Annual Meeting Day 2, August 22, 2015

There is no CME credit for drinking scotch with your friends and mentors from every stage of your career, but I really think we should apply for it next year. Of course then I'd probably have to take notes, and that might not go well. Alas, here's day 2. One caveat, there are 3 separate specialty sessions, but only time to attend two. We will never know what I missed.

John Rusher, MD, JD

Legislative Update

• CCNC saves $3 for every dollar invested.
• Call your senators and congressmen now and remind them to take into account children in Medicaid reform, also to support provider led entities. Now is the time to call!

Senator Bill Purcell, MD accepts the Senior Section Advocacy Award. Dr. Purcell's legacy in our state is hard to overstate.

John Rusher accepts Special Achievement Award from the AAP for his work on the NC Pediatric Society and the AAP Committee on State Government Affairs. Rarely has an award been so deserved. Thanks, John!

Jason Dranove

Dysmotility in Children

(picked up a little late)
 

• Voiding dysfunction may not just go away from treating underlying constipation.
• Constipation really affects families’ quality of life, more even than GERD or inflammatory bowel  disease
• CHACC guidelines are hugely helpful: http://communitycarenc.com/media/files/pediatric-constipation-guidelines.pdf
• 95% of children with constipation have no underlying disorder
• Classic history: starts with painful stools, either with onset of solids, toilet training, or beginning of school (no one likes school bathrooms)
• Enemas are not helpful beyond PO medications.
• Cleanouts: add bisacodyl, senna starting at age 3
• Miralax works best for constipation cleanout when you give a whole bunch at once, not gradually.
• Inpatient is Polyethylene Glycol Electrolyte solution by NG tube, start slowly, advance slowly stop at 250 ml per hour in order not to be called at midnight with vomiting/distention.
• Stools have to be liquid, not clear.
• Severe impactions not responsive to cleanout may need manual disimpaction under anesthesia.
• PEG should be 0.8 g/kg/day, ranges 0.2 to 1.4 g/kg/day
• Do a cleanout first! Otherwise you’re just going to push stool around the impaction and get soiling.
• PEG 3350 (1 teaspoon is about a quarter of a capful). Safe down to 6 months of age.
• If you’re not getting response to 2 capfuls a day, add a stimulant, start thinking about other factors affecting stooling.
• Stories in press sometimes suggest that PEG is not safe. The data so far do not support this.
• Lubiprostone (Amitiza), studied in adults, one study in kids shows that it is safe and effective, but if a child is holding stool or has sensory integration dysfunction, then this is not going to work. Think of it for bloated teenager, females. Expensive, prior authorization needed.
• NO milk and molasses enema. Just don’t. Can cause cardiopulmonary compromise, perforation, death in children.
• NO oral phosphosoda can cause nephropathy.
• Constipation tends to resolve with age, but if you get to the late teen years and stil have it, you’re less likely to improve.
• Motility: the movement of contents through the GI tract. Measure by radiography with contrast, scintigraphy, or radioopaque markers
• Manometry: study of pressure changes in the GI tract over time. How well are the muscles and nerves working? Normal study = normal neuromuscular integrity. Does not mean that transit times are normal.
• Conscious control of motility occurs at the rectum with contraction of the external anal sphincter. Rectum accommodates and the internal anal sphincter contracts as well.
• Anorectal manometry: rare, maybe 1/100 of patients referred for constipation get this. Essentially you’re looking for sensory function, Hirschsprung’s disease. Blow up a balloon with air, see what the patient can feel. Looking to see internal anal sphincter relax in response to rectal distention. Much nicer than rectal biopsy for diagnosing Hirschsprung’s disease.
• Colonic transit study uses a SitzMark Capsule: 24 little rubber circles. 80% of more should be gone 5 days after ingestion. In slow transit they get spread all over, in pelvic floor dys-synergia they collect in the rectum.
• SitzMark can serve as a cost-effective screening tool in intractable constipation.
• Colonic Manometry: rubber catheter with 8 pressure sensors throughout the colon. Looking for normal high-amplitude propagating contractions. Takes 6 hours, usually with bisacodyl. Can diagnose neuropathy, myopathy.
• In dysmotility, there appears to be a problem with the interface between the nerves and the muscles. The contractile wave falls apart before it fully propagates.
• Malone Antegrade Continent Enema (cecostomy). Place a conduit through the appendix to flush the colon. Started in spina bifida patients. Not effective in the presence of abnormal motility study.
• Esophageal manometry for difficulty swallowing, now high resolution, shows upper sphincter, lower sphincter, peristalsis in between.
• Gastroparesis. Usually post-infectious, usually improves on its own. Tends to be overdiagnosed. Usually resolves.
• Nuclear medicine gastric emptying scan to diagnose gastroparesis. At 2 hours after a meal, as long as <60% is remaining, then it’s normal.
• Most GI docs avoid Reglan, prefer erythromycin.
• Manage expectations of motility specialists: can’t always find what’s wrong and fix it.
• It’s critical for the primary GI and the motility specialist to communicate.

