Joseph Segeleon, MD - Sanford Health News

Doctors, nurses sound the alarm as vaccination rates drop

Alan Helgeson (announcer):

This is the “Health and Wellness” podcast brought to you by Sanford Health. The conversation today is about childhood immunizations and vaccines. Our host is Dr. Joseph Segeleon, vice president medical officer, Sanford Children’s Hospital.

Dr. Jospeh Segeleon (host):

Good afternoon. This is Joe Segeleon, and welcome to a Sanford podcast on childhood immunizations or vaccines. I’m very excited today to talk about this subject that I know has caused some controversy and has been in the news quite a bit in the last couple of years. Vaccines have generated a lot of attention in the past few years, so let’s tackle this important issue so we can shed guidance and clarification and really give our recommendations on science-based guidance. So today, I’m excited I’ve got two great, great experts that are going to add quite a bit to this conversation, and I’ll have them introduce themselves first. So, Andrea, why don’t you go first?

Andrea Polkinghorn:

Yeah, thanks for having me. My name is Andrea Polkinghorn. My background is I’m a nurse and I’m currently the lead immunization strategist for Sanford Health.

Dr. Jospeh Segeleon:

Great. And welcome. It’s good to have you here. And then we also have Dr. Dani Thurtle as well. Dr. Thurtle, why don’t you introduce yourself as well?

Dr. Dani Thurtle:

So, I am a pediatrician. I am boarded in general pediatric medicine as well as pediatric hospital medicine. I also have a special interest in vaccines and immunization, and I co-chair the (Sanford Health) Enterprise Immunization Committee with Andrea.

Dr. Jospeh Segeleon:

So as our audience can tell, we have two experts that have significant experience in childhood vaccines. And so we’ll go ahead and dive in.

I think what we’ll start with is, I know the entire subject of vaccines as a whole is fairly daunting. But for our listeners, maybe if either one of you would like to offer a brief history of vaccines, why are they important both in the United States and in the world for everyone? What is their place in preventive health medicine, and perhaps what have been some of the success stories, or what have we learned and what have we gained from having childhood vaccines?

Dr. Dani Thurtle:

So I guess I can kick it off. Vaccines have been around for a really long time. Actually, the first that we think of is a smallpox vaccine, which was developed in the late 1700s. Our vaccine science has come a really long way. Modern vaccines really started around the 1950s with the polio vaccine. And since then, our technology and our knowledge of viruses and bacteria has really taken off in a way that’s allowed us to create safe and effective vaccines against a wide range of diseases that we see every day.

I think the most impressive worldwide impact is when we can eradicate a disease. So like we did with smallpox in 1980, the CDC and the World Health Organization declared smallpox eradicated, which means you can’t really catch it anymore. It only exists in labs and we’re able to prevent death and hospitalizations in all kinds of settings from that.

Andrea Polkinghorn:

Yeah, so I think Dr. Thurtle outlined it really well. I think the other thing that I’d like to highlight or help people understand is, you know, when we’re vaccinating, we’re not always working to prevent a hundred percent of disease. And there are some side effects, very mild, that are associated or you can get from vaccines. But we see the same thing, and that’s why we developed the vaccine.

So if you think about the complications that came from polio, so people having to be in iron lungs or not being able to walk any longer. I know an adult polio survivor who lives in Brookings and he’s wheelchair bound. Thankfully those are his only complications and that he didn’t have a more severe reaction from that disease. And so everything is a risk versus benefits, but they’re safe and effective, and that’s why we have more vaccines now today than we have in the past.

Dr. Jospeh Segeleon:

Well, thank you. I appreciate that. So I saw Dr. Thurtle brought up smallpox and we certainly, I haven’t seen a case of smallpox in my career and we attribute that success to vaccines. And of course, a vaccine does not work unless it goes into an arm (laugh).

So let’s talk a little bit about other success stories in measles, diphtheria, pertussis. Other things come to mind. So maybe Andrea, maybe you’d be best to talk about that from the standpoint of, are vaccines effective in eradicating organisms from people or from the population in general?

Andrea Polkinghorn:

Yeah, so really it goes down to public health and we need so many people to get vaccinated so that we can prevent the spread of that disease or having like a large outbreak. We have seen great success. So if you go back and look at the data of the incidence of pertussis before the vaccine came out, it was very high. And it’s much, much lower today when you look at the data. So while we still see some cases, we’re not seeing the outbreaks because a sufficient number of people have been vaccinated to help prevent that from happening. And so when you look at the historical data compared to where we are today, the incidence that these diseases are happening is much less.

The flip side to that is that what they say is vaccines are a victim of their own success. And so people aren’t seeing the diseases as frequently, which leads them potentially to have a feeling that they’re not needed anymore. And that’s just simply not true. These diseases, you know, they occur more frequently or at a higher rate in other parts of the world. And so with international travel, if we loosen up on our immunization right here and people are traveling, if they’re not vaccinated, not only are they susceptible to those diseases, but potentially bring them back and cause an outbreak here.

Dr. Jospeh Segeleon:

Great, thank you. And I think we’ll expand upon that point maybe in a couple minutes here because we acknowledge that vaccine rate is in fact declining and we have concerns about decline of that uptake. So we’ll tackle that in just a couple of minutes.

What I’d like to do now for our listeners is I’ll go to Dr. Thurtle. Dr. Thurtle is a pediatrician. So Dr. Thurtle, if you will, for the individuals who may be on the listening end, let’s pretend that you are talking to new parents as they get ready to start their journey in parenthood, recognizing there’s no manual that I know of yet. And so they’re going to their pediatrician. And how would you discuss what does childhood immunizations look like and also influence their decision on how important the immunizations are for the health of their child?

Dr. Dani Thurtle:

Thank you for this opportunity. It’s definitely a really big topic. Anytime you’re letting someone affect the health of your child, it’s a really big decision. So I love that parents are curious about this. Childhood vaccination really starts at birth. We now have two different viruses that we can immunize against in the hospital, including RSV, which you may get in the hospital or shortly afterwards, or the hepatitis B vaccine, which we know is most effective the closer it’s given to birth.

So we try to give within the first few hours of life, childhood vaccinations go through the entirety of childhood up to 17 and 18 years old. And there’s over 17 different viruses or bacteria, depending on how you count, that are recommended for all children to be vaccinated against. The real bulk of those immunizations start at the 2-month visit. And then at the 2-, 4- and 6-month visit, we’ll see quite a few different vaccines. Those are mostly bacteria that cause brain and lung infections and even polio and tetanus and whooping cough are in that batch.

Then kind of scattered throughout the 15-, 18-month and 1-year visit, there’s a few more. And then at 4 years old we do the kindergarten shots. That’s the point at which most people think your traditional childhood vaccines are kind of wrapping up. Then we get into the group of older kid vaccines, which include more whooping cough and things that older children are more susceptible to, such as brain infections, like meningococcal disease.

So I think the important points here are that vaccines are really targeted to the population that is most at risk. So we know young babies are more at risk for some things, and that’s when we vaccinate. And older kids are specifically at risk for different things, so that’s when we vaccinate for those. It’s really targeted at the time and then you have to get quite a few doses of many of those to get a response. So that’s why there’s numerous booster doses.

Dr. Jospeh Segeleon:

Great. And so for those young children that are so vulnerable, what would be the risk if they did not get vaccinated?

Dr. Dani Thurtle:

So the risk really does go up and include death. And I don’t mean to be really morbid and the bearer of such bad news, but we really vaccinate against very serious diseases. Things like pneumococcus you might have heard of, or haemophilus influenza type B. Those are well known to cause very serious blood, brain and lung infections that can kill children in a short period of time.

We’ve seen a significant decrease in death in this age group because of those. Some of them like rotavirus you might know and have more experience with. Children do get diagnosed with rotavirus or vaccinated against rotavirus in the 2-, 4- and 6-month vaccines. That’s been more useful in preventing hospitalizations and like very severe dehydration. So it really runs the gamut of mild to severe. But I don’t want people to discount the importance of these vaccinations. They’re very important and very devastating illnesses.

Andrea Polkinghorn:

Dr. Thurtle, me, myself, I had chickenpox and I think that’s a really good example of a lot of people or a lot of adults today had chickenpox and probably thought, oh, I was uncomfortable for a period of time, but I did just fine. And so can you talk about some of the complications that we saw there, which is why we actually recommend vaccination now, even if somebody was lucky enough just to have that itchy rash when they had the disease in the past?

Dr. Dani Thurtle:

Yeah, so many common childhood illnesses actually have a small percentage of very severe complications. Chickenpox is going to be one of those where you can actually have a devastating brain infection that can cause scarring and seizure disorders later in life. Additionally, if you have a very severe chickenpox infection, it can put you at risk for bacterial infections.

The same thing with measles. Measles has a long-term complication that can cause devastating brain effects and neurological outcomes later in life. So things that people think are really simple illnesses, a small percentage of those do have devastating and severe complications that we can’t prevent, we can’t predict and we can’t reverse. So the safest and best way to prevent those is through vaccination.

Dr. Jospeh Segeleon:

I want to thank both of you for those great comments. As a physician and as a pediatric critical care physician, I was in my training and in my early practice years prior to some of those bacterial vaccines that Dr. Thurtle spoke about had come out. And so I did want to make sure that we pointed out that we don’t want to take it for granted that we don’t see as much of those illnesses because we don’t see it because, in fact, children are vaccinated against those. And so with our rates declining, I wanted to make sure we pointed that out.

I also wanted to comment on something that Andrea said earlier. We now have an RSV vaccine. RSV is the number one cause of hospitalization in children. We have a flu vaccine, which we’ve had for many, many years, and though you may still get the infection, if you are vaccinated, the likelihood that you will get very sick or hospitalized or die is significantly reduced if you’re vaccinated. So I thank you both for pointing out those extremely important points.

Andrea Polkinghorn:

Dr. Segeleon, I like that you touched on flu because I was going to lift that up relative to Dr. Thurtle’s comments. Every year there are on average probably about 150 to 200 children who die from influenza every year. A majority of those are unvaccinated. I think people also tend to think, oh, they’re probably kids with chronic conditions, but the data does not show that. These are completely healthy children who are dying from this disease. And so people who, you know, say that, well, the flu vaccine doesn’t work that well, I don’t want it, kind of what I’ve told them is like, it’s the best defense that we have. And yes, even if it’s only 30 to 60% effective in preventing you from getting sick, that’s still better than zero and it will prevent you from those severe complications like hospitalization and death.

Dr. Jospeh Segeleon:

Yeah, I appreciate that. As an intensive care doc, we’ve all taken care of children who have had severe flu, just like also you reminded me in asking about chickenpox. Prior to the chickenpox vaccine, the secondary pneumonia that kids can get is also extremely virulent. So thank you.

We said at the beginning of the conversation that vaccines have really been in the media quite a bit, and there’s been some, perhaps some unnecessary controversy surrounding vaccines. The unfortunate result of that is that the rates have been declining. So I would like to ask both of our guests perhaps what their opinions might be on why are these rates declining? And then for either of you, what are the consequences of vaccines declining for both an individual and also for the general population?

Dr. Dani Thurtle:

Yeah, I think that what we’ve seen is, especially through the pandemic, we saw a lot of this. That fear is an incredibly powerful motivator for people and how they act and how they protect themselves. Since vaccines are, as you’ve already heard Andrea say, a victim of their own success, fear is no longer on the side of these illnesses to motivate for vaccination. They do cause severe complications and death, and they are things that I think parents should be afraid of. Instead, fear’s on the side of what we see more often, everyday things in our social media feeds, right?

So there are complications to vaccines, just like with any medical treatment that we do. There’s always a risk-benefit analysis. As a pediatrician, for the majority of patients, the risk-benefit analysis is going to come out on the side of the vaccine. But people are going to see more about complications, particularly when you’re surfing social media. So people see more about different conspiracy theories and other considerations. There have been waves of these kinds of things such as in autism and other things going through the news.

These are always debunked with really, really good evidence and studies that again and again have affirmed that vaccines are safe, they’re constantly monitored, they’re constantly reviewed, they are constantly scrutinized. The CDC does a great job with this. So I fully endorse the safety of vaccines. But I think that there is serious fear out there and we know people respond to fear as a motivator.

Dr. Jospeh Segeleon:

I hear the passion in your voice. Andrea, go ahead please.

Andrea Polkinghorn:

So I think it’s important for people to know that vaccine hesitancy isn’t new. There’s a infographic or it was really a cartoon back from when the smallpox vaccine was coming out that essentially tried to tell people that if you accepted the vaccine it would turn you into a cow. I think what has changed since that’s not new is the ability to quickly, effectively, and broadly disseminate misinformation.

So you talk about things like Facebook, that’s absolutely true. But even some of these news articles, like if you saw something, there’s usually buttons below it that you could share it quickly with like 15 other websites. And so that’s something unfortunately that we have to work to overcome. I think the questions are OK. I totally agree with Dr. Thurtle. You know, when you see that information, it can be really alarming. So I think the important thing is that people are following up with their provider to have discussions about what they saw and to get their questions and concerns really addressed or seek credible websites. Some of the opposition groups actually have robust websites that really look credible, but they’re not.

Dr. Jospeh Segeleon:

Great. OK. Well thank you. I heard Dr. Thurtle use the word “fear” a number of times. And I think of fear, and then when it comes to information or misinformation, I naturally go to the word trust. So if I want to get a trusted information source – and Andrea, you appropriately pointed out the myriad of social media that is available to all of us when it comes to childhood vaccines – what should be my trusted source? Where is that information out there that we can advise and guide our listeners so that they can get credible science-backed information that they can trust?

Dr. Dani Thurtle:

I always say that the best source of information is going to be your child’s doctor. And the big reason for this is because they know you and they can respond to specific concerns in the context of your family and your child’s health. So for example, when I was seeing family in clinics, if I had a family who had a history of seizure disorders, then I could focus on the adverse reactions that I thought were most likely for that family. And then we can talk to those very specific concerns that pertain to you in a really methodical and thorough way to answer specific questions. But that’s why the pediatrician is going to be the best source of information.

Outside of that, the CDC has a wealth of websites and information that are really great to look at. They’re really easy to read, full of excellent information and infographics. You hardly have to read anything. It’s all in pictures, but it does address a lot of the concerns and controversies in a really evidence-based way that’s easy to digest. So I also enjoy the CDC. The American Academy of Pediatrics has good information as well, targeted towards families. But where else do you point families to Andrea?

Andrea Polkinghorn:

Probably not as well known, but Vaccinate Your Family has a pretty good website as well. I think the readability of the CDC is probably a little bit better there. That’s honestly my go-to, especially if you don’t have a clinical background. It’s put in into very good layman’s terms for people without that background.

Dr. Jospeh Segeleon:

Well, I appreciate that. I heard primary care physician, I heard some great sites on the CDC and other sites. We discussed some of the misinformation and the fear, and the importance of trust.

Before we go to access to vaccines, I think I did want to just for a moment talk about, as we’ve seen some decline in vaccines, well, every year in the United States we hear about measles outbreak. We look globally, we have seen some resurgence of diseases that we really haven’t seen in quite a while. So I guess I would like one of you to talk about with this misinformation which has resulted in a decreased (immunization) rate. Maybe we can use measles to talk about what’s the danger to both to our population. We hear about schools that have measles outbreaks, et cetera. Andrea, are you willing to tackle this one?

Andrea Polkinghorn:

I absolutely can. So I would say there is a lot of concern for those of us who work in health care or public health about potential measles outbreak due to the decline in childhood immunization rates.

Measles is a very contagious disease and we need about 95% of people to be immunized to prevent the broad spread of that disease. So even if you look at the data and see that we’ve dropped two, that’s like 2%, that’s still a lot because we can’t keep ourselves protected.

We kind of talked about the other parts of the world too, and measles occurs more often there. And so the concern that we have is that if we lessen, if we loosen up and drop our immunization rates, that our communities are going to be vulnerable to a measles outbreak, which we absolutely do not want.

Dr. Thurtle, I don’t know if you want to talk about some of the complications of measles?

Dr. Dani Thurtle:

Yeah. So I already kind of mentioned it earlier, but you can definitely get secondary bacterial infections, pneumonias, things like that. But the one that we really worry about is something called subacute sclerosing panencephalitis, which I like to say out loud because it sounds really scary, but it’s essentially a brain deterioration that happens years and years after your original measles infection.

So even if you think you get through the original infection and bounce back OK, there’s always that lifelong risk that you could have a reactivation and deterioration in your brain function later. It’s not uncommon to see rebounds of these. I think there were over 6,000 cases of mumps last year, and that’s over 50 cases of measles in the United States last year. These are things where we used to have zero cases every year. So they are around, you’re exposed to them and like Andrea said, we have to have a large percentage population to be vaccinated in order for everyone to be protected.

Dr. Jospeh Segeleon:

Well, thank you. I appreciate those comments. I think what I would add as well is with respect to whooping cough or pertussis, when you are a young child, until you complete your first three series of pertussis (immunizations), you remain vulnerable. And often when a young infant gets pertussis, it is life-threatening. Pertussis is the same as whooping cough, and they frequently may get it from a grandparent or a parent or an older sibling if they haven’t been immunized.

So we do continue to see pertussis. It is a very, very serious illness in our young children. And so that’s another circumstance where immunizing a general population protects our most vulnerable children. So really in recapping our conversation we had a great conversation about the history of vaccines. The phenomenal success of vaccines have been for our children both globally in the United States.

I appreciate Dr. Thurtle’s walking through that new parent to understand what lays ahead of them for childhood vaccines and the importance of them. We also unfortunately had to discuss why rates may be declining, predominantly because of fear and misinformation.

And the way for us best to combat that is to provide trusted information, to provide trusted resources and of course to have that valuable relationship between primary care provider and patient and family.

So now I’d like to talk a little bit about the logistics. How do we get access to vaccines? Are these given only in annual physical visits or just clinic visits? And perhaps we talk a little bit at the end about the Vaccines for Children program as well.

Andrea Polkinghorn:

Yeah, I can start us off here. So I think the rural nature of our footprint here in the Midwest does cause some access barriers in certain geographic areas. At Sanford, anybody can walk in a primary care clinic for a vaccine to get updated. I think what Dr. Thurtle kind of talked about earlier though is as children age, you know, they can talk to us and tell us if they aren’t feeling well. We do see those annual wellness exams start to decline at about 15, 18 months. And in particular she talked about kind of those sixth graders around 11 to 12 years. So we’ve been doing a lot of work to incorporate vaccines into things like sports physicals, or even better yet, educating the public that if they’re overdue for annual wellness exam to schedule it that way and the sports physical can be completed as part of that visit.

Along with updating immunizations, I know that our pediatricians really value the annual wellness exams because they’re looking for appropriate growth and development things that might not be caught as easily. I know my daughter’s pediatrician actually caught a small curve in her spine that had we not had that annual wellness exam, I wouldn’t have known at all. So they’re super important.

Dr. Dani Thurtle:

So we always do them at well child visits, we’ll always look at what you’ve had and what you need and what you’re due for. So that’s the best place to do them.

There’s other places to get them though, especially if you live far away from your primary pediatrician, as we know many people do. There are community health clinics or county health clinics. Sometimes the state has some health clinics out there. So there’s usually a very close place to you to get these vaccines.

Dr. Jospeh Segeleon:

Well, Andrea, I wonder if you could talk to us a little bit about the VFC program or Vaccines for Children.

Andrea Polkinghorn:

Yes. So the Vaccines for Children program, there was concerns, I think it was in the 1990s sometime about the risk for children without insurance to potentially, essentially the parents would not vaccinate them because they don’t have insurance. And therefore, again, our communities would be vulnerable to outbreaks of these diseases. And so the government funded a program called the Vaccines for Children program. So essentially the government is providing vaccines for children. This is through 18 years to any VFC-enrolled provider, for example. I think this is done very widespread.

All of our Sanford primary care clinics participate in this program, but it would provide any routinely recommended vaccine for a child at no cost to them. They can charge an administration fee, but if the person is not able to pay the administration fee, it must be waived. So you can always visit the Department of Health website no matter what state you’re in to identify if your local clinic participates in it. But again, it’s really well known, and I would say most health care providers or clinics who are caring for children participate in this program.

Dr. Jospeh Segeleon:

Thank you. I appreciate that. And the bottom line is that finances are not an impediment to vaccinating your child.

Andrea Polkinghorn:

Exactly.

Dr. Jospeh Segeleon:

Great. Well, I think we’ll go ahead and wrap up here. I want to thank my two guests, Dr. Dani Thurtle and Andrea Polkinghorn, for their expertise and their conversation on this very important issue. We continue to try to be a valuable resource and insight for our consumers to give them the most trusted information and to try to, with the goal of the best health care outcomes for our children.

Alan Helgeson (announcer):

Sanford Health has information about immunizations for all ages at sanfordhealth.org. This podcast is part of the “Health and Wellness” series by Sanford Health. For additional podcast series by Sanford Health, find us on Apple, Spotify, and news.sanfordhealth.org.

