Pediatric Perspectives Summer 2009 - Cleveland Clinic

INSIDE
Puzzler: Infant with Low
Sodium, Weight Loss 4
Key Crohn’s Disease Study
Conducted Here 5
Transcatheter Closure
Reduces Risks of
Coronary Fistulas
Story on page 2
Nomograms May Increase Donor
Kidney Longevity 6
Arthroscopy Relieves Femoroacetabular
Impingement 7
Area's Largest Heart Team
Partners with Pediatricians 8
Image of the Issue 10
Treating Cyclic Vomiting
Syndrome 11
Endoscopic Resection Safe,
Effective for CNS Tumors 12
Pediatric Perspectives
A Physician’s Newsletter from Cleveland Clinic Children’s Hospital | Summer 2009

Dear Colleague:
While it’s been a challenging year for healthcare
institutions, I am pleased to report that Cleveland
Clinic Children’s Hospital continues to provide
excellent, comprehensive services to the community,
the region and beyond.
We welcome four pediatric cardiologists — Drs.
Alex Golden, Fran Erenberg, Ernest Siwik and
Kenneth Zahka — to what was already the largest,
most experienced team in the region. They will
work closely with Dr. Constantine Mavroudis,
respected Chair of Pediatric and Adult Congenital
Heart Surgery. Dr. Mavroudis recently recruited
surgeon and investigator Dr. Marshall Jacobs as
Director of Clinical Research.
We are expanding our general surgery staff to five
with the addition of Dr. Federico Seifarth from
Miami Children’s Hospital in Florida, a specialist
in the surgical care of newborns.
Our facilities and operations are growing as well.
We are establishing a unique Pediatric Cardiac
Rehabilitation Program at our Shaker Campus,
have expanded our Pediatric Hematology/
Oncology Unit, are adding cardiac inpatient beds
and expanding our Pediatric ICU. Next year, we
will open a Special Delivery Unit to streamline the
management of complicated pregnancies and
deliveries, and facilitate immediate newborn care.
Finally, please know that any patients you guide
to us will be in excellent hands. We ranked among
the “Best Children’s Hospitals” for 2009 in eight
of 10 specialties in U.S.News & World Report. Our
Pediatric Neurology and Neurosurgery programs
again ranked No. 4 (best in Ohio), while our Digestive
Disease, Heart and Heart Surgery, Kidney
Disorders, Orthopaedics and Urology programs
claimed the highest rankings in Northern Ohio.
More than 80 of our staff are also listed as “Best
Doctors in America.”
We look forward to continued collaboration with
you, and invite your comments and questions.
Sincerely,
Robert Wyllie, MD
Calabrese Chair of Pediatrics
Chairman and Physician-in-Chief, Pediatric
Institute & Children’s Hospital
wyllier@ccf.org
Sophisticated Catheter Interventions
Reduce Risks of Coronary Fistulas in
Childhood, but Follow-up Essential
By Lourdes Prieto, MD
A continuous murmur on cardiac examination is almost
always due to a patent ductus arteriosis. However, in rare
cases it results from another abnormal vascular connec-
tion: a fistula from a coronary artery to another chamber,
usually on the right side of the heart. Fistulas vary a great
deal in size and anatomy, and are typically asymptomatic.
It is clear that not all fistulas should be closed. Most would
agree that small fistulas that are silent on cardiac exami-
nation and are not associated with enlargement of the cor-
onary artery from which they arise do not require closure.
However, when fistulas are large, congestive heart failure
can develop during infancy. Other complications —
including angina, myocardial infarction, congestive
heart failure, arrhythmias, endocarditis and progressive
dilation, with rare reports of spontaneous rupture — may
also arise during childhood. Thus, elective closure is
typically recommended for children with larger fistulas.
Closure was traditionally performed surgically before the
advent of transcatheter techniques. Today, closure can be
accomplished in more than 90 percent of patients in the
catheterization laboratory using different devices. How-
ever, a high level of technical expertise is required.
Not all murmurs are due to a patent ductus
Three years ago, 10-year-old Mary Fuerst was referred to
Cleveland Clinic Children’s Hospital when her pediatri-
cian detected a continuous murmur incidentally during a
visit for conjunctivitis. The 7-year-old had a 2-3/6 continu-
ous murmur, loudest slightly to the right of the mid-left
sternal border — not the typical location for a patent
ductus.
An echocardiogram demonstrated moderate dilation of
the proximal right coronary artery, with a fistula arising
ON OUR COVER: Ten-year-old Mary Fuerst loves fast-pitch baseball
— as a pitcher, outfielder and batter. But three years ago, she was
often too tired to keep up with her peers. When her pediatrician
detected a heart murmur during a routine visit, Mary was referred to
our Center for Pediatric and Congenital Heart Diseases. Instead of a
patent ductus arteriosis, a large coronary fistula was discovered. After
a sophisticated catheter procedure to close the fistula, Mary was “back
to her old self,” reports her mother, Molly Fuerst.
Page 2 | Pediatric Perspectives | Summer 09 | Cleveland Clinic’s toll-free physician number is 800.553.5056

from it and feeding an aneurysmal sac that appeared to
empty near the region of the SVC-RA junction.
New application for closure device
The procedure, led by Larry Latson, MD, began with car-
diac catheterization, which confirmed the echocardio-
graphic findings. A wire within the catheter, positioned in
her proximal right coronary artery, was advanced across
the fistula and into the right atrium.
After close examination of the anatomy, we decided
to deliver a closure device from the venous side to the
fistula. A “wire rail” was created from the arterial to the
venous side by snaring the wire in the right atrium and
bringing it outside the body, allowing a delivery sheath to
be advanced from the venous side to the fistula. We be-
lieved the Amplatzer patent ductus closure device would
work well for this fistula because of its configuration.
We advanced it into the delivery sheath and placed it in
the fistula. Before releasing it, we made sure the device
did not interfere with flow into the normal right coronary
artery, was in stable position and would not migrate, and
eliminated flow through the fistula. Multiple contrast
injections via the catheter in the right coronary artery
confirmed appropriate positioning.
The device was then released and remained in excellent
position. Mary was discharged the following morning.
She is followed on an outpatient basis and has had no
cardiac symptoms. Follow-up echocardiograms have
demonstrated no residual flow through the fistula and
Visit clevelandclinic.org/peds
Left: Selective angiogram in right coronary artery (RCA) shows a dilated proximal
RCA (solid black arrow) giving rise to a fistula that continues as a very large,
aneurysmal sac before draining into the right atrium (dotted black arrow). Note
normal-caliber RCA distal to the fistula (white arrow).
Center: A wire (black arrow) is advanced from the coronary artery through the
fistula into the right atrium, then caught by a snare (white arrow) to pull it down
into the femoral vein and out of the body. The closure device’s delivery sheath can
then be advanced over this wire from the femoral vein to the fistula.
Right: Selective angiogram in the RCA shows closure device occluding the fistula
(black arrow); the aneurysmal sac that had drained into the right atrium is no
longer seen. Flow into the RCA distal to the fistula remains normal (white arrow).
normal flow into the right coronary artery. The proximal
right coronary artery, though still larger than normal, has
decreased in size since the fistula was closed.
Follow-up is key
It is increasingly evident that some patients develop com-
plications after surgical or catheter closure. The most
significant are thrombosis of the dilated coronary artery
segment proximal to the closure site and stenosis of the
coronary artery distal to the closure site, either of which
could result in myocardial ischemia or infarction.
Closure during childhood may decrease these risks by
halting progressive dilation and perhaps allowing at least
partial involution of the vessel. This is particularly true
for patients with fistulas originating very distally in the
coronary artery, or with severe dilation of the coronary
artery branches proximal to the closure site, as they may
be at greater risk for thrombosis.
The long-term course of patients following fistula
closure has not been well-studied, due to the small
number of patients at any one institution and the lack of
standardized follow-up. We are spearheading a national
registry of patients with coronary artery fistulas to better
understand this rare lesion and answer important
questions.
To refer patients to interventional cardiologists in our Center for
Pediatric and Congenital Heart Diseases, call 216.445.5015. Dr.
Prieto may be reached at 216.445.3865 or prietol@ccf.org, and
Dr. Latson at 216.445.6532 or latsonl@ccf.org.
| Pediatric Perspectives | Summer 09 | Page 3

