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November 16, 2018

Although the number of children with elevated blood lead levels continues to decrease, lead exposure remains a problem in Minnesota.

The Minnesota Department of Health (MDH) Lead and Healthy Homes Program is planning to update its Childhood Blood Lead Clinical Treatment Guidelines for Minnesota and welcomes input from pediatricians who wish to help revise these guidelines.

The time commitment is four meetings with conference call lines available for those who wish to join remotely. The first meeting will be held Wednesday, November 28 from 6-8 p.m. Committee members will be asked to independently review and provide feedback on the current guidelines and background materials as well as feedback on the revised guidelines generated by this process.

If you would like more information about participating, please contact Kathryn Haugen with MDH as soon as possible at

November 5, 2018

My grandfather was a farmer in North Dakota who worked very hard from sun up to sun down. Along with the example of a strong work ethic, he instilled in me the significance of the privilege and duty to vote – even impressing this on me at a very young age. He loved to engage in a robust discussion of how elected public servants and their policies were impacting his day to day life, including the economy and the business of running his family farm. To this day I can’t imagine not voting. In turn, I have imparted this legacy onto my children who are now 20 and 23 years old. My children can tell you that their mom has repeated way too many times these past couple of months: “Make sure you get your flu shot and make sure you vote!”

This mid term election in Minnesota is pivotal. Hanging in the balance is our Minnesota governorship, both of our U.S. Senate seats, several very competitive congressional races, all state constitutional officers and the entire Minnesota House. It is with our voice as pediatricians and as voting citizens that we can participate in our democracy in a most meaningful way.

I recently checked in with Mary, a pediatrician in Wilmington, North Carolina asking in an email how she was doing in the aftermath of hurricane Florence. Mary and I were residents together. She has practiced pediatrics in Wilmington for over 30 years. These are Mary’s words: “Thank you for your concern. We are safe and powered up again but the tree damage in our neighborhood is just incredible. It will take months for this area to recover. Low lying inland property is still dealing with flooding. And then there’s all the people who live on the edge everyday who will fall over with this sort of thing. I always worry for the children”.

This couldn’t be said any better. I want to acknowledge how hard you work for children and families in your practice and communities because you “worry for the children.”

Lori DeFrance MD,FAAP
MNAAP President

By Christina Falgier, MD, Essentia Health St. Mary’s Children’s Hospital, Neonatology, Section Chair

While the number of infants with neonatal abstinence syndrome (NAS) has decreased in our NICU at Essentia Health St. Mary’s Children’s Hospital in Duluth, it remains a significant problem for our patients and their families.

In the past year, approximately 6 percent of our annual admissions required NICU care for treatment of NAS. This represents a decline from previous years, with a recent peak of 12 percent of our annual admissions. However, we remain significantly above our previous steady baseline of 1-2 percent of our annual admissions prior to 2010. Additionally, infants are often in the hospital for weeks if therapy with oral morphine is needed, and we have had many days in the past where infants with NAS accounted for 50 percent or more of our daily census.

We have worked to streamline the care of the NAS patient during the birth hospitalization. Newborns exposed to long acting opioids in utero, such as methadone and buprenorphine, now remain in the hospital for 4 days after birth to monitor for the development of significant NAS symptoms. This is done using a standardized scoring system. Parents receive support and instruction in how to care for their infant using positioning and holding techniques, strategies to minimize environmental stress, and other calming techniques by our NICU therapies team and nursing staff.

The infant is transferred to the NICU for initiation of oral morphine therapy if scoring criteria are met. The parents are encouraged to continue to provide care to their baby, including breastfeeding, if appropriate.

When morphine therapy is needed, it is titrated based on infant symptom scores. We have historically used the Modified Finnegan Scoring System. This system scores infants based on the comprehensive signs of withdrawal, which includes GI, CNS, and autonomic systems. The current trend in treatment is to focus on babies that have symptomatology that interferes with their ability to do what babies need to do, which is eat, sleep, and calm. Based on the recent literature, we are in the process of moving to the Eat, Sleep, Console (ESC) scoring system. The goals of the switch are to focus on maximizing non-medication management, thereby decreasing the number of infants that require oral morphine therapy. This approach recognizes that if infants can meet their basic needs by maximizing parental response to their symptoms, then oral morphine therapy is not needed. We expect to see a significant decrease in the number of patients needing NICU admission for oral morphine therapy and, consequently, in the length of hospitalization.

Upon discharge from the hospital, close monitoring of these infants continues with frequent follow-up with their primary care clinician, who continues to monitor weight gain and provides support for symptom management. We are also seeing these infants in our NICU Follow-up Clinic to monitor their growth and development, providing referrals for therapies and psychological support as needed. Many of these infants are placed in foster care at the time of discharge and the general feeling is that more of these parents are working on reuniting with their infants than we have seen in the past.

