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VIRGINIA PEDIATRICSAmerican Academy of Pediatrics Virginia ChapterThe King’s Daughters Milk Bank at CHKD is Named HMBANA’s 18th Milk Bank in North AmericaIssueFall 2014Michelle Brenner, MD General Academic Pediatrics Breastfeeding Medicine SpecialistChildren’s Hospital of the Kings DaughtersIN THIS2234567910121314171820PRESIDENT’S MESSAGECHOR-VCU ACCREDITATION FORADOLESCENT WEIGHT LOSS SURGERY PROGRAMDATES TO REMEMBERCME INFORMATIONCHILDREN’S TRAUMA CENTER AT CHOR RECEIVESNATIONAL VERIFICATIONEATING DISORDERS AND OBESITYEXTREMELY OBESE CHILDREN ARE AT RISK FORKIDNEY IMPAIRMENTIS IT SAFE TO ORDER THAT CT SCAN?PREVENTIVE PEDIATRIC CARDIOLOGY: REDUCINGTHE LOAD THAT YOUNG HEARTS BEARGETTING A GRIP ON “THE DRIP” - UPDATE ONTREATMENT OF GONORRHEACME REGISTRATION AND EVALUATION FORMIMPROVEMENTS IN THE CARE OF PATIENTS WITHCYSTIC FIBROSIS2015 LEGISLATIVE PREVIEWPROMOTING SAFER SLEEPWHAT’S THE LATEST WITH THE FLU?About UsWe welcome your opinions and ideas.Please send comments on articles,ideas for new articles,letters to theeditor, suggestions for making VirginiaPediatrics more useful and addresschanges to:Virginia PediatricsJane Davis:Executive Director2201 West Broad Street, Suite 205Richmond, VA 23220 Phone: (804) 622-8135 Fax: (804) 788-9987 email: [email protected] Next Issue: Winter 2014 Deadline for entries: 12/10/2014 Publication of an advertisement inVirginia Pediatrics neitherconstitutes nor implies aguarantee or endorsement byVirginia Pediatrics or theVA-AAP/VPS of the product orservice advertised or of the claimsmade for the product or service bythe advertiser.Royalty Free Images: Bigstock:: newsletter design layout :: FlutterbySocialMedia.com ::The King’s Daughters Milk Bankopened in June of 2014, is one of only18 non-profit milk banks in NorthAmerica, a member of the Human MilkBanking Association of North America(HMBANA), and is the first milk bank inVirginia. With overwhelming supportfrom The King’s Daughters, the philanthropic organization that foundedCHKD, the milk bank went fromconcept to reality in under 18 months.The King’s Daughters is a charitableorganization that was founded in 1896to promote superior pediatric wellness for every child in southeasternVirginia. One of the early endeavors of this organization was the Milk and Ice Fund, whichoperated in the early 1900s collecting pennies to provide milk and ice to local families inneed. Upon learning of the hospital’s donor human milk treatment program for preterminfants, funding the start up of the milk bank at CHKD became the King’s Daughters mission.Since June, the response from the community has exceeded all expectations. During thefirst few months of operation, The King’s Daughters Milk Bank has initiated the screeningprocess for more than 100 potential donors and has accepted over 35,000 ounces of breastmilk. Deliveries to the CHKD NICU preemies began immediately, and the milk bank is readyto provide pasteurized donor milk to other neonatal intensive care units in the state that arecurrently purchasing donor milk or are interested in starting a donor human milk treatmentprogram.Donor Screening and Milk Processing:The milk bank follows strict screening, processing, and testing guidelines that is similar tothat of blood banking. The HMBANA guidelines were written with the help of the Center forDisease Control (CDC), the Food and Drug Administration (FDA) and the blood and tissuebanking industry. All costs of screening are covered by the King’s Daughter’s Milk Bank,there is no charge to donors.How are donors screened? Donor mothers are screened verbally and by written survey for lifestyle and medical history. The milk bank staff obtains approval letters and prenatal screening results from both themother’s OB-GYN and the donor child’s pediatrician. Serological screening is performed for HIV 0/I/II, HTLV I/II, Hepatitis B and C and syphilis ata LabCorp facility and at the milk bank’s expense. After screening, local moms can drop off their milk donation at the milk bank or we willarrange for overnight shipping at our expense. YouTube Video on the KDMB Screening Process:https://www.youtube.com/watch?v twVlcTO4Juk&list UUsItKNXKw-9aqGrmcgscC0AWhy are people excluded from donating human milk? Medication use (with a few exceptions)Herbal product use (including herbal galactagogues)Tobacco product useIllegal drug useRisk for HIV and hepatitis, including tattoos, body piercings, or acupuncture with nonsterile needles; or the recipient of a blood transfusion within the past 4 months. Daily alcohol usecontinued on page 2.

