Common pediatric issue: Managing spinal deformities
Early detection of spinal deformities is important in order to initiate measures to control progressive deformities. The term "scoliosis" (meaning "crooked spine") was first used by Galen A.D. 150, and it has been recognized as a common deformity since ancient times. Parents who have a spinal asymmetry should have a thorough history and physical. Back pain is unusual; a patient with a severe scoliosis rarely has back pain in adolescence. Persistent back discomfort may require evaluation with an MRI. The spinal outline both from the back and the side view should be assessed for rotational abnormalities or evidence of spinal malalignment. A neurologic evaluation also is important to rule out a potential etiology for an apparent idiopathic scoliosis. Leg lengths should be checked. A mild leg length discrepancy can easily give the appearance of spinal curvature in the standing and forward bend positions.
Diagnostics: Scoliometer
One method to quantify the degree of rotational malalignment is with the use of a scoliometer, a commonly used screening device which provides a simple method for assessing which patients need further evaluation and treatment. As the patient performs the forward test, the scoliometer is placed on the surface of the patient's back perpendicular to the long axis of the body. The scoliometer must be placed over the apex of maximum deformity. The scoliometer then gives a reading of the "angle of trunk rotation." If the patient has more than one scoliotic deformity, each curve should be measured separately. The current recommendation is for referral of patients with an angle of trunk rotation of seven degrees or greater. In one study, this resulted in a referral rate of approximately three percent of the individuals screened.
Diagnostics: Quantec device
Other methods have been used to quantify the body surface topography in patients with idiopathic scoliosis. For a number of years, specialists at Children's Hospital of Wisconsin have used the Quantec device, which measures at least a dozen different parameters of trunk asymmetry along the entire length of the child's spine. It minimizes with number of radiograph for patients with minor curvatures needing frequent follow-up. This device has been used to minimize the child's total radiation exposure during the monitoring period. Patients who receive multiple spinal radiographs over the years develop an increased lifetime risk for breast carcinoma or other types of carcinoma. Continues research is underway at Children's Hospital for refining the role of spinal surface topography in the assessment and treatment of patients with scoliosis.
Diagnostics: MRI
Patients with apparent idiopathic scoliosis who may have signs or symptoms which indicate an underlying neurological etiology often require assessment with an MRI. Patients with syringomeyelia, tethered cord and Arnold Chiari malformation often develop a progressive spinal deformity, and may require neurosurgical intervention to prevent a situation of continued curve progression and neurologic deterioration. These entities are more commonly seen in infantile and juvenile onset scoliosis. An MRI should be performed in patients who have a left thoracic curve, who show signs of neurologic deficits, who show an unusually rapid curve progression, or who show evidence of a progressive lower extremity deformity such as a cavus foot.
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| Progressive lumbar scoliosis caused by hemivertebra |
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| Complete correction of deformity achieved by resection of hemivertebra through combined anterior/posterior approach |
Value of screening
The role of screening in the assessment of patients with scoliosis has been controversial. Screening programs have yielded a high number of false positive results; that is, patients who have spinal asymmetry but upon referral have no appreciable scoliosis requiring treatment. In addition, questions have arisen regarding the cost-effectiveness of school screening programs. These screening programs are designed to identify curvatures at an earlier stage and appropriately initiate treatment, which could minimize the need for surgical intervention. Although this initially was thought to be the case, more recent studies have led equivocal results as to the decrease in the number of patients requiring surgery. School screening continues to be supported by the American Academy of Orthopedic Surgeons, the Scoliosis Research Society and the Wisconsin Orthopedic Society.
Risk of scoliosis progression
Which patients with idiopathic scoliosis are most likely to have continued progression? There is a higher risk for progression of scoliosis in patients who are skeletally immature, at their peak growth velocity, are premenarcheal, or have curves that are larger at the time of detection. Thoracic curves are more likely to progress than lumbar curves, and double cures (thoracic and lumber) progress more frequently than single curves.
Curvatures can continue to progress after skeletal maturity. Thoracic curves over fifty degrees at maturity will very likely progress, and lumbar curves of more than thirty degrees could potentially have continued progression during adulthood. Cardiopulmonary compromise is unusual in adolescent onset scoliosis, unless the curve becomes severe; it is more likely to develop in patients with very early onset curves.