Pediatric
Puzzler
Cleveland Clinic Children’s Hospital
Offering Pediatric Care throughout Northeast Ohio
Cleveland Clinic Children’s Hospital,
Main Campus
Cleveland Clinic Children’s Hospital,
Shaker Campus
Cleveland Clinic Regional
Hospitals:
Fairview Hospital
Hillcrest Hospital
Huron Hospital
Lakewood Hospital
Marymount Hospital
Cleveland Clinic Family Health
Centers:
Avon Pointe
Beachwood*
Brunswick
Elyria
Independence
Lorain*
Solon
Strongsville*
Willoughby Hills
Wooster
*also an Outpatient Surgery Center
For the most up-to-date list of locations, or for more information about
staff and services at each site, visit clevelandclinic.org/peds.
Services for Patients
By Douglas Rogers, MD
Case History: A 6-week-old male infant presented to his pediatrician with a
3-week history of dramatically declining oral intake, emesis and weight loss.
The mother reported that feeds took more than an hour. The baby was awake
and alert, though pale and thin at 4.1 kg. Examination revealed sunken eyes
and a disconjugate gaze; dry mucous membranes; and a grade 2/6 systolic
murmur. The baby had a head lag, did not focus on faces and had generalized
weakness. The rest of the exam was normal. Initial laboratory studies revealed
low sodium (114/mmol/L) and high potassium (7.4 mmol/L) levels.
Turn to page 10 for diagnosis
Medical Concierge Complimentary assistance for out-of-state
patients and families
Global Patient
Services
Appointments
Call 800.223.2273, ext. 55580, or email
medicalconcierge@ccf.org
Complimentary assistance for national and
international patients and families
Call 001.216.444.8184 or visit
clevelandclinic.org/gps
216.444.KIDS (5437) or 800.223.2273.
Pediatric Perspectives offers updates on
diagnosis and management from specialists
at the Cleveland Clinic Pediatric Institute
& Children’s Hospital at 9500 Euclid Ave.,
Cleveland, OH 44195.
Chairman Robert Wyllie, MD, welcomes your
feedback at 216.444.2237 or wyllier@ccf.org.
Please direct correspondence to Editorial
Board Co-Chairs:
Rita M. Pappas, MD
pappasr@ccf.org, 216.444.4998
Jeffrey S. Palmer, MD
palmerjs@ccf.org, 216.445.7504
Editorial Board: John DiFiore, MD, Thomas
Edwards, MD, Rita Pappas, MD, Jeffrey
Palmer, MD, Kathy Whitford, PNP
Editor: Cora M. Liderbach
Art director: Amy Buskey-Wood
Photographers: Tom Merce, Steve Travarca,
Willie McAllister
The Pediatric Institute & Children’s Hospital
is one of 26 institutes at Cleveland Clinic that
group multiple specialties together to provide
collaborative, patient-centered care. Backed
by the full resources of Cleveland Clinic, the
institute offers comprehensive medical, surgical
and rehabilitative care for infants, children
and adolescents. More than 250 pediatric
physicians accommodate 500,000 patient
visits annually at our Main Campus, Shaker
Campus, community hospitals and family
health centers. Cleveland Clinic is a nonprofit
multispecialty academic medical center.
Founded in 1921, it is dedicated to providing
quality specialized care and includes an
outpatient clinic, a hospital with more than
1,000 staffed beds, an education institute
and a research institute.
Pediatric Perspectives is written for physicians
and should be relied upon for medical education
purposes only. It does not provide a complete
overview of the topics covered, and should not
replace a physician’s independent judgment
about the appropriateness or risks of a procedure
for a given patient.
© The Cleveland Clinic Foundation 8.09
09-CHP-031
Page 4 | Pediatric Perspectives | Summer 09 | Cleveland Clinic’s toll-free physician number is 800.553.5056

Cleveland Clinic Study Shows Adult Medication to Be Effective
Option for Children Severely Allergic to Crohn’s Disease Therapy
Pediatric gastroenterologists at Cleveland Clinic
Children’s Hospital are the first to report encouraging
results from pediatric use of an easily administered
medication for adults with Crohn’s disease.
About 5 percent of children and adolescents with mod-
erate to severe Crohn’s disease develop severe allergic
reactions to the standard pediatric regimen, infliximab
(Remicade ® ) infusion.
Reactions include chest tightness, flushing, shortness of
breath, oxygen desaturation, hypotension, elevated tem-
perature and/or rash. These symptoms typically develop
during or within several hours of the infusion.
Efficacy demonstrated over four years
A four-year study led by the pediatric gastroenterology
team demonstrated positive outcomes for children and
adolescents treated with adalimumab (Humira ® ), a re-
combinant human IgG1 monoclonal antibody approved
in 2007 for use in adults with Crohn’s disease.
Its mechanism of action is similar to infliximab, a tumor
necrosis factor-alpha antibody, but because the new drug
contains only human peptide sequences, it is believed to
be less immunogenic.
“Adalimumab is an important alternative for children
and adolescents who are unable to continue infliximab
infusions,” says one of the investigators, Marsha Kay,
MD, Director of Pediatric Endoscopy in the Department
of Pediatric Gastroenterology and Nutrition. “It has
allowed our patients to avoid surgery, has minimized
the complications of their disease, and has allowed us to
reduce usage of some of their other medications.”
The study, published in the Journal of Pediatric Gastroen-
terology and Nutrition in July 2008, involved 15 patients
treated at Cleveland Clinic Children’s Hospital between
January 2003 and March 2007. They ranged in age from
10 to 21 years (average age: 16). Six patients had colitis
alone, while nine had ileocolitis. The mean duration of
treatment was 6.5 months.
Visit clevelandclinic.org/peds
Researchers found that 50 percent of the patients re-
sponded completely to treatment with adalimumab,
while 14 percent had a partial response and 36 percent
did not respond to therapy. No serious adverse events
were reported.
Left: Typical appearance of moderately severe Crohn’s
colitis with mucosal exudates and pseudopolyp
formation. Right: Crohn’s colitis in a patient on
adalimumab. Only mild mucosal friability and small
aphthous ulcerations are seen.
Ease of use, cost appealing
Another attractive aspect of adalimumab is its ease of
use, says Dr. Kay. Infliximab must be infused intrave-
nously over several hours in a hospital setting or specially
designated outpatient area. Adalimumab, on the other
hand, can be self-administered or administered by par-
ents by subcutaneous injection at home — an appealing
option for the parents of pediatric patients who live great
distances from hospitals and clinics.
Because adalimumab is less expensive to administer,
insurance providers will begin to view the drug as a cost-
effective alternative for the treatment of pediatric Crohn’s
disease, says Dr. Kay, who expects its cost to drop further.
“Other institutions are now offering adalimumab, and I
believe it will be adapted as one of the standards of treat-
ment for many reasons,” she says. However, notes Dr.
Kay, additional studies are needed to evaluate its efficacy
and to determine optimal dosing of the drug in the pedi-
atric Crohn’s disease population.
To refer patients to Cleveland Clinic Children’s Hospital gastroenterologists,
the largest such specialty group in the region,
please call 216.444.9000. Physicians may contact Dr. Kay at
216.444.3564 or kaym@ccf.org.
| Pediatric Perspectives | Summer 09 | Page 5

