Inside Pediatrics Winter 2015

P E D I A T R I C S A Publ ication by Chi ldren’s of Alabama

Fall/Winter 2015

Successfully Treating Epilepsy, page 8

Saving the Smallest Patients, page 4

Dr. Bruce Korf Creates Undiagnosed Diseases Program on NIH Model, page 10

On the cover:

Pediatric neurosurgeon Jeffrey Blount, M.D., calibrates a ROSA Robot as he makes preparations to perform a SEEG procedure on one of his patients with epilepsy whose seizures are not controlled by medication. Read more about our epilepsy program on page 8.

F ounded in 1871, Birmingham was dubbed “the Magic City” because of its rapid and seemingly overnight growth as a major iron and steel producer and as a key railroad hub of the Deep South. Today, similar growth is seen in the Magic City’s strong presence in other industries, including banking and, especially, health care.

Birmingham is home to more than a dozen hospitals and specialty healthcare facilities, including Children’s of Alabama, the only freestanding pediatric hospital in the state. Indeed, the Magic City is thriving, and people have noticed. Our urban parks win national awards and our restaurants earn national acclaim. Our sports facilities draw major athletic competitions. And, most importantly to us, our doctors are developing groundbreaking therapies that are changing, improving and saving lives. Doctors like nephrologist David Askenazi, who is among those pioneering the use of aquapheresis in the pediatric population to reduce potential consequences of excessive fluid accumulation from kidney disease. Doctors like neurosurgeon Jeffrey Blount, who with a collaborative team of epileptologists, EEG technicians and

specially trained nurses, improve the quality of life in 70 to 75 percent of the small number of patients who undergo surgery for epilepsy at Children’s. You’ll learn more about their world-class work and that of their Children’s colleagues in the following pages. Yes, Birmingham is the Magic City, but here at Children’s, we know that what we do isn’t magic. The care and curing that happens here is the result of our staff’s unwavering commitment to provide the finest pediatric health services to all children in an environment that fosters excellence in research and medical education, to be an advocate for all children and to work to educate the public about issues affecting their health and wellbeing.

Mike Warren CEO and President

2

Children’s of Alabama 1600 7th Ave. S. Birmingham, Alabama 35233 (205) 638-9100 www.childrensal.org Inside Pediatrics President and CEO... Mike Warren Chief Communications Officer............... Garland Stansell Editor......................Kathy Bowers Design..................... Trent Graves Photography........... Denise McGill Digital Content........... Amy Dabbs Contributors............. Andre Green Adam Kelley John Tracy Physician Marketing.......Tiffany Kaczorowski Mitchell Cohen, M.D. Katherine Reynolds Ireland Chair of Pediatrics University of Alabama at Birmingham Physician-in-Chief, Children’s of Alabama W. Jerry Oakes, M.D. Dan L. Hendley Chair in Pediatric Neurosurgery University of Alabama at Birmingham Chief of Pediatric Neurosurgery and Surgeon-in-Chief, Children’s of Alabama Tina Wilson Hollie Odom

