PEDIATRICIAN Spring 2003 - AAP-CA

california
PEDIATRICIAN Spring 2003
AMERICAN ACADEMY OF PEDIATRICS, CALIFORNIA DISTRICT IX
Pediatric Bilateral Living Donor
Lobar Lung Transplantation
Page 13

EDITOR-IN-CHIEF
Jeffrey S. Penso, M.D.
9696 Culver Blvd., #108
Culver City, CA 90232
(310) 204-6897
jpenso@ucla.edu
ASSISTANT EDITOR
Marianne Hockenberry
aapmarianne@aol.com
ADVERTISING
Stuart A. Cohen, M.D.
6699 Alvarado Rd., #2200
San Diego, CA 92120
(619) 265-3400
scohen98@ipninet.com
DESIGN AND PRODUCTION
Rosalie Blazej
50 Laidley St.
San Francisco, CA 94131
(415) 695-0264 FAX (415) 641-5409
rblazej@pacbell.net
DISTRICT EXECUTIVE DIRECTOR
Kris Calvin, MA
853 Ramona Ave.
Albany, CA 94706
(510) 559-8383 FAX (510) 559-8464
aapcalifornia@aol.com
Marianne Hockenberry
Associate Director
EDITORIAL BOARD
Chapter 1
Lewis Nerenberg, M.D.
Chapter 2
Joan E. Hodgman, M.D.
Chapter 3
Howard Taras, M.D.
Chapter 4
Stanley Galant, M.D.
CHAPTER OFFICES
Chapter 1 Executive Director
Beverly Busher
900 Fifth Ave. #204
San Rafael, CA 94901
(415) 459-4775
aapbev@aol.com
www.aapca1.org
Chapter 2 Executive Director
Kathleen Shematek, MPH
6233 East Allison Circle
Orange, CA 92869
(714) 744-8245
aapca2kshematek@socal.rr.com
www.aapca2.org
Chapter 2 Chapter Administrator
Eve Black
P.O. Box 2134
Inglewood, CA 90305
(323) 757-1198
aapcach2@aol.com
Chapter 3 Executive Director
Erika Kalter
3020 Children’s Way
MC 5073
San Diego, CA 92123
(858) 569-8816
sdpeds@chsd.org
www.aapca3.org
Chapter 4 Executive Director
Debbie Monfea
12377 Lewis Street, #103
Garden Grove, CA 92840
(714) 971-0695
ca4aap@sbcglobal.net
www.aapca4.org
Address comments and questions to
Jeffrey S. Penso, M.D.
jpenso@ucla.edu
2 District Report
Burton Willis, M.D. and Kris Calvin, M.A.
3 Childhood Cancer Survivors Report Life Changes
Brad J. Zebrack, Ph.D., M.S.W., and Mark A. Chesler, Ph.D.
Today 75% of children diagnosed with various forms of cancer in the
United States are expected to survive their disease and treatment. But
what of their quality of life expected, enjoyed, or endured?
4 Tandem Mass Spectrometry in Newborn Screening
George C. Cunningham, M.D., M.P.H.
The Department of Health Services keeps us current on neonatal
screening.
5 Culturally Appropriate Communication Is
Good Medical Practice
Allan Lieberthal, M.D., FAAP
Poor communication results in inferior medical care, and is not in
compliance with federal government standards. Can we improve
compliance?
6 CMA House of Delegates Report
Paul Y. Qaqundah, M.D.
State budget concerns were key but access to the care and employer
mandate proposals were issues we wrestled with in San Francisco.
7 Weighing the Radiation Risks of CT Scans
Nikta Forghani, M.D., Ronald A. Cohen, M.D., Myles B. Abbott,
M.D.
CT scans expose children to high doses of ionizing radiation. What
are the best ways to use CT scans?
8 Adolescent Idiopathic Scoliosis
Robert M. Bernstein, M.D.
What is the natural history of scoliosis, which cases need to be
referred? What are the treatment options?
9 Preventing Ear Infections in Children
Harry Pellman, M.D.
AOM is the most common bacterial infection diagnosed in children.
What is known to reduce the frequency of middle ear problems?
10 A Low-Glycemic Index Diet in the
Treatment of Pediatric Obesity
David S. Ludwig, MD, PhD, et. al.
Obesity is arguably the most prevalent medical problem in the
United States today. Weight loss on current reduced-fat diets is
characteristically modest and transient. Can a novel treatment, the
low-glycemic index diet, be the breakthrough we need?
12 Why California’s MICRA Is Good for the Nation
Ron Bangasser, M.D.
We face a national medical liability crisis. The solution is California’s
MICRA.
13 Ten-Year Experience with Pediatric
Bilateral Living Donor Lobar Lung Transplantation
Marlyn S. Woo, M.D. and Vaughn A. Starnes, M.D.
The medical team had exhausted all conventional medical and surgical
options. What about lung transplantation for this dying patient?
14 The Tao of Pediatrics and Chinese Medicine
Wendy Yu, M.S., L.Ac., Jeffrey I. Gold, Ph.D.,
Michael H. Joseph, M.D.
Health is not just about a disease factor, it’s about the whole
environment.
17 In Memoriam — Joseph H. Davis
A beloved pediatrician is recalled by his son.
18 Chronic Pain in Children: A Multidisciplinary Biopsychosocial
Treatment Approach (Part III)
Michael H. Joseph, M.D. and Jeffrey I. Gold, Ph.D.
we must decrease all ongoing nociceptive pain and support,
encourage, and reinforce the child in working through chronic pain
symptomatology.
21 Twenty-Five-Years of Home Mechanical Ventilation in Children:
The Program at Childrens Hospital Los Angeles
Manisha Witmans, M.D., Sheila S. Kun, R.N., M.S., and
Thomas G. Keens, M.D.
The last 25 years has witnessed enormous improvement in home
mechanical ventilation. Since the inception of the home ventilator
program in 1977, the program at Childrens Hospital Los Angeles
CHLA has grown to include over 375 children.
CONTENTS
CALIFORNIA PEDIATRICIAN — SPRING 2003/ 1

TABLE OF CONTENTS continued
District Report
AAP-CA Advocacy in Hard Times:
Multiple Strategies to Success
Burton Willis, M.D. and Kris Calvin, M.A.
Despite the flowering trees around the majestic Capitol dome, Sacramento
offers few pretty pictures this year. Take a shot of the full landscape: an
unprecedented $30 billion dollar-plus state deficit looms. Zoom in for a
family portrait? Democrats, Republicans and the Governor’s office seem trapped on
their own limited platforms, with no real solution in sight. Worse yet for pediatrics,
snapshot photos of the health budget show only shrinking dollar signs. This is because
health dollars are largely unprotected in an era of budget “lock-ins” in other areas due
to initiatives or other mandates.
The California District of the American Academy of Pediatrics (AAP-CA), representing
all four California AAP Chapters, has developed a pragmatic, yet hopeful
approach to this state crisis. Strategies include:
• Increased AAP-CA leadership and participation in coalitions to ensure that
children’s health advocates are heard above the din in the budget debates in
Sacramento. This includes intense advocacy with 70 other groups to oppose
proposed cuts to Medi-Cal physician reimbursment.
• Build on successes. Last year AAP-CA and our allies were successful in saving
and expanding the Child Health and Disability Prevention (CHDP) state-only
program. If state-only CHDP had been eliminated these children would have
fallen into the ranks of the uninsured and an important source of pediatric revenue
to sustain their care would have been eliminated. This year AAP-CA has
worked closely with the state to protect the program and improve it. Starting
July 1, 2003 CHDP providers will be able to pre-enroll children into the Medi-
Cal program through the Internet or new Point of Service devices. For more
information go to www.medi-cal.ca.gov/new_chdp.asp.
• “Back-end” involvement in implementation of children’s programs. Programs
are best protected in the budget if they are fully implemented and working well
for both physicians and children. For example, AAP-CA “Chapter Champions”
are working with the state to ensure that the already enacted Newborn Hearing
Screening Program is fully implemented with appropriate reimbursement.
• Prevent budget problems before they start. This includes careful legislative monitoring
and intervention to ensure that only those bills whose benefits outweigh
their costs are enacted. This requires AAP-CA to be available to legislators and
their staff as an expert resource on a wide range of issues, including vision
screening, early brain development anticipatory guidance and HMO contracting
issues. We have already had great success this year in this regard.
• Engage legislators and policymakers by utilizing credible pediatrician advocates.
Legislators and other policymakers prefer to hear from you, practicing
pediatricians with first-hand experience with children and families, rather than
from lobbyists and staff. Something as simple as a “form” letter from you to
your legislator on a priority AAP-CA issue matters. Those of you with a flair for
public comment can make a tremendous difference by testifying for AAP-CA
on a bill or budget item in Sacramento. Building an ongoing trust relationship
with your local legislator in his or her home office is invaluable. If you have
not already completed the brief AAP-CA Grass Roots Advocacy Survey please
request one from aapcalifornia@aol.com.
Improving the state child health picture in California this year will take more
than just a pretty new frame. AAP-CA will continue to work towards real change for
pediatricians and the children and families that you serve.
22 Childcare Health Linkages Program: How
Pediatricians Can Collaborate with Local
Childcare Health Consultants
Robin Calo, R.N., M.S., P.N.P. and
Karen Sokal-Gutierrez, M.D., M.P.H.
When you think about the young children in your
practice, who besides their parents takes care of
them? Is a childcare consultant coming to your
neighborhood?
23 Eve Black Honored
24 Annual Las Vegas Seminars —
25 Years of District Education and Support
Rosalie Blazej and Milton Arnold, M.D.
For 25 years, pediatricians have flocked to Las Vegas
to learn and relax.
25 Selling Tobacco Products as a
Public Health Issue
Trisha Roth, M.D.
At the urging of the California Medical Association
and with the help of the Preventing Tobacco Addiction
Foundation, a proposal is on the table to increase the
minimum age for purchasing tobacco to 21.
26 Early Hearing Detection and Intervention
Sudeep Kukreja, M.D.
To be successful, California needs to address several
issues in the Newborn Hearing Screening Program.
29 SED — California Region
Leonard Kutnik, M.D.
One in 10 children suffer from a mental health
illness but only one in five children receive specialty
services. Unfortunately, even this rate of treatment is
not achieved in the Healthy Families Program.
29 California Surgeon General Needed to
Protect Californians
31 Retirement Options for Pediatricians
Joan E. Hodgman, M.D.
Retirement should not be dull or boring. With the
increase in the average life expectancy, more and
more of us can look forward to years of active life
after retirement.
32 Last Word: After the Iraq War
Jeffrey S. Penso, M.D.
Even with victory an implacable worldwide enemy
will remain. While physicians are aware of the
continued threat of bioterrorism, we have yet to
recognize that bioterror will change relationships
between physicians and the community.
33 President-Elect Candidates
33 Contributors
35 Officers and Committees
California Pedatrician does not
assume responsibility for authors’
statements or opinions. Opinions
expressed are not necessarily those
of California Pediatrician or the California
District, American Academy
of Pediatrics.
Vol. 19 No. 1 Spring 2003
California Pediatrician [ISSN 0882-3421] is
the official publication of the American Academy
of Pediatrics, California District IX.
Copyright © 2003 American Academy of
Pediatrics, California District IX
2 / CALIFORNIA PEDIATRICIAN — SPRING 2003

Childhood Cancer Survivors Report Life Changes
Brad J. Zebrack, Ph.D., M.S.W., and Mark A. Chesler, Ph.D.
“I used to get really depressed
on the anniversary when I got
sick, August 4. I used to get really
upset; I even wore black to work.
You know, this is the day my life
changed... Like this is really weird,
I see a grave, and that’s the person
that died, on August 4, 1985. She’s
gone. Because you know, my life
had to change, I had cancer and
I can’t go back there, I can’t go in
the past, so it’s like, she’s gone.
(24-year old survivor of childhood
cancer).”
Prior to the 1970s and the advent and use of
multi-modal chemotherapy, survival rates
for children diagnosed with leukemia and
other forms of cancer were dismal. Today,
advances in treatment and the coordination of
pediatric treatment through clinical trials have
greatly increased the long-term life chances
of these young people. Indeed, recent reports
indicate that 75% of children diagnosed with
various forms of cancer in the United States
are expected to survive their disease and treatment.
As we witness increasing lengths of survival
for individuals diagnosed with cancer as
children and a growing number of long-term
survivors there is no indication of their quality
of life expected, enjoyed, or endured. In
1998, the American Cancer Society Task Force
on Children and Cancer reported that “(T)he
progress achieved in attaining 80% survival
among children and adolescents and young
adults with cancer can be justified only if their
physical, emotional, and social quality of life
also are protected.” Thus, success in pediatric
oncology requires researchers and health care
professionals to attend to the psychosocial and
behavioral consequences of treatment and to
the quality of life of these survivors.
Cancer Survivorship
Research literature on cancer survivors consistently
refers to the notion that experiencing
cancer can lead to changes in people’s lives.
While many studies of cancer survivors document
long-term sequelae as having deleterious
effects on psychological well-being and social
functioning, relatively few have investigated
positive adaptation and factors associated with
the potentials for positive life changes which
survivors attribute to cancer.
People often report that they have made
positive changes in themselves and their lives
after a negative event or trauma. Several scholars
have described such changes as part of a
process of cognitive reappraisal in the face
of, or aftermath of, trauma. People thus may
reframe or reinterpret their illness experience
or themselves (e.g., from “victim to victor”),
making new meaning out of their situation.
Seminal work by Taylor indicated that a sizable
proportion of women experienced positive
life changes following their experiences
with breast cancer. Similarly, in a comparison
of adult bone marrow transplant patients to
a matched control group without a history
of cancer, the patients equaled or exceeded
controls in the likelihood of reporting positive
psychosocial changes in life.
Some investigators, however, caution
against such interpretations in that reports of
positive outcomes may be “illusions,” “repressive
denial,” or self-serving distortions that are
more typical of poor mental health rather than
positive adaptation. Our own view, based on
empirical work as well as on our own personal
and clinical experiences, is that cancer and
other trauma should not be viewed as a stressor
with uniformly negative outcomes but rather as
transitional events that create the potential for
both positive and negative change.
Life changes for survivors of
childhood cancer
These issues are beginning to surface in
recent research with survivors of childhood
cancer. There is general agreement that many
adolescent and young adult survivors of childhood
cancer have lasting physical deficits and
that some experience negative psychological
changes as a result of their illness. At the same
time, several scholars argue from empirical
findings that demonstrate that a sizable portion
of this population is coping more positively
than their peers and that they have changed
their psychologic orientations and outlooks
for the better. These positive outcomes are not
necessarily unrealistic or naïve “halo effects”
because often they are accompanied simultaneously
by details of how cancer has had deleterious
effects. Furthermore, these results mirror
findings and interpretations reported in the
literature about gains in “secondary benefits”
such as enhanced relationships with family
members, emotional maturity, and greater life
appreciation.
Young adult survivors’ own words illuminate
the changes they attribute to having had
cancer as children.
“I feel I’ve learned good lessons
from it (my cancer). I realize what’s
important in life and I don’t take
everything for granted. I want to
live life to the fullest.”
“I think I’m stronger. I am very
independent now. I set my mind
to doing something and I do it. I
think a part of me has definitely
been impacted by the fact that
I’ve had cancer. There are a lot
of go-getters out there, but when
you’ve accomplished something
like surviving the cancer and
treatments, when you’ve gotten
through something like that, it just
gives you a determination, a drive,
to achieve well in school and to do
well in life.”
In addition, many long-term survivors of
pediatric malignancies indicate that there is
something inherent to the cancer experience
that makes dealing with the “normal” challenges
of every day life different from a life
without cancer.
“You know, it’s definitely a huge
adjustment getting married, and
having a child, so that’s adjustment
CALIFORNIA PEDIATRICIAN — SPRING 2003/ 3

in and of itself, but I think you
throw a whole other element in
that, you know, like going through
what I went through [cancer],
and you need to try to fit that in
somewhere. And you don’t know
where it fits.”
These statements above are consistent
with what Tedeschi & Calhoun refer to as
“philosophical outcomes” or “new priorities”
in life. They reflect an internal process of
“meaning making,” whereby many of these
survivors (with help from external supports,
no doubt) have reframed or reinterpreted their
initial trauma, placed their current worries or
negative effects in context, and made new and
positive meaning out of their cancer experience.
Complementing recent concern about
evidence of a “post-traumatic stress syndrome”
among childhood cancer survivors, some
survivors may experience “post-traumatic
growth” or a sense of “thriving.” The need for
further research on these issues, and resultant
estimates of the proportion of the childhood
cancer survivor population falling into either
category, is vital.
Implications for intervention
Evaluating reports of positive change and
enhanced quality of life associated with cancer
is important for two reasons: (1) it challenges
us to try to understand the reality and validity
of such reports; and (2) it suggests the need
for psychosocial interventions that not only
prevent or alleviate negative sequelae but also
promote positive outcomes and increase longterm
survivors’ opportunities for expressing
and experiencing cancer as a potentially transformative
experience. Such interventions may
start with the subtle positive messages often
presented at diagnosis (“you will survive this
illness”), then subsesquently include the mobilization
of family and friends’ supports, and
skilled peer (“let me tell you what I learned”)
or professional counseling.
In the current context, where medical
survival from childhood cancer is no longer a
singular or rare phenomenon, the possibilities
of full psychological survival and even growth
have enormous theoretical and practical implications.
The long term impact of experiencing
or recognizing positive change is yet to be fully
explored, but theoretically it has additional
implications for the construction, or re-construction,
of personal and social identity for
adolescent and young adult cancer survivors.
Tandem Mass Spectrometry in
Newborn Screening
George C. Cunningham, M.D., M.P.H.
The state is currently conducting a legislatively mandated demonstration project to
evaluate the most efficient way to add the Tandem Mass Spectrometry (MS/MS)
technology to our newborn screening for metabolic disease. This technology measures
47 different analytes in a blood specimen and can detect over 25 different disorders.
This report is to inform pediatricians generally about the progress and future of this proposed
expansion. Since starting in January 2002, 221,913 newborns have participated in this voluntary
MS/MS screening. The Genetic Disease Branch classified 349 as initially positive and
referred them to metabolic centers for diagnostic evaluation, leading to a definite diagnosis
in 33 newborns. Participation in the pilot is only being offered in 60% of maternity hospitals,
but is accepted by 90% of the mothers when offered. The initial referred rate at this time is
about 8 of every 10,000 newborns screened and approximately 1 in 10 of the referred newborns
have a disorder. The disorders are serious and with a few exceptions can be prevented
or ameliorated by treatment. (See Chart)
The project has demonstrated that the cost of case detection will be $60 to $80,000 per
case, which is offset by the benefits of lives saved and costly hospitalization for treatment
averted. We appreciate the cooperation received from pediatricians in making this project a
success. There are 24 states that are implementing or using MS/MS to expand their programs
at this time. Unfortunately, there are no funds in the current budget to continue this project and
unless funds are added during the budget process, the project will terminate in June 2003.
Category Description Example Number
Diagnosed
Amino Acid
Disorders
Organic Acid
Disorders
Fatty Acid
Oxidation
Disorders
Caused by the
accumulation of
amino acids in the
blood (e.g. arginine)
Caused by the toxic
buildup of organic
acids in the blood
(e.g., proprionic acid
or methylmalonic
acid).
Caused by a defect
in the conversion of
fats into fatty acids
for use as an energy
source
Arginemia 1
Methylmalonic acidemia
(MMA)
Propionic acidemia (PA) 2
3-methylcrotonyl-CoA
carboxylase deficiency
(3MCC)
Medium chain acyl-CoA
dehydrogenase deficiency
(MCADD)
Short chain acyl-CoA
dehydrogenase deficiency/
Ethyl malonic aciduria
(SCADD/EMA)
Multiple acyl-CoA
dehydrogenase deficiency
(MADD or GA-2)
Total 33
7
1
11
10
1
4 / CALIFORNIA PEDIATRICIAN — SPRING 2003

Culturally Appropriate Communication Is
Good Medical Practice
Allan Lieberthal, M.D., FAAP
California is the most culturally
diverse state in the country. Fortyseven
percent of the population
is white, 32 % Hispanic, 12 % Asian and
Pacific Islander, 7 % African American, and
1% Native-American. As many as 46% of
the population has Limited English Proficiency
(LEP). Over 100 languages are spoken
including, in addition to English and Spanish,
Tagalog, Armenian, Chinese, Thai, Korean,
Arabic, Vietnamese, Hebrew, Russian, Farsi,
and Hindi. We, as pediatricians, face a constant
challenge to communicate with our patients
and parents effectively. Many of us speak
Spanish or another language, in addition to
English. Some of us are fluent in that language
while others try to get by with limited fluency.
We are used to getting by with interpretation
by children, friends, other parents, or a combination
of the parent’s limited English and what
little we may know of their primary language.
The consequence may be that important information
is miscommunicated or omitted during
the medical encounter.
A recent article in Pediatrics 1 points out
the pitfalls of inadequate interpretation. In a
sample of 13 encounters, six with a hospital
interpreter, six with ad-hoc interpreters and one
with an 11-year-old child interpreting, there
were an average of 31 errors per encounter.
Seventy-seven precent of errors made by the
ad hoc interpreters and the child had clinical
significance. This was significantly more than
the 53% of clinically important errors made by
the hospital interpreters. Errors included omission,
false fluency, substitution, and addition.
Recognizing that poor communication
results in inferior medical care, the federal government
has set standards for Culturally and
Linguistically Appropriate Services (CLAS)
(www.hhs.gov/ocr/lepfinal.htm). Standards
published by the Department of Health and
Human Services (HHS), Office of Civil Rights
(OCR) apply to covered entities that include
“any state or local agency, private institution
or organization, or any public or private individual
that operates, provides or engages in
health, medical or social service programs that
receive or benefit from HHS assistance.” The
federal CLAS standards require covered entities
to identify the language needs of patients
and to provide proficient interpretation in a
timely manner. At the state level, Assembly
Bill 292 (Yee) has been introduced and, if
passed and signed into law, would prohibit the
use of children as interpreters.
There are many approaches to providing
adequate interpreter services. Kaiser-Permanente
in Panorama City has introduced a prototype
program to comply with the standards.
Employees who serve as interpreters must pass
the language proficiency test for interpretation.
These are mostly Spanish speakers. We rarely
have interpreters available for the many other
languages we encounter in our multi-ethnic
practice. In order to meet the needs of all of
our LEP patients, patients are identified as
needing interpretation at the time of making
an appointment and at check-in. A printed
area on the registration papers indicates the
preferred language of the patient and whether
interpretation services are needed. If there is no
interpreter available, we are using Language
Line Services (www.languageline.com), a
telephone-based service that can provide interpretation
in over 140 languages. This can be
done in the exam room using a pair of portable
phone extensions, one for the patient/parent
and one for the physician. The process requires
only a small increase in time as compared to
having an interpreter on site.
Shortly after the Language Line Service
was in place, I was seeing one of my Armenian
patients whose mother speaks very limited
English. It appeared to be a routine sick visit.
Through halting English, I understood the
symptoms of a common cold, but felt a little
uneasy because the mother did not appear to
understand my English instructions. I tried the
Language Line and soon found out that I had
totally misunderstood the illness. In fact the
child had a history consistent with cough variant
asthma. Had I been forced to communicate
in English, I am sure the mother would not
have understood my explanation and instructions.
Using the Language Line it was easy
Over 100 languages are spoken including, in addition to English
and Spanish, Tagalog, Armenian, Chinese, Thai, Korean, Arabic,
Vietnamese, Hebrew, Russian, Farsi, and Hindi.
to get a good history and to explain what her
child had since she was hearing it in her own
language. The mother, who I had seen on several
previous occasions without interpretation
services, was effusive in thanking me and telling
me how happy she was with the visit. From
initial skepticism, I became a convert.
Unlike pediatricians in private practice
or in network managed care practices, I do not
have to deal directly with the cost and reimbursement
for interpretation services. This is
especially important for doctors practicing in
poor communities with a high percentage of
ethnic minorities. Use of the Language Line
may cost as much as $15 for a 10 minute visit.
If a practice has a large number of patients
requiring interpretation by a nurse, workflow
may be impaired or additional personnel may
be needed. This should be recognized as an
additional expense and must be reimbursed
appropriately.
Even consistent professional interpreter
service will not bring us to a single standard
of medical care. The reality is that there is a
severe shortage of qualified health professionals
in all minority groups. Until our patients
can receive competent care from clinicians
who share their culture and language, we must
do our best to be sensitive and responsive to
their needs.
REFERENCE
1. Flores G, Laws B, Mayo SJ, et. al. Errors
in medical interpretation and their potential
clinical consequences in pediatric emergencies
Pediatrics 2003(1):111:6-14
CALIFORNIA PEDIATRICIAN — SPRING 2003/ 5