Pediatric nephrologists at Cleveland Clinic Children’s
Hospital are excited about the potential of nomograms to
increase graft longevity.
“We do our best to provide the ideal organ for each patient,
with live donors providing the best results. Nomograms
incorporate numerous factors to objectively match a
good donor with the ideal organ recipient. This can only
improve outcomes,” says pediatric nephrologist Charles
Kwon, MD.
Kidney Transplant Nomograms Improve Donor-Recipient Match
A new system of nomograms for kidney transplantation appears to improve the donor-recipient match. The system
has been validated in adult patients, but has implications for pediatric patients, since children receive adult kidneys.
Predicting graft function, survival
The nomograms were developed by Cleveland Clinic
adult and pediatric kidney transplant surgeon David
Goldfarb, MD, and colleagues. They analyzed data from
the United Network for Organ Sharing registry to deter-
mine which factors played key roles in renal function and
graft survival and reported their findings in the March
2009 issue of the Journal of Urology.
The following variables had the greatest impact:
• demographic factors, including donor and recipient
age, gender and size
• immunological factors, such as antigen-antibody
matching immunosuppressive regimens
• organ procurement technique
They then used these factors to develop two nomograms
that predict kidney graft viability at one year. To develop a
third nomogram, predicting five-year graft survival, they
used other variables — delayed graft function, rejection
episodes and estimated glomerular filtration rate at six
months post-transplant.
“When we are better able to match donors and recipi-
ents prior to transplant, we can optimize outcomes and
reduce the likelihood that the patient will need another
kidney in the next five years,” said Dr. Goldfarb.
Ideal match critical for children
Although reducing the need for retransplantation re-
mains a universal goal, achieving an optimal match in
children is critical because best outcomes are seen with
the first transplant.
“When patients develop renal failure at a young age, it
is crucial for their immediate growth and development
— and for their long-term life prospects — to receive a
transplant with the optimal organ as soon as possible,”
says Dr. Kwon.
“The success rate for renal transplantation is high, with a
one-year graft survival rate of more than 90 percent. How-
ever, we are always striving to improve on that rate, and
nomograms may be one tool that can help.”
Kidney transplantation extends length of life and
significantly improves quality of life for both pediatric
and adult recipients.
Kidney donation safe
Kidney donation does not adversely impact a donor’s
health. A study reported in the January 29, 2009, New
England Journal of Medicine found that kidney donors
have survival rates similar to those of the general popula-
tion. A donor’s risk for developing end-stage renal
disease, hypertension, diabetes or cancer was similar to
that of a person of the same age, gender and ethnicity
who was not a donor.
In addition, most donors had their glomerular filtration
rate preserved, normal albumin excretion and an excel-
lent quality of life. The authors found that a donor’s risk
of kidney failure was actually lower than the rate reported
in the general population.
Physicians may reach Dr. Kwon at 216.444.6123 or
kwonc@ccf.org, and Dr. Goldfarb at 216.444.8726
or goldfad@ccf.org.
Cleveland Clinic’s toll-free physician number is 800.553.5056

By Ryan C. Goodwin, MD
Femoroacetabular impingement (FAI) can be devastating
for active young people. Occurring between the early teen
years and the fourth and fifth decades of life, it can cause
significant pain and severely limit participation in every-
day activities.
Symptoms include groin pain with activity, mechanical
symptoms such as locking, catching and clicking, pain
with stair climbing and pain with prolonged sitting.
Impingement results from abnormal proximal femoral
(cam) or acetabular (pincer) anatomy that produces bony
impingement within what should be a normal arc of hip
motion. Prolonged impingement may lead to early degen-
erative changes within the hip joint.
Surgical treatment of FAI can reduce pain and improve
range of motion by recreating the femoral neck offset
(removing the bone causing the impingement). Impinge-
ment-related changes, such as labral tears, may also be
addressed at the time of surgery. Open procedures for
FAI, including surgical dislocation of the hip, have gained
popularity in North America over the past few years.
Same pathology, less morbidity
More recently, arthroscopic techniques have been de-
veloped to treat FAI with significantly less morbidity and
more rapid recovery. As a result, the open procedures,
still relatively new, are now giving way to arthroscopic
treatment. In selected cases, the same pathology can of-
ten be addressed via the arthroscope.
The primary indications for arthroscopic treatment of
FAI include painful osseous limitation of joint motion
Visit clevelandclinic.org/peds
Arthroscopic Treatment Relieves
Femoroacetabular Impingement in
Selected Cases
and associated pathology, such as labral tears. Most cas-
es respond poorly to non-surgical treatments due to the
anatomic nature of the problem. FAI may be idiopathic,
or secondary to conditions such as Legg-Calvé-Perthes
disease or slipped capital femoral epiphysis.
Dislocation not required
Hip arthroscopy is performed as outpatient surgery un-
der general anesthesia, typically through two standard
arthroscopic portals. The hip is distracted, allowing ac-
cess to the joint, but true dislocation of the joint is not
required, as it is in many open procedures.
The procedure begins with a thorough inspection of the
hip joint, including the articular cartilage, labrum and
any pathoanatomy related to FAI. Bony cam impinge-
ment lesions can then be resected with a burr under
both fluoroscopic guidance and direct visualization. As-
sociated labral pathology can be addressed in the same
setting using debridement or repair with suture anchors.
Resection of acetabular pincer lesions is also possible,
with subsequent labral reattachment.
Postoperatively, weight-bearing is protected on the oper-
ated limb for one to two weeks, and a graded physical
therapy program follows. Full recovery is variable, but
most patients return to full activities, including sports, in
six to 12 weeks on average.
Dr. Goodwin specializes in pediatric orthopaedics,
including scoliosis surgery, hip disorders, hip
arthroscopy and orthopaedic trauma. Physicians may
contact him at 216.444.4024 or goodwir@ccf.org.
X-rays of 18-year-old female with
symptomatic cam impingement before
and after arthroscopic treatment.
Top of page: Intraoperative arthroscopic
image of cam lesion resection.
| Pediatric Perspectives | Summer 09 | Page 7