News, Honors & Awards

• Peter W. Glaeser, M.D. , Emergency Medicine, received the 2015 Rocco V. Morando Lifetime Achievement Award, recognizing a lifetime of commitment and contributions to Emergency Medical Services (EMS). It is the National Association of Emergency Medical Technicians (NAEMT)’s most prestigious award. • Waldemar A. Carlo, M.D. , Neonatology, is a Southern Society for Pediatric Research (SSPR) Founders Award recipient for 2016 in recognition of his work in promoting the SSPR and research in pediatric health. • Randy Cron, M.D., Ph.D. , Rheumatology, has been selected to serve a three-year term on the Society for Pediatric Research (SPR) Fellows Basic Research Awards Selection Committee. • The Accreditation Council for Graduate Medical Education (ACGME) announced the appointment of Prescott Atkinson, M.D., Ph.D. , Allergy, Asthma and Immunology, to the ACGME Review Committee for Allergy and Immunology. • Crayton A. Fargason, Jr., M.D. , General Pediatrics, has had his appointment on the Healthcare Safety & Quality Improvement Research study section of the Agency for Healthcare Research and Quality extended for a year. • Drew Davis, M.D. , Rehabilitation Medicine, has been selected by the American Board of Physical Medicine and Rehabilitation to serve a three-year term as an item writer for the Pediatric Rehabilitation Medicine Board Examination. • David W. Kimberlin, M.D. , Infectious Diseases, received the American Academy of Pediatrics – Alabama Chapter Special Achievement Award. He also presented the annual Philip Porter Lecture at Massachusetts General Hospital for Children and Harvard University. • David B. Joseph, M.D. , FAAP , FACS , the Beverly P. Head Chair in Pediatric Urology at Children’s of Alabama, received the 2015 Wallace Alexander Clyde Distinguished Service Award for Excellence in Pediatrics from the UAB Department of Pediatrics, Children’s and AL- AAP. The award, initiated in 1984, recognizes outstanding physicians who have devoted a lifetime of service to children and their families. Recipients are chosen by a committee of leaders in the pediatrics field. • Richard Whitley, M.D. , Infectious Diseases, has been named as Co-Chair of the NIH Recombinant DNA Advisory Committee’s Biosafety Committee. • Myriam Peralta-Carcelen, M.D. , M.P.H. , FAAP , General Pediatrics, has been elected to serve as a member of the Section on Developmental and Behavioral Pediatrics Executive Committee for a three-year term.

• Susan Walley, M.D. , Hospital Medicine, has been selected as a member of the Executive Committee of the national AAP Section on Tobacco Control (SOTC) and currently serves as the AAP SOTC Publications Chair and Newsletter Editor. She has also been selected to author the AAP Policy Statement on Electronic Nicotine Delivery Systems (i.e., electronic cigarettes). • William S. McMahon, M.D. , and Mark Law, M.D. , Cardiology, were recently certified to implant a new device used for closure of patent ductus arteriosus. This new device, specifically designed for percutaneous PDA closure, facilitates non-surgical closure of PDA in infants and children. • Children’s of Alabama has been granted a three-year term of accreditation in the area of Pediatric Transthoracic Echocardiography by the Intersocietal Accreditation Commission (IAC). Accreditation by the IAC means that the lab has undergone a thorough review of its operational and technical components by a panel of experts. The IAC grants accreditation only to those facilities that are found to be providing quality patient care in compliance with national standards through a comprehensive application process, including detailed case study review and ongoing quality improvement initiatives. Children’s has the only pediatric echo lab in the state with IAC accreditation. • The American College of Radiology awarded accreditation to Children’s Russell Campus CT and MRI, and renewed accreditation to the Children’s South MRI. • The Joseph S. Bruno Pediatric Heart Center at Children’s became the first pediatric cardiovascular center in the Southeast, and one of only eight in the nation, to be recognized as a pediatric heart failure institute by The Healthcare Colloquium. • Children’s is the first pediatric hospital to earn ABRET accreditation for its neurophysiologic intraoperative monitoring. The neurophysiology lab is one of the few labs in the country to be accredited in EEG, EMU and NIOM. • The UAB Pediatric Pulmonology division at Children’s of Alabama was recently selected as a recipient of the annual quality care award by the Cystic Fibrosis Foundation. • Children’s of Alabama welcomed the Woodrow Wilson School of Public and International Affairs at Princeton University and the Brookings Institution to Birmingham in July to present Volume 25, Number 1 Spring 2015 issue of The Future of Children, Policies to Promote Child Health . This collaboration of two world-class institutions is aimed at translating the best social science research about children and youth into information that is useful to policymakers, practitioners, grant-makers, advocates, the media and students of public policy. The presentation of The Future of Children marks the first time the journal has been unveiled in a pediatric hospital.

