Medical News – Spring 2020

COVID-19 (Coronavirus) FAQs

In an effort to help ease concerns and educate our patients and families, Connecticut Children’s has developed numerous resources for providers and patient families. Visit our COVID-19 Updates for Clinicians page for the latest clinical information. To access resources for patients and families, visit our Coronavirus Information Center.

Clinical Pathways Library Now Available on Connecticut Children’s Website

More than 35 clinical pathways are now available on Connecticut Children’s website! The pathways have been developed by Connecticut Children’s Clinical Pathways Program to standardize best practice, improve patient outcomes and reduce cost. This is accomplished by decreasing unnecessary variation while promoting safe, effective and consistent patient care.

The Clinical Pathways team is led by hospitalists Ilana Waynik, MD and Anand Sekaran, MD and comprises other pathway specialists and clinical quality data experts. A wide variety of medical and surgical issues are covered ranging from Blunt Liver and Spleen Injury to Fever in the Neonate to Eating Disorders. Congratulations to all on developing a robust library of clinical pathways that will help Connecticut Children’s to deliver the best care possible.

Visit www.connecticutchildrens.org/clinicalpathways to access the pathways.

Case Study: When Curiosity Becomes a Hazard

Connecticut Children's otolaryngologists Christopher Grindle, MD and Katherine Kavanagh, MD share a recent case involving a child who sniffed a nail into their nose after watching a similar stunt performed on YouTube.

Sometimes when you see something, you have to try it. Why not? It looks really cool. So, when an otherwise healthy 6-year-old boy saw a YouTube video of someone sniffing a nail into his nose, he had to try it.

He was at home, watching YouTube, and saw a video of someone putting a nail in his nose and he decided to try it. He inhaled forcefully through his nose and became uncomfortable (predictably). He immediately began coughing and choking. His sister went and told his parents what he had happened and the parents administered some back blows to help with the choking. He seemed to settle down and breathe better. The parents assumed that he must have swallowed the object. They then monitored his stool for the next several days to see if it passed. It did not! During the next week, he began to feel unwell. He had a low-grade fever and a worsening cough and was complaining of some abdominal pain. His parents were concerned and they presented to an outside hospital. A chest x ray was obtained and he was transferred to Connecticut Children’s for further management after it was revealed that he had a metallic foreign body (consistent with a nail) in his left main stem bronchus and an associated left lower lobe pneumonia (see image). He was admitted to Connecticut Children’s and went to the Operating Room for bronchoscopy and removal of foreign body (which turned out to be a pushpin). He remained in the hospital a few days for treatment of his pneumonia and was discharged home uneventfully.

Aspirated and ingested foreign bodies are a common problem treated at Connecticut Children’s. Last year we removed a foreign body from the upper aerodigestive tract over 40 times. Presentations can vary from life threatening episodes of choking, coughing and inability to swallow one’s own secretions to much more benign presentations like the case above. Coins are the most commonly ingested foreign body, but if you can imagine it, we have likely removed it (open safety pins, peanuts, sunflower seeds, board game pieces, hair clips etc.). Symptoms of aspirated and ingested foreign bodies are variable based on location and include cough, throat pain, inability to swallow secretion, intolerance of solid foods. Physical exam findings include drooling, crackles, decreased breath sounds or absent breath sounds. Chest x-ray is the diagnostic modality of choice. Radiopaque objects are usually easy to identify. Non-radiopaque items (food, plastics, etc.) can be more challenging to identify. Lateral decubitus films can be used to help identify air trapping. A high level of suspicion should be maintained for all young children, who have a cough or abnormal swallow that does not resolve in the expected period of time. Definitive diagnosis and management is done with esophagoscopy and/or bronchoscopy.

Although almost anything may be ingested and or aspirated and requires prompt evaluation and management, button batteries are a special case. Any suspicion of an aspirated or ingested button battery requires emergency management. Most button batteries will pass through the esophagus into the stomach and may be allowed to pass naturally. Some, button batteries, especially the 3V lithium ion “coin” batteries, can get stuck in the esophagus. There, an electric current can form around the outside of the battery that generates hydroxide and can cause tissue injury in as little as 15 minutes. If there is any suspicion of button battery ingestion, call the 24-hour National Battery Ingestion Hotline at 800.498.8666. In most cases, an x-ray should be performed immediately to identify the location of the battery. Notification of the Connecticut Children’s Emergency Department of the concern will facilitate rapid imaging. Updated 2018 guidelines also recommend giving the child honey on the way to the emergency department. Give 10 mL of honey (regular commercial honey) every 10 minutes up to six times. Studies have shown that honey effectively prevented the expected battery-induced pH increase and reduced severity of mucosal injury. More information on button battery management can be found at https://www.poison.org/battery and https://www.poison.org/battery/guideline.