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Blood and bone marrow transplant care at Sanford

Courtney Collen (Host):

Hello, welcome to our medical series Called to Care by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. Called to Care brings forward medical experts who can give fellow clinicians some advice and guidance that they can use in their primary care practice. And information about when it is time to refer patients and families to more specialized care. Joining me for these conversations is Dr. Joseph Segeleon, who is vice president and medical officer for Sanford Children’s Hospital and a leader in pediatric critical care. But he’s here as my co-host, if you will, to help us dive even deeper into a lot of these topics and provide the best insight in care for our patients and communities. Dr. Segeleon, good to have you back here.

Listen: Called to Care by Sanford Health

Dr. Joseph Segeleon:

Courtney, it’s wonderful to be here. It’s good to see you again.

Courtney Collen (Host):

In the fall of 2021 at the Sanford Roger Maris Cancer Center in Fargo, a team of specialists completed the first autologous bone marrow transplant where a patient’s own stem cells are collected and stored. It was a major milestone making Sanford Health one step closer to becoming a national destination for cancer treatment. Joining us to tell us more about the bone marrow transplant program is Dr. Seth Maliske. He’s a Sanford physician who specializes in hematology oncology and has unique training in blood and bone marrow transplants. Dr. Maliske, thank you for being here.

Dr. Joseph Segeleon:

Yes. Welcome Dr. Maliske.

Dr. Seth Maliske:

Thank you for having me.

Dr. Joseph Segeleon:

Just as I think about Sanford as a rural health center and the journey that we’re on, you really think about how fortunate we are to have an institution like the Roger Maris Cancer Center. And so I’m excited to learn more about the program that they’re doing in Fargo, as well as the opportunities and the resources that this brings to our patients and our communities and our providers. I think for us to start maybe we should level set with some of the terms that we’ve we use to describe this field. So maybe you could clear, clear up bone marrow transplant versus stem cell transplant, autologous versus allogenic and those type of things.

Dr. Seth Maliske:

Sure. The term bone marrow transplant versus stem cell transplant. They, they get used interchangeably. Really, when we talk about stem cell transplant, we have stem cells throughout our, throughout our body. But with this therapy, it’s specifically stem cells for the bone marrow. We call them hematopoetic stem cells. They’re the stem cells that are at least partially differentiated so that they can evolve into our blood cells. And so it’s not stem cells that help with maybe orthopedic issues or other health endeavors. It’s, they’re strictly stem cells that give rise to our blood cells. And so that’s why you can use them interchangeably. But what we mean are that the stem cells are, are meant to help grow the, the cells that give rise from the bone marrow, the word bone marrow transplant is maybe falling out of favor because most of the time the stem cells are collected off of the blood. And so when you were introducing me, you, we called it blood and bone marrow transplant. So that’s why we use those words is because actually with newer medicines, we can collect the stem cells off of the bloodstream instead of having to access them from the bone marrow environment. As far as the other terms, you mentioned, autologous and allogeneic, those terms define who the donor is. So autologous means you’re your own donor. So it’s a self donor: we’re collecting stem cells from the patient, him or herself prior to giving chemotherapy, whereas allogeneic transplant, we use allo donors, which means it’s somebody else. It’s not the patient stem cells, but a relative or an unrelated person. And those stem cells then are used to treat a cancer as well.

Dr. Joseph Segeleon:

Thank you. That helps clarify those terms, which I think are often confusing. And I suspect since stem cells are obtained peripherally, that is a lot more appealing for donors, such that they do not have to undergo a bone marrow procedure.

Dr. Seth Maliske:

It’s not only appealing. But it also is more effective. We can collect more stem cells from the bloodstream than we can from the bone marrow itself so we can get higher numbers or higher quantities of stem cells, which are beneficial when we use them for transplant.

Dr. Joseph Segeleon:

As we talk about the center up in Fargo, what conditions and what do patients generally have as far as their disease process that you mostly see and that you utilize these procedures for?

Dr. Seth Maliske:

The use of autologous stem cell transplant or autologous bone marrow transplant is commonly used in multiple myeloma. We use it very often in multiple myeloma, either early on in one’s therapy or sometimes we reserve it for later. But it commonly becomes part of the treatment of myeloma patients. Autologous transplant is also used in relapsed lymphoma. So we don’t do it unless the cancer is relapsed, meaning not cured up front. Those lymphomas include B-cell lymphomas as well as T-cell lymphomas. When we talk about allogeneic stem cell transplant, when we have to use a donor, those, those cancers that we use allergenic transplant for include leukemia. So more traditional aggressive leukemias, like acute myeloid leukemia, acute lymphoblastic leukemia. We also treat aplastic anemia as the most common groups of cancers that we treat with allogeneic stem cell transplant.

Dr. Joseph Segeleon:

So if you will for the providers who are listening and to give them a good idea of what their patients will experience, walk us through a typical myeloma patient with a stem cell transplant.

Dr. Seth Maliske:

Myeloma patients are initially treated with multi-drug chemotherapy regimens or anti myeloma therapy regimens. They receive that medicine for approximately three or four months. And then once the cancer is, is debulked more or less, we then can take them to transplant. The transplant process begins by interrupting that therapy so that their bone marrow is healthy enough to collect stem cells. We then mobilize the stem cells from the bone marrow into the blood. And we do that with the assistance of growth factor medicine. It’s a collection of shots that precede the collection by four days. And then the collection is usually a one to three day event where we’re essentially using a dialysis machine. It’s not exactly like a dialysis machine, but the idea’s the same. We basically create a circuit where blood comes out of the patient’s body through the machine.

Dr. Seth Maliske:

The machine is calibrated to collect a layer of the blood where the stem cells sit and then everything else is returned back to the patient through the opposite side of the circuit. And so blood just circulates around this circuit for several hours, probably four to five hours altogether. And then at the end, we’re left with about a pop can full of stem cells. So it’s blood and plasma and stem cells. And then that bag is then sent to our lab where we use special freezing media so that the cells are unharmed as they freeze and then we store them until they’re needed for transplant. We often interrupt the collection or separate the collection of stem cells and the transplant by at least one week. This allows patients to just recover , helps their platelet count recover, helps them feel a little bit better as we then bring them into the hospital for chemotherapy.

Dr. Seth Maliske:

The chemotherapy is given in myeloma, at least, just over one day. In lymphoma, it’s given over six days. And then after the chemotherapy is given, after the chemotherapy is basically metabolized by the body so it can’t harm stem cells anymore, we then give the stem cells back. So that’s usually about 24 to 30 hour break between last dose of chemotherapy and the giving of stem cells. Everything after that’s just a long recovery for patients. So it’s about two weeks in the hospital until those stem cells start to work. The stem cells are just given by gravity through a catheter. So it’s really just like a blood transfusion. Not a whole lot different, any different than the way red cells or platelets are given by transfusion. But then those stem cells go through the bloodstream and are basically recruited back to the bone marrow environment where they engraft and grow and produce normal, healthy cells. And it takes about two weeks for those normal healthy cells to start being made and push back into the bloodstream where the patient’s safe to go home. And then again, they just slowly recover after that. They usually feel a little unwell for about a month. They start to feel more like themselves by the end of the second month. And then really, I feel, I think completely back to normal by the third month.

Dr. Joseph Segeleon:

So since a number of the patients travel to the Roger Maris center for their care, if I heard you correctly, the patient spends two weeks in the hospital, and then is there additional time that they stay within the proximity of Fargo?

Dr. Seth Maliske:

That is correct. Yes. We keep patients in hospital for that two-week period. Once they leave the hospital, once they’re safe to leave, we keep them in Fargo for another seven to 14 days, just to make sure that they don’t have any early setbacks. It’s just a way to, I think, ensure that they’re well cared for through that first month where they’re the most vulnerable.

Dr. Joseph Segeleon:

And I understand a caregiver comes, accompanies the patient then as well. Is that right?

Dr. Seth Maliske:

Yeah. We define a caregiver up front. Kind of the, the person’s yeah, their partner in this endeavor. They, you know, oftentimes it’s a husband or a wife or their spouse. But other times it’s children or a sibling, but that person is with them throughout the whole journey. And they’re a big part of the team.

Dr. Joseph Segeleon:

If I understood correctly, the cell preps are done at Sanford as well?

Dr. Seth Maliske:

So we have our own lab. We have our own machines, so everything is done at Sanford. So when I describe the mobilization and the collection, that’s all done, outpatient, it’s all done here at Sanford. And then the freezing and the thawing of cells are all done here as well.

Dr. Joseph Segeleon:

OK, great. Now, as far as in those two weeks and then as you said, the recovery period, what kind of complications do you look for? And then after discussing what kind of potential complications a patient may have, maybe we could segue into some survival statistics as well.

Dr. Seth Maliske:

So for the autologous stem cell transplant, the toxicity is primarily of chemotherapy. This is what we call ablative chemotherapy. It’s meant to ablate the bone marrow, wipe out the, the bone marrow. So it’s harming what we hope to be all the cancer cells, but will also injure the normal cells of the bone marrow. Therefore patients almost universally need some blood transfusion, whether it’s red cells or platelets. It also renders them very vulnerable to infection. And that’s the main reason they’re in the hospital for that two-week period. They’re at higher risk for infection because of how suppressed their immune system is, but also because the chemotherapy is quite toxic to the GI tract. So everywhere from the mouth to the bottom and the mouth can get sores, or really the bowel wall can kind of have breakdown and that can serve as a portal of infection for bacteria.

And that is why they’re so much more vulnerable than even the average chemotherapy patient. So taken together the bone marrow and the gut being quite affected by the chemotherapy., we watch those two organ systems, the best. Very seldomly do they need like artificial feeding, but we always tell them that their nutrition is gonna be affected because they feel unwell. There are a lot of times lying in bed for not a long time, a few days, but this just makes it so that they’re maybe a little unsteady on their feet before they leave. So we have to make sure they’re eating and drinking, walking strong on their feet before they go. In addition to making sure they’re well protected from infection. That’s the typical story I convey to patients with autologous transplant. Allogeneic transplant creates a whole new realm of risks.

And that’s because when donor cells are used, they’re used to create an anti-cancer effect. We call that graft versus tumor effect. And that’s what we want to see because it’s gonna help treat the cancer. But another part of the person is just the rest of their bodies. So we call that graft versus host disease, and that can affect really any part of the body from head to toe. So skin, bowel, liver, lungs, really anything become affected. And then on top of it to prevent that graft versus host from happening, we have to suppress a person’s immune system, even on top of what it’s already suppressed from the chemo, and that leaves people even more vulnerable to infection. So these competing risks of outcome, beyond cure, include risks of harm from graft versus host, much higher risk of infection, and then there’s other more, I guess, rare side effects that are life-threatening too, but allogeneic stem cell transplant is, is just a whole new, a whole new level of, of care. It really requires a, a huge team to support people through allogenetic stem cell transplant.

Dr. Joseph Segeleon:

And, what about for autologous transplant? What are the survival statistics at this time?

Dr. Seth Maliske:

As far as treatment related harm? And when I describe that to patients, I, what I mean by that is what are the chances me performing transplant actually shortens your life, not necessarily the cancer shortening one’s life. So that’s treatment related harm or treatment related mortality. With autologous transplant, that’s probably 1%. Maybe one in a hundred people may have a really bad infection or a bad bleeding episode or another event at the time of their transplant caused by chemotherapy that could potentially shorten their life. It may even be less than that, but it’s about 1%. As far as chances of curing the cancer, myeloma’s tricky because we don’t think of it as a curable disease. What we’re doing is putting it into a deeper remission so that the cancer stays away for longer. And usually by transplant, in an average patient with standard risk disease, we can keep the cancer away for a number of years, maybe four or five years.

Compared if we don’t do transplant, it’s probably half as long, maybe two and a half years. Something like that. When we look at lymphoma, another cancer that we commonly treat with autologous transplant, we’re probably increasing, we’re doubling the odds of cure as an average guess doubling the odds or increasing the odds to about 50 50. It may not sound as good as patients want to hear, but I think without transplant, we consider it relatively uncurable and we need to use transplant to, to if the cancer’s proven to be sensitive to chemotherapy, I should add in that case, we can cure about 50% of relapse, large B cell lymphoma. So again, a 50% chance of cure with a very, very low chance of cure, otherwise in taking a chance of 1% risk of harm, highly in favor of doing transplants and large B cell lymphoma. And then as far as allogeneic stem cell transplant, it’s very individualized based on the patient, the donor and the disease becomes very difficult, but we talk about treatment related mortality, more on the more on the spectrum of 10 to 20%, and then the chances of cure again, highly variable. So too general to, to comment, I guess, without a patient in front of me.

Dr. Joseph Segeleon:

Well, thank you. Thanks for that. That’s a lot of very useful information. Now for our primary care physicians and providers that are listening. After the patient, the stem cell transplant recipient goes back to their community, are there specific things that the primary care provider has to watch for, has to be aware of?

Dr. Seth Maliske:

I think early post-transplant, we always worry about infection. That’s kind of the first, second and third thing on our minds, to be honest. If we can prove there’s no infection, we, a lot of times it’s just residual chemo toxicity and patients just need time to recover. Otherwise, can the stem cells cause harm? You know, a month or two down the road, generally not. There are some longer term chemo toxicities that are possible. The chemo can sometimes affect the lungs weeks or months down the road. So there are unique events, but for the most part, we worry about infection. Beyond that, I guess we always have to be concerned about blood clots, post-hospitalization and side effects of any subsequent medicines that we’re using. But for the most part, much of the toxicity happens in the first two to four weeks while they’re here in Fargo.

Dr. Joseph Segeleon:

I understand some of these patients will need revaccinated with vaccinations they’ve had in the past. Does that occur at the provider’s office, the primary care providers, or do they come back to the transplant center for those?

Dr. Seth Maliske:

So at least in myeloma, patients do get therapy to maintain remission afterwards. So if they’re seen by a cancer provider say in Sioux falls or Bismarck, Bemidji, et cetera, we have them restart this, what we call maintenance therapy with their local cancer providers. And we have them start the vaccines there. We help guide the vaccines and make sure that they’re done on time. So there’s communication with our nurse navigating team, as well as their teams locally. But for the most part, these vaccines do happen at their local offices. Perhaps, maybe the very first vaccine we do here, not because of risk or harm, but just because I always see patients at that six month mark, just to see how they’re doing. And that’s oftentimes when we start the vaccines, but it doesn’t have to happen with us here in Fargo. Ultimately my goal is to get people through transplant, get ’em out past that first 90 day window, and then try and return as much of their care as possible back to their local oncologists, who they garnered so much trust with before.

Dr. Joseph Segeleon:

1. And so those, those patients do have some vulnerability to some illnesses that prior to the transplant, they perhaps did not. Is that correct?

Dr. Seth Maliske:

Yes, that’s correct. So when I was referencing much of the harm being in the first two to four weeks I’m not trying to describe the risk that their immune system is back to normal at the end of the first month. Really their immune system recovers over an extended period of time. So we have our innate immune system, which is neutrophils and something called natural killer cells. Those things recover first, and those are the things that prevent neutropenic infections, the infections that can really make people sick very fast. And those are the things that the most life threatening early post-transplant. So once those things are, once the neutrophils and natural killer cells are recovered, they’re much safer, but they’re not completely back to normal until closer to two years. And the reason why is because our lymphocytes, our B cells and T cells, they start to function more normally in that three month to maybe nine-month window. And so we delay vaccines until closer to six months. The vaccine schedule happens over a year and a half, actually, and so it’s not really until you’re fully revaccinated that your immune system really functions like it did prior to transplant. This ablative chemotherapy really wipes out our memory cells, as well as our normal innate immune system. And so we have to retrain it to protect against the against the infections that we can vaccinate against.

Dr. Joseph Segeleon:

Great, thank you for that. I know that the Roger Maris Cancer Center had been preparing for this program for quite some time. Tell the listeners the benefit of having a program like this in Fargo.

Dr. Seth Maliske:

So I kind of hopped on board after a lot of the heavy lifting was done. So I was amazed at what the team had accomplished in the years prior. So it’s – to build a transplant program, you have to have a huge team. You have to have a lab. You have to have an oncology program. You have to have an inpatient and outpatient program, and it takes a lot of work and a huge testament to the team at Sanford having built that. I started about a month or two prior to our first transplant. So I got to start really when all the heavy lifting was done. And so even in the last year, being here, it’s been remarkable to witness the stories that patients convey along the way. I knew of toxicity associated with transplant.

I knew of it a lot in the form of chemo toxicity and just how much time it takes to recover. But I don’t think I really appreciated just that, that toxicity of, of just proximity, that not just the time of recovery, but the time people spend going to and from doctor visits or the time people spend just traveling before transplant for the workup. That stuff, maybe I was aware, but become much more aware of as I’ve listened to patient stories over the last year. Patients are so pleased to be able to have their cancer care closer to home. It allows them to, I think, feel more comfortable, but not just comfortable being closer to home, but a lot of times their cancer doctors are other providers here in Fargo. I have a, a group of colleagues that are all malignant hematologists and they may treat the patient’s myeloma or the patient’s lymphoma.

Dr. Seth Maliske:

Maybe the nurses are more familiar. The nurses on the inpatient side become familiar. And then when we can do transplant in that same environment where people have already earned that, we’ve already earned their, their trust. That goes a long way as well. They’re not relocating, they’re not learning new doctors, they’re not learning new rooms. They, they just so feel, feel so much more comfortable just being at home. Now, of course, there are people that come from Bemidji and Grand Forks and Bismarck and surrounding communities. So not all of our cancer patients come from Fargo, but just having that familiarity is a huge aspect that patients appreciate as well. But yeah, I, I think, it’s truly remarkable. How, how appreciative patients have been of this program in just the first year of its existence.

Dr. Joseph Segeleon:

Yeah, I think very, very well put, I mean, the, you know, to have that trust in your environment to have the trust in physicians and nurses and hospitals that you already know, not to mention reducing the anxiety of the travel costs and all of the costs associated with travel and being away from home, it’s really an incredible benefit that we have within our community, a center like the Roger Maris center and the procedures and the cutting edge comprehensive care that you are providing, you and your colleagues. And I appreciate that it takes a team and there’s been a lot of foundational work that has brought you to the point that you are today. Why don’t we close up with two questions. Two questions I wanted to ask is maybe describe current state, what procedures you are currently doing, and then what does the future hold for your therapies and where you would like to see the program go?

Dr. Seth Maliske:

So we’ve spoken a lot about autologous, as well as allogeneic stem cell transplant. We’re well established with autologous transplant. We’ve completed a dozen or more transplants. I think the team’s doing a wonderful job and I look forward to continuing to do good care for autologous transplant. Allogeneic stem cell transplant will begin here in the fall. We’re not too far away, but it’s just a, it’s not just having the infrastructure, now it’s finding the right patient and treating the right disease. So I really expect that to – we’ll probably complete our first allogeneic stem cell transplant, sometime between October and December. I think we’re ready to go just about any time. We just have to find the right team in the right environment. And then as far as the future beyond allogeneic stem cell transplant, we haven’t discussed car T therapy a lot.

Car T stands for chimeric antigen receptor T cells. It’s just a genetically modified T-cell that is trained to fight cancer. We have a lab, we have all the foundation set up for that. We’re just kind of creating a a little bit more electronic medical record build and some education with nursing staff, but hope to bring that on board in early 2023. And then I think beyond just the technologies, I hope to bring a little bit more of a research infrastructure, more clinical trials. I would envision us being able to enroll kind of these advanced phase trials, you know, stage two, stage three, perhaps industry sponsored trials that really will support our patients with need for these cellular therapies such as stem cell transplant and car T therapy. So I think there’s a lot to look forward to, and I think the future is bright here in Fargo.

Dr. Joseph Segeleon:

That’s fantastic. And I certainly appreciate and have enjoyed the time we’ve had to talk about this. There’s great things that you’re doing up there for Fargo that you’re doing for the entire region and for Sanford. And I am looking forward to all that you are doing up there. I’m looking forward to learning more about this. I think it’s great that our patients, families and our providers know that there is this caliber of care that is close to home that we are comfortable with, that we know our colleagues and it really is a fantastic benefit for Sanford patients, families, and providers. So thank you again for your time, and I’m gonna turn it back over to Courtney.

Dr. Seth Maliske:

You’re very welcome. Thank you for your time as well.

Courtney Collen (Host):

Dr. Maliske, Dr. Segeleon, as always, thank you for joining us. This was another episode of our Called to Care podcast series by Sanford Health. I’m Courtney Collen. Thanks for being here and we will see you soon.

Learn more:

Fargo leukemia patient receives bone marrow transplant

First bone marrow transplant patient healing close to home

Regenerative medicine options for orthopedic pain

Courtney Collen (Host): Hi there. Welcome to our medical series Called to Care by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. Called to Care brings forward medical experts who can give fellow clinicians some advice and guidance that they can use in their primary care practice and more information about when it’s time to refer patients and families to more specialized care.

Joining me for these conversations is Joseph Segeleon, MD, who is vice president and medical officer for Sanford Children’s Hospital and a leader in pediatric critical care. He’s here to help us dive even deeper into these topics to provide the best insight and care for our patients and communities.

Welcome, Dr. Segeleon, good to see you.

Dr. Joseph Segeleon: It’s wonderful to be here. It’s good to see you again.

