1. Common pediatric issue: Asthma
Under-diagnosis of pediatric asthma continues to be a problem, especially in children who wheeze with respiratory infections. This article highlights effective methods to diagnose and treat pediatric asthma.
Diagnoses that suggest asthma
- Reactive airway disease.
- Wheezy bronchitis.
- Recurrent bronchiolitis or pneumonia.
- Allergic or asthmatic bronchitis.
- Chronic cough.
Tests to diagnose asthma
- Symptom pattern: recurrent cough, wheeze, chest tightness or shortness of breath.
- Chest x-ray.
- Lung function testing, most children older than 5 years of age can perform reliably.
Spirometry (preferred testing method) measures FVC, FEV1, FEF25-75, peak flow and flow-volume loop and is best performed at initial diagnosis and for periodic monitoring.
Peak flow monitoring is not sensitive enough to establish the diagnosis of asthma and primarily measures large airway function. This test can be helpful when used over two weeks to measure variability between a.m. and p.m. values, and when spirometry is normal.
Effective asthma management
- Determine severity.
- Identify and avoid asthma triggers.
- Educate patient, family and/or school teacher.
- Administer appropriate asthma pharmacotherapy.
- Develop an asthma action plan.
- Monitor peak flow (for children 5 years of age or older).
- Follow up with patient at regular intervals.
- Make a referral to an asthma specialist, if appropriate (see below).
- For selected patients, consider allergen immunotherapy.
Goals of asthma therapy
- Minimize or eliminate symptoms during the day and while sleeping.
- Maintain normal activity, including sports/exercise levels.
- Maintain normal pulmonary function.
- Prevent exacerbations to decrease emergency room visits and hospitalizations.
- Achieve regular school attendance.
- Avoid the need for oral steroids.
- Optimize pharmacotherapy to minimize side effects of medication.
Determining asthma severity: the "Rules of Twos"
If any of the following conditions exist, reevaluate patients for daily controller medication:
- Asthma symptoms present more than two times per week during the day.
- Asthma symptoms present more than two times per month at night.
- Use more than two bursts of oral steroids per year.
- Use more than two canisters of albuterol every six months.
- More than two unscheduled asthma visits required in six months .
Pharmacotherapy
Controller medications are used daily to control/prevent symptoms caused by inflammation.
Anti-inflammatories
- Inhaled corticosteroids: Pulmicort, Flovent, Azmacort, Q-Var, Aerobid.
- Leukotriene modifiers: Singulair, Accolate.
- Non-steroid inhalers: Intal, Tilade.
Long-acting bronchodilators
- Inhaled bronchodilator: Serevent, Foradil.
- Oral bronchodilator.
- Theophylline.
Combination inhaled steroid and long-acting bronchodilator
- Advair (Flovent + Serevent)
Quick-relief medications relax the airways to treat symptoms acutely but do not control asthma.
- Albuterol: Proventil, Ventolin.
- Pirbuterol: Maxair autohaler.
Although asthma is a chronic lung disease for which there is no cure, it can be controlled. The biggest challenge is differentiating intermittent from persistent asthma in the younger patients and initiating appropriate therapy. Recent evidence suggests early treatment with anti-inflammatory therapy in younger patients my improve airway function compared to delaying initial and anti-inflammatory therapy. The notion of airway remodeling in under-treated asthma patients appears to be one challenge in treating asthma.
When to make a referral to a pediatric asthma specialist
- Life-threatening exacerbation.
- Severe, persistent asthma.
- Children younger than 3 years of age with moderate or severe persistent asthma.
- Asthma therapy goals not being met after three to six months.
- Atypical signs and symptoms.
- Associated complicating conditions including allergic rhinitis, sinusitis or GERD.
- Additional diagnostic testing needed, such as allergy skin testing or pulmonary function testing.
- Additional education needed regarding guidance on adherence and avoidance triggers.
- Considering use of allergen immunotherapy.
- More than two bursts of oral steroids per year, high-dose inhaled steroids or long-term oral steroid therapy.
Tips for optimizing care within time constraints of a typical office visit
- Ask patients to complete an assessment questionnaire.
- Schedule more frequent office visits at the beginning of treatment and after an exacerbation.
- Handle the asthma assessment and education during several different visits.
- Use videos and printed materials for asthma education.
To refer a patient
Pediatric Asthma/Allergy Department
(414) 266-6480.
