Cottage Children’s

fall 2013

Breastfeeding Communicating and Drug Use for Better Care page 1 page 4 Recognizing MTBI CCH Earns in Pediatric Prestigious New page 2 Designations Getting Ready page 5 for Flu Season page 3

Tamir Keshen, MD, and Rebel Bobbit Dear Physician Colleagues, Welcome to Cottage Children’s Hospital magazine, a biannual publication that introduces you to our physicians and helps you become more familiar with our programs and scope of services. Cottage Children’s Hospital (CCH) provides comprehensive care to ill and injured infants, children, and adolescents through our neonatal and pediatric intensive care units, acute inpatient pediatric services, and outpatient subspecialty clinics. We are especially pleased to report two significant accomplishments by our physicians and staff in 2013. CCH’s three hospital-based outpatient clinics in hematology-oncology, gastroenterology, and endocrinology were named Special Care Centers by the California Children’s Services (CCS) program. This means children with acute and chronic diseases specific to these three specialties will no longer have to travel to Los Angeles or beyond to obtain comprehensive care. In addition, under the leadership of Dr. Steve Kaminski, Medical Director of Trauma Services, we have been verified as a Level II Pediatric by the American College of Surgeons. This makes CCH the first and only pediatric trauma center on the Central Coast. More information on both of these accomplishments follows on page 5. CCH is also a proud member of the Children’s Hospital Association (CHA). As a member of CHA, we are joined by over 220 other children’s from across the country with the purpose of enhancing the care of hospitalized pediatric patients. I hope you will take the opportunity to enjoy this publication, and to contact us if we can be of service to you and the children to whom you provide care. Curt Curtis B. Pickert, MD Pediatric Critical Care Medicine Chief of Medical Services Medical Director, PICU and Acute Pediatrics cottage children’s hospital santa barbara

Table of Contents Breastfeeding and Drug Use Communicating for Better Care Should a mother who tests positive CCH offers full-time pediatric hospitalists 1 be allowed to nurse her baby? 4 and daily multidisciplinary rounds by christophe le renard, md by kathy lou reynolds, md, and gina randall, rn Recognizing MTBI in Pediatric Patients Prompt diagnosis of symptoms is Cottage Children’s Hospital Verified 2 required to prevent long-term sequelae as Pediatric Trauma Center; by mehrdad mehr, md 5 Three CCH Clinics Designated as Special Care Centers Getting Ready for Flu Season Cell-based influenza vaccines will be We welcome your feedback about Cottage 3 used for the first time in 2013-14 Children’s Hospital magazine. Please email your by heather hindo, md thoughts and comments to [email protected]

cottage children’s hospital magazine Curtis B. Pickert, MD Executive Medical Editor, Gary Hopkins Executive Editor, Maria Zate Advisory Editor, Albert Chiang + Deja Hsu Art Directors

Cottage Children’s Hospital Breastfeeding and Drug Use Should a mother who tests positive be allowed to nurse her baby? by christophe le renard, md physicians who care for newborns on a regular basis are facing the following question with increasing frequency: “If a mother tests positive for marijuana, cocaine, amphetamines or opiates, should we allow her to breastfeed?” The response varies, depending on which drug is being used.