Host: So our topic today really is fascinating focusing on regenerative medicine. Orthobiologics at Sanford Health is treating musculoskeletal injuries through cells from fat, blood, and bone marrow, which can reduce a patient’s pain speed up healing, improve overall recovery. That’s really all I know about this. So I’m excited to dive even deeper with you and with our physician expert, who is joining us, Dr. Donella Herman, who specializes in non-surgical orthopedic conditions, including fractures, arthritis, overuse injuries in endurance athletes and concussions through a variety of treatments.

Dr. Herman, welcome.

Dr. Donella Herman: Hi, thank you so much for having me. It’s a pleasure to be here today.

Dr. Joseph Segeleon: Yeah, I tell you Courtney, I share your perspective on this. When I was prepping for this session, I really came to realize how much I did not know about this subject and so I’m sure our listeners are also quite excited to learn about this. So, Dr. Herman, again, thank you so much for being here. We really look forward to our conversation that’s upcoming.

Why don’t we start off by telling us a little bit about yourself and your training?

Dr. Donella Herman: So I have been working at Sanford Health for the last four years. I kind of took a roundabout way to get into my medical training. I was actually previously an athletic trainer and then did some fetal alcohol syndrome research and then decided I wanted to kind of pursue medical school. I kind of had a natural draw towards sports medicine and research at that point, given my background. So I went to medical school at USD and then I did my family medicine training here in Sioux Falls. After my family medicine training, I did a year fellowship at Duke University in North Carolina. That sports medicine fellowship focused some on research, a lot of ultrasound guided injections, the overall treatment of musculoskeletal injuries, including fracture management, and then also some additional training in the regenerative medicine realm.

Dr. Joseph Segeleon: Great. Well, fantastic. Thank you. We really are so fortunate to have you here in our region. So why don’t we just get to it? What are orthobiologics?

Dr. Donella Herman: So orthobiologics is kind a big fancy word, and it’s an umbrella term that we use in terms of how we can use our body’s own resources in an attempt to provide a better environment for healing. And a lot of times there’s kind of, I don’t know the fancy words that you hear in the news about how we’re going to regrow things and the stem cells. For us, we’re trying to find ways to use cells that we have, that we know are a part of the healing process. Things like platelets, things like mesenchymal stem cells, things that we know help in the healing process when we have an injury and how can we harness that for some of the everyday things that we see in our clinic. So that’s kind of what orthobiologics is as a whole. It’s harnessing the body’s own resources and trying to utilize those to improve an environment and promote healing.

Dr. Joseph Segeleon: So is orthobiologics a part of regenerative medicine or is it different from regenerative Medicine?

Dr. Donella Herman:  It depends on where you are. It’s, it’s kind of a regional term more or less. Some people will call orthobiologics regenerative medicine. Some people will call regenerative medicine orthobiologics. I see it more as orthobiologics is a small area under the umbrella of overall regenerative medicine, because we can use regenerative medicine in cancer treatments. We can use it in other diseases as well. The orthobiologics, we are focusing that on musculoskeletal injuries versus kind of whole body treatment.

Dr. Joseph Segeleon: Okay, perfect. That’s very helpful. Thank you. That really clarifies it for me. In thinking about what’s the best way to sort of unpack this, this topic, perhaps maybe we could start with: what kind of patients come to see you for specifically for this technology and then maybe we can drift into the actual technology itself.

Dr. Donella Herman: Absolutely. I see a wide variety of patients in my everyday clinic. When it comes to the regenerative medicine and orthobiologics portion of my patients, it really is people who likely have a chronic injury. Osteoarthritis is one area that we treat pretty extensively with orthobiologics. But we also have things like chronic tendon injuries, whether it be rotator cuff or achilles tendon. With that being said, you can also use some of this for acute injuries or injuries that maybe we have an athlete that has an acute injury to the rotator cuff or to a muscle. Using these products, we can try to expedite healing, you know, get them better, faster, kind of a, of a mentality, but also do it in a safe way where we know we’re promoting maximum healing.

Dr. Joseph Segeleon: Yeah. I was surprised, when I was prepping for this, in 1939, there was a bone marrow aspirate used for a nonunion fracture. So I don’t know if I was doing a crossword puzzle in medical school during period or what happened, but very interesting. So chronic injuries and I know chronic conditions like osteoarthritis affects something like 50 million people, knee osteoarthritis in the United States. What are the advantages and disadvantages of orthobiologics? Or if you’d like to get right into the usages of whether it be plasma, derived products or stem cells it’s really up to you.

Dr. Donella Herman: Yeah. I think that one thing that we’re focusing on and a lot of people focus on with orthobiologics is it’s a non-surgical option. We’re looking for right now. We have steroid injections or we have lubricating injections, or, you know, we have have things that are, are manmade that we can inject and then we have surgical options and there’s not a lot in between. And so these are kind of seen as conservative measures that aren’t quite as invasive as a surgery. Although I will say that bone marrow aspiration is not an un-invasive procedure. It’s kind of something, if we don’t want to go in and surgically intervene or have a joint replacement, we kind of see these as options of that kind of gray area where… it seems like we go from really conservative stuff and then don’t have a whole lot in between that big surgical intervention. For us, this is hopefully going to help bridge that gap. But there, there are different kinds of, of cells that we can utilize to try to bridge that gap.

The less invasive thing to do is to use a blood product. So, you can have your blood drawn. We spin it down in our clinic, we take platelets and sometimes we add some white blood cells in if we’re going into a tendon. But we use those platelets and we inject that into the injured area, whether that be a joint or a tendon. And the hope is that those platelets who are the first, you know, the first cells at the scene of the accident is how, what I always tell my patients, you know, you cut your fingers and the platelets get there first and signal your body what to do.

Well, we anticipate that these platelets, we put them in a concentrated amount, into a joint space or into an injured tissue and they’re going to signal the body, ‘hey, let’s, let’s have you come in here and bring some healing in’ or bring the products we need to, to promote healing. And it’s really about trying to create that better environment for that joint or for that injured area. And so that’s kind of a less invasive way to do it, but then, okay, the next step, maybe we want to do something more with the regenerative cells that we get from bone marrow from fat. And so for those, we have a little bit more invasive procedure, but we also know that the mesenchymal stem cells also have a lot more signaling power than a platelet does. And so we can go in and do a bone marrow aspirate off the back of the pelvis. And then we have a process where we clean the cells and we count the cells. We make sure they’re alive. Most importantly, we see how many we have. We also make sure that there’s not any toxins in there. And we make sure there’s nothing infectious in there. And those four steps are something important because that’s not something everybody does. And so we make sure that we know what we’re injecting and that it’s a safe product to inject. And then we inject it to the injured area. We can also get those same sort of regenerative cells from fat tissue. And so we can go in and do basically kind of what we call a mini lipoaspirate or a small volume liposuction. And so we do that either off the abdomen or the gluteal areas and we take those cells and they have the same different processing standpoint, but we are looking for the same things prior to injection. We want to make sure they’re safe. We don’t want any toxins in there. We want to make sure that we have live cells and that there’s enough of them that we’re actually gonna get a good response from it when using these cells as the same thing, I’m not going to promise you, oh, we’re going to come in and regrow new cartilage. We just don’t have evidence of that yet. But we do know that if we inject these things, people have improved pain, they have improved function. They’re able to do the things that they enjoy more often. But we’re also following that with all of these regenerative cells. We are following our patients so we know how long they’re having relief for, how much activity they’re doing, if they have improvement of pain and motion. These are the things that we’re following and kind of measuring.

Cause right now we just, we don’t have a lot of information. There’s a lot of people doing it all over the country. You can go anywhere and there’s kind of pop-up shops that are, are offering these stem cells are offering, you know, they’re making a lot of promises that we can’t necessarily say they’re delivering on. And so what we’re trying to do is hopefully in five years, people will come to Sanford and say in a patient with this condition, which product works the best? And we’ll have that information. We’ll be able to say, yeah, we’ve done all three products in, in this kind of an injury or this kind of a population. And this product seems to be working the best. So that’s kind of our overall goal with it.

Dr. Joseph Segeleon: I read I read in prepping the stem cells are viewed as the general contractor coordinating the repair job and the plasma rich or platelet rich plasma is supplies added to do the jobs, or I thought that was or supplies needed to do the job. So I thought that was interesting. So most of these treatments are symptom relief, is that accurate?

Dr. Donella Herman: It’s symptom relief, functional improvements. And so we do generally want to see less pain, but we also want to see improved range of motion, improved strength and improved overall function. And so those are all the things that we follow. We have a way of capturing patient reported outcomes for our regenerative medicine orthobiologic patients. And in doing that, we’re hoping to see maybe we’ll again, in five years, we’ll find out that this, this one helps most with pain. So if their primary problem pain, we should probably go in this direction. But if we’re really looking to get back to doing more high level activities, then you know, we’ll, we’ll hopefully be able to steer ourselves in our patients in the right direction.

Dr. Joseph Segeleon: And when you talked about duration of effect, does that vary with product? Does it vary with the injured area? Or can you comment on a little bit of, is there preliminary data that gives you an idea of what the duration of effect is?

Dr. Donella Herman: It’s kind of hard to predict. It’s kind of like the other options we have currently that are widely used, like the steroid injections and the Viscosupplementation. We know that some people get the injection and it may last for years and some people get the injection, it may last for months. And so, it can be a little bit difficult to predict. I think that there’s been some data showing that, you know, six months out people are still seeing improvement with the regenerative cells. I know that there are health systems and health insurance plans that do cover some of the platelet rich plasma injections for joints and they can allow them up to twice a year. And so kind of, again, that six month mark is what we’re kind of seeing for improvement with that being said, anecdotally, I can tell you if people I know that have had the regenerative medicine and orthobiologics and they have had years of relief and have significantly improved their function.

Dr. Joseph Segeleon: Okay. Cause that’s good to know. I know that there are differences with regards to what’s allowed with the cells prepped and the length of time between aspiration and injection. I get the sense that much of this as FDA and legal, that is specific to the United States and then also perhaps different rules or different legalities pertain to outside the United States. Can you comment a little bit on that?

Dr. Donella Herman: Yeah. The FDA has some pretty strong statements in terms of minimally manipulated cells. That’s the term that they like to use. That gives us a window of time of processing these cells and injecting the cells and also what can you mix together and what can’t you. There’s restrictions in terms of, of, you know, taking a couple of products and putting them together and seeing if we mix some, is it better? Well, that’s kind of, we’re manipulating things at that point. And so things have to happen in individual injections. There has recently been some kind of more robust statements from, from the FDA in terms of, they want to restrict kind of the places that are maybe trying to take advantage of the, oh, what’s the word I’m looking for…

The FDA has come out with a lot of some strong statements in terms of one, we obviously don’t want to manipulate the cells. That’s always been the, the rule, but also if you’re doing this, you need to make sure that you’re doing it appropriately, that you’re doing it for the reasons of collecting patient reported outcomes. And, and in ways that the FDA says it’s okay to do that. One interesting thing of the stem cells, of the regenerative cells that we’re utilizing, is that for the fat derived stem cells, we have an FDA registry for that. We’re the only place in the country that has an FDA registry. So really nobody else should be injecting these, these process cells for, for joint pain or for osteoarthritis in the, in the five joints that we have the registry for.

But the reason we have the registry is because it’s something that’s kind of needed right now in medicine, because there are so many other places doing it. We need something that’s controlled, but it’s hard to do a double blind randomized controlled study for every single joint for every single thing. So they’re asking us to kind of start with the registry and then get some preliminary data from that and then see from there, if we can kind of, okay, what can we use for head-to-head studies thereafter, but it’s going to give them a lot of information in terms of what they can be used for in the future. But that also means we have a registry and we’re being watched. And so, you know we have a lot of safety measures in place. We have a lot of rules that we need to follow, especially our processing. This is something that even with the bone marrow derived regenerative cells, you know, we have a window, we want in from the time we start processing the cell to the time we inject it, we want to get that done in less than two hours, because we want to have the highest cell viability. We want as many cells to be alive as possible. We want the least risk of it being, you know, contaminated by something. And so we try to get everything done within a two hour window for the regenerative cells from bone marrow and fat. For the PRP, we inject those within 20 minutes. I mean, it’s a 20 to 30 minutes between when we draw the blood because we do it directly right there in clinic and this blood draw. So it’s a little less invasive.

Dr. Joseph Segeleon: I can certainly see with the huge number of individuals who are affected by osteoarthritis, by injuries, orthopedic problems, I can certainly see where there’s a need for this. And I can also see where there might be some opportunities for people to take advantage of people that are vulnerable and that have chronic pain syndrome. So I’m delighted to hear Sanford is part of clinical trials and really leading the way domestically with this registry. I think that’s fantastic. Let’s talk a little bit about costs and you alluded to earlier that some insurance companies cover this how do most patients afford this or is cost prohibitive?

Dr. Donella Herman: It can be for some patients. I say some health insurance plan, Sanford health insurance covers the PRP injections to the knee. And that’s one of the few that does. They just cover it for knee osteoarthritis at this point but we’re hoping that eventually we’ll be able to expand that to other joints as well. A lot of insurances don’t cover it though because it’s still considered to be an investigational use. And so until we get consistent data and that involves everybody actually collecting the data until we get that insurance companies are really hesitant to cover for it. With us having the FDA registry, we’re not here to make a profit. We can’t make a profit if we have an FDA registry. But, it does cost money to do these. And so for all of the, the orthobiologics procedures, we do what we call cost recovery, which is basically that we have the patient pay for it, but it is basically covering the cost of the procedure and the injection. And so it’s not it’s not anything that is necessarily for profit for Sanford. We’re just trying to cover the cost. If you’re doing it into a joint, oftentimes it requires more than one injection. So we’re doing usually two, sometimes three injections into the joint. So that can add up. For the tendons with the platelet rich plasma, we can generally get by with just doing one. It has a little more restriction afterwards. You know, if we inject into a joint, people usually get back to the regular stuff pretty quickly. With the tendons, we have some restrictions afterwards, but we can generally do that as a one-time injection for the bone marrow aspirate and the, the fat derived cells.

Dr. Joseph Segeleon: Okay. Thank you. I do want to go back a little bit to the physiology and the science of this, if you will. I understand that cartilage – because it has very little blood supply – does not really heal very well. And that’s one of the attractive features of stem cells. Is that correct?

Dr. Donella Herman: That’s one of the attractive selling points for stem cells. I’ll say, I know that there’s been some studies in the past that have shown that there have been cartilage defects that have had improvement after, after stem cells. I don’t think it’s necessarily the same kind of cartilage. You know, we have this, this really robust cartilage at the end of the bones on those weight-bearing bones. We certainly don’t make promises that we’re going to rebuild cartilage because we just don’t have evidence that that’s what it’s doing. For me, I prefer to think of it as we’re just creating this environment where we have these signaling. And, you know, for me to say, if I put a stem cell into your knee is going to regrow cartilage. Well, if I say it can do that, I don’t necessarily think I can say that it won’t turn into an ear. You know, I mean, we have the, if we think that the stem cells can just figure it out that quickly, for me, it’s more that we’re putting the stem cells in there, it’s in this environment and it’s creating a better environment where the body can come in and kind of heal the area. And it’s probably not going to put down this big, robust cartilage, but it may create an environment where there is some protection for where the cartilage has worn through.

Dr. Joseph Segeleon: Okay. Thank you. That’s very helpful. Let’s talk a little bit about what we’re doing here at Sanford. Why don’t we well, let’s just talk about what, what in your practice, what is, what’s your typical day, or how are you applying his orthobiologics to your practice?

Dr. Donella Herman: I love my practice because I don’t have a typical day. But you know, I, I I’ll see a wide variety of you know, young people to, you know, 6, 7, 8 year-olds to 96 year-olds. But when it comes to the orthobiologics a lot of the times the people I’m seeing are people who it’s either a, an athlete who has had an acute injury, and we’re trying to get in there and promote maximum healing quickly, or it is somebody who has had a chronic condition. Who’s looking for a non-surgical option. Generally, what we do, we have them come in. If we need to get some imaging, we do a lot of times they have some imaging. But we kind of look at their underlying issue and talk about all the things that they’ve tried and then kind of talk about the differences in orthobiologics and based on our kind of conversations and their goals and expectations, we decide what the next best step for them is going to be. And whether that’s a regenerative cell or if it’s more of the platelets, we can kind of determine based on, you know, cost. Is that going to be prohibitive? Or is it going to be difficult for you to be laid up for a few weeks if we inject a tendon? Things of that nature. It’s really an individualized conversation with each patient about what their overall goals are expectations and how orthobiologics can assist them in the most meaningful way.

Dr. Joseph Segeleon: I think I heard you say that there were five joints, is that correct? And what are those?

Dr. Donella Herman: Yes. We have five joints that we can utilize. We have the wrist joint, the shoulder, the hip, the knee, and the ankle. When we do the bone marrow derived stem cells. If you have let’s say you have some arthritis in your hand or, or in your midfoot we can utilize those for, for other joints as well. So there’s a little bit broader use for the bone marrow derived cells. We can also use those cells and things like rotator, cuff tears and tendon injuries.

Dr. Joseph Segeleon: Okay. And are these procedures typically same-day procedures?

Dr. Donella Herman: I usually tell people if we’re going to do the procedures for the regenerative cells, either the bone marrow or the fat that you should plan on giving me half of your day. And so we have you come in either early in the morning and we get you out by lunch, or we have you come around lunchtime and we have you out by five. Like I said, we want that kind of short processing window. We don’t want too much time to go by. And so it’s usually kind of an in and out procedure for them.

Dr. Joseph Segeleon: Okay. And what about recovery or the tendon injuries?

Dr. Donella Herman: That’s a little bit longer. We do, we do a little bit more to protect tendons then after the injection, because we create this inflammatory response and we don’t want to start pulling around on that tendon. So for that, I tell people, you know, at six weeks after that injection, we’re hoping to get you back into those higher level activities that you enjoy, or sports specific activities for an athlete. For joints, we tell people, we kind of just, it’s kind of common sense for the first couple of weeks afterwards, just don’t overdo it kind of reduce your impact activities. Or if it’s a shoulder, don’t do a lot of overhead stuff, but if we’re going into a joint, it’s kind of two weeks of, let’s take it easy and not overdo it, and then gradually try to increase your activity after that.

Dr. Joseph Segeleon: Okay. Well, it seems like this field of orthobiologics… I’ve heard so much about it, particularly in the last five years or so. So I’m going to have you do some predictions here. What does the future hold for this field?

Dr. Donella Herman: I’m hopeful that in five years, we’ll be able to say we have other options for people who are either not surgical candidates, cause there’s people with co-morbidities that that just don’t have good surgical options. But that we also, in five years maybe have a better understanding that we’re standing to glean more of that information of: you have this kind of a problem you’re in this age group you’ve, you’ve tried A, B or C … can we start what what’s going to be the best option for you and where you’re at and your life with this condition, I’m hoping in 10 years, we’ll be able to say, you know what, maybe we should be doing this earlier. Maybe we shouldn’t be doing as many steroid injections. Right now, people are getting in as they run out of options. Maybe in 10 years, we’ll realize that maybe this is an earlier option that will kind of give us additional options moving forward. So, that’s what I’m hopeful for is that in five years, we’ll have a better idea of which patients fit where, and in 10 years we’ll be able to say, maybe we need to start sooner.

Dr. Joseph Segeleon: Okay. All right. And finally can anybody refer patients to you and can patients self-refer to you?

Dr. Donella Herman: Absolutely. So if patients have interest in orthobiologics, they can certainly make an appointment. With our clinic, they generally try to funnel them to me so we can, we can have that individualized conversation, but sometimes they come from other people within our clinic, if they have interest in and mention it to another provider, if you’re a provider outside of our clinic, we actually have an orthobiologics referral within the epic system. So if you just type in orthobiologics that referral will pop up, you, you associate the diagnosis and it will get them directly to my clinic for the conversation.

Dr. Joseph Segeleon: Okay. Well, great. Well, I know the time seemed to go quickly. This seems like a topic that we could wait into for hours, but I hope this was a good overview. Is there anything that I left out that you’d like to comment upon?

Dr. Donella Herman: You know, it’s an exciting time for orthobiologics. I’m really proud to be a part of it at Sanford because I do feel like we’re doing it right. And that’s kind of always been our, our mantra within the orthobiologics group is that if we’re going to do this, let’s make sure we’re doing it right. And I think that we have a really unique opportunity to not only provide the best care for our patient population, but also to develop information that can be used across the United States and the world in terms of how orthobiologics could be used and should be used moving forward.

Dr. Joseph Segeleon: Well, I appreciate your scientific integrity and I certainly appreciate all that you do clinically. I really appreciate educating Courtney and I on this topic because I learned a lot. So I’ll turn it back to Courtney.

Host: I learned a lot too, Dr. Segeleon. Thank you as always for being here, again, to help guide the conversation as we speak to our clinician experts in this space. Dr. Herman, wonderful to meet you and learn more about your practice and the healing that you provide for patients with pain. Thank you again for being here.

Dr. Donella Herman: Absolutely. It was my pleasure.

Host: Our Called to Care podcast series by providers for providers continues right here with our Sanford Health experts. I’m Courtney Collen. Thank you so much for being here. We’ll see you soon.

Learn more

• Sanford Health pioneers use of body’s own stem cells
• PRP injection helps patient with chronic ankle injury
• What is regenerative medicine?

