On Halloween Night, the Children...

On Halloween night, the children unite,

Their costumes so vivid, a thrilling sight.

Trick-or-treat bags filled, a candy spree they foresee,

Pediatricians caution, "Brush teeth," they plea.

President's Column

Nicole Webb, MD, FAAP

Happy fall everyone! This month I’m excited and honored to lend my column to my good friend, injury prevention collaborator mentor, and all-around amazing human being, Kristina Pasma! Kristina is a registered nurse, wife, mother, and health/safety advocate with over 21 years of Pediatric Emergency and Trauma experience at Valley Children’s Healthcare. She is passionate about keeping children safe from unintentional injury and has been a Nationally Certified Child Passenger Safety Technician for 9 years and a CPS Instructor for 7 years. Kristina is also the Coalition Coordinator of Safe Kids Central California, through which she helps keep the over 1.3 million kids in central California safe. She truly believes that injury prevention is everyone’s job.

I was fortunate to introduce Kristina to AAP President-elect and nationally renowned child passenger safety expert Dr. Ben Hoffman a couple of years ago and watching them geek out about all things injury prevention was pretty awesome. As motor vehicle collisions are the second leading cause of death of US children, I imagine many of us share that passion. Read on for some of her expert tips for child passenger safety.

“In my experience, child passenger safety is an area that many healthcare professionals dread discussing with parents and caregivers. We know it is important and we know it saves lives, but most of us never receive education on it during our training. I am excited to share with you some of my top child passenger safety tips.

1. Don’t be afraid to have the child passenger safety discussion. You are not expected to be a “car seat expert” but it is helpful to know where to go for resources. Safe Kids Worldwide is a great resource for all things injury prevention. Child passenger safety technicians want to be a resource for you so do not feel ashamed about reaching out to your local technicians for help or referring parents to them. Here is a link to help you locate one near you: Find a car seat tech. Car seats and vehicles are complex, so the misuse rate is very high. The more we can get children and families to a technician, the more we can ensure their seats are installed correctly. 
2. Encourage parents to keep those kiddos rear facing as long as possible. Under CA law, children must be rear facing until 2 years OR 40 pounds OR 40 inches tall. The AAP and child passenger safety technicians recommend that children ride rear facing until the height/weight limit of the child. Most convertible car seats can be used rear facing up to 40 pounds, but there are some car seat manufacturers that do allow for a higher weight limit so parents should check with the limits on their seat. Most parents are worried about their child’s legs being injured during a crash but research has shown that myth to be false. It is far more dangerous to be forward facing too early, especially since the majority of crashes are frontal impacts. 
3. Encourage parents to avoid “graduating” to the next seat too early. As a child transitions/graduates from one seat to the next, they lose an element of safety. Children should be kept in the 5-point harness up to the weight limit of the harness. The harness helps to distribute crash forces, which helps to reduce the risk of injury in a crash. For those school-aged children, having a discussion about riding in the backseat is important, especially since most crashes are frontal impacts.
4. Medically complex kiddos, do they all need a special needs seat? Most medically complex children can use a conventional car seat until they have reached the weight and weight limit of that seat. It is often a lengthy process to acquire a medical seat, so if you have a patient who you think might need one, I encourage you to start the process 5-10 pounds before the child reaches the weight limit of the conventional seat. There is an additional training that child passenger safety technicians go through to become special needs trained and I encourage you to seek out a special needs technician for additional assistance. Unfortunately, there is not a one size fits all. In the CPS technician class, we discuss “good, better, best” ways of transport, and for some medically complex children, it can often feel like there is not even a “good”. We need more professionals to help us advocate at the legislative level for safe transport for ALL children and families. 
5. Know key resources from the AAP. They have some great resources for child passenger safety, both for parents here on healthychildren.org and for providers here on aap.org.
6. Know the resources in your community. Many counties have child passenger safety resources for low-income families. These programs vary but for a list of resources and agencies who participate, click here for the "Who's Got Seats?" As you are screening for topics like food insecurity, please think of child passenger safety. If a family is unable to provide food for their family, they often cannot purchase car seats or other safety devices for their children.
7. Always assume parents are trying to do the right thing. During every child passenger safety technician class, I explain this to the students. In my experience, parents and guardians want to do the right thing but either do not have the knowledge, the resources, or both to keep their children safe. If we approach the discussion with a non-judgmental attitude, they are often open to learning and changing unsafe behavior. You are their trusted source of information and can make a difference in the safety of your patients because injury prevention is everyone’s job.”

