Spring 2010 - SSM Cardinal Glennon Children's Medical Center

SSM Cardinal Glennon Children’s Medical Center
Spring 2010
www.cardinalglennon.com
FOCUS ON
Pediatrics
MEDICAL NEWS FROM SSM CARDINAL GLENNON CHILDREN’S MEDICAL CENTER
AND THE DEPARTMENT OF PEDIATRICS, SAINT LOUIS UNIVERSITY SCHOOL OF MEDICINE
SM

ON THE COVER
Medin Gets His “Picture Taken”
Kristin Casten, RT, helps Medin Grabic, 5, get his
a chest x-ray before his appointment for asthma care at
SSM Cardinal Glennon Children’s Medical Center.
During a typical first-time pulmonary visit, patients
receive an extensive history report, physical exam, lung
function studies and visits with a pulmonologist, nurse
and respiratory therapist. Children often get a chest
x-ray and all patients are taught the proper usage of an
inhaler, nebulizer and peak flow meter.
FOCUS ON
Pediatrics
SM
Editor In Chief
Sherlyn Hailstone
President
SSM Cardinal Glennon
Children’s Medical Center
Medical Editor
Kenneth Haller, MD
Associate Professor of Pediatrics
Saint Louis University
School of Medicine
Editor
Andrew Sutton
Physician Services Manager
SSM Cardinal Glennon
Children’s Medical Center
Writer & Designer
Katelyn Ideus
Physician Services Assistant
SSM Cardinal Glennon
Children’s Medical Center
For comments and suggestions, please email FocusOnPeds@ssmhc.com.

Living a Better Life
Cardinal Glennon Division of Pulmonary Medicine
ACC Medical Director and pulmonologist Gary Albers, M.D., examines Natalie Nickels, 7, during her January check up for cystic fibrosis. Find out more about cystic fibrosis on page 11.
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The blue hallway of SSM Cardinal Glennon
Children’s Medical Center’s ACC is
buzzing this morning. Blake Noyes, M.D.,
Gary Albers, M.D., and Anthony Rejent, M.D.,
are writing notes, ordering chest x-rays and performing
exams on their young patients.
Some of the Division’s particular interests include:
• Vocal cord dysfunction
• Abnormalities of surfactant protein metabolism
• Impact of CPAP on children with sleep-disordered
breathing
Photography by Stew Smith
But the hustle of the morning doesn’t stop Dr.
Noyes, Director of the Division of Pulmonary
Medicine, from grabbing the stool in a patient’s
room, pulling it beside the exam table where the
child is sitting and asking about his or her latest
activities.
Sara Rohrbough, 17, tells Dr. Noyes that she
performed in the color guard during the half time
show at the Capitol One
Bowl, and Andria Leezy
talks about her 18-monthold
son’s latest game of
running laps around the
dining room table.
The ease of the conversation
isn’t surprising
considering the time Dr.
Noyes has spent with each
of these patients. Sara is
recovering from a bout of
complicated pneumonia
and Mark Leezy, Jr., was
born with cystic fibrosis.
But no matter the history,
each patient who visits one
of the pulmonary clinics
receives compassionate,
individualized care.
The Division of Pulmonary
Medicine holds clinics for
asthma, general pulmonary
medicine, cystic fibrosis
and sleep disorders. Each patient is seen by a physician,
nurse, respiratory therapist, dietitian and
social worker if necessary.
These clinics provide comprehensive care for all
respiratory disorders, including:
• Asthma
• Complicated pneumonia
• Cystic fibrosis
• Chronic cough
• Recurrent pneumonias
• Recurrent or persistent wheezing
• Sleep disorders
Blake Noyes, M.D., examines cystic fibrosis patient
Mark Leezy, Jr., 18 months.
Dr. Noyes suggests referral to a pediatric pulmonary
specialist for all of the following patients:
• Cough for more than 4-6 weeks
• Three or more documented pneumonias in
one year
• Wheezing unresponsive to routine asthma
therapy
• Respiratory symptoms associated with poor
growth
Providing the care are Cardinal
Glennon’s experienced
pulmonologists. Dr. Rejent
served as the Director of the
Cystic Fibrosis Center for 40
years and helped advance the
services for pediatric cystic
fibrosis patients nationwide.
