ohio pediatrics - spring 2013 - ohio aap

More than 150 people helped the Ohio AAP Foundation raise morethan $14,000 at the 7th Annual Signature Fundraiser, “Lions, Literacy, andLunch” on May 18 at the Columbus Zoo and Aquarium. The event fea-tured three guest readers, raffle prizes, and a full day of family fun at theZoo.

New this year was the opportunity to bring foster families to the event.Sponsor donations provided tickets to over 40 foster children and par-

In This Issue• Sports Shorts - Performance

Enhancing Substances

• Case Study: Spondylolysis

• Health Plan Assistance Guide

• Tips for proper vaccine storage

Members often wonder what theOhio AAP is doing for them. In oneword – PLENTY.

Here are some of the Chapter’saccomplishments in the past year:

• Bike Helmet Safety AwarenessWeek – Distributed more than4,000 helmets; reached more than12 million people with the cam-paign; had 60 groups in Ohioreceive helmets representing 40%of Ohio counties.

• Continue to advocate OhioMedicaid to make sure Ohio phys-icans will receive their enhancedreimbursements.

• Established four MOC programsfor members – Building MentalWellness (BMW), Asthma, InjuryPrevention, and Pound of Cure.

• Distributed more than 150,000books to Reach Out and Read

See Lions...on page 7

What has theChapter done for YOU lately?

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$14,000 raised at OhioAAP Foundation event

The Ohio AAP’s SecondAnnual Bike Helmet SafetyWeek, held May 6-10,reached millions in Ohio.John Sherman Elementarystudents (at right) took partin a bike rodeo. See storyand more photos on pages24 & 25.

William Knobeloch, MD, Ohio AAP Foundation Board member,makes friends with a dingo at the Columbus Zoo fundraiser.

36037_Peds Spring 2013_Ped Spring 2007copy 4 co copy 2 6/10/13 5:41 AM

www.ohioaap.org Ohio Pediatrics • Spring 2013

A Publication of the Ohio Chapter, AmericanAcademy of Pediatrics

OfficersPresident....Judith Romano, MD

President-Elect....Andrew Garner, MD, PhD

Treasurer....Robert Murray, MD

Delegates-at-large:Jill Fitch, MDAllison Brindle, MDMike Gittelman, MD

Executive Director:Melissa Wervey Arnold450 W. Wilson Bridge Road, Suite 215Worthington, OH 43085(614) 846-6258, (614) 846-4025 (fax)

Lobbyist:Dan Jones Capitol Consulting Group37 West Broad Street, Suite 820Columbus, OH 43215(614) 224-3855, (614) 224-3872 (fax)

Editor:Karen Kirk(614) 846-6258 or (614) 486-3750

Ohio’s Medicaid expansion debate –Better than a movie!Fans of The West Wing or Houseof Cards can cancel their Netflixsubscription, there is a way moreentertaining show for you –Ohio’s Medicaid expansion de-bate. Over the last few months,Medicaid expansion has domi-nated the debate surroundingHouse Bill 59, the state operatingbudget. The Ohio House of Rep-resentatives removed expansionfrom Gov. John Kasich’s pro-posed budget in April; after thebudget passed the House andmoved to the Ohio Senate, Presi-dent Keith Faber (R-Celina) im-mediately said his chamberwould not add expansion backin. Legislative Democrats, health-care provider organizations in-cluding the Ohio Chapter, pa-tient advocates, and othergroups have continued to pressfor expansion during committeehearings, at Statehouse rallies,and on editorial pages.

Following passage of the budget,the House began a series of infor-mal hearings focused on Medi-caid “reforms.” Most of the de-bate has centered on past initia-tives including managed care,PCMH, and the welfare reformsof the mid 90s

’

. Additionally,State Rep. Barbara Sears (R-Sylvania) has introduced a stand-alone measure (House Bill 176)which would allow Ohio Medi-caid to expand coverage; Rep.Sears has been a leading voicein the Republican caucus forexpansion. House SpeakerWilliam Batchelder (R-Medina)has said he wants to have a

Medicaid reform package pass-ed by June 30, the same timeframe as the state operatingbudget. We do anticipate thatother reform packages will be in-troduced by conservative HouseRepublicans who would seek toshift some populations off of theMedicaid rolls and increase per-sonal responsibility requirements(drug testing, job seeking, etc.).Members who support this ap-proach are opposed to House Bill76, and vice versa.

Over in the Senate, State SenatorDave Burke (R-Marysville), a li-censed pharmacist and leaderon health-care issues, has said hewill begin hearings as part of aMedicaid study committee. TheSenate is set to pass the budgetin early June, setting up a confer-ence committee between thetwo chambers to resolve differ-ences. The budget must be pass-ed by June 30. At this point it isvery unlikely that Medicaid ex-pansion will find its way into thebudget in conference commit-tee, despite the fiscal impact itcould have on state spending.Further, it is unclear what the leg-islature will be able to pass; de-spite controlling both chambers,legislative Republicans are verydivided on this issue.

It’s also important to highlightanother budget issue outside ofthe expansion debate that hascaught us all by surprise – chiro-practors and concussions. Ohio’slandmark concussion law wentinto effect earlier this year. As you

know, after showing signs of aconcussion a youth athlete mustbe removed from play and keptout for at least 24 hours, and onlyafter they are cleared by ahealth-care professional. Non-physicians must consult with aphysician before clearing an ath-lete to return to play. A small pro-vision slipped into the state oper-ating budget by the House wouldallow chiropractors to clear ath-letes to return to play without con-sulting a physician. The Ohio AAPand other stakeholders have ada-mantly opposed this change, andcontinue to press legislative lead-ers to remove the provision. Thankyou to all who have called or writ-ten their legislator on this issue!

Daniel Hurley, LobbyistCapitol Consulting Group

Update from the Statehouse

2



President’s Message

Reflecting on Chapter activities,accomplishments this year

3

It’s hard to believe that my presi-dency is half over! I thought itappropriate to take this time toreflect on the activities of thepast year. I hope you will payparticular attention to the articleon Chapter accomplishments formembers this year (see page 1).There has been so much activityit is impossible for me to highlightall of them, but I would like toshare a few that demonstratethe Chapter’s commitment tochildren and to the pediatriciansserving them.

As you may recall, your leader-ship made a bold decision torevamp the organization of theOhio AAP using what we nowcall the four pillars approach. Thefour pillars are Child Health, Pedi-atric Practice, Advocacy, andOperations. By using this model,we have successfully used pro-cess to dictate structure which Ibelieve has resulted in an in-

crease in efficiency. By usingdedicated staff members work-ing alongside our pediatricianvolunteers, our successes haveskyrocketed.

A beautiful example is our activi-ties around injury prevention.These include a Quality Improve-ment/Maintenance of Certifi-cation program; legislative advo-cacy which resulted in enact-ment of the Ohio concussionlaws regarding return to play;and an extraordinary bike helmetsafety initiative. The “Put a Lid onIt” campaign, which developedthe 2013 Bike Helmet AwarenessWeek, reached an estimated 12million people. In addition 40% ofOhio counties had groups receiv-ing free bike helmets. I applaudMichael Gittleman, MD, FAAP,and Sarah Denny, MD, FAAP, fortheir success and thank HayleySouthworth and Angela Krile fortheir hard work.

Another change for the Chapterthis year was the structure of theExecutive Committee meetings.Using that time together to iden-tify new topics and directions forthe Chapter has proven fruitful.At the September 2012 ExecutiveCommittee meeting, two topicswere identified and resulted inactivities. One of these topicswas adolescent issues which de-veloped into a very successfulAdolescent Vaccine Roundtablewhich was held in April. Atten-dance from key stakeholdersaround adolescent immuniza-tions has resulted in the intent to

develop a Quality Improvement/Maintenance of CertificationProgram. Another topic identifiedat that meeting was foster care.Jonathan Thackeray, MD, FAAP,took the lead and representedthe Chapter in statewide discus-sions with the Attorney General.The result Is a specific recom-mendation for creating a stan-dardized computer-based sys-tem to share medical Informationfor foster children – an actionlong desired by the Chapter!

The Chapter recognizes the im-portance of engagement of ouryoung physicians:

Congratulations to Allison Brin-dle, MD, FAAP, who received aCommunity Pediatrics TrainingInitiative Grant, and with VisitingProfessor Lisa Chamberlain, MD, FAAP, developed an advocacytraining collaborative for pedi-atric training programs – four pro-grams participated representinghalf of the training programs inthe state.

I could go on with many moreexamples, but will close by say-ing that I am extremely thankfulto all of our pediatrician volun-teers and our dedicated staff,who have accomplished somuch for the good of the chil-dren in Ohio.

Judith T. Romano MD, FAAPOhio AAP President

President Judy Romano, MD


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www.ohioaap.org Ohio Pediatrics • Spring 2013 4


Editor’s note: The author of this case study is DrewDuerson, MD, is a Second Year Pediatric Resident atNationwide Children’s Hospital, Columbus.