Skilled Congenital
Heart Surgeons Offer
Care from Infancy
through Adulthood,
Focus on Outcomes
Constantine Mavroudis, MD, Ross Chair of Pediatric and
Adult Congenital Heart Surgery, and Chairman of the
Department of Pediatric and Congenital Heart Surgery,
brings extensive experience to the Cleveland Clinic
Children’s Hospital’s heart team. He is an expert in atrial
arrhythmia surgery, Fontan conversion, valve-sparing
tetralogy of Fallot repairs, and repairs of congenital
coronary artery anomalies and transposition of the great
arteries. Dr. Mavroudis specializes in congenital heart
surgery for adults as well as children. He has numerous
research publications and is currently overseeing the
publication of the fourth edition of his Pediatric Cardiac
Surgery textbook. To contact Dr. Mavroudis, please call
216.636.5288 or 800.223.2273, ext. 65288.
Marshall L. Jacobs, MD, joined the Department of
Pediatric and Adult Congenital Heart Surgery as Adjunct
Professor of Surgery and Director of Clinical Research on
June 1. An accomplished and innovative congenital heart
surgeon, Dr. Jacobs will now focus on outcomes research
and the development of new strategies and technologies
to enhance the care of pediatric and congenital heart
disease patients. Dr. Jacobs holds leadership positions
in many professional societies, and serves as Editor
of World Journal for Pediatric and Congenital Heart
Surgery. His specialty interests include surgery for
single-ventricle anomalies and improved quality of care,
and he participates in the national databases of the
Congenital Heart Surgeons Society, Society of Thoracic
Surgeons and American Association for Thoracic Surgery.
To contact Dr. Jacobs, please call 216.444.8912 or
800.223.2273, ext. 48912.
Page 8 | Pediatric Perspectives | Summer 09 |
Congenital Heart Disease Follow-up
Between Primary Care Physicians
Children with congenital heart disease require
close medical follow-up throughout their lives. The
Cleveland Clinic Children’s Hospital pediatric heart
team partners with pediatricians and family physicians
throughout the region to manage patients’ cardiac
conditions from birth through adulthood.
In this country, the incidence of congenital
heart disease is 6 per 1,000 live births. That
rate more than doubles for mild to moderate
defects such as bicuspid aortic valve, at 13 per
1,000 live births.
Depending on the severity of the defect and the
complexity of the repair, surgical mortality for
these patients is generally 4 to 5 percent or less.
At Cleveland Clinic Children’s Hospital, our
surgical mortality rate for all congenital heart
disease patients is less than 2 percent.
With survival rates this high, 760,000 congen-
ital heart disease patients are expected to be
over 18 years of age by the year 2020.
Key issues to keep in mind when following
these patients include:
Feeding and weight gain. Early on, many cardiac
defects impact feeding and weight gain.
Counseling parents on the importance of
high-calorie formulas and diets is critical.
Infant feeding specialists at Cleveland Clinic
Children’s Hospital for Rehabilitation are
available to ensure adequate nutrition for
young patients with feeding issues.
New Cardiac Rehabilitation Program for Children
A comprehensive Pediatric Cardiac Rehabilitation Program
is now available at the Cleveland Clinic Children’s
Hospital for Rehabilitation on our Shaker Campus.
Infants, children and adolescents recovering from heart
surgery or heart transplantation will receive individualized
inpatient or outpatient care from therapists supervised by
our pediatric cardiologists.
The goal is to build young patients' endurance, strength,
aerobic capacity and flexibility. Family education is a key
component of the program.
For more information, call Gerard Boyle, MD, Chairman of
Pediatric Cardiology, at 216.444.3083.
Cleveland Clinic’s toll-free physician number is 800.553.5056

Requires Partnership
and Heart Specialists
Growth and development. Monitoring children
with congenital heart disease is especially
important when growth and development lag,
because prompt referral to early intervention
programs can be beneficial. Developmental
pediatricians at our Children’s Hospital for
Rehabilitation are well-attuned to the needs of
children with congenital heart disease and will
work closely with referring pediatricians.
Immunization. When a patient requires
cardiopulmonary bypass for an upcoming
heart operation, the timing of immunizations
is critical. Children’s Hospital heart specialists
always notify colleagues in primary care about
the need to delay immunizations in their
patients with congenital heart disease.
Red flags. Any complaints of chest pain, palpita-
tions and/or syncope should be promptly evalu-
ated and discussed with the child’s cardiologist
to determine whether intervention is needed.
For example, arrhythmias are especially dan-
gerous in children or adolescents with single-
ventricle physiology.
Our heart surgeons, cardiologists, and cardiac
nurse practitioners and nurses will respond
to questions about your patients by phone or
email.
Cardiac Referrals, Urgent Consults, Transport
Same-day appointments are available with a staff
cardiologist in our Center for Pediatric and Congenital
Heart Diseases. To refer infants, children or adults, call
216.445.5015 or 800.223.2273, ext. 55015.
To reach a pediatric cardiologist after hours, please call
216.444.2200 or 800.223.2273 (CCF.CARE) and ask
for pager no. 24444.
To transfer patients to Cleveland Clinic Children’s
Hospital, our Pediatric Critical Care Transport Team offers
24/7 ground, rotor-wing or fixed-wing transport from
any location across the globe. Call 216.444.8302 or
800.553.5056.
Cleveland Clinic Children’s Hospital
Expands Pediatric Cardiology Team
Our pediatric cardiology team in the Center for Pediatric
and Congenital Heart Diseases has been the largest in
Northern Ohio, including:
Gerard Boyle, MD
Chairman
Janine Arruda, MD
Thomas Edwards, MD
Larry Latson, MD
Richard Lorber, MD
Tamar Preminger, MD
Lourdes Prieto, MD
Athar Qureshi, MD
Marcy Schwartz, MD
Richard Sterba, MD
On July 1, 2009, the group welcomed four new
pediatric cardiologists to further expand its ranks:
Francine Erenberg, MD
Specialty Interest(s): Echocardiography, fetal
echocardiography, pediatric cardiology
216.445.7144 or erenbef@ccf.org
Alex Golden, MD
Specialty Interest(s): Interventional pediatric
cardiology
216.445.7116 or goldena@ccf.org
Ernest Siwik, MD
Specialty Interest(s): Interventional cardiology,
pediatric cardiology
216.445.7118 or siwike@ccf.org
Kenneth Zahka, MD
Specialty Interest(s): Genetic cardiovascular
diseases (Marfan syndrome, Ehlers-Danlos
syndrome, hypertrophic cardiomyopathy, familial
aortic aneurysm, mitochondrial disease), exercise
physiology, cardiovascular sports medicine, adult
congenital heart disease
216.445.7146 or zahkak@ccf.org
Our pediatric cardiologists now see patients at even
more community locations across Northeast Ohio.
For a complete staff directory and location list, visit
clevelandclinic.org/peds-heart.
Our new staff, left to right: Drs. Zahka, Siwik, Golden and Erenberg
Visit clevelandclinic.org/peds | Pediatric Perspectives | Summer 09 | Page 9

