1. health and fitness
2. disease

C hol es tas i s
He art t ra nsplant
and failure
CT scan of
14-year-old with
rhinosinusitis.
See story on
Page 2.
Rhi nos i nus i ti s
A physician publication produced by Children’s Hospital of Wisconsin and The Medical College of Wisconsin, located in Milwaukee.
S uic ide
VOL. 11 ISSUE 1
PEDIATRIC ROUNDS
Save the date for Best Practices in Pediatrics fall 2011 conference
Our Best Practices in Pediatrics conference will provide the latest information about common problems
encountered in pediatric practice and will benefit all health care providers who work with children,
including pediatricians, family practice physicians, nurse practitioners and physician assistants.
When: Friday, Sept. 23, and Saturday, Sept. 24
Location: Grand Geneva Resort, Lake Geneva, Ill.
Detailed conference information will be available online in April at chw.org/bestpractices.
Tune in to Practical Pediatrics CME webcasts
Lectures on recent advances and current knowledge in pediatrics and pediatric specialties now are
easy to access, interactive and available when you are. Each month a new lecture is added online.
You can view these presentations from your computer when it’s convenient for you and earn
continuing medical education credits. To view on demand, visit chw.org/practicalpediatrics.
The Medical College of Wisconsin is accredited by the Accreditation Council for Continuing
Medical Education to provide continuing medical education for physicians.
The Medical College of Wisconsin designates this enduring material for a maximum of 1.0
AMA PRA Category 1 CreditTM. Physicians should only claim credit commensurate with the
extent of their participation in the activity.
The Medical College of Wisconsin designates this activity for up to 1.0 credit hour of
continuing education for allied health professionals.
Children’s Specialty Group names new CEO
Marc Gorelick, MD, MSCE, has been named chief executive officer and
senior associate dean for Clinical Affairs for Children’s Specialty Group.
The specialty group is a joint venture between Children’s Hospital and
Health System and The Medical College of Wisconsin. Dr. Gorelick
also is pediatric Emergency Medicine specialist at Children’s Hospital
of Wisconsin, associate director of Children’s Research Institute and a
professor of Pediatrics (Emergency Medicine) at the Medical College.
Dr. Gorelick assumes responsibility for the leadership and practice
operations of Children’s Specialty Group and is chair of the board of
Marc Gorelick, MD, MSCE
directors. He will ensure the development and execution of strategic plans
that align with the vision and goals of the Medical College and Children’s
Hospital and Health System, and he is responsible for developing strategies for clinical programs and
business operations for the multispecialty group practice.
Dr. Gorelick earned his medical degree from Duke University in Durham, N.C., and completed a Master
of Science in Clinical Epidemiology at the University of Pennsylvania in Philadelphia. Dr. Gorelick is a
member of a number of professional societies including the Society for Pediatric Research, the Society for
Academic Emergency Medicine and the American College of Emergency Physicians. He currently serves as
the chair elect of the Section of Emergency Medicine of the American Academy of Pediatrics.
Physician referral and consultation (800) 266-0366
4
INS ID E
2
Management of pediatric rhinosinusitis
6
Cholestasis in infants
9
Pediatric heart transplantation and heart failure:
Early referrals save lives
12
Case study: Follow-up for suicide attempt in primary care
15
Program notes
16
Specialty Spotlight – Spine Center
18
New hires
We want to make it easy for you and your patient
families to connect with us
Physician Referral Center (Consultations • Referrals • Transports)
Toll-free (800) 266-0366
chw.org/refer
When you want to contact a Children’s Hospital of Wisconsin specialist –
for consultation, referral or transport – one number is all you need to know.
The 24-hour physician call center connects you to a nurse clinician who will
expedite your request. We look forward to working with you to care for your
pediatric patients.
Family Accommodations Program
Toll-free (800) 556-8090
We understand that traveling with a sick child to a new city can be stressful
for families. To make a stay at our hospital as easy as possible, we have
developed a program to help out-of-town families coordinate their travel
and lodging arrangements in Milwaukee. Negotiated discounts are available
through the program.
chw.org
1
Management of pediatric rhinosinusitis
by Cecille Sulman, MD, and James Lustig, MD,
Cecille Sulman, MD, is a pediatric otolaryngologist at Children’s Hospital of Wisconsin. She also is an assistant
professor of Pediatrics (Otolaryngology) at the Medical College and a member of Children’s Specialty Group.
James Lustig, MD, is an asthma and allergy specialist at Children’s Hospital of Wisconsin. He also is a professor
of Pediatrics (Asthma/Allergy) at The Medical College of Wisconsin and a member of Children’s Specialty
Group.
Introduction
Rhinosinusitis is a common disease. On average, children get 6-10 upper respiratory tract
infections per year. Between 5 and 10 percent of upper respiratory tract infections are
complicated by rhinosinusitis.
Rhi nos i nus i ti s
Acute rhinosinusitis most commonly presents as a upper respiratory tract infection. Symptoms
persist beyond 10 days or symptoms become worse at 7-10 days. Primary symptoms include nasal
discharge, cough and halitosis. Fever may be present. Otitis media is present in up to 50 percent
of the children. The most common pathogens include Streptococcus pneumonia, Haemophilus
influenza and Moraxella catarrhalis. Chronic rhinosinusitis is a more indolent infection that
lasts more than three months, with symptoms including nasal congestion, cough, halitosis,
behavioral problems, headache and nasal discharge.
In addition to Streptococcus pneumonia, Haemophilus
Figure 1
influenza and Moraxella catarrhalis, anaerobic bacteria
Left middle meatus with purulence.
(Peptococcus, Peptostreptococcus, Bacteroides) and
Staphylococcus aureus may play a role in chronic
rhinosinusitis. Recurrent acute rhinosinusitis is
a recurrent infection lasting less than 30 days with
relatively asymptomatic periods in between that
last at least 10 days.
Figure 2
Ostiomeatal complex.
Physical examination
The presence of purulent secretions in the region
of the middle meatus is highly suggestive of
sinusitis. (See Figure 1.) This may be seen via
anterior rhinoscopy, visualizing the middle meatus
by positioning the speculum beyond the nasal
vibrissae. A flexible nasopharygoscope also may be
used to see the middle meatus and adenoid pad.
Imaging studies
Imaging should be reserved for children who
are refractory to therapy, being considered for
surgery or if concern is present for complications
of rhinosinusitis. The gold standard for sinus
imaging is computed tomography with images in
the coronal and axial plane. Plain film radiography
is not a reliable screen for sinus disease. Obtaining
plain films does not provide cost savings over a
sinus CT. A lateral neck film is helpful in determining
the presence of adenoid hypertrophy in a child with
persistent rhinorrhea and nasal obstruction.