History: A 13-year-old female gymnast presents to clinic withinsidious onset of low back pain. She states that thepain started about 3 months ago and has beensteadily worsening ever since. She denies any specif-ic injury that led to the onset of pain. The pain typi-cally worsens with activity, especially those that re-quire extension or rotation, and improves with rest.She reports no previous history of back pain. Shedenies neurological symptoms, such as radiatingpain, numbness, tingling, or bowel or bladder incon-tinence. She denies night pain, fever, chills, or weightloss. She is currently a level 8 gymnast and practicesapproximately 15 hours per week.

Physical Exam:She is a healthy appearing female in no acute dis-tress. Examination of her back reveals mild lumbarhyperlordosis but no scoliosis, excessive thoracickyphosis, or visible step-offs. She is tender to palpa-tion at the L5 vertebrae with surrounding mild bilater-al paraspinal muscle spasm. She has full range ofmotion in her lower back with the exception of ex-tension, which causes her increased pain. She en-dorses pain with single-leg hyperextension, or theStork test, bilaterally. FABER test is negative bilateral-ly. She denies radiating pain upon straight leg raise.She has full strength with hip, knee, and ankle flexionand extension. Her lower extremity sensation and re-flexes are normal and symmetric, without evidenceof clonus.

Differential Diagnosis:Spondylolysis, Spondylolisthesis, Lumbar Strain/Mech-anical Low Back Pain, Scheuermann’s Kyphosis,Herniated Disk, Spinous Process Apophysitis, LimbusVertebra, Vertebral Fracture, Inflammatory Joint Dis-order, Tumor, Infection

Tests/Results: Screening AP and standing lateral radiographs ofher lumbar spine were normal. Due to increasedclinical suspicion of pathology, a SPECT scan wasperformed, which revealed increased tracer uptakein bilateral pars regions of the L5 vertebrae.

A limited, thin-cut axial CT was performed to furthercharacterize the lesions. Bilateral spondylolytic de-fects of the pars interarticularis at L5 were revealedshowing evidence of sclerotic margins, indicatingchronicity.

Final Diagnosis:Bilateral Spondylolysis of L5

Treatment:Once diagnosed with a spondylolysis, the patientwas removed from her sporting activities and restedfor 12 weeks. For comfort she was placed in a softlumbar corset brace to be worn as needed. Afterher prolonged period of rest she was referred to phy-sical therapy to focus on core strengthening andhamstring flexibility. She completed a total of sixweeks of rehabilitation with the first, second, and lasttwo weeks spent on flexion, extension, and function-al activities, respectively. Follow-up after the com-pletion of PT revealed that our patient had regainedpain-free range of motion with improved strengthand flexibility, and she was allowed to return to hersport without restrictions. She was advised to returnfor follow-up in one year, for a standing lateral lum-bar spine radiograph, to ensure that progression tospondylolisthesis had not occurred.

Discussion: Patients with spondylolysis will present to the office

5www.ohioaap.org Ohio Pediatrics • Spring 2013

Case Study: Spondylolysis

See Case Study...on page 6



complaining of acute or chronic low back pain. Onphysical exam, range of motion testing will discoverpain mostly with extension. The Stork test is a specialtest used to identify spondylolytic defects. It is simplyperformed by having the patient stand on one legwhile flexing the other to 90 degrees. The patient isthen asked to hyperextend the back, with any result-ing low back pain indicating a positive test. Otherspecial tests used to evaluate low back pain shouldinclude FABER’s and the straight leg raise tests. TheFABER’s test is performed to evaluate for sacroiliacjoint dysfunction. It is completed by having the pa-tient Flex, ABduct, and Externally Rotate their hipwhile the examiner provides posteriorly directed pres-sure to the knee and stabilizes the opposing hip. Painelicited posterior on the contralateral side is consid-ered a positive test. The straight leg raise is a sensitivetest used to screen for an underlying herniated disk.With the patient supine the examiner lifts the patient’sleg to an angle of 30 to 70 degrees. Recreation ofpain down the leg is considered a positive test; painelicited by raising the opposing leg increases thespecificity of this test.

If the physical exam raises suspicion for spondylolysis,a radiographic workup is necessary. Included in thismust be a standing lateral radiograph, as supine lat-eral films may miss a spondylolisthesis of less than 25%.While bilateral oblique views may reveal the tradition-al “Scotty dog collar,” they are not always performedsecondary to the increased amount of radiation ex-posure.

With a sensitivity of less than 50%, radiographs do notalways detect a spondylolytic defect. In the pres-ence of appropriate history (pre-teen or teen, pro-longed period of pain, athlete competing in exten-sion based activities) and exam (pain with extension,positive Stork test, spina bifida occulta on X-ray) ad-vanced imaging is recommended. A single photonemission computed tomography (SPECT) scan lookingfor increased uptake in the areas causing pain candistinguish a bony source of pain. CT scans may beobtained to help clarify the lesion, using thin cuts limit-ed to the positive areas on the SPECT scan to helpguide prognosis and treatment.

Treatment of these lesions is controversial. The lengthof activity restriction, bracing versus not bracing,types of braces used, the timing of rehabilitation, and

the physical therapy protocol followed can all vary.However, the focus of a treatment plan should alwaysbe pain relief for the patient, and this most oftencomes with rest. Using the CT scan as a guide, thelength of relative rest can be short with pain-free ad-vancement into rehab for chronic appearing lesionsor up to 3 months of activity restriction for those thatappear more acute or subacute. Bracing is typicallyconsidered when rest alone is not effective in alleviat-ing the patient’s symptoms. Braces can range fromsoft lumbar corsets to rigid Boston braces and areoften chosen based on physician preference. Lastly,it is also important to recognize the potential for bilat-eral spondylolyses to progress to spondylolisthesis,especially during the adolescent growth spurt, mak-ing annual screening standing lateral radiographs animportant part of your overall treatment plan, untilthe patient reaches skeletal maturity.

REFERENCES• Axelsson, P; Johnsson, R; Stromqvist, B. “Effect of lumbar orthosison intervertebral mobility.” Spine 1992;17:678-681 • Bernstein RM; Cozen H. Evaluation of Back Pain in Children andAdolescents. Am Fam Physician 2007 Dec 1;76(11):1669-1676 • Fischer A. "Spondylolysis in the Adolescent". OAFP 2011; 63(3):28-29 • Gregg CD, Dean S, Schneiders AG. Variables associated withactive spondylolysis. Physical Therapy in Sports 2009;10:121-124 • Luke A, Micheli LJ. Spondylolysis and Spondylolisthesis: Principlesin Diagnosis and Management. International SportMed Journal2000;1(4) • Sairyo K, Shinsuke K, et al. Athletes With Unilateral SpondylolysisAre at Risk of Stress Fracture at the Contralateral Pedicle and ParsInterarticularis – a Clinical and Biomechanical Study. The AmericanJournal of Sports Medicine 2005;33(4):583-90 • Standaert CJ, Herring SA. Expert Opinion and Controversies inSports and Musculoskeletal Medicine: The Diagnosis and Treatmentof Spondylolysis in Adolescent Athletes. Archives of PhysicalMedicine and Rehabilitation 2007;88:537-40 • Wicker, Antony. Spondylolysis and spondylolisthesis in sports – FIMSPosition Statement. International SportMed Journal 2008; 9(2):74-78 • Yamane T, Yoshida T, Mimatsu K. Early Diagnosis of LumbarSpondylolysis by MRI. J Bone Joint Surg [Br] 1993;75-B:764-768 • Spondylolysis and Spondylolisthesis in Children and Adolescents:Diagnosis, Natural History, and Nonsurgical Management. J AmAcad Orthop Surg 2006; 14(7):417-424

Drew Duerson, MDSecond Year Pediatric ResidentNationwide Children’s Hospital, Columbus

Case study...from page 5


ents who joined Ohio AAP andcommunity members for lunchand activities. Shelley Robbins, RN,LNC-CSp, C.H.A.M.P. Coordinatorfor the Rocking Horse Center, wason hand during the event to speakabout the “My Story” Foster Careprogram and to share the daywith some of the foster families sheassists. This program is very close toher heart, as she shared at theevent.

“I am not sure who quoted this butI have this on my wall in my officesurrounded by tons of pictures of‘my kids’ over the past 10 years.When the kids come to the Rock-ing Horse they come in to see iftheir picture is still there. I haveeven had children that are not in-volved in the foster system bringme pictures of themselves to placeon my wall. I get to look at it everyday and it helps keep me goingfor these children. It is simply ‘Everychild has a story yet to be told,’”Robbins said.

Other foundation initiatives werealso introduced to the audience,including Injury Prevention andObesity Prevention. WilliamKnobeloch, MD, an Ohio AAPFoundation Board Member, dis-cussed why he supports the EarlyLiteracy program; see the Founda-tion Focus on page 9 for more in-formation on exciting develop-ments with this program.