CMA House of Delegates Report
Paul Y. Qaqundah, M.D.
The 132nd CMA House of Delegates met at the
Hilton Towers in San Francisco on March 22-
25 2003. This year, the California AAP hosted
its tenth annual breakfast for pediatrician delegates. Your
three specialty representatives, Alan Burkin, Stuart Cohen,
and myself, together with our State Executive Director of
the Academy, Kris Calvin, provided an important opportunity
for county medical society pediatric delegates to dialogue
and coordinate a strategy to influence CMA policy
through the house. Issues discussed included:
1. Extended access to the uninsured, including review of
employer mandate proposals.
2. Medi-Cal physician reimbursement and other state
budget concerns.
3. Options for tapping mental health funds to support
pediatric practice.
4. Coordinated support for resolutions including those
related to reimbursement, obesity, soda sales and junk
foods. Approval of school lunch options, physical
education in schools and Medicaid block grants to
states.
I will highlight the actions of the House on issues that
pertain to pediatrics.
Science and Public Health
The house supported our resolution on childhood obesity
to encourage inclusion of obesity prevention in public
school curricula, support collaborative efforts among
health organizations, promote education, treatment
of obesity, and develop regional centers for comprehensive
treatment of morbid childhood obesity to be
financed through private and public sources.
On our resolution to improve school physical education,
the CMA supported measures that mandate increased
physical activity in schools and explore methods to
protect schools from litigation when school facilities
are made available to communities for after hours
physical activity.
CMA supported AAP’s resolution on sale of soda and fast
foods in schools, i.e. to work with health organizations
to strengthen existing standards established by
the “Pupil Nutrition, Health and Achievement Act” of
2001 that all foods provided in public schools (K-12)
meet national government nutritional standards. CMA
urges physicians and local medical societies to work
with local schools to implement these standards.
CMA supported our resolution on Epi-Pen administration
in schools to allow non-CPR certified school personnel
to administer Epi-Pen for anaphylactic reactions
if a CPR certified person is not available. This will
protect schools against litigation.
Emergency contraception. To assist appropriate use of
contraception, CMA supports legislation to prohibit
pharmacists from charging consultation fees when
dispensing emergency contraceptives.
Insurance and physician reimbursement. In 2002 CMA
adopted “Fair Vaccine Payment Resolution” and
requested a report back this year. CMA calls for all
California health plans and Medicare to reimburse
physicians at the average wholesale cost (AWC) of
vaccines plus 10%. CMA also insists on reimbursement
for costs of vaccine administration, at least at the
rate presently paid by Medi-Cal- $9.51.
Child protective services — CMA endorses review of
policies of California Child Protective Services. We
demand that CCPS give substantial weight to recommendations
of treating physicians in the disposition of
any at risk child.
CMA is advocating nationally to fix the absurdities of
HIPAA rules.
The House will work with insurance companies to maintain
a single mailing address for the submission of
claims, the address to be clearly printed on patient
insurance cards. All payers should maintain a single
electronic address and notify physicians of any
changes of addresses.
Newborns who test positive on toxicity screening. CMA
supports immediate entry of the mother into a chemical
dependency treatment program. CMA supports
legislation to increase the number of chemical
dependency treatment and rehabilitation programs
in California.
Jack Levin M.D., CMA’s C.E.O. noted that, “Our
nation remains in a 3 year recession. Our state is broke.
The events of 9/11 made all of that worse. The stress on
health executives from these combined factors have been
horrendous and now we are a nation at war.”
Nevertheless, CMA has fought to protect further
erosion of medical practice by reversing RBRVS cuts
and blocking the impending 4.4% additional cuts in the
2003 budget. AMA and CMA have saved each physician
involved in Medicare and Medicaid over $15000 in
income. This amounts to the equivalent of CMA dues for
all of a physician’s practice life. When Gov. Davis proposed
$1.6 billion in Medi-Cal cuts the CMA engineered a
complete reversal of those cuts.
CMA has preserved its malpractice rules (MICRA)
despite constant assault by trial lawyers. Thanks to CMA,
California MICRA remains the national gold standard for
malpractice reform. To preserve this, I suggest that you
give generously to CALPAC, the CMA political action
committee.
CMA has additional accomplishments too lengthy
for this report. See www.cmanet.org. President Bush has
stated that it is time to take control of medicine back from
bureaucrats, trial lawyers and HMOs and give it back to
physicians and patients. Don’t believe that anybody will
give you anything. We have to support and join our professional
organizations and take charge of medicine for the
sake of our patients.
6 / CALIFORNIA PEDIATRICIAN — SPRING 2003

Weighing the Radiation Risks of CT Scans
Nikta Forghani, M.D., Ronald A. Cohen, M.D., and Myles B. Abbott, M.D.
Computed tomographic (CT) scanning
is a valuable imaging modality
on which pediatricians increasingly
rely. However, pediatricians may not realize
that CT scans expose children to high amounts
of ionizing radiation that may have detrimental
long-term consequences. Recent data from
studies of survivors exposed to low-dose radiation
from the atomic bombs in Hiroshima and
Nagasaki 1 , and the increased risk of leukemia
in children who have two or more radiologic
procedures 2 , suggest that pediatricians should
be more circumspect when ordering CT scans.
More than two million CT scans are done
on children each year in the United States. 3 The
use of CT imaging in both adults and children
has increased by 700% over the past ten years 3 ,
although it has been estimated that 40% of CT
scans performed on children are unnecessary. 4
This increase is in large part due to the fact that
CT imaging has been more widely recognized
as a superior imaging modality for many clinical
problems. While CT imaging has enormous
diagnostic benefit, its widespread use is a
source of potential harm, especially to pediatric
patients. The National Research Council’s
Factors and Procedures
Yearly exposure at sea level 3
Living in Denver (high altitude) 6
Transcontinental flight 0.25
Committee on the Biological Effects of Ionizing
Radiation on Children has determined
that children under 10 years of age are several
times more sensitive to ionizing radiation than
middle-aged adults. 5 In addition, since children
have a longer life span, their potential longterm
risk of radiation damage is increased.
Furthermore, some of the new advances in
CT technology make the scans faster and
more accurate (and therefore more appealing
in the context of pediatric radiology), but may
come with a price of higher ionizing radiation
exposure.
To appreciate the amount of radiation
in a CT scan, it may be helpful to compare
CT radiation with both a standard chest X-
ray and the background radiation to which
we are all exposed in the environment. The
exposure from an abdominal CT scan is 5 to
10 millisieverts (mSv) 1 , which is 250 to 500
times greater radiation than a standard chest
radiograph (which is .02 mSv). The amount of
background radiation varies in different locations,
but the average background radiation in
the United States (excluding medical sources)
is about 3 mSv per year. The table shows the
Table: Representative Values of Effective Radiation Doses Associated with
Various Environmental Factors and Medical Procedures 7, 8
Chest X-ray 0.02 – 0.05
Skull X-ray
Abdominal X-ray
Intravenous pyelogram
Upper gastrointestinal series
Barium Enema
Head CT
Chest CT
Abdominal CT
Ultrasonography 0
Magnetic Resonance Imaging 0
Effective dose in mSv
0.1– 0.2
0.5 – 1.5
2.5 – 5.0
3.0
3.0 – 7.0
2.0 – 4.0
5.0 – 15.0
5.0 – 15.0
approximate amount of radiation associated
with various environmental factors, medical
procedures involving ionizing radiation, and
medical procedures that do not expose patients
to radiation.
Much of the current concern about the
effects of ionizing radiation on children stems
from recently published research about cancer
risk in atomic bomb survivors. Today, more
than 50 years after their initial exposure,
individuals have been identified who received
radiation doses that are similar to doses
achieved with modern CT scans (8-30 mSv).
The research shows that these individuals have
a small but statistically significant increased
mortality risk from cancer.
Pediatricians and pediatric radiologists
ought to work collaboratively to determine the
best imaging technique for each patient. When
non-radiation modalities (ultrasonography or
MRI) are as diagnostic as CT for the child’s
condition, they should be preferred. However,
CT scans are often the most appropriate imaging
modality. When CT is used, there are ways
to reduce the exposure to radiation:
• Reduce CT settings, which can be
done without significantly compromising
image quality. In one recent trial, ionizing
radiation exposure in children was reduced by
75% while quality was maintained. 6
• Utilize more focused or limited CT
scans to minimize the extent of radiation exposure.
For example, when trying to identify a
hepatic abnormality, CT can focus on the liver
rather than the entire abdomen and pelvis.
• Perform only the minimum number
of CT scans necessary for the diagnosis. There
are very few circumstances when multiple CT
scans are necessary.
• Be judicious in repeating CT scans
to follow a pathologic process. Consider other
imaging modalities to follow the process.
REFERENCES:
1. Pierce DA, Preston DL. Radiation-related
cancer risks at low doses among atomic
bomb survivors. Radiation Research. 2000;
154:178-186.
2. Infante-Rivard C, Mathonnet G, Sinnett D.
Risk of childhood leukemia associated with
CONTINUED ON PAGE 28
CALIFORNIA PEDIATRICIAN — SPRING 2003/ 7

Adolescent Idiopathic Scoliosis
While it is normal for the spine
to have curvatures in the lateral
plane (lordosis in the lumbar and
cervical regions and kyphosis in the thoracic
region), the spine is normally straight when
viewed from the frontal plane. Scoliosis is a lateral
curvature of the spine, and is always abnormal.
The term scoliosis is derived from the
Greek term ‘scolio’ (curved or bent). There are
many causes of scoliosis but the most common
is adolescent idiopathic scoliosis (AIS), which
accounts for a great majority of cases. This is
a structural (stiff) curve with rotation of the
spine that occurs at or near the onset of puberty
without an established cause. A variety of possible
etiological factors have been implicated,
including hormones, genetic predisposition,
muscular imbalance and neurologic abnormalities.
However, no direct link between these factors
and the development of scoliosis have been
established in this population.
The diagnosis of AIS is suspected by the
presence of asymmetry on the Adams forward
bend test. However, some children may have
muscular asymmetry without a true scoliosis.
In addition, care should be taken to account
for any leg-length discrepancy (LLD) as this
can also produce asymmetry of the spine and
a lateral curvature. If scoliosis is suspected,
a standing postero-anterior (PA) radiograph
should be obtained. A curve of 10 degrees or
greater confirms the diagnosis of scoliosis. The
prevalence in the adolescent population (10 to
16 yrs) is approximately 2 to 3%. The female:
male ratio for smaller curves is almost equal,
whereas the female:male ratio for larger curves
is 3.6:1.
The history should include any family
history of scoliosis or other back problems,
prior lower extremity fracture, any neurologic
complaints (including bowel and bladder
function) as well as any history of back pain.
Pain is not normally associated with AIS,
whereas painful scoliosis may be the result of
a herniated disk or tumor. A careful physical
examination should include an evaluation for
LLD and inspection of the back and skin for
any abnormal skin markings, dimples or hairy
patches that may indicate an underlying spinal
cord abnormality. The entire body should be
inspected for the presence of cafe au lait spots
or other manifestations of neurofibromatosis.
Finally, a detailed neurologic examination
including upper and lower extremity motor
Robert M. Bernstein, M.D.
strength, sensation, and reflexes should be
undertaken. Abdominal reflexes (stroking each
side of the umbilicus gently with a blunt object
should result in equal movement of the umbilicus
toward the stimulated side) should also
be checked as asymmetry of this reflex may
indicate intra-spinal pathology.
Pain, asymmetry of abdominal reflexes,
or any abnormal neurologic finding may indicate
an underlying spinal cord abnormality and
should be investigated. The incidence of spinal
cord abnormality (syrinx or chiari malformation)
is extremely low in AIS, and in general,
only a plain radiograph (PA) need be obtained.
PA radiographs are preferred over anteroposterior
radiographs because the radiation
exposure of the breast is minimized. Curves
measuring less than 10 0 should be considered
a normal variant and do not require further
evaluation. In addition, it should be kept in
mind that labeling the child with a diagnosis of
scoliosis may have implications with respect to
future insurability.
The majority of children with AIS will
never require active treatment (less than 10%).
The natural history is related to a number of
factors: the age (maturity) of the patient, the
location of the curve, the curve pattern, and the
size of the curve. Younger patients have more
potential growth and thus have a greater risk
of curve progression. Curves in the thoracic
region are stabilized by the ribs and thus are
less likely to progress than lumbar and thoraco-lumbar
curves. Double curves are more
likely to progress than single curves, and larger
curves are more likely to progress than smaller
ones.
Once the patient reaches skeletal maturity,
curve progression slows dramatically or stops.
Thoracic curves under 30 0 don’t progress after
skeletal maturity. Those curves between 30 0
and 50 0 may progress but do so very slowly.
However, thoracic curves between 50 0 and 75 0
have the greatest risk of progression and may
do so at up to 1 0 per year. The biggest concern
with thoracic curves is the loss of normal
thoracic kyphosis. Loss of kyphosis with progression
of the curve can result in a decrease
in pulmonary function. This loss of function
is measurable when the curve reaches 60 0 to
70 0 , but will not be noticeable to the patient
until the curve reaches over 100 0 . Lumbar
and thoraco-lumbar curves under 30 0 tend not
to progress after maturity. Those greater than
30 0 will progress but the extent of progression
is difficult to predict. They may result in a
significant trunk asymmetry that is cosmetically
displeasing to the patient and family. The
association between curve magnitude and a
decrease in pulmonary function only occurs
with thoracic curves and does not apply to
lumbar and thoraco-lumbar curves.
Treatment may involve simple observation,
bracing, or surgery. While exercises and
electrical stimulation have been utilized in the
past, there is no evidence that these modalities
affect curve progression. In addition, recent
literature has not shown any benefit from
chiropractic manipulation. As the majority
of AIS curves are small and thus have a low
likelihood of progression, most patients will
simply require regular follow-up visits with
radiographs to look for curve progression.
Bracing is instituted in skeletally immature
patients in order to prevent the curve
from achieving a magnitude that will continue
to progress after maturity. Once the brace is
removed, the curve usually returns to its prebrace
magnitude. A brace is recommended
when progression has been documented in
curves under 30 0 , for those curves measuring
30 0 -40 0 on initial presentation, and occasionally
for somewhat larger curves. Curves over
50 0 are likely to progress even after maturity
and thus are generally not brace candidates.
The current surgical treatment for scoliosis
is spinal fusion, usually with instrumentation.
The primary goal of fusion is to
prevent further progression of the curve, and a
secondary goal is to improve cosmetic appearance,
usually by decreasing the size of the
curve using rods, hooks, wires, and/or screws.
Reducing the curve size is only important to
the patient in how it affects their appearance,
and this must be balanced with the risk of
neurologic injury. As a general rule, the curve
can safely be reduced by about 50% its original
size. The indications for surgery vary and are
related to curve magnitude, progression, curve
pattern, and cosmetic appearance. Once a thoracic
curve has reached 50 0 , the risk of progression
after skeletal maturity is high and most of
these patients should undergo fusion. Curves
over 40 0 that progress in spite of bracing are
also fusion candidates. The indications for surgery
in the lumbar and thoraco-lumbar spine
is more controversial. If little trunk imbalance
is present, no intervention may be the best
approach, as fusing into the lumbar spine significantly
affects mobility and may increase the
risk of back pain. However, curves that create
significant trunk imbalance may be candidates
for surgery from a cosmetic standpoint.
The choice between posterior spinal
fusion, anterior spinal fusion, or both is somewhat
surgeon dependant and is also related to
the location of the curve, risk factors for non-
CONTINUED ON PAGE 26
8 / CALIFORNIA PEDIATRICIAN — SPRING 2003

Preventing Ear Infections in Children
Harry Pellman, M.D.
Acute Otitis Media (AOM) is the
most common bacterial infection
diagnosed in children and the most
common reason antibiotics are prescribed in
this age group. Despite these facts, there is still
quite a bit of controversy on how to best make
the diagnosis of AOM and a good strategy for
treating these infections. The American Academy
of Pediatrics is intently working on new
guidelines for the diagnosis and treatment of
acute otitis media (AOM) in children.
There are a variety of strategies known to
reduce the frequency of middle ear problems.
Implementing as many of these strategies as
possible may be like closing the barn door
before the cows get out.
Breast feeding has been clearly shown to
reduce both the incidence of AOM and
otitis media with effusion (OME) in
multiple studies. The protective effect is
related to the duration and exclusivity of
breast feeding and is most prevalent in
infancy.
Avoid environmental tobacco poisoning
(aka cigarette smoking). This type of air
pollution is clearly related to more AOM
and OME.
When bottle feeding, use fully vented bottles.
Fully vented bottles allow air inflow
as the milk exits the bottle and prevents
negative middle ear pressure. Negative
pressure in the middle ear promotes the
entrance of nasopharyngeal contents into
the middle ear chamber. Children using
fully vented bottles have middle ear pressures
that appear to be similar to infants
breast feeding.
Use of pacifiers beyond 18-24 months of age
has been associated with more middle ear
disease. The reason for this association is
not clear. Whether this occurs because
of abnormal pressures generated in the
middle ear, more viral infections associated
with pacifier use, or another mechanism
is unknown.
There are a variety of strategies known to reduce the frequency
of middle ear problems. Implementing as many of these
strategies as possible may be like closing the barn door before
the cows get out.
There is a suggestion that babies that have gastroesophageal
reflux disease (GERD)
have a higher incidence of middle ear
disease. In one study, middle ear fluid
obtained from children having myringotomy
and tube insertion revealed pepsin
and pepsinogen levels 1000 times higher
than serum levels in more than 80% of
children. Ongoing investigations will help
clarify this issue.
Daycare is associated with both an increased
incidence of middle ear disease and the
presence of more resistant bacteria when
infections occur. Of course, daycare
is essential for many working parents.
Training daycare workers to wash hands
frequently and employ hygienic measures
is a Herculean task.
Vaccines will have a dramatic impact on
AOM. Prevnar vaccine provides significant
protection against the seven strains of
streptococcus pneumonia (in the past, the
most common bacteria isolated in AOM)
in the vaccine plus five cross-reacting
strains. The vaccine has only reduced the
overall incidence of AOM about 5-10%.
However, the serotypes of streptococcus
pneumonia present in the vaccine are both
some of the most common bacteria present
in AOM and the most resistant and
difficult to treat bacteria we encounter.
This vaccine has reduced the necessity
for ear tubes about 20%, the frequency
of having multiple episodes of AOM in
an infection-prone child up to 20%, and
changed the bacteriology of AOM so that
non-typable hemophilus influenza bacteria
is now the most common bacteria isolated
in AOM in children vaccinated with
prevnar. Work is presently being done
on a nine-valent pneumococcal vaccine
and a non-typable hemophilus influenza
vaccine. Their impact on reducing AOM
remains to be seen.
Since most episodes of AOM follow viral
respiratory illnesses, it appears that
reducing these illnesses will lessen the
frequency of AOM. Influenza vaccine,
especially the newly released coldadapted
live influenza vaccine, has been
shown to effectively lessen the incidence
of AOM. If a safe, effective RSV vaccine
is ever approved by the FDA, we should
expect a further reduction in AOM episodes.
Xylitol is a natural, non-absorbable sugar most
commonly harvested from birch trees.
Xylitol chewing gum has been used in
Finland for many years to reduce the
incidence of dental caries, an infectious
disease caused by strep mutans. Children
on long term xylitol chewing gum were
found to have as much as 40% fewer
episodes of AOM. However, if used only
during a high risk period, such as a viral
respiratory infection, xylitol may not be
protective. The usefulness of xylitol in
other forms (syrup, lozenges, etc.) is still
being investigated.
There is a suggestion that iron deficiency
anemia may be associated with an
increased risk of AOM.
It sounds like the ideal situation for maximum
middle ear health is an infant exclusively
breast fed for at least six months, living in a
healthful environment without daycare, no
pacifiers, bottles (if used) should be fully
vented, kept on an iron rich diet, fully vaccinated,
properly positioned to lessen GERD,
and chewing xylitol chewing gum when old
enough to do so.
If employing the above strategies fails to
reduce the incidence of ear infections, since
frequent AOM seems to have some kind of
genetic link, the child should consider choosing
different parents!
CALIFORNIA PEDIATRICIAN — SPRING 2003/ 9