John Wooten, MD

Headaches in Clinical Pediatric Practice

• First question: are these primary or secondary headaches?
• Getting a history is really critical. Can be difficult with kids.
• Ask about “sinus headaches” in family history: 90% of these are migraines.
• Ask about impact on quality of life.
• Ask what the family is worried about.
• Rizatriptan approved for childhood, 6 and up.
• Use anti-inflammatory rather than acetaminophen.
• Amitriptyline has a lot of history for headache prophylaxis, up to 1 mg/kg/day. For many patients 10 mg is enough.
• Look at biobehavioral therapy: CBT, healthy habits, biofeedback, etc.
• Goal for symptomatic therapy is response in 2 hours. Limit to 3 days a week.
• Prophylaxis tends to help within 2 to 6 weeks of starting it.
• If a child never gets a headache-free day in a week, your success rate is going to be low.
• Where does it hurt? When did it start? How long does it last? Pounding versus steady pain? Nausea, vomiting? Sensitive to light, noise, or exertion? Activities of daily living?
• Neurologic function may be impaired for 3 days after onset of a migraine in teens.
• ADL’s: sleep pattern consistent? Stresses? Caffeine? Diet (avoid carb loading)? Healthy snack or meal every 2-3 hours, especially in elementary aged child? Hydration?
• Teens withdraw from caffeine quickly compared to adults, presents with headache, usually in the morning.
• Look at fundi, pupils as part of your exam.
• Labs should be driven by suspected illness.
• EEG is rarely useful.
• LP for subarachnoid hemorrhage, idiopathic intracranial hypertension, meningitis.
• Neuroimaging: MRI better than CT scan. If you think they’re going to end up in a bunch of ED’s, just go ahead and get one to save them from a CT scan.
• Image for dramatic change in pattern of headaches, progressively worse headaches, nocturnal or early AM awakening with headaches (especially with nausea/vomiting), focal signs of symptoms, occipital headaches, immune suppression/HIV/cancer.
• MRI is still better than CT for trauma imaging, may show contusions that CT scans miss.
• CT is better for bone/skull concerns such as fibrous dysplasia
• Consider prophylactic therapy if headaches occur more than 4 times a month.
• Limit rescue therapy to 2-3 days per week to avoid rebound headaches.
• Beta blockers are great for prophylaxis, also tricyclics
• Treat all headaches as early as possible.
• Refer if unresponsive to simple interventions or if too complex.
• FDA approval does not equal insurance-covered.
• For abortive therapy, Axert, Maxalt, Zomig NS, Treximet are the only 4 FDA approved triptans for pediatric headache. ED’s may use DHE protocol.
• Avoid narcotics!
• Anti-emetics can be helpful, antihistamines, anxiolytics, magnesium sulfate, dexamethasone, ergots, valproate, ketorolac
• When a child is on a prophylactic medication, the rescue medications tend to work better, faster
• Manage expectations: we can make patients better, but rarely make the headaches go away.
• Topiramate is now approved in patients 12 years and older.
• Atenolol is his preferred beta blocker, useful for athletes (against the rules for golfers)
• Valproate, zonisamide, levitracetiam, gabapentin, carbamezepine
• Can also use venalfaxine, duloxetine
• B2, magnesium, and Butterbur have solid data in adults. Some supplements have the right combination (Migavent, Migralief)
• OCP’s may help some patients.
• Sphenogpalatine Ganglion block (3 devices approved for adults)
• Cephaly head band (for adults, by prescription)
• Refer: any time you’re worried.