Guest readers included DaveKaelin of the WNCI Morning Zooradio show reading The StinkyCheese Man, a zookeeper readingBrown Bear, Brown Bear, What DoYou See? and Frankie Hejduk ofthe Columbus Crew reading PolarBear, Polar Bear, What Do YouHear? Bob McElligott, Columbus

Blue Jackets color analyst, re-turned for a second year as eventemcee. McElligott was impressedby the Ohio AAP Foundation atlast year’s Signature Fundraiser.

“I thought you guys were great,and I really enjoyed myself,”McElligott said of his experience atSafety, Sandwiches, and Slapshotsin August 2012. “I think the cause isworthwhile and you do great work.When you asked me to comeback it was really a no-brainer.”

Thanks to the generosity of atten-dees at the Ohio AAP’s Adoles-cent Immunization Expert Round-table, raffle prizes for this year in-cluded an iPad mini, gift cards,and book gift sets for kids andadults. The Columbus Blue Jacketsalso donated a signed stick andpuck that were awarded in theraffle.


Lions...from page 1

Current and past presidents,from left, Bill Cotton, MD, GerryTiberio, MD, Judy Romano, MD,Toni Eaton, MD, and TerryBarber, MD.

Sponsor donations providedtickets to 40 foster children.

Amy Sternstein, MD, discussesthe Pound of Cure initiative.

A Columbus zookeeper readsto the children from “BrownBear, Brown Bear, What DoYou See?”

Thank You to Our Generous Sponsors:$1,000 Level Sponsors• The Center for Cognitive andBehavioral Therapy• Nationwide Children’s Hospital

$500 Level Sponsors• Accel Inc.• American Dairy Association Mideast• Andrew Garner, MD• Drs. Bill Cotton & Patty Davidson• Chuck Spencer, MD, & PediatricRheumatology* The Dave Thomas Foundation forAdoption• Edwin and Carol Hall• Judy Romano, MD• Krile Communications• Libby Ruppert, MD• Thad & Barbara Matta & family• William Knobeloch, MD

Special Thank You to:• Frankie Hejduk, Columbus CrewBrand Ambassador• Dave Kaelin, Dave and JimmyMorning Radio Show• Bob McElligott, color analyst for theBlue Jackets Radio Network• The Columbus Zoo & Aquarium• The Columbus Blue Jackets



Injury prevention by the numbers In the United States, a child or adolescent visits anemergency room once every second, and almostone-half of these visits are due to unintentional in-juries. This accounts for an estimated cost of $4 billionper year.

In Ohio, the numbers of children from birth through 14years old, are just as staggering:

166,032: The average number of children in Ohiowho are treated in Emergency Departments (ED) forunintentional injuries, annually.

3,274: The average number of children who areadmitted to a hospital for unintentional injuries in Ohioper year.

266: The average number of children who die fromunintentional injuries in Ohio annually.

All of this leads to #1. Unintentional Injuries are thenumber one cause of morbidity and mortality in chil-dren and adolescents. In fact, injuries cause moredeaths to children less than one year of age than alldiseases combined, including cancer, heart disease,and infectious diseases.

What is a pediatrician to do? Providing injury prevention anticipatory guidance atwell-child visits has been shown to improve child andfamily functioning by changing the behavior of thefamily, and ultimately, reducing injuries. Bass and col-leagues (Pediatrics, 1999) showed that injury preven-tion counseling during an office visit is associated withincreased motor vehicle restraint use, safe home hotwater temperature settings, the presence of smokealarms in the house, and increased use of outlet cov-

ers, decreased falls, and decreased home and autopassenger injuries.

Pediatricians addressing the injury problem duringoffice visitsThe Ohio Chapter, AAP conducted a membershipsurvey in the fall of 2011 to determine the injury pre-vention anticipatory guidance at well-child visits perage for children younger than 12 months old in Ohiopractices. This was later followed by observations ofinjury prevention documentation written in pediatri-cian’s charts. Injury prevention anticipatory guidancewas documented less than half the time for all rec-ommended topics. In the survey, physicians providedfour common barriers to providing injury preventionanticipatory guidance at well-child visits:1) Lack of time (80% of respondents reported)2) Uninterested parents (29%)3) No reimbursement (24%)4) Lack of confidence in effective counseling (20%).

Mike Gittelman, MD, Co-Principal Investigator for theInjury Prevention Learning Collaborative states “Toaddress these barriers, the Ohio AAP launched theInjury Prevention Learning Collaborative in September2012, which is highlighted by the development of ascreening tool for use at each well-child visit to helppediatricians address age-appropriate injury preven-tion topics with families. These tools identify currenthigh-risk behaviors and allow pediatricians to haveneeded discussions to prevent future injuries.”

In addition to the screening tools, talking points areprovided for each risky behavior to assure providersare comfortable with the anticipatory guidance theyare asked to provide to families.

How has this screening tool increased awareness forinjury risk?To date, six practices throughout Ohio have partici-pated in the Injury Prevention Learning Collaborative,and have gathered data on a monthly basis aroundwhether providers addressed and documented injuryprevention discussions with families at each of thewell-child visits for children under 1 year of age. Priorto the start of learning collaborative, 45% of pediatri-cians documented that they addressed sleep safety

See Numbers...on page 20



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See Roundtable...on page 23

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Chapter...from page 1

programs in Ohio.

• Enacted Ohio concussion lawsregarding return-to-play.

• Advocated for Medicaid expan-sion.

• Sponsored Adolescent VaccineRoundtable; discussions resulted ina Quality Improvement programto be initiated in the state.

• Distributed more than 1,100 fos-ter care bags with portable med-ical records.

• Received $215,000 grant fromthe Centers for Disease Controland the Ohio Department ofHealth (ODH) to continue theMaximizing Office Based Immuni-zation (MOBI) program.

• Received a $7,500 grant fromHonda for bike helmets.

• Received a $200,000 grant fromODH for early literacy books.

• Received a $340,000 grant forBMW and $212,000 for the obesityprogram from ODH, GRC andMedicaid.

• Received a $60,000 grant forInjury Prevention from EmergencyMedical Services for Children.

• Received a $75,000 grant fromCareSource for the Chapter’sasthma initiative.

• The Ohio AAP Pediatric CareCouncil put together a Health PlanAssistance Guide with a list ofphone numbers of medical consul-tants and major Ohio insurers. (Youcan find a copy on page 21 in thisissue.)

Adolescent immunization discussed atRoundtableForty experts gathered forthe Ohio AAP AdolescentImmunization Expert Round-table in April. Speakers pro-vided background on theissue of adolescent immu-nizations in Ohio, as well asresources available, beforeattendees were invited toprovide feedback as part ofa focus group.

The day began with an over-view of the issue provided byMichael Brady, MD, Physi-cian-in-Chief at NationwideChildren’s, and an infectiousdisease expert. Dr. Brady ex-plained current regulationsand issues facing four keyadolescent vaccines, includ-ing TDap, Meningococcal,HPV, and Influenza. This wasfollowed by an update onavailable resources by TinaBickert, MA, Health PlanningAdministrator for the OhioDepartment of Health.

Following a panel discussionover lunch, attendees brokeinto two focus groups to pro-vide their opinions on theadolescent immunization is-sue and the future of anOhio AAP Quality Improve-ment program on this topic.Some interesting observationsfrom the focus group includ-ed:

• Parents who choose tovaccinate will also be those



Wave 2 of BMW coming to a closeThe 12 primary care practices participating in Wave 2of the Building Mental Wellness (BMW) Learning Col-laborative are nearing the end of their nearly eight-month commitment to improving mental wellnesswithin their practices. After months of data entry,action period calls and PDSA cycles, I am happy toshare that this second group of practices will be com-pleting the project in June.

Just as in Wave 1, participating physicians received25 Part IV MOC credits for their participation in theproject. More importantly, these clinicians were giventhe opportunity to truly transform the way that mentalhealth is addressed within their practice. On behalf ofthe BMW Project Team and the Chapter, I would liketo thank and acknowledge the following practices:• Akron Children’s Hospital Pediatrics – Green

• Children’s Health Clinic of Dayton

• Locust Pediatric Care Group (Akron)

• Oxford Pediatrics and Adolescents (Oxford, Brookville, Ross)

• Partners in Pediatrics (Westlake)

• The Pediatric Group (Piqua)

• Pediatric Associates, Inc. – Hilliard, Lewis Center,Whitehall, Pickerington

• Pediatric Associates of Springfield

• Wilmington Medical Associates

As mentioned in the last issue of Ohio Pediatrics, we

are currently in the planning phase of Wave 3 of theBMW Project. This wave of the project will take suc-cessful elements from the first two waves and incor-porate them into a new format that will allow the pro-ject team to provide practices with more individual-ized learning. Additionally, we plan to allow providersto have the opportunity to “put their toes in thewater” through a variety of online learning modulesthat will allow pediatric practitioners to commit tochanges in their practice at a level that is comfort-able and convenient for them. In another effort tohelp spread the project around the state, there willbe four learning sessions to allow providers to learn alot without travelling a lot. The learning session loca-tions and times are tentatively scheduled for:

• Oct. 12 – Toledo Museum of Art, Toledo

• Nov. 9 – Athens Community Center, Athens

• Feb. 22, 2014 – Cincinnati

• April 26, 2014 – Cleveland

If you are interested in finding out additional informa-tion about the BMW Project, or if you would like tostay informed about the plans for the next wave ofthe project, please contact Sean O’Hanlon, BMWProject Manager, at [email protected] or (614)846-6258.