To make an appointment
Central Scheduling
(414) 607-5280 or (877) 607-5280
Sources: Michael C. Zacharisen, MD, sees patients in the Allergy/Immunology Department at Children's Hospital of Wisconsin and is an associate professor of Pediatrics and Medicine at the Medical College of Wisconsin.
Kevin J. Kelly, MD, is director of the Asthma/Allergy Department of Children's Hospital and professor of Pediatrics and Medicine at the Medical College of Wisconsin, where he also serves as chief of Allergy and Immunology. Kelly also is the chair of Children's Specialty Group board of directors.
2. Common pediatric issue: Feeding and swallowing problems in infants and children
Feeding and swallowing problems vary significantly in clinical presentations, level of severity and underlying diagnoses. When infants and young children have difficulty feeding, parents can become very stressed. Successful feeding experiences, along with appropriate growth and weight gain, are basic to parent and child interactions. The following information is designed to highlight clinical presentation, as well as considerations for diagnosis or evaluation and treatment.
"Bottom line" questions for physicians
When physicians ask for questions to help to determine whether a feeding or swallowing problem exists, I recommend the following:
- How long does it usually take to feed your child? If it takes more than 30 or 40 minutes, there likely is a problem.
- Are there any signs of respiratory difficulties?
- Difficulty sucking, swallowing and breathing.
- Increased effort in breathing while feeding.
- Increased congestion as mealtime progresses.
- Gurgly voice quality, indicative of pooling secretions at level of larynx.
- History of pneumonia or asthma.
- Are mealtimes stressful?
- Behavioral and interaction problems.
- Temper tantrums.
- Throwing or spitting food.
- Refusing food.
- Grazing through the day, especially excessive juice consumption.
Answers to these questions will not yield a comprehensive evaluation of the swallowing and feeding problems, but the information can help determine if a referral to a specialist is needed.
In addition to information from parents, physicians may find the following helpful during office visit physical examinations.
Pediatric dysphagia: Clinical presentations and diagnostic conditions
Upper airway or pulmonary signs and symptoms (acute or chronic):
- Increased respiratory rate in infants during feeding.
- Breathy voice quality.
- Stridor.
- Stertor.
- Wheezing.
GI tract signs and symptoms:
- Underfed of "failure to thrive."
- Emesis, regurgitation or gastroesophageal reflux (GER).
- Constipation.
- Irritability and arching during feeding or apart from feeding times.
Oral-motor dysfunction:
- Prolonged mealtimes (on average, more than 30 minutes.)
- Excessive drooling or saliva build-up in oral cavity.
- Excessive gagging on oral secretions or during mealtimes.
- Delayed or difficult initiation of the swallow.
- Questionable safety of progressing oral feedings.
Unusual or inappropriate feeding patterns:
- Selective food refusal or feeding resistance.
- Limited oral intake.
- Failure to accept age-appropriate foods ("developmental age" in children with delayed or disordered development).
- Excessive adaptations required to "encourage" feeding (e.g., thickening liquids, offering only limited textures, using toys and other distractors).
Diagnostic conditions may include, but are not limited to:
- Anatomic or structural defects (congenital or acquired).
- Neurologic deficits (cerebral palsy, genetic syndromes, traumatic brain injury).
- Systemic and other health-related conditions (respiratory diseases, GI tract disorders and other health-related conditions).
- Complex medical situations (premature birth, medically fragile).
Referral to an interdisciplinary feeding and swallowing team
For children with complex feeding problems, referral to an interdisciplinary team should result in comprehensive evaluation and management recommendations for optimizing nutritional health status. Team members may include, but are not limited to:
- Physician (e.g., gastroenterologist, developmental pediatrician).
- Nurse.
- Dietitian.
- Speech-language pathologist.
- Psychologist.
- Social worker.
- Occupational and/or physical therapist.
Managing difficult and complex feeding and swallowing patients
Management of options vary according to the complex factors for each individual. Quick fixes are not expected when the issues involve multiple systems. Priorities must be set. Stability of the airway and adequate nutrition/hydration are absolutely critical. No interventions should ever jeopardize the airway or nutrition status. Management considerations that may be carried out singly or in combination include, but are not limited to:
- Oral feeding expectations relate closely to developmental age (gross and fine motor skills, communication and cognition), or corrected age in the case of premature infants, rather than chronologic age during the first two years of life.
- When swallowing safely is questionable, an instrumental swallow examination will aid in decision making (e.g., videofluoroscopic swallow study [VSS], also known as oral pharyngeal motility study [OPMS], and fiberoptic endoscopic examination of swallowing [FEES] that may include sensory testing).