In the summer of 2009, Dr.
Rejent retired from this position
and passed leadership to
Dr. Noyes.
“The one word that would
describe Dr. Noyes is ‘outstanding,’”
Dr. Rejent says of
his successor. “He is outstanding
in his leadership as
a Division Director, in his
organizational abilities and
in his communication with
every member of the Division
from top to bottom, as
well as his patients.”
Along side Dr. Noyes is Dr.
Albers, who also serves as the Medical Director
of the ACC, and Robert Wilmott, M.D., who
sees patients while serving as Cardinal Glennon’s
Chairman of the Department of Pediatrics. Shalini
Paruthi, M.D., and Glen Fenton, M.D., co-direct
Cardinal Glennon’s recently-accredited Sleep
Center.
“These faculty have a great understanding of these
diseases and this translates into superb care at the
bedside,” Dr. Rejent says. “I continue to learn a
lot from all of them, and we are fortunate to have
them at Cardinal Glennon.”
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Marissa Lowe, 18, is used to the injections. She even
smiles occasionally as Kathy Forcelledo, RN, administers
one into each arm.
After several visits to various institutions, Marissa was brought
to SSM Cardinal Glennon when she was three years old.
Within a week, Cardinal Glennon diagnosed her with chronic
asthma. Cardinal Glennon also found relief for Marissa
through the monthly injections.
“When I was younger, I couldn’t go out and play,” Marissa
says. “But now I feel really good. There have been less hospital
visits over the last couple years.”
Though asthma seems common in children, it is not a benign
diagnosis, and when it goes under-treated or untreated it can
cause permanent airway remodeling, says Susan Mason, RN,
PCNS.
Signs and symptoms of asthma include wheezing, chronic
cough and respiratory distress.
There are several ways to control asthma including:
• Inhaled steroids • Environmental measures
• Albuterol • Avoidance of allergens
• Leukotriene
modifiers
• Elimination of environmental
tobacco smoke exposure
Living With
asthma
However, if these treatments do not help, or when any of the
following occur, it is time to refer to a pediatric pulmonary
specialist:
• Frequent hospital admissions
• Frequent emergency room visits
• Poor control of symptoms
• Any hospital admission where an ICU stay is included
Kathy Forcelledo, RN, administers Marissa Lowe’s monthly injection for chronic asthma.
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Once brought to Cardinal Glennon’s asthma clinic, each
patient undergoes an extensive history and physical exam, as
well as lung function studies and often a chest x-ray. A plan
is developed and reviewed, and patients are taught the proper
inhaler or nebulizer and peak flow use. They are then evaluated
by a physician, nurse and respiratory therapist.
“Our quality benchmark is among the best in the National
Association of Children’s Hospitals and Related Institutions
(NACHRI),” says Division Director of Pulmonary Medicine
Blake Noyes, M.D. “The availability of pulmonary to work
with pediatric allergy and immunology specialists is an important
service, and we’ve seen short inpatient stays relative to
NACHRI standards due to our care.”
To consult with one of Cardinal Glennon’s pulmonary specialists
on any condition, please call the Cardinal Glennon
Access Center at 1-888-229-2424.
Blake Noyes, M.D., examines Jazmine Griffin, 11 months, during an asthma check up.
Jazmine was brought in for pneumonia at three months of age but was diagnosed with
asthma.

Living With
Complicated Pneumonia
During her January visit, Sara Rohrbough, 17, completes a pulmonary function test with Pat Lewis, RRT. Cardinal Glennon helped Sara through complicated pneumonia in the fall.
On New Years Day 2010, Sara Rohrbough, 17, performed
in the color guard at the half time show of
the Capital One Bowl in Orlando, FL.
Today, Jan. 15, however, she is back in St. Louis at SSM
Cardinal Glennon.
Though not one to get sick, Sara got the flu in late October
and stayed sick for more than a month. Finally, she gave in
to her shortness of breath, cough and racing heart and visited
the emergency department at SSM St. Clare Health Center in
Fenton, MO.
After an exam and chest x-ray, Sara was told a surgeon would
have to drain the fluid that accumulated between her lung
and chest wall through a tube in her back. The mucus, however,
was so thick a pediatric surgeon would have to perform
the procedure.