John Duby, MDBMW Medical Director

Immunization Conference: Keeping your vaccines,your community, and your bottom line healthyThe recent introduction of theAffordable Care Act andchanges to billing and codingpractices has substantially im-pacted physicians, providers,health-care workers and the pub-lic alike. The 2013 StatewideImmunization Conference pre-sented by immunizeohio.org –The Consortium for Healthy &Immunized Communities Inc. –focuses on effective strategies to

improve the systems for immuniz-ing adults, teens and children. Topics will include: ImmunizationUpdate, Billing and Coding, Im-pact of Health Care Reform onVaccine Payment and Delivery,New Recommendations in Stor-age and Handling, Vaccinationof Pregnant Women, and more.

Who should attend?Physicians, nurses, nurse practi-

tioners, office staff and publichealth professionals.

The conference will be held Oct.18, 2013 at the 100th BombGroup Restaurant, 20920 Brook-park Rd., Cleveland, from 7:30a.m. to 4:15 p.m. Cost: $75 (non-physician); $85 (physician). Regis-tration opens July 1 and closes onOct. 1. For more information visitwww.immunizeohio.org.



Ohio AAP's asthma program:Improvement for pediatricians andtheir patientsEditor’s Note: The following article appeared in theMarch issue of “To Your Health” in The ColumbusDispatch. It is reprinted with permission.

By Misti CraneThe Columbus Dispatch

Ohio pediatricians working together to keep youngasthma patients well have seen significant improve-ments, prompting more doctors to join the effort.

The Ohio Chapter of the American Academy ofPediatrics’ project is part of a national effort toimprove quality of life and keep kids in school andout of the hospital.

The last round of the project in Ohio, which ran fromSeptember 2011 to October 2012, concluded with asignificant cut in missed school days, missed workdays for parents, and urgent-care and emergency-department visits. The academy evaluates “optimalcare” using a number of factors and has reportedthat the medical practices are seeing good results.From September to August, the practices went fromdelivering “optimal care” from 50% of the time to 80%of the time. Starting in March, more pediatricianshave joined a new round of the project. In all, 42practices are involved.

To improve care, doctors follow certain guidelines foridentifying and caring for asthma patients, includingfinding the best medication to keep the diseaseunder control and limit flare-ups.

Elizabeth Dawson, the director of education at theOhio Chapter and the project’s leader, said the mostimportant thing participants are doing is creating“asthma action plans” for patients.

The plans detail the optimal care for each childbased on his or her circumstances. Some childrenhave particular problems with seasonal allergies, forinstance, while others have asthma typically aggra-vated by exercise. Parents are encouraged to keepa diary that tracks asthma attacks to try to better

identify triggers, shesaid.

William Long, MD,who works atPediatric Associatesof Pickerington,said this projectgives doctors con-crete goals andmeasurements, which have made a difference.

At his practice, more time is now devoted to patienteducation, and there is more focus on spirometrytests, which measure lung function, Dr. Long said.

He said he was surprised to learn that at the begin-ning of the project, his practice met all the best stan-dards with 17 percent of patients. Now, it’s 80 per-cent. For Zion Fitzgerald, a 13-year-old from Reynolds-burg who goes to Long’s practice, good asthma con-trol has meant taking oral medications every night.

When Zion was younger, he relied on an inhaler andhad frequent and frightening asthma attacks. A fewtimes, his parents had to call an ambulance, said hisfather, Garvin Wilson. Now, he has an inhaler foremergencies but doesn’t have to use it often.

Dr. Jerry Tiberio, who practices at Muskingum ValleyHealth Center in Zanesville, said that participation hasprompted better education of doctors and nurses.One area that requires vigilance is making sure chil-dren understand how to use their inhalers. “I thinkmost parents want to do what’s right for the children,but sometimes it just doesn’t play out,” Tiberio said.

Dr. Suzanne Gunter, a Brown County pediatrician,recently joined the quality-improvement effort andsaid her practice will benefit from standardizing asth-ma care for kids.

“This puts it in a more-structured form so people don’tfall through the cracks,” she said.



GUIDELINES FOR PHYSICIANS

Performance Enhancing SubstancesA performance enhancing substance (PES) is any substance taken in non-pharmacologic doses specifically for the purpose of improving sports performance.This includes substances taken in supratherapeutic doses or without therapeutic indication, those taken for weight gain or weight loss, those used to increaseoxygen carrying capacity, and any agent used to mask detection of, or minimize, the side effects of another PES. Examples include anabolic androgenicsteroids (AAS), steroid precursors or prohormones, human growth hormone (hGH), creatine, stimulants such as ephedrine and caffeine, erythropoietin (EPO),diuretics, laxatives and nutritional supplements. This article will focus on the more commonly used substances in the pediatric population.

Side effects of Anabolic Androgenic Steroids (AAS)

intake. Commonly reported side effects include weight gain through waterretention, muscle cramps, diarrhea and rarely impaired renal function. Thelarger problem with nutritional supplements is that they are not regulated bythe FDA. This means that manufacturers do not have to prove the safety orefficacy of their products. Multiple studies have shown that stated ingredientsare often missing or present at levels much higher than what has been re-ported on the label. Also, steroids and stimulants have been shown to bepresent in up to 25% of nutritional supplements.

PreventionDrug testing is widely used as a deterrent at the collegiate, professional andamateur elite levels of sports but is more problematic in the school-agedpopulation because of time constraints, high cost, and a relatively low yieldof positive tests which occurs for a variety of reasons. On the other hand,education, in the form of interactive classroom and training activities led bycoaches and peer leaders that teach kids about the side effects of PES andways to reject offers to use them, have been shown to decrease the report-ed use of these substances.

Other tips for physicians in dealing with the use of PES• Encourage discussion of PES during yearly pre-participation exams.• Be honest – Acknowledge that some PES do work, but emphasize thatmany of these gains are incremental improvements that may help elite ath-letes much more than the typical school-aged athlete.• Discuss the side effects that are most likely to have an immediate impacton the adolescent’s appearance or performance.• Screen for use of other substances (alcohol, tobacco, illicit drugs).• Describe alternative ways to improve performance - nutrition or utilizing acertified strength and conditioning coach.

EpidemiologyBoys are 2-3 times more likely to use PES than girls and those that use alcohol,tobacco and other illicit drugs are also more likely to use PES. PES use is morecommon in athletes than in non-athletes, especially those involved in sportsthat rely mostly on strength, power and speed. However an estimated 30-40% of adolescents that use PES do not participate in a school sport, butinstead take them to improve their physical appearance and self-esteem.Usually these substances are acquired from a physician, health food stores,at the gym, or the Internet.

Prevalence rates vary somewhat from study to study but in general show:Anabolic Adnrogenic Steroids Creatine or other protein supplement4-6% of adolescent boys 11-35% of adolescent boys1-3% of adolescent girls 30-40% of college athlete 1.5% of junior high students

Nutritional SupplementsUp to 58% of high school athletes; Up to 88% of college athletes

AAS and Steroid precursorsAAS are synthetic testosterone derivatives taken orally, transdermally, or byinjection that have anabolic and anti-catabolic, as well as emotional ef-fects, which promote muscle building. They are classified as schedule 3 con-trolled substances. AAS have been shown to increase strength and leanbody mass through muscle hypertrophy as well as the formation of new mus-cle fibers. They also have numerous adverse effects which involve nearlyevery body system (see table at right). Steroid precursors or prohormones aretestosterone precursors taken in an attempt to increase testosterone levelsand achieve effects similar to AAS. Studies have shown that they do neither.They do, however, have many of the same side effects as AAS.

StimulantsThe stimulants most commonly used as PES are ephedrine and caffeine.Ephedrine is the active ingredient of the herb ephedra, which was bannedby the FDA in 2004 after being linked to numerous deaths. Ephedrine, how-ever, is still accessible in over-the-counter cold medicines. These substanceswork as PES by increasing heart rate, contractility and blood pressure, in-creasing central nervous system stimulation and decreasing the perceptionof exertion during activity. Caffeine, especially, has been shown to increaseperformance in endurance sports although its influence on shorter bursts ofactivity is less conclusive and it may even impair functioning at higher doses.Stimulants can produce numerous adverse effects including arrhythmias,diuresis, increased core body temperature, tremors, anxiety and seizures.