New treatment options for orthopedic pain

When to refer to fertility, reproductive specialists

The following data in this episode was accurate as of April 16, 2021 upon the recording and publishing of this podcast. Edited to note 1 in 6 couples struggle with infertility. 

Courtney Collen (Host): Hi there. Welcome to our medical series Called to Care by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. Called to Care brings forward medical experts who can give fellow clinicians some advice and guidance that they can use in their primary care practice and more information about when it’s time to refer patients and families to more specialized care. Joining me for these conversations is Dr. Joseph Segeleon, who is vice president and medical officer for Sanford Children’s Hospital and a leader in pediatric critical care. He’s here to help us dive even deeper into these topics to provide the best insight and care for our patients and communities. Welcome, Dr. Segeleon, good to have you here.

Dr. Joseph Segeleon: Courtney, it’s great to be here. Wonderful to see you again.

Host: We are talking about infertility and raising awareness about the challenges a lot of couples face when trying to start – or grow – their family. More specifically, talking about referring to a fertility specialist and the patient’s journey from there.

Dr. Keith Hansen specializes in reproductive endocrinology at the Sanford Health Fertility and Reproductive Medicine Clinic in Sioux Falls, South Dakota, and we’re happy to have you, Dr. Hansen. Welcome.

Dr. Keith Hansen: Thank you. And thanks for having me, Courtney, it’s a pleasure.

Dr. Joseph Segeleon: Hi, Dr. Hansen. It’s good to see you again, a wonderful having you here and I know our providers are quite excited to hear about the information that you have to offer.

Dr. Keith Hansen: And it’s nice to see you again, Dr. Segeleon.

Dr. Joseph Segeleon: Just to start off, reproductive endocrinology, give us a little idea of your background and the training that goes into becoming a reproductive endocrinologist.

Dr. Keith Hansen: Sure. Basically, the training to be an a reproductive endocrinologist, usually you do an obstetrics and gynecology residency and then we do a three years of fellowship training at one of the fellowships throughout the country. There’s another way you can also approach it through internal medicine and then do another three years of fellowship and reproductive endocrinology but most people go through it the OB/GYN route.

Host: According to the national infertility association, infertility is increasing. And right now one in eight couples are having trouble achieving pregnancy, whether it’s their first, third or fourth child, is there any rhyme or reason why so many couples are facing these challenges?

Dr. Keith Hansen: You’re exactly right. That there is a large percentage of couples who have difficulty either getting pregnant the first time or after that. There’s a lot of theories on why it may be why we may be seeing more couples with infertility over time. Is it just the more it’s becoming more aware and people are seeking care for it? That’s one possibility. Is it the fact that women are delaying childbirth so they can get into their professional lives and continue to practice, you know, to get their practices or their other jobs more well-situated and get started in that area before they try to get pregnant? Is there changes in male fertility that’s occurring? I mean, there’s a lot of studies going on looking at, you know, is there a lowering of the total sperm count over time and males and other potential factors that may be impacting a couple’s ability to conceive?

Dr. Joseph Segeleon: Just to level set, for the pediatrician in the room, we define you would define infertility as…?

Dr. Keith Hansen: That’s a great question. Infertility is for a woman under the age of 35, we define it as the inability to conceive for at least one year of trying of, you know, unprotected intercourse. However, the definition changes when the woman is over the age of 35. Then we like to, if they have not conceived after six months of trying to conceive, then we want to see them for evaluating fertility, mainly because of the effects that age have on ovarian function. We also want to see couples, like if there’s some history that suggests that they might have trouble getting pregnant, like if a young woman stops her birth control pills and has no menstrual cycles. Because of that, we know that she’s not ovulating, we want to get her in as soon as possible so we can figure out why she’s not ovulating and get her on medications to help her ovulate so she can get pregnant. If there’s a history, like if the male has had a history of chemotherapy for cancer, we want to get him in so we can evaluate the sperm count and make sure that there’s adequate levels of sperm so that they can get pregnant or if there’s some other history that might suggest an infertility problem, we want to see them earlier rather than later.

Dr. Joseph Segeleon: Great. Thank you. And so I’m thinking that most patients come to you after some time in their primary care provider and they’ve discussed this issue or they’ve brought it up. For our primary care providers who are listening, are there groups of patients to refer to you? Is there anything as a primary care provider that I should do, with regards to a workup, treatment, or counseling prior to referring to a reproductive endocrinologist?

Dr. Keith Hansen: It is nice when the primary care provider, you know, really sits down with a couple and evaluates them in terms of a history and physical examination, especially looking for diseases that might impact pregnancy or their ability to get pregnant, as well as a family history, trying to determine are they at high risk for any sort of genetic illness that could be passed on to the baby. If that’s the case, then we need to know about that. I think from a primary care provider, one of the things, you know, we really kind of divide infertility into three major groups: One is the male so it’s important to know, you know, what is his history? Has he had any history of pubertal abnormalities? Has he ever been on steroid hormones? Steroids can suppress the testicle… especially testosterone therapy is bad for sperm counts. Has he ever had any other history that would suggest a problem with sperm, including using tobacco? Tobacco is very bad for sperm, both smoking and chewing tobacco is really bad. So, we really like those guys to get off of the tobacco products. And then one thing they could do is get a semen analysis and let us figure out, does the guy have a normal sperm count? Does he have a good motility? What does the sperm morphology look like? So that, you know, can be sort of a basic understanding of the guy. The other area is looking at the woman and the best indicator we have of how good or ovary is working is her history of her menstrual cycles. Hopefully she’s had a normal age of onset of her menstrual cycles of menarche and then, if she’s having regular periods every 28-30 days, she can tell when they’re coming. She tells when she ovulates those gals, you know, are pretty sure that they’re ovulating. And so it’s good to know that there are, you know, that that’s going on, that they’re having regular ovulatory cycles. The other thing that we like to evaluate, especially if the woman is over 35, is how good is her ovarian function and the way we do that is with what’s called an anti-malarial hormone, also known as AMH. And if that is suppressed, then that’s a sign that her ovaries are starting to go through dysfunction. Like in the most common one is menopause. Menopause causes a very low AMH level, undetectable. So we’re worrying that they’re starting to do that. The other thing we like to do is get a FSH, LH and estradiol level when they’re on day two, three or four of their menstrual cycle. And then also at the same time, get an ultrasound while they’re on the second, third or fourth day of their cycle and get a good look at the uterus and look at their ovaries and count all the little follicles in there. Those three tests: the antral follicle count the FSH LHS estradiol on day three and the anti-Malarian hormone. Give us a really, really good idea about how good the ovaries are working.

Dr. Joseph Segeleon: Are those tests that you would do, or the tests that a primary care provider might do?

Dr. Keith Hansen: Either one. We get some primary care providers who do them, you know, all the time. We have some that automatically get those. We have others just refer the patients here and we’re happy with either way. The other test that’s nice is a hysterosalpingogram or HSG, for short. That’s where we go to x-ray put a catheter, the uterus inject contrast, and we get to see as the inside of the uterus normal and are both fallopian tubes open or not. Once again, that’s a test that a lot of times the primary care doctors will send to us and we’ll do the test. We do have some that are comfortable doing it. And that is wonderful if they’re willing to do it. Then if they do do it, it’s nice if they could, when they refer the patient to us, if they could just send us the films, because it’s nice to look at them. But a lot like to send us and we were happy to see the patients and get them started.

Dr. Joseph Segeleon: Great. Thank you. When I do these podcasts, my goal is always to learn something and I had no idea that tobacco had an effect on sperm count. So that’s my fact that I gained today. So thank you for that. I heard you mentioned family history, a couple of times, infertility runs in families?

Dr. Keith Hansen: Once again, that’s a great question. And yes, I mean, there are a couple of diseases that can result in infertility. One of them is endometriosis, which actually the very first studies that confirmed that it was familial in nature, came out of Yankton, South Dakota. We actually were, the, the state here was one of the first places to ever suggest that it was familial. Since then, we now know that it definitely has a familial history to it. And also uterine fibroids can be more common in families. Both of which can cause problems getting pregnant or staying pregnant. The other thing though, one of the other reasons we asked family history, is for birth defects. If there’s a family history of cystic fibrosis, spinal, muscular atrophy, or one of the other genetic illnesses. If we know that a couple are carriers of a genetic disease, we can actually then test the embryo and make sure we can do in vitro fertilization, test the embryo, make sure it’s normal before we put it back in. We get referrals quite frequently where couples have had a baby with like cystic fibrosis or spinal muscular atrophy and they come in and they want to prevent it from happening again. So then we’re able to do that. We just, we get their blood and it’s fascinating. We send it to a lab and they determine exactly where the mutation is and then they develop primers around that. Then they have to develop primers along the ilial so that they can tell that, you know, if that they actually have that ilial or they don’t. And so they, we can test the Ambrose and find one that doesn’t have that disease, put it in and they can have a totally normal embryo. So, that’s why we ask the family history. We also ask them if they want to be screened for a lot of these mutations. Cause we can do, what’s called the it’s called the council screen. What they do is they give a blood sample or saliva. We send it to a lab out in California or there’s other labs, but they just tell us if they’re carrying the most common mutations versus cystic fibrosis, spinal muscular atrophy, fragile X syndrome, and a whole bunch of other genetic illnesses, all of which, as you are aware are very, very serious illness.

Dr. Joseph Segeleon: Interesting. This is fascinating. I didn’t know any of this. I’m curious, we talked about family history and endometriosis. Is there any other groups of patients that you see more commonly… I guess what’s coming to my mind is polycystic ovary disease. Is that a population that you see?

Dr. Keith Hansen: Yes. We see quite a bit of, of individuals with polycystic ovary syndrome. You know, those are the ones that come in with no menstrual cycles and they’re not ovulating. So we have to treat them with medications to help my violate. We also see patients with tubal disease either due to endometriosis or scar tissue from like a ruptured appendix, tuberculosis, gonorrhea, chlamydia or major abdominal surgeries. We see a lot of male factor with guys that, you know, where the sperm counts are low, the motility is low or the way that the sperm looks, the morphology is low. If the morphology is low, the sperm can have a real dickens of a time getting into the eggs.

Dr. Joseph Segeleon: And, and just to be clear, you see both men and women in your practice?

Dr. Keith Hansen: Yes.

Dr. Joseph Segeleon: Okay. So thank you for that. I think we’ve got the patient now. We’ve got them worked up from the primary care they’re referred to you. And I know that there’s a myriad of different pathways, but for the, for the, for the providers listening, what what’s a typical journey look like through this process for, for their patients?

Dr. Keith Hansen: Well, once again, like you said, I mean, it depends a lot on what the definition is. One good example is those with unexplained in fertility, you know, the couple where you absolutely have no idea why they’re not getting pregnant, they have open fallopian tubes, she’s ovulating every month in the sperm count is totally normal. In that situation, a lot of times what we’ll do is we’ll treat them with like ovulation induction agents, like clomiphene citrate, where we give them five days of the medicine to help them ovulate, to try to recruit more than one follicle. Then, we do what’s called the intrauterine insemination. Where what we do is we have the husband come in close to ovulation and he gives us a sample, we wash it and then we put it right up inside the uterus, you know, to get them going in the right direction.

They actually did a big study called the faster trial where they basically showed that the most efficient way cost and cost effective way to treat unexplained infertility is to do three cycles of Clomid 90 Y. And if they aren’t pregnant, moved straight to in vitro fertilization, and you have the chance of getting a successful pregnancy at the lowest cost for the couple Other options, like for somebody with polycystic ovary syndrome, a lot of time we’ll use ovulation induction agents like Letrozole is the most common one, which is also known as Femara. It’s a aromatase inhibitor and it’s not been approved by the FDA for ovulation induction, but it works wonderfully and especially in polycystic ovary syndrome, it works a little bit better than clomiphene does. And so we like to use that drug to help those people. In male factor, it depends on how severe the problem is. If it’s mild, many times we can do like Clomid or clomiphene citrate and intrauterine insemination. If it’s severe, then we’re having to turn to things like in vitro fertilization where we go in under a big microscope, pick up a normal sperm or the closest to normal we can find, and inject it into the egg or turn to things like donor sperm or donor embryos or adoption.

Dr. Joseph Segeleon: So just curious, you had said that in the cases that you do not know the etiology for the infertility, what roughly what percentage of your practice is it unknown?

Dr. Keith Hansen: Probably about 10%.

Dr. Joseph Segeleon: Okay. thank you. Thank you. Now let’s say the couple are pregnant. Do you follow them then through their pregnancy?

Dr. Keith Hansen: Once a couple is pregnant, we usually follow them like for the first 12 weeks. Most primary care physicians and OB/GYN really wait to see the patient until around 10 to 12 weeks. So what we do is we see them and then we tell them to call up and make an appointment with their primary care doctor or their OB/GYN doctor. Then, they can make their appointment and be seen by them and, and get to get their care set up.

Dr. Joseph Segeleon: Do you see them later in the pregnancy?

Dr. Keith Hansen: Just when they come back to show us, you know, like the little baby, hopefully, or babies.

Dr. Joseph Segeleon: I did not know that.

Dr. Keith Hansen: Yeah, that’s really fun when they bring the little babies back and show them off and stuff.

Dr. Joseph Segeleon: Incredibly rewarding. I know I’ve read before about the cost of infertility being being something out there in the public eye. Can you expand on that a little bit or what are the options?

Dr. Keith Hansen: The problem with infertility is as many times it’s not covered by insurance. So it’s very similar to the cost of other medical care, you know, other surgical procedures and all of that. But, it is expensive. I mean, if you go through in vitro fertilization, there’s about $12,000 to $15,000 for that from us. And then it’s usually about three to $5,000 in medications. So it usually comes out probably about 18,000 by the time you’re done, which you know, is very similar to a lot of other medical procedures. We’re hoping that we can slowly get it approved by insurance and hopefully, at some point, it will be covered.

Dr. Joseph Segeleon: Anything else. In the remaining minutes that we have that you’d want the referring providers and the primary care providers listening to know about your practice or about you?

Dr. Keith Hansen: We’re very happy to see couples with infertility and we’re happy if they do part of the workup or if they want to refer them directly to us. We also see patients with recurrent pregnancy loss, which are sad cases where a woman has had two or more miscarriages and we can work those up. Many times we can find something to help them with, which is nice. I also take care of pediatric and adolescent gynecology, too.

Dr. Joseph Segeleon: It sounds like your practice is incredibly varied and incredibly busy. I know that you’re the reproductive endocrinology is a fairly scarce resource. So for our listeners, how would we refer patients to you?

Dr. Keith Hansen: You’re right. I mean, there are very few of us around. We’re happy to, you know, to take referrals directly from the primary care doctors or we have patients we’ll actually just call up and come in and see us. So, I mean, we’re happy to see them whichever way they want to refer to us.

Dr. Joseph Segeleon: Wonderful. I can’t thank you enough, Dr. Hansen. This was very enlightening and it’s always a pleasure talking to you. I always learned something and Courtney, I’ll send it back to you.

Host: Dr. Segeleon, Dr. Hansen, thank you for being here and for all that you do for Sanford. Our Called to Care podcast series by providers for providers continues right here with our Sanford Health experts. I’m Courtney Collen. Thank you so much for being here. We’ll see you soon.

The following data in this episode was accurate as of April 16, 2021 upon the recording and publishing of this podcast. Edited to note 1 in 6 couples struggle with infertility. 

Learn more:

• Sanford Health helps navigate fertility option
• Ep. 16: Sanford fertility expert helps same-sex couples
• What to know about an ectopic (tubal) pregnancy

How to encourage good sleep habits in children

Courtney Collen (Host): Hello, welcome to our new medical series ‘Called to Care’ by Sanford Health. I’m your host, Courtney Collen, with Sanford Health News. Called to Care brings forward medical experts who can give fellow clinicians some advice and guidance they can use in their primary care practice and information about when it’s time to refer patients and families to more specialized care.

Joining me for six episodes, focusing on children’s care is Joseph Segeleon, MD. He’s the vice president and medical officer for Sanford Children’s Hospital and a leader in pediatric critical care. Glad to have you here, Dr. Segeleon. Today, we’re talking about sleep hygiene in children.

Dr. Segeleon, tell us why you chose this topic.

Dr. Joseph Segeleon: Thanks. I’m just incredibly excited about this subject. Well, the simple explanation is that everybody sleeps. You hear so many parents talk and about getting their kids to sleep. How can I get my kids to sleep better? And right, we recognize how important it is for everything, for learning and for playing and for growth and health and yet it becomes a topic that a lot of people talk about. I think sleep as a topic is so incredibly important and for us to have a sleep specialist that we can call on as a resource for information, and his expertise is just really exciting. And I think our, our listeners are going to be really excited to hear what he has to say.

Host: And speaking of let’s welcome Dr. Arveity Setty. Dr. Setty, welcome to the conversation.

Dr. Arveity Setty: Thanks for having me here today. I’m excited to talk to you.

Dr. Segelon: Dr. Setty, it’s really great to have you here today, you know, before we begin, I think I shared with you earlier. I did critical care for 26 years, and I don’t really think I knew a pediatric sleep specialist. So for our listeners, tell us a little bit about the training and how you become trained in pediatric sleep.

Dr. Setty: Sure. I did my residency in Flint, Michigan. I was already a pediatrician before I moved to United States from India. And after that, I chose to do sleep medicine mainly because I was very interested in sleep medicine. And during my residency training, I used to shadow a lot in neurology and I used to read sleep study because the attending was also a sleep physician. It was very interesting to see all those way forms, which looks like worms. Obviously it took me about three to four months even to understand what those stages of sleeps were. But then I chose to go to Cincinnati Children’s, but continued my sleep fellowship planning there.

Dr. Segelon: Well, fantastic. We are just really fortunate to have you, so I’m going to get right to it because I know people want to, it’s the good information here as a provider, parents are always talking about how can I get my child to sleep? How can they sleep better? So, as a provider, what kind of information and advice can you give parents to foster good sleep hygiene?

Dr. Setty: Well, it’s always challenging to put a child bed if they do not have a very good sleep hygiene. So, I guess the question is what is a good sleep hygiene? So yeah, but a good sleep hygiene is which helps a child or a body to understand – or get a cue to the brain – that this is sleep time, and the brain starts secreting melatonin. So melatonin it’s very essential for us to understand the whole melatonin secretes. So we can talk about a sleep hygiene and how this is related to that. Melatonin is one of the earliest sleep chemical, which rises in the brain, and then all the other sleep chemicals go based on what the melatonin does. So usually melatonin is at its peak before you fall asleep and it stays peak for about few hours and then gradually it goes down. So, assume that you go to bed at 10 o’clock. So melatonin will be at its peak and by in the morning, when you wake up at, say, for example, 7:00 AM. So if you have gotten a good sleep quality of sleep and also a good duration of sleep, then melatonin will be at its lowest level at the time. But melatonin is pretty sensitive to two important things. It maintains a circadian rhythm, which we know that for sure. So the circadian rhythm depends upon the wake-up time, not necessarily the bedtime. So wake up time is more essential compared to the bedtime or the water important for a sleep hygiene don’t get me wrong… but it is the wake-up time, which is more helpful. So on weekends, some people try to go to bed a little later because they’re watching movie or maybe Super Bowl, whatever it is, but they still need to maintain their wake-up time at the same time so that the circadian rhythm is sinking to them. So the second reason melatonin is sensitive to is blue light. Now in this technology world, I mean, you can’t live without technology in this world, so you definitely need technology, but at the same time, you should be mindful of this technology at least one hour before you go to bed. So blue light, which is emitted by screen, it should be, it could be any screen. Doesn’t matter how big it is. It could be a small watch like your Apple Watch. It could be in the movie theater. So irrespective of that, the melatonin can be completely suppressed if you’re exposed to blue light. So when we say a blue light, it’s basically mostly for adolescents and teens, but nowadays, even anger kids have their own cell phones, but most importantly, in kids’ bedrooms, usually they have a projected glides which are blue colored, sometimes like a, imagine a Spiderman type of projected lights. But they’re real literally exposing them to a blue light. Now that is not very good. So stopping blue light exposure one hour before bedtime and do some relaxation techniques, which will be very helpful. In adults, we always talk about relaxation like mindfulness and all those things. But in kids, usually a family time is extremely important because they are, kids are going to school and parents are working, so they have very little time to spend as a family. So the family time is really very helpful. It builds a bonding between them, but it also helps them calm down. So they are not exposed. Now nobody’s exposed to blue light with this. So that is very helpful for them to calm down and then go to bed.

Now. So, as I said before, you should have a bedtime routine too. Now, a bedtime routine, it’s up to a family and how they want to do, but we always talk about the ‘Rule of B’s: book reading, brush, bath and then bed … but they could do it in any way. It does not have to be this it’s just like relaxing before they go to bed. For some reason, shower usually helps them to calm their body down because internally, the body cools down when you’re taking a warm shower because of the blood vessels on the skin dilate and more blood flow onto the skin. So internally it cools down. So that is helpful for the body to relax and then it fall asleep. So if they have a bedtime routine, they need, if they don’t have one, they have to have one. And in a same fashion is what gives a cue to the brain. And that is when the melatonin starts secreting. Now, if you have a bedtime routine, but it is very inappropriate. I mean, you do however you want on it everyday, but you think that you’re doing it, the brain may not be getting any cues. So it does not know if it’s has to secrete melatonin. So that may be hard for it.