Lee I. Ascherman, M.D., M.P.H. Chief of Service, Child and Adolescent Psychiatry University of Alabama at Birmingham

Contact us at: insidepediatrics@childrensal.org . An online version of the magazine is available at www.childrensal.org/insidepediatrics .

facebook.com/ childrenshospitalofalabama linkedin.com/ company/children’s-of-alabama twitter.com/ChildrensAL Instagram.com/childrensofal

3

Novel Approach to Dialysis in Babies is Saving Lives

From his office on the fifth floor of the Lowder Building at Children’s of Alabama, David Askenazi, M.D., M.S.P.H., heads the international Neonatal Kidney Collaborative to more closely unite neonatologists and pediatric nephrologists in saving the lives of the tiniest babies who are battling acute kidney disease. To provide those infants with the best available comprehensive multidisciplinary clinical care, education and research, Askenazi established the Pediatric and Infant Center for Acute Nephrology (PICAN) at Children’s in 2013. His innovative approach to caring for babies who need renal support therapy is by using the Aquadex FlexFlow™, a machine specifically designed to remove salt and water in adults with heart failure that has a smaller filter and tubing size than other similar equipment. Askenazi and his team are the first in the nation to adapt the Aquadex for use in providing clearance of toxins, electrolyte balance and fluid removal in neonates. “Because Aquadex machines have much smaller blood filters and tubing than traditional dialysis machines, they allow us to effectively support these infants in a much safer way,” he said. In the past two years, Askenazi and his team have used the specialized equipment in treating more than 20 infants and small children. His approach has doubled the typical survival rate and prompted Seattle Children’s and Cincinnati Children’s Hospital Medical Center to follow his lead in adopting similar programs. “Prior to having this machine, when faced with a baby who needed acute dialysis, our choice was either to do nothing or to attempt to support the infant with a machine designed to provide Pediatric nephrologist David Askenazi, M.D., M.S.P.H., has successfully adapted the use of the Aquadex Flexflow to support critically ill infants who have acute kidney failure. The smaller size tubing and filter allow circuit initiation with less hemodynamics instability, avoiding the dagerous dramatic fluctuations in fluid volume encountered with the use of standard adult equipment.

Inside the Medicine

4

acute dialysis for adults,” Askenazi said. “Now we have a better alternative.” Already, Askenazi is gaining international acclaim for his work through the PICAN. In July of this year, he was awarded the Best Oral Abstract prize by the 8th International Conference on Pediatric Continuous Renal Replacement Therapy in London for “Smaller Circuits for Smaller Patients: Improving Renal Support with the Aquadex™ Machine.” PICAN is a joint collaboration between Children’s and the University of Alabama at Birmingham (UAB) Department of Pediatrics, the UAB School of Medicine and the UAB Center for Clinical and Translational Science. “Our vision is far- reaching,” Askenazi said. “By improving our understanding of how to best treat these children and by disseminating knowledge, we will improve the outcomes of neonates and children with kidney disease throughout the world.” He and his colleagues anticipate that new technologies will continue to enable clinical teams to provide even safer therapies. “We are working with the Federal Drug Administration and industries around the world to develop and test machines that can support the smallest infants,” he said. “These are really sick babies. Some have heart problems, sepsis or lung problems, so we are never going to get to 100 percent survival just by supporting their failing kidney function. However, we need to ensure that those who can benefit from these machines are identified in a timely

manner and properly supported.” More information is available at www.childrensal.org/pican.

5

Revolutionizing the Treatment of Movement Disorders

Inside the Technology

Analyzing gait and motion in children with movement disorders has been a less-than-perfect science largely dependent on observations made by the naked eye. Subtleties often can neither be seen nor discerned. Until now. Earlier this fall, Children’s of Alabama took an important step in revolutionizing the care of children with movement disorders by opening the Gait & Motion Analysis Lab. It is the only pediatric clinical lab within a four-state area that includes Alabama, Mississippi, Tennessee and Florida, and one of only 23 in the United States. Located in a dedicated space within the hospital’s Physical Therapy & Occupational Therapy Department, the lab is equipped with BTS GAITLAB software, the latest advanced technology that measures movement, muscle activity and force production to create a clear, three- dimensional picture of a patient’s movement, muscle activity and postural alignment. Physicians and surgeons, particularly in orthopedics and rehabilitation medicine, use the data acquired through the analysis in conjunction with imaging scans, clinical examination, the patient’s medical history and

activity goals to guide treatment and measure outcomes. “Our pediatric gait and motion analysis laboratory

is revolutionizing our surgical and

non-surgical decision- making,” said pediatric orthopedist Michael Conklin, M.D., who serves as the lab’s medical director. “The computerized gait analysis gives us the information we need to

determine the surgical, therapeutic and orthotic interventions that will lead to best outcomes for a patient.”