A Low-Glycemic Index Diet in the
Treatment of Pediatric Obesity
Leshe E. Spieth, PhD; Jennifer D. Harnish, PhD; Carine M. Lenders, MD, MS; Lauren B. Raezer, PhD;
Mark A. Pereira, PhD; S. Jan Hangen, MS, RD; David S. Ludwig, MD, PhD
This article has been excerpted from one
printed in Archives of Pediatric Adolescent
Medicine, September 2000, pages 47-51.
Reprinted with permission. Copyright 2000,
American Medical Association.
EXCESSIVE BODY weight is arguably
the most prevalent medical problem
in the United States today. Approximately
25% of children and more than 50% of
adults are considered overweight according to
data from the most recent National Health and
Nutrition Examination Survey. 1,2 Overweight
and obesity in childhood contribute to a range
of immediate and long-term problems, including
diabetes mellitus, dyslipidemia, hypertension,
sleep apnea, musculoskeletal problems,
gastrointestinal disease, and psychosocial
difficulties. Overweight children, especially
those older than seven years, are at increased
risk for obesity and cardiovascular disease in
adulthood.
The standard approach to the treatment
of obesity involves the reduction of dietary
fat, the most energy-dense nutrient. The US
Department of Agriculture, the American
Heart Association (Dallas, Tex), and the
American Diabetes Association (Alexandria,
VA) currently recommend reduced-fat diets in
the prevention and treatment of obesity. However,
weight loss on reduced-fat diets is characteristically
modest and transient. Moreover,
prevalence rates of overweight and obesity
have risen dramatically in recent years, despite
decreases in dietary fat as a percentage of total
energy to near recommended levels.
Recently, a low-glycemic index (GI) diet
has been proposed as a novel treatment for
obesity. Glycemic index refers to the relative
rise in blood glucose occurring after consumption
of a food containing a standard amount of
carbohydrate. Most refined grain products and
potatoes have a high GI, whereas nonstarchy
vegetables, legumes, and fruits generally have
a low GI. The glycemic response to a meal
increases with the carbohydrate content and
GI of the component foods, but decreases with
fiber, protein, and fat content. 19-22 Glycemic
index may affect hunger through effects on
pancreatic hormone secretion that, in turn,
alter availability of metabolic fuels after a
meal. Of 16 studies published to date relating
GI to hunger, satiety, or voluntary food
intake, 15 demonstrated beneficial effects of
low-compared with high-GI meals. However,
the effects of GI on body weight have not been
examined.
The purpose of this study was to evaluate
the effects of a low-GI diet in a pediatric outpatient
setting. Specifically, we sought to test the
hypothesis that a low-GI diet would result in
greater weight loss compared with a reducedfat
diet among obese children remaining in
outpatient treatment for at least one month.
Participants and Methods
STUDY DESIGN
During the period between September 1, 1997
and August 31, 1998, children attending the
Optimal Weight for Life Program at Children’s
Hospital, Boston, Massachusetts, for treatment
of obesity were assigned by the program
administrator, based on schedule availability,
to one of two teams, each composed of a subspecialty-trained
pediatrician, a dietitian, and
at times a pediatric nurse
practitioner. One team
prescribed a low-GI diet,
the other a reduced-fat
diet. Except for specific
dietary recommendations,
each team provided similar
diagnostic evaluation and
treatment. To estimate the
effects of dietary treatment
on body fatness, we
retrospectively examined
the changes in body mass
index (BMI [calculated
as weight in kilograms
divided by the square of
height in meters]) and
body weight from the participant’s
initial visit to last
visit before December 31,
1998, according to dietary
treatment assignment.
PARTICIPANTS
A total of 190 patients
(excluding those with
Cushing syndrome, hypothyroidism,
hypothalamic
disease, diabetes mellitus or an obesity-associated
genetic syndrome, or those currently
following a very low-energy diet) were
evaluated during the study period. We further
excluded 83 individuals for lack of follow-up
(< 1 month) and/or incomplete data, leaving a
cohort of 107. Descriptive characteristics of
this cohort are presented in Table 1.
STANDARD TREATMENT COMPONENTS
All patients received a comprehensive medical
evaluation (medical history, physical examination,
and laboratory investigation), dietary
counseling, and lifestyle counseling (recommendations
were based on decreasing physical
inactivity and increasing physical activity).
Counseling sessions included the child and
at least one parent, when possible, according
to established practice. Specific goals were
individualized, with consideration given to the
patient’s developmental level and readiness to
change. Follow-up appointments were generally
recommended to occur on a monthly basis for
the first four months, and then as needed.
10 / CALIFORNIA PEDIATRICIAN — SPRING 2003

In addition, problem-focused behavior
therapy was provided by the program psychologist
on an individual basis when referred
by a team member. Within these sessions, a
particular nutritional or physical activity goal
was identified as a primary treatment target. A
behavioral program was then developed, using
positive reinforcement for meeting the specified
goal. Specifics of treatment were adapted
according to the patient’s age and developmental
stage.
DIETARY TREATMENTS
One team prescribed a standard balanced,
hypoenergetic reduced-fat diet because of
research demonstrating improvements in
adiposity on this diet when combined with
behavioral modification and exercise. 26, 27 The
diet followed US Department of Agriculture
recommendations for intake of specific food
types, as depicted by the Food Guide Pyramid.
Particular emphasis was placed on limiting
intake of high-fat, high-sugar, and energydense
foods, and increasing intake of grain
products, vegetables, and fruit.
Recommendations were tailored on an
individual basis to incorporate an energy
restriction of approximately 1042 kJ (250
kcal) to 2084 kj (500 kcal) per day compared
with usual energy intake. Specific macronutrient
goals were 55% to 60% carbohydrate, 15%
to 20% protein, and 25% to 30% fat.
The other team prescribed a low-GI diet
because of preliminary research suggesting
a physiologic mechanism relating GI to
body weight regulation. 16,17 The low-GI diet
was designed to obtain the lowest glycemic
response possible while providing adequate
dietary carbohydrates, satisfying all nutritional
recommendations for children, and maintaining
palatability. This diet differed from the
standard diet not just in the GI of the component
carbohydrates foods, but also in the macronutrient
ratio. Emphasis was placed on food
selection, not energy restriction: patients were
instructed to eat to satiety and snack when
hungry. Specifically, patients were told to
combine low-GI carbohydrate, protein, and fat
at every meal and snack. A “Low-GI Pyramid,”
modeled after the Food Guide Pyramid, was
used as a teaching tool. This modified pyramid
placed vegetables, legumes, and fruits at the
base, lean proteins and dairy products on the
second level, whole-grain products on the third
level, and refined grain products, potatoes, and
concentrated sugars at the top. Specific macronutrient
goals were 45% to 50% carbohydrate,
20% to 25% protein, and 30% to 35% fat.
Results
Characteristics of the cohort are described in
Table 1 according to dietary treatment group.
Mean age, length of follow-up, number of
visits, and sex were similar between the two
treatment groups. Baseline BMI and body
weight were slightly greater in the reduced-fat
group compared with the low-GI group, but
the difference was not statistically significant.
Ethnicity differed in the study cohort primarily
owing to different follow-up rates (of the 190
patients before exclusion for lack of follow-up,
white subjects comprised 71% of 118 individuals
assigned to the low-GI group vs. 67% of 72
individuals assigned to the reduced fat group).
The figure depicts the mean change in
BMI from the participant’s first to last clinic
visit according to dietary treatment and baseline
BMI tertile. For each BMI tertile, the low-
GI group had a significantly larger decrease in
BMI than the reduced-fat group. Compared
with the reduced-fat group, a larger percentage
of patients in the low-GI group experienced a
decrease in BMI of at least -3 kg/m2 (11 participants
[17.2%] vs. one participant [2.3%]. As
presented in Table 2, the overall mean change
in BMI for the low-GI group was -1.53 kg/m2,
compared with -0.06 kg/m2 for the reducedfat
group (P

Why California’s MICRA Is Good for the Nation
Ron Bangasser, M.D.
The National Medical
Liability Crisis
It is upsetting to watch physicians walk
off their jobs to protest the cost of medical
liability insurance in New Jersey, Nevada,
Mississippi, West Virginia and Florida. But it
would be far more upsetting if there were no
doctors at all to provide surgery, trauma care,
diagnose illnesses and deliver babies. Some
of these physicians are being charged up to
$200,000 annually for their liability coverage,
and like the proverbial canary in the coalmine,
these physicians are trying to warn us about a
coming national health care crisis.
California faced a similar calamity in the
1970s. Malpractice insurance was soaring with
some physicians expecting 400% premium
increases. Worried that soaring costs would
drive physicians from California and leave
patients without care, then-Gov. Jerry Brown
called a special session of the legislature to
solve the medical liability crisis.
California’s MICRA
The solution then, and now, was the Medical
Injury Compensation Reform Act. Before
MICRA, California malpractice premiums
were among the nation’s highest. But post-
MICRA, rates in California stabilized. Take a
look at the impact on rates beginning in 1986,
the year legal challenges to the law were finally
exhausted. From 1986 to 2000, premiums fell
12% in California, while rising 55% nationally
(inflation adjusted dollars). During that same
period, rates in Florida rose 809%; in Nevada
8375%!
Under our forward-thinking law, injured
patients are entitled to unlimited medical and
economic compensation, which often amount
to millions of dollars to cover true damages,
such as lost wages, medical expenses, rehabilitation,
psychotherapy and long-term care
costs. Physicians support such full compensation
of injured patients. And under MICRA,
patients can also recover an additional quarter
of a million dollars in non-economic or “pain
and suffering” awards. The law also limits
contingency legal fees so that seriously injured
patients get more (and their attorneys correspondingly
less) of the award.
Regardless, the law remains under siege
from trial lawyers. But the number of medical
malpractice suits has remained stable and
From 1986 to 2000, premiums fell 12% in California, while rising
55% nationally (inflation adjusted dollars). During that same
period, rates in Florida rose 809%; in Nevada 8375%!
awards have risen far faster than inflation since
1986, indicating injured patients retain their
access to the courts and fair recovery. And in
California, injured patients are compensated
more quickly than in all states but Minnesota.
The real reason personal injury lawyers hate
MICRA is that it limits the money they make
from patient misfortune. Trial lawyers are not
an endangered species. But physicians, emergency
rooms and safety-net programs for the
uninsured are truly threatened, and everyone’s
access to care is endangered without reform.
Stabilizing insurance premiums is particularly
essential for the poor, who get their health care
from economically fragile medical clinics and
health centers.
It’s MICRA, NOT Proposition 103
The suggestion that Prop 103 forced medical
liability rates down in California is clever
but lacks any foundation in fact. MICRA was
enacted in 1975 but was immediately challenged
in the courts. Until the legal challenges
were resolved and the courts and lawyers
got comfortable with the application of its
various provisions, there were no savings from
MICRA. After the lead case of Fein v. Kaiser
Permanente was decided in 1985 it took several
years for the judgments and settlements to
show a downward trend.
When Prop 103 was passed in 1989,
the California medical liability insurers were
already returning MICRA savings to physicians
in the form of policyholder dividends.
Several had filed for rate reductions but found
the California Department of Insurance reluctant
to even approve rate reductions until the
legal status of PROP 103 was resolved. To
break the logjam, the physician owned companies
met with Commissioner John Garamendi
shortly after he was elected. The commissioner
examined the medical liability rates and found
them appropriate. No rollbacks were required
and the policyholder dividends that the companies
were paying were accepted in lieu of
a rollback refund. Commissioner Garamendi
and his staff did not interfere in any way with
the medical liability rates. Not a single medical
liability rate filing has been denied in California
since Prop 103 was enacted.
In addition to rate reductions voluntarily
undertaken by physician owned medical
liability insurers in California since 1989, the
physician owned companies have voluntarily
returned to California physicians over half a
billion dollars in policyholder dividends in the
1990s in response to savings realized through
application of MICRA. Since Prop 103 does
not affect policyholder dividends, these reductions
cannot be attributed to Prop 103.
MICRA has kept premiums in California
fair and predictable, not Proposition 103. This
is a clever trick by the trial lawyers, but has
no basis in fact. When Prop. 103 was passed
in 1989, the California medical liability insurers
were already returning MICRA savings to
physicians in the form of policyholder dividends.
Before MICRA, California physicians
paid the highest malpractice premiums in the
country. Today they pay a fair share — 11 %
of the total premiums across the country for a
state that has about 12 percent of the national
physician population. Furthermore, using real
dollars, the cost of California premiums has
gone down 51.9% since 1976, compared to a
crisis state like Nevada who has seen the average
premium cost per person go from $4.05 in
CONTINUED ON PAGE 30
12 / CALIFORNIA PEDIATRICIAN — SPRING 2003

Ten-Year Experience
with Pediatric Bilateral
Living Donor Lobar Lung
Transplantation
Marlyn S. Woo, M.D. and Vaughn A. Starnes, M.D.
running out of options
for this kid,” said the voice
“We’re
on the phone. My heart
sank at that statement from an experienced
physician. He had called to discuss his patient
referral that had arrived at our office only a few
days earlier. He had been unable to keep the
ten-year old boy out of the hospital for more
than a few weeks at a time, even though the
child had been on almost continuous intravenous
antibiotic therapy for several months. The
young boy was oxygen-dependent and could
not walk more than a few steps without dyspnea.
He could only speak two to three words
without pausing for breath. The medical team
had exhausted all conventional medical and
surgical options. What about lung transplantation
for this dying patient?
In the past, children with end-stage lung
disease were not likely to survive to receive
cadaveric lung transplantation unless they
were referred as soon as they entered the terminal
stage of their disease. Unlike heart or
liver transplant candidates, cadaveric lungs
available for transplant are allocated based
upon the blood type, size needed, and how
long the candidate has been waiting on the
list. Although lung transplant candidates with
idiopathic pulmonary fibrosis get three months
of time added at their initial listing, cystic
fibrosis and primary pulmonary hypertension
patients with type O or A blood types must
wait over a year (at times, five years!) before
a suitable cadaveric organ becomes available.
This situation puts these fragile children at a
disadvantage compared to the adult lung transplant
candidates (the primary adult diagnosis is
chronic obstructive pulmonary disease), who
comprise the majority of the cadaveric lung
transplant candidates. Thus, it is not surprising
that children are far more likely to die than
adults while awaiting lung transplantation.
The majority of pediatric lung transplant
candidates have cystic fibrosis as their primary
diagnosis. Hence, these patients with purulent
lung disease require double lung transplantation,
which also contributes to their increased
delay in obtaining suitable cadaveric organs. It
was in this milieu that the first human bilateral
living donor lobar lung transplantation was
performed. The patient was a 21-year old girl
with end-stage cystic fibrosis lung disease,
who had been listed for cadaveric lungs for
several months. She had been hospitalized for
several weeks and was not expected to survive
for more than a few weeks. Her parents asked
the transplant surgeon (Starnes) if they could
donate portions of their lungs to save her.
Dr. Starnes had already performed successful
human single lobar lung transplantation. After
clearance with the hospital Ethics Committee
as well as the Institutional Review Board, the
successful surgery took place January 1993 at
USC University Hospital. A few months later
(May 1993), the first successful human pediatric
bilateral lobar lung transplantation took
place at Childrens Hospital Los Angeles. The
pediatric patient was a 13-year-old male who
also had end-stage cystic fibrosis lung disease.
Since those first cases, over 150 living
donor bilateral lobar lung transplants have
been performed throughout the world. While
the majority have occurred in adult and pediatric
cystic fibrosis patients, this procedure has
also been successfully utilized for patients with
primary pulmonary hypertension, non-transplant
bronchiolitis obliterans, primary ciliary
dyskinesis, and severe bronchiectasis. As of
January 2003, Childrens Hospital Los Angeles
has performed 45 bilateral living donor lobar
lung transplants in children. Although living
donor lobar lung transplant recipients are generally
more ill than our cadaveric candidates,
there has been no significant differences in
length of intubation, post-operative ICU stay,
total length of hospitalization, or in perioperative
mortality between these two groups.
Although both cadaveric and living donor
recipients receive the same triple immunosuppression
therapy, pediatric living donor lobar
lung transplant recipients have better one year
survival and a significantly lower incidence of
chronic rejection/bronchiolitis obliterans syndrome
compared to cadaveric lung transplant
recipients at our institution. So should living
donor lobar lung transplantation be preferentially
performed in all pediatric lung transplant
candidates? There are several obstacles to performing
living donor lobar lung transplantation
in all pediatric candidates.
Living donor lobar lung transplant candidates
must meet the same criteria as those
being considered for cadaveric organs (Table
1). They must be healthy enough to survive
major surgery. Importantly, they must also
have at least two healthy donors acceptable
to the Transplant Team (Table 2). Our Center,
as well as the other United States Transplant
Centers who have performed more than living
donor lobar procedures, do not accept living
donor lobar candidates who have no emotional
attachment to the proposed recipient or family;
solicited or “stranger” volunteers; nor donor
candidates who have been coerced (selling
organs). Interestingly, over half of the living
lobar lung transplants have utilized lobes
donated by healthy adults who are not related
to the recipients.
CONTINUED ON PAGE 20
CALIFORNIA PEDIATRICIAN — SPRING 2003/ 13

The Tao of Pediatrics and
Chinese Medicine
Wendy Yu, M.S., L.Ac., Jeffrey I. Gold, Ph.D., Michael H. Joseph, M.D.
Tao means “the path” and according
to one of the most ancient recorded
texts, the Tao of the universe is
“change.” This is particularly relevant to
today’s model of healthcare as it undergoes a
radical paradigm shift: a shift from diseasecentered
care to patient-centered care. As we
realize that health is not just about a disease
factor, it’s about the whole environment, it
is becoming apparent that the treatment of
modern diseases requires more than the traditional
segmented view of the person.
The ancient Taoists were renowned for
the application of intricate and profound philosophies.
One of the greatest of these applications
is in the field of medicine. The ancient
Chinese felt pictures were superior methods of
conveying information. One of their most profound
symbols is the famous Tai Ji (Yin Yang)
Photography by Robin Dixon
symbol. Aside from the expression that energy
equals matter, this symbol also expresses the
interdependence of every part of a system.
Thus, Taoist theory did not separate a disease
from the environment it thrives in.
When treating a disease, the Chinese
used several strategies typically in combination:
attack the disease directly, strengthen
the host to overcome the disease, and change
the environment to where the disease can no
longer sustain itself. How can we apply these
strategies to pediatrics?
Because the ancient Chinese were an
agricultural society, they were very aware of
the interplay between people and their environment.
Thus they described imbalances of the
body in the same way they perceived imbalances
in the environment. There were disease
factors of cold (impeded circulation, organ or
glandular hypofunction), heat (inflammation),
dampness (fungus, molds, yeasts, endogenous
or exogenous toxins), external wind (viruses,
bacteria), internal wind (tics, tremors, seizures)
and dryness (dehydration). These disease factors
could be combined as well, so you could
have wind combining with heat, which could
be a bacteria or virus associated with sore
throat, high fever, rashes and sweating.
To correct imbalances, the Chinese took
a holistic approach. In the above example, not
only would the microorganisms be addressed,
but the internal environment would be altered
and the host strengthened.
This is where Chinese medicine
becomes an art. The
physician must decide which
part of the strategy to prioritize.
For example, in a strong
child, a physician may decide
to attack the microorganism
directly. In a compromised
child, the physician may want
to deal with the microorganism
indirectly by changing
the terrain of the body.
So what does altering
the terrain mean?
The internal environment
is a result of the interaction
of many factors that
include genetics, diet, emotional
factors, and external
environmental factors (such as xenobiotics, climate,
radiation and other geopathic stressors).
Altering the terrain can involve detoxification
of xenobiotics and endotoxins, resolution of
nutritional deficiencies and regulation of other
physiological processes in the body. To accomplish
this, Chinese medicine utilizes a wide
variety of modalities such as acupuncture,
herbal medicine and dietary therapy.
Before applying these therapies, a thorough
evaluation must be performed. In children
it is difficult to rely on subjective complaints so
the Chinese have developed an intricate diagnostic
system based on observation and palpation.
Facial complexion, eyes, hands, nails,
body morphology, tongue, ears, and mouth are
examined. Qualities in the radial and carotid
pulses, variances in temperature and quality at
specific acupoints on the abdomen and along
the paravertebral muscles are often palpated.
Once the terrain has been assessed, then the
appropriate treatment can be applied.
Acupuncture
Acupuncture is a surprisingly effective modality
for affecting many physiological processes
in the body. According to acupuncture theory,
energy circulates through the body along a
series of pathways called meridians. Most
meridians correspond to different organ systems
and travel through all layers of the body.
Researchers are attempting to explain this
phenomenon in many ways. Measurements
of electrical current, release of enkephalin,
â-endorphin, serotonin, norepinephrine and
CONTINUED ON PAGE 28
14 / CALIFORNIA PEDIATRICIAN — SPRING 2003