Dr. Segeleon: You mentioned blue lights. And I just happened to, to think about it myself. Every night before I go to sleep, I use an electronic book reader. Does that decrease melatonin?

Dr. Setty: Well, there is a lot of talk on this, I mean good and bad because if you’re using any other screen apart from Amazon e-reader, I would say so only that that is a different technology I have read, and it does not emit blue light, like Kindle e-readers. But I’m not sure about it because I also read some other information that it’s stating that it doesn’t matter, even if it is an e-read or they emit blue light. Most what I have read is it does not emit blue light, but it’s always better to be safer and reading a regular book rather than an e-reader.

Dr. Segeleon: Well, great. That’s good. That’s good to know. As we’re talking about sleep hygiene, I, the thought just occurred to me also. And I know there’s so many different ages that we can talk about, but what about naps do daytime naps affect nighttime sleeping and when for our providers out there that have young children in that come to their primary care clinic, toddlers, and then early school age, what’s the story with naps?

Dr. Setty: Well, that’s a pretty good question. So maybe I left melatonin pathway in between, so to continue with that. So now when you wake up, say around seven o’clock, so melatonin will be at its lowest level. So as the day goes by, it starts to creep up a higher and higher and higher. And by the end of the day, when you’re trying to fall asleep, obviously it is at its peak. So it will help you fall asleep, provided, you know, you did everything right. When you take a nap, so that melatonin, which was creeping higher and higher is going to fall down. So to creep up again, it’s going to take longer time. So that is why we discourage taking nap, unless it is very essential for your job where you take a power nap for about 15, 20 minutes, or if you have a narcolepsy. So we recommend them taking a scheduled naps. Otherwise after five years of age, we never talk about naps in any other situations. And we call that a biphasic sleep, because you should have a uniphasic sleep. You just go to bed one time and just wake up, and then you’re not going to look at bed. You should not be doing that, but less than five, yes, they do take a nap. But statistically, with the current information we have, about 50% of the kids give up nap by two years. And about 85% by three years, about 93% by about four and about 99.9% by five years. There are still a few kids who actually take a nap, but I still think it is inappropriate unless it is situation driven.

Dr. Segeleon: Wow. Okay, great. Good to know. I can even remember that if you’re over five, no naps? Okay. I can remember that. You know, we talk about sleep hygiene and that was great information. Do kids get insomnia? Is that an entity in children?

Dr. Setty: That’s right. In fact, actually about 50% of the kids I see in my clinic is insomnia. Now there are different types of insomnia. Now, most people think it’s primary insomnia, which is just there almost since birth. So there is no precipitating cause, but that’s one of the greatest insomnia I see. I do not see them at all. It’s it’s almost very rare. But then what is the most communist insomnia do I see in kids? Well, depending upon the age, behavioral insomnia is the most common. Out of 50% of the kids I seen in the clinic, I would say about 35% of behavioral insomnia. And most of them are association type. Now there are two types of behavioral insomnia. One is association type. Now you might have seen many kids associate themselves with some toys or some teddy bear. They want to snuggle with it or a blanket or whatever it is. They want to snuggle with it. They’re associating with the toy or a blanket to go to bed. And that helps them fall asleep easily. But when they start associating themselves with a parent or a guardian or some human being, now this becomes trouble. Now, usually by about six months of age, if child sleeps in a different room than you would not see this problem, if parents tried to help the kid, whether with respect to rocking or putting them on there on, you know, to help them fall asleep in any manner, even laying down next to a kid, patting them until they fall asleep, whatever you do. But if you are present, when the child is falling asleep, the child assumes that you were presence is necessary for me to fall asleep. So by about six months, until about six months, it should be usually fine. It’s not a big deal. But after six months, if you, your culture is different than like me in my culture or kids sleep with us. So that’s a different story. But if there’s no problem, right, if your kids sleep with you and the kid is not kicking you in the bed, then that’s fine. You sleep, right? But here, the culture is different. So they want the kid to be sleeping in a different room. If that is what you want to do, then the kids should be left to sleep on his or her own in their own bed by six months of age. Every month after that, it gets tougher and tougher. So usually I see them by about two years or one and a half year by then, it is solidified. It’s very difficult to get rid of this behavior. So that is association type of behavior Insomnia.

Now, limit setting is, as the name says it is limit setting. I mean, the parents don’t have pretty good limit. I mean, yes, this is common. When I see parents are very relaxed, our parents are separated. The child, you know, spends half of the time in a mom’s house off of a time in dad’s house, in one location that is no rule, other location, there’s other role. So they get confused. So there is no limit for them. So usually how do you see this? You see this probably around like eight, nine, 10, 11, 12 years of age kids where they go to bed, but 10 minutes later, they’re out. I want a glass of water. They’ll come out. I want that. I want this. So, you know, I mean, you know, he’s fooling around. I mean, it’s, it’s not true. You don’t need it. You’re healthy.

Dr. Segeleon: I’ve seen that action before, by the way.

Dr. Setty: So that is limit settings and that’s easy to fake. So I do not see most of those things because I’m pretty sure PCPs talk about that. And parents also understand, you know, we don’t have a limit, so, you know, they have to change it, but we have insomnia something very common for me to see.

Dr. Segeleon: What about the teenager that has insomnia?

Dr. Setty: The number one cause for teenage insomnia is inadequate sleep hygiene, especially as we talked about, like with the technology and advancement, and now even with COVID, you know, they have to do homework on the computer. Some may be unavoidable, but mostly it is their willingness to look into the form of Facebook or Twitter or whatever they are doing. They want to do it until they fall asleep. So that is inappropriate obviously. So that is inadequate. Sleep hygiene is the number one cause, and it is increasing in incidents. The number two cause is anxiety and depression. So in adolescents that is a number two cause in most situations, when I see a kid, actually I had to refer them to psychiatry because they have all the symptoms of depression. So we about 85% of the kids with depression, usually present with some sort of insomnia because that may be the primary or primary symptom. That is the first symptom anybody could see, but they are seeing only as insomnia, but they are, somebody is not seeing through that this child actually has a depression, even anxiety. I mean, when they always think excessively like for BR panic anxiety, whatever it is, if they are thinking excessively on the same topic, they just can’t fall asleep. They’re worried about it. So the other insomnia, there are many other insomnia per like us central sleep apnea, like restless leg syndrome or even obstructive sleep apnea. So those are all solid sleep problems, but you will definitely see other symptoms, not just insomnia in those kids,

Dr. Segeleon: Since you brought up apnea, I think let’s, let’s go ahead and talk about that a little bit. We know in the adult world, we, you know, a lot of people are on CPAP for obstructive sleep apnea. As a provider, what should I look for in children that I might suspect obstructive sleep apnea?

Dr. Setty: That’s a pretty good question. So the incidence of obstructive sleep apnea is much more than what anybody could imagine in kids. It’s about 1% to 5%, depending upon which article you’re looking to but that I think is pretty huge. That means 1 to 5 out of every hundred kid has obstructive sleep apnea. When I looked into the incidents too, I felt it was too much. That’s a lot. So there is no way that a PCP should be missing to ask these questions. So obstructive sleep apnea symptoms are very similar to in adults. There is no difference. They usually will present with snoring, apnea, gasping, very restless, sleeping, mouth breathing, and non-restorative sleep. It doesn’t matter how long they have slept. They still wake up very tired in the day. In the daytime, they could be depending upon the age. It is again, a consequence of sleep problems is less than nine to 10 years of kids, they usually present to us as hyperactivity. After that they usually present to us as sleepy. So if somebody is diagnosing a child with the ADD’s, do they want to make sure that they are not dealing with sleep disorders because any type of sleep disorder can present to a provider as ADHD. So that will be a wrong thing to diagnose us without ruling out any sleep issues. So, in general, sleep apnea is diagnosed by sleep studies, but not everybody needs to undergo a sleep study. Why? Because we know tonsils and adenoids physiologically enlarge in size by about four to eight years of age. And they shrink in size because of lymphoid tissue growth. So tonsil centered are pretty good size. They are going to obstruct the operator way. So it’s easy for the provider to send these kids to ENT for tonsillectomy and adenoidectomy.

So then what is the role of a sleep physician? Well, for us, we would like to do a sleep study for everybody who has suspicion for sleep apnea But being only one in the whole of Sanford Health network and our sleep center being very busy. So we do not want to do it. And also it adds onto the cost also now based on American Academy of Otolaryngology, if they have all the symptoms of sleep apnea, which we discussed and also data and behavior and if the child is more than three years old and less than I would say about 9 to 10, because after that, the success of tonsillectomy and adenoidectomy is not great. So I wouldn’t usually refer any child after eight, nine years of age to tonsillectomy… which you might have seen too many adults. They have undergone tonsillectomy, but it doesn’t really help them. Sometimes yes, but most of the times it does not. So, so if these kids are in between these age groups and they’re healthy and the tonsils are big, you can directly refer those kids to otolaryngology to get an operative assessment. And if appropriate, let them take a transistor adenoids. About six to eight weeks later, if they still have symptom of sleep apnea, then they have to come to the sleep center for a sleep study, because that means the symptoms probably are better, but not to an extent that we would have expected. Great. So the other kids whom you should definitely not refer them to us is less than three year old kids because of high risk of surgery, bleeding disorders clearly official malformation because it may be affecting the operator but you don’t want to intervene unless you really know it needs an intervention. Cardiopulmonary issues. So if they have obesity, I mean, you know, the primary reason for them to have obstructive sleep apnea is because of the fatty tissue surrounding the neck. So even if you take out the tonsils, it might decrease the, you know, a symptom of sleep apnea but I do not think it will completely go away. So somebody whose BMI is much significantly higher, more than 95th percentile. So it’s appropriate to do a sleep study for them to

Dr. Segeleon: Great. Well, thank you. And I think you hit upon as primary care provider who should be referred to you. As I was thinking about this podcast today, I heard something the other day that I said, I’m going to run this by Dr. Setty. So I heard something that was interesting to me and it basically and I think it was in probably some very scientific journal, like like on, on the TV news or something like that. But it was basically what it was saying was if you wake up prior to your alarm clock going off, you have had enough sleep. You’ve your body is saying it’s time to get up. That fascinated me because I seem to always wake up before my alarm clock. So I’m looking for reaffirmation here from you. So is that, is that a reasonable comment?

Dr. Setty: The role of sleep is restorative. So in that terms, if you wake up early and if you’re fully restored and you are not tired in the day until you go to bed, then probably that duration of is sufficient for you. Now, National Sleep Foundation is the best place to look for the duration of sleep for the age. Now, although they give a, a range of sleep duration, I’ll say for example, 6 years to have a 13 year old kids need about 9 to 11 hours of sleep. Not everybody gets 9 to 11 hours of sleep, right? But that is just a gauge. And so you have, you know, a range. But I have seen many kids in my practice they need about 11 hours of sleep otherwise they won’t perform well. We have done actigraphy, we have done sleep studies, nothing came up. But if the child sleeps for about 11 hours of duration, he performs great. So that is his need of sleep. And also, I have seen many kids who just sleep only for seven hours. So reinforce them, you know, you have to, you have to get more duration of sleep, but they don’t because he won’t sleep child wakes up in the morning and he is absolutely fantastic, does great in school… So why do worry about that? And so, yeah, the important role of sleep is restorative. So if you’re restored, you’re good.

Dr. Segeleon: I like that restoration. That’s, that’s a good way to think about that. And, and, and it’s true that consistency matters as well, correct? That’s right. So you shouldn’t really sleep 12, 15 hours on the weekend, right?

Dr. Arveity Setty: You bring up another good point too. So you cannot make up a lost sleep. For example, if you lost sleep last night and probably are going to lose sleep tonight, you probably will make it up by sleeping longer tomorrow but not after that. So most kids are adolescents. They think, you know, I’m going to sleep for 15 hours, just like you said on the weekend. So I can make up for all those lost sleep I had the day will not recover that they probably will be called for Thursdays and Friday night’s sleep, but not, but not all the lost sleep for the week.

Dr. Segeleon: I think quite frankly, I think I could talk to you for hours about this. This is such a great topic and we might have to have you back for a part 2, but I want to thank you so much for for your expertise and for your advice. I know that sleep is so very important. You know that as a parent, your own sleep is important, your child’s sleep is important and I know our providers out there get lots of questions. So we really appreciate you.

Host: Thank you, Dr. Setty. Our Called to Care Podcast series focusing on children continues right here with our own Sanford Health experts. Thank you for being here today. We’ll see you soon.

Identifying abuse or non-accidental trauma in kids

Courtney Collen (Host): Hello, welcome to our new medical series ‘Called to Care’ by Sanford Health. I’m your host, Courtney Collen, with Sanford Health News. Called to Care brings forward medical experts who can give fellow clinicians some advice and guidance they can use in their primary care practice and information about when it’s time to refer patients and families to more specialized care.

Joining me for six episodes, focusing on children’s care is Joseph Segeleon, MD. He’s the vice president and medical officer for Sanford Children’s Hospital and a leader in pediatric critical care. Good to have you here, Dr. Segeleon.

Dr. Joseph Segeleon: Good to see you as well, Courtney.

Host: You have narrowed down six timely topics for us. In this specific episode, we’re talking about sentinel injuries and non-accidental trauma. Dr. Segeleon, tell us why you chose this specific topic.

Dr. Segeleon: Unfortunately, in our society and every provider out there knows this, we do see child abuse and almost more importantly, we have this sneaky suspicion that we miss child abuse. So I really thought it would be valuable if we got an expert to give us some advice and some support for how we go about handling this issue.

Host: Yeah. Well, let’s welcome Dr. Jada Ingalls to our conversation. Welcome.

Dr. Jada Ingalls: Thank you.

Dr. Segeleon: Dr. Ingalls. Thanks again for coming and agreeing to talk. We’re excited to have you here today, and I know our providers are going to really find it valuable. I think first of all, I’d like to ask you is what kind of training does a child abuse physician have?

Dr. Ingalls: Sure. So as always, we go through medical school graduate from that, we then match into a pediatric residency, which is three years of training. And then after that, you will apply and match into a child abuse pediatrics fellowship, which is also three years of training.

Dr. Segeleon: Great, thank you. You know, as a pediatric critical care physician, my entire career I’ve obviously seen sometimes just tragic and horrific consequences of child abuse, knowing that most of the providers that are going to be listening to this podcast are outside providers or rather outpatient providers. I know a lot of them often worry about missing child abuse and what signs and symptoms will help me identify the child who could be at-risk. So could you give us a little bit of a overview and some specifics on what do providers look for that makes them suspicious that a child may be being abused or neglected?

Dr. Ingalls: Sure. I always think that one of the most important topics for anybody who sees children in a medical setting to know about is what we call ‘sentinel injuries’. Sentinel injuries are relatively minor injuries from physical abuse, that if they’re not recognized and intervention does not occur to keep a child safe, typically physical abuse will become worse over time and then you can end up with a more life-threatening injury.

Dr. Segeleon: What specific patterns should I look for? So, these are minor injuries that sort of portend to something more significant in the future?

Dr. Ingalls: Yeah, so we typically use a pneumonic that’s called 10-4 Faces-P as a reminder of what are the types of injuries that are part of sentinel injuries.

So 10 stands for bruising or injury to the torso, ears and neck in any child under four years of age. When they’ve done studies that have looked at where on the body do children normally get bruises from accidental injury versus from physical abuse, it’s very unusual for children to get accidental bruising on the neck and specifically on the ears, and then the torso being the chest, abdomen and back. So, those are areas we look for.

Also the ‘four’ stands for any bruising in an infant, less than four months of age. So, the reason that’s important is because infants under four months, can’t roll. So they’re not going to be able to have an injury that a caregiver doesn’t know if they’ve managed to wiggle off of a couch or something and got a bruise from falling, then a caregiver is expected to know that fall occurred. They left them in one place and found them in another place.

Also, we look at the ‘F’ is for frenulum. So there are three frenulum, or frenna in the mouth. So there’s two labial frenulum. So one on the upper lip, one on the lower lip and then the sublingual that’s under the tongue. So whenever I do exams, I always flip up both lips, make sure the frenulums are in tact, lift up the tongue, look under there. If you see any kind of bruising, laceration, injury to that area is often a sign that an infant has had a bottle or a spoon shoved in their mouth. Or sometimes we’ll see it with smothering or suffocation where someone places a hand over the child’s mouth and they’re vigorously moving their head back and forth and attempt to breathe and that tissue gets torn.

And the other area that we look at in terms of bruising to the face would be the angle of the jaw. So around your mandible, if someone grabs a child’s chin or face and is yelling at them can leave two circular bruises around that area. Cheeks, if there’s bruising along like the fatty part of the cheek, that’s an area that’s harder to bruise. So, anywhere that has more fat is not a usual place for an accidental bruise.

Eyelid bruising is also concerning. So your orbital rim should be protecting your eyelids. So if we’re seeing bruising on the eyelid itself, that’s concerning. In infants under a year, subconjunctival hemorrhages can be concerning. So sometimes we’ll see those if somebody has squeezed a baby and you’re increasing their intrathoracic pressure and the vessels will break, you want to always be careful though that it’s not something that happened with birth, go back, review the documentation from the newborn nursery or parents have pictures from that time because that could be a birth-related finding as well, and then pattern injuries.

So pattern injuries of the skin, whether that’s pattern bruising, pattern burn, things of that nature. We think about belt marks, loop marks, hand slaps, those type of things.

Dr. Segeleon: You said something interesting about ears. Could you be a little bit more specific about ear bruising?

Dr. Ingalls: Sure. So ear bruising in kids especially if they’re not mobile is very highly specific for physical abuse because, and by not mobile, I mean not ambulatory, not completely walking independently. And so the way that we see ear bruising in children, when it’s caused by abuse is typically it could be an open-handed slap to the side of the head or a punch or a kick or strike with an object to the side of the head where the ear gets crushed between the object that’s striking the child’s head and the actual skull. And so in order to make sure that you see all of the ear bruising and my routine practice, even when I was a resident and I became aware of this, anytime I went to do an ear exam, I would flip the ear forward to shine the light back there. Because, sometimes it will only be on the back surface of the ear or it could even be on the scalp that’s budding the ear.

Dr. Segeleon: Okay. Thank you. You know, I can’t tell you as, as a intensivist, how many times I’ve seen children injured from child abuse and a common explanation is, ‘the child fell off the couch’. That just seems to be a common refrain that we hear. Can you expand a little bit on what’s kind of accidents are innocent and how, particularly if the injury seems much more than the history, what should we be looking for for the listeners out there? What should they be looking for as far as red flags?

Dr. Ingalls: Sure. So yeah, certainly we know that accidental falls can occur. When I think about accidental, these would be in the category of short falls and by short falls, that means something that’s less than six feet in most cases. And that is where a couch fall would fall into. So when we talk about short falls and there have been studies that have even been done on kids that are admitted to the hospital and have a short fall, whether it’s from the bed in the room, the couch in the room or the crib in the room. And when you look at those studies, the most common outcome of a short fall at home is going to be no injury at all. Most kids are perfectly fine.

If you look at the next level, then you’re talking about, well, maybe they have a bruise on the scalp. Maybe they have a scalp hematoma that’s palpable then after that would be a skull fracture. And then sometimes after that you could have a subdural bleed underneath of the skull fracture, sometimes subarachnoid. And then kind of when you’re getting into things that are more concerning would be a parenchymal injury. We don’t expect a parenchymal brain injury from a short fall without a specific reason. In short falls, that could be a whole talk in and of itself.

But I think, you know, for me, when I come in and I’m thinking about the history and is possible, I always want to know the child’s developmental capability, right? So if somebody says they left them all the way in the back of the couch or in the middle of the bed, is that baby able to roll? Are they able to crawl? Would it be possible asking the parents ‘how high is the bed?’ Cause not everybody has it on a, on a frame could just be lying on the floor. Is there anything on the floor or in the pathway of the fall that the child could have struck their head on? Is there a nightstand, are there objects on the floor toys, other things like that?

Dr. Segeleon: Thank you. Yeah. I think a fair generalization is that if the injury out weighs or seems much more significant than the mechanism, that’s probably a reason to be suspicious?

Dr. Ingalls: It is. And also if the history that’s given to you is not consistent with what the child’s developmental capabilities are, is always a red flag.

Dr. Segeleon: Yeah. Great. Thank you. It good, very good advice. I know as an intensivist when we saw impact injuries, particularly if it was an impact with a skull fracture, we would very often know that there was a mechanism of injury, but of course subdural bleeds that were bilateral, especially in constellation with retinal hemorrhages would be much more concerning. And I know that’ll be a topic for probably another day. So familiar I’m in the outpatient world. And I am seeing children that I have a suspicion that I’m concerned, what, what should I do? Who should I go to do I have to go to … and a lot of times providers are concerned with what if I’m wrong? What if I accused this family that has been coming to see me and I’m wrong? Can you, can you expand a little bit on that for me please?

Dr. Ingalls: Sure. So I think anytime that you have a concern, it can be uncomfortable, especially if you are in a primary care provider because the family trusts you, you may have taken care of all of the kids, even other generations of the family. And you want to, you can be concerned that they may not return to you if you have to make a report. And that is absolutely a legitimate concern. I think we have to always weigh it against the, what is the risk to the child? What if I don’t report this and this child goes home, the abuse gets worse and this becomes a near fatality with permanent disability or death. And so I think you have to consider your responsibility to the child’s safety, but also what is the mandated reporting laws in your state? And so all 50 States have requirements that if you have a suspicion for abuse of a child, that you have to report it, usually that report goes through child protective services in your respective state.