Thank you for lending us some of your precious time to read this. Kristina has been an amazing friend and collaborator and I’ve learned so much about advocacy and community engagement from her. If you have a partner whose work you’d like to highlight, let us know!

Until next month,

Nikki

Sentinel Injuries

Casey L. Brown, MD, MPH, FAAP & Melissa Egge, MD, FAAP

Co-chairs, Child Abuse Prevention, Education and Treatment (CAPET) Committee

We pediatricians love prevention. What if we could prevent Abusive Head Trauma (aka Shaken Baby)? We think we can. 

Sentinel injuries are seemingly minor, poorly explained, visible injuries, in a pre-cruising infant that raise concern for physical abuse. Sentinel injuries include bruises, intra-oral injuries, subconjunctival hemorrhages, and scalp hematomas. Recognition, evaluation, and intervention of these injuries can help prevent devastating physical abuse in the future. 



Retrospectively, 30% of abusive head trauma cases (AHT, aka “Shaken Baby”) had a previous sentinel injury that was not recognized as abuse and not reported. Most sentinel injuries (46%) are known to parents and/or medical professionals but not recognized as abuse.

No cruising, no bruising. Infants who cannot cruise, should not bruise.  

Sentinel injuries can be subtle. A history of bleeding from the mouth and a torn frenulum is noted. A single bruise on the cheek. A bruise on the back of an ear. A small subconjunctival hemorrhage outside of the birth period (2-3 weeks of age). 

Myths: Sentinel injuries are often mistakenly attributed to self-infliction, Valsalva, or siblings. 

• Self-inflicted: Young infants do not have the strength to cause injuries such as bruises or subconjunctival hemorrhages, even with toys and rattles.
• Rolling over on sleeping/lying on toys does not cause bruising
• Gumming – gnawing on fingers, pacifiers and toys does not cause frenular injury 
• Valsalva: Infants under 12 months do not have sufficient strength to Valsalva and cause subconjunctival hemorrhages. So it is not from coughing, spitting up, straining, or crying. Outside of 2-3 weeks of age, a subconjunctival hemorrhage is likely from abuse. 
• Siblings: other than scratches - bruises, scalp hematomas, oral injuries, and subconjunctival hemorrhages are not caused by siblings, especially not young siblings. Accidental injuries from an older sibling should always be considered!
• Infants do not easily bruise – it is difficult to bruise infants, they have extra padding and healthy, youthful skin!

Workup: Any sentinel injury needs further evaluation for both bleeding disorders and physical abuse. The purpose is to find occult injuries (ones we do not know about). Workup includes a head CT, skeletal survey with repeat skeletal survey, occult abdominal injury surveillance, and substance exposure surveillance.

A negative workup does not rule out physical abuse. A negative workup just means there were no additional injuries. Your original injury remains just as concerning. 

Any bruises, oral injuries, subconjunctival hemorrhages, scalp hematoma in a pre-cruising infant needs a physical abuse evaluation. Please refer them to your local child abuse team or Child Advocacy Center. A list of Child Abuse Pediatricians follows: 

• Alameda County – CCP at BCHO – Dr. Crawford-Jakubiak
• Contra Costa County – Casey Brown, MD
• Sacramento County - Angela Vickers, MD
• San Francisco County – Chris Stewart, MD and Melissa Egge, MD
• San Mateo and Monterey County – Melissa Egge, MD

Developing Concerns

Renee Wachtel, MD, FAAP

Chair, Committee on Developmental and Behavioral Pediatrics

Early diagnosis of Autism Spectrum Disorders (ASD) enables children to access early intervention services. Currently, the AAP recommends ASD screening at 18 and 24 months in Bright Futures, using a measure such as the MCHAT-R/F.  But autism researchers are studying a new methodology for screening for autism in young children, called Eye Tracking. In a recent study published in JAMA in September (Jones et al), researchers tested children ages 16-30 months with a new eye-tracking device and compared the results to a comprehensive autism assessment. 