“I was so scared and it was so overwhelming,” Sara says of
being rolled to the operating room at Cardinal Glennon. “But
then I just woke up, and it was over and everything was fine.”
Sara suffered from a pneumonia complicated by the development
of an empyema, which is a rare complication relative to
all pneumonias. This type of illness often requires admission
and IV antibiotics. It may also require either a chest tube or
surgical approach to evacuate the fluid.
After her surgery, Sara spent five days at Cardinal Glennon.
She returned for three follow up visits and will come back this
summer for what Blake Noyes, M.D., anticipates to be her
last visit. During this final check up, Sara will receive a chest
x-ray, an exam and lung function tests.
Then, hopefully, she won’t be back at Cardinal Glennon any
time soon.
“It wasn’t one of the greatest things
because I had to have surgery. But if
you are going to get stuck in a
hospital, it’s best to get stuck in a good
one like Cardinal Glennon.”
— Sara Rohrbough, 17
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Mekhi Stokes, 5, rests his head against his mother,
Tankya Hilliard’s shoulder.
“Are you tired” asks board certified Sleep Medicine specialist
Shalini Paruthi, M.D., and Mekhi brightens with a smile.
Mekhi has been visiting SSM Cardinal Glennon since 2007,
and he is getting results. After his first sleep study, he had his
adenoids and tonsils taken out and his nose passages shrunk.
He then had a follow-up sleep study in May 2009.
Mekhi no longer wakes up in the middle of the night from
night terrors, he hasn’t complained about his legs feeling tingly
and his snoring has greatly subsided, Hilliard says. Today
Dr. Paruthi reviews his medications and recommends a sinus
wash to help his runny nose.
Mekhi is one of several children seen by the Sleep Services
team, which is led by Co-Directors Dr. Paruthi and Glen Fenton,
M.D. Since Dr. Paruthi joined Cardinal Glennon in the
fall of 2008, the three-bed Sleep Lab has upgraded all of its
equipment, and the Sleep Center received accreditation from
the American Academy of Sleep Medicine in the summer of
2009.
Cardinal Glennon’s Pediatric Sleep and Research Center is
the only accredited and entirely pediatric-focused program
in Missouri, helping patients from age 1 day to 22 years.
With the accreditation, the Sleep Center can now guarantee
patients the highest quality of care for all sleep disorders
including:
Living With
Sleep Disorders
Shalini Paruthi, M.D., helps Mekhi Stokes, 5, listen to his heartbeat during his Sleep Services appointment
in January. The SSM Cardinal Glennon Sleep Center has helped Mekhi with night terrors, restless
leg syndrome and snoring.
Insomnia: Two main types: (1) difficulty falling asleep or (2)
difficulty staying asleep. Insomnia causes and treatments vary
by age. For younger children, bedtime routines, regular bedtimes
and wake times and special techniques can help. Older
children can use strategies to help them relax. Medications are
used when necessary.
Sleep Apnea: 3 to 5 percent of children have obstructive sleep
apnea, in which a blockage of the airway exists during sleep,
often due to large tonsils and adenoids.
• Night time symptoms: snoring, breathing pauses,
sweating, tossing and turning or bedwetting.
• Daytime symptoms: hyperactivity, headaches,
heartburn/reflux and excessive daytime sleepiness.
• Treatment may involve outpatient surgery to remove
adenoids and tonsils or the use of a CPAP (Continuous
Positive Airway Pressure) machine when sleeping.
Restless Leg Syndrome: Occurs in 2 percent of children and
is a significant contributor to insomnia. It is often confused
with growing pains. Children often describe pain or sensations
in their legs at bedtime or during the night, saying it
improves with movement or rubbing the legs, and is worse
with inactivity. Often due to low iron stores in the body and
can be treated with iron supplementation. Caffeine intake or
vigorous exercise can worsen condition.
Night Terrors and Nightmares:
Terrors: Children appear awake, but are asleep as they run,
kick and scream through the house. Episodes typically occur
during partial awakenings/arousals from sleep. Treatment
focuses on the underlying cause of the arousal, such as sleep
apnea or restless leg syndrome. Parents should make
the house safer by removing sharp corners and
using door alarms.