Sunita Juliana Ferns, MD

Management of Syncope and POTS

• POTS is characterized by orthostatic tachycardia, change in HR by 30 bpm in adults, 40 BPM in children or HR over 130 (under age 14) or over 120 (over age 14)
• Cause? Many theories, maybe some answers.
• Many possible causes. Primary versus secondary. Most kids are partial dysautonomic, post-viral. Also can be developmental, resulting from growth spurt that outpaces the autonomic nervous system’s ability to keep up. Can be hyperadrenergic.
• More common in girls/women. Baseline change in HR in healthy women is greater than in healthy men.
• Symptoms: palpitations, light-headedness, shortness of breath, chest discomfort, nausea and vomiting, exercise intolerance, mental clouding, poor sleep, headaches
• We can’t cure this disorder, but we can control it and make life more livable
• Almost every patient will respond to some form of non-pharmacologic treatment.
• Exercise and improving blood volume are key interventions (add fluid, salt)
• Exercise increases fitness, blood volume, LV remodeling, sympathetic tone.
• Exercise was at least as good as propranolol, far superior in terms of functional status
• Consider semi-recumbent exercise like rowing or swimming, recumbent biking. Progress to standing exercise.
• Start slowly with a goal of working up to 60 minutes 5-6 days a week
• Add strength training 2 days per week. Focus on lower body strength especially
• Swimming is especially friendly for POTS
• Fluid is effective, cheap. Avoid sugar in fluids: increases dehydration. This includes Gatorade. Coconut water is great!
• Salt: if we could give these kids salt licks, we would.
• Can push salt as high as 10 gm per day.
• Can prescribe a salt pill for patients who are just averse to salty food
• Compression stockings: need to use ones that extend all the way into the abdomen. Thigh-highs will not work. Can use abdominal binders, but need 30-40 mmHg of pressure, which takes a second person to cinch them on.
• Mast pants will work.
• Sleep hygiene is helpful. Regular bedtime timing, avoid stimulants, avoid daytime naps.
• Behavioral change: stay out of the heat, avoid alcohol, carbs and caffeine, sit/lie down, elevate the feet, shower safely (cooler water may help, shower seat), plan activities later in the day
• Standing heart rate is higher in the morning
• Meds: fludrocortisone or DDAVP, midodrine HCl (only midodrine has data to support it)
• Beta blocker is about equal to placebo, except in the small subset of population with hyperadrenergic POTS
• Assure patient that you believe her. Clarify that the goal is symptom relief, there will be several steps to get better. Be aware of grieving process in these patients.
• Reassure patients that they will grow out of it with time

