Volume 9.1 February 2009
THE IDAHO PEDIATRICIAN
2008 Chapter Awards
Awards were presented at the 2009 Idaho Perinatal Project’s Winter
Conference held in conjunction with the Idaho Chapter’s
Annual Winter Dinner and Business Meeting.
Perry Brown, MD
President Pediatrician of the Year
Creighton Hardin, MD For his years of dedicated service in training residents in the care of
children and for the establishment of the Cystic Fibrosis Clinic in Idaho.
Tom Patterson, MD
Clarence Blea, MD
email@example.com Child Advocate of the Year
For his work advocating for the improvement of Perinatal outcomes.
Kenny Bramwell, MD John M. Rusche, MD
firstname.lastname@example.org Child Advocate of the Year
Serving children, their families and putting their interests first
Sherry Iverson, RN in the Idaho Legislature.
Idaho Perinatal Project
Immunization Chair Organization of the year
Tom Rand, MD, PhD
For the boards dedicated commitment to improving the outcomes of
pregnancy throughout Idaho for over 37 years.
David Christensen, MD Would you like to nominate an individual or an organization?
email@example.com Go to www.idahoaap.org or email firstname.lastname@example.org
to submit your nomination for the 2009 Awards.
Susan Bradford, MD
A quarterly publication of
Idaho Chapter AAP
In This Issue:
President’s Message ● MRSA ● Breastfeeding ● and More
PAGE 2 THE IDAHO PEDIATRICIAN V O LU M E 9 . 1
Notes from Creighton Hardin, MD
If you are like most pediatricians, the change in the American Board of Pediatrics maintenance of
certification criteria is baffling. A quality improvement project will need to be done every five years.
Presently this can be done through a web based AAP program called EQipp. One that is available
now is nutritional assessment. Future programs are development, asthma, immunization, and
GERD. Another way of completing the quality improvement portion would be to participate and es-
tablish improvement project cleared by the AAO. One such as the Utah Chapter’s UPIQ which could
be accessed through Utah.edu\upiq. We are in the process of talking to them to see if Idaho pediatri-
cians could be part of their program. They would come to your practice site, do chart reviews, train-
ing, and follow up.
Encourage one of our fellows to consider taking over the legislative chair relinquished by Jerry
Hirschfeld to work with the Idaho chapter on legislative issues. It makes sense that someone in the
Boise area would take this very important position. Another is the PROS coordinator which is Pedi-
atric Research in the Office Setting program through the AAP to help those practices who would be
interested in participating in an office research program.
Calling all pediatricians over 55 that are interested in being a senior mentor to new pediatricians.
Please contact me or Sherry Iverson. This would be a great way to answer questions on practice or
retirement goals. Also, if any senior pediatrician is interested in heading a senior member commit-
tee, look at the AAP.org website under Sections and then under Senior Members. Wouldn’t it be
great to partner with the AARP on child advocacy issues!
We do quarterly newsletters and we are asking some of the specialists pediatricians to write a col-
umn for this. If you have any topics that you would like to be covered in the future please let us
The midwife bill will be a major project for the Idaho AAP and the Idaho Perinatal Project. Last year
amendments were proposed by the Idaho Perinatal Project to restrict midwives to low risk deliveries
and restrict significantly their scope of practice. This year the proposed bill is to allow scope of prac-
tice to be determined by a midwifery board to consist of three midwives, one physician, and one lay
person of their choosing. They did call for mandatory licensing, but exemptions would be for those
who have been in practice for more than five years and have attended ten births in the last two
years. Unlicensed midwives can be exempt for their religious beliefs. The states, Wisconsin and
Vermont, have very well spelled out scope of practice limitations to define those pregnancies and
newborn problems that warrant transfer of care to M.D.’s. If you are interested in looking at the bill,
contact Sherry Iverson at the Idaho AAP or go to the website of IPP idahoperinatal.org.
What Interests You?
Have you thought about
applying for a Remember
Join a Committee or
CATCH Grant? that February Section of the
is Children’s AAP Today!
For more information go to:
www.aap.org/catch Month For more information go to:
V O LU M E 9 . 1 THE IDAHO PEDIATRICIAN PAGE 3
AAP’s Section on
Save the Date
Learning Resources International
Chapter Breastfeeding Coordinator
3 NEW COURSES
2009 Advanced Fetal Monitoring and Certification Idaho’s Chapter Breastfeeding Coordinator (CBC) is Elsa Lee,
Preparation Seminar in 17 Locations
2009 In-Patient Obstetrics Certification MD. We would like to thank Dr. Lee for taking on this position.
Preparation in 2 Locations If you would like to contact Dr. Lee with questions or ideas, she
2009 Legally Speaking in Tampa, FL. can be reached by email at email@example.com.
THANK YOU Dr. Lee!