IN MEMORIAM
Joseph H. Davis
March 16, 1914-March 5, 2003
My father passed away last month, less than two
weeks from his 89th birthday. I am sure that a very
large percentage of California pediatricians knew
my dad personally, some of them for longer than
I did! I have been asked to write a memorial, but
since many of his accomplishments are already
widely known, I will mention only a few, and try to
share some personal reflections.
One of life’s ironies is that my father had
moved to Santa Rosa only three months ago. Many
said it was so that he could be closer to me, but,
in truth, it was to be closer to his friend and companion, Helen
Rudee. My mother passed away in 1998. “Doc” had known Helen
since she was a nursing student in one of the courses he taught at
Stanford in the 40s, and they had kept in touch through Stanford
alumni functions. She had been twice widowed and they reconnected
these past several years. My dad said that as a result, he had
never been happier. I too enjoyed having him live closer. We were
beginning a whole new relationship, and I was spending more time
with him than I ever had before.
Doc was born in San Francisco. He was an Eagle Scout, and
graduated a couple of years earlier than normal from Lowel High
School. He was identified as gifted and included in the original
study group by Dr. Louis Terman. This so called group of “termites”
was followed longitudinally over the course of their lives, as were
their offspring, and I recall taking IQ tests on several occasions as a
child to help them determine how the gene pool got diluted. I don’t
mean this as any reflection on my mother’s side of the family; it’s
just that not many people could keep up with my father’s drive and
energy. He has aptly been compared with the Energizer Bunny, but
described himself as hyperactive, and said that were he to have
attended school now, he would have been put on Ritalin. He claimed
that the only reason that he skipped grades was so that certain teachers
wouldn’t have to deal with him any more.
After graduating from Stanford Medical School and then
doing a brief period in practice in San Francisco, he went overseas
with the US Army for four years (while I was age 1-4) during
WWII and served in the Pacific, seeing action in New Guinea and
the Philippines. At the end of the war, he joined Dr. Esther Clark
at the Palo Alto Clinic, where he worked for 52 years. When he
joined, office visits were $3 and house calls $4, and he made LOTS
of house calls. Consequently, he was rarely home, and to have time
with him, my mom, my sisters and I would often ride along with
him in the evening after dinner. When he could no longer work a
full shift as a pediatrician (in his late 70s and with no hip joints)
he created a new job for himself at the clinic as the advice “nurse”
and would work half-day taking the advice calls from patients.
This was so effective, that the internal medicine department hired
some of their retired physicians to do the same.
When he finally left the clinic he continued to volunteer as
a pediatrician in other clinics, the most recent being Samaritan
House in San Mateo (where memorial donations can be made in
his name: www.samaritanhouse.com). He only left there to move
to Santa Rosa, and described himself to his new
neighbors as “semi-retired.”
In addition to the Chapter 1 AAP newsletter,
Doc was active in many other of the AAP functions.
He became an advocate for adopted children who
were trying to trace their biological roots, and for
parents who were likewise trying to find children
that they had given up for adoption. He worked
with a volunteer organization called “PACER”
(Post Adoption Center for Education and Research;
www.pacer-adoption.org) that is now located in
Carson City, NV and houses a computer database of adopters
and adoptees in the effort to promote reunions. (They are another
group worthy of charitable donations).
His other life-long interest was the Boy Scouts of America.
As mentioned, he became an Eagle Scout as a youth. He claimed
that his experience at scout camp working with the camp physician
was one of the motivating factors in his own decision to become
a doctor (besides having a Jewish mother). When I joined the
scouts, he renewed his interest and involvement. I made it to the
rank of “life” scout at around age 14, and then lost interest and
quit, but my dad stayed on, organized and ran a medical explorer
post and continued right up until the time he left Menlo Park. The
Boy Scouts awarded him the Silver Beaver (their highest award)
for his lifetime achievements in scouting (we always referred to it
as the “eager beaver award”). He was most proud of the number
of graduates from his post that actually went on to careers in the
medical professions.
On Feb. 21, the pediatrics department at Stanford had Dr.
Charles Prober present grand rounds in honor of the career of
Joe Davis. Dr. Prober gave a marvelous talk comparing the history
of antibiotics with the life of Joe Davis (he was a medical
student when Alexander Fleming discovered penicillin). This was
attended by many of his colleagues as well as some friends and
family members. In retrospect, Doc was one of the very few people
privileged to attend their own memorial service. On April 3, the
City of Palo Alto posthumously awarded the Tall Tree Award to
him. This is their highest award for a lifetime contribution of community
service.
Finally, it must be said, that Doc was vital right up to the
very end. His body wore out, but his mind never did. Ultimately,
he died of congestive heart failure after an unsuccessful attempt at
placing an implanted pacemaker. He was ill for less than a week
(that he would admit to, but that’s another story), and was physically
uncomfortable for less than three or four hours. He died the
way he would have wanted to, leaving behind long lists of things
he had been planning to do! He is survived by my sisters, Nancy
Levy and Betsy Faen, and our spouses, as well as six grandchildren
and two great grandchildren. He is missed.
A memorial service for Joe will be held at the Stanford
Chapel on June 5 at 4 p.m.
Leland Davis
CALIFORNIA PEDIATRICIAN — SPRING 2003/ 17

Chronic Pain in Children: A Multidisciplinary
Biopsychosocial Treatment Approach (Part III)
Michael H. Joseph, M.D. and Jeffrey I. Gold, Ph.D.
Having discussed a model of pain
perception and assessment, we
will now complete our three part
series with a discussion about comprehensive
treatment for children with chronic pain. Pain
perception and assessment requires a biopsychosocial
approach to treatment. As clinicians
treating chronic illness, we are all challenged
to stretch treatments beyond acute symptom
management and to embrace a rehabilitation
model of therapy. Simply stated, the child and
family cannot simply wait for the pain to go
away, but rather they must all be active participants
in maintaining the goal of increased daily
life functioning and decreased pain perception.
If our ultimate objective is to retrain the child’s
central nervous system (CNS) to decrease
overall pain perception, we must decrease all
ongoing nociceptive pain and support, encourage,
and reinforce the child in working through
chronic pain symptomatology.
Rehabilitation
The idea of a Cartesian dualistic mind/body
split significantly limits our therapeutic
options. In order to successfully treat and rehabilitate
children with chronic pain, treatment
must always include a combination of biological,
psychological and social interventions.
Once again, an interdisciplinary team approach
to treatment is essential. Those clinicians with
limited experience in an interdisciplinary treatment
approach should study a few necessary
requirements. These requirements include a
shared theoretical pain philosophy, the belief
that all pain is real and that rehabilitation is the
primary goal. Crucial to the success of an interdisciplinary
team approach is mutual respect,
cooperation, communication and consistency.
The more clearly aligned the team is with the
overall rehabilitation objective the greater the
benefit to the child and family.
In the rehabilitation model, the most
important component of care for children with
chronic pain is to maximize their functioning.
Because a child’s primary job is attending
school, clinicians and family members must
be coached to encourage and support as much
school participation as possible. Research
has shown in children with chronic pain and
terminal illness that school reintegration has
therapeutic and rehabilitative qualities (Bouffet,
Zucchinelle, Costanzo, 1997). Clearly,
school represents both academic and social
life, provides an excellent distraction from
over-focus on chronic pain symptoms and
keeps the child on a normal developmental
track. Preventing further setbacks from painrelated
absenteeism can preserve and promote
the child’s level of self-efficacy, provide social
gains, maintain academic and cognitive development
and decrease the stress associated with
missed schooling. School attendance alone has
been shown to be the most significant predictor
of long-term positive outcome for children with
chronic pain. Daily school participation and
overall functioning can often remediate specific
psychological and social deficits or problems,
enhance and maintain communication with
peers and family, facilitate adaptive coping and
problem solving skills and provide symptom
reduction due to distraction and emersion.
With a focus on daily function, a well
designed exercise program can provide additional
advantages. Research has demonstrated
that exercise provides many benefits for children
with chronic pain. To gain the maximum
benefit from exercise our emphasis is always
on non-impact aerobic exercise (walking,
biking and swimming). The overall goal is
to promote increased cardiovascular function
and physical movement, while minimizing the
potential for further injury or harm. The known
benefits from routine sustained cardiovascular
exercise include the release of endorphins,
which can be associated with decreased pain
and improved mood and sleep. Critical to this
goal is to support gradual progress and to avoid
further complications due to rigorous or excessive
exercise. Referral to a physical therapy
program is often warranted. In addition to
customizing and supervising the exercise program,
physical therapists often employ other
beneficial modalities such as massage, thermal
and cryo-therapies and electrical therapies
such and TENS and Interferential therapies.
Sleep hygiene is another area that is obviously
essential for children with chronic pain.
Sleep disturbances (initiation, maintenance,
quality) in children with chronic pain is well
documented and needs to be addressed when
developing a treatment strategy. This goal
is accomplished via medication, relaxation
and good sleep hygiene practices. This goal
requires detailed psychoeducation regarding
sleep hygiene practices, the identification of a
good sleep aid and relaxation training. Usually,
this combination therapy aids the child in initiating
and maintaining good sleep patterns.
Chronic pain therapy offers many challenges
for the child, the family and the treating
team. Patients and families often have
difficulty adopting a rehabilitation philosophy
in lieu of an acute pain management model.
They often search for the underlying etiology
and are overly concerned with the diagnosis
and medication therapy. Families who are
seeking diagnosis and acute treatments are not
as well prepared to accept the chronic nature
of the pain or the rehabilitation philosophy.
In order for the overall treatment to be ultimately
successful the child and the family
must understand and accept the rehabilitation
philosophy above the acute symptom reduction
model. Ultimately, for the program to be
successful, the family “must” work toward
the rehabilitation goals. Often, emotional and
physical demands associated with a longterm
rehabilitation model, places stress on
the family and can create additional distress
on the child. Interestingly, if the family is
resistant to the treatment philosophy or they
experience distress related to the treatment,
often the treating team may also experience
their own resistance and/or distress. In these
circumstances it is vital that the team continue
to provide support, compassion and ongoing
psychoeducation regarding the nature of the
pain and associated distress.
In the initial stages and throughout the
treatment, psychoeducation is essential in
providing the family with an alternative understanding
of pain. Rather than an emphasis
focused on finding the “cause,” discuss pain in
terms of pain mechanisms (i.e., nocioceptive,
anti-nocioceptive, nervous system dysregulation,
hyperalgisa), resulting from a neural
signaling problem versus ongoing tissue
damage. Explain that a goal is to decrease
neural “irritability” and enhance the child’s
own pain inhibitory mechanisms. Discuss
the visceral, somatic, spinal, emotional, cognitive,
and environmental factors that each contributes
to the pain. The family does not need
to become pain specialists, but they require a
framework of information from which they can
base decisions. Once the family and child have
understood and accepted the rehabilitation
model most all interventions and treatments
are designed to keep the patient functioning
and on a path to recovery.
18 / CALIFORNIA PEDIATRICIAN — SPRING 2003

Drawing by a 19-year-old female patient with sickle-cell anemia.
Cognitive and Behavioral
Therapies
All effective biopschosocial treatment plans
include psychological interventions. The
degree of intervention is contingent on many
factors, but mostly the family and the child’s
willingness to participate. Most children can
benefit from relaxation therapy and cognitive
behavioral therapy. These interventions are
effective at targeting stress reduction, sleep
hygiene, school reintegration, peer socialization,
family functioning and empowering the
child to use his/her brain to decrease pain signaling.
Teaching children relaxation exercises
has been demonstrated to be more effective in
the reduction of chronic headaches than medication
alone. These interventions often include
diaphragmatic breathing, progressive muscle
relaxation, guided imagery, biofeedback and
hypnosis. Often when focusing on relaxation
alone other stress, anxiety or depression may
emerge as a result of chronic pain problems,
or family / peer difficulties. Addressing these
issues as they arise in therapy can further
reduce distress, which contributes to overall
pain problems.
In addition to individual therapy, family
therapy (i.e., home-based behavioral programs)
can further enhance the child’s functioning and
decrease the family’s reinforcement of negative
pain behaviors (i.e., asking about pain,
over-focus on pain, doing things for the child
that s/he can do for themselves). Occasionally,
the primary pain reinforcers of the pain are the
parents. Parents often unknowingly facilitate
pain behavior, when they believe they are
assisting the child for his/her best interest. The
goals of family therapy are to further provide
a conceptual framework for understanding
chronic pain, enhance parenting skills that
target increased child self-efficacy, identify and
teach appropriate interventions to address psychological
and behavioral goals, to facilitate
emotion-based communication and promote
problem solving within the family. Ultimately,
the goal of family therapy is to reset the child
and the family’s behaviors surrounding the
newest member of the family — “pain.” By
eliminating or altering the negative pain reinforcers
the family can actively participate in
their child’s rehabilitation. Often parents need
assistance in fine-tuning their parenting skills
that eliminate the reinforcing properties of
negative pain behaviors and promote increased
daily function.
Pharmacological Therapy
The first and best pharmacological intervention
is prevention when possible. Aggressively
treat acute pain in order to prevent dorsal horn
sensitization. Once chronic pain has set in the
goal of pharmacological therapy becomes one
of support. Reducing the symptoms enough so
the patient and family can adopt the rehabilitation
model with less distress.
Few medications have been shown to be
effective. Opioids play a minimal role since
the neuro-physiology of chronic pain diminishes
their effectiveness. On the other hand if
the patient has ongoing nociceptive pain (i.e.
tumor infiltration, or chronic inflammation)
opioids can play a supportive role in therapy.
The use of a long acting preparation with a
shorter acting opioid for breakthrough pain
is the most effective regimen for pain control
and the least likely to produce psychological
addiction or conditioning. Lastly because opioids
may not be effective for chronic pain the
simple upward titration may not result in analgesia
but rather sedation and adverse effects.
Pharmacological therapy can target other
associated symptoms of chronic pain, such
as CNS hypersensitivity. Amitripytiline has
been shown in both adults and children to be
effective in many forms of chronic and recurrent
pain. It is a tricyclic antidepressant and
therefore a norepinephrine and serotonin reuptake
inhibitor. TCA’s are thought to increase
antinociceptive tone, consequently decreasing
chronic pain perception. Gabapentin an antiepileptic
medication has also been shown
to decrease the symptoms of chronic pain,
especially neuropathic pain. Its mechanism of
action is less understood, but it appears to work
at the dorsal horn level reducing hypersensitivity.
Medications can also be very useful to
facilitate night sleep (amitriptyline, trazadone),
treat anxiety/depression (SSRI) and to treat
somatic contributors (topical and local anesthetics,
muscle relaxants).
Integrative Therapy
In addition to the above-mentioned interventions
for children, integrative therapies have
been gaining increased exposure and have
undergone greater experimental rigor. While
many of the integrative therapies have been
shown to benefit children with a variety of
pain-related problems, we have listed a few
that we prescribe routinely with good results.
Hypnosis, which works through the creation
of a narrow focus of attention and specific
imagery to reduce distress, to reframe the
experience and help the child dissociate from
the pain, has been shown to be effective in
reducing pain and anxiety during medical procedures
(Zeltzer & Lebaron, 1982), decreasing
chronic headache (Olness, McDonald
& Uden, 1987) and decreasing side effects
from chemotherapy (i.e., nausea). Researchers
and clinicians alike understand that the
underlying principles that guide hypnosis are
based in stress reduction and relaxation. The
CONTINUED ON PAGE 20
CALIFORNIA PEDIATRICIAN — SPRING 2003/ 19

LUNG TRANSPLANTATION CONTINUED
FROM PAGE 13
There are also ethical issues to consider
in the living donors: it is very troubling to
endanger two perfectly healthy individuals
for a chance to prolong the life of another.
However, living donor transplantation is an
accepted option for both kidney and liver failure
patients. And in contrast to the kidney and
liver live donor transplant procedures, there
have been no deaths in the live donors for lobar
lung transplantation.
We conclude that living donor lobar lung
transplantation is an option for selected children
with end-stage lung disease. In certain cases, particularly if the child is not likely to survive
the wait for a cadaveric organ, it may be the surgery of first choice.
REFERENCES
1. Starnes VA. Barr ML. Cohen RG. Lobar transplantation. Indications, technique, and outcome.
Journal of Thoracic & Cardiovascular Surgery. 108(3):403-10; discussion 410-1, 1994 Sep.
2. Woo MS. MacLaughlin EF. Horn MV. Wong PC. Rowland JM. Barr ML. Starnes VA. Living
donor lobar lung transplantation: the pediatric experience. Pediatric Transplantation. 2(3):185-90,
1998 Aug.
3. Starnes VA. Woo MS. MacLaughlin EF. Horn MV. Wong PC. Rowland JM. Durst CL. Wells WJ.
Barr ML. Comparison of outcomes between living donor and cadaveric lung transplantation in
children. Annals of Thoracic Surgery. 68(6):2279-83; discussion 2283-4, 1999 Dec.
4. Woo MS. MacLaughlin EF. Horn MV. Szmuszkovicz JR. Barr ML. Starnes VA. Bronchiolitis
obliterans is not the primary cause of death in pediatric living donor lobar lung transplant recipients.
Journal of Heart & Lung Transplantation. 20(5):491-6, 2001 May.
Table 1 - Criteria for Living Donor Lobar Lung Transplant Candidates
End-stage lung disease that has failed conventional medical/surgical management
No significant kidney/liver disease
No significant cardiac disease/ventricular dysfunction
No active Mycobacterial disease
No active or recent psychiatric disease
Adequate psychosocial support (phone, transportation, housing, etc)
No other significant medical disease which would limit lifespan
No medical compliance problems (patient or caregivers)
HIV negative
No medical condition that would prevent access to removal of lungs (spinal fusion, etc)
Availability of at least two suitable donors (for bilateral lobar)*
* see Table 2
Table 2 - Criteria for Live Lobe Donors
ABO compatible to prospective transplant recipient
Age 18-55 years
No significant past medical history
No recent viral infections (no active EBV, Hepatitis)
Normal pulmonary function tests (FEV1 and FVC > 85% predicted)
Oxygen tension > 80 mmHg on room air
No smoking history for >5 years
Normal chest radiograph
CT scan of chest with no significant pathology (totally normal on proposed donor lobe side)
No previous thoracic surgery on donor side
Normal echocardiogram
Normal coronary angiogram (if indicated)
No coercion or payment for organ donation
Demonstrated close emotional relationship with patient and/or family
CHRONIC PAIN CONTINUED FROM PAGE 19
obvious benefits of relaxation/hypnosis are
exactly competing to the physiological arousal
associated with pain and distress. Similar to
hypnosis, meditation, or the self-focus on a
single word or nothingness while clearing the
mind of all thoughts, has also been show to
be highly effective in reducing pain intensity,
frequency and duration in patients suffering
from migraines.
Massage, defined as either light or deep
tissue and body stroking, has been shown to be
effective in reducing a number of pain symptoms
in children with a variety of pain conditions.
Studies have shown pain reduction in
children with burns, decreased stress hormones
(cortisol and norepinephrine), increased quiet
sleep, increased cytotoxic capacity in children
with juvenile rheumatoid arthritis (Field et. al.,
1997), and the treatment of migraine (Hernandez-Reif
et. al., 1998). The nature of compassionate
touch/massage to children with chronic
pain has demonstrated benefit in immediate
and long-term care.
Acupuncture — the use of needles, heat,
pressure, or other stimulation at points along
the meridian — can be used to to achieve flow
of energy or QI. Acupuncture has been shown
to decrease pain and to increase beta-endorphin
levels and opioid receptors in adolescent
migraine sufferers. Despite its increasing use
as an integrative therapy to treat pain, acupuncture
is rarely considered by pediatricians. In
part this phenomenon is due to perceptions that
it will not be acceptable to pediatric patients or
their family. For further details please review
“The Tao of Pediatrics and Chinese Medicine”
in this issue.
The treatment of chronic pain in pediatric
patients has received little attention to date.
Therefore, there is a lack of empirically based
comprehensive treatments designed to provide
care for these patients. Our clinical experience
embraces the integration of mind and
body as the most effective approach to treating
pediatric chronic pain. This integration
informs a model of assessment and treatment
focused on rehabilitation. Understanding this
model of practice requires frequent evaluation
of the child’s progress, as well as consistent
reinforcement and support of the patient and
family. The comprehensive treatment model
has generated good clinical outcomes for
patients and families who have viewed the
chronic pain clinic as the “last stop.”
“The only source of knowledge is experience.”
— Albert Einstein
20 / CALIFORNIA PEDIATRICIAN — SPRING 2003

Twenty-Five Years of Home Mechanical
Ventilation in Children:
The Program at Childrens Hospital Los Angeles
Manisha Witmans, M.D., Sheila S. Kun, R.N., M.S., and Thomas G. Keens, M.D.
Braun introduced the idea of mechanical
ventilation in 1889 and by the
mid 1940s hospitals were able to
care for adults with respiratory failure with
large ventilators called “iron lungs.” The technology
has continued to evolve from a large,
intrusive hospital based system to a lighter,
portable system that allows families to care for
medically complicated patients at home.
Home mechanical ventilation has
changed tremendously in the last 25 years.
The home mechanical ventilation program at
Childrens Hospital Los Angeles (CHLA) is
an example of what is achievable in children
with chronic respiratory failure who require
mechanical ventilation. Since the inception
of the home ventilator program in 1977, the
CHLA program has grown to include over 375
children who are followed for home mechanical
ventilation. The program children requiring
assisted mechanical ventilation have ventilatory
muscle weakness (45%), chronic lung disease
(hypoplastic lungs and chest wall defects)
(26%) and central hypoventilation syndromes
(29%). The CHLA program is unique in that
there is a large number of small infants with
chronic lung disease.
The need for mechanical ventilation
is likely when there is either an increase in
respiratory load or deficiency in the ventilatory
muscle power or central drive, such that
adequate oxygenation and ventilation cannot
be achieved without assistance. Chronic ventilatory
failure is defined as a medical condition
from which an infant or a child, who is
otherwise medically stable, requires mechanical
ventilation and cannot be weaned from
ventilation, despite repeated attempts. Unlike
adults, infants and children are more prone
to respiratory failure because of decreased
ventilatory muscle strength, diaphragm muscle
fatiguability, and smaller airways prone to atelectasis
and obstruction, and proportionately
increased respiratory loads. Thus, infants and
children require different ventilatory strategies
compared to adults.
The philosophy of home ventilation is
quite different from the intensive care perspective
because the goal is to provide chronic,
not acute, support of ventilation. The ventilator
is adjusted to completely meet the child’s
age-appropriate physiological ventilatory
requirements rather than just providing support
to minimize work of breathing. Using the
ventilatory parameters from the intensive care
setting often underestimates ventilatory needs
for home, as children are more likely to be
active at home. This approach allows the child
to expend energy for activities of daily living,
rather than ventilation alone. The strategy
for chronic ventilation is also different from
intensive care units. Smaller, uncuffed tracheostomy
tubes are better alternatives because
they prevent tracheomalacia, iatrogenic tracheal
trauma and allow room for ventilation to
bypass the tracheostomy in the event of tube
obstruction. In addition, they allow children to
speak, as many children on home mechanical
ventilation are able to attend school and other
social events where speaking is necessary.
Ideally, the ventilator parameters are adjusted
to meet the patients’ needs instead of making
the patient adapt to the ventilators mechanical
capabilities.
A variety of modes of ventilation and
types of ventilators are available in the United
States. The choice of ventilator is dependent on
the underlying medical condition and the individual
patient needs. The modes of ventilation
include: non-invasive positive pressure ventilation
with bi-level positive airway pressure,
positive pressure ventilation with a tracheostomy,
negative pressure ventilation and diaphragmatic
pacing. The most common mode of
ventilation is via a tracheostomy and a portable
home ventilator. Compared to older ventilators,
the advantages of the newer ventilators
include: continuous flow, ventilatory strategies
that provide pressure support and/or positive
end-expiratory pressure and have a lightweight
internal battery. Ventilator malfunction is also
surprisingly uncommon. The newer ventilators
are able to provide ventilation for children with
more severe lung disease at home, which has
resulted in improved survival quality of life.
A popular method of providing assisted
ventilation non-invasively is bi-level positive
airway pressure (B-PAP). The interface
consists of a nasal or facemask that delivers
compressed air to splint the airway open
and provide positive inspiratory pressure.
Currently, over 100 children on B-PAP are
followed at CHLA. Children with congenital
hypoventilation, ventilatory muscle weakness
and certain types of chronic lung disease can
be ventilated with B-PAP, especially if the
ventilatory requirements are sleep related. This
type of ventilation does not require a tracheostomy,
has minimal side effects (nasal irritation,
skin breakdown, intolerance of the mask) and
is well tolerated in children.
Children that need mechanical ventilation
have some special requirements related
to ongoing care and follow-up. During acute
illnesses, these children have to be monitored
closely as they may not show signs of respiratory
distress as noticeably as other children.
They may need increased bronchodilator
treatments, more airway clearance treatments,
diuretics, and/or chest physiotherapy. They
often need increased ventilatory support during
respiratory tract infections and hospitalizations.
Two relatively easy monitoring methods
are: pulse oximetry and end tidal Pco 2
monitoring
to ensure adequate oxygenation and
CONTINUED ON PAGE 27
CALIFORNIA PEDIATRICIAN — SPRING 2003/ 21