David Berkoff, MD

Post-Concussion Care in Pediatrics

• No same day return to play
• Book to read about changing behavior - Switch
• Age of first exposure to football and later-life cognitive impairment in former NFL players
• (starting under 12 seems to show more long term cognitive dysfunction)
• Concussions are bad and there are a lot of them
• Significant increase from 2001-2009; we are identifying them better, need better ways to treat them
• Person to person injury is the most common mechanism
• Impact for kids is different than adults
• Cognitive improvement is different
• Children take longer to recover
• We have no prospective data to define the injury modelNeed to educate and get on board parents, players, coaches, trainers.
• State laws make a big impact in who gets referred for concussion
• Half of players will not report a concussion
• Coaches polled had a very low rate of understanding concussions and appropriate care
• Concussion scales vary, there are multiple different scales. There are no data to support any of the grading scales out there.
• So when can kids get back in the game? Parents’ buy-in is critical here, often feel that scholarships are on the line.
• There are no prospective data on return to play guidelines.
• Concerns: second impact syndrome, prolonged recovery, risk of post-concussion syndrome, risk of prolonged neuro-cognitive deficit
• On-field amnesia is the best predictor of prolonged post-concussion syndrome
• Same-day return to play is a strong predictor of prolonged post-concussion syndrome
• The more concussions you have, the more concussions you are likely to have in the future
• Neuro-cognitive impairment is related to the total number of concussions more than to the severity of any given concussion
• NO same-day return to play! “No doubt, you’re out.”
• Symptom management: no one really knows, but don’t give NSAIDs or aspirin due to bleeding risk. Consider physical modalities like ice packs, massage.
• Avoid meds in the acute period that might alter mental status or cause vomiting.
• Initially restrict physical activity that increases heart rate or blood pressure: gym, sports, working out, recreational activities like skateboarding, video games, etc. Include brain rest, because that is the organ that is injured.
• Work with the school on how to accomplish physical and brain rest.
• No clear guidelines on return to school. Have to be flexible, work with the school. Increase activity as tolerated without exacerbation of symptoms. Half of schools have no guidelines on how to do brain rest, accommodate concussions.
• 2/3 of school nurses have some sort of training in recognizing, treating concussions
• Brief neurocognitive testing: be careful using these in kids, developed for adults. Research does not support the reliability of these tests. The baselines vary all over the place. Really these kids need a neuropsychological exam from a qualified professional if they are having prolonged symptoms.
• Really do need to be completely asymptomatic in order to return to play.

Mary Catherine Brake Turner, MD

Transitioning the Complex: It’s our responsibility

• More adults than children have cystic fibrosis
• About 75% of patients with spina bifida will survive to adulthood
• At least 60% of patients with sickle cell anemia will survive into the 5th decade of life
• About 500,000 US children with special healthcare needs turn 18 every year
• 90% of children with special healthcare needs survive into adulthood
• About 12% of NC children have special healthcare needs. Only about 44% are getting the services they need to transition to adult care.
• Most common: autism, intellectual disability, cerebral palsy, type I diabetes, trisomy 21, congenital heart disease, chronic lung disease requiring O2/vent support, asthma, ADHD
• Goal of Healthy People 2020 is for all youth with special health care needs to receive the services necessary to make appropriate transitions to all aspects of adult life - health care, work, independence.
• Transition medicine: growing field seeking to provide primary medical care and coordination of care during migration from pediatric to adult care.
• Have a written transition plan by age 14! Must be individualized. Should include other aspects of assuming adult roles, such as educational and vocational/social.
• Purpose is to maximize lifelong functioning and potential.
• Barriers to transition: difficulty finding a knowledgable adult provider, reluctance to leave clinician with an established relationship, fear that adult care is not family-oriented, difficulty maintaining insurance coverage.
• Kids may lose Medicaid at age 18, may lose disability benefits, has caps on costs.
• Adolescents need to become responsible for their own health, advocate for themselves, think long-term about their actions/consequences, understand that resources are limited.
• Barriers to pediatricians: hard to find adult providers to take on these patients, lack of time and reimbursement for handling these issues, reluctance to give up the long-term patient relationship.
• Barriers to adult clinicians: Lack of training in these conditions, need for multiple consults, difficult to meet psychosocial needs of these patients, difficulty in facing disability and end-of-life issues so early
• 6 core elements of health care transition: www.gottransition.org
• Community Care of North Carolina (CCNC) and (Child Health Accountable Care Collaborative) CHACC are embedded in practices across the state to help pediatricians with transition management
• First step: create a written practice policy on transition. Share this policy with providers, staff, and families. Should involve all stakeholders in the process, provide a consensus of the process, explain legal changes that occur at age 18. Share with youth and families at age 12-14.
• Track transition: EHR flowsheets, youth registry, or refer to CCNC or CHACC
• Assess youth readiness to transition. STARx form developed by Dr. Maria Ferris of UNC. Also forms available at www.gottransition.org. This can be done at office visit by MD/RN or by CCNC care manager or CHACC.
• Plan for transition as a collaborative, cooperative process with families and youth. Without a plan, young adults can find themselves without a medical home, leading to poor and delayed care. Should include medical, educational/vocational, and social issues. 
• Needs a Portable Medical Summary with Emergency plan (1-2 page document with problems, meds, nutrition, specific care issues, living will). To stay with the youth at all times.
• Be thinking about legal issues: consent, guardianship. Get started at age 17; much simpler then than after the 18th birthday.
• Look to the future. Promote independence. Identify potential obstacles. Follow general and condition-specific screening guidelines.
• Individuals with Disabilities in Education Act mandates education plan that must be put in place by age 16, including educational goals and resources. Should have IEP, vocational rehab if needed.
• Transfer to Adult Care. Transfer when the condition is stable, not in crisis. Prepare and introductory letter. Complete transfer package with plan of care, medical summary. Confirm date of first adult provider appointment. Confirm that you remain responsible for care until the young adult is first seen by the adult provider.
• Transition completion: patient has seen adult provider, you have followed up with the family, you have confirmed that adult provider has established follow up.
• Comment: CHACC grant is over, care managers are now out of the local hospitals. CCNC is only funded through December of 2017.