2
Physician referral and consultation (800) 266-0366
Causative factors
The ostiomeatal complex is located in the middle meatus
under the middle turbinate and is the confluence of
drainage points for the maxillary, anterior ethmoid and
the frontal sinuses. (See Figure 2.) Inflammation or
obstruction of the ostiomeatal complex is a contributing
factor in the development of rhinosinusitis. Mucosal
edema and disruption of ciliary motility also contribute to
the pathophysiology of rhinosinusitis. (See Table 1.)
Table 1
Causative factors in rhinosinusitis.
• Upper respiratory tract infection
• Allergy
• Adenoid hypertrophy
• Immunologic defects
• Ciliary dysmotility
• Cystic fibrosis
Rhi nos i nus i ti s
Most sinus infections in children develop following a viral
• Gastroesophageal reflux disease
upper respiratory tract infection. Inflammation of the
• Environmental pollutants
sinus ostia causes stasis of secretions and poor ventilation
• Structural abnormalities
of the affected sinus. This leads to absorption of oxygen
and the development of a relatively negative pressure
or vacuum within the sinus. Reflux of intranasal contents and nasopharyngeal bacteria into the
sinus cavity incites rhinosinusitis. Viruses can have a direct inhibitory effect on ciliary function
contributing to stasis of secretions.
More than 80 percent of children with rhinosinusitis have a family history of allergy, as opposed
to a general population allergy frequency of 15 percent. Allergy may contribute by causing
nasal congestion and ostial obstruction. Immunotherapy has been demonstrated to decrease the
incidence of rhinosinusitis in children with known allergy and improve health-related quality of life.
James Lustig, MD, and Cecille Sulman, MD, are part of the Sinus Clinic team at Children’s Hospital of Wisconsin
Clinics-New Berlin. The clinic provides a multidisciplinary approach for children with chronic rhinosinusitis. Physical
exam and medical history review; allergy testing; exam of the nasal passages, upper airway, voice box and vocal cords;
lung function tests; imaging studies, including X-ray, MRI or CT; and lab tests can be completed during the same visit.
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The adenoid pad contributes to rhinosinusitis in children by blocking the outlet of secretions
or acting as a bacterial reservoir. Cultures of the adenoid core have shown organisms similar to
those seen in rhinosinusitis. Removal of the adenoids may improve rhinosinusitis in up to 80
percent of children.
Other diseases are associated with rhinosinusitis. These include primary immunodeficiency
(especially B-cell defects), primary ciliary dyskinesia, cystic fibrosis and gastroesophageal reflux
disease. Rhinosinusitis may be a major problem in cystic fibrosis. Patients who have nasal polyps
should be evaluated for cystic fibrosis.
Many opinions exist about the relationship between GERD and rhinosinusitis in children.
Double-lumen pH probe testing has shown that esophageal reflux can extend to the nasopharynx.
A retrospective study suggested that GERD therapy could prevent sinus surgery in almost 90
percent of children with refractory chronic rhinosinusitis. However, controlled studies are lacking
and children with chronic rhinosinusitis should be treated for GERD only if there are clear
clinical indications.
Rhi nos i nus i ti s
Environmental pollutants can irritate the nasal and sinus mucosa. The most significant irritant
in rhinosinusitis is environmental tobacco smoke. Less commonly, structural anomalies of the
sinus and nasal cavities are implicated in rhinosinusitis. These include septal deviation, concha
bullosa, hypoplastic maxilla, paradoxical middle turbinate and infraorbital (Haller) cells.
Therapies
See Table 2 for an overview of therapy options for rhinosinusitis.
Antibiotic therapy: The mainstay of therapy for rhinosinusitis continues to be antibiotics. The
ideal antibiotic should combine high susceptibility, clinical effectiveness, safety and tolerability.
Table 2
Acute rhinosinusitis
Therapy for rhinosinusitis.
Antibiotic therapyAmoxicillin 75-90 mg/kg/day
Amoxicillin allergic – cephalosporins or macrolides
Adjuvant therapy
Saline nasal irrigation
Topical decongestant
Nasal steroid
Antibiotic therapyAmoxicillin/clavulanate 90 mg/kg/day
Chronic rhinosinusitis
Amoxicillin allergic – cephalosporins or macrolides
8
4
Clindamycin
Adjuvant therapy
Saline nasal irrigation
Topical decongestant
Nasal steroid
Immunotherapy if indicated
Surgical therapyAdenoidectomy
Maxillary sinus lavage
Functional endoscopic sinus surgery
Physician referral and consultation (800) 266-0366
There is an increased resistance to amoxicillin resulting from beta lactamase production
in approximately 60 percent of Haemophilus influenza cases and 100 percent of Moraxella
catarrhalis cases. An alteration in penicillin-binding proteins also occurs in about 50 percent of
Streptococcus pneumonia cases.
Young children with mild to moderate acute rhinosinusitis should be treated with a high dosage
of amoxicillin (75-90 mg/kg/day). Allergic patients may be treated with a macrolide such as
clarithromycin or azithromycin. Children that do not respond to first-line therapy, children with
more severe initial disease and children who are considered high-risk for resistant Streptococcus
pneumonia (those who recently have used antibiotics or attend day care) should be treated
with high-dose amoxicillin/clavulanate (90 mg/kg/day of amoxicillin component). The optimal
duration of treatment has not been determined, but long courses of therapy typically are
necessary.
Rhi nos i nus i ti s
For children with chronic rhinosinusitis, amoxicillin/clavulanate (90 mg/kg/day) or the second
generation cephalosporins are recommended. Clindamycin may be used if Streptococcus
pneumonia is the suspected organism or if there is no response to other antibiotics. Antibiotic
therapy in chronic rhinosinusitis is extended for 3 to 6 weeks.
Adjuvant therapy: Other medical therapies have not been proved to be effective by
randomized controlled trials, but may provide symptomatic relief. Saline irrigations twice a
day help in clearing secretions. If significant nasal mucosal edema is present, oxymetazoline
may be used for three days. Nasal steroids commonly are used to help decrease inflammation
and should be used in children with allergies. Control of underlying causative factors, such as
allergy, gastroesophageal reflux disease, day care exposure or environmental pollutants, should
be addressed.
Surgical therapy: Adenoidectomy as a first-line surgical therapy if medical therapy has failed
may provide improvement in up to 80 percent of children. The addition of maxillary sinus
lavage allows for culture directed antibiotics. Functional endoscopic sinus surgery is considered
if all other measures have failed. This surgery involves the removal of obstructive components,
typically the uncinate process and anterior ethmoid air cells, and widening the maxillary ostia.
In properly selected children, improvement should be expected in 80-90 percent of cases. If a
child is being considered for functional endoscopic sinus surgery, causative factors should be
considered, such as allergy, immunodeficiency, primary ciliary dyskinesia or cystic fibrosis.