Childcare Health Linkages Program:
How Pediatricians Can Collaborate with
Local Childcare Health Consultants
Robin Calo, R.N., M.S., P.N.P. and Karen Sokal-Gutierrez, M.D., M.P.H.
When you think about the young
children in your practice, who
besides their parents takes care
of them? Traditionally, pediatric health professionals
have focused on parents and the home
setting to promote the health and safety of
young children. However, a large proportion
of young children spend a significant amount
of time in the care of other adults in out-ofhome
settings. When providing health services
for children and families, pediatricians need to
also consider children’s “extended families,”
including relatives and childcare providers.
Why is childcare important to
children’s health?
Over the past 20 years, as more parents return
to work and school, the proportion of young
children attending childcare has increased by
50%. 1 Currently, over 60% of children under 6
years of age regularly attend child care. 2 This
includes 44% of children under 1 year of age, 3
and 77% of 3-5 year olds. 4 For children under
age 5 in childcare, 41% spend 35 hours or more
per week in childcare. 5
Children are cared for in a variety of
childcare settings including childcare centers
and preschools; family childcare homes; and
by nannies, family members and friends in
their homes and/or the child’s home. Commonly,
families use a combination of childcare
arrangements.
Childcare providers, like parents, deal
with a wide range of child health issues on
a daily basis, including promoting children’s
development, nutrition, preventing injuries,
caring for children with special needs, reducing
the spread of infectious diseases, caring for
mildly-ill children, and emergency preparedness.
California licensing regulations require
that childcare providers have 15 hours of
health and safety training, but the training is
limited and many unlicensed caregivers have
no health training at all.
How can childcare health
consultants assist childcare
programs?
In response to the need for assistance on
child health and safety issues in childcare,
the federal Department of Health and Human
Services Maternal and Child Health Bureau
funded national and state Healthy Childcare
America initiatives and the National Training
Institute to promote health consultation
to childcare programs. Until recently, only
a few counties in California provided health
consultation to childcare. In 2000, however,
First Five California (Proposition 10) funded
the University of California San Francisco-
California Childcare Health Program (UCSF-
CCHP) to create the Childcare Health Linkages
Project (CCHLP) to develop childcare health
consultation programs in 21 counties across
California: Alameda, Colusa, Humboldt, Inyo,
Kern, Lake, Los Angeles, Marin, Mendocino,
Napa, Sacramento, San Benito, San Francisco,
San Luis Obispo, Santa Clara, Shasta, Nevada,
Siskiyou, Sonoma, and Yolo. There are also
childcare health consultation programs operating
without CCHLP funding in Long Beach,
Orange, San Diego, Santa Barbara, and San
Bernadino counties. UCSF-CCHP provides
training and technical assistance for all of the
childcare health consultation programs.
The CCHLP model of childcare health
consultation consists of a network of trained
childcare health consultants and Childcare
Health Advocates who provide health education
and consultation to all types of childcare
programs. All of the childcare health consultants
and Advocates have completed nine days
of specialized training on childcare health
through UCSF-CCHP’s California Training
Institute.
The Childcare Health Consultant is a
licensed health professional, typically a nurse
with pediatric expertise, employed by either
the local public health department or a community
agency such as the childcare resource
and referral agency. The Childcare Health
Consultant serves as a link between the pediatric
medical community, childcare providers
and families. Childcare health consultants
address a wide range of issues including access
to health care, immunizations, infant and child
nutrition, child behavior and development,
infection control, playground and child passenger
safety, special health care needs, and
child abuse. Some of their activities include:
• Making site visits to childcare programs
to conduct health and safety assessments
• Providing linkages and referrals to medical
homes, health insurance, and other
community services
• Coordinating health, dental, hearing, or
vision screenings for children in child
care
• Working with the pediatric provider,
family and childcare provider to develop
care plans for children with special needs
• Conducting trainings on specific health
and safety issues for childcare staff, parents,
and/or children
22 / CALIFORNIA PEDIATRICIAN — SPRING 2003

The childcare health advocate is usually
a teacher at a childcare program. The health
advocate is the on-site liaison who collaborates
with the childcare health consultant to
promote health and safety in the childcare
environment.
How can pediatricians link with their
local childcare health consultant?
Pediatricians and childcare health consultants
are working toward the same aim: to
promote children’s health and prevent disease
and injury. The following case studies illustrate
successful collaborations between physicians
and childcare health consultants:
In Kern County, childcare health consultants
work with local physicians to develop
individual care plans for children in childcare
with special health care needs (e.g., asthma,
diabetes, and orthopedic conditions). The care
plans instruct childcare providers on the child’s
health conditions; routine care measures,
medications and equipment; how to prevent
complications; and emergency procedures.
The childcare health consultants also help
ensure that caregivers receive the necessary
medications, equipment, and training to implement
the care plans. Since asthma is one of the
most common special health needs, childcare
health consultants have developed trainings
for local childcare providers on how to give
inhaled medications to children with asthma.
This collaboration has helped childcare providers,
parents and physicians feel more confident
that children with special health care needs are
cared for safely in childcare programs.
In Inyo County, childcare health consultants
and advocates help children prepare for
their preschool and kindergarten well-child
medical visits by setting up a practice “visitto-the-doctor.”
Local pediatricians loaned
medical equipment to the staff of the Childcare
Health Linkages Project. The childcare health
consultant and advocates set up a mini-clinic
and checked children’s blood pressures and
reflexes; looked in their eyes, ears, and throats;
listened to their hearts and lungs; and gave the
children a chance to receive a pretend shot and
a fun bandage. Parents and pediatricians stated
that the children were more prepared for their
medical visit, which made it a better experience
for everyone involved.
In other counties, pediatricians have
served as consultants to local childcare health
consultants and childcare providers on children’s
health, development and safety. Pediatricians
have also provided workshops for
childcare program staff, parents and children
on a variety of health topics; participated in
community-based health promotion and injury
prevention programs in childcare; and served
on childcare program boards of directors and
health advisory boards.
Consider exploring new avenues for
promoting children’s development, health and
safety in your community by collaborating
with your local childcare programs. For more
information, contact:
Robin Calo, RN, PNP, Coordinator
California Childcare Linkages Project
University of California San Francisco
California Childcare Health Program
1322 Webster Street, Suite 402
Oakland, CA 94612
(510) 839-1195
www.ucsfchildcarehealth.org
NOTES
1. U.S. Department of Education, National
Center for Education Statistics, 1995.
2. U.S. Department of Education, National
Center for Education Statistics, 1999.
3. U.S. Department of Education, National
Center for Education Statistics, Data from
the 1995 National Household Education
Survey, 2000.
4. U.S. Department of Education, National
Center for Education Statistics, Digest of
Education Statistics, 2002.
5. Urban Institute, 1997 National Survey of
Families, 2000.
Eve Black Honored
On February 8, 2003, at the Annual Joint District Meeting, Eve Black was honored for her
nearly 50 years of hard work and dedication to the children and pediatricians of California. In
addition to a plaque from the California District American Academy of Pediatrics, which was
presented by Burt Willis, M.D., District Chair, Eve received a check for $1,000 to the Gene
Black Summer Career Program. The summer program, which introduces high school juniors
and seniors to careers in the health professions, is named in honor of her husband, Gene Black.
It is administered by the Los Angeles Pediatric Society.
Eve’s work with Chapter 2 and with LAPS has been comprehensive and wide-ranging. As
Chapter Administrator for Chapter 2 and Executive Secretary for LAPS, Eve Black continues in
her role as champion of the children of California and the physicians who look after them.
Burt Willis presents Eve Black with a plaque honoring her many years of service.
CALIFORNIA PEDIATRICIAN — SPRING 2003/ 23

Annual Las Vegas Seminars —
25 Years of District Education
and Support
Rosalie Blazej and Milton Arnold, M.D.
November 20-23, 2003 marks the
25 th anniversary of the American
Academy of Pediatrics California
Chapters 1, 2, 3, and 4’s Annual Las Vegas
Seminars.
Conceived in the late 1970s as the first
joint California Chapters CME meeting, the
seminars offered the practicing pediatrician
a “maximum of learning in a comfortable,
relaxed, and informal atmosphere.” Twentyfive
years later, the seminars have grown from
250 registrants to over 800, but the emphasis
on learning in a venue of relaxation and
world-class accommodations has remained
unchanged. Meeting attendees come from all
over the U.S. and from foreign countries. Over
65% of 2002 registrants came from areas outside
of California.
At each meeting, nationally known
speakers deliver presentations from varied
and wide-ranging pediatric subspecialties.
Speakers for the 2003 Seminar include Angela
Anderson, M.D., Daniel L. Coury, M.D.,
Kathryn Edwards; M.D., Lewis R. First, M.D.,
Francine R. Kaufman, M.D., and Anthony J.
Mancini, M.D.
Not only do the seminars benefit the
individual pediatrician, the meetings have
become the principal source of funding for
the District’s advocacy efforts on behalf of the
children of California. Dr. Milton Arnold, who
was a catalyst in organizing the first meeting,
remains the program chairman and the educational
and financial success of the Las Vegas
Seminars is due in large part to his tireless
work. The seminars are also indebted to Dr.
Anthony Hirsch and Dr. Martin Gershman,
who were among the first to advance and support
the idea of a joint meeting in Las Vegas.
The Venetian Resort and Casino was the
site of the 2002 Las Vegas Seminars and will
again serve as the meeting venue for 2003.
Over three hundred of the hotel’s exquisite
Luxury and Bella suites have been set aside
for meeting registrants at special seminar rates.
Advance meeting and hotel registration forms
are printed on the inside back cover and are
also available on the Web at www.aapca2.org.
24 / CALIFORNIA PEDIATRICIAN — SPRING 2003

Selling Tobacco Products as a
Public Health Issue
Trisha Roth, M.D.
This year, the California State Legislature
will be acting on a bill to
increase the sale age for tobacco to
21. This proposal causes us to think about the
current state of smoking in California, question
the age-18 law that is a standard nationwide,
look for any signs that this would help reduce
tobacco addiction, and think about the social
mores regarding a person’s age and their relative
ability to take risks with their own lives.
It is clear that California is at the cutting
edge of national and international tobacco
reforms. The state has comprehensive restrictions
on smoking in public places, an 87¢
per-pack tax on tobacco, and an aggressive
anti-tobacco advertising campaign.
For most California adults, the tobacco
culture of the 60s and 70s is clearly waning.
There are few public places, aside from workplace
entryways crowded with smokers, where
adults see other adults smoke. We are also relatively
free of widespread tobacco advertising;
there is no longer a skyscraper high Marlboro
Man on Sunset Boulevard, and there are few if
any tobacco advertisements in our newspapers
and major publications.
Yet this is not a time to grow complacent.
The fact is, while we may think that the battle is
being won, it has actually just moved below our
radar. According to a Surgeon General’s report,
if a person is not addicted by the age of 21 there
is less than a 5% chance that they will ever
become addicted. For this reason, the 18-20
year old population is the new battleground, and
the tobacco companies have shifted their $10
billion advertising campaign to most directly
affect the smoking rates for this age group.
This tobacco industry strategy has
worked. In California the smoking rate for
18-20 year olds has increased more than 35%
over the past eight years. The rate of addiction
for this age group is 40% higher than for those
over 30 years old. This growing rate of smoking
threatens to undo the effects of years of
tobacco reform in California.
In addition, the tobacco industry has
recognized that their advertising to 18-20 yearolds
has a certain “spillover” to younger teens.
By advertising in Sports Illustrated, Spin, Vibe,
and Rolling Stone, they are able to reach the
impressionable minds of 12-17 year olds. To
help the tobacco companies even more, the
current 18-year old sale age for tobacco allows
thousands of high school seniors to legally buy
cigarettes and bring them to the high school
campus. Thus, the powerful combination of
advertising, peer pressure, and ready access is
permitted to take hold — all with sanction by
our current state laws.
Now the California Legislature is recognizing
the problem and trying to do something
about it. At the urging of the California Medical
Association and with the help of the Preventing
Tobacco Addiction Foundation, a proposal
is on the table to increase the minimum age for
purchasing tobacco to 21. This measure, AB
221 by Assemblyman Paul Koretz, may be just
the action necessary to stymie the industry’s
hopes for a resurgence of tobacco addiction
in our state.
The proposal to increase the sale age for
tobacco has grown out of the experience with
age limits for alcohol. In the early 70s, as the
nation reduced the voting age to 18, states
throughout the nation reduced their drinking
ages. This resulted in increased teenage alcoholism,
a spike in drinking for younger teens,
and more drunk driving deaths.
As a result of the unintended consequences
of the younger drinking age, President
Reagan championed the Uniform Drinking
Age Act in 1984, which called on all states to
return their drinking age to 21. This resulted
in a dramatic decline in usage, a reduction in
teenage alcoholism and related deaths, and
more negative teenage attitudes towards drinking.
These positive benefits came even though
there were no significant changes in enforcement
and educational efforts targeted towards
this population.
If the change to 21 for tobacco has similar
effects on usage, it can be expected that teenage
smoking would be reduced by a third. The
Board of Equalization, which collects data
associated with the tobacco tax, has suggested
that the implementation of an age-18 sale law
would reduce smoking among 12-20 year
olds by 30 million packs per year. And these
reductions in smoking are getting at the bud
of nicotine addiction. According to a report by
the Surgeon General, the chance of someone
developing an addiction after the age of 21 is
less than 5%.
A poll completed just before the 2002
General Election showed that 58% of likely
California voters support an increase in the
purchase age for tobacco to 21. This confirms
the results of a June 2002 ABC poll that found
Americans by nearly a 2 to 1 margin favor raising
the minimum legal age to buy cigarettes to
21 in their state. The support in the poll was
found to be strongest among the state’s growing
Latino population, with 68% supporting
the measure and 64% stating “strong support.”
Additionally, two-thirds of the state’s African
American voters support the increase to 21.
According to a Surgeon General’s report, if a person is not
addicted by the age of 21 there is less than a 5% chance that they
will ever become addicted.
Even with this strong support, some will
cling to the old saying “Old enough to fight and
die, old enough to drink and smoke.” Yet if the
drinking age experiment showed this country
anything, it was the necessity for us to collectively
decide the best age at which young
people can responsibly deal with these dangerous
life decisions.
We must not take lightly the need to
protect personal rights, and we should not run
roughshod over the ability of Californians to
make decisions for themselves. Yet the data
clearly suggests that delaying for a few years
access to this heavily marketed product may
avert a lifetime of addiction and premature
death in literally millions of our state’s youngest
citizens. Increasing the sale age for tobacco
is a logical, sensible and timely step for California.
To find out more information, you may
contact the author at TrishaRoth@aol.com
or www.trisharoth.com, Paul Mitchell at
paul@tobacco21.org, or visit the campaign
website at
http://www.tobacco21.org/california.
CALIFORNIA PEDIATRICIAN — SPRING 2003/ 25

Early Hearing Detection and
Intervention
Sudeep Kukreja, M.D., EHDI, Chapter Champion AAP Chapter 4
The 2nd Annual Early Hearing Detection
and Intervention (EHDI) Conference
was held in Atlanta, Georgia in
February 2003. EHDI refers to the process of
screening all newborns for hearing loss and
having all who fail the screening receive diagnostic
evaluation before three months of age.
When necessary, infants are enrolled in early
intervention programs by six months of age.
The conference was hosted by National
Center for Hearing Assessment and Management
(NCHAM) and sponsored by the
U.S. Center for Disease Control and Prevention
(CDC) and the federal Maternal and
Child Health Bureau (MCHB) of the Health
Resources and Services Administration
(HRSA) in partnership with American Academy
of Pediatrics (AAP). The purpose of the
conference was to provide a forum to present
the current knowledge regarding Early Hearing
Detection Intervention (EHDI), and to promote
information sharing and idea exchange
between states, private industry, advocacy and
partner groups, education organizations and
regarding the implementation and enhancement
of EHDI programs.
The conference was attended by over 350
delegates, including audiologists, neonatologists,
pediatricians, developmental pediatricians,
public health personnel, nurses, speech
and language pathologists, and parents of hearing-impaired
children. The State of California
was represented by Hallie Morrow, MD MPH,
Medical Consultant to the California Newborn
Hearing Screening Program (NHSP) and three
EHDI chapter champions, Sudeep Kukreja,
M.D., Richard Powers, M.D., Shirley Russ,
M.D. from AAP chapters IV, I and II respectively.
There are certain areas in the California
NHSP which require additional attention:
1. Inequities between CCS and non-
CCS approved hospitals regarding
newborn hearing screening:
The legislation regulating newborn hearing
screening in California is applicable
only to babies born in CCS approved
hospitals. The other 30% babies, born in
non-CCS hospitals may remain undiagnosed.
While legislation to cover non-
CCS approved hospitals is an important
long-term goal it is clear that the current
state budget deficit makes this not a feasible
target this year. The chapter leaders
requested information for colleagues
working in non-CCS approved hospitals,
to encourage those hospitals to voluntarily
adopt newborn hearing screening as a
standard of care. Chapter Champions plan
to meet with health plans to discuss reimbursement
for babies who are screened in
non-CCS approved hospitals. Extension
legislation may be reconsidered in future
fiscal years.
2. Shortage of pediatric audiologists:
It is estimated that 1500 infants will be
identified each year in California, at an
age that is well below the former average
of 3-4 years prior to newborn screening.
However, there is a shortage of appropriately
trained audiologists and speech
therapists to evaluate and treat infants
identified in the screening program.
3. Access to pediatric audiologist:
There are delays in evaluation due to
lack of access to otolaryngologists experienced
in evaluation of infants and young
children.
4. Lack of insurance coverage for the costs
of screening incurred by the hospitals:
Often screening costs are included in the
capitated payment for normal newborn
care, without adjustment for the incremental
cost for the required screening.
Improved insurance reimbursement will
be an incentive for voluntary participation
in newborn hearing screening by
non-CCS hospitals. Lack of health insurance
coverage for diagnostic follow up is
also a barrier.
5. Poor communication between pediatricians
and Early Intervention Programs:
There is a need for closer collaboration
between pediatricians and early intervention
services for children with hearing
loss.
6. Lack of a tracking and information
technology system to assure access to
services and follow up for identified
children and confirmatory evaluations,
indicated consultations, and auditory
amplification devices (hearing aids).
Additional Resources:
1. CALIFORNIA
www.dhs.ca.gov.pcfh/cms
(916)327-1400
AAP Chapter 1, Chapter Champion
Richard Powers, M.D., dp@rjpowers.org
AAP Chapter 2, Chapter Champion
Shirley Russ, M.D., shirlyruss@aol.com
AAP Chapter 3, Chapter Champion
Donald Miller, M.D.
dmiller@nchs-health.org
AAP Chapter 4, Chapter Champion
Sudeep Kukreja, M.D,
sudeepmd@pol.net
2. OTHER NATIONAL RESOURCES:
National Association of the Deaf
www.nad.org
National Center for Hearing Assessment
and Management
(NCHAM) www.infanthearing.org
SCOLIOSIS CONTINUED FROM PAGE 8
union (large curves, those with neurofibromatosis),
maturity, and curve stiffness. Curves in
the lumbar and thoraco-lumbar regions may be
amenable to anterior fusions with instrumentation,
thereby limiting the amount of lumbar
immoblization. Placing instrumentation anteriorly
in the thoracic spine is more controversial
given the proximity of the great vessels, and
its place in the current treatment of scoliosis is
still to be delineated. Both anterior and posterior
spinal fusions are performed when there is
a significant risk of continued growth (called
the “crankshaft” phenomenon), when the
magnitude of the curve or underlying disease
decreases the chance of a successful fusion, or
when the curve is very stiff in order to improve
correction.
Finally, a note about pregnancy and
scoliosis. The effect of pregnancy on curve
progression has been debated for many years.
Recent literature does not indicate a risk of
curve progression with pregnancy, nor does
it seem to affect the patient’s treatment from
an obstetrical standpoint. Thus, patients with
scoliosis may be counseled to not be concerned
about childbearing.
In conclusion, adolescent idiopathic scoliosis
is a lateral curvature of the spine over
10 0 in a patient between the ages of 10 and
16 years with no detectable underlying cause.
A careful history and physical examination
should be performed, and only a single plain
radiograph is necessary to document the scoliosis.
Even with evidence of scoliosis, few
children will require active treatment with a
brace or surgery.
26 / CALIFORNIA PEDIATRICIAN — SPRING 2003