The playful décor provides a child-friendly setting for the high-tech clinical evaluations performed in the new Gait & Motion Analysis Lab, one of only 23 pediatric clinical labs in the U.S.

6

Comprehensive gait analysis consists of a clinical evaluation, three-dimensional kinematics, kinetics and EMG. The clinical evaluation is performed by two physical therapists and includes measurements of joint motion, muscle strength and spasticity, observation and video analysis of gait and movement with consideration of medical history, current functional levels and family goals. Kinematics data is obtained by

force that is generated around each joint. Wireless surface EMG probes record the electrical activity of the muscles. In short, the technology provides information that can otherwise not be seen. Gait and motion analysis are most helpful when a major change in treatment is being considered, such as surgery, therapy or orthotics. The patients who will benefit most from this extensive analysis are those with diagnoses such as cerebral palsy, myelomeningocele and other neuromuscular conditions. The ideal candidate is at least 4 years old, tolerant of tactile stimuli, able to walk a distance of 20 feet multiple times with or without an assistive device and has the ability to follow directions and cooperate with a two- to four-hour test. Thus far in 2015, about two dozen patients have been evaluated in Children’s Gait & Motion Analysis Lab from across Alabama and surrounding states. “It’s a science that’s continuing to grow,” Conklin said. More information about the Gait & Motion Analysis Lab is available at www.childrensal.org/gait-lab .

reflective markers placed on the skin to record joint angles throughout the gait cycle. This information creates a 3-D skeletal model that is then compared to normative data. Kinetics are analyzed by six force plates that measure the force between the foot and the ground to determine the amount of

7

At the Forefront of Epilepsy

Inside the Red Line

epilepsy center for evaluation by an epileptologist,” said epilepologist Monisha Goyal, M.D., director of Children’s Pediatric Epilepsy Program. At Children’s, patients with epilepsy are evaluated and treated by a multidisciplinary team of epileptologists, pediatric neurosurgeons who specialize in epilepsy surgery, a neuropsychologist, specially trained epilepsy nurses, nurse practitioners, EEG technicians and child life specialists. The workup includes a detailed medical history, physical and neuropsychological examinations, blood tests and VEEG, which includes continuous closed-circuit video monitoring over several days in the hospital’s eight-bed epilepsy monitoring unit. Each patient also undergoes high-quality MRI, usually under sedation. Depending on the results of the preliminary testing, more localized studies, including PET scan and SISCOM may be performed. A functional MRI (fMRI) or Wada will also be performed to lateralize speech and movement. Patients may also undergo

for surgery. “We have a lot of new drugs, and many can be combined with tolerable side effects,” Blount said. “But one-third of the patients have few options available to them through medication. They have uncontrollable seizures that typically get worse over time and affect their quality of life.” Recent advances in imaging technology have given doctors a better understanding of how and where in the brain seizures occur. The knowledge opens the door for more surgical options. “Surgery offers a real and relatively low-risk intervention to deal with the epilepsy,” Blount said. “It used to be for the worst of the worst, but we’ve made inroads, and more and more kids are being referred for surgery.” The path to managing epilepsy often begins with the child’s primary care physician, but if prescribed medication fails to control seizures, a red flag is raised, signaling the need for more specialized care. “When two to three medications don’t work, the child needs to be referred to a specialized

Once thought to be a curse from the gods or evidence of possession by evil spirits, epilepsy has plagued those who suffer from this often baffling neurological disorder since ancient times. For centuries treatment was elusive, but today, neurologists and neurosurgeons at Children’s of Alabama are encouraged by the success they are having in reducing seizures in their patients and restoring a quality of life lacking for many. According to Children’s pediatric neurosurgeon Jeffrey Blount, M.D., epilepsy affects 50 million people worldwide. “It’s the second most common neurological affliction in children,” he said. “It’s devastating because it takes away the capability to plan and control your life because of the unpredictability and nature of the events.” Treatment options have increased and improved over the past several decades. Most children with epilepsy are successfully treated with medication, but a small number of those diagnosed with refractory epilepsy are often candidates