 

All About Conjunctivitis

Connecticut Children's ophthalmologist Caroline DeBenedictis, MD shares answers to common questions about conjunctivitis.

What is conjunctivitis?

Conjunctivitis is inflammation or infection of the conjunctiva, which is the clear layer of tissue covering the sclera (white portion of the eye). Dilation of the conjunctival vessels occurs, resulting in hyperemia of the conjunctiva. This red or pink coloration of the conjunctiva is the hallmark of conjunctivitis. Causes include but are not limited to infectious (bacterial, viral), inflammatory (allergic, immune-mediated), and chemical (medication). Conjunctivitis signs and symptoms include hyperemia of the conjunctiva, tearing, discharge, foreign body sensation, itching, and chemosis (conjunctival edema). There can be overlap in signs and symptoms. History is key in differentiation between the types of conjunctivitis.

What is “pink eye”?

“Pink eye” is a descriptive term used to describe a hyperemic eye. When most parents or patients talk about “pink eye”, they usually mean a viral conjunctivitis. However, not all “pink eye” or conjunctivitis is viral or infectious in etiology.

Viral conjunctivitis

When caused by a viral infection, patients often have a history of a recent upper respiratory infection or close contact with sick individuals. The pre-auricular nodes can be enlarged. Conjunctivitis symptoms often start in one eye, involving the fellow eye a few days later and are associated with watery discharge. Adenovirus is the most common cause. Viral conjunctivitis is self-limited although symptoms can worsen for the first 4-7 days after onset before improving. Time until resolution varies from 1 to 3 weeks depending on serotype. As viral conjunctivitis is highly contagious, patients should avoid touching their eyes and close contact with others (shaking hands, sharing towels/pillows). Frequent handwashing is imperative. Antibiotic drops are not effective in treating viral conjunctivitis although artificial tears and cool compresses can help soothe the eye if irritated. Topical antihistamine drops may be used for itching as needed. Work and school restrictions are recommended to decrease spread of infection. The patient is contagious as long as the eye is red which can range from 5 days up to three weeks.

Commonly, parents request antibiotic drops due to school policies. Unfortunately these policies do not account for the different types of infectious conjunctivitis. A child with viral conjunctivitis is contagious while the eye is red. Antibiotic drops are not proven efficacious in treating viral conjunctivitis. Therefore, it is up to the primary care physician to decide how to best treat the patient and counsel the family in this situation.

Special considerations for viral conjunctivitis include Epidemic Keratoconjunctivitis (EKC) and Herpes Simplex Virus Conjunctivitis (HSV). EKC is caused by subgroup D adenovirus serotypes 8, 19, and 37. This is a severe form of viral conjunctivitis often mistaken for pre-septal or orbital cellulitis. Patients with EKC have a significant amount of eyelid edema and chemosis. They also get blurry vision and photophobia. Patients with EKC are highly contagious as long as the eye is red or up to 21 days. Patients with HSV conjunctivitis likely have a history of fever blisters, cold sores, or recurring unilateral conjunctivitis.

Red flags for patients with viral conjunctivitis include significant pain or photophobia, worsening vision, worsening symptoms after the first few days from onset, or no signs of improvement after 1 week. These patients should be considered for referral to an eye specialist to confirm diagnosis and tailor the treatment regimen.

Bacterial conjunctivitis

Bacterial conjunctivitis is caused by direct exposure from infected individuals, proliferation of native skin flora, or spread from the patient’s own nasal and sinus mucosa. Newborns can be exposed during labor and delivery. Common causes include Staphylococcus aureus, Staphylococcus epidermis, Haemophilus influenza, Streptococcus pneumonia, and Moraxella catarrhalis. Patients have foreign body sensation and purulent or mucopurulent discharge. Itching is less frequently associated with bacterial conjunctivitis. There can be matting of the eyelids. Frequent handwashing and decreased close contact with others are recommended. Although non-virulent cases of bacterial conjunctivitis are self-limited within 1-2 weeks, most recommended treatment regimens include topical antibiotics to shorten the course and contagious period. This includes antibiotic drops or ointment 4 times per day for 5-7 days. Antibiotic choice depends on patient allergy, resistance patterns, suspected pathogen, availability, and cost. Broad spectrum options include polytrim, bacitracin, aminoglycosides, and fluorquinolones. It is reasonable to treat with polytrim or bacitracin unless there are concerns regarding bacterial resistance or allergies. Mode of delivery, drop or ointment, should be discussed with the parent as they may feel one option is easier to apply at home than the other.