10th Annual Strengthening Families he CBC position was established in 1991 after the WIC Breast-
to Prevent Child Abuse and Neglect feeding Coordinators were put into
Training Institute place. The objective was to inspire
March 17th & 18th, 2009 efforts between pediatricians and
Doubletree Riverside Boise, Idaho WIC colleagues to work together to
Keynote Speakers Judy Langford Senior promote, protect, and support
Fellow at the Center for the Study of So- breastfeeding across the US. We
cial Policy (CSSP) who is one of the gurus now have 78 CBCs in our 58 Chap-
of the Strengthening Families movement ters. The Chapter President has
and Jerry Tello Co-founder of the National the responsibility of appointing his
Compadres Network and the Director of or her CBC (or CBCs). The Sec-
the National Latino Fatherhood and Fam- tion on Breastfeeding considers our
ily Institute. CBCs to be our grassroots mem-
Registration material attached or go to bers and leaders across the nation.
our website at:
They have a vast job description
which mirrors the strategic plan of
the SOBr and have been asked to
Shot Smarts 2009 conduct breastfeeding activities in
Boise April 28th, Idaho Falls April 29th,
their Chapters including:
Coeur d’ Alene May 1, 2009
Speakers: Bill Atkinson, MD, MPH &
Donna Weaver, RN, MN
· Improving reimbursement
If you have any question or would like ad- for breastfeeding care
ditional details contact Andy Noble through the dissemination of the document Supporting
Phone: 208.334.5901 E-mail: no- Breastfeeding and Lactation: The Pediatrician's Guide to
firstname.lastname@example.org Getting Paid
· Working with their Chapter to include at least 1 hour of
breastfeeding CME per year at their Chapter's educa-
Chapter Meeting Calendar is new and improved! You tional offerings.
can now access the calendar via the CME Finder at · Helping local hospitals' training programs to implement
www.pedialink.org . Now, members of the Academy the new Breastfeeding Residency Curriculum into resi-
who are searching for a particular meeting will be
able find all meetings and relevant information in dency programs in their state.
one location, including chapter meetings, AAP meet- · Improving the environment for breastfeeding in hospitals by
ings, and CME courses. disseminating the SOBr Sample Hospital Breastfeeding Policy for
Follow these steps to access the calendar:
Go to www.pedialink.org . Click on "CME Finder"
toward the bottom of the page in the middle. From
there, click "Chapter Meeting Calendar" under
"Other CME Activities." (
PAGE 4 THE IDAHO PEDIATRICIAN V O LU M E 9 . 1
CA-MRSA – Perspective from the Emergency Room
Rob Hilvers, MD
Emergency Medicine, Family Medicine, Sports Medicine
As providers, we have all become too familiar with this new wave of community-associated MRSA; however, under-
standing the true impact has been confusing. The media has certainly done its part to sensationalize this organism with
names like ‘Deadly Superbug’ and ‘Flesh-Eating Staph.’ This relatively newer mutation typically carries the SCCmec
type IV genotype (staphylococcal cassette chromosome mec) has resulted in a 200% increased prevalence of skin and
soft tissue infections (SSTI) from 1993 to 2005, and has surfaced as outbreaks among athletic teams, daycares, military
personnel, and healthy individuals without traditional risk factors. Ninety-eight percent of CA-MRSA strains contain a
virulence factor identified as Panton-Valentine leukocidin (PVL). This cytotoxin is blamed for the intense pain, necrotic
wound, and inhibition of white cell response, possibly playing a role in colonization. On a positive note, unlike the health-
care associated-MRSA organism (SCCmec I-II genotypes) which confers multidrug resistance, CA-MRSA still has good
susceptibilities to several non-β-lactam antibiotics. Therefore understanding local prevalence patterns and antibiotic bi-
ograms is imperative in clinical management. As these isolates continue to mutate and share genes, it will only further
blur and complicate the clinical spectrum.