• Children’s recently became the first and only freestanding pediatric hospital in the U.S. and one of only five hospitals in the nation to earn accreditation for its epilepsy monitoring unit (EMU) from the American Board of Registration of Electroencephalographic Technologists (ABRET.) Accreditation is for five years. • The EMU is designated as a Level 4 unit by the National Association of Epilepsy Centers, the highest level attainable. A Level 4 center provides the more complex forms of intensive neurodiagnostics monitoring, as well as more extensive medical, neuropsychological, and psychosocial treatment. Fourth-level centers also offer a complete evaluation for epilepsy surgery, including intracranial electrodes, and provide a broad range of surgical procedures for epilepsy.

8

our excitement about the new technique with determining who’s the best candidate, and is it truly better or just a good tool for a subset of kids.” Future plans for the epilepsy program include expanding the number of epileptologists on staff and acquiring additional technology that will offer less invasive treatment methods, such as laser and thermal ablation. Goyal also wants to see greater strides in reducing the

magnetoencephalography (MEG) at the University of Alabama at Birmingham (UAB) adjacent to Children’s. “In the evaluation, we also consider the seizure semiology,” Goyal said. “We want to know what the patient does during the seizure, which side of the body exhibits more movement, whether the patient can answer questions during the seizure. The semiology, the imaging and the findings of the neuropsychologist all help us determine which part of the brain is the source of the seizures.” Once the evaluation is complete, the results are presented to and discussed by the entire team to determine the treatment plan. “Treatment is completely customized for that particular child,” Goyal said. Blount said 70 to 75 percent of the subset of patients who undergo epilepsy surgery at Children’s are cured or see improvement, but the team is striving for life-changing results in every patient with epilepsy. New technology recently added to the Children’s arsenal is expected to help reach that goal. Through a special cooperative arrangement with UAB, Children’s is using the ROSA robotic device for stereotactic EEG procedures to pinpoint the location and cause of the patient’s seizures. The robotic device enhances the surgeon’s ability to place a large number of probes more accurately, quickly and safely. “The ROSA allows us to stereotactically place electrodes in deeper structures of the brain, such as the insula, which increases our understanding of seizure propagation,” Goyal said. “We’ve never before been able to assess the insula because it’s such a deep part of the brain, so we have underestimated its role in epilepsy. We hope this knowledge will translate to better outcomes.” Children’s of Alabama is one of fewer than 10 pediatric medical centers in the U.S. currently using the robotic device for SEEG, which is being adopted worldwide. Both Goyal and Blount said they’re still evaluating the technology. “We’re in the early part of learning about SEEG,” Blount said. “We need to strike a balance between

still-prevalent stigma associated with epilepsy by further educating the public about the disorder.

More information is available at www.childrensal.org/epilepsy .

Brooke McDonald, one of the EEG technicians in Children’s EMU, prepares a patient for VEEG. As a member of the epilepsy team, McDonald works with six to eight other EEG technicians, several nurse clinicians, three epileptologists, two neurosurgeons who specialize in epilepsy surgery and a full complement of nurses on the 8-bed specialized unit.