In addition to multidisciplinary care of the infant with NAS, our colleagues in OB/GYN have established a prenatal clinic at a local opioid treatment program, called ClearPath. This is a new program in 2018 with outcome data not yet available, but it has been well received and mothers report feeling better prepared to deal with their infant’s withdrawal symptoms.
One of the challenges we face in Duluth is how to provide specialty support to our rural physician and advanced practice colleagues. Our referral area is geographically large, covering the Arrowhead area of Minnesota to International Falls, Northwest Wisconsin, and a portion of the Upper Peninsula of Michigan. Ideally, many of these infants with NAS symptoms could be cared for at their birth hospital, but support for the physicians and staff is lacking. Telemedicine is currently being developed in our neonatology department to provide not only emergent/urgent support to the ill neonate, but also non-urgent consultations. Our goal is eventually to be able to provide care for the infant with NAS at their birth hospital, keeping the parents close to home and to their support system. Initial rollout to surrounding hospitals will begin this fall.

Ultimately, the success of this approach lies in whether we can put the parent-infant dyad (usually this is the mother) at the center of the care. Literature suggests doing so significantly decreases the need for medication therapy, decreases the total dose of morphine in the instances that medication is needed, decreases length of stay and costs of medical care, improves breastfeeding rates, improves parental feelings of bonding, and decreases stigma. Families affected by NAS deserve nothing less.

By Sheldon Berkowitz, MD, pediatrician at Children’s Minnesota and MNAAP president-elect

For me, it was the aftermath of the February shootings at Marjory Stoneman Douglas High School in Parkland, FL. It is not that I wasn’t concerned before by all the other shootings and hadn’t written many letters to the editor and participated in countless discussions on the topic of reducing gun violence. But three things happened after Parkland that changed me. The first was reading a powerful piece by a pediatrician who lives and practices near Parkland and whom I know from residency. The next was seeing how the students from Parkland and elsewhere took this on as their own responsibility to fix – without waiting any longer for adults to solve it. Finally, it was the March 2018 “March for Our Lives” rally at the Capital in St.Paul that I participated in with 20,000 others. There, we heard the despair of students and their call for change. All of these have combined for me to say enough is enough. It is time to try and make changes to reduce gun violence.

In this article, I will present practical ways that you can try to reduce gun violence. The suggestions will be grouped together in three areas: convincing yourself why this is important, what you can do in your exam room with your patients and their families, and what you can do to help make changes at a community level.

If you are going to become a leader in reducing gun violence, you need to not only understand the magnitude of the problem, but also feel motivated to make a change. Each of us have only so many hours in the day and we all have to decide which projects are important to us. Here are a few statistics that may help you to understand why reducing gun violence is imperative.

  • From Jan.1, 2018 through June 25, 2018, 1632 children aged 0-17 have been killed or injured by a firearm in the U.S.
  • Since the Sandy Hook School shooting in 2012, the number of children in the U.S. killed by gunfire is greater than the total number of U.S. soldiers killed overseas in combat since 9/11.
  • Almost 100 people (of all ages) die every day in the U.S. as a result of gun violence.
  • According to the CDC, in 2016, deaths by suicide or homicide due to firearms are among the 5 leading causes for ages 5 and older (including adults).
  • Between 2007-2016, more people died in the U.S. from firearm violence than all the combat deaths in World War II.

Death by gun violence in the U.S. is now considered a public health crisis. We need to start thinking about and devoting the same energy to preventing injuries and death by gun violence as we do for other public health issues, such as motor vehicle accidents, smoking and cancer. It is also not just a pediatric issue – but rather an issue that affects all of us, regardless of age. And if you need one more reason to get involved, it is the simple statement we have heard over and over from our young people since Parkland: No one else is doing it. If we, all of us, don’t do something – nothing will change.

Once you convince yourself that you need to do something, you then need to know what you can do as a clinician in your exam room with your patient and their family. I struggled for years to know what to say, to whom to say it and when to say it. We all are concerned with offending our patients/families by asking inappropriate questions. We may be concerned that our patients may wonder why I am asking them about guns in their home – do I ask everyone? Is it because of their skin color or ethnicity? For me, it has been important to make it clear to families that I am asking everyone about having guns or weapons in their home and I am doing it so that if there are guns or weapons, we can talk about keeping everyone safe in the home. As a pediatrician, I am primarily asking the parents of my patients, but for older children, I also ask them if there are weapons in the home. If you care for adults, you would obviously direct your questions to that individual. If a person responds that they do have guns in their home, I will then ask if they are kept locked up, unloaded and with the ammunition stored separately. In addition, if there are individuals in the house with any type of mental health problems, including but not limited to history of suicide, I will discuss how it is even more important not to have guns in the house in these situations.