A sick plan for respiratory infections is available at chw.org/provider. Select Medical
Care Guidelines and look for the sinusitis section.
For outcomes from our Ear, Nose and Throat program,
visit chw.org/quality.
References
For a list of references used in developing this article, go
to chw.org/pediatricrounds and view the article online.
chw.org
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5
Cholestasis in infants
by Diana Lerner, MD, Jonathan Ramprasad, MD, and Bernadette Vitola, MD, MPH
Diana Lerner, MD, is a pediatric gastroenterology fellow at The Medical College of Wisconsin.
Jonathan Ramprasad, MD, is a pediatric gastroenterology fellow at the Medical College.
Bernadette Vitola, MD, MPH, is a pediatric gastroenterologist at Children’s Hospital of Wisconsin. She also
is an assistant professor of Pediatrics (Gastroenterology) at the Medical College and a member of Children’s
Specialty Group.
Introduction
Cholestasis is defined as reduced bile flow and abnormal accumulation of conjugated bilirubin,
indicating impaired hepatobiliary function. Conjugated bilirubin is considered abnormal if it is
1 mg/dl or above when the total bilirubin is less than 5 mg/dl or more than 20 percent of the
total bilirubin when the total is above 5 mg/dl.
Cholestasis occurs in approximately 1 in 2,500 births. Biliary atresia and neonatal hepatitis
account for most cases. The other etiologies of cholestasis are numerous and include anatomic
obstruction (such as bile sludging and choledochal
cyst), infection (such as urinary tract infection and
Table 1
CMV), metabolic disorders (such as galactosemia
Most common causes of cholestasis in
and tyrosinemia), genetic disorders (such as
neonates.
alpha-1 antitrypsin deficiency, cystic fibrosis and
Obstructive
Alagille syndrome), endocrine dysfunction (such as
Biliary atresia
hypothyroidism and panhypopituitarism) and toxins
Choledochal cyst
Biliary sludge/inspissated bile/gallstone
(such as TPN). See Table 1.
C hol es tas i s
Conjugated hyperbilirubinemia in the first month
of life is pathologic and may be a serious or even
life-threatening disease requiring urgent evaluation.
Biliary atresia is the most time-sensitive with regard
to treatment and outcomes. Surgical treatment of
biliary atresia with the Kasai portoenterostomy has
a statistically superior outcome when performed by
2 months of age. In addition, early diagnosis may
allow for optimal nutritional and medical support,
which can decrease the likelihood of complications
of chronic liver disease.
The primary care physician is critically important
in the evaluation of the jaundiced infant. It is
recommended that all infants with persistent
jaundice beyond 2 weeks old be assessed with a
fractionated bilirubin. In healthy breast-fed infants
with no signs of cholestasis, this investigation can
be postponed until 3 weeks old. If conjugated
hyperbilirubinemia is present, prompt referral to a
pediatric gastroenterologist for further evaluation is
imperative.
6
Alagille syndrome
Cystic fibrosis
Neonatal sclerosing cholangitis
Congenital hepatic fibrosis
Infectious
Urinary tract infection
Sepsis
Cytomegalovirus
Human immunodeficiency virus
Parvovirus B19
Syphilis
Other
Genetic/Metabolic
Alpha-1 antitrypsin deficiency
Alagille syndrome
Cystic fibrosis
Galactosemia
Progressive familial intrahepatic cholestasis
Tyrosinemia
Toxic
Parenteral nutrition
Medications
Endocrinopathy
Hypothyroidism
Panhypopituitarism
Systemic
Shock
Heart failure
Physician referral and consultation (800) 266-0366
Jonathan Ramprasad, MD, Diana Lerner, MD, and Bernadette Vitola, MD, MPH, use a liver model to aid in
discussion of a patient’s care. The physicians are part of the Gastroenterology, Hepatology and Nutrition Center
team. Children’s Hospital of Wisconsin has one of the largest pediatric gastroenterology programs in the country,
with leading experts in issues ranging from feeding and swallowing to cyclic vomiting.
C hol es tas i s
Clinical findings
Aside from jaundice, the clinical presentation of the cholestatic infant can vary widely depending
on the etiology. Infants with biliary atresia often are healthy-appearing and asymptomatic until
later in the disease course. Infants with cholestasis due to infection or a metabolic disease such
as galactosemia or tyrosinemia often appear ill. Cholestasis as a result of a genetic mutation may
have associated physical findings such as a heart murmur, vertebral anomalies, typical facial
features and eye findings in Alagille syndrome.
The triad of jaundice, acholic stools and dark urine should alert the clinician to the possibility
of cholestasis, especially biliary atresia. Parental reports of stool color often are misleading.
Reportedly normal stools can falsely reassure the pediatrician. It is preferable for the provider to
visualize the stool. It is not uncommon for the stool color to become acholic over several weeks
as the extrahepatic biliary drainage system becomes progressively damaged in biliary atresia.
Malnutrition and impaired absorption of fat-soluble vitamins (A, D, E and K) are significant longterm sequelae of cholestasis. Supplementation with calorically dense formula, primarily ones
containing medium-chain triglycerides, and vitamin supplementation frequently are required.
Evaluation
• Determine if the patient is acutely ill and requires urgent care.
• Assess the presence of cholestasis by measuring total and conjugated serum bilirubin.
• Review the results of the newborn screen specifically for galactosemia, tyrosinemia and
hypothyroidism.
• Evaluate the synthetic function of the liver by investigating for hypoglycemia, coagulopathy and
hypoalbuminemia.
chw.org
7
Biliary atresia
• Immediately refer to a pediatric
gastroenterologist for additional testing.
The specialist will obtain critical laboratory
tests and an abdominal ultrasound,
preferably at a center with pediatric
radiology.
• Liver biopsy and intraoperative
cholangiogram are the gold standard for
differentiating biliary atresia from other
causes of cholestasis and should be
expedited in infants approaching
6-8 weeks old.
• Scintigraphy (hepatobiliary iminodiacetic
acid or HIDA scan) adds little value to
the evaluation of the cholestatic infant
given the significant false positive results.
Referral to a pediatric gastroenterologist
should not be delayed in order to obtain a
HIDA scan.
• Occurs in 1 in 10,000-20,000 live births.
• Universally fatal if left untreated.
• Most common reason for pediatric liver
transplant.
• Potential mechanisms proposed as the cause of
biliary atresia include defects in morphogenesis,
defects in prenatal circulation, immunologic
dysregulation, viral infection and toxin exposure,
although the etiology is unknown.
• Kasai portoenterostomy has the greatest success
when performed before 60 days of age by an
experienced pediatric surgeon.
• Eventually, 70-80 percent of patients undergoing
Kasai will require liver transplantation or succumb
to their disease due to progressive liver failure.