9

Breaking the Code of Undiagnosed Diseases

Inside the Diagnosis

the patient’s current situation, what other specialties should be brought into the case and what additional testing needs to be conducted. “We see ourselves as the Supreme Court of medical evaluations,” Korf said. “We’re not a first step.” A high percentage of the patients seen in the undiagnosed diseases program need further, more complex evaluation, and that’s where the “new-fashioned” medicine plays a crucial role. Many of the diseases are genetic-based, so genome sequencing is conducted to identify them. “With genome sequencing, you’re looking at all genes, so you don’t have to know the answer in advance,” Korf said. “One test cancels the need for a lot of others.” The genome sequencing is done in collaboration with HudsonAlpha Institute for Biotechnology in Huntsville, Alabama, where Korf co-directs the UAB-HudsonAlpha Center for Genomic Medicine. In one-third to one-half of his patients who undergo genome sequencing, Korf finds the resulting diagnoses typically fall within three categories: (1) the diagnosis makes a lot of sense but is sometimes very rare and, thus, had previously gone unrecognized; (2) the diagnosis is rare, unknown or may not even have a name, so the referring physician would not have thought to test for it; or (3) the genomic findings reveal a possible diagnosis that has never been seen before. For patients, the benefits can be life-changing. “Genome sequencing cuts short the diagnostic odyssey and gives them answers that have been elusive for years and even decades,” Korf said. In children, a sure diagnosis provides peace of mind because it identifies the genetic foundation of the disease so parents know the risk of recurrence. It also may result in a new course of treatment that might not have been considered, eliminating the

Sometimes the most puzzling of medical mysteries can be solved by a delicate balance of the old and the new. That’s the foundation of the undiagnosed diseases program headed by geneticist Bruce Korf, M.D., Ph.D. By the time even his youngest patients meet Korf and his colleagues, they have assembled medical records with hundreds to thousands of pages reflecting the inconclusive results of testing that has cost a fortune by anyone’s standards. They have chronic major medical problems, but none of the specialists they’ve seen can confirm a definitive diagnosis. “They go from doctor to doctor, medical facility to medical facility, seeking answers no one can give them,” Korf said. “Tests are repeated, and there’s very little communication.” So two years ago, Korf, who served as chair of the external advisory committee for the Undiagnosed Diseases Program at the National Institutes of Health (NIH,) created a similar program at the University of Alabama at Birmingham (UAB.) It is one of the first university-affiliated programs to be developed on the NIH model. Within the next six months, the pediatrics arm of the program will be relocated to Children’s of Alabama. “It’s a powerful program. That’s why I wanted to start it here,” he said. “It’s a union of very old-fashioned medicine with very new-fashioned medicine.” Patients are typically referred when routine evaluations have not been effective. Upon the patient’s first visit, the “old-fashioned” aspect of medicine takes the lead as Korf and his team make every effort to gather as much information as possible through extensive conversations with the patient and his or her family to ensure a thorough understanding of the patient’s history and identify any gaps that exist in the work up. The team distills what they’ve learned and discusses ideas among themselves to determine next steps. Korf and his colleague Maria Descartes, M.D., then conduct an assessment of the patient to determine

10

cost and risk of side effects for therapies that ultimately offer no benefit. “It can open doors to new methods of treatment,” Korf said. In moving the program’s pediatric clinic to Children’s, Korf hopes to integrate it and expand it to take advantage of the pediatric sub-specialty expertise available through the hospital’s three dozen medical divisions. Currently, the program works directly with pediatric sub-specialists from immunology, gastroenterology, nephrology, cardiology, pulmonology, neurology, radiology, dermatology and rheumatology. Korf anticipates a patient volume of more

than 100 children per year. For more information, visit www.childrensal.org/genetics .

The National Institutes of Health undiagnosed diseases program served as the model for the UAB/Children’s of Alabama program created by geneticist Bruce Korf, M.D., Ph.D. in 2013. The goal of the program is to find answers for patients with major medical issues whose chronic illnesses have not been identified.

11

Treating Dancers as Athletes

On Service

12

Dance is different from most sports. Instead of speed and power, it requires flexibility, control and grace. This is why Reed Estes, M.D., Chief of UAB Sports Medicine at Children’s of Alabama, has developed a growing specialty in dance medicine. Estes received his bachelor’s degree from The University of Texas at Austin and his medical degree from The University of Texas at San Antonio Medical School. He then completed his orthopedic residency at the University of Alabama at Birmingham (UAB) and a pediatric sports medicine fellowship through Harvard Medical School at Boston Children’s Hospital. An athlete himself, Estes has always been interested in the types of injuries and medicine associated with sports, but that interest evolved to include dance during his fellowship at Boston Children’s. The dance medicine program there showed Estes a different side of sports medicine and gave him the opportunity work with several dance companies, including the Boston Ballet. While at Boston Children’s, Estes learned that dancers require a different approach to care and treatment. Dance medicine focuses on the prevention and rehabilitation of dance-related injuries by applying specialized care to the individual body, technique and lifestyle of a dancer. For example, most sports are seasonal, while dance is year-round—there is no off-season—so treatment must be adjusted accordingly. Other factors to consider are age, gender, mobility, prior injury history, muscular strength, cardiovascular fitness and the individual’s personal dance style. External factors that come into play in dance include lighting, staging, type of flooring, costumes and shoes. Many dancers who come to Estes for care have been managed well in general, but not properly for dance because of the

