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Posts from the ‘News’ Category

Multidisciplinary liver clinics coming to Children’s of Alabama

By Dr. Reed Dimmitt, Director, Division of Pediatric Gastroenterology
David E. Dixon Endowed Chair in Pediatric Gastroenterology

With the addition of two more physicians in the coming months, Children’s of Alabama will soon be able to expand the care we provide to pediatric patients with liver disease.

Gillian Noel, M.D., is finishing her fellowship at Emory and will join us soon. Within a few months, we will welcome Mike Leonis, M.D., from Cincinnati, Ohio, as the director of our new pediatric liver center. Both are board certified in pediatric hepatology and will be the first two such certified physicians in the state.

These staff additions are the realization of a longtime goal to establish a liver center benefitting children across Alabama. We will be able to increase the number of liver transplants performed on children around the state, allowing physicians to refer more patients to Children’s instead of Vanderbilt and Emory. We will also expand specialized clinics for other conditions such as liver disease associated with cystic fibrosis, pediatric fatty liver disease and metabolic diseases.

These clinics will be multidisciplinary, including nutrition, genetics, pulmonary, psychology and child life. When patients come in from around the state, they will be able to see everyone at one time without making multiple appointments. Even local patients will find the process to be more efficient, requiring less time off school and work to get the care they need.

In addition to helping simplify the process for patients and their parents, these multidisciplinary clinics have proven to improve outcomes. The collaborative nature of the clinics will enable us to discuss cases from our own specialty while developing a transdisciplinary approach to the care of patients. We are able to care for the total patient, not only addressing their physical needs but also how their condition affects them emotionally and developmentally in a programmatic manner.

In conjunction with the liver clinics, we are planning an expanded pediatric obesity program so we can have interventions with these children as well.  The clinics will partner as needed to provide the full scope of care for all our patients.

With the addition of these doctors Leonis and Noel, we’ll have three physicians dedicated to liver disease and 13 faculty members in our group. We are pleased to welcome them in our efforts to continually improve care through the Division of Pediatric Gastroenterology at Children’s.

Advances in genetic testing result in more effective diagnoses

By Bruce Korf, M.D., Ph.D.
UAB Professor and Chair, Department of Genetics

Dr. Bruce Korf

Dr. Bruce Korf

Birmingham pediatricians now have expanded options for easily accessing genetic expertise and testing, with the recent opening of a genetics clinic at Children’s of Alabama.

For physicians, it’s important to consider when to refer a patient for genetic evaluation, especially for those patients who were unsuccessfully evaluated in the past.

Most pediatricians have experience in recognizing children with congenital malformations, intellectual disability or developmental delay that may have a genetic component. When those patients receive a diagnosis, parents have at least a minimum understanding of what is happening with their child, how best to manage that child, and whether it may occur in their other children.

Unfortunately, in the past a large percentage of patients went undiagnosed, even with an evaluation, putting the parents of young children on a seemingly endless quest to decide how best to manage their child’s medical conditions.

A great deal has changed relatively recently, however, and new tools, including microarray and genome sequencing, are available, which means we have the ability to achieve diagnoses that were not available to us before. So if you have been following a patient with medical issues that you suspect are genetic in origin, and that patient has not had genomic sequencing, it is likely time to refer them to a clinic for retesting.

One of the new tools available to us is microarray testing, which gives us the ability to make a definitive diagnosis at much higher rates than we could expect just a few years ago. Older tools would enable us to see the big picture, much like a satellite picture of the earth. Today’s tools are more like the Google Earth app, allowing us to zoom down to street level, so we can see detail on the genome that was previously impossible.

Genome sequencing is another tool that has improved our ability to diagnose. The cost for the test is dropping dramatically. Once costing $100 million per run, the test and analysis are now in the $6,000 to $7,000 range. While that is still a lot of money, compared to the cost of other medical tests it is actually fairly reasonable.