Allergic conjunctivitis

Itching is the predominant symptom in allergic conjunctivitis along with redness and watery discharge. There can also be associated lid edema and chemosis. Allergic conjunctivitis is usually bilateral and patients often have a history of allergies or atopic conditions. Treatment begins with eliminating the offending agent if possible. Cool compresses and topical antihistamine drops can control the symptoms.

Vernal conjunctivitis is a more severe form of allergic conjunctivitis that can cause white raised dots around the limbus (where sclera meets cornea) called Horner-Trantas dots. These patients should be referred to an eye care specialist for help in management.

Ophthalmia neonatorum

Ophthalmia neonatorum or neonatal conjunctivitis is a conjunctivitis occurring within the first 4 weeks of life. Etiologies include chemical, bacterial, or viral. Chlamydial, gonococcal, and HSV infections should be considered in this age group. Birth through caesarian section does not exclude the possibility of these infections if there is prolonged or premature rupture of membranes. Neonatal conjunctivitis can cause significant morbidity and mortality without early detection. Treatment depends on suspected organism and results of gram stain, Giemsa stain, and culture. A combination of topical and systemic medication is used to decrease the chance of permanent scarring, blindness, and mortality.

Red flags in conjunctivitis

Signs and symptoms that should prompt reconsideration of diagnosis or referral to an eye care specialist include pain or photophobia, worsening symptoms, no improvement within appropriate time frame, trauma, decreased vision, or no response to treatment. Contact lens wearers with a red eye associated with pain should be referred to an eye care specialist

Should I use steroids?

No, steroids should not be prescribed for the eye by anyone other than an eye care specialist. Some conditions worsen with steroids. In addition, an eye doctor monitors for side effects, including glaucoma and cataract.

First In-State Premature Patent Ductus Arteriosus Closure with New Device

Connecticut Children's pediatric cardiologist Frederic Bernstein, DO shares how the Cardiology team was able to use the Amplatzer Piccolo™ Occluder trans-catheter treatment to treat a large Patent Ductus Arteriosus (PDA) in a neonate.

TJ came a little earlier than he was expected. Born at 27 weeks and 2 pounds 7 ounces, he was the newest star in his family. This experience was nothing like his parents’ first child who came on time, full sized, and without any special concerns. TJ required a little extra support after birth but otherwise looked very good. Due to his size and age, he was brought to the Neonatal ICU for care and management. His initial medical therapy was typical for babies his age but still startling for parents never exposed to the NICU. He required specialized IVs for fluids and blood draws, tubes for eating, and special tubes and machines for breathing.

On the second day in the NICU, he was determined to have a murmur, with an echocardiogram confirming the presence of a large Patent Ductus Arteriosus (PDA). A PDA is a potentially life-threatening opening between the aorta and arteries of the lungs; and PDAs make up 10% of congenital heart disease cases. This tube, which is normally present in developing fetuses, is important to allow for appropriate blood and oxygen circulation through the fetus’ body. For most infants, the duct seals itself closed shortly after birth. In TJ’s case, which is very common in children born very early, the mechanism for closure does not work and the tube remained open. In these instances, it allows for excessive blood-flow into the lungs, potentially leading to infants having difficulty breathing, feeding, and can even cause congestive heart failure. By 2 months of age, these were the symptoms TJ’s parents started witnessing in him.

Treatment of PDAs usually falls into two categories: medical and  procedural. Medical treatment involves multiple medications that can be used within the first several days of life but is ineffective in up to 40% of patients. When medical management does not work, the patients are older, or there are other comorbidities, a procedural treatment is needed. Typically for small children, surgery had been the only option, with non-surgical percutaneous intervention being reserved for older and larger patients. That is until this past year.