Dancers must be limber and able to perform difficult combinations of elements while also being aesthetically pleasing and maintaining full stamina. Dance rehabilitation focuses on that. “If injury has already occurred in a dancer, there are often different requirements than those for treating a different kind of athlete,” Estes said. Estes employs a multidisciplinary approach to the care and treatment of his dance patients by partnering with sports medicine experts who are also dancers themselves, including athletic trainer Megan Steirer. The program also works with Agile Physical Therapy, which employs a former Alabama Ballet dancer and has an excellent dance clinic. These partnerships enhance the program’s ability to serve dancers from across the Southeast that come seeking treatment. Under Estes, the dance medicine program at Children’s works to make sure that dancers receive the specialized care they need to perform with both grace and stamina. More information is available at www.childrensal.org/dancemedicine. Pediatric sports medicine physician and orthopedic surgeon Reed Estes, M.D., has created one of the few dance medicine programs in the U.S. at Children’s. Most of his dance patients seek treatment for injuries that commonly occur when they go en pointe in ballet.

specialized technique and movement involved. “Dance is unique because it is nothing like football or soccer,” Estes said. “It takes doctors who are genuinely interested in dance and know the dance language to care for the dancers properly. They have to understand the unique demands and nuances of movement involved in dancing.” According to Estes, foot and ankle injuries account for nearly half of injuries in dancers and typically include sprains, fractures and ligament tears or strains. About two-thirds are the result of overuse and are related to cumulative microtrauma rather than a single incident. The cumulative nature of the injuries is most often related to chronic positioning faults in combination with muscular imbalance and strength deficits. Growth spurts put young dancers at increased risk of injury because as the proportion of limb-to-torso length and body mass change, fluctuations in coordination and balance often result, along with a decrease in strength and flexibility. Dancers are also more prone to injuries when fatigued or under high stress. Of all the forms of dance, ballet has the highest risk of injury. Many of his patients seek treatment around ages 12 to 14, when they are transitioning to a higher level of dance, usually dancing en pointe. “The rite of passage in which ballet dancers begin dancing on the tips of their toes is a little like the curveball in youth baseball,” Estes said. “Start doing it too soon, and trouble is likely to follow.” Increasing treatment options and general awareness have improved the prognosis of most dance-related injuries. The first line of defense is awareness and preventing significant injuries before they happen. “While most dancers will suffer at least one major injury in their career, most are manageable,” Estes said. “It’s rare to see injuries beyond anything we can care for.”

13

Behavior Intervention

Good Health

A life-changing approach to helping children overcome the many challenges of tic disorders has families calling its founder “an angel in our lives.” Occupational therapist Jan Rowe, Dr.O.T., O.T.R./L., F.A.O.T.A., is director of the Comprehensive Behavior Intervention for Tics (CBIT) program at Children’s of Alabama, an eight-week, non-drug treatment program that seeks to embed tic strategies or “competing responses” into everyday life. In its first two years, Rowe has seen several hundred new patients from 12 different states, as well as Japan and New Zealand. Her success rate is an impressive 90 percent. The innovative clinic, housed at Children’s and associated with the University of Alabama at Birmingham (UAB,) is part of a consortium of southern universities that already has been recognized by the Tourette Syndrome Association (TSA) as one of just 10 TSA Centers of Excellence. “We all have different strengths, with Children’s being the CBIT program and the services we offer to clients, families, schools and communities,” Rowe said. CBIT consists of three important components: training the child to be more aware of tics, training the child to use “competing” behavior when he or she feels the urge to tic, and making changes to day-to-day activities to help reduce tics. The focus of CBIT is on teaching the child alternate strategies to help manage the tic disorder with discretion and confidence. The initial visit for evaluation generally lasts about two hours. Weekly sessions are 45 to 60 minutes long. Each week, the patient and the parent rate the child’s tic distress on a scale of 1 to 10 with “1” representing minimal distress to “10” indicating horrible, constant distress over the tic. Rowe said she often sees the self rating decrease from a “10” down to a “3” or “4” from one visit to the next.