Critical quick questions
• How old is the child?
• Are the stools acholic? (See image reference* below.)
• Is this biliary atresia?
• Is there evidence of liver disease: hypoglycemia or coagulopathy?
C hol es tas i s
Critical tests
• Fractionated bilirubin (total and conjugated).
• AST, ALT, GGT, alkaline phosphatase, albumin.
• Prothrombin time/INR.
• CBC.
• Glucose.
• Newborn screen.
• Abdominal ultrasound.
* For images of normal and abnormal infant stool
color, visit the American Academy of Pediatrics
website, aap.org. Search for “infant stool,” select
Screening for Biliary Atresia by Infant Stool
Color Card in Taiwan and see Page 3.
For outcomes from our Gastroenterology, Hepatology
and Nutrition Center, visit chw.org/quality.
References
For a list of references used in developing this article, go
to chw.org/pediatricrounds and view the article online.
12
8
Physician referral and consultation (800) 266-0366
Pediatric heart transplantation and heart failure:
Early referrals save lives
by Steven Zangwill, MD
Steven Zangwill, MD, is program director of Pediatric Heart Failure and Heart Transplantation and a
pediatric cardiologist at Children’s Hospital of Wisconsin. He also is an associate professor of Pediatrics
(Cardiology) at The Medical College of Wisconsin and a member of Children’s Specialty Group.
In the last 10 years, tremendous strides have been made in cardiac transplantation and
heart failure, especially in the pediatric population. This is true for the state of the art
in medical care as a whole, and perhaps even more so for our practice here at Children’s
Hospital of Wisconsin. Globally, heart transplantation and heart failure are far more
prevalent in the adult population, so new evidence and innovation tends to trickle down
from adult experiences to pediatric ones. It is the challenge of the pediatric subspecialist
to decide when and how to apply adult findings to our pediatric practices. In this
environment, collaboration between pediatric centers of excellence, partnership with
adult congenital heart disease experts and the development of subspecialty programs
and clinics are crucial steps to moving pediatric practices forward in a data-driven way.
This has been our path at Children’s Hospital. It has allowed us to improve the care
for children with heart failure, to judiciously integrate adult practices and to lead the
way in pediatric care. In some ways we have moved past standard adult paradigms by
recognizing the very real anatomic and physiologic differences in children and the often
unique circumstances that bring them to the heart failure/heart transplant specialist.
Hear t tr ans pla nt
a nd f ailure
Heart transplantation
The pediatric heart transplant program at Children’s Hospital was started in 1991 and
has seen tremendous growth over the years. In the first 10 years, 16 heart transplants
Steven Zangwill, MD, catches up with 13-year-old heart transplant patient Anna Schmidt. Children’s
Hospital of Wisconsin is among the nation’s top hospitals for pediatric heart transplant volumes. In 2010,
we performed more heart transplants than ever before.
chw.org
13
9
were performed. By comparison, in the last five years (2005-2010), we have performed more than
60. While volume has increased significantly and the children who have come to transplantation
have, as a group, been sicker and more vulnerable, the outcomes have continued to substantially
improve. In the past five years, 30 percent of the children have required some type of mechanical
support pretransplant, 22 percent have been ventilator dependent, more than 50 percent have
had some form of congenital heart disease and nearly 60 percent have had some level of antibody
sensitization. All of these factors are known to increase the risks associated with transplantation.
Despite these challenges, our overall survival during the past five years has been 83 percent
with a conditional survival (past 6 months) of 95 percent. Academically, we have participated in
the Pediatric Heart Transplant Study Group. Through this national consortium of the 36 largest
pediatric transplant centers, we have participated in numerous prospective and retrospective
research projects that have resulted in significantly improved outcomes for the field as a whole.
Additionally, in collaboration with the BloodCenter of Wisconsin, we have led the way in
the management of sensitized children who require heart transplantation. Following in vitro
research at the BloodCenter in 2004, we applied this approach in our own practice. In 2007, we
reported our experience in the pediatric population wherein we moved historically from having
7 of 8 sensitized children not surviving to transplant with a prospective crossmatch strategy to
successfully transplanting 10 of 11 consecutive children with our virtual crossmatch strategy.
In that original abstract, we coined the term “virtual crossmatch,” which has since become
ubiquitous, recognized by UNOS, and adopted nationally as a preferred strategy by pediatric and
adult programs.
Hear t tr ans pla nt
a nd f ailure
Heart failure
The growth in the pediatric heart transplant program would not have been possible without the
recognition that pediatric heart failure is a subspecialty that is best served by having resources
and expertise brought together in a programmatic fashion. We formally started the pediatric heart
failure program at Children’s Hospital in 2005 and have seen steady growth since that time.
Initially sharing resources with the transplant program, the heart failure program has grown to
become a dedicated practice with its own outpatient clinic, subspecialty-experienced advanced
practice nursing support and collaboration with support services including experts in genetics,
metabolic disease, electrophysiology and psychosocial challenges. In essence, our initial goals
in the heart failure program are to identify alternatives to heart transplantation and/or to look
for opportunities to safely improve functionality and quality of life in children with heart failure
while delaying or eliminating the need for transplant.
Early referral is recommended as it allows us to
judiciously counsel families as to the timing
of consideration for transplantation. In
numerous cases, we have been able to
… we have been
manage heart failure medically, improve
able to manage heart
dysrhythmia therapy or utilize cardiac
resynchronization, provide support
failure medically …
for the failing fontan or recommend
in ways that allow patients
surgical palliation in ways that allow
to delay or avoid the need
patients to delay or avoid the need for
transplantation. We offer heart failure
for transplantation.
consultative services either as an adjunct
to primary cardiology care or as the primary
service for these patients.
“
”
10
Physician referral and consultation (800) 266-0366
Early referral saves lives.
Indications for referral:
Heart failure:
• Patients with new or worsening heart failure.
• New diagnosis of cardiomyopathy (dilated,
restrictive or hypertrophic).
• Palliated congenital heart disease with systolic or
diastolic heart failure.
• Fontan patients with protein-losing enteropathy.
• Mitochondrial disorders or muscular dystrophies.
Heart transplant – patients with end-stage
heart disease with any of the following:
• Failure to thrive.
• Progressive pulmonary hypertension.
• Malignant dysrhythmias, syncope.
• Poor quality of life.
Going forward, we can anticipate continued growth in these programs and better alternatives
over time for children with late-stage cardiac failure. Innovations in mechanical support, the
development of tissue valves and the promise of stem cell therapies, along with improvements
in immunomodulation with monoclonal antibodies and genetically guided personalized
pharmacology, all hold the promise of near-term benefits for our patients. We believe we have
organized our resources in transplantation and heart failure, and we recognize the incredible
infrastructure of the Herma Heart Center at Children’s Hospital that will allow us to take full
advantage of these developments to improve the lives of our patients and families.