I, for one always think that it is best to tell the family if you’re going to make that report. It is difficult conversation to have, I think families take it better when they are, when they’re told that any, you know, you can try to make it so that they don’t feel like you’re exactly calling them out. Our role is never to say ‘who caused the injury?’ All we say is that there is an injury I’m concerned about. And what I tell them is that legally by the state’s requirements, as a mandated reporter, I have to make a report. Whenever I see this particular finding, that doesn’t mean that I’m saying that ‘you did it’. It’s just saying that somebody else needs to investigate it to find out what happened. We also want to make sure that, you know, we’re telling families there could be additional workup that sometimes a specialist like a child abuse pediatrician has to come in and see if there could be other alternatives, you know, medical conditions that could lead to some of these things.

But usually, I end the conversation stating that I know the family loves the child and they want their child to be safe. We want the same thing. Sometimes the conversation goes very well. Parents understand some of them are even mandated reporters in their jobs. And sometimes it doesn’t always go as pleasant as we would like it to. But at least we’ve told them upfront and then they know that CPS will be contacting them. And it also turns into I think less surprised. I never think it’s fair for a family to just get a phone call or a knock at the door from CPS and not been told that we made that report.

What happens if you make a report and you’re wrong? For you personally, as long as you’re making a report in good faith, you’re protected by the seat statute.

You’re not going to be in trouble. You’re not going to be getting you know, any century because you made a report in good faith. It’s also, I think, important to remember that the system does not 100% rely on us. So you make the report to CPS. The CPS intake worker looks at it, reviews it, the information with the supervisor, and then CPS decides whether or not they’re going to open or not. The vast majority of reports that are made to CPS go through that initial screening process and are never opened. So, you could make a report and the family is never contacted by CPS. If they do decide to open there’s two pathways that it goes into. So it either goes into an active investigation, which is rare and less common, or it goes into family assessment, which is more like what kind of services and support can we offer the family and is not a punitive route

Dr. Segeleon: I know that is something that’s on provider’s minds because you you’re often not a hundred percent sure. So that’s great information. You know, many, many, many years ago, I was a pediatrician for two years actually on the east coast. And I recall during those two years being very concerned about missing a case. You come out of pediatric residency and you understand, and you realize, unfortunately, the child abuse is much more common than is talked about. And I know that a number of my colleagues out in outpatient medicine, we do worry about missing that case and missing those children that are being abused.

Dr. Ingalls: I think it’s always, you know, you can always recognize too, that whatever system you’re working in or what, whoever you’re near, if there is a child abuse center nearby, you can call that clinic at any time and get a child abuse pediatrician to talk through with you what you’re seeing to let you know, if it’s something that they’re also worried about, sometimes that can give you reassurance, or if, you know, occasionally we’ll see things that someone’s worried about. They’re able to send pictures through MyChart, through the haiku app and we can say, ‘oh no, we recognize this as a particular skin condition or something else that someone may not be familiar with’. So I would encourage people also to consider that, to reach out either appear to the care clinic in Fargo or to child’s voice in Sioux falls. We’re always willing to help.

Dr. Segeleon: Great. Thank you. The other thing I wanted to ask you is, you know, a lot of times as an outpatient physician, you’re looking at kids do fall and kids get in injuries. And so frequently it’s broken bones, you know, there’s fractures. Are there specific things that you see on an X-ray that should alert you?

Dr. Ingalls: Sure. So there are some fractures that are highly specific for physical abuse. Those would be post your rib fractures and also any, any fracture in a child that is non-ambulatory, not walking yet.

Dr. Segeleon: Great. Thank you. That’s very helpful. So as you alluded to there’s now a child abuse center and you’re the first child abuse specialist I believe in North Dakota. Is that correct?

Dr. Ingalls: So Dr. Arnie Graf was here for a while and he had left to go to the Mayo Clinic. So I am picking up where he left off, I believe approximately six to seven years ago.

Dr. Segeleon: Oh, well, fantastic. We are so fortunate to have you here in this region, in this community. Why and when would I, as an outside provider, refer someone specifically to your center and how do I go about doing that?

Dr. Ingalls: Sure. So I think you know, we see at our center, any children where there are concerns for physical abuse, sexual abuse and neglect, we can even see kids where their concerns for psychological abuse. And we see cases of torture as well. So anything that you are concerned about, certainly you could make a referral through the the Epic system. There is an order for child advocacy is the way that you would usually find it for us. I believe there is an order also for A Child’s Voice. And then it’s as simple as just putting an order through the chart. If it’s something that can wait, you know, another week or two to schedule, that would be something like, you know, maybe parents have concerned about some sexualized behaviors or something like that. If it’s something you’re not sure whether it can wait or it needs to be seen sooner, you can always call us just directly at the phone number for the clinic or through one call.

We take calls both ways, most physical abuse concerns. I like to know about sooner rather than later, if there’s still skin injury, that’s visible because I would like to have high quality pictures of that that could be taken in my clinic or in the ER in the hospital. And also I want to help providers and get history from them to determine where is the most appropriate place to send this child? Is this a child that needs to go? Are they within the timeframe for a sexual assault kit? They need to go to the ER, is that a child that has a physical abuse injury that may be gone by the time I see them in a week or two, and maybe they need to go to the ER as well. So I personally always just appreciate getting a phone call. I know that takes some time out of the provider’s day, but I think it helps us direct the child to the right place.

Dr. Segeleon: So if I’m a provider and I have maybe just a question or a concern, it would be okay to give you a call and kind of get your advice on a case?

Dr.  Ingalls: For sure. We’re here all the time. We’re happy to take phone calls. We do multiple calls a day. We want to make sure that these kids are safe, that you feel comfortable with the clinical decisions that you’re making.

Dr. Segeleon: Thank you so much. It’s really been great to have you here. And it’s been you’re just a great information source and really helpful.

Host: Dr. Ingalls, thank you so much for your expertise on cases of non-accidental trauma and giving us more insight on when it’s time to make report and refer to a child abuse specialist like you. Our Called to Care Podcast series, focusing on children continues with topics from appendicitis to joint pain right here with our own Sanford health experts.

Dr. Ingalls, Dr. Segeleon, thank you so much for being here. We’ll see you soon.

Learn more

• Sanford Health provides resources to prevent child abuse
• Recognizing child trauma and helping kids cope
• Sanford Health supports safety throughout the heartland

Caring for joint pain in the pediatric patient

Courtney Collen (Host): Hello, welcome to our new medical series ‘Called to Care’ by Sanford Health. I’m your host, Courtney Collen, with Sanford Health News. Called to Care brings forward medical experts who can give fellow clinicians some advice and guidance they can use in their primary care practice and information about when it’s time to refer patients and families to more specialized care.

Joining me for six episodes, focusing on children’s care is Joseph Segeleon, MD. He’s the vice president and medical officer for Sanford Children’s Hospital and a leader in pediatric critical care. Glad to have you here, Dr. Segeleon.

Dr. Joseph Segeleon: Good to see you as well, Courtney.

Host: You have narrowed down six timely topics for us. In this specific episode, we’re talking about joint pain in the pediatric patient. Something we don’t always think about in children. Dr. Segeleon, tell us why you chose this specific topic?

Dr. Segeleon: We are just so incredibly fortunate to have a pediatric rheumatologists, and I think when it comes to joint disease in children, unfortunately very often there’s a delay in diagnosis and perhaps sometimes that’s because of the lack of specialty. So I really thought this was pertinent and important information to get out to our providers.

Host: Well, let’s welcome Dr. Grant Severson to the conversation again, we are so glad to have him here.

Dr. Segeleon: Thank you so much for being here. I’m really excited about this topic and I know that our listeners are as well.

Dr. Grant Syverson: Thank you guys very much for inviting me. I’m excited to be here.

Dr. Segeleon: Because you are the pediatric rheumatologists for the Dakotas essentially. And I think the first one to be in the Dakotas, which should tell us a little bit about the training that goes into pediatric rheumatology.

Dr. Syverson: So I grew up in North Dakota originally which is, you know, probably one of the main reasons I moved back here after my fellowship and my initial foray into the workforce. I went to undergraduate and medical school at the university of North Dakota. And then like most pediatric subspecialists, you do a three-year residency. I did that in Milwaukee at the Children’s Hospital of Wisconsin and then you do a secondary training area called a fellowship and that’s another three-year program. And I did that in Milwaukee as well. The fellowship is really to kind of hone down onto your subspecialty, really become an expert in that field. And it’s very focused. It usually consists about a year, a year and a half of just only clinical work and that could be spread out between the three years or compressed into one year, along with two years of research and that’s really so you can get a good understanding of what’s going on in the field of rheumatology. I was fortunate to work with some basic immunologists in Milwaukee and the field of rheumatology is going through, has gone through a lot of exciting times in the last few decades in particular with therapeutics. The types of medications that we have available today are so dramatically better than we had in the past. And that’s a lot of, a lot of that is due to the immunology work that’s been done and I was fortunate to work on some of that.

Dr.  Segeleon: Great. Thank you. Well, let’s I know everyone’s excited to hear some of these topics, so let’s get at it, you know, you think of joint problems in generally we right away go to older people. So help help me understand what kind of joint issues first off, can children have joint issues and then what kind of issues can they have?

Dr. Syverson: Yeah. ‘Kids get arthritis, too’ is kind of the Arthritis Foundation’s mantra because that’s probably the number one thing that my patients, families, and then when they explain to their friends and family, what they asked them, like ‘I thought only old people got arthritis?’. So I’ve said arthritis a few times. So for myself kids certainly can have joint pain. Like any of us, we can, all everybody can get wear and tear pain. You know, they get injuries, stuff like that. I am specifically interested in what we would call an auto-immune or inflammatory joint pain. And that’s where your immune system is overactive and starts to attack your joints. A lot of people have heard of rheumatoid arthritis. It’s essentially a similar concept in children. We don’t call it juvenile rheumatoid arthritis because it’s distinct from adults. But it is the same concept in that it is the immune system being overactive and causing inflammation within the joint.

Dr. Segeleon: Great, thanks. You know, as you said, kids complain of, of bumps and bruises and, and, and soreness, and there’s that whole concept of growing pains. So for our providers that are listening, when should a provider be concerned, whether that’s a historical or a symptom or give some advice to our providers out there when they should really start to think about joint illnesses or arthritis, as you mentioned.

Dr. Syverson: Yeah. I mean, certainly kids will have lots of, they run into walls and falls and you have bumps and bruises. I think clues for me that are always red flags are when they stop participating activities. Kids love playing and having fun and so they really, really will not stop doing something unless there’s a problem. Obviously, refusal to walk is a huge red flag. Pain if it’s there for multiple days in a row or if there’s some kind of pattern that occurs. Inflammatory joint pain classically has what we call ‘gelling’ phenomenon. So in the morning, patients with inflammatory arthritis will be stiff and they’ll have held limp in a hard time walking, but as they move around, that actually loosens up. And that’s a classic symptom that actually goes from adults to little tiny kids. And that’s kind of the really classic way they’ll present. Things like growing pains, which, you know, are certainly things that I hear about a lot … those tend to be non-inflammatory. So, they’re not associated with being inactive. They occur more randomly. They do not really interfere with day-to-day activities and they really shouldn’t have any difficulty being able to finish things.

Dr. Segeleon: Good to know. Thank you. Are there things as a provider, I mean, obviously you’re one specialist for a very large region in a very large number of patients. Are there some workups that as a provider I should initiate or I should, should start on my own prior to referring to a specialist?

Dr. Syverson: Yeah, certainly. I mean, you’re going to get lots of kids that come into your clinic for joint complaints and, you know, it’s going to vary in frequency from a little tiny kid to a teenage population. Certainly, if a child is coming in and they have a specific area that they’re complaining about, the biggest thing I would do is make sure you’re always trying to do a focused joint exam. And the nice thing about humans is we have, two of everything. So comparing both sides is a really easy and simple way to determine if there really is something you need to be more worried about. Certainly chronicity… I’ve mentioned that before. So, the longer something’s going on, the more you should be worried about it. It doesn’t necessarily mean it’s a terrible outcome, but it’s more likely to be an issue.

And so kind of easy things you can do kind of in the beginning is, you know, it makes sure they if you want to check a CBC to make sure they don’t have a significant anemia, or if there’s not another more serious process going on, I almost always get inflammatory markers like an ESR or CRP. Now you can have arthritis and have normal inflammatory markers. You can have arthritis and have completely normal labs in general because it’s a clinical diagnosis, history and physical. But if you get an ESR and it’s a hundred, obviously you’re much more worried than if it’s, you know, zero or 20 or like that. And then if it’s something where you have a history of trauma, I certainly think getting an x-ray is a good idea. Most kids that have arthritis are not gonna have any radiographic findings on a plain film. If there’s a specific patient that has a specific joint that you’re really concerned about that you think might be arthritis, an MRI is a very sensitive for that. And it’s a little hard, obviously with little kids because you have to sedate them. If you’re going to get an MRI for arthritis. One thing I would say is try to do it with contrast. In the orthopedic realm, it’s a lot of structural abnormalities and non-contrast MRI is perfect for that, but with the inflammatory processes, if you can get contrast that will give you enhancement of the lining of the joint and will really give you some understanding if there is a chronic inflammatory process.

Dr. Segeleon: Great, thank you. That’s really fantastic information. I really appreciate that. And I know our listeners will appreciate that as well. We talked a little bit about arthritis. Are there other illnesses that can affect joints in children?

Dr. Syverson: Yeah, there’s a lot. So arthritis is definitely the biggest subset of patients I see. There are things that some people may be familiar with, including something called Lupus. Lupus is a more systemic illness and certainly arthritis and joint pain can be part of that. There are patients that have muscle inflammatory diseases that will present not necessarily with joints specifically, but they will have pain and achiness that may be felt to be joint-related. And then there are other inflammatory conditions called vasculitis or inflammation of the blood vessels, which can also present with some pain and extremity complaints.

Dr. Segeleon: Where does where does malignancy fit in to this discussion? Can that present as joint pain?

Dr. Syverson: Yeah. And certainly it’s, you know, the one thing we always keep in the back of her head as it is what we don’t want to find out. Obviously malignancy is a very concerning thing. So for me, the things that are red flags that I always consider and think more about malignancy: pain in the middle of the night that’s happens consistently. Not necessarily once or twice a week, but everyday pain that’s limiting activity throughout the day. Not just in the morning or after certain activities. Refusal to walk. Most kids that have arthritis, even if they have bad arthritis, still like to move because that stiffness gets better when they move around. So, kids that have arthritis will wanna be active while kids that have something that some other process going on often will not want to emulate. And then a lot of those other kids will have a lot of other systemic symptoms: they’re very fatigued, they’re pale they’ll have high fevers and things like that.

Dr. Segeleon: Great. Well, thank you. There is one of you for this region and there’s certainly a lot more orthopedic physicians than there are rheumatologists. Can you give our listeners an idea somewhat when the referral should go to the direction of an orthopedist versus a referral to you? And then why don’t you expand on how somebody refers a patient to you as well?

Dr. Syverson: Well so yeah, there are a lot of orthopedic surgeons in, in North and South Dakota and Minnesota and Iowa and Nebraska. And, you know, certainly they see a lot more kids than I do because injuries and non-inflammatory joint pain is far and away, much more common than inflammatory joint pain. And so from my perspective, I talked about that chronicity again, if something’s going on for weeks and weeks and weeks, and it seems to have a pattern that seems to be worse in the morning, it gets better with activity, that’s probably more likely a chronic inflammatory process. If there’s not really a good history of a specific injury, this probably something… obviously kids cannot, aren’t a hundred percent reliable, but you know, that can sometimes be a clue. Patients that have arthritis will present with swelling, but patients that have a traumatic joint swelling or an overused joint swelling, they will have usually some specific incident that they can relate it to, or they will have things like bruising. They’ll have cutaneous changes that you would expect with, you know, trauma. Little tiny kids that get arthritis, which is the most common age group I see between one to five, they come in with a single swollen joint, they almost always go to ortho first, which is completely fine because our ortho colleagues and I, we get along a lot. I send a lot to them and they spend a lot to me. But they almost always come in with a history of trauma in that they’ve fallen off a chair, which is probably just a red herring that got the parent to look at the joint and see that it’s swollen. And it probably was swollen it for a long time. And it’s nothing against the parent. It’s just that because these processes are so gradual, it’s easy to miss that. As far as referral to me, certainly I have outreach clinics in, I see patients in Fargo and Bismarck and in Sioux Falls. You can contact me at any of those clinics and send, give us a call or set up a referral and through the Sanford network or you can call me through OneCall and I’m happy to discuss patients in labs and figure out a way to treat those things.

Dr. Segeleon: Fantastic. That’s, you know, I feel like in pediatrics and probably for all my primary care colleagues out there rheumatology and children is just one of those subjects that we just can’t get enough of to learn and become familiar with because also we don’t see as many children with that. So really your expertise in the community in the region is incredibly valuable for us. You alluded to earlier on about some of the treatments and, and because so many of us aren’t familiar with children with arthritis, give us a feel for perhaps in a general way, some of the treatments and then also maybe the prognosis and how do children do.

Dr. Syverson: Well, the good news is his prognosis is so much better in today’s day and age, and it was even 10, 15 years ago. The likelihood of a child going into sustained disease-free remission for the rest of their life is, you know, probably 10 times better than it used to be. The approach is, it kind of depends upon how many joints are involved. So if childhood has a single swollen joint, you can be more conservative than a child that has multiple joints. Joint injections with steroids or something we do, those can be helped very, very helpful. Obviously again, with kids, you want to be judicious because you want to not make it. You want to make it as a less stressful experience as possible so we do those with sedation a lot, and most of the time kids tolerate them very well.

We use a lot of non-steroidals. Neproxin is probably the one people hear me say the most, because if you want to get an anti-inflammatory effect, you need to take it consistently every day for the set amount of time and approximately twice a day whereas ibuprofen is four times a day. After that, then we start to getting into therapies that we cause called disease modifying drugs. So methotrexate is probably the one that’s been around the longest and rheumatology it’s used in a lot of different areas in medicine. The good news is it has a really long track record and it has a really good safety profile. Does have a lot of side effects as far as stomach upset and that is probably the biggest limiting thing is that some people will get some associated nausea, but it works really well. And then we’re probably all familiar if you watch any television at all of all of these newer commercials that are called biologics Humira, Embryl, Zeljanz, Cosentyx, all these medications that are on TV all the time that for adult arthritis. The good news is they’re on TV all the time because they’re super effective and they work really well. And over the time we’ve been able to do studies in children that show they’re as equally effective, and those are really have revolutionized peds rheumatology. If you go to, I always tell the families, this… there’s a camp for kids with arthritis. We have one in Minnesota for South Dakota, North Dakota and Minnesota patients. There’s one in Wisconsin, one in Illinois, all over the state country. If you were to go there 20 years ago and look at the campers versus now, you know, you would know who edited arthritis 20 years ago in today’s day and age, you go to camp, you don’t even know. And for me, that’s one of the most fulfilling things. And it’s one of the biggest reasons I went into rheumatology is just that we can do so much and make such an impact for kids that have those diseases.

Dr.  Segeleon: Well, thank you. That’s that’s a great message and a great positive way to end this. I want to thank you for first off, I want to thank you for being here. Our children benefit from your experience and benefit from the care that you provide. And we’re very grateful that you’re here. And I know there’s a number of providers out there that have, have learned a lot in the last 20 minutes and really interesting information. For many of us information that is is much needed. So I will turn it back over to Courtney

Host: Dr. Syverson, it was great to meet you and to hear more about your specialty. Thank you for being here. Thanks a lot. It was really fun are called to care. Podcast series. Focusing on children continues with topics from sleep hygiene, to non-accidental trauma right here with our very own Sanford health experts. Thank you both for being here and for all you do. Thank you. We’ll see you soon.

Discussing antibiotic usage in primary, urgent care

Courtney Collen (Host): Hello, welcome to our new medical series ‘Called to Care’ by Sanford Health. I’m your host, Courtney Collen, with Sanford Health News. Called to Care brings forward medical experts who can give fellow clinicians some advice and guidance they can use in their primary care practice and information about when it’s time to refer patients and families to more specialized care.

Joining me for six episodes, focusing on children’s care is Joseph Segeleon, MD. He’s the vice president and medical officer for Sanford Children’s Hospital and a leader in pediatric critical care. Glad to have you here, Dr. Segeleon.

In this episode specifically, we’re talking about decreasing antibiotic usage in urgent and primary care. Dr. Segeleon, first, tell us why you chose this topic.

Dr. Joseph Segeleon: Well, I think anybody who takes care of children and importantly takes care of children’s parents often have the issue of does my child need antibiotics or don’t they need antibiotics and that can be a real difficult judgment call. I think that our expert today will really help narrow that down and provide some valuable guidance.

Host: And speaking of, let’s welcome Dr. Fernando Bula Rudas to the conversation today. Good to see you.