- A nutritional plan can be developed to enhance calories and ensure a balanced diet, whether the child is fed orally or by non-oral supplemental feeds (e.g., gastrostomy, jejunostomy, nasogastric).
- Medical follow-up may be necessary to manage airway and gastroesophageal reflux or other gastrointestinal disorders and, in some instances, surgical intervention is required.
- Oral sensorimotor intervention, alone or in conjunction with other therapies, may be needed to improve efficiency of oral feeding. The focus may be on sensory issues for some children and on motor timing and coordination for others, under the guidance of a speech-language pathologist.
- Behavioral intervention under the guidance of a child psychologist can be carried out as an outpatient program. In some instances an inpatient stay may be needed.
Primary physicians are in a particularly good position to track development and growth in infants and children. The growth charts include height, weight, height/weight ratio and head circumference. It is important this information be maintained to note changes over time. In addition, during the regular visits by young children, physicians appropriately can ask those three bottom line questions. The child's needs may be managed without having to seek a team of professionals. When the Feeding and Swallowing Team is involved, collaboration between the primary physician and the feeding team should result in an optimal outcome for each child, whether or not total oral feeding is a realistic goal.
For more information or to make an appointment:
Feeding and Swallowing Program
(414) 266-2575 or (414) 266-3492
Source: Joan C. Arvedson, PhD, is coordinator of the Feeding and Swallowing Program at Children's Hospital of Wisconsin and clinical professor of Pediatrics at the Medical College of Wisconsin.
3. Common pediatric issue: Endoscopic treatment of vesicoureteral reflux
Vesicoureteral reflux is discovered in about 30 percent of children who present with a urinary tract infection. Considering that 8 percent of all children will develop a urinary tract infection during their lifetime, reflux is a significant disease and appears to be a topic of interest for many primary care physicians.
Approximately 30 years ago, unrecognized and untreated reflux accounted for 10 percent of end-stage renal disease. Through improved understanding of the pathophysiology of vesicoureteral reflux and urinary tract infections, pediatricians, family practitioners and urologists have almost completely eliminated end-stage renal disease in this patient population. Most patients are treated medically in anticipation of spontaneous reflux resolution. Approximately one-third, however, require open surgical treatment. The results of surgery are excellent, with a 98 percent cure rate.
For more than 15 years, European urologists have been treating reflux endoscopically with success rates approaching 70 percent. The endoscopic procedure is done on an outpatient basis with minimal morbidity. Teflon, the substance used by the Europeans for the endoscopic procedure, has been shown to migrate in the body. For this reason, the FDA has not approved it.
Urologists in the U.S. are searching for the ideal, safe and non-migratory substance for injection. Urologists at Children's Hospital of Wisconsin have been participating in a multi-institutional study investigating the safety and efficacy of these substances. This technology now is available to our patients.
Children's Hospital experts are cautiously optimistic about the new substances recently introduced for this purpose. Long-term follow-up ultimately will determine their place in the surgical armamentarium for the treatment of vesicoureteral reflux. Parents of children with vesicoureteral reflux who are candidates for surgical treatment are routinely informed of the availability of this approach at Children's Hospital.
For additional information about vesicoureteral reflux, please contact one of the Children's Hospital urology specialists: Hrair-Geroge O. Mesrobian, MD, FAAP, FACS; Charles Durkee, MD; or Anthony Balcom, MD.
For more information
Pediatric Urology
(414) 266-3794 for vesicoureteral reflux or complicated urological problems.
To make an appointment
Central Scheduling
(414) 607-5280 or (877) 607-5280
Source: Hrair-George O. Mesrobian, MD, FAAP, FACS, is director of the Urology Department of Children's Hospital of Wisconsin and a professor of Surgery (Urology) and Pediatrics at the Medical College of Wisconsin.
4. Former CHW chief resident enjoys busy practice in Fox Valley
"My training at Children's Hospital of Wisconsin helped establish me as an expert for 'failure to thrive' children in this area," said Wendy Hll, MD, a pediatrician in private practice and on staff at Children's Hospital of Wisconsin-Fox Valley (CHW-Fox Valley) in Neenah. At the hospital, Hill consults with local family practitioners who have complicated pediatric patients, in addition to caring for patients in her general pediatric practice.