He art t ra nsplant
and failure
For outcomes from our Herma Heart Center, visit
chw.org/quality.
Heart Matters
Children’s Hospital of Wisconsin’s Herma Heart Center is one
of the nation’s top programs for medical and surgical treatment
of congenital heart defects and heart disease in children. As
one of the largest pediatric cardiac programs in the United
States, we have set national benchmarks for surgical outcomes.
For more information, visit chw.org/hermaheartcenter.
chw.org
11
Case study: Follow-up for suicide attempt in primary care
by Heena Desai, MD
Heena Desai, MD, is a pediatric psychiatrist at Children’s Hospital of Wisconsin. She also is an assistant professor
of Pediatrics (Child and Adolescent Psychiatry) at The Medical College of Wisconsin and a member of Children’s
Specialty Group.
Anne is a 16-year-old girl who lives in a rural area. Two weeks ago she attempted suicide via overdose
and was admitted to a pediatric intensive care unit. After a brief stay in the PICU, she was admitted
to her local adolescent psychiatric inpatient unit for seven days before being discharged to outpatient
care.
She has a three-year history of periods of depressed mood, anhedonia, decreased appetite, increased
sleep and suicidal ideation. This was her first attempt. Her grades in school have been progressively
declining, as has her attendance. Over time she gradually has lost regular contact with her peer group
as well.
She presents with her parents for follow-up care. The next available appointment for the local
child psychiatrist is in three months. The psychiatric hospital asked the family to follow up with the
primary care physician for outpatient care until then, and to return to inpatient care for any acute
issues. Anne does have a new therapist who is conducting manualized cognitive behavioral therapy
with her, and the therapist recently sent the primary care physician a treatment plan.
Anne has been on fluoxetine 5 mg for four weeks. She reports no side effects. She denies any current
suicidal ideation. There is no drug or alcohol use.*
Management and next steps: Some considerations
Step 1: Avoiding common pitfalls
In general, suicidal patients should be assumed to have multiple problems rather than a single
problem driving their suicidality. The chronic suicidal ideation, in turn, can become a driving
force for additional problems. It can be tempting to oversimplify the issue as a “chemical
imbalance” in the brain triggering depression of which the suicidal ideation is a symptom. This
oversimplification can result in missed opportunities for intervention. Depression treatment is
critical, but psychopharmacology should not be the sole intervention in a suicidal patient.
In addition, a “no” answer to the question of whether Anne has current suicidal ideation should
not be taken as a signal that there is no need for risk factor modification. Suicidal ideation can
recur and should be monitored and planned for. Concurrently, interventions to decrease risk for
completed suicide should be implemented, placing the patient, provider and family in good stead
should the suicide crisis recur.
Suic ide
Step 2: Interventions to assess and decrease risk
Patients with suicidal ideation present on a continuum of risk. Where they are on this continuum
depends on a number of different risk factors, many of which can be modified. The two proven
interventions to decrease risk of suicide on a population level are physician education regarding
depression treatment and removal of access to lethal means.
*This case is fictional and developed to illustrate specific teaching points. Any resemblance to actual persons
is purely coincidental. This information is not a substitute for professional medical or mental health advice or
services, particularly in acutely suicidal individuals who warrant immediate evaluation in an emergency setting.
12
Physician referral and consultation (800) 266-0366
It is important to have a discussion
with the family regarding risk when
firearms are in the home. Firearms
should be removed from the
home. In addition, all medication
in the home should be locked up,
including those that are over-thecounter. The argument put forth by
some is that the adolescent simply
will obtain more over-the-counter
medications. However, I would argue
that removal of access to means
has its most significant impact on
impulsive suicide attempts and the
delay caused by a lack of access to
immediate means can provide the
suicidal individual time to “come
to their senses.” Finally, suicidal
adolescents should not keep and
manage their own depression
medications. Parents should
take responsibility for dispensing
medication to improve adherence and
decrease intentional overdose risk.
An important question to ask the
patient as part of the suicide screen
is her reasons for living. The answer
to this question prompts the patient to Heena Desai, MD, is part of the Psychiatry and Behavioral Medicine
Center at Children’s Hospital of Wisconsin. She manages the Second
think of her own reasons for living and
Opinion Clinic, which helps primary care physicians manage
offers the provider critical information. children’s mental health needs. Typical diagnoses include attentiondeficit/hyperactivity disorder, depression and anxiety. The primary
A patient who cannot list reasons
care physician receives a comprehensive report with the diagnostic
for living is at much higher risk than
evaluation and treatment recommendations, including next steps.
one who can easily and quickly state
multiple reasons for living. The patient who cannot state reasons for living should be assessed for
hospitalization for acute safety and stabilization.
Suicide
A crisis plan should be developed with the patient and the family. At minimum, the crisis plan
should identify emergency contact numbers (such as the local crisis line, parents, primary care
physician, therapist). The patient should be encouraged to program these numbers into her cell
phone, if she has one, or to memorize the numbers if she doesn’t. At least one number should be
available 24 hours a day, 7 days a week (such as the crisis line). Beyond this, the crisis plan can
identify distress tolerance behaviors. These are any behaviors patients can engage in to distract
themselves from current emotional distress or decrease it, and not act on it. Activities can include
playing with a pet, listening to mood-incongruent music, watching a movie, engaging in highintensity exercise, prayer, etc. The patient should have ready access to her crisis plan at all times.
Step 3: Medication risk
Research indicates a small but significant increase in risk of suicidal ideation in children and
adolescents on antidepressant medication. FDA guidelines recommend face-to-face evaluation
once a week for four weeks, once every two weeks for four weeks, then once a month, and then
chw.org
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as clinically indicated with every medication initiation or dose change. Primary care physicians
can enlist the assistance of the therapist in such monitoring. Medications should not be avoided
in suicidal patients because of this reason.
Step 4: Ensuring adequate treatment
Primary care physicians should ensure not only adequate pharmacological treatment but also
psychological treatment. For chronically suicidal patients, patients with multiple problems
or patients who have otherwise failed usual outpatient management, consider an intensive
outpatient treatment called dialectical behavioral therapy. Unfortunately, this treatment is not
available in many communities.
Ensuring adequate treatment includes adequate psychopharmacology. In general, two
antidepressants, escitalopram and fluoxetine, are approved for adolescent depression. Ideally,
Anne would have been started on 5 mg of fluoxetine with an increase to 10 mg at one week. The
general recommendation is to wait 6-8 weeks between dose adjustments. However, a minimal
effective dose is generally 10 mg rather than 5 mg for adolescents. Further dose changes can be
made at a 6-8 week interval.