The Amplatzer Piccolo™ Occluder is the first trans-catheter treatments approved for the treatment of PDAs in patients under 2 kg. Developed by Abbott Pharmaceuticals, the device received FDA clearance in January 2019 and had its first U.S. implant in March 2019. The Occluder is a pea-sized, self-expanding wire-mesh device that can be used non-surgically to close PDAs. It is inserted through a femoral venous approach, done in the catheterization lab. The procedure typically takes 60-90 minutes and does not result in any significant scarring nor does it require opening of the chest wall. In February of this year, TJ became the first patient at Connecticut Children’s Medical Center, and the first in all of Connecticut, to receive this device as a method of closing his PDA. After 2 hours, TJ was back in the NICU with his parents and in his parents’ arms that afternoon. Within days, the parents and team began noticing improvements in his breathing and comfort, as well as his weight gain. Still needing to work on eating by mouth, he was able to be moved from the NICU to a medical -surgical floor the following week and discharged home several days after that.

The success with TJ and his implant was not only felt by him and his family. The week following his procedure, a second premature infant with a significant PDA was brought to the lab and became the second patient repaired with this new device. We expect this procedure to be able to add to the armamentarium of our abilities to treat the smallest and sickest patients in Connecticut with the safest and least invasive methods possible.

A Spin on the Generic Learning Experience – Care Network

This past January, the Connecticut Children’s Care Network launched its first Learning Community – a series of educational lectures that combine expertise, peer-to-peer networking, and collaboration between members of the Care Network.

With the first session focusing on the value of well child care, participants learned about the data behind increasing the volume of well visits, including how it improves pediatric healthcare, how to decrease no show rates, and how to set your practice up for success. This interactive style of learning eliminates the isolation that many community pediatricians experience, while having valuable discussions with peers on best practices. This event was well-attended by pediatricians, registered nurses, registration staff and practice managers, in effort to include all involved in pediatric care. This is one of the many benefits included when joining the Connecticut Children’s Care Network, as it continues to build a stronger pediatric community.

The Connecticut Children’s Mobile App – Now Available for Patients and Families

The new mobile app created exclusively for patients and families is now available to download.

This is a one-stop shop for everything from wayfinding and valet summoning, to MyChart, kid-friendly games and real-time surgical updates. Please join us in encouraging patient families to download this by searching: “Connecticut Children’s” on the App Store or Google Play Store.

The Value Podcasts Bring to the Table

With the generational transition into a world of accessible and convenient information, the podcast is born. From your morning coffee and ride sharing, to grocery shopping and paying your bills, everything is available to you at the palm of your hand – including education.

Daily commutes to work are slowly shifting from radio-host banter to an informative podcast catered to your interests specifically. Podcasts can be a valuable tool to help you use your time wisely while pre-occupied with other daily life tasks. Following The Curbside Consult, a Connecticut Children’s podcast, will provide value whether you are a practicing pediatrician, a parent, or just curious about medicine. With supporting capabilities through Apple, Google, and Spotify, subscribing has never been easier. Both Apple and Google devices have a podcast app pre-programmed and Spotify users also have easy access. With the introduction of technology comes varied levels of difficulties. For support, questions, or suggestions, please email us at CurbsideConsult@ConnecticutChildrens.org.

Congratulations to our Surgical Research Team

Please join us in congratulating the following specialists whose research proposals were selected to receive funding through the Connecticut Children’s Surgical Research Innovation fund.

Their research includes, but is not limited to:

David Hersh, MD
Division of Neurosurgery

  • Impact of low-intensity pulsed ultrasound on bone resorption following cranioplasty

Markus Bookland, MD
Division of Neurosurgery

  • Automation of departmental research metrics through web-scraping software

Melissa Santos, PhD
Division of Surgery

  • The creation of the adolescent bariatric surgery registry

James Healy, MD
Division of Surgery

  • Improving and tracking the peri-operative activity for pediatric bariatric patients using wearable fitness-tracking technology

Brendan Campbell, MD
Division of Surgery

  • A multicenter evaluation of a firearm safety intervention in the pediatric outpatient setting – phase II

Courtney Rowe, MD
Division of Urology

  • Development of pediatric-specific surgical simulation resources
  • Integration of growth factors and biomaterials to optimize urethral healing

American College of Surgeons Clinical Congress

During the American College of Surgeons Clinical Congress in San Francisco, Brendan Campbell, MD, MPH, director of pediatric trauma at Connecticut Children’s, presented results from the membership survey on firearm injury prevention.