he american Academy of Pedi- experience a stroke, prompting consider- atrics (AAP) currently recom- ation of neuro-imaging (such as an MRI) mends that a mother testing pos- for exposed newborns. If the mother has itive for marijuana not breastfeed reported a history of prior use, or antici- Ther baby if she plans to continue using the pates any ongoing exposure to amphet- drug for any reason, including medicinal amines or cocaine, it is critical that she or recreational purposes. This is based on immediately discontinue breastfeeding. If evidence of possible developmental delay it can be determined that the mother will Christophe Le Renard, MD at 1 year of age in breastfed babies of not have any ongoing exposure to these marijuana-smoking mothers. If the father drugs, breastfeeding may be resumed after ing a baby exposed to maternal opiates, uses marijuana, there is also an increased detailed counseling regarding risk to the as the infant may not demonstrate signs infant. Our practice of withdrawal until the third day of life, at Cottage Children’s or later. The likelihood of withdrawal is Hospital when caring not dose-dependent. Many newborns can for such babies is to experience withdrawal even when their offer consultation by specialized pediatric clinical social work- Our practice at Cottage ers, in addition to the Children’s Hospital when education provided by our physicians. caring for such babies Opiate use nation- ally is growing to is to offer consultation epidemic proportions, by specialized pediatric with upwards of 25 percent of Newborn clinical social workers, (NICU) babies in in addition to the many institutions education provided by admitted for opiate withdrawal. Opi- our physicians. ate use and abuse is increasingly being ob- mothers have only been prescribed a low served in mothers at all dose of opiate medication. socio-economic levels. Much more information about ma- risk of Sudden Infant Death Syndrome Mothers who have used opiates or tested ternal drug exposure and its effect on (SIDS) in the baby. It is vital to discuss opiate-positive may continue breastfeed- the newborn infant is expected to be these potential risks with parents and im- ing their newborn babies. In fact, it has forthcoming, as there is extensive ongo- mediate care providers. been shown that, even for babies who ing research in this area. In the meantime, Infants of mothers testing positive for undergo withdrawal, breastfeeding sig- it is vital to discuss with the mother the amphetamines or cocaine must not be nificantly decreases the number of days in potential risk of exposure to the baby, and breastfed in the newborn period due to an the hospital. However, for mothers who educate her thoroughly about the risk and increased risk of sudden death. Exposed are not part of a methadone maintenance benefit of breastfeeding in this population newborn babies showing acute symptoms, program, care should be taken in choosing of infants. cch such as irritability and poor sleeping to breastfeed because they may be using, pattern, are demonstrating toxicity, not knowingly or unknowingly, other illegal To learn more about CCH, visit withdrawal. Approximately 6 percent of drugs in addition to heroin. www.cottagechildrenshospital.org. newborns exposed to cocaine in utero may Care should be taken when discharg- See back cover for physician and staff directory.

Cottage Children’s Hospital 1 Recognizing MTBI in Pediatric Patients Prompt diagnosis of symptoms is required to prevent long-term sequelae by mehrdad mehr, md

mild traumatic brain injury (MTBI), often referred to as “concussion,” is defined as head injury with a temporary loss of brain function. The physical, cognitive and emotional symptoms that result from the structural and neuropsychiatric insult to the brain may be subtle enough that MTBI remains undiagnosed. A retrospective survey in 2005 suggested that 88 percent of concussions go unrecognized. Therefore, it is imperative to be vigilant about the recognition of the broad spectrum of associated symptoms and implement the necessary measures to prevent long-term sequelae.

unconsciousness (typi- cally less than 30 minutes), post-traumatic amnesia of less than 24 hours, and Mehrdad Mehr, MD a Glasgow Coma Score (GCS) of 13-15. Comput- tom-free. If symptoms appear, the individ- erized Tomography (CT) ual should drop back to the prior level and of the head is recommend- advance only when symptom-free. ed for a GCS of less than MTBI has a mortality rate of almost 14, though most concus- zero and problems are seldom permanent. sive head injuries without Outcomes are usually excellent. However, complications cannot be one concussion makes the brain more detected by CT scan or Magnetic Resonance Imag- ing (MRI). Abnormalities Given that repeated have been reported with concussions may MRI and Single-Photon Emission Computerized increase risk in later hysical, cognitive and affec- Tomography (SPECT) imaging in patients tive symptoms are present with with the post-concussion syndrome. MTBI life of dementia, MTBI. The most common may or may not produce abnormal electro- Parkinson’s disease and physical components are head- encephalogram (EEG) results. Paches, dizziness, nausea, vomiting and lack After checking for immediate signs depression, recognition, of motor coordination. Visual symptoms, of injury and their appropriate manage- including light sensitivity and tinnitus, are ment in an and/ treatment and guidance also reported. Seizures that occur during or inpatient setting, physical and cognitive of MTBI become the or immediately after the injury are likely rest is indicated until the symptoms clear. secondary to a momentary disruption of Cognitive rest includes reducing activi- foundation for improved brain function and not predictive of post- ties that require concentration and atten- traumatic epilepsy. Post-traumatic amnesia, tion, including school work, video games long-term outcome. a hallmark of concussion, as well as confu- and text messaging. Even leisure reading sion, disorientation and difficulty focusing commonly worsens symptoms. Sufferers susceptible to another. Smaller subsequent with short attention span are common should also receive adequate sleep at night impacts may cause the same or worse cognitive symptoms. Loss of consciousness and during the day. symptom severity. may occur and is not correlated with the Athletes must be symptom-free before Given that repeated concussions may severity of the concussion if it is brief. Rest- they can resume physical activity, and even increase risk in later life of dementia, Par- lessness, irritability, lethargy, loss of interest then should progress through a series of kinson’s disease and depression, recogni- in favorite activities or items, and inappro- graded steps – for example, light aerobic tion, treatment and guidance of MTBI priate display of emotions in response to a activity followed by sport-specific activi- become the foundation for improved long- situation are characteristic of the affective ties such as running drills and non-contact term outcome. cch symptoms seen with MTBI. training drills. They should then graduate The diagnosis of MTBI is based on to full-contact practice followed by game To learn more about CCH, visit the physical exam (with emphasis on the participation. Advancement up this ladder www.cottagechildrenshospital.org. neurological assessment), duration of requires a 24-hour period of being symp- See back cover for physician and staff directory.