Ensuring adequate psychotherapy is a larger challenge. Anne clearly is receiving appropriate
therapy. While cognitive behavioral therapy and interpersonal psychotherapy (another evidencebased psychotherapy for depression) are more widely available than dialectical behavioral therapy,
they can be difficult to find. In cases such as Anne’s, symptom resolution in a timely fashion is
critical. It is important to ensure that Anne is receiving manualized, evidence-based treatment.
Some of the interventions that Anne should receive in therapy, and that can be reinforced
at her primary care visits, include developing a list of activities of mastery and pleasure and
to participate in at least one each day: exercising daily, ensuring adequate nutritional intake,
maintaining a regular sleep schedule with good sleep hygiene and regular school attendance.
The parents should monitor their child closely.
Finally, there always is room for generating hope. Frequent reminders that the depression will
resolve are helpful for both the patient and the family, particularly when it has been ongoing for
some time.
References
Mann JJ, Apter A, Bertolote J, Beautrais A, Currier D, Haas A, Hegerl U, Jouko L, Malone K, Marusic A,
Mehlum L, Patton G, Phillips M, Rutz W, Rihmer Z, Schmidtke A, Shaffer D, Silverman M, Takahasi Y,
Varnik A, Wasserman D, Yip P, Hendin H. Suicide prevention strategies: A systematic review. JAMA. 2005,
294(16), 2064-2074.
Hammad TA, Laughren T, Racoosin J. Suicidality in pediatric patients treated with antidepressant drugs.
Archives of General Psychiatry. 2006, 63, 332-339.
Stone M, Laughren T, Jones ML, Levenson M, Holland CP, Hughes A, Hammad TA, Temple R, Rochester
G. Risk of suicidality in clinical trials of antidepressants in adults: Analysis of proprietary data submitted to
US Food and Drug Administration. BMJ. 2009, 339(b2880), 1-10.
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC,
American Psychiatric Association. 2000.
Practice parameter for the assessment and treatment of children and adolescents with depressive disorders.
Journal of the American Academy of Child and Adolescent Psychiatry. 46:11, 1503-1526.
Suic ide
Mosholder AD, Willy, M. Suicidal adverse events in pediatric randomized, controlled clinical trials of antidepressant drugs are associated with active drug treatment: A meta-analysis. Journal of Child and Adolescent
Psychopharmacology. 2006, 16(1/2), 25-32.
Linehan MM, Goodstein JL, Nielsen SL, Chiles JA. Reasons for staying alive when you are thinking of killing
yourself: The reasons for living inventory. Journal of Consulting and Clinical Psychology. 1983, 51(2), 276-286.
Linehan MM. Skills Training Manual for Treating Borderline Personality Disorder. The Guilford Press. 1993.
14
18
Physician referral and consultation (800) 266-0366
Program notes
Children with complex aerodigestive abnormalities that
impact breathing, voice, swallowing and feeding require
integrated support from multiple specialists. The Airway,
Digestive and Voice Center at Children’s Hospital of Wisconsin
provides and coordinates the full range of services these children need
for proper diagnosis and effective treatment. Team members collaboratively
develop treatment plans and confer regularly on each child’s progress. Visit
chw.org/advcenter for more information.
Birthmarks and Vascular Anomalies
The Birthmarks and Vascular Anomalies Center at Children’s Hospital offers
interdisciplinary expertise, with international leaders in these fields providing the
very finest in clinical treatment and groundbreaking research. Patients see all of the
necessary physicians in each visit, reducing the number of trips to the clinic.
To make an appointment, contact Marcia Seefeldt, RN, nurse coordinator, at
(414) 266-3727. Visit chw.org/birthmarks for more information.
Hyperhidrosis
The Dermatology Clinic at Children’s Hospital now offers a Hyperhidrosis Clinic. The
clinic offers medical solutions as well as everyday strategies for coping with excessive
sweating. Special hyperhidrosis treatments include topical therapies, iontophoresis,
botulinum toxin and anticholinergic medications. Visit chw.org/dermatology for
more information.
Primary ImmunoDeficiency
The Primary Immunodeficiency Program is made up of a multidisciplinary
team that specializes in the diagnosis and treatment of complex primary
immune deficiencies (non-AIDS) for children and adults. The goal
is to make an accurate and early diagnosis, which is critical in
patients with severe immunodeficiencies. Our program is
recognized as a Jeffrey Modell Diagnostic Center for
Primary Immunodeficiencies. Visit chw.org/pip
for a list of the top 10 warning signs of
primary immunodeficiency.
To make an appointment
Pro g ram notes
Airway, Digestive
and Voice
in these programs,
except where noted,
call Central Scheduling
at (414) 607-5280 or
toll-free at
(877) 607-5280.
chw.org
15
Specialty Spotli g ht
Specialty Spotlight
16
Spine Center
Conservative approach
Our conservative approach saves surgery for only the most severe cases.
Nonoperative management of scoliosis is the goal of the entire orthopedic
team at Children’s Hospital of Wisconsin. We see more than 3,000 scoliosis
patients each year. While we perform many scoliosis surgeries (more than 100 per
year for the last several years), surgical patients make up only 3 percent of our total
scoliosis visits.
Lower charges
Improved surgical techniques, an experienced group of inpatient nurses and early
physical therapy have enabled us to shorten hospital stays and dramatically improve
rehabilitation after spinal surgery. We also charge significantly less than the average of
our peer hospitals* for spinal fusions.
Advanced imaging
Children’s Hospital has installed an EOS low-dose radiation scanner, one of two
in a pediatric hospital in the nation. EOS is able to obtain 3-D visualization
of the spine with 1/1,000 the radiation dose of a CT scanner. It also uses 10
times less radiation than
conventional X-rays.
EOS allows for 3-D
reconstruction of
individual bone
position, rotation
and orientation.
Access
Allison Duey-Holtz,
MSN, APNP, and
Annette Husske, PA-C,
each have more than 10 years
of experience in pediatric spine
care. They see new and follow-up
patients with diagnoses of:
• Spinal asymmetry.
• Mild scoliosis.
• Curves under 20 degrees.
• Screening for scoliosis.
Quality
More quality information for our
orthopedics program is available online
at chw.org/quality.
A patient is positioned in the EOS low-dose radiation
scanner.
Physician referral and consultation (800) 266-0366
Spine Center team
Value
In one visit, your patients will have low-dose
imaging with interpretation and a plan of care
the same day.
John Thometz, MD
Medical Director, Orthopedic Surgery
*Pediatric Health Information System is maintained by
the Child Health Corporation of America, a business
alliance of pediatric hospitals from across the U.S. PHIS
collects clinical and financial data from leading children’s
hospitals in an effort to support quality and outcomes
improvement.
