Pro Bono Publico - American Academy of Pediatrics National ...

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October 20-23, 2012 | New Orleans
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Pediatric Bowl Returns
to NCE
Seminar to Focus on UTI in
Very Young Children
Faculty to Reach 25-Year
Teaching Milestone
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Pro Bono Publico
n the day
before Mardi
Gras, Rex, King
of Carnival, arrives by
riverboat and mounts his
throne to rule New
Orleans, eager to
oversee the imminent
revelry. He
proudly proclaims
his code of law,
“pro bono publico”
or, in English,
weeks have
“for the common Joseph Zenel, MD, bearing on
FAAP, Editor
good.” This axiom
the phrase
may conjure moral, ethical,
or political thoughts The Supreme Court
“for the common good.”
but I’m pretty sure Rex’s upheld the Affordable
rule is more tongue-incheek
than
Care Act, confirming
scholar-inresidence.
Rex is indeed
mischievous. He challenges
that fun is the common
good, as New Orleans
makes merry before entering
40 days
of renewing
one’s soul
(Lent).
For me,
events these
past three
ADHD Presentation will Address
Stimulant, Non-Stimulant Treatments
In recent years, there have
been so many new products
that have come to market
to treat attention-deficient/
hyperactivity disorder
(ADHD) that it is sometimes
hard for pediatricians to keep
up with all of the different
formulations.
Andrew Adesman, MD,
PRO BONO PUBLICO continued on page 2
FAAP, plans to help
pediatricians weed
through some of the
options in stimulant
and non-stimulant
treatment in his
presentation “ADHD
Medications:
Stimulants and
Beyond” (S1102)
Andrew Adesman,
MD, FAAP
Saturday, Oct 20.
Dr Adesman’s
primary goal
is to provide
pediatricians with
practical advice
regarding what to
do when a patient
doesn’t respond
ADHD continued on page 3

2
PRO BONO PUBLICO continued from page 1
access to care for children in need.
Some political pundits argue the
Chief Justice voted for the common
good of the court. Last week I was
asked to consult on a child from a
rival practice, a consult that led to
multiple consults; competing practices
all pitched in for the common
good of the child and his family.
Medicaid helped. At my institution,
our very first pediatric interns are
now entering their second year of
residency and are readily guiding the
new interns and medical students,
contributing to the common good
of the residency program. This
weekend an article in the New York
Times reported a study that found
that spending money for the good
of others made one happier than
spending money on oneself. And
yesterday I received the minutes of
the recent AAP Combined District
VI/VII meeting in which Jeff Britton,
vice president of the Wisconsin
Chapter, wrote that we members of
the AAP should “focus on
the ‘pediatric soul,’ i.e.,
we are here because of
the desire to do something
good for the children.”
These random yet
intertwining occasions
lead me
Pediatric Bowl (V4069)
Tuesday, October 23
12:30 PM-1:30 PM
Ernest N. Morial
Convention Center
Special Non-CME Event Free to
Conference Attendees
‘Pass a good time’ at the Pediatric Bowl! Play along
with Louisiana’s pediatric residency programs
competing for the meconium cup. Defending
Champions (2003) Bonnie Desselle/Paul Cooper
and their “Tchoupitoulas Tigers” from Louisiana State
University will compete against Todd Washko and his
“Gris-gris Green Waves” from Tulane University and
newcomers Alston Dunbar and his “Cajun Krewe”
from Our Lady of the Lake Children’s Hospital Baton
Rouge. Who dat They’re the famed facilitators
of fun! Watch moderators Lewis First, editor of
Pediatrics; Marshall Land, American Board of
Pediatrics; and William Gerson, University of Vermont
College of Medicine challenge the rising stars of
pediatrics.
playfully to the next paragraph.
To me, the NCE is the theater
for medical students, residents,
fellows, faculty, and private practitioners
to play their role and
find their pediatric soul. In the
mirthful midst of receptions, Kid’s
Camp, Mardi Gras World family
night festivities, Pediatric Bowl,
and Fun Run, there are section
meetings, plenaries, business luncheons,
workshops, and seminars
dedicated to improving and advocating
care for children. Rex would
approve of this forum for mixing
pleasure with business.
This month’s issue of AAP Today
touches on ADHD treatments,
UTI diagnosis and therapy, and the
proper use of the ophthalmoscope.
This issue also teases you with
lighthearted blurbs about other
NCE affairs. View the clip on the
Pediatric Bowl and make sure you
read the humorous yet true story of
an attendee in the article “Faculty
Approach 25-Year Teaching Milestone
at AAP Conference.”