IMAGE OF THE ISSUE
Lateral fluoroscopic image of the subtalar
joint shows iodinated contrast in the middle
and posterior subtalar joints (large arrows),
and the needle (small arrow).
T
s
s
s
Coronal ultrasound image shows
“bubbles” of steroid being injected
into the posterior subtalar joint
(arrows). Talus (T); calcaneus (C).
C
s
Pediatric Puzzler
Continued from page 4
Diagnosis and Management: The baby was
admitted to Cleveland Clinic Children’s
Hospital for IV administration of isotonic
D5NS, and his sodium level slowly
increased.
A renal ultrasound showed mild to moderate
hydronephrosis. To treat possible saltwasting
congenital adrenal hyperplasia,
oral hydrocortisone and fludrocortisone
were administered along with 1/8 teaspoon
of sodium bicarbonate in 24 ounces of
formula throughout the day.
Page 10 | Pediatric Perspectives | Summer 09 |
s
Imaging-Guided Steroid Injection
for Juvenile Arthritis
A therapeutic radiologic procedure produces dramatic results in children with
multiple joints affected by juvenile idiopathic arthritis (JIA, also know as
juvenile rheumatoid arthritis). Ultrasound or fluoroscopically guided steroid
injection can be performed in patients from infancy through adolescence.
Sedation or anesthesia in the OR is especially beneficial for many patients
for whom office injections might be difficult because of the child’s inability to
remain motionless. In addition, pediatric rheumatologists may refer children
with multiple joints affected; we have frequently injected three to six joints
under one sedation.
At Cleveland Clinic Children’s Hospital, pediatric radiologists work closely
with pediatric anesthesiologists in the typically 15-minute procedure. Under
continuous ultrasound guidance, each site is marked, and using a fine-gauge
needle, we inject a local anesthetic, followed by triamcinolone.
For some joints, needle position is confirmed with a fluoroscopic arthrogram
performed by injecting a small volume of iodinated contrast. A Band-Aid is
then quickly applied.
Imaging guidance allows us to inject the smallest, least accessible joints while
avoiding adjacent nerves, arteries and veins. Precise placement of injections
can also prolong the anti-inflammatory effects.
By Janet Reid, MD, Head of Pediatric Radiology, a specialist
in pediatric body MRI, pediatric neuroimaging, fetal MRI and
resident Web-based education. Physicians may reach her at
216.445.2999 or at reidj@ccf.org.
A subsequent renal ultrasound revealed
megaureters without evidence of
obstruction, and moderate bilateral
hydronephrosis. A urine culture was
positive for E. coli, and oral sulfadiazine/
trimethoprim was started.
Subsequent lab work revealed elevated
aldosterone (883 ng/dL; normal 5.8-110)
and renin (79,000 µU/mL; normal 0-160).
Levels of 17-hydroxy-progesterone, cortisol,
free T4 and TSH were all normal.
Transient pseudohypoaldosteronism (TPH),
caused by a UTI without obstructive uropathy,
was diagnosed. TPH can occur in
infants secondary to congenital urinary
tract malformations such as posterior
urethral valves, or obstructions of the
ureteropelvic or ureterovesical junction.
Such patients (typically males under
3 months of age) can develop a sodiumwasting
syndrome due to aldosterone
resistance that may initially mimic saltwasting
congenital adrenal hyperplasia.
Although our patient had moderate bilateral
hydronephrosis with megaureters, there
was no evidence of obstruction. A thorough
review of the literature revealed 68 cases
of TPH reported since 1983: 48 involved
obstructive uropathy, vesicoureteral reflux
or another urinary tract anomaly with UTI;
eight involved obstructive uropathy or VUR
without UTI; and five involved infection
without obstruction, as in our case.
Clinical Pearl: In TPH, an inflammatory
process can desensitize aldosterone receptors
even without obstruction if a urinary
tract malformation is present.
Physicians may reach Dr. Rogers, Head of
the Section of Pediatric Endocrinology, at
216.445.8048 or at rogersd@ccf.org.
Cleveland Clinic’s toll-free physician number is 800.553.5056

By Sumit Parikh, MD
Cyclic vomiting syndrome (CVS) is characterized by explo-
sive, recurrent, prolonged and severe attacks of vomiting
with no underlying etiology.
Vomiting occurs many times an hour, for hours to days,
on a weekly or monthly basis. Episodes are self-limiting,
with a complete return to normal health in between.
CVS can occur at any age, but most often develops in child-
hood, typically near the end of preschool. Females are
affected slightly more than males. CVS patients are prone
to motion sickness and often have a family history of mi-
graine; most transition to migraines as adolescents. Thus,
most CVS cases are believed to be a migraine variant.
Symptoms and triggers
Episodes can begin at any time, but occur more fre-
quently in the mornings. Associated triggers include
stress (positive and negative), certain foods, motion and
viral illness. Pallor develops, anxiety increases and activ-
ity decreases. The child has environmental sensitivities
such as photo- and phonophobia, as seen in migraine.
Loosening of the stools or diarrhea may occur.
Autonomic symptoms include low-grade fever and mild
hypertension. Vomiting is often worse at the beginning
of the cycle, then gradually subsides; the lull is then fol-
lowed by sleepiness. The child often experiences moder-
ate midline abdominal pain, sometimes with headache.
The vomiting is usually bilious and infrequently bloody.
Rare complications include gastric herniation and
esophageal tears from frequent vomiting. Spells usually
end as abruptly as they start as the child “magically”
becomes well.
Misdiagnosis common
Visit clevelandclinic.org/peds
Diagnosing and Managing
Cyclic Vomiting Syndrome
CVS is still considered a novel diagnosis that cannot be
confirmed by a single test or procedure. It is frequently
misdiagnosed as viral gastroenteritis or food poisoning
until the spells recur. Despite increasing awareness,
diagnosis is typically delayed two to three years.
The diagnosis is made after careful review of the patient’s
history and exclusion of other pathology, including
epilepsy, increased intracranial pressure, abdominal
malrotation, volvulus or obstruction, and renal colic due
to hydronephrosis.
Studies must be performed both when the child is well
and during a bout of vomiting. They include metabolic
testing of blood and urine, amylase and lipase levels, an
upper GI series, abdominal ultrasound, brain MRI and,
potentially, an EEG.
Concerns have recently arisen about the possibility of
metabolic disease in patients who demonstrate:
• mitochondrial dysfunction or abnormal fatty acid
oxidation on biochemical testing
• a higher incidence of mitochondrial DNA mutations or
• a response to mitochondrial medications such as levo-
carnitine and coenzyme Q10.
A small number of children are diagnosed with a primary
disorder of fat metabolism, such as short- or very long-
chain acyl-CoA dehydrogenase deficiency (SCAD or
VLCAD).
Acute and long-term treatment
Treatment of these conditions is both abortive and
prophylactic. Acutely, anti-nausea and anti-migraine
medications are combined with a mild sedative. For
prevention, the patient is started on a medication such
as amitriptyline or cyproheptadine. A treatment protocol
has been developed by the National CVS Association
Medical Advisory Board.
At Cleveland Clinic, we hold the only CVS clinic in the
region, the third such clinic in the country. Patients see a
team of specialists in pediatric headache, pediatric gas-
troenterology, neurometabolic disorders and pediatric
psychology. Three of our members are on the National
CVS Medical Advisory Board.
To refer a child for evaluation in our CVS clinic or for more information,
physicians may contact Dr. Parikh, a pediatric metabolic
neurologist, at 216.444.1994 or at parikhs@ccf.org.
| Pediatric Perspectives | Summer 09 | Page 11