Hill began her residency at Children's Hospital in 1994, becoming chief resident sin 1997. She was in a two-physician practice in Milwaukee for about a year when her husband accepted a head track/assistant football coaching job in the Fox Valley. The couple moved to Appleton in 1999 and Hill joined a nine-physician pediatric practice with Touchpoint/ThedaCare. Her practice grew quickly, drawing patients from as far north as Shawano and as far west as Waupaca. The service area is considered approximately a one-hour driving radius.
Hill frequently relies on her colleagues, the pediatric specialists at Children's Hospital sites in Milwaukee and in Neenah, to deal with difficult diagnosis and treatments.
"Well-baby checks, ear infections, upper respiratory infections, bronchiolitus, rotavirus and fevers dominate my practice," Hill said. "While I enjoy the common pediatric problems, I also like taking on the challenging cases and appreciate having the benefits of specialists in the Fox Valley and only two hours away in Milwaukee. Having specialists working with me is wonderful. Ongoing management of difficult cases is so much easier with their help."
Recently, Hill dealt with a particularly challenging case involving a 15-year-old who was a probable Type II diabetic. Hill relied on the Children's Hospital specialists in Milwaukee to do the lab work and other tests and to develop a care plan involving diet and medication. Another case involved a small boy who had a restrictive lung disease and developed seizures when on oxygen. "The pulmonologist I referred this little guy was very supportive," Hill said. "I believe I have an advantage to have trained in Milwaukee. When my partners ask about resources, I have many specialists to refer them to."
Hill also enjoys the monthly grand rounds provided by Children's Hospital specialists at CHW-Fox Valley. "Grand rounds not only have given me new information about providing better care to children in our area, they directly connect me to the Children's Hospital pediatric specialists I may refer to in the future," said Hill. "I like meeting these physicians and asking them questions about specific cases."
5. Grants awarded to fight childhood asthma
To combat rising rates of asthma - the leading serious chronic illness in children in America - Fight Asthma Milwaukee (FAM) Allies and six other community coalitions across the country are mobilizing to address this problem with innovative approaches, thanks to funding totaling $1.35 million from the Robert Wood Johnson Foundation. Fight Asthma Milwaukee Allies include 80 organizations and 280 health care professionals, community representatives, government officials and parents of children with asthma.
In addition, the foundation has funded Children's Health System and three other health institutions in a nationwide effort to reduce emergency department visits for uncontrolled attacks through its Managing Pediatric Asthma Emergency Department Demonstration Program. Because uncontrolled attacks in the U.S. lead to almost two million emergency department visits annually - with one out of three children having asthma - this initiative is key to improving the way patients, parents and health care providers monitor and manage childhood asthma.
Asthma is a chronic inflammatory disease of the airways affecting 17 million Americans, including an estimated five million children. Asthma causes more school absences than any other chronic childhood disease, accounting for more than 10 million missed school days.
Over the next three years, six hospital emergency departments in southeastern Wisconsin, including Children's Hospital of Wisconsin, will collaborate on a project to improve pediatric asthma management. Project components include training health care providers to recognize and treat asthma appropriately; helping young patients and their parents identify and manage the environmental and other factors that may trigger asthma flare-ups; and tracking data trends on children with asthma visiting the emergency department.
For more information about the Emergency Department Demonstration Program, contact Kevin Kelly, MD, director, Children's Hospital Asthma/Allergy department, and professor of Pediatrics and Medicine and chief of Allergy/Immunology at the Medical College of Wisconsin, at (414) 266-6840. Contact John Meurer, MD, MBA, coalition director, and assistant professor of Pediatrics at the Medical College of Wisconsin, at (414) 456-4116 for more information about Fight Asthma Milwaukee Allies.
6. New programs and services
Children's Transport and Physician Referral Center
If you have an emergency, emergent or non-urgent patient issue, you now have an easy way to access services at Children's Hospital of Wisconsin. With a single call to the Children's Transpport and Physician Referral Center, you will connect with the resources you need, whether facilitating a patient transport, consulting with a physician specialist or facilitating a clinic appointment with a pediatric specialist.
Transport nurse clinicians staff the line from 6:30 a.m. to 6:30 p.m., Monday through Friday. Later this summer, the line will be staffed 24 hours a day, seven 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) 2460 or toll free (800) 266-0366.
Children's Hospital of Wisconsin-Fox Valley moves into new quarters
On June 11, Children's Hospital of Wisconsin-Fox Valley (CHW-Fox Valley) moved into a new home. CHW-Fox Valley is located on the campus of Theda Clark Medical Center. Since it opened in February 2001, more than 1,100 children have been cared for in the facility. A new 4-story addition recently was completed to house the Theda Clark Trauma Center, as well as CHW-Fox Valley.