2 Cottage Children’s Hospital sphere include: season included the in 2013/2014northern hemi - for the Bstrain each season. The strains the 50percent amismatch possibility of B).type quadrivalent The vaccine addresses quadrivalent be will (twotype A and two trivalent vaccines, somevaccines influenza vated Fluzone vaccine. In addition to the providing be we will the trivalent inacti- the most common each season. At CCH, one B)that type research indicates be will the(two three typeviruses A and influenza infection and illnesscaused by are to protect designed against care providers. vaccination for our health have mandatory influenza Additionally,indicated. we then administered vaccine, as vaccinationinfluenza and screenedis for for eligibility intake process, patient every ers. During our admission protecting patients and work- vaccine influenza of use for we encourage widespread Cottage Children’s Hospital, reported from their weekly surveillance vaccine.2012-2013 influenza CDC The percent CI=47percent-63 percent) for the ness to onset enrollment) 56percent of (95 self-rated health status, and days from- ill ed for age group, study site, race/ethnicity, overallmid-season vaccine efficacy (adjust- Wisconsin/1/2010-like (B/Yamagata lineage), replaces B/ • • • cell-based flu vaccines. of use older. An exciting development for this upcoming the is season first recommended annual vaccination for everyone age 6months and Practices forinclude again theseason 2013-14influenza Immunization guidelines on the issuedby Committee Advisory Victoria/361/2011) vaccines) monovalent (same strain for used was as 2009H1N1 A Cell-based influenza vaccines willbeusedforthefirsttimein2013-14 Getting Ready forFluSeason A/Texas/50/2012(H3N2,replaces A/ A/California/7/2009(H1N1)-like Massachusetts/2/2012-like B Seasonal influenza vaccines influenza Seasonal Data published reported by the CDC a pandemic at influenza possible and seasonal prepares we for Source: Centers forDisease Controland Prevention current vaccines. Cell-basedinfluenza cine reactions were similarto those with age, clinical in trials the cell-based flu vac- established for people under 18years of Although safety and efficacy are notyet Drug Administration November in 2012. cine approved was by the U.S. Food and May 8, 2013(seefigurebelow). ed pediatric deaths from Sept. 30, 2012to that there- had 138influenza-associat been A/California/7/2009(H1N1), seeningold. Colorized transmission electronmicrograph of Number of deaths The nation’sfirst flu cell-based vac- 10 15 20 25 30 35 40 0 5 2009-40

2009-46 Numbers ofDeaths Reported =282 2009-52 2009-10 2010-06 Number ofInfluenza-Associated Pediatric Deaths 2010-12

2010-18 by Week ofDeath: 2009-10seasontopresent 2010-24 2010-30 2010-36

2010-42 Numbers ofDeaths Reported =123 2010-48 2010-11 2011-02 by

2011-08 heather Week of Death 2011-14 2011-20 See back for cover physician and staff directory. www.cottagechildrenshospital.org To learn more aboutvisit CCH, vaccination strategies. hopefully yield more effective vaccines and will theseason 2013-2014influenza of protect our pediatric population. Analysis prevention,the best means of especially to confer 100percent protection, it remains process the in apandemic. event of thestartup vaccine of manufacturing supply eggs. It of allows also for faster technology, which relies upon an adequate may more be flexible than the traditional flu vaccine are that culture cell technique potentialThe of benefitsthe cell-based animal cells rather than chicken’s in eggs. vaccines are made by growingin viruses 2011-26 and workers. protecting patients influenza vaccine for widespread useof Hospital, weencourage at CottageChildren’s pandemic influenza seasonal andpossible As wepreparefor

2011-32 hindo While vaccination influenza does not 2011-38 2011-44 Numbers ofDeaths , md