Endoscopic Pediatric Brain Tumor
Resection a Safe, Effective Alternative
to Conventional Open Surgery or
Biopsy and Shunting
By Xiao Di, MD, PhD
Tumors of the central nervous system (CNS) account for
22 percent of all malignancies occurring among children
up to age 14, and 10 percent of tumors occurring among
children 15 to 19 years old. Brain tumors are considered
the most common solid malignancy in children under
the age of 15, second only to leukemia as a cause of
cancer deaths in that age group.
The biological behavior and management of childhood
CNS tumors depend not only on their histological charac-
teristics, but also on their location.
Most low-grade gliomas of childhood, such as pilocytic
astrocytoma and subependymal glial cell astrocytoma in
patients with tuberous sclerosis, are relatively benign.
Occurring infrequently in adults, these tumors tend
to grow slowly, intra-axially and in the posterior fossa,
causing obstructive hydrocephalus.
Surgery curative, but risks are feared
Low-grade gliomas of childhood are reported to be cur-
able in more than 90 percent of patients by surgical re-
section alone. However, due to concerns about the high
s
s
Case 1: MRI with contrast, axial (left) and
coronal (right) views, show a cystic tumor of
the right cerebellum involving the cerebellar
pedicles on top, and total resection of the
tumor endoscopically below.
Page 12 | Pediatric Perspectives | Summer 09 |
s
Juvenile pilocytic astrocytoma
s
Gross total resection of tumor
mortality and morbidity of total surgical tumor resec-
tion, simple tumor biopsy is widely employed, followed
by a shunt procedure for obstructive hydrocephalus.
Subsequently, these tumors continue to grow, involving
adjacent and critical structures, and eventually become
unresectable.
Many pediatric neurosurgery and neuro-oncology groups
support surgery to remove even high-grade brain tumors
as safely as possible, with follow-up chemotherapy and/or
radiotherapy.
Combining endoscopy and ‘keyhole’ surgery
In pediatric patients, we combine endoscopy with key-
hole surgery to resect brain tumors involving the lateral
ventricle, fourth ventricle, cerebellopontine angle or cer-
ebellar hemisphere. Instead of a conventional bone-flap
craniotomy, we introduce an endoscope under frameless
stereotactic guidance through an approximately 2-cm
keyhole incision and burr hole.
The endoscope is used as a solely optical device during
the procedure, and it is also calibrated as a virtual wand
for neuro-navigation. The endoscope provides ample
illumination of the surgical field and real-time imaging
Cleveland Clinic’s toll-free physician number is 800.553.5056

on screen, and accurately guides the surgeon’s navigation
toward the target and resection of the tumor while
avoiding important adjacent neural structures.
Following are two cases in which the endoscope was
successfully used to surgically resect low-grade pediatric
gliomas.
Obstructive hydrocephalus Fourth ventricle medulloblastoma
Improved hydrocephalus Gross total resection of tumor
Case 2: Preoperative Flair MRI axial images
on top show the hydrocephalus and tumor
inside the fourth ventricle. Postoperative
contrast MRI axial views below indicate air in
the bilateral frontal horns and tumor removal
from the fourth ventricle.
Case 1: A 4-year-old boy with a right cerebellar tumor
A previously healthy boy presented with a three-month history of
intermittent headache and nausea. An outpatient non-contrast CT
scan showed a right posterior fossa cystic lesion, displacing and
compressing the fourth ventricle, causing significant mass effect
and hydrocephalus. Endoscopic MRI-guided frameless stereotactic
resection was performed, using the retrosigmoid approach to the
right cerebellum. Postoperatively, the fourth ventricle reopened,
and the hydrocephalus resolved without a shunt. The postoperative
pathology report indicated pilocytic astrocytoma.
Case 2: An 18-year-old female with a fourth-ventricle tumor
This teenager presented with a recent, six-month history of severe
headache plus several episodes of vision loss and intermittent
nausea. An MRI indicated obstructive hydrocephalus and a tumor
that filled the fourth ventricle. Endoscopic resection of the fourthventricle
tumor was performed, assisted by neuro-navigation via
a suboccipital craniectomy. The cerebrospinal fluid pathway was
opened following tumor resection without a shunt. The postoperative
pathology report indicated medulloblastoma.
Dr. Di is a member of the Section of Pediatric and Congenital
Neurosurgery in the Neurological Institute. Physicians may
reach him at 216.444.5747 or at dix@ccf.org.
Visit clevelandclinic.org/peds
s
s
General Patient Referral
Pediatric Institute & Children’s Hospital
24/7 Hospital Transfers/Admissions/Critical Care Transport
Main Campus
216.444.8302 or 800.553.5056
Cleveland Clinic Children’s Hospital for Rehabilitation,
Shaker Campus
216.448.6400 or 800.635.2417
Outpatient Appointments/Referrals
Medical and Surgical Subspecialties - Main Campus
216.444.DOCS (3627) or 800.553.5056
Medical Clinic - Cleveland Clinic Children’s Hospital for
Rehabilitation, Shaker Campus
216.448.6179
clevelandclinic.org/peds
Cleveland Clinic
24/7 Hospital Transfers or Physician Consults
800.553.5056
clevelandclinic.org
Services for Physicians
Physician Directory
View all Cleveland Clinic staff online at clevelandclinic.org/staff.
Pediatric Physician Liaison
Referring physicians have a direct and personal link to Cleveland
Clinic Children’s Hospital with physician liaison Janet Zaibek,
RN. For assistance with any staff interactions at Children’s
Hospital, email zaibekj@ccf.org.
Critical Care Transport Worldwide
Cleveland Clinic Children’s Hospital’s critical care transport
team serves critically ill and highly complex patients across the
globe. The transport fleet comprises mobile ICU vehicles, helicopters
and fixed-wing aircraft. Transport teams are staffed by
physicians, critical care nurse practitioners, critical care nurses,
paramedics and ancillary staff, and are customized to meet your
patient’s needs. To transfer an infant, child or adolescent to our
Children’s Hospital, call 216.444.8302 or 800.553.5056.
Improved Communication, Improved Care
Cleveland Clinic DrConnect is a complimentary service providing
our referring physicians with secure, online access to the electronic
medical record information related to a patient’s treatment
progress. To receive your next patient report electronically, please
log onto clevelandclinic.org/drconnect to establish your own
DrConnect account.
Outcomes Data Available
The latest Outcomes book from the Cleveland Clinic Pediatric
Institute & Children’s Hospital is available. Our Outcomes books
contain clinical outcomes data and information on volumes, innovations,
research and publications. To view Outcomes books for
many Cleveland Clinic institutes, visit clevelandclinic.com/quality/
outcomes.
Stay Connected to Cleveland Clinic
| Pediatric Perspectives | Summer 09 | Page 13