Martha F. Perry, MD

Adolescent Drug Abuse: Current Trends in North Carolina and Beyond

• Alcohol remains the #1 drug of abuse, followed by marijuana and tobacco
• Trends have been encouraging over the last few decades, especially for alcohol and cigarettes, with illicit drug use stable. Peak for drug use was late 1990’s, early 2000’s.
• 8th graders: 12% using marijuana. 12th graders: 35.1% using marijuana. Inhalants, synthetic marijuana, prescription drugs follow.
• Lots of good news in terms of decreased drug use among adolescents
• Biggest concerning trend: e-cigarettes, hookas, decreased perception that marijuana is dangerous
• Teens find a lot of interesting ways to use alcohol: hand sanitizer, vodka on the eyes, rectal use, mixing with energy drinks, nebulized. Binge drinking remains the biggest concern.
• Binge drinking: increased in high-risk behaviors, accidental injury/death.
• Many forms of tobacco other than cigarettes: cigars, e-cigs, chewed/sniffed (snus), hookas, dissolvable oral tablets
• E-cigarettes: battery powered, vaporize chemicals with a heating element. Hundreds of brands, use has risen from 1.5% to 17.2% of teens over 4 years. Teens perceive them to be less harmful than cigarettes, but we don’t know what those risks are. Risks are different, but we don’t know how.
• E-cigs are just as addictive as tobacco products.
• FDA can regulate e-cigs, but has not fully asserted this authority. E-cigs are being used to vape other substances.
• E-cigarettes: wide variety of appealing colors, shapes, sizes, flavors
• Marijuana: most commonly used illicit drug in the US. Some parents just aren’t that concerned, think MJ is safe for kids.
• Concentrated resins from cannabis are now popular: hash oil, budder, amber-like, butane-based (may explode).
• MJ impairs judgement, reaction time (doubles risk of MVA). 17% become addicted, cannot stop despite interfering with many aspects of life. Withdrawal symptoms exist, last about 2 weeks.
• Long-term damage: average loss of 8 IQ points if used during adolescence. Permanent structural and functional changes in the hippocampus, impaired connectivity in the executive function areas of the brain. Poorer educational outcomes, reduced academic attainment.
• Not at all clear that MJ is a “gateway drug.” Chicken and egg question. Alcohol and nicotine seem just as common as first drugs for those who go on to use others.
• Synthetic MJ was legal until 2012 (K2, Spice). Shredded plant laced with cannabinoid compounds. Some smoked, but ingested, too. Not detectable on most urine drug screens.
• Next most used: Rx drugs. Adderall, Vicodin, tranquilizers, cold medicines, amphetamines. Come from friends, relatives, grandparents. Encourage safe Rx drops.
• “Pharming” or “Skittles” party: take handfuls of whatever kids find in their homes.
• Cognitive enhancement is the main source of recent increase in stimulant abuse. Abusers still have lower GPA’s than non-users. May be a perception that they’re doing more, but does not match the reality.
• Opioids: most common liquid codeine (Sizzurp, Lean), Fentanyl, hydrocodone, oxycodone. More deaths than from heroin and cocaine combined as of 2014.
• Barbiturates, benzodiazepines less popular, used to come down from stimulants.
• Don’t prescribe a controlled substance until you’ve done a drug screen: you may find more than the drug they are asking for.
• Inhalants: decreasing in popularity, but remain popular. Volatile substances, solvents, aerosols, nitrous oxide, nitrites. “Huffing,” “bagging.”
• Effects occur within seconds, very short-lived, followed by hours of drowsiness/headache. Leads to repeated inhalations over several hours. These kids are at very high risk of using other substances.
• Look for stains on clothes, soaked rags, spray paint.
• Can have arrhythmias, asphyxiation, suffocation.
• Dextromethrophan: usually taken orally, often with alcohol or marijuana. “Robo-tripping” or “skittling” produces effects similar to ketamine and PCP’s.
• Teach kids stress-relief, sleep skills to avoid use of DM for sleep help
• Effects start within a few minutes, last up to 6 hours
• Salvia: Maria Pastora plant, “Magic Mint” “Seers Sage” Legal, up and coming.
• MDMA/Ecstasy. Combined with Viagra, Prozac (afterwards). Look for water bottles, these kids get thirsty.
• Side effects: hyperthermia, sweating, dehydration, bruxism. Many tablets are mixed with other substances. May lead to permanent dopamine changes with single use.
• Bath Salts. Now illegal. Not the same as actual bath salts. Used by snorting, smoking, ingesting. May lead to excited delirium, suicide, rhabdomyolysis. Rates of use are falling dramatically.
• Look to www.ndews.org for latest and greatest on emerging drugs of abuse
• Enforcement matters, does drive drug use patterns.
• “Molly” powdered MDMA, may be laced with bath salts,which led to deaths and hospitalizations.
• Use a screening tool in your office: CRAFFT, SBIRT, NIDA Quick Screen
• www.drugabuse.gov/ Great resources!
• Reassure patients that you are not going to turn them in.