VIRGINIA PEDIATRICS2. (cont.) The King’s Daughters Milk Bank at CHKDHow is donor milk processed?Frozen donor milk is thawed, pooled, homogenized and sealed in tamper evident, BPAfree bottles. The donor milk is then pasteurized (heated to 62.5C for 30 minutes to killany potential bacteria/viruses). Pasteurized milk is quickly cooled and frozen at -20C.Microbiological cultures are obtained after pasteurization. Only milk that remains bacterial culture negative for 48 hours is dispensed. Pasteurized donor milk bottles are labeledwith a batch number for tracking.The King’s Daughters Milk Bank is excited to expand the availability of this preciouslifesaving commodity to more preterm infants. For more information about The King’sDaughters Milk Bank at CHKD, please visit us at www.CHKD.org/milk or contact us at:757-668-MILK (6455).President’s MESSAGEBarbara M. Kahler, M.D. President Virginia Chapter American Academy of PediatricsIt’s back!VA-AAP and The Pediatric Alliance are combining to present the first Annual Business Meeting. We have tried to maintainthe varied flavor of Art and Business agenda, while opening the conference to all pediatricians.Talks will include topics such as: the new Bright Futures; discussion of the new statistics from the State Child Fatality Teamon Safe Sleep, Conflict Resolution, Human Trafficking, Establishing Peer Review in your office, Postpartum Depression,Social Media, and ICD 10 Coding.AnnualBusinessMeetingM A Y15-162015There are several speakers of note: Karen Remley, MD (former Health Commissioner now with Anthem) on Unsafe Sleep,Lt. Gov. Ralph Northam on Advocacy, AAP Representative on the new Bright Futures and more.Please save the date! May 15-16, 2015. Also keep your eyes open for more from the Chapter as we get closer.Children’s Hospital of Richmond at VCU Receives Accreditation for Adolescent Weight Loss Surgery ProgramDavid A Lanning, MD, PhDSurgeon-in-Chief, Children's Hospital of RichmondVirginia Commonwealth University Medical CenterMetabolic and bariatric surgical procedures have been shown to reduce obesity, improvemortality, and decrease health risks from diseases associated with obesity in adolescentpatients. The Children’s Hospital of Richmond at VCU’s Adolescent Weight Loss SurgeryProgram at the Healthy Lifestyles Center has achieved accreditation as a ComprehensiveCenter of Excellence with Adolescent Qualifications through the Metabolic and BariatricSurgery Quality Improvement Program (MBSAQIP) that is overseen by the American Collegeof Surgeons and the American Society for Metabolic and Bariatric Surgery. We are the onlycenter in the State of Virginia to have achieved this designation that uses rigorous standardsand extensive peer evaluation in accordance with nationally recognized metabolic andbariatric surgical standards. Through a multidisciplinary approach, our team of pediatricsurgeons, endocrinologists, psychologists, dieticians, exercise physiologist, nurse practitioners, research coordinator, and other pediatric specialists offers comprehensive treatmentfor overweight and obese adolescent patients. Our program offers a standard bariatric surgical option as well as a novel surgical approachthat does not remove a portion of the stomach, is reversible, and has been associated with very good initial results. Unfortunately, somemorbidly obese children do not respond to extensive lifestyle modification programs and have no other treatment option other than bariatric surgery. Fortunately, our Center of Excellence program can now fulfill that need for these children and their families from our region.www.virginiapediatrics.org

VIRGINIA PEDIATRICSDates to Remember -----------------------------------------Pediatric General Assembly DayThursday, January 29th, 20157:30 AM – 2:00 PMThe home base for the Pediatric General Assembly DayHilton Garden InnLocated at 501 E. Broad Street In Richmond.This venue is a flat, 3.5 block walk from the General Assembly Building.Shuttle service will also be available.The Hilton Garden Inn offers valet parkingand is convenient to several public parking lots.For more information go to www.virginiapediatrics.org after January 1, 201535th McLemore BirdsongPediatric ConferenceApril 17th – 19th, 2015Wintergreen Resort, VirginiaRegistration opens December 1, 2014www.cmevillage.comAnnual Business MeetingMay 15th & 16th, 2015presented by VA-AAP and The Pediatric Alliancewww.virginiapediatrics.org3

Children’s Hospital of The King’s Daughters and the American Academy of Pediatrics, Virginia Chapter4PresentVIRGINIA PEDIATRICS NEWSLET TERAmerican Academy of Pediatrics – Virginia ChapterContinuing Medical EducationThis activity has been planned and implemented in accordance with the Essential Areas and policies of Medical Society of Virginiathrough the joint sponsorship of Children’s Hospital of The King’s Daughters and the American Academy of Pediatrics – Virginia Chapter.Children’s Hospital of The King’s Daughters designates this enduring material for a maximum of 1.25 AMA PRA Category 1 Credit(s) .Physicians should only claim credit commensurate with the extent of their participation in the activity.Content DirectorC. W. Gowen, Jr., MDProfessor of Pediatrics, Eastern Virginia Medical SchoolEVMS Foundation DirectorChairman, Department of Pediatrics, EVMSSenior Vice-President for Academic Affairs, CHKDCME CommitteeKamil Čák, DMin, BCC, Nancy Leigh Gainfort, RN, BSN, C.W. Gowen, Jr., MD,Eric Y. Gyuricsko, MD, John Harrington, MD, Rosalind W. Jenkins, Janice Karr,Jamil Khan, MD, Windy Mason-Leslie, MD, Amy