Cleveland Clinic Children’s Hospital Staff
Robert Wyllie, MD
Calabrese Chair of Pediatrics, Chairman and Physicianin-Chief,
Pediatric Institute & Children’s Hospital
VICE CHAIRMEN
Steve J. Davis, MD
Michael J. McHugh, MD
QUALITY REVIEW OFFICERS
Rita M. Pappas, MD
Oliver Soldes, MD
PATIENT SAFETY OFFICER
Shannon Phillips, MD, MPH
ADOLESCENT MEDICINE
Ellen S. Rome, MD, MPH,
Head
216.444.3566
Laura Gillespie, MD
ALLERGY
Al Melton Jr., MD, Head
216.444.6817
Velma Paschall, MD
ANESTHESIOLOGY
Julie Niezgoda, MD, Chair
216.444.0278
Pilar Castro, MD
Glenn E. DeBoer, MD
Rami Karroum, MD
Sara Lozano, MD
Dorothea Markakis, MD
Marco Maurtua, MD
Kathleen Rosen, MD
L. Mounir Soliman, MD
Wai Sung, MD
Judith Van Antwerp, MD
George Youssef, MD
BEHAVIORAL HEALTH
Michael J. Manos, PhD, Head
216.445.7574
Joseph Austerman, DO
Gerard A. Banez, PhD
Meghan Barlow, PhD
Jeffrey E. Bolek, PhD
Cara Cuddy, PhD
Kristen Eastman, PsyD
Thomas Frazier II, PhD
Catherine Gaw, PsyD
Page 14 | Pediatric Perspectives | Summer 09 |
Vanessa K. Jensen, PsyD
Eileen Kennedy, PhD
Julie Knapp, PhD
Kathleen Laing, PhD
Amy Lee, PhD
Beth Anne Martin, PhD
Ted Raddell, PhD
Margaret (Mara) Richards, PhD
Sandra Sommers, PhD
Pamela Senders, PhD
CARDIOTHORACIC
ANESTHESIOLOGY
Julie Niezgoda, MD
216.444.0278
Raja Gopalan, MD
CARDIOLOGY
Gerard Boyle, MD, Chair
216.444.3083
Janine Arruda, MD
Thomas Edwards, MD
Fran Erenberg, MD
Alex B. Golden, MD
Larry A. Latson, MD
Richard Lorber, MD
Tamar Preminger, MD
Lourdes R. Prieto, MD
Athar Qureshi, MD
Marcy Schwartz, MD
Ernest Siwik, MD
Richard Sterba, MD
Kenneth G. Zahka, MD
Jennifer Brubaker, CPNP
PEDIATRIC AND CONGENITAL
HEART SURGERY
Constantine Mavroudis, MD,
Chair
216.636.5288
Marshall Jacobs, MD
Denise A. Davis, CPNP
Jamie Thomas, CPNP
John Neff, PA
CRITICAL CARE MEDICINE
Stephen J. Davis, MD, Chair
216.444.3321
Elumalai Appachi, MD
A. Marc Harrison, MD
Nicole Johnson, MD
Valerie Kalinowski, MD
Daniel Lebovitz, MD
Michael J. McHugh, MD
Carrie Fuller, CPNP
Cheryl Malek, CPNP
Cathy Tichy-Dreher, CPNP
ENDOCRINOLOGY
Douglas G. Rogers, MD, Head
216.445.8048
Ajuah Davis, MD
Anzar Haider, MD
Cheryl Switzer, CPNP
EPILEPSY AND SLEEP
DISORDERS
Prakash Kotagal, MD, Head
216.444.9083
Jyoti Krishna, MD
Deepak Lachhwani, MD
Ingrid Tuxhorn, MD
Elaine Wyllie, MD
Molly Delaney, CPNP
GASTROENTEROLOGY
Robert Wyllie, MD, Chair
216.444.2237
Christine Carter-Kent, MD
Lisa Feinberg, MD
Ariel Feldstein, MD
Vera F. Hupertz, MD
Barbara Kaplan, MD
Marsha H. Kay, MD
Lori Mahajan, MD
In 2008-2009, 80 Cleveland
Clinic Children’s Hospital
specialists and general
pediatricians were listed in
Best Doctors in America, and
22 were listed in America's
Top Doctors. The 2009
U.S.News & World Report
“America’s Best Children’s
Hospitals” survey also ranked
Cleveland Clinic Children’s
Hospital highly in 8 of 10
pediatric specialties.
Franziska Mohr, MD
Kadakkal Radhakrishnan, MD
Rita M. Steffen, MD
GENETICS
Charis Eng, MD, PhD, Chair,
Genomic Medicine Institute
216.444.3440
Rocio Moran, MD
Marvin Natowicz, MD, PhD
GYNECOLOGY, ADOLESCENT
Marjan Attaran, MD, Head
216.445.2492
Gita Gidwani, MD
HEMATOLOGY/ONCOLOGY
Gregory Plautz, MD, Chair
216.445.4044
L. Kate Gowans, MD
Eric Kodish, MD
Michael G. Levien, MD
Tanya Tekautz, MD
Margaret C. Thompson, MD,
PhD
Holly Clark, CPNP
Holly Kubaney, CPNP
Tara Malbasa, CPNP
HOSPITAL MEDICINE
Michelle Marks, DO, Head
216.444.4998
Scott Beichner, MD
Nella Blyumin, MD
Allison Brindle, MD
Julie Cernanec, MD
Rolly Chaudhary, MD
Julia Frantsuzov, MD
Skyler Kalady, MD
Sangeeta Krishna, MD
Cleveland Clinic’s toll-free physician number is 800.553.5056