“Our program is highly dependent on the commitment of the child to adhere to the practice sessions outside of clinic time,” Rowe said. “An occupational therapy practitioner works with each child to promote participation in activities or occupations that are meaningful in his or her daily life. The idea is to develop a competing response for tics, thereby limiting the interruption of tics on the patient’s health, well-being and development.” Two occupational therapists assist Rowe in clinic and while she is on the road training other professionals. To date, she has trained 42 OTs through two-day events that teach participants what CBIT is and how to implement it. She uses case studies, videos and small group practice during the training sessions. Following the training, occupational therapists who seek recognition as a CBIT provider by the Tourette Association of America must be supervised while working with their first two patients. Rowe provides that supervision distantly with her trainees via emails, phone calls or Skype calls after each of the patient’s eight sessions.

Research in Tourette syndrome and tic disorders is another facet of Rowe’s work. “We just completed a pilot study with the Weill Cornell Medical College and recently received approval for a handwriting study,” she said. “I’m also working on a training manual for occupational therapists for the Tourette Association of America, and more publications will be out in the coming year.” Rowe is currently accepting new patients, but she emphasizes that the child needs to be distressed by the tics in order to be a candidate for the program. “If the child is unaware or lacks concern for the tics, he or she will not be motivated to do the weekly work asked of them,” she said. “So we encourage the parents to allow the child to direct the path to the CBIT program.” More information is available at www.childrensal.org/cbit .

The behavior-based CBIT program run by by Jan Rowe, Dr.O.T., O.T.R./L., F.A.O.T.A., involves close and consistent interaction with patients during weekly clinic sessions.

14

JUST THE FACTS

Children’s of Alabama is the only free-standing pediatric hospital in Alabama with nearly 5,000 employees across the state.

Our world-class cancer center treats more than 90 percent of all children diagnosed with cancer in Alabama.

Children’s of Alabama averages more than 650,000 outpatient visits and nearly 14,000 admissions every year.

Our Pediatric Heart Center is the first in the Southeast and one of only nine in the U.S. to be recognized as a Pediatric Heart Failure Institute by The Healthcare Colloquium, the highest level of accreditation for cardiovascular programs.

Children’s of Alabama is the first pediatric hospital in the world to earn ABRET Accreditation for Neurophysiologic Intraoperative Monitoring.

CHILDREN’S OF ALABAMA

15 • Has Alabama’s only state-designated Level 1 pediatric trauma center • Offers one of the largest pediatric cardiovascular programs in the Southeast • Has one of the largest pediatric rheumatology programs in the nation • Operates one of the largest pediatric kidney dialysis programs in the country and the only one in Alabama • Is home to the state’s only pediatric cleft and craniofacial center • Offers the only pediatric ECMO program in the state • Serves as the primary site of the University of Alabama at Birmingham (UAB) pediatric medicine, surgery, psychiatry, research and residency programs • Offers 60 sub-specialty clinical fellowships and 82 residencies • With UAB, Children’s has the only Level IV NICU in the state, with a combined 168 NICU/CCN beds • Registered more than 64,000 ER visits in 2014, making it the busiest pediatric emergency department in the Southeast • Is home to the state’s only pediatric bone marrow transplant facility • Is the site of Alabama’s only pediatric burn center, one of the largest in the Southeast

1600 7th Avenue South Birmingham, Alabama 35233

2 0 1 6 Pediatric Academic Societies a n n u a l m e e t i n g Visit our booth #626

April 30-May 3, 2016 Baltimore Convention Center

16