Provider Q&A

Jennifer Bauer

Jennifer Bauer, MD, MS is the only orthopaedic surgeon at Seattle Children’s whose elective practice is singularly dedicated to the treatment of pediatric spine problems.

She has been selected this year for both the Scoliosis Research Society’s Edgar Dawson North American Traveling Fellowship and the Pediatric Orthopaedic Society of North America’s International Traveling Fellowship, both of which will bring her to other leading centers to exchange ideas, give lectures and discuss research collaboration.

What is the basic treatment algorithm for idiopathic scoliosis?

Dr. Bauer: In general, children with curves of 20 to 25 degrees on an upright spine radiograph who still have at least a moderate amount of growth remaining (Risser 0-2) will be recommended a thoracolumbosacral orthosis (TLSO) brace to keep the curve from progressing, as well as offered scoliosis-specific Schroth physical therapy as an adjunct to the brace. This is continued until growth stops. If a child is younger than 5, they may be casted instead of braced. Children with curves over 45 to 50 degrees who still have a large amount of growth left will be offered surgery with growth-friendly implants that allow continued height. These will be converted to a final fusion once appropriate growth has completed. In patients with curves of this size without as much growth left (at least after their tri-radiate cartilages have closed), a final fusion may be recommended. The goal for surgery is to stop a curve from progressing, as curves that reach 70 to 80 degrees affect pulmonary function, and secondarily to correct deformity. The majority of curves over 50 degrees, even after a child stops growing, will continue to slowly progress, and thus these are offered surgery. Read full post »

The U.S. population faces seven times more exposure to ionizing radiation from medical procedures than it did in the early 1980s, largely due to the growth in computed tomography (CT) and nuclear medicine, according to the National Council on Radiation Protection and Measurements. Children’s hospitals are increasingly looking for ways to use lower radiation doses for diagnosis and treatment. Success has come from using new technologies and equipment specially designed for children and constantly being on the lookout for opportunities to share information and collaborate better across teams.

Tom Lendvay

Why is radiation bad for children?  

Tom Lendvay, MD, urologist, Seattle Children’s: If you start receiving radiation exposure as a child, you run the risk of having a larger lifetime dose of radiation. Children exposed to radiation, especially those undergoing X-rays and CT scans to evaluate primary cancers, are also at increased risk of developing what is called a secondary malignancy, or cancer due to the DNA-damaging effects of radiation exposure as a child. These include hematologic (blood cell) cancers.

For all these reasons, we look for ways we can reduce the amount of radiation our patients are exposed to during diagnosis and treatment.

What are some of the ways kids are exposed to radiation in the hospital?

Dr. Lendvay: Children may be exposed to ionizing radiation through X-rays, CT scans, fluoroscopy (live X-rays), nuclear medicine tests and intraoperative imaging. Fortunately, children’s bodies are generally smaller and contain less fat than adults, which makes ultrasound technology a good choice much of the time. However, there are a number of conditions that require radiation imaging tests. Over the last two decades, CT scans have provided rapid, rich data and anatomic detail that surpass many other imaging modalities and has proven invaluable to the diagnosis of severe medical conditions. Thus, the use of CT scans has increased in adults and children over the last two decades. Read full post »

Seattle Children’s welcomes epilepsy specialists Dr. Priya Monrad and Dr. Ahmad Marashly to the Epilepsy Program, where they will serve as Epilepsy Monitoring Unit medical director and surgical program director, respectively. They come from Children’s Hospital of Wisconsin and bring a combined 15 years of experience seeing the most complex patients, including those needing surgery. They joined Seattle Children’s this fall.

What are your plans for the epilepsy program at Seattle Children’s?

Dr. Monrad: We have the largest epilepsy program in the Pacific Northwest, but we want to make it more accessible to families, especially to those families living in Washington state south of Seattle. Starting in December, we’ll be seeing patients at our regional clinic in Federal Way for the first time. Previously, we offered epilepsy services only at the main hospital and the Bellevue and Everett regional clinics.

Dr. Marashly: We’re also going to be putting a stronger emphasis on making sure providers in the community have easier access to us and can get their epilepsy-related questions answered. We know PCPs can handle so much of their patients’ epilepsy care if they have a good connection with a specialist when needed. We want to be a resource to them. Read full post »

Scott Manning

John Dahl

Is thyroid cancer on the rise?

Scott Manning, MD, program director, Otolarnygology Education, and John Dahl, MD, PhD, MBA, pediatric otolaryngologist, Seattle Children’s: Yes, the reported incidence of thyroid nodules across all age groups is increasing in the United States, with thyroid cancer now the fastest-growing cancer diagnosis for adult women. We believe environmental factors are contributing to this rise. For children, a thyroid nodule has an even higher chance of being malignant than for adults; in some centers, as many as 20% of pediatric thyroid nodules turn out to be cancer, versus 5 % in adults. That said, it’s important to keep in mind that the majority of thyroid nodules in children and adults turn out to be benign. About 350 pediatric thyroid cancers are reported each year in the United States.