Nutritional SupplementsThe term nutritional supplement generally refers to substances such as pro-tein/amino acid preparations, trace elements, vitamins, minerals and herbalpreparations. Creatine, a complex, non-essential amino acid, is the mostpopular supplement used as a PES. It is thought to increase muscle mass andstrength, shorten recovery times during workouts and increase training loadoverall. It does appear to improve strength and performance in short-dura-tion, anaerobic events but has little effect on endurance activities. Also, upto 30% of people seem to be “non-responders” to creatine, likely becausethey have already maximized creatine stores in the body through dietary

Cardiovascular • Increased LDL• Decresed HDL• Thrombus formation• Coronary vasospasm• Hypertension

Hepatic• Elevated LFTs• Cholestasis• Hepatocellular adenomas

Reproductive/EndocrineMales• Testicular atrophy • Decrease spermatogenesis• Gynecomastia• High pitched voiceFemales• Amenorrhea• Breast tissue atrophy• Deepened voice• Clitoromegaly• Hirsutism

Infectious • Soft tissue & muscular abscesses• HIV/Hepatitis risk

Musculoskeletal• Increased likelihood of tendonrupture• Physeal arrest

Dermatologic• Severe acne• Striae• Premature balding

Psychiatric• Mood swings • Hypomania• Mania• Depression• Decreased libido• Aggression• Addiction• Withdrawal



GUIDELINES FOR PARENTS

WHO IS MOST LIKELY TO USE PES?• Boys more than girls• Kids that use alcohol, tobacco and other drugs• Athletes more than non-athletes• Football, baseball and basketball players, gym-nasts, wrestlers, weightlifters and track athletes • Kids that are trying to improve their physicalappearance

WHERE DO KIDS GET PES?• From their physician• At the gym• On the internet• Health food stores

HOW DO THEY WORK?Most PES are taken to build muscle and increasestrength. Steroids, hGH and creatine have all beenshown to improve strength to varying degrees in stud-ies of adults. Stimulants and steroids can also increaseenergy levels, allowing for more frequent, prolongedor intense workouts. hGH and creatine have beenshown to increase athletic performance in short-dura-tion exercise such as sprints, while stimulants tend tohelp more with endurance events.

Many of these substances are illegal if obtainedwithout a prescription from a doctor, and all havepotential side effects, some more dangerous thanothers. The Ohio High School Athletic Association(OHSAA) policy states that students using PES willbe ineligible for competition.

• Rapid gain in strength or muscle bulk• Severe acne on the face, chest and back• Premature balding• Stretch marks• Growth of breast tissue, shrunken testicles, high-pitched voice (boys)• Menstrual irregularity, deepened voice, excess hairgrowth, loss of breast tissue (girls)• Mood swings/aggressive behavior/depression

WHAT TO LOOK FOR IF YOU SUSPECT YOUR CHILD ISUSING PERFORMING ENHANCING SUBSTANCES

WHAT’S THE DOWNSIDE TO USING PES?

Performance Enhancing Substances

This information is available on the Ohio AAP website www.ohioaap.org

A performance enhancing substance (PES) is any substance used in a way in which it wasn’t intended or pre-scribed, specifically for the purpose of improving sports performance. This includes substances taken in higherthan normal doses or without a true medical reason, those used to gain or lose weight, those taken to helpthe body use oxygen more efficiently, and any agent used to cover up the use of, or minimize, the sideeffects of another PES. Examples include steroids, human growth hormone (hGH), creatine, stimulants such asephedrine and caffeine, erythropoietin (EPO), water pills, laxatives and nutritional supplements.

What about supplements?Many times nutritional supplements are thought to besafe because of their name. Unfortunately, these sub-stances are not regulated by the FDA and thereforelittle is known about the actual ingredients they con-tain. Oftentimes supplements list misleading informa-tion on their labels and lack some or all of the statedingredients. Studies have shown supplements aresometimes contaminated with steroids or stimulants.

PreventionMost states, including Ohio, do not test for PES at thehigh school level and below because it is expensiveand relatively few positive tests are found. If you areconcerned that your child may be using PES, explainthe negative effects that can result, emphasizing dis-qualification from sport and the adverse effects tophysical appearance. If the child is actively trying toimprove performance, make an appointment with aregistered dietician to discuss proper nutrition or tohave him/her work with a certified strength and con-ditioning coach to make sure workouts are structuredin the most beneficial way.

Author: Steven Cuff, MD, Nationwide Children’s Hospital SportsMedicine


The following Ohio physicians have beenawarded 2013 CATCH Planning Grants:• Patricia Gabbe, MD, Nationwide Children’s,Columbus. Project: “The Children of MOMS2B”• Gregg Kottyan, MD, and Leah Kottyan, PhD,Blue Ash. Project: “Avondale Moves!”• Orville Bignall, II, MD, Cincinnati. Project:“Empowering Fathers as Child Health Advo-cates”

The CATCH Planning, Implementation, andResident Grants “Call for Proposals” is nowopen. The deadline for submission is July 31,2013 at 2 p.m. CDT.

For more information and assistance, contactHeng Wang, MD, PhD, State CATCH facilitator,at [email protected].

Have you ever thought abouthow the imminent change ofweather in our temperate cli-mate affects your practice?

Does the focus of your patientdiscussion change from feverand influenza to anticipatoryguidance about the events ofsummer?

I would propose that it should,and that you might like toconsider some of the risks and hazards that will ac-company our children as they venture out into theworld in the weeks and months ahead.

First, the vehicle miles traveled will increase signifi-cantly and it is important to provide the anticipatoryguidance that infants and young children should riderear facing in car seats to the highest weight orheight allowed by the manufacturer of a convertibleseat (usually 35-40 pounds). Just having a medicalcaregiver say, “Children are 500% less likely to die orhave serious injury in the second year of life whenrear facing than forward facing” can make a hugedifference to a parent. Using seats with full harnessesas long as possible and booster seats to 4’9” is alsoimportant advice, and do not forget the teens be-hind the wheel and urging parent involvement in theearly driving experiences.

Deaths and injuries in and around cars includingbackovers as toddlers become mobile, and hyper-thermia/heat stroke when children are forgotten or“left for just a minute” in cars also escalate in summermonths. Do you know that the temperature in even apartially closed vehicle can reach 125 degrees Fahr-enheit in minutes?

This is also the season for opening pools and going tothe beach. Parents must ensure close “touch supervi-sion” in the pool and use of personal floatation de-vices whenever in or near the water. Avoidance ofthe tragedy of a drowning, or near-drowning, issomething for which you most likely will not bethanked, but about which only you will know whenthe counseling has been provided.

District V Report

Marilyn Bull, MD

Facing warm weather challenges


Cycling is wonderful exercise for our youth and re-minding parents and young people that 70% of bikefatalities occur from head injuries and that bike hel-mets worn correctly are 85% effective for preventionof head injury is another important message. Helmetuse starting with tricycles to establish consistency ofbehavior is also important to emphasize.

Anticipatory guidance is expected, appreciated andheeded by families and caregivers. The concern of apediatrician is a strong and effective message. Re-sources to help you provide the best messages possi-ble are found in Bright Futures, Healthychildren.organd at AAP.org.

I leave you with a reminder to watch for the an-nouncements about the upcoming registration forthe AAP National Conference and Exhibition (NCE)2013. The kickoff event will be a Peds 21 pre-confer-ence program on Oct. 25, which will address the criti-cal topic of Early Brain and Child Development. This,and a packed NCE Program, are not to be missed.

Marilyn Bull, MDDistrict V Chair

CATCH Grant recipients


40th Annual Pediatrics for the Practicing Physician Symposium

Program Supported by: The University of Toledo, College of Medicine and Life Sciences

Department of Pediatrics Mercy Children’s Hospital, Toledo Children’s Hospital

and The Ohio Chapter of the American Academy of Pediatrics

Friday, September 27, 2013 7:30am - 4:30pm and

Saturday, September 28, 2013 8:00am - 1:00pm

Location: Hilton Garden Inn-Levis Commons, Perrysburg, OH

For more information, go to Website: cme.utoledo.edu or call 419-383-4237

Ohio’s Infant Mortali-ty Rate (IMR), whichis disturbingly high at7.9 per 1,000 livebirths (national aver-age 6.05), up from7.7, and with a worri-some racial disparity(African-AmericanIMR 15.8). Breast-feeding promotion isone of several strate-gies being activelypursued. RogerEdwards, MD, spoke about en-gaging pharmacists in the breast-feeding discussion, and it openedup a whole new arena for partici-pants to consider. None of us hadeven thought about a role for


‘Breastfest 2013’ suggests engaging pharmacists in breastfeeding discussions

Sarah Riddle, MD, IBCLC, Tara Williams, MD,and Lydia Furman, MD, at the OhioLactation Consultants Association annual

As new Chapter BreastfeedingCoordinators (CBC) we appreci-ated an invitation from the orga-nizing committee of the Ohio Lac-tation Consultants Association(OLCA) to participate in their an-nual meeting “Breastfest 2013,”held in Dublin, Ohio, March 15-16.We used this terrific opportunity tomeet each other in person for thefirst time, to network, and to show-case the AAP and its Section onBreastfeeding.