Microarray can be expected to pick up the genetic cause of 15 to 20 percent of autism spectrum disorder cases. Genome sequencing can pinpoint a diagnosis in about 30 percent of cases of children with intellectual disability, autism spectrum disorder, or congenital anomalies. Putting the two tests together means we can expect a definitive diagnosis in 50 percent of the cases presented to us. Considering that even five years ago we could only expect to diagnose about 5 percent, that’s a tremendous step forward in a very short time.

At one time, a genetic diagnosis relied on the physician’s ability to predetermine the underlying problem in order to test for that particular disorder. Today, we are able to diagnose based on the tests, even finding conditions so rare that no physician would have considered testing for them in the past.

And when a diagnosis still eludes us initially, we can now share results and experience with other geneticists around the world, enabling us to establish a diagnosis we may not have been able to make alone.

In short, the tools we have at our disposal now have never been more powerful, so if you are a pediatrician following a patient and have been unsuccessful getting a diagnosis in the past, it is worth taking a second look now.

Of course, putting a name to a disorder is only part of the battle. The next step is knowing how to treat a patient’s condition, and we have made progress in that area as well. Certainly, we can’t say we are able to treat every condition we see, but once we figure out which gene underlies the condition, we then begin to ask why the change in the gene causes the problems it does. And we are gradually figuring that out and identifying drugs that improve quality of life.

With such dramatic and rapid developments in the field of genetics, there are many implications to be considered as we move forward. There is increasing discussion that perhaps everyone should have their genome sequenced, as the cost goes down and the feasibility of the testing goes up. This emerging area will have to be addressed carefully. Between 1 to 3 percent of people whose genes are sequenced will discover a condition they did not realize they had or were at risk for, and virtually everyone can learn how their body manages specific medications or can become aware of risk factors for common diseases. But there are also questions about what options exist to manage these risks once they are known. We will have to proceed carefully in light of our increasing technological abilities.

For patients with known medical problems that can be addressed with genetic evaluation, however, there are ample reasons to make referrals and try to determine a diagnosis that can improve quality of life for the patient and their family.

We have a new clinic integrated into Children’s, with access to parking and other specialists, making genetic evaluation more convenient for parents than ever before. In addition to our Children’s clinic, we have a prenatal diagnosis program through ob/gyn and maternal fetal medicine at UAB, and our newest clinic at Kirklin Clinic for adults.

If you have questions about referring a patient to one of our Birmingham area clinics, please call (205) 934-4983 to discuss.

 

Talking to Children about Current Events

In this day and age, children are exposed to violent and disturbing topics on the news. Reports on natural disasters, shootings and terrorist attacks can be confusing to a child, teaching them to view the world as a scary place. But there are benefits in raising children who are aware of what’s going on in the world.

Dr. Dan Marullo is a Pediatric Psychologist at Children’s of Alabama. He says whether parents should share current events with their child depends on the age and developmental level of the child.

“It definitely depends on the age of the child,”Dr. Marullo says.”Kids of different ages have different needs and different developmental levels. I think regardless of the age of the child, one thing to keep in mind is children learn how to cope with adversity by watching their parents.”

Dr. Marullo says the first thing for any parent to do is to check how they’re coping with the news or what’s going on around them. Parents should keep things in perspective and help children to understand that television has a way of shrinking the world and bringing it into our living rooms. A child watching a news story about an earthquake in California may lose sleep thinking the same thing could happen in Alabama.

Dr. Marullo says younger children, toddlers and preschoolers probably don’t need to see a lot of the bad things on television. “They would have a very hard time managing that so minimizing exposure would be important,”he says.

For school age children, the approach should be different. “For older children, they’re probably going to come across media on their own,”Dr. Marullo says. “It’s important for parents to have a dialogue with their child. Watch the media with them, watch the news with them. It certainly makes a great topic of conversation for dinner time. That way parents can monitor their child’s exposure but also answer their questions and model their own behavior.”