Treatment: Bracing
In skeletally immature patients who have a curve of more than 25 to 30 degrees, brace treatment is warranted to attempt to prevent progression to surgical magnitude. The Milwaukee brace devised by Walter Blount, MD, was one of the first methods attempted to inhibit curve progression.
Currently, "low profile" scoliosis braces do not extend beyond the upper torso, and patients are allowed a number of hours per day out of the brace for sports and other activities. Under certain circumstances patients may be treated with a nighttime-only brace or flexible cloth brace.
Treatment: Surgery
Larger curves that are relentlessly progressing or will continue to progress after reaching maturity require surgical stabilization. The role of anterior spinal surgery is expanding; this approach often allows a greater correction with a more limited extent of fusion. Video-assisted thoracic surgery is useful in certain thoracic curves, requiring only a few small thoracic portal incision instead of a thoracotomy incision. Use of posteri- or pedicle screws may aid correction with certain curves. New bone graft substitutes are on the horizon to eliminate the need for the patient's bone or cadaver bone.
Congenital issues and further study
Congenital malformations of the spine also may lead to progressive deformity of the spine. There are two basic types: failure of part of vertebral body to form (hemivertebra), and failure of two adjacent vertebrae to separate (bar). The latter type (congenital bar) always leads to early rapid progression of deformity and requires surgery. No form of bracing helps control congenital scoliosis. It is important to remember that other organ system anomalies are common, especially of the urinary (20%) and cardiac (10%) systems. Intraspinal anomalies such as tethered cord and syrinx may cause neurologic deterioration.
At Children's Hospital, our pediatric orthopedic research director, Dr. Liu, has created an animal model of experimentally induced scoliosis. Further studies currently are underway to modulate the growth of the scoliotic spine.
The primary care physician, by monitoring the child's spinal contour, can identify and refer appropriate deformities. This will allow for optimal early intervention, minimize the need for surgical intervention and avoid the physiologic and psychologic sequelae of severe scoliosis.
Source: John Thometz, MD, is medical director of Orthopedic Surgery and sees patients in the Orthopedic Center at Children's Hospital of Wisconsin. He is an associate professor of Orthopedic Surgery at the Medical College of Wisconsin and a member of Children's Specialty Group.
For more information
Orthopedic Center
(414) 266-2414
To make an appointment
Central Scheduling
(414) 607-5280 or (877) 607-5280
Common pediatric issue: Sun protection
Sunburns are the most preventable risk factor for melanoma. Approximately 65 to 90 percent of melanomas are caused by ultraviolet (UV) exposure. It is important to limit UV exposure in childhood since 80 percent of a person's lifetime exposure occurs before 20 years of age. Children and adolescents have more time and opportunities than adults to be exposed to sunlight. Individuals with a history of more than one blistering sunburn during childhood or adolescents are twice as likely to develop melanoma than those without this experience. Children with red of blond hair, blue or green eyes, freckles or excessive moles also are at increased risk. Infants are especially vulnerable to solar damage, as their skin is thinner and more sensitive to the sun.
Three general methods to protect children from cutaneous damage from UV light include avoiding the sun, wearing protective clothing and using sunscreen. Many parents think appropriate sunscreen use affords complete protection from sun damage, however, there is growing evidence that this is not the case.
Traditional sunscreens are effective in preventing sunburn reaction, development of basal cell carcinoma and squamous cell carcinoma. Sunscreen use alone has not yet been shown to decrease the incidence of melanoma in the United States. It should be stressed to parents that sunscreen should be used in combination with sun avoidance and protective clothing.
Sun avoidance
- Limit or avoid sun exposure during the peak hours of 10 a.m. and 4 p.m.
- Be aware that clouds do not prevent UV exposure; up to 70 percent of the sun's rays can pass through clouds.
- Seek shade.
- Avoid sunlamps and tanning beds.
- Pavement, water, snow and sand reflect and intensify the sun's rays.
- Keep infants younger than 6 months of age out of direct sunlight.
Sun protective clothing
- Choose lightweight long-sleeve shirts.
- Wear fabrics with a tighter weave. Hold the fabric up to the light and choose the fabric that is most opaque.
- Wear fabric with darker colors.
- Avoid wearing fabric that is wet or has been stretched.
- Wear hats with a brim greater than 3 inches.
- Wear sunglasses that have a coating to protect against both UV-A and UV-B.
Use sunscreen
- Look for a broad-spectrum sunscreen with both UV-A and UV-B protection.