TWENTY-FIVE YEARS OF HOME MECHANICAL VENTILATION IN CHILDREN CONTINUED FROM PAGE 21
ventilation. We generally keep the end-tidal
Pco 2
at values between 30-35 torr at all times
to provide the children with some respiratory
reserve in the event of an illness. It is imperative
that each child has a general pediatrician
participate in her overall care.
Mechanical ventilation is not always a
life-long therapy. Some of the children may
be weaned from ventilation depending on
the underlying lung disease. The types of
patients that can be weaned include those with
chronic lung disease and some children with
ventilatory muscle weakness. The process of
weaning, also known as “sprinting,” should
be gradual, with brief periods of time breathing
spontaneously off the ventilator. These are
progressively increased as long as the patient
tolerates the changes. The tolerance of the
weaning regimen can be assessed clinically
and objectively by means of oximetry and
carbon dioxide monitoring. These children are
weaned during waking hours first and should
be able to tolerate this regimen before considering
changes in nighttime ventilation.
The goals of home ventilation are: 1) to
ensure medical safety, 2) prevent and minimize
complications, 3) optimize quality of life and
rehabilitation potential, and 4) reintegrate the
child back into the family. The success of a
home ventilator program is dependent on the
dedicated and integrated services provided by
the hospital and the community. Once an infant
or child is deemed to need home mechanical
ventilation, the coordinated effort for transition
from hospital to home is dependent on
multiple factors including: the availability of
ventilators, the education of the parents, and
the availability of home nursing. Criteria for
discharge to home are: medical stability with
stable ventilatory settings, family commitment
to home care, education of parents regarding
technical aspects of care of children with
mechanical ventilation, adequate home care
environment (power, telephone and electricity),
access to emergency services, and vendor
services as well as access to a pediatrician.
Local pulmonary services should be consulted
to help plan the process of implementing ventilatory
support.
In summary, home ventilation has
approached a new era with many changes in
the last 25 years. With the new technology,
children with severe lung disease are able to
live at home and reintegrate into their families
with a reasonably good quality of life. The
transition from hospital to home is possible
with more portable technology and with the
dedication of all those involved in the program,
in the hospital and in the community.
Address Correspondence to:
Thomas G. Keens, M.D.
Division of Pediatric Pulmonology
Childrens Hospital Los Angeles
4650 Sunset Boulevard, Box #83
Los Angeles, California 90027-6062
Phone: 323/669-2101
FAX: 323/664-9758
E-Mail: tkeens@chla.usc.edu
Head to Toe: Orthopaedic Aspects of the Growing Child.
Orthopaedic problems are a common cause of concern for parents and a frequent reason for
visiting the primary care provider. The evaluation and treatment of these problems is rapidly
evolving. This course will focus on orthopaedic problems commonly encountered by primary
care physicians (pediatricians and family practitioners), including congenital abnormalities of the
hip and feet, fractures, sports injuries, and developmental deformities such as lower extremity
bowing and leg length discrepancies. Participants will have the opportunity to actively discuss
these problems with experts in the field.
SATURDAY, October 18, 2003
7:30 am to 4:30 pm
Cedars-Sinai Medical Center
Harvey Morse Auditorium
8701 Gracie Allen Drive
Los Angeles, California
For additional information call the Office of Continuing Medical Education at
(310) 423-5548 or 423-2935; you may also email: stokes@cshs.org
CALIFORNIA PEDIATRICIAN — SPRING 2003/ 27

THE TAO OF PEDIATRICS AND CHINESE MEDICINE CONTINUED FROM PAGE 14
CT SCANS CONTINUED FROM PAGE 7
cortisol levels have all been demonstrated, but
these do not explain many of the physiological
changes these points can induce. There is
other promising research being conducted at the
University of California Irvine by Dr. Zang Hee
Cho, one of the inventors of the MRI. Utilizing
the fMRI, Dr. Cho has demonstrated the effects
of distal acupuncture points on blood flow in the
brain. For example, when a point traditionally
indicated for the treatment of ocular disorders
was stimulated, the fMRI showed an increase in
blood flow in the visual cortex.
Unfortunately, research in acupuncture in
the West is still in its infancy. There have been
relatively limited numbers of Western studies
done in pediatrics. Examples of some of the
research in which acupuncture was shown to
be effective in pediatrics include pain, postoperative
nausea and vomiting, constipation,
drooling, nocturnal enuresis and asthma. However,
the range of conditions spans far beyond
those mentioned due to the inherent energetic
nature of acupuncture.
Modern acupuncture needles are very fine
(generally between 32 and 38 gauge). They are
manufactured in sterile blister packs and are
disposed of immediately after use. Children are
very sensitive to the effects of acupuncture and
needles do not need to be retained very long.
The older the child, the longer the needles are
retained. Generally, the length of the needles
is between 1⁄2 and 1 inch. Many pediatric acupuncturists
use very shallow insertion (5mm),
especially within the Japanese traditions.
Both research and anecdotal reports
indicate that many children find acupuncture
“positive or relaxing.” Most fears were found
to be overcome through communication and
positive reinforcement. Should fear continue
to be an issue, there are several effective noninvasive
techniques available. These include:
• Microcurrent electrostimulation to acupoints
• Shonishin: Japanese pediatric technique
involving a set of tools to be used to
stimulate strategic meridians
• Magnet therapy (800-10000 gauss)
• Laser therapy (1-10 mW)
• External application of herbal preparations,
essential oils or seeds to acupoints
• Massage and acupressure
Herbal Medicine
Herbal medicine can be a gentle and
effective therapeutic modality. In Chinese
Herbology, herbs are very rarely used alone.
Combining herbs allows the practitioner to
customize the formula to the specific needs of
the child.
For example, a commonly used herbal formula
from the later Han dynasty (25-220 CE)
used for influenza is cinnamon twig decoction
(Gui Zhi Tang). This formula includes 5 ingredients:
Cinnamomum cassia, Peony lactiflora,
Zingiber officianal, Ziziphus jujube, and Glycyrrhiza
uralensis (honey-fried). Cinnamomum
has been demonstrated to have antibiotic properties
against such microorganisms as Staphylococcus
aureus, ECHO virus and Salmonella
typhi. It also has antipyretic and vasodilating
properties. Peony lactiflora is anti-inflammatory
and antibiotic in nature (Shigella sonnei,
Staphylococcus aureus, herpes zoster). The
remaining herbs are primarily for mitigating
inflammation, and to protect, soothe, and
strengthen the gastrointestinal tract. They can
help alleviate symptoms such as nausea, sore
throat, and abdominal discomfort. They also
prevent negative interactions between incompatible
herbs or other medications. While the
great majority of research exists in the Chinese
Medicine literature, empirically based research
in the United States is less established.
As the terrain begins to change, an adequately
trained herbalist will modify the ingredients
and dosages. Herbal medicine can also
be used in conjunction with pharmaceuticals
to help support the child and minimize adverse
drug reactions.
Dietary Therapy
According to Chinese Medicine, children
under the age of 6 do not have adequately
developed digestive tracts. It is felt that many
pediatric diseases can be directly attributed to
inadequate dietary habits or the relative inability
of the child to digest his/her foods. This
creates toxic by-products the Chinese termed
dampness. The dampness can be thought of as
the undigested by-products and the heat can
be thought of as the body’s response (possibly
allergies, otitis media, sinus infections). Acupuncture
and herbal medicine are used to correct
imbalances, but if the imbalance is rooted
in the digestive impairment, it may continue to
recur until the diet is addressed.
When used properly, Chinese Medicine
can be a safe and effective adjunctive therapy
for children. Research has shown that children
respond favorably to acupuncture and
herbal medicine. In 1992, NIH formed the
National Commission for Complementary
and Alternative Medicines and was allocated
50 million dollars for research. Currently, the
NCCAM is expecting 113.2 million dollars
in funding. Presently, at Childrens Hospital
of Los Angeles, we are beginning a research
program in collaboration with the Magik Pain
Program and the Childrens Center for Cancer
and Blood Diseases examining the integration
of acupuncture for decreasing pain and
fear in children going through painful medical
procedures.
diagnostic irradiation and polymorphisms in
DNA repair genes. Environmental Health
Perspective. 2000; 108:495-498.
3. Radiation and Pediatric Computed Tomography.
National Cancer Institute. Summer
2002. Website: www.cancer.gov/cancerinfo/
causes/radiation-risks-pediatric-CT
4. Frush, D. Pediatric CT: practical approach to
diminish the radiation dose. Pediatric Radiology.
2002; 32:714-717.
5. FDA Public Health Notification: Reducing
Radiation Risk from CT for Pediatric and
Small Adult Patients. Pediatric Radiology.
2002; 32:314-316.
6. Donnelly LF, Emery KH, Brody AS, et al.
Minimizing radiation dose for pediatric
body applications of single-detector helical
CT: strategies at a large children’s hospital.
AJR American Journal of Roentgenology
2001; 176:289-296.
7. Brody A, Guillerman RP. Radiation Risk
from Diagnostic Imaging. Pediatric Annals.
2002;31:643-647.
8. Huda, W. Radiation Dosimetry in Diagnostic
Radiology. AJR American Journal of
Roentgenology 1997; 169:1487-1488.
FOOTNOTES
1 The sievert (Sv) is the current standard international
unit used to describe a human radiation
dose, used preferentially over the more
familiar “rad.” Sv refers to the effective
dose, taking the type of radiation and tissue
involved into consideration, while rad refers
to the absorbed dose.
ERRATA
The text below was missing from Dr. Harvey
Karp’s article Solving the Colic Mystery:
The Fourth Trimester, the Calming Reflex
and the Five “S”s, which appeared in the Fall
2002 issue of California Pediatrician. California
Pediatrician regrets the omission.
The calming reflex and Five “S”s are
presented in detail in Dr. Karp’s new
book and video, “The Happiest Baby
on the Block.” To learn more, visit
www.thehappiestbaby.com.
28 / CALIFORNIA PEDIATRICIAN — SPRING 2003

SED — California Region
Leonard Kutnik, M.D.
California Surgeon
General Needed to Protect
Californians
The Surgeon General’s Office reports
that one in ten children and adolescents
suffer from a mental health
illness (1), but only one in five of these children
receive specialty mental health services.
Unfortunately, this rate of treatment is not
being achieved in the State’s health insurance
program for children, the Healthy Families
Program. Only one-half of one percent of
enrolled children were referred to a county
mental health department for evaluation and
treatment of a Serious Emotional Disturbance
(SED). Primary care providers (including
pediatricians) are ideally positioned at the
frontline to identify HFP children with mental
health problems. Therefore, greater assistance
is needed from primary care providers (PCPs)
to refer children who present signs and symptoms
of SED to county mental health programs
for evaluation and treatment.
The Healthy Families Program is a state
and federally funded insurance program that
provides health care to low-income children
up to age 19 who do not qualify for Medi-Cal
and do not have private health insurance. The
HFP provides comprehensive mental health
services through participating health plans
and local county mental health departments.
Basic mental health services are provided
by the participating health plans. Evaluation
and treatment of SED are provided by county
mental health departments. Serious emotional
disturbance of a child is defined in the California
Welfare and Institutions Code, Section
5600.3(a)(2) as a mental disorder as identified
in the most recent edition of the Diagnostic and
Statistical Manual of Mental Disorders (other
than a primary substance use disorder or developmental
disorder) which results in behavior
inappropriate to the child’s age according to
expected developmental norms. SED treatment
services provided by county mental
health departments include outpatient services,
inpatient services and prescription drugs.
Most children enrolled in the HFP are
members of health plans that require a primary
care provider (PCP). Because of the
large number of children who are affiliated
with a PCP, the PCP plays a crucial role in
the early detection of mental health problems
and in improving HFP children’s access to
SED services. HFP data indicate that in 2000,
approximately 57% of children enrolled in
the program for 12 consecutive months saw
a PCP. Reports show that most families, and
to a higher degree, ethnic minority families,
are more likely to seek help from primary
care providers as opposed to specialty care
providers. (2) Given the large number (80%)
of HFP subscribers who belong to an ethnic
minority group, these reports further validate
the importance of the PCP in detecting mental
health problems.
PCPs can receive assistance from participating
health plans in referring children
to county mental health departments for SED
The Healthy Families Program provides comprehensive mental
health services through participating health plans and local county
mental health departments.
treatment. The health plans use a variety of
methods to assist physicians in serving HFP
subscribers and to communicate information
about the HFP benefits. Examples of these
methods include periodic newsletters and
bulletins, quick reference guides, periodic luncheon
meetings, electronic mail and website
access. The methods used are specific to individual
health plans. Physicians should call the
health plans they are affiliated with for more
information.
In addition to the assistance the health
plans provide, the California Institute of
Mental Health (CIMH), with funding from
the David and Lucile Packard Foundation, has
developed a provider manual. This manual,
Healthy Families Resources Binder, was
developed through collaboration among counties,
health plans, State staff and CIMH. The
binder provides information about the HFP and
the SED referral process that is practical and
easily accessible. Specific information provided
includes health plan and county mental
health liaison phone numbers, flow charts for
CONTINUED ON PAGE 31
On April 10, 2003, the Little Hoover Commission
urged policy-makers to fortify California’s
public health system so it can better detect and
respond to a wide range of threats, from emerging
diseases and hospital-acquired infections to
bioterrorism.
The Commission recommended the State
develop expert leadership, establish standards,
increase training, improve communications,
and strengthen laboratory and other capacities
essential to the public health infrastructure.
The report — To Protect and Prevent:
Rebuilding California’s Public Health System
— was issued after 10 months of public meetings,
interviews, and deliberations, during
which an array of experts identified specific
weaknesses and practical improvements to
a system that has gradually eroded over the
last three decades. The Commission initiated
the project after the terrorist attacks of 2001
revealed that the traditional capacities of the
public health system to detect and respond
to epidemics and other disasters had been
neglected as a public attention focused on individual
health care. The Commission concluded
that the improvements are needed to protect all
California from a range of health risks.
The Commission recommended that the
core public health functions be consolidated
into a single state department and that the State
re-establish a volunteer public health board
to provide expert involvement and public
accountability to the government’s efforts.
The State needs to strategically develop
and employ technologies and trained professionals
to make sure the system detects and
assesses health threats, develops the most
effective responses, and communicates with
health care providers and the public. Together,
the reforms would redefine public health as the
third component of California’s public safety
triad — police, fire, and public health.
A fortified public health system would
reduce the risk to all Californians, ensuring
capacities in times of emergency, and reducing
demands on the overall health system.
While the federal and state government
have taken steps since September 11, 2001
to repair the system, the fundamental and
structural problems have not been adequately
addressed in California.
The Little Hoover Commission is a bipartisan
and independent state agency charged
with advising the Governor and Legislature on
ways to improve the efficiency and effectiveness
of state programs. The full Commission
report is available on www.lhc.ca.gov.
CALIFORNIA PEDIATRICIAN — SPRING 2003/ 29

A LOW-GLYCEMIC INDEX DIET IN THE TREATMENT OF PEDIATRIC OBESITY CONTINUED FROM PAGE 11
ing in treatment programs. Much of this weight
is regained within 12 months, with a virtually
complete relapse after five years. Clinical studies
of obesity treatment in children have yielded
mixed results. This situation has prompted calls
from experts and official agencies for the development
of innovative treatment strategies. 33 The
results of this study suggest that a low-GI diet
may be one such approach.
Children receiving the standard reducedfat
diet showed no change in adjusted BMI
during the course of the study, representing
a modest improvement over the increase in
BMI that would be expected with increasing
age. By contrast, children receiving the low-GI
diet showed an adjusted decrease in BMI of
1.15 kg/m 2 . This result is especially interesting
in that the low-GI diet involved no restriction
of total energy or specific macronutrient consumption.
Instead, patients in this treatment
group were encouraged to eat to satiety and
snack when hungry. Furthermore, the magnitude
of the effect seen here may have been
limited by factors inherent to an urban pediatric
obesity clinic, including a heterogeneous
patient population, inadequate insurance coverage
for obesity management, and poverty.
To our knowledge, the vast majority of
pediatric obesity studies to date have tested
different behavioral modification techniques
or multimodality programs (behavioral
therapy, diet, and physical activity together).
Surprisingly few studies involving children
have examined the effects of dietary composition
on weight loss per se, while controlling for
other interventions. In our study, by contrast,
specific dietary prescriptions differed between
groups, whereas dietary counseling methods
(parent and child), behavioral modification
techniques, ancillary recommendations (to
increase physical activity and decrease inactivity),
and treatment intensity did not.
Regarding possible underlying mechanisms,
a low-GI diet may facilitate weight
loss by lowering insulin levels. High-GI
diets stimulate more insulin secretion than
isoenergetic, low-GI diets, as evidenced by
higher postprandial insulin levels and greater
c-peptide secretion. Acutely high insulin
levels would tend to promote uptake of nutrients
into liver, muscle, and adipose tissue;
inhibit hepatic release of glucose; and suppress
lipolysis. After the nutrients of a high-GI
meal have been absorbed from the digestive
tract, the body may have difficulty accessing
stored metabolic fuels, leading to excessive
hunger and overeating. Chronically, hyperinsulinemia
would tend to direct nutrients from
oxidation to storage. Several, though not all,
epidemiological studies have shown that individuals
with the highest fasting or stimulated
insulin levels at baseline gain the most weight
prospectively. Moreover, insulin treatment of
type 2 diabetes, and intensive insulin treatment
of type 1 diabetes predictably results in weight
gain. In animal studies, a high-GI diet was
found to increase fatty acid synthetase activity,
adipocyte size, glucose incorporation into total
lipids, and insulin resistance compared with a
low-GI diet.
Several issues relating to study design
and interpretation should be addressed. First,
participants were not formally randomized
to treatment group. Thus, the presence of
confounding influences, such as selection
bias and provider effects, cannot be excluded.
Second, dietary change was not monitored
following intervention (as, for example, with
diet records). Therefore, the degree to which
noncompliance affected outcome is not known.
Third, mean follow-up time was relatively
short (4.3 months); long-term evaluation of the
dietary treatments is beyond the scope of this
study. Fourth, the target macronutrient composition
of the low-GI diet differed from that of
the reduced-fat diet, in an attempt to obtain the
After the nutrients of a high-GI meal have been absorbed from
the digestive tract, the body may have difficulty accessing stored
metabolic fuels. . .
lowest possible glycemic response. Therefore,
the effects of this diet cannot be attributed
solely to GI. In light of these qualifications, our
findings should be viewed as preliminary.
Nevertheless, we believe that these
findings are relevant because the magnitude
of the observed effect is large and remained
significant after adjustment for a variety of
potentially confounding factors; the low-GI
diet was tested against the current standard of
care; and the data are consistent with a plausible
physiologic mechanism. Moreover, the
study reflects experience of a major, clinical
pediatric obesity program, not a specialized
research protocol employing carefully selected
subjects and costly interventions. Rather, our
study confronted a variety of problems inherent
to the outpatient treatment of childhood
obesity today, including variable motivation
and compliance (eg, some patients enrolled
in our program at the insistence of a parent
or physician, and have little interest in losing
weight), limited resources (ie, inadequate
insurance reimbursement), and a lengthy waiting
period for clinic appointments. Thus, the
findings speak to the clinical effectiveness of
this dietary approach. Finally, this study underscores
the need for a prospective, controlled
clinical trial of a low-GI diet in the treatment
of obesity.
Corresponding author: David S. Ludwig,
MD, PhD, Department of Medicine, Children’s
Hospital, 300 Longwood Ave, Boston, MA
02115 (e-mail: ludwigd@tch.harvard.edu).
For references, see the original article in
JAMA Archives of Pediatric and Adolescent
Medicine, 2000.
WHY CALIFORNIA’S MICRA IS GOOD FOR THE NATION CONTINUED FORM PAGE 12
1976 to $254.22 in 2000 (an increase of 2073%
when adjusted for inflation).
National MICRA
Mindful of the national problem, Senator
Dianne Feinstein (D-California) has courageously
proposed a law modeled on California’s
27-year experience of dealing fairly with
injured patients and protecting access to health
care.
Here it is in dollars and cents: In California
two years ago, an OB/GYN paid on
average $47,500 for malpractice insurance.
In Florida, she paid $173,000. Neurosurgeons
paid $68,436 in Los Angeles County in
2002, but $278,829 in Dade County, Fla., and
$163,000 in suburban Detroit and New York.
In California in 2002, an orthopedic surgeon
paid $22,730, but in Pennsylvania $90,297.
Why should patients care? It’s difficult
to put a value on having doctors there when
you need them. But patients in Nevada drive
hundreds of miles to find obstetricians who
still deliver babies. And for accident and cardiac
victims, it is a matter of life and death if
there is no neurosurgeon or ER doc at the local
hospital.
California has health care problems, but
this insurance crisis isn’t one of them. That’s
why the rest of the nation needs to take California’s
lead and adopt medical malpractice
reform.
30 / CALIFORNIA PEDIATRICIAN — SPRING 2003

Retirement should not be dull or
boring. With the increase in the average
life expectancy, more and more
of us can look forward to years of active life
after retirement. If it is not necessary to make
money, the number of choices available is
truly astonishing. Fortunately this is true even
for those with physical limitations. Retired
pediatricians can choose to stay in touch with
their profession. Alternately, this is a time to
pursue some favorite activity which was limited
by time available before retirement. It is
even possible to go back to school and become
educated in an entirely new area. A partial list
of possibilities organized by category follows.
Pediatric Related:
Retirement Options for
Pediatricians
If a retired pediatrician is located in an area
with access to a medical school or training
program, there are opportunities for teaching.
Many programs use practicing or retired pediatricians
as voluntary faculty. This involves
making rounds on wards or supervising students
and residents in clinics for assigned periods.
Selection of a clinic in a particular area in
which the physician can indulge a long standing
interest can be very rewarding. Malpractice
insurance for the faculty is covered by the
medical school or hospital in most instances.
Contact can be made with the Chairman of the
Pediatric Department or the Chief of the Resident
Training Program.
Most medical schools have a mentor program
for students usually starting in the first
or second year. Students are assigned to physicians
in areas of specialty which they choose.
Practicing physicians are particularly desirable
as having different experiences from faculty.
Mentoring can take minimal or more time
depending on the number of students and the
interpersonal chemistry involved. Information
can be obtained from the Student Affairs Office
of the medical school.
Many communities have free clinics for
families without health care coverage. These
can be sponsored by religious organizations,
schools or community organizations. It is possible
to cover a specific time for a specified
period. Malpractice insurance can be a problem
for retired physicians and this should be
investigated before making a commitment.
Joan E. Hodgman, M.D.
American Academy of Pediatrics:
Each Academy Chapter has a number of
committees chaired and manned by volunteer
members. The number and level of activity
depend largely on the interests of the chapter
members. Areas that are particularly active
include legislation, access to care, reimbursement,
membership, violence and accident prevention,
school health and international health.
Participation is actively encouraged and well
received. It is possible for a member with a
special interest to develop a task force to work
on that issue. Each chapter has staff available
to assist with meeting notices, agendas and
minutes. California District IX has an active
State Government Affairs committee with representatives
from each chapter who have been
appointed because of their interest.
Educational:
Schools are encouraging older individuals to
become students again. After retirement is an
optimal time to return to school and study a
subject just for pleasure. Local community colleges
have little or no tuition and a full curriculum
of courses, including cultural subjects such
as music appreciation and art history, courses
in foreign languages, drawing and sculpture are
available, as well as computers. Taking a shop
course is a great opportunity for a woman of
a certain age to learn how to take care of the
upkeep of her house, something she was not
taught in her youth.
Hobbies:
Retirement is a time to seriously indulge a
hobby. Gardening, Bridge, physical activities
such as tennis, swimming and running are all
available at community centers. There are
competitions organized by age group for many
of the activities particularly swimming, tennis
and rowing. Access can be through a community
senior center. Many communities have
amateur performance groups where an individual
can indulge a taste for singing, dancing
or acting. This is also a time to polish skills in
playing a musical instrument or learn to play a
new one. And, one is never too old for golf.
Community Service:
The potential here is mind-boggling. All museums
have docents who are regularly educated
in the specialties of the museum and then
volunteer to conduct tours for members and
guests, including children’s groups. Big Brothers
and Big Sisters are represented in many
communities. Retired pediatricians make
particularly knowledgeable candidates to support
a disadvantaged child. Communities have
appointed committees to advise the officials in
specific areas such as cultural affairs, population
growth, property density among others.
Interest in community affairs could lead to
entering politics as a member of the school
board or city council.
The above suggestions are only the tip of
the iceberg. California Pediatrician would like
to hear from readers with their own experiences
to share. These should be sent to the
author by e-mail, FAX or snail mail.
Joan E. Hodgman, M.D.
494 Stanford Drive, Arcadia, CA 91007
(323) 226-3440 FAX
hodgman@hsc.usc.edu
SED CONTINUED FROM PAGE 29
the SED referrals and billing processes and
HFP updates. A copy of the binder can be
obtained at www. cimh.org.
Since PCPs play an important role in providing
and coordinating care for their patients,
PCPs can have a positive impact on access to
appropriate treatment for SED services. Early
detection and treatment of SED can restore
the functioning of children with mental health
disorders. Active teamwork between PCPs in
private health programs and county mental
health coordinators can help to assure the
best outcomes of access to care and improve
the lives of SED children. Toward this end,
pediatricians and other providers who serve
HFP enrollees are encouraged to refer children
who present signs and symptoms of serious
emotional disturbances to county mental health
programs for SED evaluation and treatment.
REFERENCES
1. Burns, et al. (1995) & Shaffer, et al. (1996).
The Surgeon General’s Conference Children’s
Mental Health September 18 & 19,
2000 – The Conference Summary
2. Cooper-Patrick et al. (1999). U.S. Department
of Health & Human Services (2001).
A Supplement to Mental Health: A Report of
the Surgeon General. The Substance Abuse
and Mental Health Services Administration
(SAMAHA) Report.
CALIFORNIA PEDIATRICIAN — SPRING 2003/ 31