For parents of school age children, keep in mind a little exposure to adversity is beneficial. “The way we learn to deal with adversity is by experiencing adversity,”Dr. Marullo says. “That doesn’t mean we expose our children to everything, but a little exposure with good guidance from a parent is crucial for their healthy development.”

Parents may also want to talk to their child about what can be done to help in a tragic event. Children may gain a sense of control and feel more secure when they think of ways they can help those affected by the tragedy.

If a child seems overly anxious, parents should encourage a break from television. Read, play board games or go outside. Look for opportunities to bond as a family and put things in perspective.

Potentially Life-Changing Changes Afoot for Children with Food Allergies

Prescott AtkinsonDr. Prescott Atkinson is Director of Pediatric Allergy and Immunology at Children’s of Alabama and a Professor of Pediatrics at UAB. He is board certified in pediatrics, as well as allergy and immunology. He received his MD/PhD from Emory University in 1987, completed his pediatric residency at Georgetown University and completed a fellowship in allergy and immunology in 1992 at the National Institutes of Health. He joined the UAB faculty in 1992.

New medical research is ushering in big changes in how doctors think about food allergies and the way they will be treated in the near future.

The turning point came last year with the LEAP (Learning Early About Peanut) Study published in the New England Journal of Medicine. This five-year study showed that avoidance of food allergens by children at risk for food allergy is often the wrong strategy, which, of course, is contrary to something doctors had been advising for decades.

Data in the study were so powerful that doctors have already changed the advice they are giving to parents with children pre-disposed to food allergies. Meanwhile, the American Academy of Allergy and Immunology together with the American College of Allergy and Immunology are working with the National Institutes of Health to firm up a position paper to formalize these new recommendations.

Researchers with the Immune Tolerance Network conducted the LEAP Study by enrolling hundreds of infants from 4 to 11 months old who were predisposed toward peanut allergy. Children in the study were not yet sensitized to peanuts, but they had the family history plus a strong sign of developing food allergies—severe eczema. It is likely that eczema is associated with food allergies because breaks in the skin allow allergens to sensitize children.

Children in the study were divided into two groups. One group was fed peanuts daily, and the other group strictly avoided peanuts. After five years, researchers looked at which children had become allergic to peanuts and which had not. Only about 2 percent in the group that was exposed repeatedly to peanuts developed a peanut allergy. By contrast, nearly 14 percent of the children in the peanut avoidance group developed allergies. We seldom see differences like that in human studies. It was striking and statistically significant.

So there’s a new recommendation for infants at risk for food allergies. We can do testing, of course, and if they are not already allergic and are able to tolerate the food allergen, we are recommending that they should be fed the food frequently. That is the opposite of the previous recommendation, which warned parents to avoid exposing children to potentially allergenic foods for as long as possible.

For children who have already developed food allergies, some hopeful trials are underway that may offer protocols for desensitization. This approach would be similar to how allergists desensitize people who are allergic to pollen. Pollen desensitization is usually done with injections, but that’s dangerous for people with food allergies. With food allergies, the desensitization would be attempted with a graded, oral protocol. These are being developed for egg, nut and peanut allergens.

Patients would be challenged in clinic to see how much of an allergen they can tolerate. Then, a patient will consume that amount daily, possibly increasing that amount according to how they fared in subsequent challenges. Researchers have found that food tolerance gradually increases in most patients. In about a third of cases, patients can become completely desensitized, even those who had severe allergic reactions. A majority of patients are desensitized to the point that they can tolerate a small amount of allergens safely. That substantially lowers risks for severe, life-threatening allergic reactions.

Obviously, there is great interest in these protocols since about 5 percent of children have food allergies. We expect to have the new protocols available in general clinical use in the not-too-distant future.

This changing paradigm about food allergies is making doctors take a second look at why food allergies have been increasing. Most likely doctors have been contributing to this pattern by giving new mothers the wrong advice. Until the LEAP Study, we just didn’t have the data to make a good scientific recommendation, so we depended upon logic and common sense. We turned out to be wrong.