Dr. Fernando Bula-Rudas: Good to see you. And thank you for having me here.

Dr. Segeleon: At Sanford Children’s, we’re really just incredibly fortunate to have some, some great pediatric infectious disease physicians who really are the experts in, in febrile illnesses and infectious illnesses for children, both in the hospital and also as an outpatient. And so that’s why I thought that Dr. Bula-Rudas’ expertise would be a great way to tip off this series and it gives some great advice for providers. Dr. Bula-Rudas, maybe perhaps we’ll start by just saying, what is a pediatric infectious disease specialist? What kind of training have you had?

Dr. Bula-Rudas: So just as he says we treat mainly infectious diseases in children. We treat both outpatient and inpatient. We combine both of our settings complicated infections in the hospital. Also we do infection prevention, the strategies to prevent healthcare associated infections and also we manage the outpatient setting, kids that do not need to be admitted and can be managed as an outpatient.

Dr. Segeleon: Thanks. I know with with my own children and certainly when you talk to other parents it seems like kids are sick a lot, especially when they’re young. And there’s a fair amount of pressure when kids have febrile illnesses, especially with whether it’s getting back to daycare, parents going back to work permission to go back to school. So I can feel for our providers on the call who really get pressured a fair amount about antibiotics. What guidance could you give, first to our providers, on when is it appropriate to give antibiotics or I think I suspect where you’re going to go more approach more importantly, when is it not appropriate?

Dr. Bula-Rudas: Correct. So it is a very valid concern for parents to think that, okay, ‘what is wrong with my child? I just feel that my child or my baby’s sick all the time, especially if a child is going to, to daycare and being exposed to too many viruses’. I take it as sometimes as being sign off like as a sign of being healthy. That means that your immune system is responding to agents, foreign agents that are coming in contact with, with that infant. And then they’re responding, you know, in a way is to say that they’re creating that immunity. So as long as they were like non-complicated in viral infections that the child, once the fever is down, is back to normal self and, and playing, that is a very reassuring sign. But I can understand the, the valid concern that the parents can have and, especially if my child is well for, you know, one week, then I feel like it’s, you know, just like boogers and you know, a runny nose for the whole winter.

Dr. Segeleon: So, I take it, you’re talking about upper respiratory infections, which kids get a fair amount of. So how do I, if I’m a provider and I see a parent and they have a URI, and there really is pressure to get back to school or where there really is pressure to get back to the daycare, how do I make the visit less transactional and lower their expectations that an antibiotic is going to one make their child better right away? And two is, is the right thing to do?

Dr. Bula-Rudas: Correct. So these type of illnesses, as I mentioned, they were mostly viral, they were mostly caused by a virus and so antibiotics are not the treatment for, for viruses. So the parent is concerned and I think one of the very important issues to manage in this type of visit is to communicate well with parents. Give them the reassurance that yes, your child is sick at this moment, may not feel well, may have like some fevers, not being in the best state of health. I acknowledge that there are some symptoms that I can manage, like the fever, like the runny nose, maybe if there’s like some cough, how to help parents manage that. But also reassure them that antibiotics would not make them feel better or would not treat the specific viral infection that they have.

Dr. Segeleon: And this is specifically after you do an exam and rule out any specific signs of bacterial infection, correct?

Dr. Bula-Rudas: Exactly. We’re talking probably with a child that about our child that the physical exam does not point into a complicated or, you know, a more serious bacterial infection.

Dr. Segeleon: Now, what about, I often get asked about temperatures, right? Fever. Is there a certain temperature that you know, parents, especially if the fever is quite high, parents get more nervous about an illness. Does temperature at all weigh into the decision about antibiotics?

Dr. Bula-Rudas: Exactly. So well, first of all, is one of the things is to have a fever. We make the recommendation of temperature above 100.4-degrees Fahrenheit. That becomes a fever. So then parents can say, ‘well, my child has, has a fever’, any temperature below that we can like probably, you know, ask the parent if they gave like any antibiotic or any medication to to lower the fever, to make sure that there was no fever at home. And then by the time they get seen, the fever has, has gone down.

Dr. Segeleon: A lot of times you do hear patients talk about that, you know, we’ve, we’ve seen children that have been on a lot of antibiotics. I think some of the things that can be used to advise parents is that antibiotics are not without their own consequences and side effects, right? So what are some of the things that we can tell our parents so that they’re more educated about the, the potential negative side effects and aspects of antibiotic use?

Dr. Bula-Rudas: Exactly. Joe, I wanted to mention some numbers to show the importance of the antibiotic prescription. So a study that was conducted by the Pew Trusts and the CDC found that in the United States, approximately 150 million visits a year and then adults and children have at least one antibiotic being prescribed in those visits. That accounts for 13% of all visits for, for outpatient visits in the U.S. And they also found it that 30% of these antibiotics that were prescribed were considered unnecessary or not indicated, based on the clinical findings on that. So, it is important to know that there is an antibiotic over-prescription in this case. And antibiotics are by no means, you know, a 100% benign medication. They carry side effects as any other medication can have. And this side effects can be, in the short term, can present in the short term adverse events, more commonly seen are rashes or GI disturbances, like abdominal pain diarrhea. The frequent use of antibiotics can develop to a more serious condition, which is the clostridium difficile colitis which is a more serious condition. But also can affect the blood cells decreasing the, the neutrophils. Some antibiotics have the risk of creating renal problems. So they are by no means benign. And then in the long term, what we are seeing as the problem of anti-microbial resistance, that superbugs…

Dr. Segeleon: Superbugs.

Dr. Bula-Rudas: Superbugs, yeah. What are the called the superbugs and one of the, you know, interesting data about, about the antibiotic prescription in the U.S. is that basically any child by the age of two, like about like one child or every child in the U.S.by the age of two would have received at least one prescription for antibiotics and in their lifetime.

Dr. Segeleon: Yeah. And I, I know the superbugs and the resistance we read about that quite a bit. I also, I know I’ve read research on how really is the single episode or a single course of antibiotics can affect the microbiome is as well. Is that right?

Dr. Bula-Rudas: Exactly. There are many studies on the, on the microbiome and especially those have been done in newborns, in premature babies, that receive antibiotics in the NICU. And these works have shown that the colonization with this microbiome, or what we call the good bacteria, is completely different than those babies that have received antibiotics early in life. To this extent, we are not quite sure what will be the impact of, of that, but certainly those differences are, are, you know, are going to create like some sort of consequences. And also, you know, and as I said in the long-term, we’re probably seeing the children that are being exposed very early in their lives to multi-drug resistant to bacteria, to the superbugs. So those are children that are going to need you know, very specific antibiotic to treat multi-drug resistant infections.

Dr. Segeleon: Well, thanks. Yeah. I, I mean, you, you can’t really pick up a magazine without reading about microbiome and the importance of your, your own flora in your gut, and certainly antibiotics disturb and can change that so I appreciate that insight. Thanks. And I think that helps give our providers who are listening information that they can use with parents because really that’s throughout the lay literature.

Okay. Let’s shift gears. We talked about when not to give antibiotics. So what are some of the things you can offer to the providers listening… What are some of the indications to give antibiotics? And if you want to do that by either severity or grade of illness, or if you want to go through some specific conditions, that’d be awesome as well.

Dr. Bula-Rudas: So you’re absolutely right. I mean we know that for example, in children, vaccines have caused a decrease in the bacterial causes of infection. I’m talking specifically about acute otitis media, about ear infections. Mainly the pneumococcal vaccine and Haemophilus influenza type vaccine have created a major impact in decreasing like this type of infections. So mostly those ear infections are going to be viral. However, there are specific indications where we want to give antibiotics in this particular situation. For example, when there is an infant, when there’s a child, less than two years of age, we have to be more cautious because of the severity and the complications that that can cause. So if we have a bilateral ear infection, that is an indication of treating with antibiotics in an infant. If we have you know, for example, a urinary tract infection that is going to be an indication to treat with, with an antibiotic.

Dr. Segeleon: What about fluid behind the ears?

Dr. Bula-Rudas: So fluid behind the ears depends on like the clinical exam. It it takes skills to make that diagnosis and to be able to visualize, and then also the severity of the, of the illness. If we have fever for more than 48 hours, if we have pain, we have to check that the child for example, is as immunized or if there’s a guarantee of good compliance and, and follow-up. So parents still can be instructed in this type of situations on like when we can wait and we can watch, and you can have a follow-up in a couple of days, and I can check the status of the ear to see if the patient needs antibiotics.

Dr. Segeleon: Great. Well, thank you. I know our in both the acute care world, as well as primary care often see children with sore throats, and the question is ‘strep or not strep … tonsillitis or not tonsillitis’? Frequently the discussion of antibiotics comes up when it comes to sore throats. Can you get shine some light on it for us, for our providers that are listening?

Dr. Bula-Rudas: Yes. So absolutely as I have mentioned, you know, many times, and in this conversation is like the number one cause of pharyngitis is a virus is like viral pharyngitis. In school age, children, and, and mainly those like four years of age and older, then they start having the classic strep throat. And that presents of course, with classic signs and symptoms that are not consistent or that do not represent a viral illness of viral pharyngitis. So when we have like this type of clinical presentation than a basic simple test, that is the, the strep test, the rapid strep test would give us like valuable information in this patient to start the antibiotic or not. So we basically have the means to, to have an answer in a couple of minutes in order to start or to prescribe an antibiotic in this specific situation. On the contrary, kids that are less than three years of age is not routinely recommended to do this test. We know for many reasons that these patients, these children do not get, or do not have the receptors to create the complications of these infections so then antibiotics or the tests are not recommended.

Dr. Segeleon: So that’s, that’s good to know. So children, less than age three routinely should not be checked for strep throat. Is that what I heard?

Dr. Bula-Rudas: Yes, that is correct.

Dr. Segeleon: Great. Okay. And what about, are there other symptoms that would lead you away from doing a rapid strep or a strep throat or throat culture?

Dr. Bula-Rudas: Cough? The nasal discharge and symptoms are mainly consistent with with a viral upper respiratory infection.

Dr. Segeleon: Great. Thank you. I guess the last thing I would want to cover is blood cultures, or when do you culture, particularly for our colleagues who are working in urgent cares or perhaps ERs, is there an indication for a blood culture in a certain population or a certain degree of illness? And do you give antibiotics when you culture? Can you, can you shed a little light on that information?

Dr. Bula-Rudas: Yeah, so that will depend especially on a specific specific situations and mainly the age of the, of the child is one important factor to consider there. Then the next factor I would say is the, the severity of the illness, how the child is presenting are the vital signs abnormal? How many days of fevers have, have there been there? Blood cultures can be very valuable in patients, immunocompromised patients who have central lines and they present to an acute care setting to determine if there is a line infection or if there’s another bacteria causing more trouble there. They’re not routinely recommended for example, a patient that that has clear signs of, of a viral URI and the fever is caused, or the fever is caused by an ear infection, we don’t necessarily need to get blood cultures in this type of situation. So to summarize, I would say mainly the age: we want to get a blood culture along with all the tests in newborns and in particular cases in some infants and toddlers, depending on the severity and the age as well.

Dr. Segeleon: Oh, I know when I, when I trained, which was just a little bit, little, few years ago, I guess when I trained we use that eight weeks, you know, a true fever in a child less than eight weeks was was a cause for alarm and some real significant evaluations. Do we still use the eight weeks or has that shifted lower?

Dr. Bula-Rudas: So as, as of now, they’re like, you know, every institution manages based on their risk, they establish their own criteria. But I would say that caught off where no one has any doubt about it as the four weeks and below, but then, you know, we have, okay, what is a five week old baby? What if the baby was not born full term, we’re dealing with some situations that, yes, we probably need to get a blood culture and further evaluation.

Dr. Segeleon: So really use your clinical judgment, especially with those infants is what it sounds like.

Dr. Bula-Rudas: Exactly.

Dr. Segeleon: Great. Well, really thank you for the information. I feel like we could talk about UTI and VCU, GS and bronchitis and pneumonia, and I think the list could go on and on, but really appreciate your insight. I know this is the pressure about to antibiotics is really a real one that affects many of our providers, and they often have those somewhat difficult conversations with parents about why they’re not prescribing an antibiotic. I guess to close up, I would ask you when should a provider refer a patient specifically for an evaluation by a pediatric infectious disease physician like yourself?

Dr. Bula-Rudas: Yes, Joe. I want to hold on that question just to you know, follow up on a comment that you just, just that you just made in terms of providers probably feeling the pressure from the parents on, on one end on antibiotics. I would say to providers that parents want your expertise, or they’re looking for your expertise and your expert advice, and they would follow most of the times, whatever, you know, a provider has to say and education and the language to communicate is key into reassuring the parents and saying your child is ill right now, but I don’t think your child needs antibiotics and offer that follow up opportunity, an alternative gave me a call in a couple of days, or I want to see you in a couple of days and see how things are going. And we’ll determine if there is the need for antibiotic.

Now going back to your question yes, we do see, you know, referrals from our community. One of the main things that, that we see is like prolonged fevers or recurrent infections. With prolonged fevers, what we see in disease referrals are patients, children who have more than one week of fever and despite laboratory workup imaging multiple physical exams, there’s no clear evidence or where this infection is coming from. So, we might be dealing with a more serious situation. And then yes, we would like to evaluate and and see what are the risks and what are the potential infections or causes for, for these fevers. Then with the recurrent infections, as we talked about that child that is probably sick all the time, sometimes those recurrent viral infections are not that concerning, but if my child is having positive blood cultures, if my child is having recurrent urinary infections or recurrent confirmed pneumonias with x-rays, then that’s something that can raise a concern. There is my child dealing with with an immunodeficiency or there’s something wrong with the immune system that they’re not able to respond well or it’s causing this recurrent infections. In the region that we live, we have infections that are transmitted by animals and by insects and those infections sometimes require like specific laboratory workup or a specific imaging and we would like to help into those infections to treat with the right antibiotic and establish the appropriate risk for that patient.

Dr. Segeleon: Good information. Thank you.

Host: Dr. Segeleon and Dr. Bula-Rudas, thank you so much for your expertise on this topic.

Our Called to Care podcast series focusing on children continues with topics from appendicitis to joint payments and many more right here with our Sanford Health experts. Thank you both for being here and for all that you do. We’ll see you soon.

When an appendectomy is necessary, less invasive

Courtney Collen (Host): Hello, welcome to our new medical series ‘Called to Care’ by Sanford Health. I’m your host, Courtney Collen, with Sanford Health News. Called to Care brings forward medical experts who can give fellow clinicians some advice and guidance they can use in their primary care practice and information about when it’s time to refer patients and families to more specialized care.

Joining me for six episodes, focusing on children’s care is Joseph Segeleon, MD. He’s the vice president and medical officer for Sanford Children’s Hospital and a leader in pediatric critical care. Glad to have you here, Dr. Segeleon. Today, we’re talking about cost-effective diagnosis and management of acute appendicitis.

Dr. Segeleon, tell us why you chose this topic.

Dr. Joseph Segeleon: You know appendicitis is something that a lot of providers see and, and you hear about, and that’s, it’s not uncommon for a child to have appendicitis or to need a appendectomy. So, I thought it would be really useful to get a pediatric surgeon’s perspective of this common condition.

Courtney Collen: Let’s welcome, Dr. Adam Gorra to the conversation today.

Dr. Segeleon: Dr. Adam Gorra, welcome.

Dr. Adam Gorra: Well, thanks for having me.

Dr. Segeleon: We really are glad to have you here, and I know our providers are quite excited to listen to what you have to say. What should we start off by telling us a little bit about what is the training for a pediatric surgeon?

Dr. Gorra: As a pediatric surgeon, we have to get board certified first in  general surgery. So that is usually five years of training after medical school which covers all aspects of general surgery: pediatric and adult. And then it requires more advanced training and it fellowship in pediatric general surgery. And that covers any condition from neonatal congenital anomalies all the way up through usually 18 years of age and trauma, malignancies, cancer surgery, thoracic surgery… so, we really cover a broad spectrum of cases in ages of, of patients. I did my general surgery training in Portland, Maine at Maine Medical Center. And then I did my fellowship at Omaha Children’s Hospital in Omaha.

Dr. Segeleon: Well, great. Thank you. And, and how many pediatric surgeons do we have here at Sanford?

Dr. Gorra: We have three, three board certified pediatric surgeons in our practice here at Sanford Children’s.

Dr. Segeleon: Great. So I, you know, I think the Sioux falls market has three pediatric surgeons and the Fargo market has two, I believe. Is that correct? Great, super well, let’s go ahead and get onto our topic. You know, appendicitis is something we all learned about in medical school and, and certainly a number of our providers see children with appendicitis. Maybe you can expand it and some of the new things and the, the current perspective on the management of appendicitis in children,

Dr. Gorra: Well, appendicitis obviously is a condition that we’ve been treating for centuries. There’s been a lot of advancements in how we care for it surgically over the last 20 to 30 years with the advanced minimally-invasive techniques. And I think those techniques started in adult surgery and quickly expanded into pediatric surgery as well. So that would be the big advancement from a surgical perspective and how we manage it would be more minimally-invasive approaches. But even so, we’ve actually really kind of streamlined our medical treatment of complicated appendicitis as well, to the point where we have efficient, cost-effective techniques, management protocols to get these patients through the hospital and out of the hospital, as you know, with fewer complications. A lot of people come to us with appendicitis and they think that the, they think it’s a dire surgical emergency that child’s potentially, you know, they hear the word sepsis, and they say things like that and the child’s gonna, you know, on death’s door. In reality we’ve really become, we’ve really become adept with modern antibiotics and sort of and how we manage these patients post-operatively to the point where I always reassure the parents that every single one of these patients is gonna get better. It’s just, sometimes it takes a little longer for some than others.

Dr. Segeleon: Great. So, I think that a lot of these patients present to their outside emergency department. For our providers that are listening, what should the workup entail for the patient that you’re concerned about appendicitis?

Dr. Gorra: I think the most important thing is as always it’s a thorough physical exam and history, you can get most of the diagnosis, you can arrive at a really narrow it down pretty quickly with a really good history and physical exam. And the classic findings of right, lower quadrant, paraumbilical pain rating, eventually rating to the right lower quadrant right lower quadrant point tenderness associated with nausea, anorexia, vomiting and eventually fever. These are all sort of classic signs of appendicitis. And there aren’t a lot of things that cause us in children so if you really focus on this sort of constellation of signs and symptoms, you can narrow it down pretty quickly. And really then, then it’s just about getting some confirmatory testing. With modern imaging cat scans are extremely sensitive or modern cat scans can really pick up even the earliest appendicitis and so it is easy and tempting to just go right to a CAT-scan to sort of confirm your suspicion. But if you’re tempted to do that, you may end up getting a lot of CAT-scans in patients who don’t have appendicitis. So they may have a few of those symptoms, but not really the whole constellation that really raises your, your real raises your suspicion. You know, that, that this is appendicitis. And so you end up getting a CAT-scan you end up potentially getting cat scans on patients that don’t need it, or don’t have appendicitis. And you also may end up ordering cat scans on patients that are so obvious that they have appendicitis, that it really wasn’t a helpful test. So we’ve developed some the pediatric surgeons had sort of led the way in developing workup protocols to minimize radiation and streamline the process to really hammer in the diagnosis. Now there are going to be some patients that still end up getting cat scans because they don’t fit the classic presentation, and we do get fooled occasionally. But with the use of these protocols and these algorithms, we have been shown we’ve shown that we can really reduce radiation in children and, and long, big large-scale studies have demonstrated that radiation significantly increases the risk of long-term malignancy, specifically lymphoma. There’s some concerns about that. So whenever we can avoid radiation, we like to do that. Of course, ultrasound is a modality that is relatively low cost and zero radiation and risk risk to the patient. And that’s something we’re certainly have been emphasizing here locally and throughout the region with our referring providers.

Dr. Segeleon: Well, I’m really glad you hit on the CT and the radiation subject, because I think you see that a lot in the consumer literature and in the lay press. I think there’s a lot of parents that are, that are quite informed about that and of course in children’s hospitals, we do have the capability to limit radiation and give appropriate dose radiation based on guidelines. So, I appreciate that. And, and thank you.

You spoke a little bit about ultrasound and the role of ultrasound in the workup of appendicitis. Could you expand that a little bit? Particularly, do I sense there’s an expertise that’s required, or just expand a little bit on ultrasound with appendicitis?

Dr. Gorra: Really the, the number one thing is you need, you need access to an ultra sonographer. And many facilities have that during the day during the weekday. Many of them don’t have many facilities or in the, in the region, don’t have access to that at night or on the weekends, but when they do have access to it, it’s a, it’s an excellent first step in, in working up appendicitis. And you will be able to pick up the signs of appendicitis on ultrasound on most patients. And then there will be some patients who still require some additional imaging or further workup. Yes, it does require an ultra sonographer that can identify the appendix or the secondary signs of appendicitis within the abdomen. Studies have shown that the more they do it, the better they get at it. So, that’s why we encourage our providers that are seeing these patients in the emergency department or in urgent care centers, or even in clinics to get the ultrasounds when they suspect appendicitis, if they have access to an ultra sonographer to really get in the habit of doing it because the more they do it, the better they are, the better they will get at it. Pediatric centers do a lot more ultrasounds on children than general hospitals do and that’s been well documented in the literature well studied in the literature that children who come to pediatric centers are more likely to get ultrasounds and less likely to get ionizing radiation in their workup. And so we encourage our referring facilities to utilize that option when it’s there.