The conference included severalgreat presentations. Arthur James,MD, Co-Chair of the Ohio Collab-orative to Prevent Infant Mortality(Ohio Department of Health)gave a “wake up call” talk about

pharmacists prior to hearing thisgreat presentation.

We talked about our role as CBCsin supporting breastfeeding inOhio. We displayed a poster de-scribing activities and initiatives ofthe Section on Breastfeeding,CBC duties, and information onthe AAP’s online breastfeedingcurriculum. We received a greatreception with an invitation toreturn next year.

Laurie Nomsen-Rivers, MD, spokeon delayed onset of lactogenesiswith up-to-date scientific data.Breakout sessions included:“Ethics, Marketing and the WHOCode,” and “Treatment of TongueTie,” and challenges of breast-feeding for first-time mothers. Thefinal presentation was given byTina Carderelli the Indiana Peri-natal Network BreastfeedingCoordinator, who has been anactive agent of change in India-na. For details go to OLCA web-site (http://www. ohio-olca.org/contrib/confconfhome.shtml).

Sarah Riddle, MD, Tara Williams,MD, and Lydia Furman, MD



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PAA is helping practices of all sizes and specialties nationwide

On Saturday, Sept. 21 at the OhioAAP Annual Meeting 2013, youcan earn 20 points toward yourPart II MOC requirement whilereceiving expert instruction in thearea of sports medicine. KelseyLogan, MD, FAAP, will lead an in-teractive group session where youwill not only answer the questionsof the sports medicine self-assess-ment, but also have the opportuni-ty to ask questions and hear moredetails about the resources usedto complete the assessment. Thissession is scheduled from 10:30a.m. – 12:30 p.m. on Saturday; allparticipants will receive copies ofthe resources in advance, and youwill need to bring your laptop.

Attendees will receive an addition-al 10 CME credits just for this ses-sion, 7.5 credits are available forthe rest of Annual Meeting.

Annual Meeting will be held Sept.20-21 at the Columbus SheratonHotel on Capitol Square, with a

Pre -Annual Meeting AdvocacyWorkshop at the new Ohio AAPChapter office in North Columbuson Sept. 19.

Other topics and events that willbe featured during Annual Meet-ing include:

Earn 20 points toward your Part IIMOC requirement at Annual Meeting

See Annual Meeting...on page 27

“Annual Meeting is an investment of time that I happilymake each year…not only for the continuing educationalopportunities, but for the networking with colleaguesthroughout the state, the chance to hear about upcomingtrends in our profession and the opportunity to meet andtalk with like-minded professionals who offer diverse per-spectives on issues that we face each and every day.” –Allison Brindle, MD, Ohio AAP Young Physician



Drowning incidents on the riseAs what seems to meto be the longest,coldest, wettest,grayest winter of alltimes, finally draws toa close, there is a hintof warmth and sun-shine in the air. Andwith that warmth andsunshine, sadly willalso come the pre-dictable increase indrowning and neardrowning incidentsaround Ohio and nationwide. In Ohio, drowning isthe 2nd leading cause of injury death in youngchildren, with an average of 34 Ohio children ages1-19 dying from drowning every year. The summermonths, May-August see a 119% increase in drown-ing deaths among Ohio youth. Knowing thesetrends, we should be increasing our water safetydiscussions at well-child visits throughout the sum-mer.

By age:• < 1: most of the drowning deaths in infants occurin the home: bathtubs, toilets, buckets.• 1-4: Drowning is the leading cause of injurydeath in children ages 1-4, most commonly drown-ing in swimming pools.• Adolescents: most likely to drown in natural bod-ies of water, and these drowning deaths often in-volve substance abuse.

Who is at risk?Nearly 80% of drowning deaths occur in males.From ages 0-4 years, white males had the highestrate of drowning deaths, but from 5-14 the drown-ing fatality rate in African American males is almostthree times that of white children.

These deaths are PREVENTABLE!• Installation of four-sided fencing is the only en-vironmental prevention proven to be effective intoddler drowning.• Most toddlers enter a pool from their homethrough an unprotected side of the pool.• Four-sided fencing is associated with a >50% de-crease in pool immersion injuries,

AAP recommendations for newborn to 5 years• Never leave a child alone near a bathtub, pool,water bucket, even open toilets.

• Residential pools should be surrounded by a four-sided fence.

• Pool covers are not a substitute for four-sidedfencing.

• “Touch supervision” is recommended for infantsor children while around water.

• Parents should inquire about exposure to waterand water-related activities for out-of-home childcare.

• Do not use flotation devices as a substitute forsupervision or in place of life preservers.

• Keep rescue equipment and a telephone by thepool.

• All parents, caregivers, and pool owners shouldlearn CPR.

• Swimming lessons are not developmentally ap-propriate until age 4.

• Use approved flotation devices when riding in aboat, or when at risk of falling into water.

AAP recommendations for 5-12 years• Teach children to swim but realize limitations.• Teach children to never swim alone or withoutadult supervision. • Be aware of underwater hazards – feet first, firsttime.• Use approved flotation devices when riding in aboat or when at risk of falling into water.• Recognize drowning risks during the cold sea-sons.• Constant supervision is needed for children withseizure disorder.

AAP recommendations for adolescents• Counsel about the dangers of alcohol use duringaquatic activities.• Be aware of underwater hazards – feet first, firsttime.• Use approved flotation devices when riding in aboat.• Teens should learn CPR.

Sarah Denny, MD, Co-ChairInjury Prevention Committee



Obesity management improves withPound of Cure Learning CollaborativeAs a pediatrician, how do youdefine success when it comes toyour overweight or obese pa-tients? Is success defined by tan-gible outcome measures such asweight loss, a decrease in bodymass index (BMI), or a decreasein the child’s blood pressure? Ordo you define success by the in-creased knowledge a family hasabout the importance of eatingbreakfast or getting enoughsleep?

The providers who are participat-ing in the Pound of Cure LearningCollaborative unanimously saidthey have changed the way theydefine success in weight man-agement since starting the col-laborative either in January 2012or July 2012. Now, definitions ofsuccess for these providers,include:• Having a patient attempt a life-style change because they havelearned about nutrition and un-derstand why past behaviorshave been unhealthy.• No weight gain, or slowerweight gain, especially for chil-dren who are growing in heightand can grow into their currentweight.• Applying new behaviorchanges.• Parental understanding of po-tential adverse effects of over-weight status, and their willingnessto address the problem.

“The Pound of Cure project takesthe overwhelming task of manag-ing obesity and makes it man-ageable. The Pound of Cure tool-kit provides a system for identify-ing problematic habits and pairs

each area of concern with spe-cific patient education handoutsto evoke lifestyle change. Thispractical approach has resultedin much healthier lifestyles for myoverweight and obese patients,and has even trickled down toimproved habits for my healthyweight patients,” wrote one cur-rent Pound of Cure provider in ananonymous survey.

A Pound of Cure is a training pro-gram for obesity counseling in pri-mary care. Training and resourcesare offered to clinicians to aidthem in evaluating, interviewing,educating, tracking, and follow-ing up with overweight andobese children and their families.Wave One of the Learning Col-laborative launched in January2012 and half of the practicesregistered for Wave One, contin-ued to participate in Wave Twoof the collaborative, whichlaunched six months later. WaveOne was targeted at patients 2-11 years old identified as over-weight or obese at well-child vis-its. Wave Two added patients 12-18 years old, to provide continuityof care throughout all ages.

While clinicians have refined theirdefinition of success for their pa-tients, they have made progresstoward the outcome measures toensure their patients are meetingtheir goals along the way. Pro-viders have been expected tomeasure BMI at each visit, as wellas take it one step further anddocument an overweight (>85thBMI percentile) or obesity (>95thBMI percentile) diagnosis. Duringthe collaborative, providers have

consistently documented BMI inthe patient’s chart above thegoal of 90% of the time. Actuallydocumenting overweight orobese in the chart has beenmore sporadic for the providers,but is improving toward consis-tently measuring around the 90%goal line.

Documenting blood pressure atinitial and follow-up visits has alsoconstantly been measured at100% during the collaborative,however documenting bloodpressure category (normal-ten-sive, pre-hypertensive, or hyper-tensive) has steadily increasedfrom less than 10% of patients atthe start of each wave of the col-laborative, to 100% at the end ofthe collaborative.

Project Manager, SamanthaAnzeljc, PhD, explained, “Withoutidentifying the child’s blood pres-sure as either pre-hypertensive, orhypertensive, it is difficult to rec-ommend a treatment plan, or dif-ficult for parents and children tounderstand why an elevatedblood pressure is a concern forthe child’s health.”