I
write in late March, as American forces
entered Iraq. War brings inevitable
destruction and human tragedy, and
the outcome is unclear. Even with victory
an implacable worldwide enemy will remain
and the threat of terrorism at home will continue.
Protection of our civilian population
remains of paramount concern. Physicians
have become acutely aware of the threat of
bioterrorism, a term which includes microbial,
chemical and radiological agents used indiscriminately
against civilian population targets.
Much has been written about the response to
these threats. See www.bt.cdc.gov.
We have yet to recognize that bioterror
will change relationships between physicians
and the community. Despite hardships and
challenges, a sense of crisis can stimulate
positive change. No matter what our political
opinions, physicians will have to elevate our
community leadership and become effective
agents of progress.
There are many key objectives physicians
should seek today. Here are the top ten:
10. Renew the importance of
primary care.
Primary care doctors must maintain consistent
quality while treating a diverse group of
patients. We pediatricians now add the role of
“first responders.” Infectious diseases that were
once relegated to the small print in textbooks-
— the zebras — are now in play. Skin lesions
take on new significance. What was once a
white pimple may now be smallpox. Could
that dark lesion be anthrax? Recall that one of
the initial anthrax cases in 2001 involved an
infant whose pediatrician recognized the lesion
and saved the child’s life.
9. Brush up on toxins.
We hear and read about once exotic substances
like VX, sarin and ricin. Physicians need to
know more about these. Sarin is out there and
has already been used by terrorists in Tokyo.
Ricin, the preferred toxin of Iraqi agents, is a
component of castor beans, which grow wild
in Los Angeles. Even in “normal” times plant
toxins are a potentially deadly risk to California
toddlers.
8. Improve our ties with health
departments.
Physicians’ relations with health departments
LAST WORD
After the Iraq War
Jeffrey S. Penso, M.D., Editor, California Pediatrician
and government agencies have left much to
be desired in recent years. Pronouncements
have appeared from on high and responses
demanded. For example, recent HIPAA regulations
require us to present each patient family
with a multiple page document regarding
privacy — quite a reading chore for a young
mother with a crying, sick child. But recently
relations have improved. County agencies now
send us compelling materials about smallpox
and other infectious diseases. There is suddenly
a new respect for local clinicians. Health agencies
actually request your assistance in disease
detection and smallpox vaccine programs. We
should reply positively to these requests.
7. Become better teachers
“Doctor” is Latin for “teacher” — that is our
first avocation. In a time of crisis when many
people are skeptical and fearful, we remain the
trustworthy source of information for the families
under our care. We have the responsibility
and opportunity to care for physical needs and
to assist communities in coping with crisis.
6. Strengthen appreciation of
vaccines
In recent years, disinformation has poisoned
public understanding about vaccines. Now
our community has learned of new, very lethal
diseases that may be coming to our neighborhoods.
Here, again is our chance to effectively
teach patients about the risks (low) and benefits
(great) of vaccines. We also must bolster
the Vaccines for Children Program, and eliminate
its chronic shortages of prevnar and other
key vaccines.
5. Work with first responders
First responders like firefighters and paramedics
have strong ties to local hospital emergency
centers. These systems, all understaffed,
require additional citizen assistance even in
“normal” emergency situations like earthquakes.
The threat of bioterror should make
us redouble efforts to strengthen response
systems. Trauma centers also need appropriate
funding. Citizens need to be trained in
CPR and in Community Emergency Response
Teams (CERT). We physicians must take the
lead in these efforts.
4. Eliminate legal barriers
The time has come for more physicians to contribute
more time in service to the community.
Those who volunteer should be treated as the
Good Samaritans that they are. Retired physicians
and those starting careers would make
excellent volunteers, but are blocked by persistent
litigation issues. It is time that legislatures
removed these barriers to care as part of real
tort reform.
3. Upgrade public health
It is time to end the disgraceful underfunding
of public health services in California. We need
the ability to detect and monitor all illnesses
that have public health implications. The barrier
of political correctness must also fall. We
have the power to eliminate virtually all cases
of pediatric HIV. It is CDC policy that all pregnant
women should be tested for HIV, unless
they opt out. California does not have this
policy and is out of step with sound national
guidelines. The state should be brought into
compliance. Children’s lives are at stake.
2. Assist veterans
Returning veterans should be honored for
their service. Appreciation should be more
than verbal. They and their families must have
access to quality health care, through expansion
of Healthy Families or other programs.
Veterans have significant skills and positive
work ethic. They would be excellent health
professionals, and should be encouraged to
receive training as nurses, paramedics and doctors.
This would be a solution to the shortages
of these professionals in our communities.
1. Support nation building
America has been the traditional leader in
medical education throughout the planet. We
have assisted higher education in Cairo and
Beirut for over one century. This is, in some
way, in response to the contributions Arab culture
made to western science and medicine one
millennium ago. Can the Middle East return to
its historic tradition of tolerance and knowledge?
Can America again become a beacon of
learning and friendship? This task of course,
will be the most difficult of all. It will require
patience and bravery, and certainly the leadership
of the medical community.
32 / CALIFORNIA PEDIATRICIAN — SPRING 2003

PRESIDENT-ELECT CANDIDATES
CONTRIBUTORS
Carol D. Berkowitz, MD, FAAP
Torrance, CA
Dr. Carol Berkowitz, born in New York, attended
Barnard College, Columbia University College of
Physicians and Surgeons, and did her pediatric training
at Roosevelt Hospital. After a number of years in practice, she joined
the full-time faculty at Harbor-UCLA Medical Center in Torrance, CA,
where she is currently Professor and Executive Vice Chair in the Department
of Pediatrics.
Carol’s clinical interests have been in general and emergency pediatrics,
with a focus on child maltreatment. Academically, she has been
active in the area of Women in Pediatrics, having founded the Women in
Medicine Special Interest Group of the Ambulatory Pediatric Association.
She also served as the APA’s President.
Carol currently serves on the AAP’s Committee on the Pediatric
Workforce, and its subcommittee, Women in Pediatrics. She spent six
years on the Board of Directors of the American Board of Pediatrics,
serves on the Program Directors Committee of the ABP, and helped
develop the Resident Program on Professionalism in Pediatrics. She
was a pediatric program director for 20 years, and currently serves on
the Accreditation Council on Graduate Medical Education. She was the
Academy’s representative to the Residency Review Committee in Pediatrics,
and was the Chair of the RRC and of the Council of RRC Chairs.
She is currently the AAP’s representative to the Council of Medical
Specialty Societies.
She is the author of multiple articles and the editor of Pediatrics:
A Primary Care Approach – a text used by many medical students and
residents in their continuity clinic.
Francis E. Rushton, Jr, MD, FAAP
Beaufort, SC
Dr. Francis Rushton, throughout his 24 years as a
practicing pediatrician, has successfully balanced a
busy private practice with numerous child advocacy
efforts, academic endeavors, and involvement with the
American Academy of Pediatrics. Currently, Francis is senior partner of
Beaufort (SC) Pediatrics, a member of the AAP Committee on Community
Health Services, chapter CATCH facilitator, and Clinical Associate
Professor of Pediatrics at the University of South Carolina’s Institute for
Families in Society. In recent years, he participated on the Academy’s
Nominating Committee, served as president of the South Carolina
Chapter of the AAP, led the state legislative committee, and chaired the
Alliance for South Carolina’s Children. Dr. Rushton authored the book,
Family Support in Community Pediatrics, and worked as a visiting
professor at Okinawa Chubu Hospital in Japan for three months. Still
seeking avenues to promote child health issues, he ran for – but lost by
four votes – the SC House of Representatives in 1998.
In 2001, Governor Jim Hodges presented Dr. Rushton with the
Order of the Palmetto, South Carolina’s highest citizen award, for his
commitment to children and pediatricians. In 2002, the Georgetown
University Communities Can! Program recognized Beaufort’s collaborative
early childhood team as one of five outstanding community
programs nationally.
Dr. Rushton attended Phillips Exeter Academy, University of
Florida, Georgetown University, and University of Miami School of
Medicine before completing a pediatric residency in Birmingham, AL
and serving three years with the National Health Service Corps in Tennessee.
He is married to Margaret and has three teenage children.
To vote online, go to the AAP members-only channel and choose “Web-
Based National Academy Election” under “What’s New.”
Myles B. Abbott, M.D.
Weighing the Radiation
Risks of CT Scans
Dr. Abbott is a private
pediatrician in Berkeley
and Orinda, California
and a Clinical Professor
of Pediatrics at the University of California
San Francisco School of Medicine.
Milton Arnold, M.D.,
FAAP
Annual Las Vegas
Seminars —25 Years of
District Education and
Support
Dr. Arnold graduated from
Franklin and Marshall College in 1948
and received his M.D. from Chicago
Medical School in 1952. He completed
his medical education in Los Angeles and
continued to practice and teach in Southern
California. He has been active in
both California Chapter 2, AAP and the
Los Angeles Pediatric Society, holding
the chairmanships of many committees.
He is presently the District Chair of the
Committee on Medical Education.
Ron Bangasser, M.D.
Why California’s MICRA is good for
the Nation
Dr. Bangasser is a board-certified family
physician and Director of External
Affairs for the Beaver Medical Group
in Redlands. In March 2003, he was
elected President of the California Medical
Association. From 2001-2002, he
was Speaker of the California Medical
Association House of Delegates, CMA’s
policy-making body. He currently is a
member of the California Delegation
to the AMA and in June 2001, he was
elected to AMA’s Council on Medical
Service.
Robert Matthew
Bernstein, M.D.
Adolescent Idiopathic
Scoliosis
Robert Matthew Bernstein,
MD is director of
Pediatric Orthopedic Surgery at Cedars-
Sinai Medical Center’s Ahmanson
Pediatric Center. He is Assistant Clinical
Professor of Orthopedics at UCLA
School of Medicine. Dr. Bernstein is a
recognized expert in the areas of scoliosis
and spinal deformity, hip dysplasia,
clubfoot, arthrogryposis, and pediatric
limb deficiencies.
Rosalie Blazej
Annual Las Vegas
Seminars —25 Years of
District Education and
Support
Ms. Blazej received her
degree form Pratt Institute
in 1967. She has been art director of
California Pediatrician for 17 years. She
is also a published writer with wide-ranging
interests, including a keen interest in
science. She lives in San Francisco with
her husband of 35 years, Lucian Blazej.
They have three grown children.
Robin G. Calo, R.N., M.S., P.N.P.
A “Parents’ Instructional Manual”
Robin Calo obtained her M.S. degree and
Pediatric Nurse Practitioner certificate
from the University of California San
Francisco School of Nursing. She is
currently the Project Coordinator for the
California Child Care Health Linkages
Project, a statewide project funded by
FIRST 5 California.
Ronald A. Cohen M.D.,
FAAP
Weighing the Radiation
Risks of CT Scans
Dr. Cohen is Director of the
Deptartment of Diagnostic
Imaging at Children’s Hospital,
Oakland. After attending Medical
School at the University of California,
Davis, he was a Pediatric Resident at
the University of Arizona, a Radiology
Resident at Stanford University and a
Pediatric Radiology fellow at Cincinnati
Children’s Hospital. His special areas of
interest include special applications of
Computed Tomography and imaging of
child abuse.
Kris Calvin, M.A.
District Report
Ms. Calvin has been
Executive Director of
AAP-CA for 13 years.
Prior to that, she was
Manager of Maternal
and Child Health Policy at the California
Medical Association. Trained in
health economics and child psychology
and development at Stanford and UC
Berkeley, Ms. Calvin staffs legislative
and policy activities for the District. In
her spare time she is a single mother of
three.
Mark A. Chesler, Ph.D.
Childhood Cancer
Survivors Report Life
Changes
Mark A. Chesler is Professor
of Sociology at
the University of Michigan, Ann Arbor,
Michigan. He has published widely in
the area of childhood cancer and its
impact on the family, voluntary and
self-help organizations, and race and
ethnic relations. He is a past-president
of the Candlelighters Childhood Cancer
Foundation and the International Confederation
of Childhood Cancer Parent
Organizations. He is a member-advocate
and consultant with a variety of other
public agencies and educational organizations.
He is married and has two adult
children.
George C.
Cunningham, M.D.,
M.P.H.
Tandem Mass
Spectrometry in Newborn
Screening
Dr. Cunningham has a
B.S. degree from USF, an M.D. from
the UCLA, and an M.P.H. from the UC
Berkeley. A Board Certified pediatrician,
he has been with the California Department
of Health Services since 1965. He
is currently Principal Investigator of the
Pacific Southwest Regional Genetics
Network. He has been appointed to the
FDA Panel on Molecular and Genetic
Testing, and serves on the Workgroup
on Newborn Screening reporting to the
Secretary’s Advisory Committee on
Genetic Testing.
CALIFORNIA PEDIATRICIAN — SPRING 2003 / 33

Nikta Forghani, M.D.
Weighing the Radiation Risks of CT
Scans
Dr. Forghani is a second year Resident
at Children’s Hospital Oakland and a
graduate of the UC Davis School of
Medicine.
Jeffrey I. Gold, Ph.D.
Chronic Pain
in Children: A
Multidisciplinary
Biopsychosocial
Treatment Approach
(Part III); The Tao of
Pediatrics and Chinese Medicine
Dr. Gold has specialized in the assessment,
treatment, and clinical investigation
of acute and chronic pain in children,
adolescents, and adults with sickle cell
disease and cancer. After graduating with
his doctoral degree in Clinical Psychology
(1999), Dr. Gold completed a post-doctoral
fellowship in the Departments of
Hematology/Oncology and Psychiatry
at Children’s Hospital Oakland. He is
currently a Clinical Assistant Professor
of Pediatrics at USC, Keck School of
Medicine.
Joan E. Hodgman,
M.D.
Retirement Options for
Pediatricians
Dr. Hodgman received
her M.D. at UCSF in
1946 and pediatric
internship at UC Hospital. From 1955
to 1986, Joan was director of the nursery
service at LA County-USC Medical
Center. She has devoted her career to the
American Academy of Pediatrics and has
served AAP at local, state and national
positions of leadership. Dr. Hodgman
is a widow and has two daughters, four
grandchildren, and a black labrador.
Michael H. Joseph,
M.D.
Chronic Pain
in Children: A
Multidisciplinary
Biopsychosocial
Treatment Approach
(Part III); The Tao of Pediatrics and
Chinese Medicine
Dr. Joseph is a pediatrician that specializes
in pain management. After receiving
his MD at Creighton University School
of Medicine in 1993 and his pediatric
residency at the UCI Medical Center Dr.
Joseph completed a fellowship in Pediatric
Pain Management and a postdoctoral
research fellowship in Psychoneuroimmunology
at UCLA Medical Center.
Now as an Assistant Clinical Professor
at USC Keck School of Medicine he is
the Director of Pain Services at Childrens
Hospital Los Angeles. At CHLA he has
created a multidisciplinary service that
treats both acute and chronic pain in
children.
Thomas G. Keens, M.D.
Twenty-Five-Years of Home Mechanical
Ventilation in Children: The Program at
Childrens Hospital Los Angeles
Dr. Keens is a Professor of Pediatrics,
Physiology and Biophysics, at the Keck
School of Medicine of the University of
Southern California, and a member of
the Division of Pediatric Pulmonology at
Childrens Hospital Los Angeles.
Sheila S. Kun, R.N., M.S.
Twenty-Five-Years of Home Mechanical
Ventilation in Children: The Program at
Childrens Hospital Los Angeles
Sheila Kun is a Nursing Care Manager
for children on home mechanical ventilation
in the Division of Pediatric Pulmonology,
Childrens Hospital Los Angeles.
Sudeep Kukreja, M.D.
Early Hearing Detection
and Intervention
Dr. Kukreja is a staff
Neonatologist at Children’s
Hospital of Orange
County. He is AAP-CA
Chapter 4 Champion for the Early Hearing
Detection and Intervention Program
as well as Chairman of Chapter 4’s International
Child Health Committee. He is
also currently a member of the advisory
board to the California Department of
Health’s Newborn Hearing Screening
Program and Director of the Newborn
Hearing Screening Program at Children’s
Hospital of Orange County.
Leonard Kutnik, M.D.
SED — California Region
Dr. Kutnik attended medical school
at UCLA and received an MBA from
UC Irvine. He practiced primary care
pediatrics in San Diego for 20 years
and is presently Chief Executive Officer
and Medical Director for Children
First HealthCare Network (CFHN) in
Oakland CA. From 1991-1997, he was
District Chair of California District IX,
AAP and is now the chair of recently
developed Pediatric Reimbursement
Advisory Team.
Allan Lieberthal, M.D.,
FAAP
Culturally Appropriate
Communication is Good
Medical Practice
Allan Lieberthal MD,
FAAP is Vice-President of
AAP California Chapter 2. He practices
general pediatrics and clinical pediatric
pulmonology at Kaiser-Permanente in
Panorama City where he was Chief of
Pediatrics for 13 years. He is also Director
of the Kaiser Permanente Southern
California Cystic Fibrosis Center and
was lead physician in the development
of the Kaiser Permanente Immunization
Tracking System (KITS). He is Clinical
Professor of Pediatrics at the University
of Southern California
David S. Ludwig, M.D., Ph.D.
A Low-Glycemic Index Diet in the
Treatment of Pediatric Obesity
David Ludwig, MD, PhD, is Director of
the Obesity Center at Boston Children’s
Hospital and Assistant Professor of
Pediatrics at Harvard Medical School.
Dr. Ludwig is a graduate of Stanford
University School of Medicine.
Harry Pellman, M.D.
Preventing Ear Infections in Children
Dr. Harry Pellman is in private practice in
Huntington Beach and Fountain Valley,
California. He is Clinical Professor of
Pediatrics at the University of California,
Irvine, College of Medicine. Harry
is also past president of AAP California
Chapter 4. Since 1991, Dr. Pellman has
been author of a monthly column, “What
Parents Want to Know About...” in Pediatrics
for Parents.
Jeffrey S. Penso, M.D.
Last Word
Dr. Penso, editor of
California Pediatrician,
is in pediatric
practice in Culver City.
He did his pediatric residency
at UCLA, where
he is now Associate Clinical Professor of
Pediatrics. Dr. Penso was the physician
representative to the Healthy Families
advisory panel, and led the Department
of Health Services Committee on
Outreach to underserved and uninsured
children of California. He enjoys walks
with his wife, Rebecca, and his dog.
Paul Y. Qaqundah,
M.D.
CMA House of
Delegates Report
Dr. Qaqundah is Clinical
Professor of Pediatrics
at University of
California, Irvine. He
was the first president of the AAP Orange
County Chapter and was elected Pediatrician
of the Year by the Orange County
Chapter of AAP in 1988.
Trisha Roth, M.D.
Selling Tobacco
Products as a Public
Health Issue
Dr. Roth has been a
practicing pediatrician
for the past 30 years.
Her main focuses have been policy on
tobacco, alcohol and other drugs; underage
drinking; verbal abuse; and ADHD.
She is also currently the chair of AAP-
CA Chapter 2’s committee on Substance
Abuse and in October 2002 was honored
with the SHARE Recovery Award for
work on promoting self-help groups.
Karen Sokal-
Gutierrez, M.D.,
M.P.H.
Childcare Health Linkages
ProgramDr. Sokal-
Gutierrez works at the
University of California,
Berkeley, School of
Public Health in the Health and Medical
Sciences Program and the Center for
Community Wellness; and the University
of California, San Francisco, California
Child Care Health Program. She is the
chair of the AAP Chapter 1 Committee
on Early Childhood and Dependent Care,
on the national AAP committee on Early
Brain and Child Development and the
Executive Committee of the Section on
Community Pediatrics.
Vaughn A. Starnes, M.D.
Ten-Year Experience
with Pediatric
Bilateral Living
Donor Lobar Lung
Transplantation
Dr. Vaughn Starnes, Director of the
Heart Institute, is one of the world’s
most renowned pediatric cardiothoracic
surgeons. Dr. Starnes is also the Chair
of the Department of Cardiothoracic
Surgery at the Keck School of Medicine
of the University of Southern California.
His major areas of research interest
include heart transplantation, heart/lung
transplantation, congenital heart surgery,
lung tissue growth and development, and
adult acquired heart disease.
Burton F. Willis, M.D.
District Report
Dr. Willis is District Chairperson, California
District, AAP. Dr. Willis helped
establish California Chapter 4 and has
served as Secretary, Program
Chair, Vice-President
and President of the
chapter. He was a past
editor of the California
Pediatrician. Dr. Willis
has been practicing primary
care pediatrics in a
multi-specialty group for over 30 years
and is a Clinical Professor of Pediatrics at
the University of California Irvine Medical
Center, Department of Pediatrics
Manisha Witmans, M.D.
Twenty-Five-Years of Home Mechanical
Ventilation in Children: The Program at
Childrens Hospital Los Angeles
Dr. Witmans is a Post-doctoral Fellow in
Pediatric Pulmonology at the Childrens
Hospital Los Angeles.
Marlyn S. Woo, M.D.
Ten-Year Experience
with Pediatric
Bilateral Living
Donor Lobar Lung
Transplantation
Dr. Woo is a pediatric
pulmonologist and the former Director
of the Cystic Fibrosis Center at Childrens
Hospital Los Angeles. She has been a
member of the Childrens Hospital Los
Angeles Cardiothoracic Transplant Team
since its inception in 1992. Currently, Dr.
Woo is an assistant professor of pediatrics
at the Keck School of Medicine at
the University of Southern California.
Wendy Yu, M.S., L.Ac.
The Tao of Pediatrics
and Chinese Medicine
Wendy Yu is an Oriental
medical practitioner in
private practice with
office locations in West
Los Angeles and Pasadena.
She received her bachelor’s degree
from Rutgers University in New Jersey
and her graduate degree from Samra
University of Oriental Medicine in Los
Angeles. She is collaborating in clinical
research with the Magik Pain Program
and the Childrens Center for Cancer and
Blood Diseases at Childrens Hospital of
Los Angeles.
Brad J. Zebrack,
Ph.D., M.S.W.
Childhood Cancer
Survivors Report Life
Changes
Dr. Brad Zebrack is
a research fellow at
the David Geffen School of Medicine
at UCLA, Department of Pediatrics,
where he studies the impact of cancer on
patients, survivors and their families. Dr.
Zebrack obtained his doctorate degree
in Social Work and Medical Sociology
from the University of Michigan in
1999, and has masters degrees in both
social work and public health from the
UC Berkeley.
34 / CALIFORNIA PEDIATRICIAN — SPRING 2003