Richard Chung, MD & Abigail English, JD

Sex Trafficking & Sexual Exploitation of Children, Adolescents, & Young Adults

Abigail English:

• Victimization is everywhere: every region, country, & local community
• Traffickers & exploiters reap big rewards
• Purchashers come from all walks of life
• Young people of all ages are victimized. When victims turn 18, they are treated very differently by the law, even though the process of victimization has not changed.
• International attention and interventions really began to occur in the 1990’s. leading to international treaties and conventions that have local impacts.
• Universal Declaration of Human Rights, 1948. UN Convention Against Trans-national Crime (Palermo Protocol). UN Convention on the Rights of the Child.
• Universal Human Rights: Life,liberty, security. Freedom from slavery/servitude. Health and well-being. Medical care. Movement. Freedom of expression.
• UN Protocol on Human Trafficking: States must prohibit child prostitution. Defined as use of a child in sexual activities for remuneration or any other form of consideration. Criminalizes sexual exploitation of children. Protects rights of child victims in judicial proceedings.
• UN Convention on the Rights of the Child: right to life. Freedom from violence. Health. Optional protocol on the sale of children.
• Palermo definition: “the recruitment, transportation, transfer, harbouring, or receipt of persons by means of threat or use of force or other forms of coercion…” Purpose: sex or labor.
• Defining sexual exploitation is tricky, should include prostitution, survival sex, pornography, sex tourism, mail order brides, stripping, performing in sexual venues.
• Sex trafficking is not exactly the same term as sexual exploitation. Minors are trafficked both for labor and for sexual exploitation.
• US Federal and state laws emphasize prosecution more than prevention, provide little focus on services.
• Include Trafficking Victims Protection Act. All 50 states and DC have anti-trafficking laws. Also seeing a new category, “Safe Harbor” laws, which treat victims as victims, not as criminals.
• Various governmental agencies share responsibility for protecting children, addressing demand, reporting cases, and child welfare and juvenile justice handling of victims. Programs and protocols overlap in many ways.
• NC is among the top 10 states for human trafficking.
• Child sexual exploitation is included in state child abuse reporting laws. Some question about reporting abuse by others who are not parents/guardians/caretakers.
• Mandatory reporting can be an important tool, but it does not always provide for the safety and wellbeing of victims.
• NC has a safe harbor law, created in 2013. Addressed adults and minors, provided stronger penalties for perpetrators, disallowed defenses of consent and mistaken age, protected minors from being charged with prostitution, adults get a first offender program.
• Only about 8-10 states have safe harbor laws like the above
• Institute of Medicine report: sex trafficking/exploitation must be understood as acts of abuse/violence against children. Minors are not criminals. The process should not further harm children.

