As always, summer brings with it changes and challenges. We have an outstanding group of new residents who are enthusiastically beginning their training. We have a full complement of interns, six Pediatric and four in the combined Medicine/Pediatric residency.
The Pediatric Inpatient Unit moved to a new Pediatric Pavilion on the fifth floor of KU Hospital, adjacent to the nurseries. This is a wonderful, newly-renovated area that includes 26 inpatient beds, the school room and the Child Life Area, and a brand new Family Room.
We have also had several new faculty members join the KU Children's Center:
We would also like to welcome our second Pediatric Surgeon, Ravindra Vegunta, MD, Assistant Professor, who will have a joint appointment in the Departments of Surgery and Pediatrics. He is joining our current Pediatric Surgeon, Roberta Sonnino, MD. Peter D. Witt, MD, will be joining KU as the Chief of Pediatric Plastic Surgery.
Professor and Chair, Department of Pediatrics.
It's the season for preschool physicals and everything is going well, except that hematuria and/or proteinuria shows up from the lab.
Proteinuria alone may be ominous or harmless. If the child has proteinuria without hematuria on the daytime urinalysis, have the child bring back a first-morning urine after having completely emptied the bladder before sleep the night before. If proteinuria has now disappeared, this orthostatic proteinuria is harmless.
Hematuria alone in an asymptomatic child might indicate potentially serious progressive renal disease, or it could be transient and benign. In school-aged children it is common to have very transient hematuria. It is acceptable to wait a week and recheck the year and as long as the blood pressure is normal. Infection is rarely, if ever, a cause of isolated asymptomatic hematuria.
If the repeat sample is positive for blood, you have a difficult dilemma. It is important to check for family history of hematuria as well as personal history of mild to moderate trauma. A detailed microscopic analysis is in order.
The presence of dysmorphic red cells has the same weight in reaching a diagnosis as hematuria with proteinuria. It would indicate a significant glomerulonephritic process. Although it is common to assume a post streptococcal glomerulonephritis, this is actually unlikely unless there is a confirmed recent episode of streptococcal disease with positive antibody reaction.
The child almost certainly will need a renal biopsy to find out the cause.
What, then, should one do about a patient with massive proteinuria, or with proteinuria between 0.5 in 3 grams, or the patient who has waited for the disappearance of isolated hematuria? Massive proteinuria is, by definition, nephrotic syndrome, and rapid diagnosis is essential so that appropriate therapy can begin. A younger child can often be treated without an invasive procedure. The presence of hypertension, decreased renal function, or age > 10 years, will all suggest the need for renal biopsy before embarking on therapy. The patient with proteinuria between 0.5 in 3 grams per day may also have an even greater chance of more serious disease. It often implies a scarring process such as focal glomerular sclerosis.
What might we then find with isolated, persistent hematuria? If the ultrasound and screening tests for hypercalciuria have been negative, a stone diathesis is possible but less probable. The most important glomerular cause of isolated hematuria in the world at large is probably IgA nephropathy, which is basically a defect in the IgA structure which allows accumulation of the IgA molecule in the glomerulus, resulting in insidious development of chronic renal disease. Timely diagnosis is essential so that appropriate treatment can be started. Isolated hematuria may also be due to a defect in the basement membrane, such as the classic familial nephritis (Alport's syndrome), but may also be due to another variety of basement membrane defect.
For further information, answers to specific questions, or patient referrals please feel free to call The KU Children's Center Division of Pediatric Nephrology at 913-588-6336.
Professor and Division Chief, Pediatric Nephrology.
The Healthy Steps Program for Young Children is a local as well as a national initiative that provides a new approach to pediatric care. This approach emphasizes a close relationship between health care professionals and parents in addressing the physical, emotional, and intellectual growth and development of every child from birth to age three.
The program brings new members to the pediatric care team: the Healthy Steps Specialists. These individuals have training in child development to enhance the services available to parents. The Specialists work with the pediatric team to address the behavioral and developmental issues of the children and families that they serve, giving the pediatric practice the ability to provide a holistic style of pediatrics.
The Healthy Steps approach has three underlying premises:
"Healthy Steps is an important first step toward using the development of the baby as a language to reach out to parents," says Dr. T. Berry Brazelton. "Parents are passionate for the answers to two questions when they come in for a checkup: 'How am I doing as a parent?' and 'How is my baby doing?' Unless they get some answer, they leave the visit seriously disappointed."
In 1996 the Commonwealth Fund Survey of Parents with Young Children revealed that, although mothers and fathers felt pressed for time and money, they were eager for more information on issues of normal growth and development such as how to promote learning, and how to discipline, toilet train, manage sleep problems, and deal with a crying baby. Only a little more than half of the two thousand parents interviewed felt satisfied with their pediatricians' guidance on those matters. Not surprisingly, parents were more likely to rate as "excellent" those physicians who provided useful information or guidance.
The Healthy Steps approach is being implemented and tested in numerous pediatric practices around the country, including a primary site at KU MedWest. Eighteen sites have been approved for a national evaluation; six affiliate sites are in operation and are being evaluated separately. The sites are coordinated by The Commonwealth Fund and are funded by community-based foundations and local health care providers. Here in Kansas City, the program is sponsored by Blue Cross and Blue Shield of Kansas City, The Commonwealth Fund and the Greater Kansas City Community Foundation and coordinated by The Commonwealth Fund in New York. The program was developed by Boston University School of Maternal and Child Health, and is being evaluated by Johns Hopkins. Services provided by Healthy Steps include:
At KU MedWest, the Healthy Steps program is implemented by our Healthy Steps team: Paul Brown, MD, Lead Pediatrician; Rozina Mohiuddin, MD, Pediatrician; Beth Rankin, Nurse Practitioner; Kathy Sanchez, MA Ed., and Kim Danaher, RN, MSN, the Healthy Steps Specialists; Juliet Hawley, MS Program Director; and Tammy Miller, BA, Site Evaluation Coordinator.
If you are interested in obtaining more information regarding Healthy Steps, you can call our child development information line directly at 913-588-8474 or by e-mail at kimkathy@swbell.net For the Healthy Steps web site, go to www.healthysteps.org
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The University of Kansas Medical Center