I suspect Rex also asserts,
“Multa veritas tenuit in iocum”
or, in English, “Many a truth
is held in jest.” I always believe
there is truth in humor, and one
is truly happy and entertained
when helping others. I like Rex,
and I like his kingdom. New
Orleans is just the right host city
for this year’s NCE where we will
meet “pro bono publico” and
have fun.

3
July Preview
ADHD continued from page 1
to an initial treatment trial of firstline
medication or when the patient’s
condition is more complicated.
“The published response rate for
stimulants when you try a single
stimulant is estimated at about 70
percent. So approximately 30 percent
of the time, clinicians will need to try
a different stimulant or try a different
medication altogether. I will provide
some suggestions or guidance
on how to optimize medication
response,” said Dr Adesman, who is
Chief, Developmental & Behavioral
Pediatrics at Steven & Alexandra
Cohen Children’s Medical Center of
New York in New Hyde Park, NY.
His presentation will include some
discussion of alternative therapies
and what place – if any – treatments
like fish oil have in the treatment
approach of children with ADHD
as well as provide information about the
effectiveness of dietary and nutritional
formulations currently available.
According to Dr Adesman,
pediatricians should be comfortable
understanding the many different
medication options and some of
their nuanced differences in terms of
choosing the right medicine. That
comfort should extend to developing
and implementing a second line of
treatment when the initial treatment
plan doesn’t appear to be adequate.
Second-line therapy should include
non-stimulants and alternative
stimulant formulations.
“I’ll also talk about the use of non
stimulants, either as a first-line or
second-line medication, or as an adjunct
treatment,” he said.
One of the major challenges for a
pediatrician dealing with patients with
ADHD involves setting appropriate
family expectations in terms of benefits
and side effects. The pediatrician has to
be sensitive and responsive to parental
concerns, requiring the pediatrician to
consider the different potential areas of
functional improvements one hopes to
see from medication and that the right
outcome criteria measures medication
“Setting the right expectations is
always important. If parents expect
too much or if they are looking
for improvement in the wrong
domains of function, they may be
disappointed.”
effectiveness. It is also important to
consider possible comorbid conditions
that affect the medication choice, the
medication response or the child’s
overall function.
Dr Adesman noted that challenging
issues of communication with families
can be time consuming. “I’ve written
that I believe it is easier for my oncology
colleagues to give their patients strong
chemotherapy than it is for us to give
our patients a prescription for Ritalin
just because there is so much hesitation
and misinformation.” Resistance,
anxiety, doubt and unrealistic
expectations can plague the parent of
a newly diagnosed child. “Setting the
right expectations is always important.
If parents expect too much or if they are
looking for improvement in the wrong
domains of function, they may be
disappointed,” he said.
There are also possible logistical
challenges for families such as availability
of preferred medications and dealing
with prescription plan formularies.
“Choosing the best medicine is
not always an option because we as
pediatricians need to be mindful of what
is available and affordable for families in
formulary options,” he said.
Dr Adesman will review the
major revisions to the AAP
treatment guides for ADHD,
including the expansion of
the guidelines from preschool
through adolescence. He plans to
address medication management
in the preschool population with
attention to patient friendly
formulations and issues specific to
the young child.
“We have to recognize that
preschool kids can’t swallow pills and
thus consider what that means in terms
of treatment options,” he said. “I’ll
also talk about some of the sensitive
issues with adolescents in terms of
diversion, potential misuse, and some
of the specific challenges of meeting
the individual needs of an adolescent
and college student in terms of their
longer academic days and more variable
schedules.”
In the end, it is important that
pediatricians can comfortably optimize
the response of children and adolescents
to medication for ADHD. “That can
translate into making sure pediatricians
are able to adjust the medications and
pick the right formulation so that
benefits are maximized and side effects
are minimized.”

4
Seminar to discuss urinary tract
infections in the very young
rinary tract infection
(UTI) is a common
cause of fever in infancy
and is probably the most
common serious childhood
bacterial infection. A seminar
Monday, Oct. 22, at this year’s National
Conference and Exhibition will focus
on how pediatricians should manage a
young patient with UTI.
“After the First UTI: Controversies
and Consensus” (S3091) will feature
Ellen R. Wald, MD, FAAP, Chair of the
Department of Pediatrics at the University
of Wisconsin School of Medicine
and Public Health, and Steven G.
Docimo, MD, Vice Chair and professor
of Urology at the University of Pittsburgh
School of Medicine.
Dr Wald will discuss the new AAP
guidelines for managing the initial UTI
in febrile infants and children up to 24
months of age. The original guidelines
were published in 1999. In November
2011, the AAP revised these guidelines
and Dr Wald served on the Subcommittee
on Urinary Tract Infection that was
Don’t miss the AAP Section
on Urology Program’s Master
Classes, a Live Robotic
Surgery Pyeloplasty, and
more! View urology program
highlights at www2.aap.
org/sections/urology/SOU_
Draft_Schedule-040212.pdf
View all conference sessions
at www.aapexperience.org/
planner.
responsible for the update.
