2005 Summer Issue

Contents:

• Chair's Column
• Kawasaki Disease
• Immunization Rates Rise
• Children's Miracle Network
• Staker Wins helen Taylor Award

Chair's Column

Dear Friends and Colleagues,

Summer is a busy time in pediatrics! We have quite a few changes taking place this summer about which I am happy to update you.

First of all, we are pleased to welcome ten new residents to our program. Our classes of seven pediatric residents and three medicine-pediatrics residents are both very strong, and we are looking forward to their contributions to our department.

We are also delighted to announce that Dr. Kirsten Evans will be joining our practice in the division of ambulatory pediatrics. Dr. Evans is an alumna of KU’s medical school and pediatric residency program. She has worked in private practice in Topeka and, most recently, in the Washington, D.C. metropolitan area. Dr. Evans is well respected by patients and colleagues, and will be a welcome addition to our department.

Sadly, we are saying goodbye to two of our colleagues as well. Dr. Norma Villegas, ambulatory pediatrician at our Overland Park office, is leaving to join her family in Texas, and Dr. Lynn Sheets, sexual abuse specialist, has accepted a position at the University of Milwaukee-Wisconsin. Our physicians and nursing staff in ambulatory pediatrics will continue this important work in our department. Both of our departing colleagues will be greatly missed.

Finally, we hope you enjoy the changes in this issue of Kid Talk. We are dedicated to maintaining this newsletter as a helpful clinical resource with regular didactic articles. However, we have decided to complement that objective by adding updates about our department for those of you who refer to KU Pediatrics or are alumni. Hopefully, the insert in this month’s newsletter will make it easier for you to contact us as well.

As always, I welcome your comments and suggestions. Please email me at cjohnson5@kumc.edu with your thoughts.

-- Chet D. Johnson, MD

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Kawasaki Disease

Kenn Goertz, MD
Pediatric Cardiology

Kawasaki disease is the leading cause of acquired cardiac disease in children in the United States. Kawasaki disease is most common in children less than five years of age, and has an incidence of 5-10 per 100,000 in the US and Europe, and 90 per 100,000 in Japan. Diagnosis can be difficult, as patients may present with incomplete or atypical disease, or may present with massive lymphadenopathy.

The principal diagnostic criteria are as follows:

• Fever of greater than five days duration
• Bilateral conjunctival injection
• Changes in the mouth, including strawberry tongue, diffuse oropharyngeal erythema, and fissuring and crusting of the lips
• Changes in the peripheral extremities, including induration of the hands and feet, erythema of the palms and soles, desquamation of the tips of fingers and toes (approximately two weeks from onset of illness), and transverse grooves across fingernails (approximately two to three months after onset)
• Erythematous rash, typically scarletiniform or morbiliform in nature
• Enlarged lymph node mass (greater than 1.5 cm in diameter)

Other common symptoms include irritability and perineal rashes.

The diagnosis can be supported by laboratory abnormalities. Elevations in the WBC (greater than 20,000/mm3) with increased neutrophils, an increased ESR and CRP, and thrombocytosis in the range of 600,000-1.8 million are the common findings. Sterile pyuria and aseptic meningitis are also common.

Standard treatment is 2 gm/kg IVIG given in a single infusion. This decreases circulating neutrophils by accelerating cell death. IVIG can be repeated once or twice with the persistence of symptoms or prompt recurrence. Aspirin therapy should also be instituted at 80 mg/kg/day. Ideally, therapy should commence within the first seven days of illness. However, recent studies have shown no benefit to treatment before the fifth day of symptoms.

Recommendations vary regarding the duration of high dose aspirin, but at our institution, we continue until laboratory markers of inflammation have returned to normal. The patient’s dose is then decreased to 3-5 mg/kg/day for four to six months. If coronary artery abnormalities are identified, aspirin may be continued indefinitely. Continued low-dose aspirin therapy may be appropriate for asymptomatic patients with mild and stable coronary artery disease.

The development of giant aneurysms (greater than six millimeters in diameter) is the least common, but most serious, complication of Kawasaki disease. Giant aneurysms can lead to coronary thrombosis or stenosis as a result of scarring during the healing process. The standard antithrombotic regimen for patients with giant aneurysms is low-dose aspirin together with warfarin, maintaining an INR of 2.0 to 2.5.