Channing Tassone, MD
Contact us
Nurse line: (414) 266-2411
Patient appointments: (877) 607-5280
chw.org/orthopedics
Allison Duey-Holtz, MSN, APNP
Annette Husske, PA-C
chw.org
17
New hires
Adolescent Medicine
Katie DuBois, MSN, RN, is an adolescent medicine nurse practitioner at Children’s Hospital of Wisconsin
and The Medical College of Wisconsin and a member of Children’s Specialty Group.
Bachelor of Science: University of Wisconsin-Green Bay, Nursing.
Master of Science: University of Wisconsin-Milwaukee, Nursing.
Board certification: Family nurse practitioner.
Tia Medley, MSN, APNP, is an adolescent medicine nurse practitioner at Children’s Hospital of
Wisconsin and The Medical College of Wisconsin and a member of Children’s Specialty Group.
Bachelor of Art: Loyola University, Chicago, Psychology.
Master of Science: Loyola University, Counseling; University of Wisconsin-Milwaukee, Nursing.
Board certification: Family nurse practitioner.
Anesthesiology
Michael Malan, MD, is an anesthesiologist at Children’s Hospital of Wisconsin, an assistant professor of
Anesthesiology and Pediatrics at The Medical College of Wisconsin and a member of Children’s Specialty
Group.
Medical degree: University of Utah School of Medicine, Salt Lake City.
Residency: The Medical College of Wisconsin, Anesthesiology.
Fellowship: The Medical College of Wisconsin, Pediatric Anesthesiology.
Asthma/Allergy/Immunology
Lisa Crandall, MSN, APNP, is an asthma, allergy and immunology nurse practitioner at Children’s
Hospital of Wisconsin and The Medical College of Wisconsin and a member of Children’s Specialty Group.
Bachelor of Science: University of Wisconsin-Madison School of Medicine and Public Health, Nursing.
Master of Science: Marquette University, Milwaukee, Nursing.
Board certification: Pediatric nurse practitioner-Primary Care.
cardiology
Andrea Bobke, MSN, APNP, is a pediatric cardiology nurse practitioner at Children’s Hospital of
Wisconsin and The Medical College of Wisconsin and a member of Children’s Specialty Group.
Bachelor of Science: University of Wisconsin-Milwaukee, Nursing.
Master of Science: University of California-San Francisco, Nursing.
Board certification: Pediatric nurse practitioner-Primary Care.
Susan Foerster, MD, is a pediatric cardiologist at Children’s Hospital of Wisconsin, an assistant professor
of Pediatrics (Cardiology) at The Medical College of Wisconsin and a member of Children’s Specialty Group.
Medical degree: University of Manitoba-Faculty of Medicine, Winnipeg, Canada.
Residency: Children’s Hospital Health Sciences Centre Winnipeg, Pediatrics.
Fellowship: Children’s Hospital Boston, Pediatric Cardiology.
child protection
Alice Swenson, MD, is a child protection specialist at Children’s Hospital of Wisconsin, an assistant
professor of Pediatrics (Child Protection) at The Medical College of Wisconsin and a member of Children’s
Specialty Group.
Medical degree: State University of New York, Downstate Medical Center, Brooklyn.
Residency: University of Minnesota Medical School, Minneapolis, Pediatrics.
Fellowship: Children’s Hospitals and Clinics of Minnesota, St. Paul, Child Abuse Pediatrics.
Board certifications: Pediatrics and Child Abuse Pediatrics.
dermatology
Dawn Siegel, MD, is a pediatric dermatologist at Children’s Hospital of Wisconsin, an assistant professor
of Pediatric Dermatology at The Medical College of Wisconsin and a member of Children’s Specialty Group.
Medical degree: University of Wisconsin-Madison School of Medicine and Public Health.
Residencies: Children’s Hospital and Research Center-Oakland, Calif., Pediatrics; University of CaliforniaSan Francisco, Dermatology.
Research fellowship: University of California-San Francisco, Dermatology.
Fellowship: University of California-San Francisco, Pediatric Dermatology.
Board certifications: Dermatology and Pediatric Dermatology.
18
Physician referral and consultation (800) 266-0366
emergency medicine
Susan Boebel, PA-C, is a pediatric physician assistant at Children’s Hospital of Wisconsin and The
Medical College of Wisconsin and a member of Children’s Specialty Group.
Bachelor of Science: University of Wisconsin-Madison, Physician Assistant Studies.
Board certification: Physician Assistant.
Catherine Ferguson, MD, is a pediatric emergency medicine specialist at Children’s Hospital of
Wisconsin, an assistant professor of Pediatrics (Emergency Medicine) at The Medical College of Wisconsin
and a member of Children’s Specialty Group.
Medical degree: The Medical College of Wisconsin.
Residency: University of Colorado School of Medicine, Aurora, Pediatrics.
Fellowship: University of Colorado School of Medicine, Pediatric Emergency Medicine.
Board certification: Pediatrics.
Jodi Spahr, MSN, RN, CPN, is a pediatric emergency medicine nurse practitioner at Children’s Hospital
of Wisconsin and The Medical College of Wisconsin and a member of Children’s Specialty Group.
Bachelor of Science: University of Illinois, Nursing.
Master of Science: University of Illinois, Nursing.
Board certification: Pediatric nurse practitioner-Primary Care.
Margaret Thew, APNP, is a pediatric emergency medicine nurse practitioner at Children’s Hospital of
Wisconsin and The Medical College of Wisconsin and a member of Children’s Specialty Group.
Bachelor of Science: University of Wisconsin-Milwaukee, Nursing.
Master of Science: University of Wisconsin-Milwaukee, Nursing.
Board certification: Family nurse practitioner.
gastroenterology
Bernadette Vitola, MD, MPH, is a pediatric gastroenterologist at Children’s Hospital of Wisconsin, an
assistant professor of Pediatrics (Gastroenterology) at The Medical College of Wisconsin and a member of
Children’s Specialty Group.
Medical degree: University of Illinois College of Medicine, Chicago.
Residency: Cincinnati Children’s Hospital Medical Center, Pediatrics.
Fellowship: Washington University School of Medicine, St. Louis, Pediatric Gastroenterology; Cincinnati
Children’s Hospital Medical Center, Pediatric Transplant Hepatology.
Board certification: Pediatrics.
Sara Williams, PhD, is a pediatric gastroenterology psychologist at Children’s Hospital of Wisconsin, an
assistant professor of Pediatrics (Gastroenterology) at The Medical College of Wisconsin and a member of
Children’s Specialty Group.
Doctorate: Vanderbilt University, Nashville, Tenn., Psychology.
Fellowship: Children’s Hospital Boston, Pain Management.
general pediatrics
William Frese, MD, is a pediatrician at Children’s Hospital of Wisconsin, an assistant professor of
Pediatrics at The Medical College of Wisconsin and a member of Children’s Specialty Group.