I strongly suspect that the incidence of food allergies in children will begin to subside after new recommendations take effect.

It’s also worth mentioning that there are some new biologic drugs in the pipeline that are promising for children with severe allergic asthma. We’ve been using one of these injection drugs, Xolair (omalizumab), for about a decade. Now, new ones will be available soon and some are effective at controlling severe asthma and even severe hives.

These new drugs will be expensive, but for people who are often hospitalized with severe asthma, they may be cost-effective and could certainly improve their quality of life.

Children’s of Alabama Pediatric Spondyloarthritis Clinic

Matthew StollMatthew Stoll, M.D., Ph.D., MSCS, treats pediatric rheumatology patients at Children’s of Alabama. Dr. Stoll is also an associate professor in the University of Alabama at Birmingham Department of Pediatrics, Division of Pediatric Rheumatology.

The Division of Pediatric Rheumatology at the University of Alabama at Birmingham (UAB) and Children’s of Alabama was created in 2007 in response to a great need for pediatric rheumatic care in the state of Alabama, the largest state population without a pediatric rheumatologist at the time. A partnership between UAB, Children’s, the local chapter of the Arthritis Foundation and the greater Birmingham community helped to establish new clinic space, the creation of an endowed chair in Pediatric Rheumatology and ongoing support for the growth of the division.

The Pediatric Spondyloarthritis Clinic at Children’s of Alabama is devoted to the clinical care and research of children diagnosed with juvenile spondyloarthritis. The clinic was established in March 2014. Today, more than 150 children are being treated for spondyloarthritis at Children’s.

According the Arthritis Foundation, nearly 300,000 children — from infants to teenagers — in the United States have some form of arthritis. Juvenile idiopathic arthritis (JIA) is the most common type of arthritis in children, in which the immune system mistakenly attacks the body’s tissues, causing inflammation in joints and potentially other areas of the body.

Spondyloarthritis is one of six types of JIA. It involves inflammation and tenderness in areas where the ligaments and tendons attach to the bones, accompanied by pain and swelling in the joints. In some cases, spondyloarthritis primarily affects the spine. Some forms can affect the peripheral joints, primarily — but not exclusively — those in the legs. Typical symptoms are low back pain and stiffness, joint swelling and pain in areas such as the Achilles tendon.

In addition, some patients with spondlyoarthritis may experience inflammation in parts of the body other than the joints. My research has focused specifically on the links between inflammation in the gut and in the joints of children and adults with spondlyoarthritis.

Children who are referred to the weekly Pediatric Spondyloarthritis Clinic benefit from the continuity of care from a team of doctors with targeted clinical expertise in this area. While there are few effective therapeutic options in the management of spondlyoarthritis, current treatment regimens include conventional therapeutic drugs, as well as newer biologic therapies.

While the exact cause of juvenile idiopathic arthritis, including spondlyoarthritis, remains unknown, clinic patients can participate in our ongoing research that will help advance understanding of pediatric spondyloarthritis.

The Pediatric Spondyloarthritis Clinic also provides screening and treatment specifically for temporomandibular joint arthritis (TMJ), a joint frequently ignored in children with JIA as a whole.

Children’s of Alabama Expands Child Maltreatment Services

Dr. Michael A. Taylor is director of the newly created Division of Child Abuse Pediatrics at Children’s of Alabama and professor of Pediatrics at the University of Alabama at Birmingham (UAB). He is board certified in general pediatrics and child abuse pediatrics. He has extensive experience in providing medical services and support to abused and neglected children.

Michael Taylor

Michael Taylor

Child maltreatment is a significant public health problem in Alabama, as it is in all states. The most recent statistics available show there were nearly 20,000 reports of child abuse or neglect during 2013 in Alabama, with about 9,000 children confirmed as victims. And that is just the tip of the iceberg, with cases often going unreported and under-reported. Studies indicate that about 1-in-8 children nationally are victims of serious abuse or neglect by the time they reach their 18th year.