How did they determine eye tracking in infants and young children?

Social visual engagement data were collected using  investigational eye-tracking devices, one at each  of 6 clinical sites. Device operators were staff technicians employed by each clinical site, trained for approximately 1 hour when each device was delivered, with no other required specialization or prior training. The device was located in available space within the clinic (ie, examination room, playroom). Data collection procedures were automated, with no instructions required of the child. Software guided the device operator through eye-tracking calibration, validation of calibration, and automated data collection. 

The eye-tracking index test measured social visual engagement while children watched video scenes of social interaction, 14 video scenes were presented, each with a mean duration of about 54.0 seconds (range, 21.7 seconds to 1 minute 29.7 seconds).  Following collection, index test data were automatically uploaded to a secure cloud-based server for processing and analysis. Processing and analysis were automated, and each participant’s data, once analyzed, yielded categorical determination of either autism or non-autism, as well as 3 continuous measures: a social disability index, verbal ability index, and nonverbal ability index.

What did they find?

Eye-tracking measurement of social visual engagement was successful in 475 (95.2%) of the 499 enrolled children (mean  age, 24.1  months)  By expert clinical diagnosis, 221 children (46.5%) had autism and 254 (53.5%) did not. In all children, measurement of social visual engagement indicative of autism risk by eye tracking had sensitivity of 71.0% and specificity of 80.7%. In the subgroup of 335 children whose autism diagnosis was certain, sensitivity was 78.0% (95% CI, 70.7% to 83.9%) and specificity was 85.4% (95% CI, 79.5% to 89.8%). The sample  included a very broad spectrum of children with autism—both with and without co-occurring intellectual and developmental delays—as well as many children without autism who nonetheless had significant speech-language and global developmental disabilities. The challenge of reference standard differential diagnosis in this sample was highlighted by clinician uncertainty in 29.5% of children. 

What does this mean for pediatricians?

Several things can be concluded from this study. For one, current autism screening tools still need improvement, if we are to identify children with autism early. In this study, even with expert clinical evaluations in six nationwide autism centers, there were a significant number of children 16-30 months in which the diagnosis was unclear. However, this appears to be a promising avenue for further research into its application for autism screening in pediatric primary care. 

Jones W, Klaiman C, Richardson S, et al. Eye-tracking–based measurement of social visual engagement compared with expert clinical diagnosis of autism. JAMA. Published September 5, 2023. doi:10.1001/jama.2023.13295

Grant Money Available to Support Improving Your Practice!

Diane Dooley, MD, MHS, FAAP

Chair, Mental Health Committee

Equity and Practice Transformation Payments Program

California has recently announced that they will be incentivizing practices that want to implement improvements in their primary care prevention and treatment capacity. The Equity and Practice Transformation Payments Program is a $700 million initiative to advance equity, reduce COVID-19-driven care disparities, invest in up-stream care models and partnerships to address health and wellness, and fund practice transformation to allow Medi-Cal providers to better serve the state’s diverse Medi- Cal enrollee population. 

If your practice serves Medi-Cal patients, you should consider looking at this program soon. Applications are due October 23. If accepted into the program, approved applicants would have 5-year funding to:

• Complete an assessment of their organizational and clinical practices relevant to the quality of care they provide

• Commit to make improvements in care for children and youth, such as implementing dyadic care, screening for SDOH, implementing best practices for tracking and completing children's preventive care, and/or implementation of an integrated behavioral health model in their practices

• Track their improvements

DHCS plans to convene a multi-disciplinary learning collaborative to help practices make these changes.

You can find more information about this program on their website: 

https://www.dhcs.ca.gov/qphm/Documents/EPT-Guidance-for-Primary-Care-Practices-and-Medi-Cal-Managed-Care-Plans.pdf 

AAP Chapter 1 is considering supporting practices applying for this program. If you have questions or want more information, contact Diane Dooley MD at 4dianedooley@gmail.com.

