussing or asking about suicide leads to increased suicidal thoughts. In the last decade, there has been a large increase in the number of patients prescribed antidepressants. There has been some decrease in suicides over the same time frame. It is unclear if this is related to treatment with antidepressants but it is likely to have helped.
If a patient appears to be particularly treatment resistant - he or she does not respond to adequate trials or two or more antidepressants - the patient should be evaluated by a child psychiatrist. This evaluation should focus on diagnostic clarity and psychosocial issues that might be preventing full response.
Treatment: Duration
The duration of treatment with antidepressants also is somewhat controversial. In adults, depression has typically been treated for six to nine months after the remission of depressive symptoms. Some studies have found that longer durations of treatment, two or more years, leads to a decrease in the number of relapses. For a first episode of depression, treatment for six to nine months is recommended after full remission of symptoms for children and adolescents. Patients with numerous recurrences or chronic depression may need to stay on antidepressants for extended periods, for many years or for their lifetime.
It is important to objectively measure the severity of depression and its response to intervention. There are a variety of clinician-administered (Hamilton Depression Rating Scale) and patient self-administered (Beck Depression Inventory) scaled that can be used to assess the patients' response to treatment. Whether a formal scale or a Liekert scale (1-10) is used to assess the severity of depression it is recommended that you monitor response.
In summary, child and adolescent depression generally is treated adequately with medications that are well tolerated.
Source: Russell Scheffer, MD, is medical director of Child and Adolescent Psychiatry and holds the Chuck Aring Chair in Child and Adolescent Psychiatry at Children's Hospital of Wisconsin. He is an associate and chief of the Child and Adolescent Psychiatry Department at the Medical College of Wisconsin and a member of Children's Specialty Group. Through a partnership with Roger's Memorial Hospital, Scheffer also serves as medical director for Roger's Memorial Child and Adolescent program to bridge the continuum of youth treatment between Children's Hospital and Roger's Memorial.
For more information:
Child and Adolescent Psychiatry and Behavioral Medicine Center
(414) 266-2932
To make an appointment:
Central Scheduling
(414) 607-5280 or (877) 607-5280
6. Physicians taking aggressive action on patient safety
Concern over issues of medical error, medical injury and patient safety has escalated over the last five years. Conservative estimates using chart review methodology are that 44,000 to 98,000 patients die annually in American hospitals as a result of preventable medical injuries. Causes of these injuries include medication errors, misdiagnoses, procedural complications and nosocomial infections.
Children's Specialty Group physicians and staff members at Children's Hospital of Wisconsin continue to work on ways to prevent or mitigate harm to patients. These efforts focus on reducing medication errors by implementing technologies such as practitioner computer order entry and bar coded medication administration, as well as considering changes to processes using a technique called failure modes and effects analysis (FMEA).
Another focus is on product and device safety. Research has identified more than 14 ways that devices can enter a hospital without formal review for safety implications. Evaluation is performed in several categories, and plans are underway to systematically evaluate all new requests for devices at Children's Hospital. In addition, plans for the new GE Centricity system implementation and the new monitoring systems will include safety evaluations. The new GE system will provide the ability to combine documents, data and images with a fully integrated clinical information system.
Currently, safety research is being conducted by at least three Children's Specialty Group physicians, in conjunction with their work at the Medical College of Wisconsin. John Meurer, MD, MBA, assistant professor of Pediatrics at the Medical College of Wisconsin, is evaluating the pediatric use of the Wisconsin Medical Injury Reporting System. Glenn Flores, MD, FAAP, associate professor of Pediatrics at the Medical College, is studying the impact of a lack of translators on medical errors in patients with limited English proficiency. Matthew Scanlon, MD, program director of Patient safety at Children's Hospital of Wisconsin and assistant professor of Pediatrics (Critical Care) at the Medical College, is evaluating the impact of bar coding technology on both medication errors and employee workload and satisfaction. The latter project reflects the forward thinking of Children's Hospital and Children's Specialty Group staff by recognizing that errors are inherent to human behavior, and safety can best be achieved through redesigning systems and work to decrease stress and distractions on health care providers.
A final area of work focuses on the Joint Commission on the Accreditation of Healthcare Organizations' (JCAHO) National Patient Safety Goals. These 13 requirements were chosen in response to significant safety problems reported across the country. These safety goals include writing down and reading back verbal and telephone orders, hand cleansing before patient contact, and performing site marketing and a "time-out" before invasive procedures. Physician participation is crucial to guaranteeing the safety of the children cared for at Children's Hospital.
Additional patient safety work and research in a number of environments is planned and information about these studies will be shared in upcoming editions of this newsletter.
7. Children's Specialty Group physician to lead new Children's Research Institute
Robert Kliegman, MD, has been named executive vice president of the Children's Research Institute. This new entity within the Children's Hospital and Health System family will provide a physical location and infrastructure needed to continue to expand pediatric medical research programs.