Perkins, Amy SampsonHow to Obtain Credit:Review the articles on pages 5-14. Complete the attached VA-AAP Newsletter Registration and Evaluation Form and return to theChildren’s Hospital of The King’s Daughters, CME Office, 601 Children’s Lane, Norfolk, VA 23507, or 757-668-7122. You may also visithttps://www.surveymonkey.com/s/VAAAPFall2014 and complete online. Please allow 8 weeks to receive your certificate.Disclosure of Significant Relationships with Relevant Commercial Companies/OrganizationsThe Children’s Hospital of The King’s Daughters endorses the Standards for Commercial Support of Continuing Medical Educationof the Medical Society of Virginia and the Accreditation Council for Continuing Medical Education that the providers of continuingmedical education activities and the speakers at these activities disclose significant relationships with commercial companies whoseproducts or services are discussed in educational presentations.For providers, significant relationships include large research grants, institutional agreements for joint initiatives, substantial gifts orother relationships that benefit the institution. For speakers, significant relationships include receiving from a commercial companyresearch grants, consultancies honoraria and travel, other benefits, or having a self-managed equity interest in a company.Disclosures:TThe following faculty have disclosed that they do not have an affiliation with any organization that may or may not have an interest in thesubject matter of this CME activity and/or will not discuss off-label uses of any FDA approved pharmaceutical products or medical devices.Richard Brookman, MDKerri Carter, MDRachel Gow, PhDJeffrey Haynes, MDEdmond Wickman, III, MD, MPHGreg Vorona, MDNianzhou Xiao, MD, MSThe CME committee members and content director have disclosed that neither they nor their spouses or partners have an affiliationwith any corporate organization that may or may not have an interest in the subject matters of this CME activity.None.

VIRGINIA PEDIATRICS5Children’s Trauma Center at CHoR Receives National VerificationJeffrey H. Haynes, MDDirector, Children’s Trauma CenterChildren’s Hospital of Richmond at VCUTraumatic Injury is responsible for more pediatric deaths than all other childhood diseasescombined. The magnitude of this publichealth problem cannot be understated. Inresponse and to offer the highest level oftrauma care, the Childrens’s Trauma Center atCHoR recently undertook external validationby the American College of Surgeons and hasbeen verified as the first and only Level 1 Pediatric Trauma Center in the Commonwealthof Virginia. This designation reflects thehighest level of preparedness for all pediatrictrauma patients and reflects leadership levelefforts in teaching and outreach, preventionand advocacy, research and most importantlycontinuous performance improvement.The cornerstone of trauma clinical preparedness at CHoR is instant availability of pediatricspecialists in trauma, emergency medicine,neurosurgery, anesthesia, orthopedics,plastic surgery and critical care medicine. Inconcert with pediatric nursing and supportObjective: Review resources refined and available at a Level 1 ACSverified Pediatric Trauma Center.ACGME Competencies: Patient Care, Medical Knowledgefrom respiratory therapy, radiology and theimmediate availability of an operating room,the response to the sickest and most injuredchildren is comprehensive.As a leader in pediatric trauma, educationand outreach are essential components ofour program to ensureoptimal trauma care.Critical trauma carebegins on the scene. Tosupport our partners inEmergency Medical Services, we have offered education and trainingopportunities that reach across the state.We partner with the Pediatric EmergencyDepartment to offer the Emergency PediatricCourse to area EMS providers, have developed a training video and will speak at theupcoming VA EMS Symposium. We also offerthe Emergency Nursing Pediatric Course andthe Trauma Nurse Core Course on site at theMCV campus, with openings to area nurses.Injury prevention is an essential componentof our program. CHoR is the state home toSafe Kids Virginia. Risk areas of focus include:child safety seats, traffic safety, distracteddriving, burn prevention; and, more recently, unattended children in automobiles.Internally, through a generous grant fromthe MCVH auxiliary, a multi-sport helmetprogram has been implemented. Childrenpresenting to the emergency department oradmitted to the hospital with injuries from awheeled sport activity such as biking, rollerskating or skate boarding, receive a brandnew helmet.The Children’sTrauma Centerhas contributedto peer-reviewedand published research. Recent publicationsinclude analysis of metabolic markers at presentation as indicators of injury in pediatrictrauma as well as participation in a nationalstudy to develop a clinicalpredictive rule for abusive headtrauma. CHoR contributedthe second largest number ofpatients to this study. Ongoing studies include minimizingradiation in both pediatric bluntabdominal trauma and cervical spine clearance, and themanagement of isolated closedhead injuries in children. Thelast two topics will be presentedthis fall at the Pediatric TraumaSociety meeting in Chicago.The Childrens Trauma Centeris instantly available as a statewide resource by calling JeffreyH. Haynes MD, Director, 804828-3500 or Kelley Rumsey RN,MSN, Program Coordinator at804-828-2424. Patient referralsand physician consultation areavailable anytime through theCHoR/VCU transfer center 804828-2638.