- Look for a sunscreen with a sun protection factor (SPF) of at least 15.
- Choose a sunscreen with one of the following active ingredients: titanium dioxide, zinc oxide or Parsol 1789.
- Products are available as creams, lotions, sticks, sprays or gels. Parents should choose the preparation they like, as the products are equally efficacious.
- Physical sunblocks (zinc oxide and titanium dioxide) are opaque creams that scatter, reflect and block UV light. These are helpful for sensitive areas such as the nose, ears, lips, or cheeks.
- If a patient has a skin condition such as atopic dermatitis or history of sunscreen sensitivity he or she should look for a fragrance-free, alcohol-free sunscreen with a physical sunblock as its active ingredient.
- Adolescents should use non-comedogenic or oil-free sunscreen on their faces to avoid exacerbation of acne.
- Avoid products that contain insect repellants as reapplication of the product may increase risk of DEET toxicity.
- Apply sunscreen to clean, dry skin 10 to 15 minutes before going outside.
- Apply sunscreen liberally, using at least 1-2 ounces for a 5-year-old child.
- Sunscreen should be reapplied every two hours or after swimming, even if it is waterproof sunscreen.
- Do not rub in sunblocks or opaque sunscreens; the skin should look white if used properly.
- Avoid waterproof sunscreens in young children, especially on hands and face, as it often gets rubbed into the eyes and can cause significant irritation.
What can be done if a child develops a sunburn?
Sunburn is caused by overexposure of the skin to UV rays from the sun or a sunlamp. The symptoms of sunburn do not appear until two to four hours after the sun's damage has been done. The peak reaction is not seen for 24 hours.
Symptoms of sunburn include redness, pain, heat, swelling and even blistering and peeling. The sensation of pain and heat usually last 48 hours. Giving the child acetaminophen early after the onset of the symptoms and continuing to administer on a prophylactic basis for two days can greatly reduce the discomfort. Over-the-counter one percent hydrocortisone cream or other moisturizing creams applied three times daily also can decrease the symptoms. Applying ointments or petroleum jelly should be avoided because they can keep heat and sweat from escaping. Also advise the patient to avoid first-aid creams or sprays for burns because they often contain benzocaine, which can cause an allergic rash. The patient also may find cool baths or applying wet cloths to the burn areas soothing. The child should drink extra water to replace fluid loss and prevent dehydration and dizziness. Peeling usually occurs within one week and moisturizing cream should be applied two to three times daily.
Advise the patient or parent to call if the child develops a temperature greater than 101 degrees Fahrenheit, begins acting very sick or tired or if the sunburn develops red streaks, pus or other signs of infection. A healthcare provider should immediately see any child younger than the age of 1 year with sunburn.
Sunburn treatment
- Administer acetaminophen every four to six hours for discomfort and for fever up to 101 degrees Fahrenheit.
- Increase fluid intake.
- Apply moisturizing cream two to three times daily.
- Apply cool wet towels or sit in a cool bath.
- Call a healthcare provider if the fever is greater than 101 degrees Fahrenheit, or there is a change in mental status or signs of infection.
Children especially are vulnerable to the effects of the sun. Most sun damage occurs during childhood and adolescence. Exposure to UV radiation during childhood plays a role in the future development of skin cancer as well as premature aging. Developing positive behaviors early in life may increase the likelihood of these behaviors being maintained as children increase in age.
Sources: Beth Ann Drolet, MD, sees patients in the Dermatology Clinic at Children's Hospital of Wisconsin. She is an associate professor of Dermatology at the Medical College of Wisconsin and a member of Children's Specialty Group.
Joree Ruiz, PA, is a physician's assistant in the Dermatology Clinic at Children's Hospital of Wisconsin.
For more information
Dermatology office
(414) 805-5304
To make an appointment
Central Scheduling
(414) 607-5280 or (877) 607-5280
New International Adoption Clinic opens
Based in the Child Development Center, a new clinic offers services to families adopting children from outside the United States. The International Adoption Clinic at Children's Hospital of Wisconsin aims to be a unique resource for families who are adopting children from international settings, many of whom may have medical or developmental needs. Only a few such programs are offered throughout the country and no other exists in Wisconsin.
This new program will provide three services:
- Pre-adoption medical record review.
- Arrival medical evaluation.
- Post adoption and follow-up evaluation.