Patients with CA-MRSA infections most commonly present to outpatient clinics or emergency departments with purulent
SSTI (pustules, furuncles, carbuncles and abscess +/- surrounding cellulitis), however, the clinical spectrum ranges from
asymptomatic colonization to life-threatening invasive infections. Nationwide data demonstrated the prevalence of
MRSA was 59% among adults presenting with SSTI to 11 university-affiliated emergency departments (NEJM 2006;
355). Other common organisms included MSSA (17%) and strep species (7%). Of the MRSA isolates, 97% repre-
sented the USA 300 clone and 74% a single strain: USA300-0114. The SCCmec IV genotype and PVL toxin was pre-
sent in 98% of these isolates, in other words, this newer CA-MRSA isolate. Looking at regional Idaho data for 2007, St
Luke’s RMC reported the rate of MRSA among all staph species was 36%. Susceptibility for these MRSA isolates are
as follows: TMP/SMX 99%, tetracycline 97%, rifampin 98%, clindamycin 72%, ciprofloxacin/levofloxacin 27/28%, and
erythromycin 6%. From these data, it is obvious there are several good pharmacologic options, but providers need to be
up to date with prescribing patterns. Evidence-based clinical recommendations regarding indications for antibiotics,
whether or not to obtain wound cultures, and treatment options for recurrent infections (i.e. skin colonization) are not well
established. A conclusive, multicenter, randomized, placebo-controlled clinical trial is needed is help establish clinical
Most common identifiable source of SSTI. Suspect with all purulent infections.
Risk Factors: skin trauma, frequent skin-skin contact, crowding, recent antibiotic exposure, and potential fomite
exposure. Traditional risk factors for HA-MRSA often are not present.
Beware of the chief complaint ‘Spider Bite.’ Clinical features of MRSA abscess are very suggestive of brown
recluse (Loxoceles) bite. This spider not endemic in Idaho!
If antibiotics indicated (abscess > 5cm, surrounding cellulitis, co-morbid conditions, etc.), include empiric cover-
age for CA-MRSA. Oral dosing regimens for suspected CA-MRSA (mild-moderate severity):
TMP-SMX : 8-12 mg/kg (TMP component) divided bid*
Doxycycline: Age > 8years; 2-4 mg/kg divided bid*
Clindamycin: if susceptible via D-zone test; 30-40 mg/kg divided tid/qid
Rifampin: 10-20 mg/kg divided bid; synergistic coverage only (decrease eradication/colonization)
*Consider beta-lactam coverage for strep species.
**For severe infections or systemic infections, consider vancomycin or linezolid. Consult local infectious
Heightened suspicion for invasive infection: necrotizing PNA (post-influenza A), hematogenous osteomylitis,
sepsis, etc. Associated with increased mortality, longer hospital stays and higher healthcare costs.
No longer simple I&D. Now need incision, drainage and debridement. Adequate analgesia will be necessary!!
Patients often require parental and local analgesics.
Culture wound? Arguments for pros and cons. Understand local prevalence and susceptibility pattern.
Decolonization strategies with recurrent infections. Consider chlorhexidine gluconate washes daily and 2%
mupirocin ointment intranasally tid for 7-10 days. 4% Chlorhexidine gluconate available OTC as Hibiclens at
Next superbug?? Probably not, however important to maintain awareness as prevalence and resistance pat-
V O LU M E 9 . 1 THE IDAHO PEDIATRICIAN V O LU M E 9 . 1
MRSA: Part of the medical landscape
Tom Rand MD PhD
MRSA was appreciated as a healthcare-associated pathogen since the 1970s but did not impact rountine pediat-
ric practice until recently. During the 1990s several closely related strains of MRSA developed special virulence outside
the hospital environment. Community-acquired MRSA has become familiar to pediatricians as abscesses and furuncles.
The predominant community acquired MRSA are within a family of related strains termed USA300, as distinguished by
pulsed-field gel electrophoresis to determine genetic relatedness. In our community, 36% of Staph aureus cultures are
As we gain practice experience with MRSA infections, we become more successful in our management. I hear the fol-
lowing fallacies that arise out of discouragement or ignorance. Such fallacies lead to poor outcomes:
Fallacy #1. “MRSA infections are not treatable.” Just because MRSA are resistant to cephalosporin or semisynthetic
penicillins used for traditional empiric therapies for skin and soft tissue infections does not mean that MRSA are diffi-
cult to treat. Different antibiotics need to be used for MRSA.