In my practice, I have decided not to ask about guns and weapons in the home at each visit, but rather at certain well child visits (e.g. 2 years old as children are more able to get into things at home, again at 5 years old as they are in school and then again at 12 yrs old as they enter adolescence). I also bring it up if I am dealing with a patient with developmental issues or mental health issues or if there is a history of substance abuse or domestic violence, since individuals with these risk factors might be more at risk of causing harm – to themselves or others, if they had access to a gun. Finally, I make it a point to discuss this with my patients and their families myself – not simply to have my nurse ask about it. This way, I believe I impart additional importance to this topic.

Last, I want to give you ideas of what you can do on a community level. The first is to participate in marches and rallies to stop gun violence. I have made a conscious decision not to make this an issue about guns, but rather, about gun violence. For me, the issue is not whether a person owns a gun, but rather are they being safe with it to hopefully prevent gun violence. I am also aware that as a society, we need to work at changing the culture which sees guns as a solution to too many problems. Next, write letters and op/ed pieces to your local newspapers. Don’t get discouraged if they aren’t printed. Keep sending them and hopefully the next one will. Remember, your voice as a clinician is strong and respected. Use it to make a point. Next, talk to your state and national legislators to find out how they stand on the issue of reducing gun violence. Let them know that you believe this to be a high priority. If you find they aren’t supportive of legislation to reduce gun violence – consider voting for other candidates that will. And lastly, be willing to financially support organizations that are working on a national level to reduce gun violence (e.g. Brady Campaign to Prevent Gun Violence, Americans for Responsible Solutions, Everytown For Gun Safety).

While reducing gun violence in our society may seem to be an overwhelming project to accomplish, there are ways we can join together to help make it happen. Connect with the professional medical organizations that you belong to and get out and join with your community when there are rallies to attend. We can make a difference.

Reprinted with permission. MetroDoctors Sept/October 2018.

By Mark Mannenbach, MD, Assistant Professor of Pediatric and Adolescent Medicine at the Mayo Clinic College of Medicine, Division Head of Pediatric Emergency Medicine, and Vice Chair of Education in the Department of Emergency Medicine

As a child, I remember playing games of hide-and-go-seek with family and friends. In the fall, we had great fun playing in the leaves and the cooler temperatures with a relief from the hot and humid days of summer. I can still hear the words, “Ready or not, here I come!” echoing in our local apple orchard as we played together.

Unfortunately, ready or not, the days of fall will also bring the challenges to care for infants and young children with bronchiolitis. In the January 19, 2018 issue of MMWR, Rose EB, et al reported nationally, across three RSV seasons, lasting from the week ending July 5, 2014 through July 1, 2017, the median RSV onset occurred at week 41 (mid-October), and lasted 31 weeks until week 18 (early May). The median national peak occurred at week 5 (early February).

In my experience, I have found the care of these patients to often be very frustrating given the limited successful treatment options available. I can already envision my need to spend extra time with families to explain the natural course of this disease process which is nearly always longer than anyone would like to see. I will worry and be unsure about the children I send home from our emergency department. I will wonder how they will be doing and hope that the illness will not be too much for families to handle.

What can we do to best prepare to care for these children? A tool I will be using to remind me of best practices is the 2014 American Academy of Pediatrics Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. The most important aspect of this guideline is the emphasis on diagnosis based upon history and physical exam. I will be paying close attention to infants with respiratory symptoms to determine the severity of their illness as well as the potential for other diagnoses. Through careful attention to the child’s respiratory rate, work of breathing, oxygen saturation, and hydration status, I hope to provide reassurance to most of the families challenged to care for these sick infants.

I will be very tempted to obtain chest x-rays and blood work that will most often have little positive impact for the care of these children. These diagnostic studies should be reserved for children with concerns for other diagnoses such as myocarditis. I will need to be diligent to look for organomegaly in all of the infants with poor feeding, tachypnea, or retractions. Many false positive results like the “patchy infiltrate” found on the chest x-ray will lead to my inappropriate use of antibiotics and inappropriate expectations of their value for these families.

I will be tempted to offer other treatments such as bronchodilators or steroids despite the lack of evidence supporting their efficacy. If the child does not respond to a bronchodilator treatment in our department, I will not recommend continued use of this therapy at home. The AAP policy statement provides its strongest recommendation in its emphasis NOT to administer corticosteroids to infants with bronchiolitis. I will have honest discussions with families regarding the lack of treatment options and emphasize the value of nasal suctioning as well as smaller and more frequent feedings. I will emphasize my willingness to re-evaluate these patients knowing the difficulty in assessing them over the typical two to four week duration of the illness.

For those children with increased work of breathing and the need for hospitalization, I will be utilizing the high flow nasal cannula technology we found so successful last season. Just as Schibler A, et al found a change in their ventilatory practice, including a reduced need for intubation in their 2011 study in Intensive Care Medicine, we also saw improvements in our care of hospitalized children when using this helpful tool.

I will be relying upon these studies to guide me through the busy and hectic days ahead in my practice. I hope they help identify those children who require more aggressive care as you seek to deliver consistent and quality care for the children.

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