The clinic is located in the Child Development Center on Level 1 of the Curative Care Network across the visitor parking lot from the Children's Hospital and Health System office building. The International Adoption Clinic is held Friday mornings. To make an appointment, call the Child Development Center at (414) 266-2928. Reviews of pre-adoption materials can be arranged by calling Fran Thalke at (414) 266-2945. Additional information is available on the Children's Hospital Web site, www.chw.org, under Programs and Clinics.
Program launched to deal with pediatric obesity
The Nutrition, Exercise and Weight Management (NEW) Kids Program at Children's Hospital of Wisconsin is geared toward a holistic treatment of pediatric obesity for children ages 2-18. It involves a coordinated effort of nurses, nurse practitioners, psychologists, dietitians, exercise physiologists and physicians. In partnership with the YMCA of Greater Milwaukee, NEW Kids offers two programs to care for overweight children.
The NEW 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 from being overweight. In addition, family-centered exercise therapy is provided at local YMCAs.
NEW Kids at the Y is a community-based program that takes place at three branches of the YMCA of Metropolitan Milwaukee. Designed by the multidisciplinary team at Children's Hospital and the YMCA, this program provides families with in-depth nutrition, behavior and exercise education in a comfortable, family-friendly atmosphere. Primary care physicians medically manage the child, providing support to the family and monitoring progress.
Due to the level of services needed to address this problem, these programs will see children and families by physician referral only. Families must be motivated and want to make a change. Children with possible co-morbidities will be identified and sent to the NEW Kids Program at Children's Hospital. 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.
For additional information or to make a referral, call the NEW Kids Program at (414) 266-6917. NEW Kids Program information, including referral information and forms, also is available on the Web site, www.chw.org, under Programs and Clinics.
Partnership announced with GE Medical Systems Information Technologies
Children's Hospital of Wisconsin announced plans to implement technological advancements designed to improve patient safety and enable doctors and nurses to spend more of their time delivering high-quality patient care. The hospital has partnered with GE Medical Systems Information Technologies to implement one of the most comprehensive computerized medical record systems of any hospital in the nation.
The new system, to be deployed throughout the Children's Hoptial main campus, located in Milwaukee, will replace the paper charts that most hospitals still use to keep patients' medical records. It will store patients' medical histories, laboratory test results, diagnostic images (such as X-rays) and other information needed to decide on the best treatment.
Instead of waiting for charts to be delivered and searching through folders full of paper forms, caregivers will be able to call up complete information about a given patient almost instantly at the touch of a keyboard.
The electronic medical record system will be implemented in phased approach over the next four to five years. Ultimately, it will cover multiple care areas in the hospital, including the emergency room, surgical areas, heart care, radiology and pharmacy. It also will be used for bedside care in patients' rooms and for outpatient care. At the end of the process, Children's Hospital will have a nearly paperless medical record system.
The GE technologies at Children's Hospital will include Computerized Physician Order Entry (CPOE), which enables doctors to enter orders for treatments or medications on a computer. The advanced technology, tightly linked to the pharmacy system, is designed to enhance patient safety by eliminating errors that can occur if caregivers misread treatment instructions or prescriptions handwritten on paper forms. Further, the CPOE system provides automatic warnings is a doctor prescribes a drug that might react with another medication that patient is taking or to which the patient has an allergy.
Children's Hospital also will have a computerized system for managing medical images. This advanced GE technology, called a Picture Archiving COmmunications System (PACS), will store X-rays, magnetic resonance scans, ultrasound studies and other diagnostic pictures so that clinicians can call them up easily and review them on screen, instead of having to wait for films to be retrieved and delivered from storage.
Besides using the electronic record system to benefit its staff and patients, the hospital will work with GE to further develop and enhance the technology for specific pediatric use.
New referring physicians newsletter published
Referring to Children's first was published in May as a quarterly update to referring physicians on Children's Hospital of Wisconsin programs and clinics.The newsletter is sent to the 4,000 pediatricians and family practice physicians in Wisconsin, northern Illinois and the Upper Peninsula of Michigan.
The goal of the newsletter is to reduce individual mailings to referring physicians, supply them with more coordinated information about the hospital and its programs and reduce the costs to clinics associated with individual mailings.