The development of a bloodpressure slide rule tool has beeninstrumental in aiding practices inincreasing their diagnosis of hy-pertension or pre-hypertension.Melissa King, MD, from Children’sHealth Clinic in Dayton recentlysaid, “these tools have allowed usto identify those risk factors moreaccurately; they have been avaluable tool for us, and our fami-lies.”

See Pound...on page 23



with parents of newborns, 38% addressed sleep safe-ty with parents of 2-month olds, and 39% with parentsof 4-month olds. This is comparable to the informa-tion from the 2011 Ohio AAP survey comparing re-ported discussion versus documented discussion, asoutlined in Figure 1 below. Six months later, 82%, 86%,and 89% of pediatricians in the collaborative addres-sed and documented sleep safety with parents atthe newborn, 2-month and 4-month well-child visitsrespectively. This increase in discussion is believed toreduce the incidence of infant death due to suffoca-tion.

Figure 1: Reported vs. Documented Injury PreventionAnticipatory Guidance Discussions for Children <1Year at Well-Child Visits

Similar increases in discussion of car safety, fire/burnsafety, family interactions, supervision, fall prevention,water safety, choking prevention, unintentional in-gestions, home safety, and play safety have occur-red, although not all to the same extent.

“The injury prevention tool has been successfullyused in primary care practices. It works to determinespecific high-risk behaviors so that the pediatriciancan concentrate only on those issues familiesscreened at risk; enabling them to maximize theirtime with the family,” Dr. Gittelman says.

What’s next? The pilot phase of the Injury Prevention Learning Col-laborative is wrapping up this month, with plans tolaunch a second phase in October. This phase willcondense the screening tool and allow the projectteam to determine changes made by families in re-sponse to recommendations made by their pediatri-cian. For more information, please see the article atright.

Numbers...from page 8

Participate in PhaseTwo of the InjuryPrevention LearningCollaborativeFormer United States Surgeon General C.Everett Koop, MD, once said “If a disease werekilling our children in the same proportions asinjury, we would be outraged and demand thiskiller be stopped.” Join the Ohio AAP in reduc-ing the risk of injury to children from birth to 1year old by participating in the Injury Preven-tion Learning Collaborative.

Mark your calendar to attend the day longlearning session in Columbus on Friday, Oct. 18,2013. At this learning session, you will betrained in the use of the screening tools thatwill be given to parents during well-child visits,and the corresponding talking points for eachsection of the screening tool. Providers will alsoreceive training in quality improvement topicsto help them make changes within the prac-tice to be successful.

Benefits to participating in the Injury PreventionLearning Collaborative include:

1) Participating pediatricians will receive 25Part IV Maintenance of Certification credits asapproved by the American Board of Pedia-trics.

2) Each practice will receive tools and talkingpoints to address injury prevention issues forchildren less than 1 year of age that will maxi-mize time spent with families.

3) Each practice will potentially receive $1,000stipend for participating, depending on grantfunding for the collaborative.

For more information, contact Sean O’Hanlonat [email protected], or (614) 846-6258.



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Proper vaccine handlingand storage is important


Proper vaccine storage and handling is of the utmost importance toensure that vaccines retain their efficacy and that patients receive thebest possible protection against vaccine-preventable diseases. Unfor-tunately, proper vaccine storage and handling can sometimes be chal-lenging for physician offices. These challenges were recently noted in areport released by the U.S. Department of Health and Human Services(HHS) Office of the Inspector General (OIG) this past summer, after theOIG had undertaken a study to assess the vaccine management ofVaccines for Children (VFC) providers. The report, titled “Vaccines forChildren Program: Vulnerabilities in Vaccine Management,” describedsome vaccine management practices that increase the chance thatan ineffective vaccine may be administered to a patient.

The OIG study showed that the VFC vaccines stored by 76% of the 45selected providers were exposed to inappropriate temperatures for atleast five cumulative hours during a two-week time period. Exposure toinappropriate temperatures can reduce vaccine potency, increasingthe chance the patient will not develop protective antibodies againstthe vaccine-preventable disease for which the vaccine was adminis-tered. Thirteen providers stored expired vaccines together with non-expired vaccines, increasing the risk of mistaken administration ofexpired vaccines. To read the full report, go to: https://oig.hhs.gov/oei/reports/oei-04-10-00430.pdf.

While the OIG report only addressed the storage and handling of VFCvaccines, non-VFC or private stock vaccines would likely be similarlyaffected since VFC and non-VFC vaccines are usually stored and han-dled in a similar manner. All vaccine providers and their office staff thathandle or administer vaccine should be aware of proper vaccine stor-age and handling procedures. Physician offices should have internalpolicies that safeguard the efficacy of all vaccines, both VFC and pri-vate stock.

Since the issuance of the OIG report, the Centers for Disease Controland Prevention (CDC) has worked to help providers assure that vac-cines are effectively stored and handled. CDC has updated theVaccine Storage and Handling Toolkit as a tool for VFC and non-VFChealthcare providers to assimilate new vaccine storage and handlingstandards and updated VFC protocols and requirements for all VFCproviders to assure vaccines are managed effectively.

The Ohio Department of Health (ODH) has also updated policies andpractices to work more closely with VFC providers and community part-ners to improve vaccine storage and handling procedures. The Immuni-zation Program provides a variety of services to VFC vaccine providers,including vaccine administration, storage and handling education,

See Vaccines...on page 23

1. Designate primary and sec-ondary vaccine coordinatorsin the office to manage dailyvaccine monitoring, storage,ordering, etc.

2. Download and review theCDC’s Vaccine Storage andHandling Toolkit athttp://www.cdc.gov/vac-cines/recs/storage/toolkit/default.htm.

3. Store vaccines with ade-quate space for air circulationin the storage unit; never storevaccines in the door or draw-ers of the refrigerator. Use ap-propriate refrigerators for vac-cine storage; never use a dor-mitory-style refrigerator.

4. Use a certified, continuous-reading thermometer to moni-tor storage temperatures.

5. Record storage tempera-tures twice daily each daythat the office is open, on apaper log.

6. If storage temperatures goout of range, immediatelycontact vaccine manufactur-ers to determine whether ornot the vaccine is still viable.

7. Utilize proper vaccine rota-tion so that short dated vac-cines are used first and imme-diately remove expired vac-cines from the storage unit.

8. Set target storage tempera-tures for vaccines in refrigera-tors at 40°F. This will help toassure that refrigerated vac-cines will not be exposed totemperatures below 35°F.

Tips for propervaccine storage



technical assistance and quality assurance. The ma-terials that have been developed are posted on theODH website and non-VFC providers are welcome toreview them as well for guidance in developing officepolicies and procedures for their non-VFC vaccine.

ODH’s Vaccine Handling and Wastage Policy pro-vides a framework for appropriate vaccine manage-ment and prevention of VFC vaccine wastage. Thepolicy, along with a variety of other resources for safevaccine storage, handling and administration can befound on ODH’s website, http://www.odh.ohio.gov,under the Immunization Program – Vaccines for Chil-dren and can be used by both VFC and non-VFCproviders to guide the development of office policiesand procedures for handling and administration of allvaccine, both VFC and private stock.

It is recommended that all vaccine providers recordvaccine storage unit temperatures twice a day foreach day that the office is open, including the VFCproviders who use ODH-provided, continuous-readingtemperature data loggers. If vaccine storage temper-atures deviate from the recommended range, imme-diate action must be taken to restore appropriatestorage temperature or relocate vaccine to a prop-erly functioning storage unit.

The ODH provided data loggers for VFC providers areprogrammed to read temperatures every 30 minutesand then trigger a red light alarm if temperatures areout of range for three consecutive readings. WhenVFC providers check temperatures twice daily, dataloggers should be observed for at least 20 seconds toensure the light is flashing green and the red alarmlight has not been triggered. If the red light alarm isflashing, the VFC provider must contact the ODHImmunization Program immediately at (800) 282-0546.The Immunization telephone number is staffedMonday – Friday, 8 a.m. – 5 p.m. by employeestrained to assist with vaccine storage and handlingquestions and concerns. ODH should always be noti-fied when VFC vaccine has been exposed to a coldchain failure.

Taking these simple steps to ensure appropriate vac-cine storage and handling will reduce the risk of ad-ministering nonviable vaccine. For additional informa-tion regarding vaccine administration or storage andhandling, visit the CDC’s vaccine page at http://www.cdc.gov/vaccines or call the ODH ImmunizationProgram at (800) 282-0546.

Vaccines...from page 22

Roundtable...from page 10

who have had a personal experi-ence with the disease.• The biggest problem is gettingadolescents into the doctor’s of-fice. There is also the case of miss-ed opportunities in giving vac-cines when a teen does comes infor a sick visit. • Teenagers are given the optionto make vaccine decisions, andthat shouldn’t be the case.• Establishing a rapport with thechild seems to ease fears andincrease buy in.