VIRGINIA PEDIATRICS6Eating Disorders & ObesityRachel Gow, PhD, LCPAssistant Professor, Department of PsychologyAlexis AplascaMelanie Been, MDEdmond Wickham, MDAssociate Professor of Internal Medicine and PediatricsDivision of Endocrinology and MetabolismDirector of Research, Comprehensive Pediatric Obesity Research and Treatment CenterChildren’s Hospital of Richmond at VCUirginia Commonwealth UniversityObjective: Discuss the prevalence of eating disordersamong adolescents across the weight spectrum. Reviewthe signs and symptoms and recall referral options.ACGME Competencies: Patient CareEating disorders can be present in childrenand adolescents at any weight. They aremost prevalent among adolescents ages 1318 years, with onset peaking during theseages. Lifetime prevalence estimates amongadolescents (ages 13-18 years) are 0.3% forand anorexia nervosa (AN), 0.9% for bulimianervosa (BN), and 1.6% for binge eatingdisorder (BED).1 Although full thresholdrates are around 1%, unhealthy attitudesand efforts to control weight, which maynot meet diagnostic criteria for AN, BNor BED, are common. By age 20, as manyas 12% of children and adolescents meetcriteria for eating disorder, not otherwisespecified (defined as subthreshold AN,BN, purging disorder, or BED).2 Moreover,over half of adolescent girls (55.3%) and aquarter (28.6%) of boys surveyed in ProjectEAT reported dieting in the past year.3 In thesame study, unhealthy weight control behaviors (fasting, eating very little food, usingfood substitutes, skipping meals, smokingcigarettes) were reported by 60.7% of girlsand 27.9% of boys. Extreme weight controlbehaviors such as purging, using diet pills orlaxatives, were reported by 12.6% of adolescent girls and 2.1% of boys.3 Binge eating(eating a large amount of food and feeling a“loss of control” while eating) was reportedby 9.9% of girls and 3% of boys.3 Additionally, body dissatisfaction is prevalent amongboth girls (35%) and boys (18%).4 Disorderedeating behaviors are associated with a pervasive course and several psychological andmedical comorbidities.Dieting and unhealthy weight controlpractices are problematic because they areassociated with several negative outcomes,including increased risk for weight gain,obesity, and eating disorders in adolescentsand young adults.5 Normal weight childrenwho engage in unhealthy weight controlbehaviors are at increased risk for both disordered eating and obesity in adolescenceand as young adults.5 Simalarly, adolescentswho engaged in unhealthy weight-controlbehaviors were at three times greater riskfor being overweight five years later.5 Theseadolescents were also at increased risk forbinge eating and compensatory behaviors(e.g., self-induced vomiting and use of dietpills, laxatives, and diuretics) five years later,compared with adolescents not using anyweight-control behaviors.Adolescent patients who are overweight orobese are at significant risk of developingan eating disorder; however, their symptoms are frequently not recognized and gountreated. Compared to their normal weightpeers, overweight and obese adolescentsengage in more unhealthy weight controlbehaviors. More specifically, data fromProject EAT-I6 indicated that 50% of adolescent girls, 69% of overweight adolescentgirls, and 76% of obese adolescent girls usedunhealthy weight control behaviors. Overweight adolescents reported more bingeeating behaviors than their non-overweightpeers 6 and are at elevated risk for BED7 andBN8 as adults.Pediatric primary care providers are atthe frontline and have the opportunity toidentify eating pathology and provide criticalearly intervention. Indeed, early intervention with eating disorders is associated withthe best long-term outcomes. Regardless ofweight status, providers are encouraged tobe aware of signs of disordered eating. Forexample, if a patient loses weight rapidly,www.virginiapediatrics.orginquire about methods used. Is he or sheexercising excessively or skipping meals? Ingeneral, patients can be screened by askingabout eating patterns, meal skipping, feelings of loss of control or guilt with eating,comfort with their appearance, and teasing.Potentia