While Pediatric Rounds will continue to announce new physicians and include articles specific to physicians specialties, Referring to Children's will promote new clinics or services and communicate improved clinical processes. For example, the May issue included articles on the International Adoption Clinic, comprehensive Herma Heart Center, decreasing the risk of genetic disorders, off-site North Shore clinic and Biofeedback Clinic treats voiding dysfunction.
For more information or to provide feedback regarding Referring to Children's, call Erica Halbleib, Children's Hospital and Health System Public Relations, at (414) 266-5430.
Pain management services continue to expand
Specialists in the Jane B. Pettit Pain and Palliative Care Center evaluate and treat various pediatric pain problems. Established in 1993, it is the only multidisciplinary pain management program for children in the upper Midwest. Specialists provide collaborative family health care for children and adolescents with simple and complex pain problems. The team of pain specialists provide integrated biomedical and psychosocial care to help eliminate or manage children's pain. Patients can be evaluated efficiently in one location by a team of specialists that includes: physicians, nurses, therapists and social workers.
Patients with chronic pain can include children with headaches, chronic abdominal pain, fibromyalgia, myofacial pain, complex regional pain syndromes, phantom limb pain, temporomandibular joint pain, sickle cell anemia, cancer pain, spasticity of cerebral palsy, juvenile arthritis and collagen vascular disease. These patients have significant alterations in their lifestyles and often have poor school attendance and social withdrawal. The entire family usually is impacted by the pain condition.
Most child health specialists have limited experience treating patients with chronic pain, and pediatric textbooks offer little to no guidance. Often, these patients move from one specialist to another, sometimes from one city to another, and almost all of them have undergone extensive medical testing that has been costly and revealed little or no insight into what the problem may be.
A multidisciplinary pain team model, such as the one developed at the Pain and Palliative Care Center, provides the best strategy for treating these patients. The goals of the evaluation include a family narrative of the pain problem and a thorough, pain-focused physical assessment. The child and family also meet with other team members who evaluate how the child and family are coping with their particular pain problem and how it has impacted their relationships. Pain then can be eliminated or controlled through a combination of pharmacological, physical and occupational therapy interventions; massage therapy; and cognitive-behavioral pain management strategies including deep relaxation, guided imagery, mindfulness meditation and individual counseling; and acupuncture.
Patients also are counseled in how nutrition, sleep and exercise can impact pain problems. Major goals are established to improve psychosocial functioning (decrease in school absences), psychosocial support for the entire family and communication with both the patient's school and personal physician or other healthcare providers who have become involved in the patient's management. The elimination of pain is always the goal, but sometimes this may not be possible, In such cases, efforts focus on lowering the pain to tolerable levels, allowing there to be regular school attendance, a return to participation in activities with friends and enhancement of the child's and family's life. The majority of patients are seen over a period of only one to six months to accomplish these goals.
For more information about the services of the Jane B. Pettit Pain and Palliative Center, please call (414) 266-2775.
The Jane B. Pettit Pain and Palliative Care pain team:
Steven J. Weisman, MD, medical director, Pain Management; pediatric anesthesiologist and pediatrician
Lynn M. Rusy, MD, associate medical director, Pain Management; pediatric anesthesiologist and medical acupuncturist
Jaya Varadarajan, MD, Anesthesiology fellow, Pediatric Anesthesiology/Pain Management
Kim Anderson, PsyD, pediatric psychologist
Michelle Czarnecki, RN, MSN, PNP, advanced practice nurse (inpatient/acute)
Donna Harris, RN, MSN, PNP, advanced practice nurse (inpatient/acute and outpatient/chronic)
Renee Ladwig, RN, MSN, advanced practice nurse and family therapist (outpatient/chronic)
Nancy Lillis, administrative assistant
New Medical Director for Child and Adolescent Psychiatry
On July 1, Russell Scheffer, MD, become medical director for Child and Adolescent Psychiatry at Children's Hospital of Wisconsin and joined the Medical College of Wisconsin as an associate professor and chief of Child and Adolescent Psychiatry. In his clinical leadership role, Scheffer will focus on the development of comprehensive child psychiatry services for children and families. His personal interests are the early identification and intervention of bipolar and psychotic disorders.
Most recently, Scheffer was with the University of Texas Southwestern Medical Center. His medical degree is from Kansas University Medical Center, and he completed a residency in general psychiatry at Dwight David Eisenhower Army Medical Center (DDEAMC). Scheffer completed a fellowship at the DDEAMC Medical College of Georgia in child, adolescent and family psychiatry.
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