Dr. Segeleon: Well, great. Thank you. That’s, that’s very helpful. Now, before we get to, to surgical techniques or the type of surgery that you do, are there any patients where the diagnosis may not be as straightforward?

Dr. Gorra: Well, there’s certainly patients who have complicated histories. If they have prior surgical histories or other significant co-morbidities, congenital anomalies, it certainly raises, you know, increases the number of possible etiologies of their, of their symptoms. Most of the patients that come to see us don’t have a prior surgical history. We care for a lot of patients that have complicated problems, but, you know, statistically speaking, most kids out there have no surgical history. So, most of the kids are coming to care without any really a history of surgery on their abdomen or any other major medical comorbidities. But there is one subset of patients that can, that can require a little bit more thought. And those are females, especially adolescent females. The adnexal pathology that ovaries uterus specifically the ovaries and the fallopian tubes can certainly bring pathology that will mimic appendicitis. And so those, those patients tend to require a little further investigation. That may just be where if you have a 14 year-old girl with classic right, lower quadrant tenderness similar to a 14 year-old boy, you may not do any further imaging on the boy, but on the girl you, you want to rule out a benign nonsurgical GYN issue. And so you’ll confirm that with an ultrasound, probably the first step. But there are many times where boys in that adolescent age would come to see us and they’re so classic that we don’t even do any further imaging it’s the girls that typically require and that age group, especially the adolescent girls, would require probably more, more likely to require a little bit more of a workup.

Dr. Segeleon: Great, thank you. That that’s, that’s very helpful information. I know that the surgical technique alone in appendicitis has just changed dramatically and has evolved over the years from open to laparoscopy, if you would, for our listeners in, in sort of a general way, give us current state, as far as the technique, how long does a child usually stay in the hospital? When do they get back on their feet? When do they get a normal diet, those types of things, if you would please?

Dr. Gorra: Sure. It used to be patients would always get an open 30, 30, 40 years ago. Patients would always go got an open, right lower quadrant incision over McBurney’s Point and do an open appendectomy. And then with the advent of laparoscopy quickly, laparoscopic surgery became kind of the standard. Then in pediatric surgery especially, the standard is accepted within our field is a laparoscopic approach. That allows for a quicker recovery time, less pain, smaller incisions and traditionally the laparoscopy has been done through three ports. So, it’s usually one port in the umbilicus, another port typically above the super pubic area, and then third port in the left lower quadrant. And one of these ports being 12 minutes millimeters in size, and the other two being 5 millimeters in size. And that’s sort of been a standard for at least a decade or more maybe 15 years in pediatric surgery. That that’s kind of the accepted standard there. I don’t know any pediatric surgeons who are board certified now that are doing open appendectomies upfront. But recently, we’ve been able to develop techniques of single site laparoscopy, which is just through the umbilicus itself. So we put a special device through the umbilicus and we’re able to insert the laparoscope and a couple of instruments, and we’re able to retrieve appendix all through the umbilicus with an incision that’s about two centimeters in one and a half to two centimeters in length. The incision ends up kind of getting buried in the center of the umbilicus. And typically within four to six weeks, they heal with the healing. It’s difficult to tell the patient the child even had surgery. So there’s a cosmetic benefit to that, to that, but I believe there’s also a real benefit from a surgical morbidity standpoint in terms of pain control and also I’ve seen, in my practice, very few wound infections when we go directly through the center of the umbilicus. The center of the umbilicus has no fat plane so we avoid going through a fat plane. Whereas when you go through other other regions of the abdomen especially in patients who have a little bit more subcutaneous fat, there’s sort of that dead space there, then that’s an increased risk for postoperative wound infection, especially in the setting of perforated appendicitis. So, we’ve seen very few surgical site infections with single site laparoscopy. Obviously patients and family and parents love the idea of a minimally invasive approach with almost no scarring long-term. So overall patient satisfaction is excellent. Complication rate is no different and we can manage perforated appendicitis or non-preferred appendicitis equally. In terms of postoperative care, we’ve been able to fast track this to the point where for most patients with non perforated appendicitis. We’re able to get them home within 24 hours and typically I try to get them actually discharged from PACU. So as if it were a day surgery and that’s really any time of day. So if I were to do an operation at 11 o’clock at night, and it was acute appendicitis, I tell the family I’m willing to send you home from the recovery room. There’s really no real major advantage to keeping you in the hospital because we don’t give any post-operative antibiotics in that setting. And it’s mostly about pain control. With a single site these patients go home on Tylenol and ibuprofen. For patients with more complicated appendicitis with perforation or abscess, they do require a stay in the hospital typically it’s 72 hours minimum to get IV antibiotics and there’s a significant risk of postoperative abscess of about 30% in those patients with a perforation and keeping them on antibiotics for a period of time decreases that risk. We can get them home within 72 hours on oral antibiotics and most of them do well. They will develop a a postoperative abscess and the advantage of being in a facility like this is we have access to seven days a week access to interventional radiologists who are able to manage our postoperative abscesses with CT guided drainage and that allows us to take care of the inter abdominal abscess without another operation. It’s very rare that we have to take a child back to the operating room for an intro dominal abscess. Our radiologists here are excellent, they provide timely care and that’s a huge advantage to being in this facility that they can get that full spectrum of care of no matter how complicated the disease process is.

Dr. Segeleon: Well, well, thank you that well, it’s pretty amazing. So you can get operated on for appendicitis and go home essentially the same day. That’s pretty, pretty startling, and really speaks to the evolution in our, in our care, our workup or complications. I know it’s always great to get patients up on their feet and home where they can, where they can heal.

Pediatric surgery is a, is a is a valuable and incredible resource for our region but there’s only a few of you here. So give our viewers, or give our listeners a bit of an opportunity to understand when should a provider call a pediatric surgeon? So in general, what types of things should they refer for a pediatric surgery?

Dr. Gorra: We care for a broad spectrum of diseases and conditions. Like I said before, and anything from inguinal hernias in babies up through skin lesions in teenagers, chest wall, abnormalities in teenagers… there’s a huge broad range of conditions that we care for. I really think, if there’s a provider out there, whether they are a family practice doctor or a general, a general surgeon out in the community who sees a condition that they just, they don’t see on a regular basis, they haven’t seen in a long time, they feel that they probably could care for it, but they’re not necessarily exposed to this on a, on a routine basis, we’re happy to take the phone calls. First of all, we’re happy to take the phone calls and guide you through what would be best for the patient. But we’re also always willing to willing to see those patients because we, there’s three of us here. We’re on call 24 hours. There’s always one of us here on call 24 hours a day and we have access to all our sub-specialists here. And so really, if there’s ever a doubt in your mind about, about what’s going on, we’re happy to see the patient. Including working a patient up for something as simple as appendicitis before you order that cat scan, or before you make that transfer call you know, that the decision to transfer the patient, we always happy to, to kind of walk you through that on the phone and make sure that we’re able to deliver that care, even if it’s sort of remote guidance. If we’re able to deliver that care that we would provide here locally, and if they need to come here and we’re always happy to have them.

Dr. Segeleon: Well, thank you. That’s very helpful. And I know that here at the children’s hospital, we benefit as well from having pediatric anesthesia who works with you and can help in that recovery. And so those are very beneficial. Thank you for all you do. The pediatric surgeons are also extraordinarily involved with pediatric trauma and with safety across the state, and really a valuable resource that our colleagues benefit from, but also, and more importantly, our patients and families benefit from. So thank you so much.

Host: Dr. Segeleon, thank you. Dr. Gorra, thank you for your expertise and for all that you do here at Sanford.

Dr. Gorra: Thanks for having me.

Host: Our Called to Care podcast series focusing on children continues right here with our Sanford Health experts. Thanks for being here. We’ll see you soon.

Pediatric mental health

Courtney Collen (Host): Hello, welcome to our new medical series ‘Called to Care’ by Sanford Health. I’m your host, Courtney Collen, with Sanford Health News. Called to Care brings forward medical experts who can give fellow clinicians some advice and guidance they can use in their primary care practice and information about when it’s time to refer patients and families to more specialized care.

Joining me for six episodes, focusing on children’s care is Joseph Segeleon, MD. He’s the vice president and medical officer for Sanford Children’s and a leader in pediatric critical care. Good to have you here, Dr. Segeleon.

Dr. Joseph Segeleon: Wonderful to see you again, Courtney.

Host: You have narrowed down six timely topics for us. In this specific episode, we’re talking about pediatric mental health. Dr. Segeleon, tell us why you chose this specific topic.

Dr. Segeleon: I think that if you follow both the lay literature as well as if you follow public health concerns, mental health – particularly in children – is becoming an increasing concern because of the alarming numbers. We’re seeing serious mental health issues, not only in a larger volume of children but also in younger children. And that’s why I thought it’d be great for our providers to get some insight into this subject.

Host: Let’s welcome Dr. Jennifer Haggar to the conversation. Thank you for being here.

Dr. Jennifer Haggar: Hi, thanks for having me.

Dr. Segeleon: Dr. Haggar. Oh, it’s great to have you here. And it’s wonderful to see you again. I think this is a topic that’s been on everybody’s mind and obviously it’s both a big concern to providers and also it’s a resource that tends to be scarce. I know you’re a pediatrician in the Sioux Falls area, but you bring some special skillsets to this subject. Why don’t you elaborate on that somewhat.

Dr. Haggar: As part of my training, I was able to do a year of additional training in child and adolescent psychiatry. So, I am a general pediatrician and that’s what my day-to-day looks like, but thankful for some additional experience, time with really the experts in this area, and I feel that helps me translate in my practice that bridge between general care to the psychiatric care.

Learn more: Pediatric care at Sanford Health

Dr. Segeleon: Great, thanks. Well, we’ll go ahead and we’ll get to the subject at hand. I was just reading recently about with, in light of the pandemic from, I believe it was mid March to mid-October, there was a 25% increase in emergency department visits due to mental health situations in children. Is that what you’re seeing in the outpatient world as well, mental health issues and the pandemic?

Dr. Haggar:  Yeah, I absolutely feel like that’s what we’re seeing and that’s pretty incredible when we think that overall we’ve seen less volumes, we’ve seen less hospitalizations, we’ve seen less ER visits. And then when we look at this specific area really increasing, that’s pretty striking in my practice. And I think if you talk to my partners, there’s some afternoons where most of my conversations are centered around mental health. And I really expect that to expand as we move into our summer season, when we see a lot of our adolescents that we’re going to really uncover some of the impact that this pandemic has had on our, our children and adolescents.

Dr. Segeleon: Thank you. I know in the intensive care unit here at Sanford Children’s Hospital, we have more than one and, more often, it’s usually around two patients per week, every week of the year, with a suicide gesture and a suicide attempt. We know these numbers have been increasing both in the volume of, of children as well as the early age at which children are attempting suicide. Tell our listeners out there that our primary care providers and other providers, what can they do from a prevention standpoint in their office?

Dr. Haggar: Yeah, I think as we find in so many areas of what we do, prevention is where we can have the biggest impact. I think it’s so important that we try to integrate suicide prevention into our practices even before we have a concern about a particular patient. So, this goes to talking to our families about, “do they have firearms in the home? Are they secured? Do they have a plan for securing medications? Do they, have they looked around their home?” Similar to how we look around our house when we have a newly mobile toddler, right? We start to look at where do we need a gate and where do we need to make things safe? We can then start to look at, OK, I have, I now have a preteen in my house, where do I need to make sure everything’s safe? And it’s not that that safety is an important at younger ages, but some of that access really leads to lethality. So if we can start to just reduce access, we can have a big impact on really the most of your outcomes of suicide.

Dr. Segeleon: Now, what about the subject of screening?

Dr. Haggar: Yeah, I think if we don’t ask the question, we don’t know that there’s a problem and screening can look a couple different ways, but in general, doing a generalized screening when a well-child is coming into the office can help us know who we need to think about. Maybe going a little bit deeper, putting kids on our radar families to just ask, make sure they’re connected to resources. There are a lot of validated screeners out there. Our office uses the PHQ-9, which is a generalized depression screener, but also has some specific information about suicidal thoughts. I think that’s a great gateway, but I don’t think it replaces the provider just asking the hard question and making sure they know if this is a concern for their patient at that time.

Dr. Segeleon: Are those questions usually asked when you’re alone with the patient? How does that work in the outpatient world?

Dr. Haggar: Yeah, really, it’s helpful to just create that standard and practice that in those pre-teen years, we start asking the parent to step out into the hallway. We always make sure just logistically that we have a place for them that makes it more comfortable. And even before that, introducing the concept of that, the visitor to before saying, ‘Hey, this year, we’re going to talk with, with all of us, but next year, as you’re getting older, I like to talk to you alone. So we’ll have your mom or dad step out in the hallway and we’ll make sure we have some time to talk confidentially’ can really kind of start to lay that groundwork. I also think it’s important to explain confidentiality. I usually do that with my patients once I have their parents step out. And in that is that clause that ‘the stuff we talk about is between you and me, but if you’re going to harm yourself or someone’s harming you, I have to tell somebody about that’. So, it’s an important segue to make sure that, you know, we’ve laid the groundwork for confidentiality, but it gives me the ability to keep them safe if I need to and find out something, you know, very concerning during that discussion.

Dr. Segeleon: Great. Thank you. That’s very informative. Are there specific – or general – warning signs that you see in, in children of any age really that would make you be concerned about suicide ideation or suicide actions?

Dr. Haggar: I think there are a number of warning signs and it really can look like a change from norm and that’s where parents can be good partners for us because they know their kids and if they start to see big changes, then maybe we need to make sure that’s not a warning sign, but really specifically those kids that are starting to kind of pull away, not normal teenager, ‘I want to go to my room sometimes and be alone, but really pulling back, not sharing information, being very quiet, internally oriented even with their family. If they’re starting to say things about feeling helpless or hopeless or some of those more negative, personal self comments. If they’re feeling like they’re a burden to others or if they’re going through something really hard … so we know that our patients with chronic health conditions are at higher risk. So at the time of those diagnoses and at challenging times in the diagnosis, it can be important to make sure we’re looking closely. And then we think about patients that are exhibiting signs of mental health problems, like depression or anxiety. So if those things are there, it’s a good reminder that we should be looking closely at those patients.

Dr. Segeleon: Has it been your experience that most parents have an inclination that there’s something going on that feel like something’s not quite right?

Dr. Haggar: I think parents know their kids and that’s what we do is listen to the parents, listen to the patient, they’re going to tell you what’s going on. And so I do think most of the time parents have an idea that something’s there. They may not know how much but they usually have a pretty good idea that we should be worried.

Dr. Segeleon: Great, thanks. So we do our screening, what and recognizing that resources are going to be different throughout a footprint and to the listeners on the podcast, they may have access to different resources, but what do you do with the child who screens positive in your office?

Dr. Haggar: So after you listened to this, think about what resources you have, think about your community, who you have in your clinic what you have available. Cause it’s a lot easier to, to identify that, to write down those phone numbers now than it is when you’re in a, with an acutely suicidal patient in your clinic. So sometimes we have mental health professionals in our clinic. Sometimes we have mental health professionals we can use through referral services, but identifying those ahead of time, knowing what the crisis number is in your community, knowing those kinds of things can really just make you more comfortable when you start to run into these scenarios.

Dr. Segeleon: Are there any situations where it comes up with your screening or perhaps maybe further on interviewing either the child or the parent that you really worry about safety that you really worry about ‘is this child imminently going to hurt him or herself?’

Dr. Haggar: Yeah. So I think first and foremost, we’re asking, you know, if they have thoughts about self-harm, are they having thoughts about suicide? If I have a patient endorsed that, then I’m asking, ‘have you ever thought about how?’ Starting to assess, have they thought this through to the point of a plan, if they have a plan that I’m assessing, do they have access to that plan? You know, if they’re talking about, you know, harming themselves in a specific way, would they be able to accomplish that today after they leave my office or would they have to go through some additional steps? And then I start to look at, can we lay boundaries around to reduce access to that plan? And what other ways can we help the child develop coping so that they can start to alter their thought process if they are having thoughts about self harm?

Dr. Segeleon: Are there times when you refer them to an emergency room?

Dr. Haggar: Absolutely. So if I have a patient in my office, they are thinking of hurting themselves, they have a plan of how to do it and they have access to that plan, I think oftentimes the best thing for their safety is to have them assessed at a higher level of care… whether that’s an emergency room or being evaluated for hospitalization, either just safety, hospitalization, or psychiatric hospitalization to work through what may be underlining those thoughts.

Dr. Segeleon: OK. Thank you. That’s very helpful. Any other comments in reference to suicide or prevention that you might want to reflect upon?

Dr. Jennifer Haggar: I do think that it’s important for, especially for those of us who care for adolescents, to go back to what we know about their development, which is one of the riskiest things about them is they’re impulsive. And so while sometimes this comes after an episode of depression, sometimes they don’t have an underlying mental health disorder and they have something hard happened in their life, either in their family or a relationship … and then they make a choice in that instant to harm themselves. And so remembering that it is not just that kid who has a chronic mental health disorder, but that really all of our adolescents, because by development, they are impulsive or at slightly increased risk.

Dr. Segeleon: There is a, a relationship I think, between, for example, attention deficit disorder and suicide, is that correct?

Dr. Haggar: Absolutely. It’s one of the risk factors is just a tendency towards impulsivity. And that probably also brings out other important things… like, if you have a child who is using substances, who is using alcohol or other substances, that also increases their likelihood because it impairs their ability to think through the situation in the way that they normally would.

Dr. Segeleon: Let me ask you two things, and I know we have some time to talk about this, but to two things that just came in my mind, family history of mental health disease, or suicide. And also if you could, let’s talk about teenage clusters and we’ve seen this both in the media recently we saw a show that had some publicity about this. So if you could comment on those two things: family history, what relevance it has and then clusters, when a suicide occurs in a school or a peer group, something like that.

Dr. Haggar: Yeah. I’d love to talk about those. And I might just pull in a couple other risk factors so we can make sure that we’re identifying all of those patients. So we know that exposure to suicide increases suicide so that that’s clusters. If we have, if you are in a community and a suicide happens, your patients are at risk. And it’s the impact of that, the trauma of it, the awareness, the perception, there’s so many pieces that go into it for children and adolescents, but we certainly see increase suicide around other episodes of suicide. Having a family history of suicide has a similar impact. So, a parent first degree relative, or just a family member who was close for that child can also increase their risk, trauma and abuse. If you have a patient with a history of trauma or abuse, they are at increased risk. Isolation, which is a little scary when you look at that on the list and think that most of our teenagers are experiencing that to some extent with the pandemic, medical illness, which I touched on. And as you talked about that, that impulsivity. So I think those are all important things to identify as we’re assessing a patient in our office to really put that all together into a package to understand their true risk.

Dr. Segeleon: Dr. Haggar, you know, these subjects can be very sensitive and very challenging to get there, to ask these questions of your patients of kids. What recommendations and advice can you give to the providers listening on how you can approach some of these really difficult subjects and questions with their patients?

Dr. Haggar: Yeah, I think that’s so important. I think that’s what I miss most about being in training is watching other doctors be doctors and learning from how they do it. And so I think after you’ve had the conversation about confidentiality, hopefully when you’re with the alone, but if it has to be with the parent, that’s OK too… it’s important to just ask the question, which is, ‘have you ever had thoughts about hurting yourself? Have you ever wished you were dead? Have you ever had a way that you would hurt yourself?’ Just go through some of those practice, scripted questions … ask them, make eye contact with the patient. You know, this isn’t the time to be adding to my notes, but just give them the space to answer it. And I think that’s what I found most in my psychiatric training was I was pretty impressed with how open kids and adolescents would be and how much information they would share if you just ask the question.

Dr. Segeleon: Great. Well, wonderful advice. Thank you. So wrapping up a little bit here, what, when as a provider for those listening, when would I refer to a specific child psychiatrist or a mental health professional?

Dr. Haggar: This can be a challenging topic. And so I would really encourage the listeners if you’re feeling uncomfortable, reach out whether it’s a conversation with one of the experts, just to help you build up your skills or whether it’s to refer that specific patient. Most specifically, if you have a patient who is acutely suicidal in your office, they need a higher level of care. So that’s a time to refer. This is my personal belief, but I think if you have a patient who has attempted suicide, they deserve at least a psychiatric evaluation with a child psychiatrist, if not ongoing care with them. Having attempted suicide themselves puts them at increased risk for that again. I think that having someone really with that expertise in their field is an important piece of their medical team.

Dr. Segeleon: Well, great. Thank you. I know this is a topic that is very heavy but it is a topic on a lot of people’s minds. And I know that this is a scarce resource and we are so thankful to have you in our community and to have your expertise. I really learned a lot in just this brief period of time. So thank you again.

Host: Thank you, Dr. Segeleon and I echo that Dr. Haggar, thank you so much for your time and your expertise and all that you do here at Sanford.

Our Called to Care Podcast series focusing on children continues with topics from appendicitis to good sleep hygiene and the use of antibiotics right here with our Sanford Health experts. Thank you again for being here and thanks for all you do.

We’ll see you soon.