Nightmares: Typically happen in later hours of
sleep and most children remember them vividly. If a
particular dream recurs, imagery rehearsal is recommended,
in which the child and parent talk about
the bad dream(s), and come up with alternate,
satisfactory endings. This is done for 10 to 15
minutes before bed for four weeks.
Narcolepsy or Other Hypersomnias:
Narcolepsy is now understood to be an autoimmune
disorder, with an environmental trigger and a
peak incidence near 15 or 16 years of age. It can be
diagnosed and treated successfully in most children
using lifestyle modifications and stimulant medication.
Watch Dr. Paruthi’s Sleep Services presentations on
Pediatrics on Demand and earn CME credit.
www.PediatricsonDemand.com
Username: ds\r010-online, Password: webcme

Living With
Cystic Fibrosis
At 18 months, Mark Leezy, Jr., never stays still. With
his blond hair matted down from sweat and his cheeks
red from his last sprint across SSM Cardinal Glennon’s
ACC lobby, it’s hard believe Mark spent the first three months
of his life in Cardinal Glennon’s NICU.
He was born with a meconium perforation, an intestinal obstruction
caused by mucus build up in his bowels, and a red
flag for cystic fibrosis. When an ultrasound early in Andria
Leezy’s pregnancy showed the meconium perforation, Andria
and her husband, Mark Leezy, Sr., were tested and found to
be carriers of cystic fibrosis. But it wasn’t until Mark Jr. was
born that it was confirmed he had the chronic lung disease.
“I guess we are one of the lucky ones because we’ve known
and been able to treat him early,” Andria says. “Some parents
don’t find out until their kids are much older.”
Though a life-threatening disease, cystic fibrosis can go misdiagnosed
as chronic cough, asthma or pneumonia, thus going
untreated.
However, as of December 2009, all states are required to perform
newborn screenings for cystic fibrosis, as early detection
can greatly improve a child’s quality of life.
An infant with a positive screening should be immediately
referred to a Cystic Fibrosis Foundation accredited center like
Cardinal Glennon. However, the threshold for testing older
children should remain low as infants can be missed on the
newborn screen.
Kevin Powell, M.D., exams cystic fibrosis inpatient Alando Harris, 15.
Through the leadership of Anthony Rejent, M.D., Cardinal
Glennon has been at the forefront of quality improvements,
such as infant screenings, for the last 40 years. In 2004, Cardinal
Glennon was one of the first centers to initiate quality
improvement efforts for the delivery of care and processes.
“I want to continue the impressive quality efforts initiated under
Dr. Rejent’s leadership through an ongoing review of our
patient registry data and combining that with care recommendations
put forward by the Cystic Fibrosis Foundation,” says
Blake Noyes, M.D., who became the director of the Cystic
Fibrosis Center after Dr. Rejent’s retirement in the summer of
2009.
But beyond delivery and processes, is the care provided by
Cardinal Glennon’s pulmonologists.
Alando Harris, 15, has spent several days and nights at Cardinal
Glennon battling illness due to the condition. He also
suffers from cystic fibrosis related diabetes mellitus.
Alando has worked with all of Cardinal Glennon’s
pulmonologists including Dr. Noyes, Dr. Rejent and
Dr. Gary Albers.
“Dr. Albers always tries to make Alando laugh because
he is so quiet,” Alando’s mother Tanya Bridges said.
“Somehow, Dr. Albers succeeds with one of his silly
jokes.”
And while Bridges appreciates the work of the physicians,
nurses and staff, it seems the care givers are just
as touched by the effort of the patients and families
they care for.
Judy Brussatti, RN, CPNP, shows Mark Leezy, Jr., 18 months, a book about breathing during his visit
to the Cardinal Glennon Cystic Fibrosis Center.
“You become so involved with the whole family,”
Judy Brusatti, RN, CPNP says. “I stay in this because
the diagnosis and treatment are challenging, but also
because caring for these children has made me a better
nurse, a better person and a better parent. They are
truly inspiring.”
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Q&A
Blake Noyes, M.D.