AAP National's Committee on Continuing Medical Education (COCME)

M. Virginia Barrow, MD

Chief of Medical Education, North Valley, Assistant Chief of Pediatrics, Kaiser Permanente Lincoln Medical Office

Formed in 2000, the Committee on Continuing Medical Education (COCME) at AAP National comprises leading continuing medical education/continuing professional development (CME/CPD) experts dedicated to supporting the American Academy of Pediatrics’ (AAP) development of the Best Pediatric CME/CPD for the Best Pediatric Care. The COCME encourages innovation and active teaching and learning in AAP educational activities, and members have presented on these topics to AAP constituent groups and at national meetings.  The COCME convened its spring meeting on June 23-24, 2023, during which the committee reviewed and discussed many items related to its role in providing oversight to the AAP CME/CPD program and promoting active learning and teaching in AAP educational activities.  I was able to attend in person at the beautiful AAP headquarters in Itasca, right outside of Chicago.

The first evening, we held a virtual Best Practices for Active Teaching and Learning Webinar.  COCME will continue to share information about and encourage active learning strategies and educational formats and design in its outreach and communications with AAP constituent groups and planners.  The committee anticipates developing another webinar in the next year.  In the meantime, the COCME website has myriad documents that we continue to curate.  A journal club discussion was included and the committee plans to update the COCME website with additional tip sheets and article summaries for literature that the committee found most helpful.  Also, the COCME is currently working on developing Equity, Diversity, and Inclusion resources for education, including a basic tips sheet and a more detailed annotated EDI resource list.  Information was shared from the CMSS CPD Research Project on Medical Specialty Society Annual Meetings and Learner Preferences.  We discussed our recent ACCME reaccreditation visit, reviewed and approved two section/council CME courses for 2024-2025, and an opportunity for COCME to collaborate with the PediaLink Editorial Board in developing an Educational Activities Dashboard. Updates were shared about AAP educational activities, including a vision for PediaLink and PREP, live and virtual education activities, and other organizational endeavors. 

The COCME recently contributed a commentary for the 75th anniversary edition of Pediatrics, you can read our work here:  Commentary From the AAP Committee on Continuing Medical Education | Pediatrics | American Academy of Pediatrics

Thank you for supporting me to represent Chapter 1, and TPMG, California on the COCME.  It’s been a great learning experience and I’m grateful for the opportunity.

8th Annual Pediatric Puzzles CME Conference

REGISTRATION NOW OPEN: Saturday, December 2

California Academy of Sciences

Our 8th Annual Pediatric Puzzles CME Conference is back this December! Pediatricians, family practitioners, nurse practitioners, and Physicians-in-Training are invited to receive the latest updates on pediatric sports medicine, dermatology, mental health, and physical therapy from lectures, Q&As, and networking lunches with our faculty. Participants are tentatively eligible for 5 hours of CME credits. This year’s event is in-person-only at the California Academy of Sciences in San Francisco, making it a great opportunity for a family trip! Join us Saturday, December 2. We still have a free Academy ticket for your guest if you register soon!

For the most up-to-date information on AAP California bill positions, letters, and outcomes from the current California Legislative year, go to www.aap-ca.org/bill. For the latest organizational advocacy updates follow @AAPCADocs on Twitter. If you have questions and/or are interested in knowing more about certain legislation, reach out to our State Government Affairs Chapter Representative Nora Pfaff, MD, FAAP and Anna Kaplan MD, FAAP at info@aapca1.org. 

Diving into the Implications of ACEs on Interpersonal Relationships and Healthcare - Tuesday, October 10, 11:30 am - 1:30 pm 

Join the Sierra Community Medical Foundation (SCMF) for a free virtual training on the effects of Adverse Childhood Experiences (ACEs) on interpersonal relationships, as it relates to the health of adults, children, couples, and families. The workshop is intended for physicians and other healthcare workers interested in learning to properly engage with and treat patients with a history of ACEs.