2011-50 Reported =34

2012-04 2011-12 2012-10 2012-16 2012-22

2012-28 cch

Cottage Children’s Hospital 3 2012-34

2012-40 Numbers ofDeaths Reported =138 2012-46 2012-13 2012-52 . 2013-06 2013-12 2013-18 Communicating for Better Care CCH offers full-time pediatric hospitalists and daily multidisciplinary rounds by kathy lou reynolds, md, and gina randall, rn

“The good physician treats the disease; the great physician treats the patient From left: Julie LeBourveau, RN; Regina Medina, LCSW; Kathy Lou Reynolds, MD; Justin Twitchell, who has the disease.” dr. william osler 1849-1919 RCP; Jaynie Wood, CLS; Vicki Lekas, RN; Sebastian Lebeau, MSW; Gloria Saguto, RD; effective communication is the gold standard in disseminating Deborah Wessel, PT; Amy Jenneve, RN; and patient care information. In 2006, the Joint Commission added the Stephanie Anderson, PharmD. following to its national patient safety goals: “Improve the effectiveness continuity of care to pediatric patients. of communication among care providers.” Cottage Children’s Hospital The pediatric hospitalists assure com- (CCH) takes pride not only in being on the cutting edge of medical munication with the child’s primary care doctor at both admission and discharge, information and technology, but also in improving delivery of care typically via a telephone call and a sum- and medical services to the children of the Central Coast. Full-time mary of the hospital course. The hospi- pediatric hospitalists and daily multidisciplinary rounds are just talists also provide acute consultation to two of the means by which we are enhancing the effectiveness of physicians in the community, including emergency department physicians and communication among providers of care to children. primary care providers. Under the leadership of Liz Lundquist, ottage children’s Hospi- CCH pediatric hospitalists manage pe- RN, Director of Children’s Services for tal offers the services of four diatric medical patients and consult on CCH, daily multidisciplinary rounds full-time pediatric hospitalists, pediatric trauma and surgical patients. were instituted over four years ago. The each of whom is an experienced, They work closely with other pediatric CCH multidisciplinary team consists of Cboard-certified pediatrician paneled by subspecialists locally, as well as through- a remarkable group of professionals, all California Children’s Services (CCS). The out the region, to provide quality with specialty pediatric training in their

4 Cottage Children’s Hospital often join the rounds, Full-time pediatric as do residents, medical hospitalists and daily students and students in other specialties, as part of multidisciplinary their education. Every morning, in both rounds are just two of the Pediatric Intensive the means by which Care Unit (PICU) and then in Acute Pediatrics, we are enhancing the multidisciplinary team gathers to discuss the effectiveness of each child in the hospi- communication tal. By congregating the entire team each day and among providers of discussing the needs of each patient, we are able Kathy Lou Reynolds, MD, and Gina Randall, RN care to children. to provide a highly indi- vidualized hospital experience for every multidisciplinary plan for the day is for- field of expertise. The team includes a child and family. Starting the morning mulated. By enhancing communication, pediatric clinical nurse specialist; social with multidisciplinary rounds ensures this unified team approach has improved workers; child life, speech, occupational that each team member knows exactly the delivery, safety and organization of and physical therapists; respiratory thera- the role he or she will be playing in the patient care at Cottage Children’s Hospi- pists; pediatric case managers; dietitians; child’s care. tal, leading to an enhanced experience for a pediatric sedation nurse and a pediatric The discussion of each patient begins pediatric patients and their families. cch pharmacist, in addition to the direct care with a pediatric hospitalist presenting nurse, nurse manager and pediatric hospi- the reason for admission, followed by the To learn more about CCH, visit talist or pediatric intensivist. Other pedi- direct care nurse reviewing events from www.cottagechildrenshospital.org. atric subspecialists and pediatric surgeons the last 24 hours. From this discussion, a See back cover for physician and staff directory.

Cottage Children’s Hospital Verified as Pediatric Trauma Center; Three CCH Clinics Designated as Special Care Centers