Richard Chung:

• This issue is relevant to all of us, not just children, pediatricians, law enforcement
• The battered child syndrome was described in 1962 by Dr. Henry Kempe, who estimated that across the country over 700 children were being abused. With mandatory reporting, the estimated numbers of course increased logarithmically.
• Look at clinical report from Pediatrics published earlier this year (Greenbaum et al)
• Question #1: Has anyone ever asked you to have sex in return for something that you needed?
• Question #2: Has anyone ever asked you to have sex with another person?
• Question #3: Has anyone ever taken sexual pictures of you?
• Risk factors: Abuse, neglect, maltreatment. Homeless, runaway, thrown away. being involved in juvenile or criminal justice system, foster care. Stigma and discrimination. Family conflict, disruption, dysfunction. Gang involvement, under-resourced schools, neighborhoods, communities
• Red flags: truancy, running away, signs of physical abuse or restraint, unexplained injuries, multiple STI’s or abortions, neglect/delay in care, evidence of branding.
• Barriers to care: Lack of understanding, lack of time, absence of protocols, mandated reporting, stigma/shame, cultural or language barriers, loyalty to the exploiter, immediate safety concerns, failure to self-identify as a victim (normalizing the situation)
• There is a national hotline for reporting, can provide locally relevant next steps upon reporting.
• Health implications involve physical, social, developmental, psychological, and spiritual consequences
• Health issues involve developmental issues, infection, reproductive issues, trauma, mental illness, and nutritional issues.
• We may encounter victims in an acute setting, but we may also be treating survivors, but we also have a role in prevention.
• Prevention: cycle can involve linking of love sexual abuse, violation of boundaries, guilt and shame, child’s view of self as a sexual object, low self-esteem, runaways, history of abuse.
• Great resource for understanding this process: http://www.gems-girls.org
• Secondary prevention: after care, help, for someone who has already been exploited.
• Primary prevention: addressing a patient who is actively being exploited.
• Primordial prevention: address risk factors such as ACE’s prior to exploitation occurring. This is where our focus is going
• The exploited child and the victimizers were all our patients beforehand.
• We have an obligation to advocate for patients outside of the walls of our offices.
• Gary Haugen: “the poor don’t have much in the way of money or possessions to steal—so it turns out that the most profitable thing to steal is the whole person.”