Aida Mandapat, MD
Jennifer Marcy, MD
Larissa Negron, MD
Margarita Neyman, MD
Rita Pappas, MD
Shannon Phillips, MD, MPH
Raj Rambhatla, MD
Mona Rifka, MD
Amrit Sidhu, MD
Toni Tilden, MD
Wendy Van Ittersum, MD
Farah Wadia-Brink, MD
INFECTIOUS DISEASES
Johanna Goldfarb, MD, Head
216.445.6863
Lara Danziger-Isakov, MD,
MPH
Charles Foster, MD
Camille Sabella, MD
LIVER TRANSPLANTATION
Charles Miller, MD, Director
216.445.2381
Federico Aucejo, MD
Bijan Eghtesad, MD
John J. Fung, MD, PhD
Vera Hupertz, MD
Charles Winans, MD
NEPHROLOGY
Charles Kwon, MD, Head
216.444.6123
Charles A. Davis, MD
NEONATOLOGY
Ricardo Rodriguez, MD, Chair
216.444.0297
Vladimir Burdjalov, MD
Marita D’Netto, MD
Sabine Iben, MD
Yoav Littner, MD
Eric N. Mosqueda, MD
Jennifer Peterson, MD
Douglas Powell, MD
Craig H. Raskind, MD
Firas Saker, MD
Jeffrey Schwersenski, MD
William Zaia, MB,ChB, DCh
Donna Cress, NNP
Tina DiFiore, NNP
Maryann Dominick, NNP
Karen Kuhn, NNP
Susan Levar, NNP
Wendy May, NNP
Barb Miguel, NNP
Visit clevelandclinic.org/peds
Carmela Lemcke, NNP
Shawn Schuster, NNP
Susan Taylor Hach, NNP
Amy Toth, NNP
NEUROLOGY AND
NEUROSURGERY
Elaine Wyllie, MD, Head,
Neurology
216.444.2095
Mark Luciano, MD, PhD,
Head, Neurosurgery
216.444.5747
William E. Bingaman, MD
Bruce H. Cohen, MD
Gerald Erenberg, MD
Tatiana Falcone, MD
Neil R. Friedman, MB,ChB
Debabrata Ghosh, MD, DM
Ajay Gupta, MD
Gary Hsich, MD
Sally Ibrahim, MD
Irwin Jacobs, MD
Prakash Kotagal, MD
Jyoti Krishna, MD
Deepak Lachhwani, MBBS,
MD
Sudeshna Mitra, MD
Manikum Moodley, MD
Sumit Parikh, MD
David Rothner, MD
Tanya Tekautz, MD
Ingrid Tuxhorn, MD
Xiao Di, MD, PhD
OPHTHALMOLOGY
Elias I. Traboulsi, MD, Head
216.444.4363
Andreas Marcotty, MD
Paul Rychwalski, MD
ORTHOPAEDIC SURGERY
R. Tracy Ballock, MD, Head
216.444.5775
Ryan Goodwin, MD
Alan Gurd, MD
David Gurd, MD
Thomas E. Kuivila, MD
OTOLARYNGOLOGY
Paul Krakovitz, MD, Head
216.444.4306
Samantha Anne, MD
PLASTIC SURGERY
Francis A. Papay, MD, Head
216.444.6905
Mark Hendrickson, MD
PSYCHIATRY
Kathleen M. Quinn, MD, Head
216.444.5997
Joseph Austerman, DO
John Glazer, MD
Jennifer Haut, PhD
Patricia Klaas, PhD
Barry Simon, DO
PULMONOLOGY
John Carl, MD, Head
216.445.7572
Samiya Razvi, MD
Diane Kenny, CPNP
Christine Stuart, CPNP
RADIATION ONCOLOGY
John Suh, MD, Chair
216.444.5574
Roger M. Macklis, MD
RADIOLOGY
Janet Reid, MD, Head
216.445.2999
S. Pinar Karakas, MD
Stuart Morrison, MD
Ellen Park, MD
Paul Ruggieri, MD
Neil Vachhani, MD
RHEUMATOLOGY
Steven Spalding, MD
216.445.1099
SPORTS MEDICINE,
ADOLESCENT
Anthony Miniaci, MD,
Executive Director, Sports
Health
216.518.3466
John A. Bergfeld, MD
Jack T. Andrish, MD
Paul Saluan, MD
SURGERY
David Magnuson, MD, Chair
216.445.4051
John W. DiFiore, MD
Federico G. Seifarth, MD
Oliver Soldes, MD
Anthony Stallion, MD
Lucy Andrews-Mann, CPNP
UROLOGY
Jeffrey S. Palmer, MD, Head
216.445.7504
Karen Burns, CPNP
CHILDREN’S HOSPITAL
SHAKER CAMPUS
Michael McHugh, MD,
Medical Director, Cleveland
Clinic Children’s Hospital for
Rehabilitation
216.444.4377
Judith Hall, CPNP
Linda Schnell, CPNP
Kathy Whitford, CPNP
DEVELOPMENTAL AND
REHABILITATIVE PEDIATRICS
216.448.6179
Roberta Bauer, MD
Douglas Henry, MD
Special Programs
Center for Autism
216.448.6440
Feeding Disorders Program
216.448.6024
Fetal Care Center
866.864.0430
International Adoption Program
216.445.3033
Metabolic Services
216.444.3303
Pain Rehabilitation Program
216.448.6158
Palliative Medicine Service
216.445.1404
For our most up-to-
date, detailed list of
staff and locations, visit
clevelandclinic.org/peds.
| Pediatric Perspectives | Summer 09 | Page 15

The Cleveland Clinic Foundation
Pediatric Perspectives
9500 Euclid Avenue/AC311
Cleveland, OH 44195
Cert no. SW-COC-002546
10%
CME Pediatric
Join Us for a Conference on
Medical Child Abuse and Child Advocacy
Dec. 5, 2009, Bunts Auditorium
Our free half-day Saturday CME event will review
pediatric, psychiatric and legal approaches to
medical child abuse, also known as factitious
disease by proxy (Munchausen by proxy).
Thomas A. Roesler, MD, and Carole Jenny,
MD, authors of Medical Child Abuse: Beyond
Munchausen Syndrome by Proxy, will speak.
Dr. Roesler is an Associate Professor of Child and
Family Psychiatry and Dr. Jenny is a Professor of
Pediatrics at Brown University. Dr. Jenny also chairs
the Committee on Child Abuse for the American
Academy of Pediatrics and directs the ChildSafe child
protection program at Hasbro Children’s Hospital.
Cleveland prosecutor Yvonne C. Billingsley, JD, and
Cleveland Clinic attorney Thomas Allison, Esq.,
legal experts in the field, will also speak. Johanna
Goldfarb, MD, Head, Center for Pediatric Infectious
Diseases, will chair the event.
A question-and-answer session will follow. For
further details, visit ccfcme.com, call 216.445.3572
or email wilsoni2@ccf.org.
Institute & Children’s Hospital
Symposia
Sept. 25
7th Annual Pediatric Neurology
Update Seminar
Executive Caterers at Landerhaven, Mayfield
Heights, Ohio
Oct. 9
Congenital Heart Disease in the Adult:
The Second Annual Ronald and Helen
Ross Symposium
InterContinental Hotel Cleveland, Cleveland
Clinic campus
Nov. 12–15
3rd World Congress on Hypospadias and
Disorders of Sex Development
(Co-sponsored by Cleveland Clinic Children’s
Hospital)
Marriott Hotel Toronto, Eaton Centre, Toronto,
Ontario, Canada
For details about Pediatric Institute symposia,
visit clevelandclinicmeded.com, or call
the Cleveland Clinic Center for Continuing
Education at 216.448.0770 or
800.238.6750.
Saturday CME
NON-PROFIT ORG
US POSTAGE
PAID
CLEVELAND, OH
PERMIT#1940
Cleveland Clinic Children’s Hospital offers
a free, monthly Pediatric CME series on
Saturday from 8 a.m. to 12:30 p.m. at our
Main Campus. Upcoming CME will focus
on topics ranging from Neonatology in
September to Medical Child Abuse and Child
Advocacy in December.
Pediatricians will earn AMA PRA Category 1
Credit.
Grand Rounds
Community physicians are welcome to earn
CME credit at our monthly Pediatric Grand
Rounds, from September through May, at our
Main Campus and Shaker Campus.
To browse upcoming speakers and topics for
our Saturday CME series or Pediatric Grand
Rounds, visit clevelandclinicmeded.com, call
216.445.3572 or email wilsoni2@ccf.org.