OFFICERS
CALIFORNIA DISTRICT
District Chair
Burton F. Willis, M.D.
9900 Talbert, #201
Fountain Valley, CA 92708
(714) 965-2531
burtfwill@aol.com
Past District Chair
Lucy Crain, M.D., M.P.H.
400 Parnassus Ave.
UCSF Box 0374
San Francisco, CA 94143
(415) 476-4988
lcrain@itsa.ucsf.edu
Alternate District Chair &
Lead Contract Medical Director
Robert Adler, M.D.
4650 Sunset Blvd.,
Mailstop 76
Los Angeles, CA 90027
(323) 669-2110
radler@chla.usc.edu
District Resident Coordinator
Theresa Murdock-Vlautin, M.D.
UCSD Medical Center
200 Arbor Dr.
San Diego, CA 92103
tmurdockvlautin@ucsd.edu
Representative, Annual
Chapter Forum
Quynh Kieu, M.D.
11100 Warner Ave., #116
Fountain Valley, CA 92708
(714) 641-0850
qkieu@projectvietnam.net
Chair, Committee on
State Government Affairs
Robert Black, M.D.
920 Cass St.
Monterey, CA 93940
(831) 372-5841
Chair, Program
Committee
Milton Arnold, M.D.
27434 Rainbow Ridge Rd.
Palso Verdes Peninsula,
CA 90274
(310) 377-2698
marncalaap@aol.com
Representative, National
Nominating Committee
Paul H. Jewett, M.D.
900 Fifth Ave. #204
San Rafael, CA 94901
(925) 837-2634
hpjewett@aol.com
Pediatric Delegate to
CMA House of Delegates
Paul Qaqundah, M.D.
17822 Beach Blvd.,#278
Huntington Beach,
CA 92647
(714) 842-1441
pqaqundah@aol.com
President, Children’s
Health Systems
Leonard Kutnik, M.D.
1835 Alcatraz Ave.
Berkeley, CA 94703
(510) 428-3472 (wk)
leonardak@aol.com
Subspecialty Liasion
Joan Hodgman, M.D.
494 Stanford Drive
Arcadia, CA 91007
(323) 226-3406 (wk)
Hodgman@hsc.usc.edu
District CATCH Representative
Arnold Gold, M.D.
800 Third St.
Marysville, CA 95901
(530) 749-3326
algold@pol.net
District School Health Group Chair
Sidney Smith, M.D.
601 Cascada Way
Los Angeles, CA 90049
(310) 472-8034
sidsmith@ucla.edu
District Young Physician
Representative (YPS)
Elaine Ong, M.D.
25800 Industrial Blvd., Apt G362
Hayward, CA 94545
(510) 784-6953 (hm)
District Treasurer
Myles Abbott, M.D.
2999 Regent St., #325
Berkeley, CA 94705
(925) 254-9203 (wk)
mabbottmd@aol.com
CHAPTER 1
OFFICERS
President
George J. Monteverdi
900 Fifth Ave. #204
San Rafael, CA 94901
(707) 253-8511
ggmale@napanet.net
Vice President
Mika Hiramatsu, M.D.
20101 B Lake Chabot Rd.
Castro Valley, CA 94546
(510) 581-1446 x126
cho.dr.mhi@cho.org
Secretary
Yasuko Fukuda, M.D.
3905 Sacramento St., #301
San Francisco CA 94118
(415) 752-8038
Treasurer
Eileen Aicardi, M.D.
3641 California St.
San Francisco, CA 94118
(415) 668-0888
eaicardi@pacbell.net
Past President
Paul H. Jewett, M.D.
900 Fifth Ave. #204
San Rafael, CA 94901
(925) 837-2634
hpjewett@aol.com
CATCH Facilitators
Arnold Gold, M.D.
(530) 749-3326
Aparna Kota, M.D.
(415) 202-4593
CHAPTER 2
OFFICERS
President
Elliot Weinstein, M.D.
9645 Monte Vista Ave., #301
Montclair, CA 91763
(909) 621-0973
Elst@cyberg8t.com
Vice President
Allan S. Lieberthal, M.D.
13652 Cantara St.
Panorama City, CA 91402
(818) 375-2412
Allan.S.Lieberthal@kp.org
Secretary
Luis Montes, M.D.
Childrens Hospital Los Angeles
4650 Sunset Blvd.
Los Angeles, CA 90027
(323) 669-2231
lmontes@chla.usc.edu
Treasurer
Howard Reinstein, M.D.
5400 Balboa Blvd., Suite 103
Encino, CA 91316
(818) 784-5437
RhineHow@aol.com
Past President
Steven A. Feig, M.D.
3756 Santa Rosalia Dr., #600
Los Angeles, CA 90008
(323) 299-3200
Pedsdoc2@aol.com
Program Chairman
Milton I. Arnold, M.D.
27434 Rainbow Ridge Rd.
Palso Verdes Peninsula,
CA 90274
(310) 377-2698
marncalaap@aol.com
CATCH Facilitator
Elisa Nicholas, M.D.
Miller Children’s Hospital
2801 Atlantic Ave., Box 1428
Long Beach, CA 90806
(310) 933-0430
enicholas@memorialcare.org
CHAPTER 3
OFFICERS
President
Gene Nathan, M.D.
10862 Calle Verde
La Mesa, CA 91941
(619) 660-5400
gnathan@chsd.org
Vice President
Amethyst Cureg, M.D.
3851 Rosecrans St. (MSP511H)
P.O. Box 85222
San Diego, CA 92186
(619) 692-8819
amethyst.cureg@sdcounty.ca.gov
Secretary/Treasurer
Donald T. Miller, M.D., MPH
408 Cassidy Street
Oceanside, CA 92054
(760) 757-4566
dmiller@nchs-health.org
Past President
Stuart A. Cohen, M.D.
6699 Alvarado Road, #2200
San Diego, CA 92120
(619) 265-3400
schoen98@ipninet.com
CATCH Facilitator
Paul Parker, M.D.
408 Cassidy Street
Oceanside, CA 92054
(760) 757-4566
CHAPTER 4
OFFICERS
President
Quynh Kieu, M.D.
11100 Warner Ave., #116
Fountain Valley, CA 92708
(714) 641-0850
qkieu@projectvietnam.net
Vice President
Marc Lerner, M.D.
University of California, Irvine
Gottschalk Medical Plaza
#1 Medical Plaza Dr.
Irvine, CA 92697
(949) 824-8600
malerner@uci.edu
Secretary/Treasurer
Maria Tupas, M.D.
CHOC
455 S. Main St.
Orange, CA 92868
(714) 516-4238
mtupas@choc.org
Past President
Harry Pellman, M.D.
9900Talbert #201
Fountain Valley, CA 92708
(714) 965-2531
hpellman@earthlink.net
CHOC Representative
James D. Korb, M.D.
CHOC
455 S. Main St.
Orange, CA 92668
(714) 532-8338
CATCH Facilitators
Paul Qaqundah, M.D.
17822 Beach Blvd., #278
Huntington Beach, CA 92647
(714) 842-1441
Mohan Kumaratne, M.D.
17692 Beach Blvd., #200
Huntington Beach, CA 92647
(714) 847-6975
UCI Representative
Feizal Waffarn, M.D.
Department of Pediatrics
UCI Medical Center
101 City Drive South
Orange, CA 92868
(714) 456-8470
CALIFORNIA PEDIATRICIAN — SPRING 2003 / 35

COUNCIL ON
CHILD HEALTH
CHAPTER 1
Behavioral/Developmental
J. Lane Tanner, M.D.
Renee Wachtel, M.D.
Child Abuse
James Crawford, M.D.
Kevin Coulter, M.D.
Children with Disabilities
Donald Mangravite, M.D.
Felice W. Parisi, M.D.
Community Health
Aparna Kota, M.D.
Early Childhood
Adoption/Dependent Care
Karen Sokal-Gutierrez, M.D.
Environmental Health
Brian Linde, M.D.
Mark D. Miller, M.D.
Infectious Disease
Dean Blumberg, M.D.
Medical Informatics
Mark M. Simonian, M.D.
Nominating Committee
Myles Abbott, M.D.
School Health
Diane Dooley, M.D.
Renee Wachtel, M.D.
Substance Abuse
Seth Ammerman, M.D.
Martin J. Joye, M.D.
Young Physicians
Nelson Branco, M.D.
Shannon Udovic-Constant, M.D.
Youth
Tonya Chaffee, M.D.
CHAPTER 2
Injury Prevention
Mary Anne Limbos, M.D.
AIDS
Audra A. DeVeikis, M.D.
Bioethics
Joan Hodgman, M.D.
Child Abuse
Jess Diamond, M.D.
Children with
Disabilities/CCS
Robert Jacobs, M.D.
Committee on Breastfeeding
Touraj Shafai, M.D.
Environmental Health
Harvey Karp, M.D.
Fetus and Newborn
George Franco, M.D.
Foster Care and Adoptions
Kerry English, M.D.
Hospital Care
Harold N. Amer, M.D.
Infectious Disease
Wilbert Mason, M.D.
Mental Health
Eleanore U. Meyer, M.D.
Pediatric Emergency
Medicine
James Seidel, M.D.,Ph.D.
School Health
Sidney Smith, M.D.
Substance Abuse
Trisha Roth, M.D.
Youth/Adolescence
Curren W. Warf, M.D.
CHAPTER 3
Access to Care
Bronwen Anders, M.D.
Adoption/Foster Care
Gene Nathan, M.D.
Breastfeeding Coordinator
Nancy Wight, M.D.
Child Abuse
Cynthia Kuelbs, M.D.
Children with Disabilities
Howard Wolfinger, M.D.
Day Care
Laurel Leslie, M.D.
Emergency Medicine
Jim Harley, M.D.
Fetus & Newborn
David Golembeski, M.D.
Hospital Care
Erin Stucky, M.D.
Infectious Disease
John Bradley, M.D.
Injury Prevention
Tom Page, M.D. &
Sylvia Micik, M.D.
Mental Health
Martin Stein, M.D.
Healthy Tomorrows
Laura Clapper, M.D.
School Health
Gene Nathan, M.D.
Sports Medicine
Henry Chambers, M.D.
CHAPTER 4
Injury, Violence, and
Poison Prevention
Phyllis Agran, M.D.
Alberto Gedissman, M.D.
Breastfeeding Coordinator
Harry Pellman, M.D.
Child Care
Maria Tupas, M.D.
Children with Special Needs
Arleen Downing, M.D.
Anju Khanijou, M.D.
International Health
Quynh Kieu, M.D.
Mohan Kumaratne, M.D.
Sudeep Kukreja, M.D.
Practice Management
Mohan Kumaratne, M.D.
Victoria Jackson, M.D.
School Health and Nutrition
Chris Koutures, M.D.
Paul Qaqundah, M.D.
COUNCIL ON
PEDIATRIC PRACTICE
CHAPTER 1
CATCH
Aparna Kota, M.D.
Medical Education
Gena Lewis, M.D.
Membership
Devi Ananda, M.D.
Newsletter
Mika Hiramatsu, M.D.
Mark Simonian, M.D.
Public Relations
Mike Harris, M.D.
CHAPTER 2
Electronics Communications
Committee
Oved Fattal, MD, Chair
Legislation
Jeffrey S. Penso, M.D.
Membership
Sheila Phillips, M.D.
Nominating
Lawrence Ross, M.D.
Pediatric Practice
Jeffrey S.Penso, M.D.
Program
Milton Arnold, M.D.
Public Relations
Howard Reinstein, M.D.
Publications
Elliot Weinstein, M.D.
Resident Section
Martha Rivera, M.D.
CHAPTER 3
Federal Access Coordinator
Gene Nathan, M.D.
Future of Pediatric
Education
Laurel Leslie, M.D.
Kaiser Permanente Rep.
Joe McQuaide, M.D.
Legislation
Norman Gollub, M.D. &
Cynthia Kuelbs, M.D.
Membership
Donald Miller, M.D.
Managed Care
Norman Gollub, M.D.
North County Rep
Donald Miller, M.D.
Programs
Allen Schwartz, M.D.
Public Relations
Stuart Cohen, M.D.
CHAPTER 4
Continuing Medical Education
Harry Pellman, M.D.
Legislation
Quynh Kieu, M.D.
Management
Burton Willis, M.D.
Membership
Marc Lerner, M.D.
Nominating Committee
Alberto Gedissman, M.D.
Maria Minon, M.D.
Harry Pellman, M.D.
Public Policy/Advocacy
Quynh Kieu, M.D.
Pediatric Research in
Office Setting
Harry Pellman, M.D.
Valery Brouwer, M.D.
Practice Management
Mohan Kumaratne, M.D.
Victoria Jackson
Would you like to be on the mailing list?
California Pediatrician is the official publication of California
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36 / CALIFORNIA PEDIATRICIAN — SPRING 2003

ANGELA ANDERSON, M.D.
Associate Professor of Pediatrics, Brown University
Medical School; Attending Physician and Toxicologist,
Hasbro Children’s Hospital, Providence, Rhode Island.
DANIEL L. COURY, M.D., F.A.A.P.
Chief, Section of Behavioral – Developmental-
Pediatrics, Columbus Children’s Hospital, The Ohio
State University, Columbus, Ohio.
KATHRYN EDWARDS, M.D., F.A.A.P.
Professor of Pediatrics, Vice Chair for Clinical Research,
Department of Pediatrics, Vanderbilt University,
Nashville, Tennessee.
LEWIS R. FIRST, M.D., F.A.A.P.
Professor and Chair, Department of Pediatrics,
University College of Vermont, Burlington, Vermont.
FRANCINE R. KAUFMAN, M.D., F.A.A.P.
Professor of Pediatrics, Keck School of Medicine of
University of Southern California; Chief, Center for
Diabetes and Endocrinology, Childrens Hospital of Los
Angeles, California.
ANTHONY J. MANCINI, M.D., F.A.A.D., F.A.A.P.
Assistant Professor of Pediatrics and Dermatology,
Northwestern University Medical School, Chicago,
Illinois.
Pediatric Update AAP, California Chapters 1, 2, 3, 4 Venetian Hotel, November 20-23, 2003
Please remit to Venetian Hotel, 3355 Las Vegas Blvd, South, Las Vegas, NV 89109 Phone 877-2VENICE.
Name. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
City . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . State . . . . . . . . . Zip. . . . . . . . . .
Phone # ( ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accommodations Requested: ____ Luxury ($189) ____ Bella ($239) Number in Party . . . . . . .
Arrival Date/Time . . . . . . . . . . . . . . . . . . . . . . . . Departure Date/Time . . . . . . . . . . . . . . . . . . . . .
Hotel Accommodations: 300 suites of the Venetian Hotel will be available to registrants. Special rates are
$189 per day for Luxury (1 king), $239 for Bella (2 queens), subject to tax. Charge for extra person: $35
a day. Children under 12 are free. Note: Special rates will be available only until October 20, 2003 or
until all 300 blocked suites are taken. Once these are taken, regular hotel rates will apply. Chapter 2
disclaims any responsibility for hotel arrangements.
WE RECOMMEND YOU MAKE RESERVATIONS FAR IN ADVANCE OF THE MEETING.
Your credit card is acceptable in payment. MasterCard VISA American Express (circle one)
#. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Exp. Date. . . . . . . . . . . . . . . . . Signature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Please make checks payable and send to: Venetian Hotel, 3355 Las Vegas Blvd. South, Las Vegas,
Nevada 89109. Phone 877-2VENICE.
Pediatric Update AAP, California Chapters 1, 2, 3, 4 Venetian Hotel, November 20-23, 2003
Please remit this part to AAP, PO Box 2134, Inglewood CA 90305 Return policy: Refunds will be
made in full if meeting reservation cancellation is received prior to Oct. 20, 2003.
Name. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date. . . . . . . . . . . . .
Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
City . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . State. . . . . . . . . . . . Zip. . . . . . . . . . . . . .
Phone ( ). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fax ( ) . . . . . . . . . . . . . . . . . . . . . .
Email. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tuition Fee: (tuition does not include luncheon seminar costs) Before Oct. 15 After Oct. 15
Physicians: Members of AAP California Chapters 1, 2, 3, & 4 . . . . $550. . . . . $575 . . . . . . $______
All other AAP Members & Physician Non-members . . . . . . . . . . . $600 . . . . $625 . . . . . . $______
Pediatric Residents . . . . Hospital: . . . . . . . . . . . . . . . . . . . . . . . . . . $325 . . . . $350 . . . . . . $______
Allied Health Personnel Category: . . . . . . . . . . . . . . . . . . . . . . . . . $325 . . . . $350 . . . . . . $______
Physicians Emeritus with California Chapters 1, 2, 3, 4 . . . . . . . . . $100. . . . . $125 . . . . . . $______
Luncheon Seminars: $35 each. You may select one for each day. Please give a second and third
choice. Attendance is limited. Preference assignment will depend on order of receipt of registration.
Fri. Seminar: 1, 2, 3, 4, 5, 6 (enter number in box) Pref: 1o 2o 3o $35 . . . $______
Sat. Seminar: 1, 2, 3, 4, 5, 6 (enter number in box) Pref: 1o 2o 3o $35 . . . $______
Your credit card is acceptable in payment. MasterCard VISA (circle one)
Total
$______
#. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Exp. Date. . . . . . . . . . . . . . . . . Signature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Please make checks payable to: AAP, Chapter 2 and return to: P.O. Box 2134, Inglewood, CA 90305.
Phone: 310/540-6240 or 323/757-1198 for more information.

CALENDAR
May 14, 2003
Los Angeles
Pediatric Society
Annual Spring Meeting and Parmelee
Lecture
Sportsmen’s Lodge, Studio City,
California,
Call (310) 540-6240 or (323) 757-1198
or email aapcach2@aol.com
www.lapedsoc.org
May 24-26, 2003
California Chapter 1, AAP
Annual Spring Meeting
Pediatric Symposium and
Legislative Update
Hyatt Regency Hotel, Monterey,
California
Call (415) 459-4775
www.aapca1.org
June 29-July 5, 2003
University Childrens Medical Group and
California Chapter 2, AAP
Pediatrics in the Islands …
Clinical Pearls
Hyatt Regency Maui Resort, Hawaii
Call (323) 669-2305 or (800) 354-3263
(800) 3-KID-CME www.ucmg.org
September 18-21, 2003
Los Angeles Pediatric Society
60th Annual Brennemann
Memorial Lectures
Bahia Hotel, Mission
Bay, San Diego,
California
Call (310) 540-6240 or
(323) 757-1198
or email aapcach2@aol.com
www.lapedsoc.org
October 10-12, 2003
California Chapter 4, AAP
Current Advances in Pediatrics
Irvine Marriott Hotel
Irvine, California
Call (714) 971-0695
or email ca4aap@sbcglobal.net
October 11-17, 2003
University Childrens Medical Group and
California Chapter 2, AAP
Aloha Update: Pediatrics®
Hyatt Regency Kauai Resort & Spa,
Kauai, Hawaii
Call (323) 669-2305 or (800) 354-3263
(800) 3-KID-CME www.ucmg.org
November 20-23, 2003
California Chapters 1, 2, 3, 4, AAP
Pediatric Update, 25th Annual
Las Vegas Seminars
Venetian Hotel, Las Vegas Nevada
Call (323) 757-1198 or email
aapcach2@aol.com www.aapca2.org
December 6, 2003
California Chapter 1
Pediatric Infectious Disease Symposium
San Francisco, California
Call (415) 459-4775
January 14, 2004
California Chapter 2, AAP
Is There Life After Residency?
Courtyard by Marriot,
Marina Del Rey, California
Call (310) 540-6240 or (323) 757-1198
or email aapcach2@aol.com
www.aapca2.org
February 14-20, 2004
University Childrens Medical Group and
California Chaper 2, AAP
Pediatric Potpuri®
Hawaii
Call (323) 669-2305, (800) 354-3263, or
(800) 3-KID-CME www.ucmg.org
March 4-7, 2004
California Chapter 2, AAP, cosponsored
by the Los Angeles Pediatric Society and
Southwestern Pediatric Society
Combined Southern California Pediatric
Postgraduate Meeting—
Clinical Pediatrics
Hilton Palm Springs Reosrt,
Palm Springs, California
Call (310) 540-6240 or (323) 757-1198
or email aapcach2@aol.com
www.aapca2.org
April 15-18, 2004
California Chapter 2, AAP
Advances in Pediatrics, 15th Annual
Las Vegas Postgraduate Meeting
Flamingo Hotel, Las Vegas, Nevada
Call (310) 540-6240 or (323) 757-1198
or email aapcach2@aol.com
www.aapca2.org
July 3-9, 2004
University Childrens
Medical Group and
California Chapter 2,
AAP
Pediatrics in the
Islands...Clinical Pearls
Hawaii
Call (323) 669-2305 or (800) 354-3263
(800) 3-KID-CME www.ucmg.org
American Academy of Pediatrics
California District
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Albany, CA 94706
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