Children’s of Alabama is responding to this widespread problem with the creation of a new Child Abuse Pediatrics Division. It will expand the current services provided by the Children’s Hospital Intervention and Prevention Services (CHIPS) Center.

Child maltreatment encompasses a wide variety of conditions, including physical abuse, sexual abuse, caregiver fabricated illness (previously referred to as Munchausen syndrome by proxy), neglect and psychological/emotional abuse. Thus, child abuse pediatricians must work within medical, child welfare, law enforcement and judicial systems. We are often called to testify in court.

The CHIPS Center has provided forensic medical evaluations, psychosocial assessments, play therapy, counseling, case management services, prevention education, court support and expert court testimony in cases of suspected child abuse. Drs. Melisa Peters and David Bernard have provided medical care to maltreated children at Children’s for many years through the CHIPS Center and the Emergency Department (ED); however their availability to provide care has been stretched between these two services.

The UAB Department of Pediatrics and Children’s created the new Division of Child Abuse Pediatrics along with a full-time director, a position I am honored to hold. This division will provide oversight for existing child maltreatment services being offered through Children’s and UAB. This includes The CHIPS Center, the pediatric sexual assault nurse examiner (P-SANE) program, which operates out of the ED, and other physical abuse and neglect services. Drs. Bernard and Peters have invaluable experience serving maltreated children and are both board certified in general pediatrics, child abuse pediatrics and pediatric emergency medicine. They will continue to play key roles with Dr. Bernard as the medical director for the SANE program and Dr. Peters as the medical director for The CHIPS Center.

These actions are moving Children’s to the advanced tier of services for child maltreatment. Over the next five years we will move to develop at Children’s a “Center of Excellence,” the top tier as defined by the Children’s Hospital Association (CHA). This expansion will involve an extended regional presence, larger child protection teams, an accredited fellowship, research initiatives and increased family intervention and prevention services.

I have a special affection for Children’s, having served my pediatric residency here and serving as a long-time pediatrician at the University Medical Center in Tuscaloosa. And I am passionate about providing medical services to our most vulnerable children.

Children’s has a Level 1 Trauma Center, a Burn Center, a large Emergency Department, a nationally known neonatal intensive care unit, pediatric cardiovascular services, the Alabama Center for Childhood Cancer and Blood Disorders and many other top organizations within top organizations. Children’s is now becoming a leader in the recognition, management and prevention of child maltreatment.

Not just the joints—treating Juvenile Arthritis

RavelliDr. Angelo Ravelli is considered an international expert in the field of pediatric rheumatology, which affects 50,000 kids across the country. An Italian native, he is traveling halfway across the globe to present his knowledge and research findings with the medical staff here at Children’s of Alabama. We asked Dr. Ravelli what he hoped to share with our clinicians that would in turn help the families they serve.
Here is what he had to say:

Q. What is the one thing you wish people outside of the medical field knew about Juvenile Arthritis?
A. In my view, people should know that although there has been an enormous progress in the care of children with JIA [Juvenile Idiopathic Arthritis] in the last decade and that frequency and severity of permanent disease-related damage has diminished markedly, this illness still causes a considerable burden to children and their families, owing to its protracted course, tendency to flare after treatment discontinuation, potential to induce pain and functional limitations and impact on quality of life related not only to clinical symptoms, but also to the need of long-term administration of medication therapies.

Q: What drew you to pediatric rheumatology?
A: I chose to join the general pediatrics residency program at the University of Pavia, Italy, in 1981, just when the rheumatology program was starting. I then became a pediatric rheumatologist by chance, because the chairmen of the Pediatric Department assigned me to that program. Then, I fell in love with this subspecialty and kept practicing it for the rest of my medical career.

Q. What is your biggest hope for parents and families who are dealing with JIA on a daily basis? Do you think that one day there will be a cure?
A: Nowadays we are able to reach remission or, at least, a satisfactory control of disease activity in most, if not all, children with JIA. In my opinion, the priority in daily clinical care of these patients is the ability to predict and prevent disease flares, which are quite common, particularly after treatment ends. I’m sure that one day there will be a cure for JIA. However, it is currently not possible to foresee when this will happen.