Meggan Goodpasture, MD

Medical Child Abuse

• Munchausen Syndrome by Proxy: the terminology until 1977
• Factitious Disorder by Proxy: DSM-IV
• Pediatric Condition Falsification: APSAC
• Now Caregiver-Fabricated Illness in a Child/Medical Child Abuse (Roesler and Jenny, 2009)
• Child receiving unnecessary,harmful, or potentially harmful medical care at the hands of a caregiver.
• Don’t have to know the caregiver’s motivation to make the diagnosis. Still matters for intervention and treatment.
• May overlap with other types of child abuse: physical abuse may lead to unnecessary medical intervention.
• Medical neglect is failing to get needed medical care for a child, this is kind of the opposite.
• Prevalence may be 0.5-2/100,000, but it’s really hard to find this stuff, so this is likely an underestimate. Only the most severe cases get diagnosed.
• Crosses SES/Educational boundaries. More common in developed countries.
• Continuum from parental anxiety to exaggerating symptoms to fabricating symptoms to inducing symptoms. Where is the line? But parents who are real perpetrators often are not anxious at all, so is this a fair characterization?
• Sequelae: children begin to see their reality as normal. Once kids get older, children start to think of themselves as sick, internalize this identity. Other kids get older and refuse to participate
• Risk indicators for caregivers: interest or expertise in medicine, seems to know more about the illness than the provider. Model parent/martyr. Enmeshment: overly comfortable with medical staff. Does not appear relieved with normal test results. Promotes invasive tests and procedures. Enjoys being in the spotlight. May have personality disorder, Munchausuen’s, or somatization. Not really helpful or accurate in diagnosis. Emotionally or physically absent father. Life revolves around child’s illness/hover. All of the above, of course, can overlap with parents who are caring for truly ill children.
• Usually takes about 18 months to arrive at a diagnosis. This is just a hard thing to figure out.
• Some argue that the caregiver herself may not be aware of the deception.
• Diagnosis: Are the history, signs and symptoms of disease credible? Is the child receiving unnecessary, harmful, or potentially harmful medical care? If so, who is instigating the evaluations and treatment?
• The presence of true disease does not rule out medical child abuse. Present in about 1/3 of patients with medical child abuse.
• Most common presentations: apnea, seizures, FTT/feeding intolerance, multiple allergies, vomiting/diarrhea, pain, constipation, odd constellations of symptoms. Many of these kids have mitochondrial disease on the differential at some point
• Physician profiles: trusting, sympathetic, trusting, like working closely with patients, go the extra mile, sensitive to the emotional needs of parent and child, interested in rare diseases.
• Treatment of the caregiver: most important element is for the parent to admit what she has been doing. Increases the success of treatment, usually involves ascertaining the caregiver’s motivation, helps perpetrator confront the reasons why she harmed her child.
• Prognosis is better with input from spouses/grandparents, successful short term foster care before returning to the caregiver, offender’s long-term therapeutic relationship with a social worker, successful remarriage for the offending caregiver, early adoption, long-term foster care.
• Trends are moving away from video observation toward simply isolating the child from the caregiver.
• Some system issues make us more vulnerable: the EMR, family-centered care, increased focus on patient satisfaction scores, increased reliance on subspecialists who may only know part of the patient history.
• If you see the child get better in the hospital, this is a strong sign of medical child abuse, especially when the improvement seems to increase parental anxiety.
• Remember, there is always a differential diagnosis!
• Long-term sequelae: depression, PTSD, anxiety, relationship difficulties, substance abuse. Mortality risk is 6-10%.
• Graphs and charts can be very helpful in presenting data from these cases.
• Remember that we are all mandatory reporters of suspected child abuse. We don’t have to confirm it in order to report it.
• Spreadsheet: system, subjective signs/reported symptoms, objective signs of problem, intervention, results
• Medical records, staff changes, can risk losing prior diagnoses of medical child abuse. Parents sometimes (often) talk clinicians into removing the problem from the problem list after it has been added.
• Avoid blame, but anticipate conflict. These are highly emotional cases. Often there is disagreement among members of the care team. Being involved in bringing harm to a child is emotionally painful for a provider.
• Difficult to make definitive diagnoses, makes it hard for DSS to address when we can’t be certain.
• Malpractice is instigated by the physician, not the caregiver. When a caregiver provides false history, we are not liable for the decisions we make based on it.
• When possible, try to maintain continuity of care for these kids.
• Caretaker blogs can provide a window into what is going on. Check it out: are they holding a bake sale for a transplant in a child who doesn’t need a transplant? Might see images on the blog, public sharing of medical information, contradictory statements on the blog, Wish foundations, money solicitations.
• Covert Video Surveillance is controversial. Is it safe/ethical to set a patient up for abuse? But without it, can you make a definitive diagnosis? May also rule out medical child abuse. If you use it, get Risk Management to set up a protocol. Must monitor 24 hours continuously, remember the bathroom! How are you going to respond if you witness abuse on camera?
• Overt video surveillance can discourage the concerning behavior, help resolve conflicting reports by family and medical team.
• Trust but verify. Get records, call colleagues who have seen the patient, review sibling charts.