Fallacy #2. “Once you have MRSA, you will always be a carrier.” For many MRSA infections, drainage of infection or
limited use of antibiotics is enough to eliminate the problem. For those who become MRSA carriers, we have a hier-
archy of treatments that are ultimately successful, so long as the individual does not have an indwelling device such
as a tracheostomy. Therapies may include combinations of antibiotics will rifampin, nasal mupirocin ointment, and
bathing with disinfectants such as clorhexidine, triclosan, or hypochlorite (bleach).
Fallacy #3. “Eradicating MRSA from the home environment is impossible.” I think that knowledge of a few measures is
very helpful to protect household contacts from MRSA and are desirable hygiene measures generally. A practical
guide can be found at
(Courtesy of the Tacoma/Pierce County Department of Health)
Fallacy #4. “Athletes with MRSA can no longer participate on their sports teams.” The school districts have quite rea-
sonable guidelines for athletes in contact sports, for which I provide printed guidelines to clinic patients. Basically,
treated and covered sites of infection allow return to team participation.
Because of the prevalence of MRSA, some changes in clinical practice are necessary:
Routinely obtain cultures from infections that may include Staph aureus.
Include an MRSA agent (sulfatrim, clindamycin, a tetracycline) for outpatient infections while awaiting cultures.
For serious infections, include vancomycin IV or another MRSA agent (clindamycin, linezolid). The intitial inpatient regi-
men I prefer for musculoskeletal infections is vancomycin plus cefazolin IV.
Nasal screen for MRSA (by culture or PCR) can identify patients that need to be managed presumptively for MRSA in-
Rise to the challenge of management of an evolving problem!
Do you Know why snowmen get cold feet in bed? They sleep on sheets of Ice
What do you call a grizzly bear with no teeth? A gymmy bear
What is the biggest diamond in the word? A baseball diamond.
What is a shark’s favorite game? Swallow the Leader.
PAGE 6 THE IDAHO PEDIATRICIAN V O LU M E 9 . 1
Idaho Teen Dating Violence Awareness & Prevention Week
Boise, ID (January 30, 2009) – On January 29, 2009, Governor “Butch” Otter declared February 2nd – 6th Idaho Teen
Dating Violence Awareness & Prevention Week. Dating violence can happen to anyone – nationally, 1 in 3 teens in a
dating relationship have been abused by their partner. And, just because you haven’t been hit doesn’t mean that you
aren’t in an abusive relationship. Abuse can be verbal, emotional, sexual, or physical.
In the most recent Idaho Youth Risk Behavior survey, a staggering 13% of high school students report being hit,
slapped, or punched by their dating partners within the past 12 months, and 11% of high schools girls were forced to
engage in unwanted sexual contact.
The Idaho Teen Dating Violence Awareness & Prevention Project, a partnership of the Idaho Coalition Against Sexual &
Domestic Violence, St. Luke’s Regional Medical Center, the Idaho Department of Education and other allied organiza-
tions, has developed an education and prevention strategy to eliminate the prevalence and cultural acceptance of teen
dating violence in Idaho.
Posters and stickers promoting healthy teen relationships as part of the NO MEANS KNOW campaign were distributed
to all of Idaho’s public and private secondary schools. During February, high schools throughout the state are sponsoring
and holding awareness activities in their schools and communities. And students in 9th – 12th grade can enter an Idaho
writing contest – KNOW LOVE. For more information writing contest go to www.nomeansknow.com.
If you want to know more about teen dating violence, request a free presentation in your school or community group, free
posters or brochures, or think someone you know is in an abusive relationship, please visit www.nomeansknow.com to
get more information and links to resources or contact the Idaho Coalition Against Sexual & Domestic Violence at 384-
About the Idaho Coalition Against Sexual & Domestic Violence:
The Idaho Coalition Against Sexual & Domestic Violence is a statewide non-profit dual coalition that advocates on behalf
of victims of domestic violence and sexual assault. Incorporated in 1980, the Idaho Coalition Against Sexual & Domestic
Violence has grown to become a statewide membership network of shelter programs, counseling programs, law enforce-
ment agencies, victim witness units, prosecutors, and allied professionals – all advocating for the safety and rights of
victims of domestic violence and sexual assault. The Idaho Coalition Against Sexual & Domestic Violence is governed
by a Board of Directors elected by the membership and consists of representation from each region in Idaho.
V O LU M E 9 . 1 THE IDAHO PEDIATRICIAN PAGE 7
Idaho Chapter NONPROFIT ORG
American Academy PAID
of Pediatrics BOISE, ID
103 W. State Street PERMIT NO. 565
Boise, Idaho 83702
THE IDAHO PEDIATRICIAN