Webinar: Diving into the Implications of ACEs on Interpersonal Relationships and Healthcare

Date: Tuesday, October 10, 2023

Time: 11:30 AM - 1:30 PM

As part of our ACEs / Social Determinants of Health Coalition, SCMF aims to educate healthcare workers on Adverse Childhood experience (ACEs), which are potentially traumatic events that occur in childhood. ACEs can include violence, abuse, and growing up in a family with mental health or substance abuse problems. Toxic stress from ACEs can change brain development and affect how the body responds to stress. ACEs are linked to chronic health problems, mental illness, and substance misuse in adulthood. (Source: cdc.gov)

Our experienced presenters will offer their valuable perspectives and insights on ACEs in healthcare, providing attendees with an opportunity to understand the topic more holistically. The presentations will be followed by a Q&A/discussion.

RSVP through this link. Webinar (Zoom) access will be provided within 3 days of registering.

Honoring Diastole - Saturday, October 14 & Saturday, October 28

What transitions are occurring in your life alongside nature’s change of seasons? What leaves are falling? What bounty have you cultivated that is now ready to harvest?

Join us nearby at the coast for a one day “Honoring Diastole” retreat to pause and reset - to remember what sustainability means for ourselves and the Earth.   

Pediatricians Dr. Gail Wright and Dr. Jessie Mahoney offer evidence-based practices to improve physical health, sleep, mood, energy, and mental clarity.  CME available for MD/NP/PAs and CEUs for RNs.  Spouses and friends definitely welcome - open to everyone.  

Upcoming dates: Oct 14th and Oct 28th, 2023  (more available winter/spring 2024 soon)

Check out the Honoring Diastole retreat website to register or get more details: 

https://www.jessiemahoneymd.com/honoring-diastole 

Healthy Families: Festival of Fitness - Saturday, September 23, 9am - 1pm

This is a lobbying event in D.C. where physicians and health care workers come together to meet with Senators and Representatives to discuss gun safety legislation that can save lives. 

In April, we had 40 meetings and over 90 pediatricians from 25 states represented. After the success of our April meetings in the House and Senate, #OnCall4Kids is excited to get back to the Hill. This event is not represented by any organization. We are representing ourselves as physicians/health care workers. We are holding this lobbying event the day before the AAP National Conference in D.C. with the full knowledge of the AAP National team. 

We will again be lobbying for three bills that if implemented, could save lives:

• Assault Weapons Ban of 2023, S.25 /HR.698 
• Background Check Expansion Act, S.494/Bipartisan Background Checks Act of 2023, HR.715 
• Ethan’s Law, S.173/HR.660

RSVP link:

https://docs.google.com/forms/d/17S-NhNl6HsQBelAqNlOa44jmIBuKwiUvVUfCr5aPxw4/edit?ts=64891153

Finally, if you would like more information about our work, here is an article from the AAP News about our advocacy day in D.C. in December. Please review to see what we have been working on this year!

https://publications.aap.org/aapnews/news/23131?autologincheck=redirected

October 12 - Child Abuse Prevention, Education and Treatment (CAPET) Committee Meeting

TBD - The Balance Between Data Exchange and Privacy: Ask the Experts!

December 2 - 8th Annual Pediatric Puzzles CME Conference at the California Academy of Sciences! - REGISTER HERE!

December 8-10 - 2023 Las Vegas Seminars - REGISTER HERE!

Executive Committee:

President: Nicole Webb • Vice President: Neel Patel

• Secretary: Resham Kaur • Treasurer: Amita Saxena • Past President: Nelson Branco

Executive Director: Yolanda Ruiz

Board Members:

North Valley MAL: Thiyagu Ganesan • Sacramento Valley MAL: Lena van der List • Central Valley MAL: Deborah Shassetz • South Valley MAL: Sireesha Palkamsetti • San Francisco MAL: Maya Raman • Santa Clara MAL: Bindya Singh• San Mateo MAL: Jackie Czaja • North Coastal MAL: Jeffrey Ribordy • Monterey Bay MAL: Graciela Wilcox • Alameda MAL: Renee Wachtel • Contra Costa/Solano MAL: Omoniyi Omotoso

Pediatric Insider News Editors:

• Mika Hiramatsu • Deborah Shassetz • Alyssa Velasco

Staff:

• Project Coordinator: Sana Sayyid