She will review the guideline’s
seven action statements,
explain the rationale for these
statements, and emphasize
specific revisions.
The most controversial
change is Action Statement 6,
which describes the criteria for performing
a voiding cystourethrogram (VCUG).
The original guideline called for routinely
performing a VCUG after the first febrile
UTI, Dr Wald said, but the updated
guideline calls for postponing a VCUG
until a second UTI occurs or if an ultrasound
shows a worrisome abnormality.
Dr Wald will begin the seminar with
an overview of UTI, reviewing the
pathogenesis, bacterial etiology, signs,
and symptoms. She will define UTI in
terms of the bacterial density required to
determine whether the urine is infected
and review laboratory diagnosis, including
urine dipsticks and microscopy.
“I think that people tend to underestimate
the importance of pyuria,” she
said. “Understanding that both a lot
of bacteria as well an inflammatory
response, which is what the pyuria
indicates, are expected is an extremely
important take-home message. It will
allow the practitioner to know when a
culture result is important as opposed
to when it may be less important.”
Dr Docimo will discuss management
of recurring UTIs, which often require
management of vesicoureteral reflux
(VUR), along with the best ways to
manage voiding dysfunction. He said
voiding dysfunction is one of the most
Ellen R. Wald, MD, FAAP
common risk factors for recurring
UTI, so a physician must
assess for voiding dysfunction
and, if present, manage it aggressively.
All children with recurring
UTIs should be evaluated for
functional voiding disorders
in addition to evaluation for anatomical
issues, Dr Docimo said.
“What we’ve learned over the years,
much to our benefit and the benefit of
the kids that we treat, is that managing
voiding dysfunction and bowel dysfunction
significantly decreases the risk of
infection and, therefore, obviates a lot
of other treatments that we otherwise
might have to employ, including surgery,”
he said.
Non-surgical, non-invasive treatments
include bowel management with longterm
laxatives, timed voiding, double
voiding to empty the bladder, and
biofeedback to encourage pelvic floor
relaxation.
When surgery is indicated, Dr
Docimo said, there are new techniques
that can be done on an outpatient basis
or require an overnight stay. These
advanced techniques maintain the traditionally
high levels of effectiveness in
resolving VUR and decreasing the risk
of pyelonephritis.
“We find that we use surgery less
frequently than in the past, but when
needed, it’s still a relatively common
set of surgical procedures for pediatric
urologists,” he said. “When needed, it’s
very effective — a low-morbidity, highimpact
kind of surgery.”

5
July Preview
Faculty Approach 25-Year Teaching
Milestone at AAP Conference
ost medical students
are handed their direct
ophthalmoscopes during
the first week of their freshman year
in medical school. Very little, if any,
formal instruction is given on its use.
Examination of the eye may be covered
during one to two days of their senior
year, if that. Examining techniques are
sorely lacking, and most pediatricians
know this,” said Steven Lichtenstein,
MD, FAAO, FAAP, Associate Professor
of Clinical Surgery and Pediatrics
at the University of Illinois, College of
Medicine.
This fall, Dr Lichtenstein and Robert
D. Gross, MBA, MD, FAAP,
Clinical Associate Professor of
Ophthalmology at the University
of Texas, Southwestern
Medical School, will celebrate
a milestone of teaching 25
years for the AAP conference
at their workshop “Eye Examination
Skills: Using the
Ophthalmoscope” (W1045/
W1132) Saturday, Oct 20.
Over the years, their
presentation became better
and better. Dr Lichtenstein
attributes their biggest teaching
improvements to the
quality of pictures and advancements
in digital photography. “We started
out using dual projector Kodachromes,
which most of the younger physicians
have never heard of! Today we can take
a digital picture and insert it into our
Robert D. Gross,
MBA, MD, FAAP
Steven Lichtenstein,
MD, FAAO, FAAP
PowerPoint Presentations
instantaneously.”
Another
critical improvement
is the equipment
now available
to the pediatrician.
“While ophthalmoscopes
have been
around for a long
time, it is really
only for the past
seven or eight years
that we have had
the capability of
showing a view through an ophthalmoscope
using video. Now
we can show imaging of eye
pathology via optical coherence
tomography to further
enhance the learning experience,”
said Dr Gross.
More than 20 years ago at
an AAP conference in Atlanta,
an 80-year-old pediatrician
approached Doctors Lichtenstein
and Gross after their
first workshop and said, “I
want to really thank you for
presenting this workshop!”