There was significant support across firearm ownership status for enhancing the Nation Instant Criminal Background Check System (NICS) and preventing those with mental illness from purchasing guns. However, there were disparities between the groups in restricting civilian access to high-capacity, semiautomatic firearms, with most gun owners not at all supportive, whereas non-owners were extremely supportive. The breakdown for these questions was similar for the rural/urban divide, with most supporting mandatory NICS use and a divide in restricting high-powered semiautomatic weapons. Surgeons play a vital role in firearm safety as they are key players in challenging public health issue. Trauma centers across the U.S., including Connecticut Children’s, are required to implement injury prevention programs that address the root causes of the most common causes of injury throughout the population in which they serve.

Expanded Services & Updates

We're growing! Get the latest information on our expanded services and locations.

Farmington:

Primary Care West

Moving to 599 Farmington Avenue

Walk-In Pediatric Orthopedics and Sports Medicine

399 Farmington Avenue, 3rd Floor

  • Monday through Friday 8:00 am-4:30 pm
  • On-site X-ray with pediatric radiology reads
  • On-site casting
  • On-site physical therapy with limited same-day appointments

Fairfield County:

Cardiology

4 Corporate Drive, Suite 282, Shelton

Hematology/Oncology

761 Main Street, Bldg. E., Norwalk

Expanded Imaging Services

105A Newtown Road, Danbury, CT

  • X-ray services now 5 days a week: Monday through Friday, 8:30 pm – 4:30 pm
  • Ultrasound: Tuesday, Thursday, and Friday, 8 am – 4 pm
  • EKG only:  Monday through Friday, 8:30 am – 5 pm

South Hadley:

Rheumatology

84 Willimansett Street, South Hadley

Welcome Aboard!

We’re pleased to announce these new additions to our medical staff.

Sabina Ahmad, MD
Pulmonary

  • MD, Ross University School of Medicine
  • Pediatric Resident, SUNY Downstate Medical Center
  • Pediatric Pulmonary Fellow, SUNY Downstate Medical Center
  • Sleep Medicine Fellow, SUNY Stony Brook Medical Center

Isabella Knox, MD
NICU

  • MD, University of Pennslyvania
  • Pediatric Intern, Rainbow Babies & Children’s Hospital, Case Western Reserve University
  • Pediatric Resident, Rainbow Babies & Children’s Hospital, Case Western Reserve University
  • Neonatal-Perinatal Fellow, Rainbow Babies & Children’s Hospital, Case Western Reserve University

Marie Sanford, MD
Primary Care

  • MD, Mount Sinai School of Medicine
  • Pediatric Resident, Mount Sinai Hospital
  • Chief Pediatric Resident, Mount Sinai Hospital

Raina Sinha, MD
Cardiac Surgery

  • MD, Drexel University
  • General Surgery Resident, University of Southern California
  • Cardiothoracic Surgery Research Fellow, University of Southern California
  • Cardiothoracic Surgery Fellow, University of Southern California
  • Congenital Heart Surgery Fellow, Emory University

Edward Kim, MD
Infectious Diseases

  • MD, Albany Medical College
  • Pediatric Resident, Children’s Hospital of Michigan
  • Pediatric Infectious Diseases Fellow, Children’s Hospital of Michigan

Michele McKee, MD
Emergency Medicine

  • MD, Temple University School of Medicine
  • Pediatric Intern, Boston Medical Center
  • Pediatric Resident, Johns Hopkins Hospital
  • Pediatric Fellow, Stanford University
  • Pediatric Emergency Medicine Fellow, Children’s National Medical Center
  • Pediatric Emergency Medicine Fellow, Rady Children’s Hospital

Ana Garnecho, MD
Developmental Pediatrics

  • MD, Mount Sinai School of Medicine
  • Pediatric Resident, Maria Fareri Children’s Hospital
  • Chief Pediatric Resident, Maria Fareri Children’s Hospital
  • Developmental Behavioral Pediatric Fellow, Rhode Island Hospital & Hasbro Children’s Hospital

Hassan El Chebib, MD
Infectious Diseases & Immunology

  • MD, American University of Beirut
  • Pediatric Resident, American University of Beirut
  • Adolescent Medicine Resident, SUNY Upstate Medical University Hospital
  • Pediatric Infectious Diseases Fellow, SUNY Upstate Medical University Hospital

Esther Oziel, MD
Primary Care

  • MD, Technion Israel Institute of Technology Medical School
  • Pediatric Resident, Baystate Medical Center

 

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