According to the recent AAP clinical report on Kawasaki disease (Pediatrics. 2004;114:1708-1733), approximately 10% of patients fail to defervesce with the initial IVIG therapy. Corticosteroids can also be administered, but at present are only recommended for patients who fail to respond to a second course of IVIG. The steroid regimen most commonly used is intravenous pulse methylprednisolone at 30 mg/kg for two to three hours once daily for one to three days.

A number of studies in the past few years have shown evidence of persistent vascular changes. Altered lipid metabolism seems to persist beyond clinical resolution of the disease. Intravascular ultrasound studies have demonstrated thickened coronary artery walls; this suggests a degree of permanent alteration in the media of coronary arteries. Non-invasive assessment of arterial reactivity has shown abnormal reactivity with less flow seen during reactive hyperemia compared to control patients. According to the above referenced article, “Meaningful knowledge about long-term myocardial function, late-onset valvar regurgitation, and coronary artery status in this population must await their careful surveillance in future decades.”

-- Kenn Goertz, MD

Dr. Goertz is Associate Professor of Pediatrics and Director, Division of Pediatric Cardiology

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KUMC Immunization Rates on the Rise

A recent assessment of immunization rates at KU Medical Center shows that our pediatric staff not only does an excellent job of keeping children safe through timely vaccinations, but also we continue to improve at doing so.

A review of almost 500 clinic records show that over 90% of children seen between 12-23 months of age are up to date on their immunizations. Between 24-35 months of age, that percentage drops to 72%. However, the immunization rate for that age range was only 59% as recently as one year ago.

Debbie Eltiste, RN, Clinic Manager, notes that these numbers are particularly impressive given the population our clinic serves. Compared to many private practices, our patients are more mobile, often face language barriers, and have fewer available resources and healthcare options

The immunization rate across Kansas from July 2003-June 2004 was 64% for children 24 months of age and 79% for children 19-35 months. Kansas was ranked 35th in the nation for immunization coverage, with the fourth DTaP and varicella vaccination rates substantially lower than for other immunizations.

Source: “Kansas Immunization Rate Improved.” Vaccination News. April 2005. Topeka, KS: Kansas Foundation for Medical Care.

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Ed. Note: Every issue, Children’s Miracle Network will write a column for Kid Talk to share their work and accomplishments with our readers. In this first column, CMN Director Brian VanNorman offers an overview of the organization.

Children’s Miracle Network is dedicated to raising awareness and financial resources for its 170 affiliated hospitals across the United States and Canada. Locally, monies raised by CMN benefit the University of Kansas Medical Center Department of Pediatrics and Children’s Mercy Hospitals and Clinics. Proceeds raised from individual and corporate donations remain in the community to care for area children in need.

During our 20-year partnership with KUMC, Children’s Miracle Network has raised more than four million dollars to support pediatric services and research at the Medical Center. CMN raises funds from special events such as the annual Kansas City “Mix for Kids” Radiothon on Mix 93 FM, as well as from corporate donors such as Wal-Mart, RE/MAX International, Credit Union for Kids, and several other friends of the organization.

With each dollar we raise, CMN makes a difference every day in the lives of children who rely on KUMC for their care. In recent years, CMN funding for the Medical Center has provided for pediatric gastroenterology equipment and the motility testing program, which admits children from across the country for specialized diagnostic testing. CMN funding at KUMC continues to ensure children from the local community will receive needed care, regardless of what their health care needs are or their ability to pay.

A number of fundraisers are scheduled throughout the year to support CMN. For more information on these events and the services we provide, visit us online at www.cmnkc.org.

-- Brian VanNorman

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Director Honored by National Award

We are pleased to announce that Martha Staker, Research Assistant Professor of Pediatrics and Director of Project EAGLE, has been awarded the Helen Taylor Award for management and leadership from the National Head Start Association.

Ms. Staker’s award is the result of over a decade’s work to expand systems for children in Wyandotte County. Her efforts have resulted in the ongoing development of the Children’s Campus, a center that will bring together over 50 organizations (including KU Pediatrics) to offer centralized services for children. The center has already obtained diverse financial backing, including a one million dollar grant pledged by the Buffet Foundation.

Ms. Staker accepted this award in Orlando, Florida in late May. We offer our congratulations to her for this award and for her many outstanding accomplishments!

If you would like more information about the Children’s Center, please contact Ms. Staker at mstaker@kumc.edu.

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