Medical degree: University of Illinois College of Medicine, Chicago.
Residency: University of Michigan Hospitals and Health Centers, Ann Arbor, Pediatrics.
Board certification: Pediatrics.
genetics
Donald Basel, MD, is a pediatric genetics specialist at Children’s Hospital of Wisconsin, an assistant
professor of Pediatrics (Genetics) at The Medical College of Wisconsin and a member of Children’s
Specialty Group.
Medical degree: University of the Witwatersrand School of Medicine, Johannesburg, South Africa.
Residency: Oregon Health Sciences University, Portland, Medical Genetics and Pediatrics.
Research fellowship: University of Connecticut, Storrs, Genetics.
chw.org
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hematology/oncology
Cheryl Armus, MSN, FNP-BC, is a pediatric hematology/oncology nurse practitioner at Children’s
Hospital of Wisconsin and The Medical College of Wisconsin and a member of Children’s Specialty Group.
Bachelor of Science: University of Wisconsin-Madison, Nursing.
Master of Science: University of Wisconsin-Milwaukee, Nursing.
Board certification: Family nurse practitioner.
Matthew Myrvik, PhD, is a pediatric hematology/oncology psychologist at Children’s Hospital of
Wisconsin, an assistant professor of Pediatrics (Hematology/Oncology) at The Medical College of
Wisconsin and a member of Children’s Specialty Group.
Doctorate: University of North Dakota, Grand Forks, Clinical Psychology.
Fellowship: University of Michigan Hospitals and Health Centers, Ann Arbor, Pediatric Psychology.
hospital medicine
Anjali Sharma, MD, is a pediatric hospitalist at Children’s Hospital of Wisconsin, an assistant professor
of Pediatrics (Hospital Medicine) at The Medical College of Wisconsin and a member of Children’s
Specialty Group.
Medical degree: The Medical College of Wisconsin.
Residency: The Medical College of Wisconsin, Pediatrics.
neonatology
Rama Bhat, MD, is a neonatologist at Children’s Hospital of Wisconsin, a professor of Pediatrics
(Neonatology) at The Medical College of Wisconsin and a member of Children’s Specialty Group.
Medical degree: Mysore Medical College, Karnataka, India.
Residency: Johns Hopkins Bayview Medical Center, Baltimore, Pediatrics.
Fellowships: University of Illinois Medical Center, Chicago, Pediatrics and Neonatal-Perinatal Medicine.
Board certifications: Pediatrics and Neonatal-Perinatal Medicine.
Erwin Cabacungan, MD, is a neonatologist at Children’s Hospital of Wisconsin, an assistant professor of
Pediatrics (Neonatology) at The Medical College of Wisconsin and a member of Children’s Specialty Group.
Medical degree: University of the Philippines Diliman, Manila.
Residency: The Medical College of Wisconsin, Pediatrics.
Fellowship: University of Maryland-Baltimore, Neonatal-Perinatal Medicine.
Board certifications: Pediatrics and Neonatal-Perinatal Medicine.
Prerna Sinha, MD, is a neonatologist at Children’s Hospital of Wisconsin, an assistant professor of
Pediatrics (Neonatology) at The Medical College of Wisconsin and a member of Children’s Specialty Group.
Medical degree: G.S.V.M. Medical College, Kanpur, India.
Residency: Monmouth Medical Center, Long Branch, N.J., Pediatrics.
Fellowship: University of Pittsburgh Medical Center, Neonatal-Perinatal Medicine.
special needs
Jill Grevenow, MS, APNP, is a pediatric special needs nurse practitioner at Children’s Hospital of
Wisconsin and The Medical College of Wisconsin and a member of Children’s Specialty Group.
Bachelor of Science: University of Wisconsin-Milwaukee, Nursing.
Master of Science: University of Wisconsin-Madison, Nursing.
Board certification: Pediatric nurse practitioner-Primary Care.
Sara Petre, MSN, APNP, is a pediatric special needs nurse practitioner at Children’s Hospital of
Wisconsin and The Medical College of Wisconsin and a member of Children’s Specialty Group.
Bachelor of Science: Marquette University, Milwaukee, Nursing.
Master of Science: University of Nevada, Las Vegas, Nursing.
Board certification: Pediatric nurse practitioner-Primary Care.
Ann Scott, MS, RN, is a pediatric special needs nurse practitioner at Children’s Hospital of Wisconsin and
The Medical College of Wisconsin and a member of Children’s Specialty Group.
Bachelor of Science: University of Wisconsin-Milwaukee, Nursing.
Master of Science: University of Wisconsin-Madison, Nursing.
Board certification: Pediatric nurse practitioner-Primary Care.
20
Physician referral and consultation (800) 266-0366
One of the BEST
National hospital rankings
According to a data driven survey by Parents magazine, Children’s Hospital
of Wisconsin is the No. 3 children’s hospital in the nation. In 2010, Children’s
Hospital of Wisconsin was again included on the U.S.News & World Report
America’s Best Children’s Hospitals list.
Nursing excellence
For the second time, Children’s Hospital of Wisconsin has been awarded the
prestigious Magnet Recognition Award from the American Nurses Credentialing
Center. Magnet designation is given to health care organizations that are able to
demonstrate excellence in nursing.
ECMO Program designated a Center of Excellence
The Extracorporeal Life Support Organization has named the Extracorporeal Membrane Oxygenation
Program at Children’s Hospital of Wisconsin a Designated Center of Excellence. Children’s Hospital
first received this award for Excellence in Life Support in 2006. The hospital now is designated
through September 2012.
Best Doctors in America
More than 40 percent of Children’s Specialty Group physicians are
listed in the 2010-2011 Best Doctors in America® database. This
group practice is jointly owned by Children’s Hospital and Health System and The Medical
College of Wisconsin. The 40,000 U.S. physicians listed in the Best Doctors in
America® database represent only about 3 to 5 percent of the nation’s practicing
physicians. The listing is a singular honor. Best Doctors in America® is a
registered trademark of Best Doctors, Inc., in the U.S. and other countries.
The information presented in this publication is intended for educational purposes only, providing suggestions
for helpful interventions in primary care settings. Each patient is different and these suggestions may not apply.
This is not a substitute for professional medical or mental health advice or services, particularly in acutely ill
individuals who warrant immediate evaluation in an emergency setting. Consult appropriate specialty providers
with specific questions regarding your patients.
Pediatric Rounds is published by Children’s Hospital of Wisconsin and The Medical College of Wisconsin.
Comments should be directed to: Children’s Hospital of Wisconsin, PO Box 1997, Milwaukee, WI 53201
or e-mail [email protected].
PO Box 1997
Milwaukee, WI 53201-1997
(414) 266-2000
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