ottage children’s Hospital Additionally, the pediatric intensive care travel to SCC-designated facilities in Los (CCH) recently earned two unit and the pediatric section of the emergen- Angeles and other areas for treatment. important designations that cy department must be staffed by individuals One of the SCC designation require- elevate the superior level of care credentialed by the hospital to provide pedi- ments is that multidisciplinary teams be Calready offered at the hospital. atric trauma care in their respective areas. available at the facility to treat children In April 2013, CCH became the first In May 2013, CCH’s three hospital- who qualify for the state program. and only hospital on the Central Coast to based outpatient clinics in hematology- Besides being more costly, having to be verified as a Level II Pediatric Trauma oncology, gastroenterology, and endo- send local children covered by California Center by the American College of Sur- crinology were designated Special Care Children’s Services to out-of-the-area geons (ACS). This achievement recognizes the trauma center’s dedication to providing optimal care for injured patients. Level II Pediatric Trauma Centers must meet essentially the same clinical american college of surgeons and resource requirements as a Level I Adult or Pediatric Trauma Center, pri- Verified Trauma Center marily varying only in terms of research expectations. Pediatric trauma centers must have pediatric rehabilitation, child life and family support programs, pediat- Centers (SCC) by the state of California. facilities meant that it was difficult for pa- ric social work, child protective services, Among other things, this designa- tients to get their needed care and follow- pediatric injury prevention, community tion means that children with acute and up. Continuity of care also potentially outreach, and education of health profes- chronic diseases specific to these three was disrupted as patients needing urgent sionals and the general public in the care specialties will be able to receive compre- follow-up did not have a local physician or of pediatric trauma patients. hensive care at CCH, instead of having to facility readily available. cch

Cottage Children’s Hospital 5 Santa Barbara Cottage Hospital Nonprofit Org. 400 W. Pueblo St. US POSTAGE Santa Barbara, CA 93105 PAID www.cottagechildrenshospital.org Santa Barbara, CA Permit No. 35

Cottage Children’s Hospital

PHYSICIAN AND STAFF DIRECTORY Phone numbers listed are for daytime business hours only

NEONATOLOGY Drew Kelts, MD Curtis B. Pickert, MD PEDIATRIC SURGERY Steven C. Barkley, MD (805) 569-7876 Chief of Medical Services; Tamir Keshen, MD Medical Director, NICU Medical Director, Chief of Pediatric Surgery; (805) 569-7510 PEDIATRIC HEMATOLOGY/ Pediatrics/PICU Director of Pediatric Minimally ONCOLOGY (805) 569-8294 Invasive Surgery Barbara J. Donnelly, MD Daniel Greenfield, MD (805) 563-6560 Associate Medical Director, (805) 569-8394 PEDIATRIC NEUROLOGY NICU Sabrina Carter, MD Charles J. Stolar, MD (805) 569-7510 David Slomiany, MD (805) 563-8800 (805) 563-6560 (805) 569-8394 Theresa Lueck, MD PEDIATRIC NEUROLOGY NURSING (805) 569-7510 PEDIATRIC HOSPITALISTS Mark Corazza, MD Jennifer Ferrick, RN Heather Hindo, MD (805) 569-7115 Clinical Manager/NICU PEDIATRIC ALLERGY/ (805) 569-8294 (805) 569-7273 IMMUNOLOGY PEDIATRIC OPHTHALMOLOGIC Myron I. Liebhaber, MD Kristen Hughes, MD SURGERY Vicki Lekas, RN (805) 681-7635 (805) 569-8294 Mark Silverberg, MD Clinical Nurse Specialist, (805) 681-8950 Pediatrics/PICU Christophe Le Renard, MD PEDIATRIC CARDIOLOGY (805) 569-7497 Bilal Harake, MD (805) 569-8294 PEDIATRIC ORTHOPEDIC SURGERY

(805) 569-3146 Sean Early, MD Liz Lundquist, RN Kathy Lou Reynolds, MD (805) 687-2424 Director of Children’s Services Associate Director PEDIATRIC ENDOCRINOLOGY (805) 569-7509 Cristina S. Candido-Vitto, MD Acute Pediatrics Michael Maguire, MD (805) 569-7850 (805) 569-8294 (805) 687-2424 Gina Randall, RN

Clinical Manager, Pediatrics/PICU Marjan Haghi, MD PEDIATRIC INTENSIVE CARE Pediatric Radiology (805) 569-8238 (805) 569-7850 Richard E. Lehman, MD James Benzian, MD Director of Pediatric (805) 569-7279 Stella Riddell, RN Hidekazu Hosono, MD Transport Services Clinical Nurse Specialist/NICU (805) 569-7850 (805) 569-8294 PEDIATRIC RHEUMATOLOGY (805) 569-7508 Miriam Parsa, MD PEDIATRIC GASTROENTEROLOGY Mehrdad Mehr, MD (805) 569-7850 Helen John-Kelly, MD (805) 569-8294 (805) 569-7876

24-HOUR NUMBERS • NICU (805) 569-7522 • PICU (805) 569-8297 • ACUTE PEDIATRICS (805) 569-7273 PATIENT TRANSFERS (805) 569-7831 (877) 247-2707