Kliegman is pediatrician-in-chief and holds the Muma Family Chair in Pediatrics at Children's Hospital of Wisconsin. He also is chairman and professor of Pediatrics at the Medical College of Wisconsin and a member and vice chair of Children's Specialty Group.
Children's Hospital physicians and nurses have been conducting research almost as long as the hospital has been in existence. From stemming milk-borne illnesses in the early 1900s, to the development of the Milwaukee Brace in the 1950s, research has led to important improvements in medical care. More recent advancements by Children's Specialty Group physicians include research on blood and marrow transplantation and postoperative management of hypoplastic left heart syndrome patients.
In recent years, Children's Hospital has attracted some of the brightest minds in pediatric medicine to lead both clinical programs and research efforts. This research is taking place in small laboratories and offices throughout Children's Hospital and the Medical College. Kliegman estimates that 200 medical staff members currently are engaged in pediatric research. He expects that number to increase to 250 within the next few years.
Although decisions about a location still are pending, recruiting for research faculty and leaders has begun, and the institute will be operational in 2004. A specially designed facility, which is expected to open in 2006, will provide space for existing basic and clinical pediatric research programs and will be designed to accommodate future growth. Likely candidates to move to the institute include the Max McGee National Research Center for Juvenile Diabetes and the Birth Defects Research Center. Both currently are housed at the Medical College.
8. Program for overweight children provides two avenues for treatment
The NEW (Nutrition, Exercise and Weight Management) Kids Program at Children's Hospital of Wisconsin offers a multidisciplinary team to care for and design individual treatment plans for children who have complications of being overweight.
NEW Kids at the Y is a community-based program that takes place at three branches of the YMCA of Metropolitan Milwaukee. The program provides families with in-depth nutrition, behavior, and exercise education in a comfortable, family-friendly atmosphere. Primary care physicians will medically manage the child, providing support to the family and monitoring progress.
Due to the level of services needed to address this problem, both programs will see children and families by physician referral only. Children who do not meet the program criteria, or for whom incomplete information is given, cannot be seen. In addition, families must be motivated and want to make a change.
Evaluation and management of overweight children is challenging. To ensure that each child is referred to the proper caregivers, evaluation, and treatment guidelines were created. If the tools are used properly, children with possible co-morbidities will be identified and sent to the NEW Kids Program. In the Milwaukee area, those without an identifiable complication of overweight, but who are still motivated, can be followed by the primary care physician and participate in NEW Kids at the Y with support from the NEW Kids team at Children's Hospital.
Referring a patient to NEW Kids at Children's Hospital
If you have a patient who may need the services of NEW Kids, follow this simple referral process.
- Evaluate the child.
- Complete NEW Kids referral form.*
- Fax referral form to NEW Kids Program at Children's Hospital: (414) 266-6228.
- Start referral to child's insurance.
- NEW Kids staff will contact the family.
*Referral packets, including evaluation information and referral guidelines, are available at www.chw.org.
If you have questions about the program or suggestions for meeting the needs of overweight children, contact Stephen Sondike, MD, at (414) 266-3690.
9. North Shore Clinic: Bringing specialty care to you
A year ago, Children's Hospital of Wisconsin Clinics-North Shore opened to provide multispecialty services, including asthma and allergy care, at a new location in Brown Deer. This is a joint effort by the Medical College of Wisconsin and Children's Hospital.
The clinic offers a full-service Asthma/Allergy clinic, including skin testing and immunotherapy, Monday through Thursday. Marshall Benner, MD, Jordan Fink, MD, Michael Levy, MD, Morton Soifer, MD, and Heidi Zafra, MD see adult and pediatric patients at this new site.
Last fall, the North Shore clinic began an adult Fabrazyme infusion clinic under the direction of William Rhead, MD (Genetics). Fabrazyme is the first specific and effective treatment for Fabray disease, a life-threatening genetic disorder causing kidney failure, heart attacks, and strokes. The Fabrazyme infusion clinic is offered on Fridays.
This spring, speech and hearing services also will be offered at this location.
For appointments, call (414) 607-5280 or toll-free (877) 607-5280. For more information on the North Shore Clinic, call (414) 355-3824.
The Asthma/Allergy Center at Children's Hospital of Wisconsin offers specialty services for the entire family at five convenient locations:
Children's Hospital of Wisconsin
9000 W. Wisconsin Avenue
Milwaukee, Wis.
Children's Hospital of Wisconsin Clinics-North Shore
9074 N. Deerbrook Trail
Brown Deer, Wis.
Children's Hospital of Wisconsin Clinics-Fox Valley
Theda Clark Medical Center Campus
Medical Office Building, Suite 480
200 Theda Clark Medical Plaza
Neenah, Wis.
Children's Hospital of Wisconsin Clinics-Kenosha
Kenosha Medical Center Campus
Medical Professional Office Building
6308 8th Avenue, Suite 3090
Kenosha, Wis.
Children's Hospital of Wisconsin Clinics-Gurnee
Greenleaf Professional Campus, Suite 201
310 S. Greenleaf Avenue
Gurnee, Ill.