Q. Any comments on the Rheumatology program at Children’s of Alabama?
A. I know that the Rheumatology program at Children’s of Alabama is outstanding and is one of the most active and renown in the US. I know personally Drs. Cron and Beukelman, who are both internationally well recognized and respected authorities in the field. Dr. Cron is the co-principal investigator of the multinational project that has recently led to the development of the new classification criteria in systemic juvenile idiopathic arthritis. He has played and is still playing a fundamental role in ensuring the success of the initiative.

If you are interested in hearing Dr. Ravelli’s presentation, you can view the event live at noon on Thursday, Nov. 13 at http://www.childrensal.org/cme or watch the recorded version afterwards.

Children’s expanding, improving services for children treated for cleft palates and lips

Dr. John GrantBy Dr. John Grant

During my first year at UAB and Children’s Hospital about 16 years ago, I performed about a half dozen operations to correct cleft lips and a couple of surgeries to correct cleft palates. Last year—along with my partner, Dr. Peter D. Ray—our team performed about 200 operations. This phenomenal growth in our clinic has been accompanied by improved quality.

We use advanced techniques along with a comprehensive team approach that provides care well beyond the operating room. For example, within the past decade, pediatric plastic surgeons have learned to correct underlying muscles in cleft lips and palates, thus providing a much more natural look and better speech for our patients. The face is dynamic, and these new techniques lead to a broader range of facial expressions and better speech control. Of course, we usually work with young patients, but there is an enormous opportunity to improve outcomes for older children and even adults who underwent cleft surgeries before these new techniques were widely used.

Due to our growth, Children’s now houses one of the nation’s busiest clinics for treating cleft lips and palates. We add about 150 new patients annually, and follow them through adolescence. We are excited about our upcoming move into larger quarters. The area that previously housed the emergency department in Children’s McWane Building has been renovated and will nearly double our space. We hope this makes us more efficient and enables us to shorten waits in our clinic for children and their families.

We already offer a full-service program that is staffed with experienced health care professionals, such as audiologists, speech-language pathologists and registered nurses as well as specialized physicians and dentists. They’ve seen hundreds of patients, and there’s a cumulative knowledge base. Our staff has realistic expectations about how children heal, how much pain they may or may not have and airway issues for babies versus adults.

We are excited about the launch of our new international fellowship program. For many years, American doctors have traveled to developing countries where they quickly perform operations for cleft palates and lips. Unfortunately, there is often a lack of follow-up care, and many patients go untreated. We want to educate doctors from these countries so they can establish their own full-service clinics that will provide more thorough and consistent care. The first fellow will be coming this summer from Ghana, West Africa, for 11 months of training, and another will come next year from Egypt. We are hopeful that they will become the teachers for the next generation of doctors in their countries and make it possible for children in those places to have full-time, quality follow-up and coherent planning, instead of care based on chance.

Additionally, we are improving our techniques for conditions other than cleft lips and palates. One service line we want to increase is a technique called tissue expansion. It’s been used a lot in secondary burn reconstruction. But we are also using it for children with giant congenital nevus, or dark patches of skin, often on the face or scalp. We surgically place flat balloons under adjacent, normal skin, and families are taught to slowly inflate these balloons over weeks so a child’s skin is stretched. Then, the patient returns to the hospital for an operation that utilizes the stretched skin to replace discolored skin, restoring normal tissue. We have enhanced this service line with the help of Dr. Bruce S. Bauer of Chicago, a pediatric plastic surgeon who is renowned for his refinement and application of this technique. It’s low risk for the patient and requires little time in the hospital.

All this work is extremely rewarding for our team. Seeing families get their babies back after a cleft operation is an occasion that many parents tell us is nearly as joyful as giving birth.