Division Director of
Pulmonary Medicine
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Q: How do the years of experience of the faculty in your
division affect the care you are able to provide
A: Within the division, there is a collective experience of more
than 150 years of taking care of patients with pulmonary
disorders, so there is little that the pulmonary physicians have
not encountered in their careers.
The faculty also routinely collaborate on the approach and
care of patients with complicated respiratory disorders, which
provides each patient with a broad range of experiences.
Finally, the division has had terrific stability over the years
with our nursing, respiratory therapy and social services staff,
which provides a tremendous amount of continuity for the
patients and families.
Q: Why did you choose to specialize in pediatric
pulmonary medicine
A: I was always drawn to patients with cystic fibrosis and
always admired their resolute determination and courage in
the face of a disease which, at the time, was often fatal before
adulthood. The opportunity to follow patients and families
over a long time was always appealing to me as well.
Q: What is the most difficult part of your job
A: Without a doubt, experiencing the death of a child from a
respiratory disorder. The impact on the parents and extended
family members and the loss of the tremendous potential all
children have is always extraordinarily difficult. Making a
diagnosis of cystic fibrosis and giving that news to the parents
is always emotionally challenging since the effect on family
dynamics, lifestyle and child rearing can be so devastating.
To reach DR. Noyes
Please Call:
(314) 268-6439.

Pulmonary Medicine
Faculty
Gary M. Albers, M.D.
Medical Director of Ambulatory Care
M.D.: Saint Louis University, St. Louis, MO
Pediatrics/Internal Medicine Internship: Saint Louis University, Cardinal
Glennon Children’s Medical Center, St. Louis, MO
Pediatrics/Internal Medicine Residency: Saint Louis University, Cardinal
Glennon Children’s Medical Center, St. Louis, MO
Pediatric Pulmonary Medicine Fellowship: University of North Carolina,
Chapel Hill, NC
Blake E. Noyes, M.D.
Division Director of Pulmonary Medicine and Director of Cystic Fibrosis Center
M.D.: Saint Louis University, St. Louis, MO
Pediatric Internship: St. Louis University, Cardinal Glennon Children’s
Medical Center, St. Louis, MO
Pediatric Residency: Saint Louis University, Cardinal Glennon Children’s
Medical Center, St. Louis, MO
Pulmonary Fellowship: University of Pittsburgh, Children’s Hospital of
Pittsburgh, Pittsburgh, PA
Research Scholar: University of Pittsburgh, Children’s Hospital of Pittsburgh,
Pittsburgh, PA
Shalini Paruthi, M.D.
Co-Director of Sleep Services
M.D.: University of Missouri-Kansas City, Kansas City, MO
Preliminary Year in Internal Medicine: Saint Joseph Mercy Hospital, Ann
Arbor, MI
Residency in Internal Medicine: University of Michigan Medical Center,
Ann Arbor, MI
Fellowship in Sleep Medicine: University of Michigan Medical Center,
Ann Arbor, MI
Kevin T. Powell, M.D.
M.S. in Chemical Engineering: Massachusetts Institute of Technology,
Boston, MA
PhD in Medical Engineering: MIT/Harvard Medical School, Boston, MA
M.D.: Tufts University School of Medicine, Boston, MA
Residency in Pediatrics: University of Wisconsin, Madison, WI
Anthony J. Rejent, M.D.
M.D.: Creighton University School of Medicine, Omaha, NE
Internship: St. Vincent’s Hospital and Medical Center, Toledo, OH
Pediatric Residency: Saint Louis University, Cardinal Glennon Children’s
Medical Center, St. Louis, MO
Chief Resident, Division of Pediatrics: United States Air Force Hospital,
Columbus, MS
Robert W. Wilmott, M.D.
IMMUNO Professor and Chair of the Department of Pediatrics
M.D.: University College Hospital Medical School, London, England
Residency: University College Hospital, London, England
Fellowship in Pulmonary Medicine: Hospital for Sick Children and Institute
of Child Health, London, England
Pediatrics on Demand
March 15
“Vocal Cord Dysfunction”
Blake Noyes, M.D.
March 29
“Managing the Child with a Chronic Cough”
Robert Wilmott, M.D.
www.pediatricsondemand.com
Username: ds\r010-online
Password: webcme
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