10. Hospitalists now available at Condell Hospital
A new 7-day-a-week, 24-hour-a-day hospitalist program now is available at Condell Hospital in Libertyville, Illinois. The program is staffed by Children's Specialty Group with four pediatricians providing daily care on the 18-bed pediatric unit. Akarim Shaltooni, MD, directs the program.
To contact the hospitalist on call, use the 24-hour pager (847) 225-0177.
11. Earn CME Credits Online
Participate in grand rounds and receive CME credit in the comfort of your office or home.
Children's Hospital of Wisconsin Pediatric Grand Rounds videos now are available online at www.chw.org. Go to For Health Professionals, then click on Online Continuing Medical Education.
Forms and information about receiving CME credit for online viewing are included in the same section of the Web site.
To view the Grand Rounds, your PC must have the following minimum requirements:
- 166 MHz Pentium processor.
- 32 MB RAM.
- Windows 98.
- Windows Media Player version 7.01.00.3055.
- Internet Explorer 5.5 (Netscape, Opera, etc., will not support viewing Grand Rounds).
- Sound card.
- Speakers.
If you have problems when attempting to view videos, please contact the Children's Hospital of Wisconsin Help Desk at (414) 266-3280.
12. Children's Hospital specialists available with single phone call
If you have an emergency, emergent, or non-urgent patient issue, you have an easy way to access services at Children's Hospital of Wisconsin. With a single call to the Children's Transport and Physician Referral Center, you will connect with the resources you need, whether facilitating a patient transport, consulting with a specialist physician, or facilitating an appointment with a pediatric specialist.
Transport nurse clinicians staff the line 24 hours a day, 7 days a week. The nurse will expedite your transport, page the pediatric specialist on call, or help you schedule an appointment for your patient with an appropriate specialist.
Children's Transport and Physician Referral Center
(414) 266-2460
Toll free (800) 266-0366
13. Children's Specialty Group member changes
Additions
Carey A. Ehlert, MD, a neonatologist, sees patients in the Neonatal Intensive Care Unit at Children's Hospital of Wisconsin, and is an assistant professor of Pediatrics (Neonatology) at the Medical College of Wisconsin. She earned a medical degree from the University of Nebraska, Creighton University, Omaha, Neb. Ehlert also completed a fellowship at Children's Mercy Hospital, Kansas City, Mo. and is board certified in Pediatrics.
Andrea Hoogerland, MD, is a pediatric hospitalist at Children's Hospital of Wisconsin and an assistant professor of Pediatrics at the Medical College of Wisconsin. She earned a medical degree from the University of Michigan Medical School, Ann Arbor, Mich. and completed a residency in Pediatrics at Children's Hospital of Wisconsin.
John A. Humphrey, MD, sees patients through the Special Needs Program at Children's Hospital of Wisconsin and is an assistant professor of Pediatrics at the Medical College of Wisconsin. He earned a medical degree from the Medical University of South Carolina, Charleston and completed a residency at Children's Hospital of Wisconsin. He is board certified Pediatrics.
Kathryn N. Martin, DO, MS, is a pediatric hospitalist at Condell Medical Center, Libertyville, Ill. and an assistant professor of Pediatrics at the Medical College of Wisconsin. She earned a medical degree from Des Moines University, Des Moines, Iowa, and completed a residency in Pediatrics at Lutheran General Children's Hospital, Park Ridge, Ill.
Lola Odusanya, MBBS, FAAP, is a pediatric hospitalist at Condell Medical College in Libertyville, Ill. and an assistant professor of Pediatrics at the Medical College of Wisconsin. She earned her medical degree from the School of Medicine, University of Benin, Nigeria, and completed her residency and served as chief resident in Pediatrics at the University of Illinois of Chicago Medical Center.
Robert J. Perzacki, MD, sees patients in the Child and Adolescent Psychiatry and Behavioral Medicine Center at Children's Hospital of Wisconsin and is an assistant professor of Psychiatry at the Medical College of Wisconsin. He earned a medical degree at the Medical College of Wisconsin, Milwaukee, Wis. and completed a residency in Psychiatry at the University of Narth Dakota, Fargo. He completed a fellowship in Child-Adolescent Psychiatry at St. Louis University in St. Louis, Mo. and is board certified in Psychiatry and Neurology.
Aijaz H. Walji, MBBS, is a pediatric hospitalist at Condell Medical Center in Libertyville, Ill. and an assistant professor of Pediatric at the Medical College of Wisconsin. He earned a medical degree from the University of Karachi, Dow Medical College, Pakistan, and completed a residency in Pediatrics at the University of Illinois Hospital, Chicago.
Departures
Mark Splaingard, MD, Pulmonary, left in January. Patients can be referred to one of the other pediatric pulmonologists by calling the Pulmonary Clinic at (414) 266-3580 or calling Central Scheduling at (414) 607-5280 or toll-free at (877) 607-5280.
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