In the newly-constructed addition, CHW_Fox Valley offers a 22-bed Neonatal Intensive Care Unit on the 3rd floor and a 20-bed Pediatric Unit on the 4th floor. The new units, designed specifically for children and critically ill infants, feature the latest equipment, a child-friendly treatment room, a colorful playroom, space for parents to sleep and shower, and many more patient and family comforts.
Children's Hospital of Wisconsin-Fox Valley
130 2nd Street, Neenah
(920) 969-7900
New health information added to Web site
A number of pediatricians and family practitioners are discovering the benefits of the Pediatric Health Information content available on the Children's Health System Web site, www.chw.org.
Physicians, patients, patient families, caregivers, and Web surfers throughout the state and around the world now have access to more pediatric health and wellness information. The "Pediatric Health Information" Disorders, Diseases & Organs" content in 33 different categories was added to the Web site last fall. You can access it by going to the Children's Health System home page, clicking on "Learn about Health," then clicking on "Pediatric Health Information."
If you have questions about the Children's Health System Web site, please contact Julie Pedretti, Public Relations, at (414) 266-5427 (jpedretti@chw.org) or Peter Overholt, Infomation Services, at (414) 266-3353 (poverholt@chw.org).
Expanded 41-bed NICU opens in Milwaukee
On May 15, 23 babies moved into the new Neonatal Intensive Care Unit (NICU) at Children's Hospital of Wisconsin. The entrance to the new unit is a facade resembling a front porch. Siblings can stay occupied while having fun in the play area, and a family kitchenette provides another convenience and comfort of home.
To provide privacy and a quiet environment for patients and families, the bed spaces of the NICU are set up in pods. Each pod contains six separate infant rooms stocked with state-of-the-art equipment. Each room has rocker-recliners, private lockers, refrigerators and sinks, and can be adjusted for the unique needs of each baby.
In addition, the new NICU has twin and triplet rooms, isolation rooms and an in-unit pharmacy. Consultations and conference rooms are available for meetings or education and the bereavement room provides a secluded place for undisturbed solitude.
On the floor directly above the NICU is the family area. This hotel-like area was designed in conjunction with the Ronald McDonald House staff for NICU and PICU families in crisis who cannot leave the hospital. Amenities include seven parent resting rooms, two full baths, a self-service kitchen, lounge, dining area and laundry facilities.
Phase Two will open in September and will include an in-unit Operation/Procedure Room as well as two rooms for parents to provide independent care prior to discharge.
For more information about the NICU in Milwaukee, contact Ponthenkandath Sasidharan, MD, director, Neonatology, at (414) 266-6825 or Lisa Jentsch, manager, NICU at (414) 266-2955.
Guidelines for pediatric surgical referrals endorsed by American Academy of Pediatrics
The Surgical Advisory Panel of the American Academy of Pediatrics (AAP) has created referral guidelines to serve as voluntary practice parameters to help general pediatricians determine when and where to refer patients to pediatric surgical specialists. Communities vary and the guidelines may be difficult to achieve, but a child who needs specialized surgical care is best served by the appropriate pediatric surgical specialist.
Many congenital anomalies, malignancies, major traumas and chronic illnesses in infants and children should be managed by pediatric medical and surgical specialists at pediatric referral centers. Such centers dedicated to children can provide expertise in many areas, including pediatric medical and surgical specialties, pediatric radiology, pediatric anesthesiology, pediatric pathology and pediatric intensive care.
The guidelines cover general surgery, otolaryngology, endoscopy, ophthalmology, urology, orthopedic, neurology and plastic surgery.
For additional information, see the AAP Web site: www.aap.org/moc.
7. Medical staff additions
Fred Klingbeil, MD (Pediatric Physical Medicine and Rehabilitation)
Nalin Patel, MD (Pediatric Otolaryngology)
Diana Quintero, MD (Pediatric Pulmonology)
Michael Stephens, MD (Pediatric Gastroenterology)
Channing Tassone, MD (Pediatric Orthopedics)
Michael Uhing, MD (Neonatology)
Calvin Williams, MD (Pediatric Rheumatology)
8. CME program schedule
CME programs are available in Milwaukee, the Fox Valley (CHW-Fox Valley in Neenah, and Appleton Medical Center, Appleton), Kenosha (Kenosha Hospital and Medical Center) and Waukegan, Ill. (Provena Saint Therese Medical Center). Check the Children's Health System Web site for the schedule of programs in your area: www.chw.org.
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