Dr Lichtenstein thanked him,
yet the learner continued,
“No, I REALLY want to thank you. I
have been practicing for 50 years and
today was the FIRST TIME I have ever
seen the optic nerve!” Dr Lichtenstein
reflected, “I was truly taken aback. I
knew what we were doing was truly a
Dr Robert Gross interacts with learners and reflects, “I would say that the
most rewarding aspect of this course for a learner and for me is to hear them
tell me that for the first time they could really see the optic nerve and the
back of the eye. It is as if a whole new world has opened up to them. This is
what keeps me coming back to teach year after year.”
worthwhile and necessary endeavor,
which continues to be why I so enjoy
presenting this course.”
Every workshop the doctors have
presented has sold out, and they are frequently
asked whether they can accommodate
one or two extra participants.
They appreciate the enthusiasm of
learners and popularity of their session,
reflecting on the overall value of the
AAP conference, “What other forum allows
you to come face to face with true
experts in all subspecialties of pediatric
medicine, walk up and ask them a question
The experts that are just names in
a journal article or a textbook are right
there in front of you, and approachable,”
said Dr Lichtenstein. “Where else
can you also renew old friendships with
colleagues and mentors that you may
not have seen since medical school or
training The AAP conference has long
been this for me.”

Trauma in the ER, ICU, and Beyond:
AAP National Conference Joint Program Co-sponsored by the Section
on Critical Care and the Section on Emergency Medicine (H3025)
Monday, October 22 • 8:30AM – 11:30 AM
Ernest N. Morial Convention Center, New Orleans
American Academy of Pediatrics 2012 National Conference & Exhibition
“Pediatric Trauma is the leading cause of death and disability in almost every single country.”
Join the Section on Critical Care
(SOCC) for an exciting
educational program, “Trauma
in the ER, ICU, and Beyond”, cosponsored
by the Section on
Emergency Medicine.
The program will help the
attendee understand the
challenges in caring for children
with multiple traumatic injuries
as well as the most recent
evidence based care for
traumatic brain injury. The final
session will describe the
pediatric traumatic injuries seen
during war and how the military
health system has had to adapt.
PROGRAM SCHEDULE
Monday, October 22nd
8:30–8:45 AM
Introduction
8:45–9:40 AM
Traumatic Brain Injury
9:40–10:35 AM
Multi‐Trauma Injuries
10:35–11:30 AM
Pediatric War Injuries
The SOCC is also sponsoring a full day
educational session on Sunday, October
21 st including a session on the treatment
of respiratory failure including two newer
techniques, Non‐Invasive Positive
Pressure Ventilation and Airway Pressure
Release Ventilation (H2022).
The final speaker on Sunday will be
Niranjan “Tex” Kissoon, MD, FAAP who
will be receiving the SOCC Distinguished
Career Award. Dr Kissoon will discuss the
treatment of respiratory failure in
resource limited countries. Dr Kissoon has
been instrumental in improving pediatric
critical care around the world and played
a lead role in the recent World Sepsis
Declaration and the upcoming World
Sepsis Day in September which has been
endorsed by the American Academy of
Pediatrics.
Section member LCDR Luke Zabrocki, MC,
USN states, "A 12 year old girl with a
severe penetrating head injury can be a
challenging case for any pediatric
intensivist. Staffing an ICU in a NATO
hospital in Afghanistan makes this
especially true. Here, the ballistics are
from a high powered military grade
weapon, the hospital is staffed by
a single pediatric intensivist and a solo
neurosurgeon, simple things such as serum
osmolality tests and EEGs are unavailable, the
patient is malnourished with intestinal
parasites and drug resistant acinetobacter is a
common occurrence. Doing more with less
proves to be an essential skill. Yet somehow,
this particular patient regained nearly all
functional capacities.
Cultural considerations are no small part of
the medical care. A ‘good outcome’ must be
completely redefined for patients who have
to return to a remote and very poor village.
The role of the pediatric intensivist
supporting military operations is truly
challenging, encompassing the care of US and
coalition troops, local national security
forces, detainees, and local civilians. And just
when my comfort zone has expanded to
include all these new facets of medical care,
the incoming rocket attack alarm causes me
to scramble to find my true comfort zone,
inside the closest bunker."
The Section on Critical Care
The mission of the Section on Critical Care (SOCC) of the American Academy of Pediatrics is
to optimize the care of critically ill infants, children, and adolescents through the educational
and professional support of its nearly 800 members.
The SOCC sponsors educational programming and abstract presentations each year at the AAP
National Conference & Exhibition as well as Pediatric Critical Care Coding, PICU Practice
Management, and Preparing for Life in Academics courses.