The focus group comments will beused to design a QI Program toaddress the issues of adolescentimmunization. For more informa-tion, please contact ElizabethDawson at [email protected] or (614) 846-6258.

Pound...from page 19

With the collaborative coming to a close, each practice plans tocontinue using the Pound of Cure materials, although many prac-tices are adapting the visit structures to suit their practice needs.The majority of providers have discussed expanding the identifica-tion of overweight or obese patients to all patient visits, not just well-child visits.

Another survey provider wrote, “The Pound of Cure handouts andtools are essential for helping families with age appropriate healthliving strategies. The tools are a one-stop-shop for information on avery large variety of areas of interest or educational need. There issomething of value for everyone. These tools are an essential start-ing point for any general pediatric practice.”

The Project Team congratulates the five practices who have partici-pated in both waves: Ashtabula County Health Department; Childand Adolescent Specialty Care of Dayton, Pediatric Associates, Inc;Wheeling Hospital Center for Pediatrics; and Wilmington MedicalAssociates; as well as the five practices that participated in WaveTwo: Children’s Health Clinic; Cleveland Clinic Twinsburg; Kunz Med-ical; Pediatrics of Massillon; and Toledo Children’s Primary Care.


Bike Helmet Safety Awareness Weekreaches 12 million people in OhioThe Second Annual 2013 Ohio AAP Bike HelmetSafety Awareness Week was held May 6-10.During this week it is estimated that more than12 million people in Ohio were reached withthe message of bike helmet safety. Media out-lets throughout the state featured Drs. MichaelGittelman and Sarah Denny, co-chairs of theInjury Prevention Committee, prominently dur-ing this week.

Ohio News Network Radio spoke with Dr.Gittelman regarding a recent patient he treat-ed following a bicycle accident. "Just last weekI had a patient who tried to do a trick, landedon their head, had significant injury and isprobably going to die," he said. "This is some-thing that can happen to anybody and issomething that is easily preventable."

This story was also featured on WLWT-TV in Cin-cinnati, where Dr. Gittelman’s advocacy forstate-wide legislation was highlighted. “Helmetscan reduce the risk of injury by 85%, but rightnow only 20% of children in Ohio wear onewhen riding.”

Dr. Denny appeared at two school assemblies to highlight BikeHelmet Safety this year. On May 3 at Hawthorne Elementary in Westerville, she spoke to over 500 students after one of theirclassmates was injured while riding without a helmet. Thanks to

Sarah Denny, MD, co-chair of the Injury PreventionCommittee, spoke to 500 students at HawthorneElementary School in Westerville, after one of their class-mates was injured while riding without a helmet.

Sugar Grove, Ohio, joined in the Ohio AAP’s Bike Hel-met Safety Awareness Week. More than 12 millionpeople in the state were reached with the messageof bike helmet safety.

A young bike rider waits patiently as shegets fitted for her bike helmet at LincolnCommunity Center in Troy.



funding from the Ohio AAP Foun-dation, the “Put A Lid On It” Pro-gram was able to provide a hel-met to every student in need atthis school, totaling over 350 hel-mets.

On May 9, Dr. Denny was on handto speak to students in Cleveland’sOliver H. Perry Elementary Schoolas part of a safety assembly fea-turing former governor and sena-tor George Voinovich. The senatorexplained that he didn’t alwayswear a helmet when riding hisbike, but he now understands theimportance of protecting his brain,and he challenged the students todo the same. Over 100 helmetswere provided to this school.

Dr. Denny also appeared onWCOL’s “Woody and The Wake-UpCall” morning radio show, NBC 4’sDaytime Columbus, and the Inner-phase Video Productions “SafetyFirst” show.

“We know from studies that kidsare more likely to wear their hel-met if their parent and if theirfriends are wearing helmets,” Dr.Denny told Gail Hogan on Day-time Columbus. “If you think aboutit as a parent, you are a rolemodel and if you are not wearinga helmet, get into a bike accident,and get a traumatic brain injury,that would take a huge toll onyour family as well. There are multi-ple reasons for parents and chil-dren alike to wear their helmets.”

The program also received nation-al attention in The Wall StreetJournal on May 1. For more infor-mation on how you can get in-volved in Bike Helmet SafetyAwareness, or the “Put a Lid on It”Program, please contact HayleySouthworth at [email protected] or (614) 846-6258.

Ohio AAP staff memberHayley Southworth, right,measures a PickawayCounty youngster to getthe appropriate size hel-met for him. The eventwas part of the YMCA’sbike helmet safety week.

The Ohio StateMedical Centerheld a HealthyKids event at theHilltop YMCA. Theyfeatured a tabledevoted to theimportance ofwearing a helmetwhen riding abike, skateboard,or scooter.

A safety assembly at OliverH. Perry Elementary School inCleveland featured formergovernor and senatorGeorge V. Voinovich. Hechallenged the students towear their helmets to protecttheir brain.


John Sherman Elementary, part of Mansfield City Schools, held abike rodeo. The rodeo was organized by Physical Educationteacher Maggie Voedisch.


26

CASINO NIGHT!A fundraiser for the Ohio AAP Foundation

foundation

O H I O

Pediatricians Standing Behind Ohio’s Children

We hate lawsuits. We loathe litigation. We help doctors head off claims at the pass. We track new treatments and analyze medical advances. We are the eyes in the back of your head. We make CME easy, free, and online. We do extra homework. We protect good medicine. We are your guardian angels. We are The Doctors Company.

The Doctors Company is devoted to helping doctors avoid potential lawsuits. For us, this starts with patient safety.

In fact, we have the largest Department of Patient Safety/Risk Management of any medical malpractice insurer.

And, local physician advisory boards across the country. Why do we go this far? Because sometimes the best way to

look out for the doctor is to start with the patient. To learn more about our medical malpractice insurance program,

call our Columbus office at (800) 666-6442 or visit www.thedoctors.com.

www.thedoctors.com




(440) 526-0717www.lawrenceschool.org

LOWER SCHOOL Broadview Heights

UPPER SCHOOLSagamore Hills

Small, highly-structured classes

Personalized instruction

Multi-sensory learning

Assistive Technology

Assessment Center: LD and Comprehensive Psychological Testing

GREAT MINDS Don’t Think Alike

SERVING STUDENTS WITH DYSLEXIA, ADHD, AND OTHER LANGUAGE-BASED LEARNING DIFFERENCES

Annual Meeting...from page 17

• Concussions: The Law,the Logic and theLogistics

• The Role of the Pedia-trician in School Vio-lence: A Case Study

• MRSA Update: NewTrends and TreatmentStrategies

• Technology in Medicine: What isin the Future for Our Practices?

• 3rd Annual Casino Night: OhioAAP Foundation Fundraiser

• Poster presentations from acrossthe state

• Speed Mentoring from pediatri-cians of all backgrounds

For more details and to register,please visit: http://www.ohioaap.org/pediatrician-education/2013-annual-meeting.

For conference questions, pleasecontact Elizabeth Dawson [email protected] or call(614) 846-6258.

Dr. Mahan winsPalmer AwardJohn D.Mahan, Jr., MD,program direc-tor forPediatrics andPediatricNephrology atNationwideChildren’s Hospital/Ohio StateUniversity received the 2013Parker J. Palmer Courage toTeach Award, which honorsprogram directors who findin-novative ways to teachresidents and to providequality health care. Theaward is presented by theAccredita-tion Council forGraduate Medical


Ohio ChapterAmerican Academy of Pediatrics450 W. Wilson Bridge Rd. Suite 215Worthington, OH 43085

The Ohio AAP announces the following meetings and events.

Sept. 19-21 – 2013 Ohio AAP Annual MeetingSheraton Columbus Hotel at Capitol Square

A few of the topics to be discussed:– Concussions: The Law, the Logic, and the Logistics– The Role of the Pediatrician in School Violence– MOC Part II: Complete Your Requirements

Visit our website for more details www.ohioaap.org

Oct. 12 – Building Mental Wellness Wave 3 Learning Session Toledo Museum of Art

Toledo, OH

Oct. 18 – Injury Prevention Learning Session New Chapter office, 94 A Northwoods Blvd.

Columbus, OH

Nov. 9 – Building Mental Wellness Wave 3 Learning Session Athens Community Center

Athens, OH

Calendar of Events

Dues remitted to the OhioChapter are not deductibleas a charitable contribution,but may be deducted as anordinary and necessary busi-ness expense. However, $40of the dues is not deductibleas a business expense be-cause of the Chapter’s lob-bying activity. Please consultyour tax adviser for specificinformation.

This statement is in referenceto fellows, associate fellowsand subspecialty fellows.

No portion of the candidatefellows nor post residencyfellows dues is used for lob-bying activity.

PRESORTEDSTANDARD

Permit No. 156U.S. Postage

PAIDDUBLIN, OH

Dues disclosurestatement


ohio pediatrics - spring 2013 - ohio aap

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