What is the best way to diagnose a thyroid nodule?

Ultrasound is the best way to initially evaluate a nodule and will determine whether a particular nodule additionally needs a fine needle aspiration (FNA) biopsy in order to make the definitive diagnosis. Ultrasound does not require anesthesia/sedation or radiation and is cost-effective. It can also be used to evaluate for the presence of cervical metastases in children with thyroid cancer.

At Seattle Children’s, we are able to do FNA biopsies in clinic with our kids awake under local anesthetic, which makes the process that much safer and easier on the family and child. About 85% of our FNA biopsies are done this way, which is unique in the United States; most FNA biopsies elsewhere are done under general anesthesia.

It’s important to have a patient’s ultrasound read by a pediatric radiologist rather than an adult radiologist, because of their specialized knowledge and training in working with children and imaging.

For a variety of treatment-related reasons, we don’t recommend diagnosing a nodule by starting with a CT with contrast. Read full post »

Kathleen Kieran

Kathleen Kieran, MD is a pediatric urologist serving patients in both Seattle and Tri-Cities.

You’re from Boston originally. What brought you to Seattle Children’s?

Dr. Kathleen Kieran, pediatric urologist, Seattle Children’s: I’ve been slowly working my way across the country from the East Coast. I grew up in the suburbs of Boston, and went to college, graduate school, and medical school there. I attended the University of Michigan for my urology residency, and then the University of Tennessee for pediatric urology fellowship. I worked in Iowa for 5 years before I came to Seattle.

The greatest impetus for my move to the West Coast was that my husband (who grew up in Puyallup and is an adult urologist in Tri-Cities) loves living in the Pacific Northwest and will absolutely not entertain the idea of living anywhere else. So I called Dr. Paul Merguerian [Seattle Children’s division chief of urology], and luckily they were about to post a position. Read full post »

Michael Portman

How has our understanding of Kawasaki disease etiology changed?

Dr. Michael Portman, director, Pediatric Cardiovascular Research, Seattle Children’s: Kawasaki disease (KD) is considered a systemic autoinflammatory disease and vasculitis that shows specific predilection for the coronary arteries, resulting in dilation or aneurysm formation. Many KD experts believe that the autoinflammatory response is triggered by environmental factors in genetically susceptible children. Over the past decade numerous genetic loci and polymorphisms have been identified as influencing KD susceptibility and treatment response. For instance, studies performed at Seattle Children’s Research Institute have highlighted the importance of polymorphisms for genes encoding Fcγ receptors, which regulate immune cell responses. The specific environmental factors have not been clearly identified but may be related to a common antigen carried by certain bacteria or viruses. Read full post »

Fawn Leigh

Spinal muscular atrophy (SMA) is the leading genetic cause of death for infants. Seattle Children’s neurologist Fawn Leigh talks about the fast-changing landscape of research and treatment that is bringing new hope to patients and their families.

What do you want providers to know about SMA?

Dr. Fawn Leigh, neurologist, Seattle Children’s: Being aware of SMA and spotting it early is very important in getting babies into treatment. It can be seen as early as during the newborn checkup. The most common feature of infants with SMA is hypotonia (low muscle tone). We typically see babies with neck flexor weakness, where they can’t lift their head on their own, and significant head lag when pulling up. There’s an absence of reflexes too. But the main thing is hypotonia; that’s the red flag providers should watch out for. Read full post »

Mark Boos

How are children affected by climate change?

Dr. Mark Boos, pediatric dermatologist, Seattle Children’s: We are all affected by the changes in our natural environment that have been precipitated by the climate emergency our world is experiencing secondary to elevated atmospheric carbon dioxide levels. But while natural disasters such as wildfires, hurricanes and other forms of extreme weather can cause lasting physical, mental and emotional harm to all people, specific populations are more adversely affected. This includes children, the elderly and individuals with disabilities. Currently, it is estimated that 88% of the existing global burden of disease secondary to climate change affects children less than 5 years old.

Children are uniquely vulnerable to changes in the environment, specifically to extreme changes such as heat waves and air pollution that are worsened by climate change. Children have an immature physiology and metabolism that prevent them from optimally regulating their temperature. Additionally, children have a greater challenge in clearing inhaled or ingested pollutants, while simultaneously having an increased exposure to these agents (per unit body weight) in air, food and water. Furthermore, their distinctive behavior patterns (i.e., spending more time outdoors) and dependence on adult caregivers place children at much higher risk of climate-related health burdens than adults. Specifically, children may suffer from impaired lung development, asthma exacerbations, worsening allergies and malnourishment as a result of climate change. Post-traumatic stress, physical injury, disruptions in education and loss of a stable home environment are additional ways that children can be negatively affected by natural disasters.

Read full post »

Randall Bly

What are cranial base diagnoses?

Dr. Randall Bly, principal investigator, Seattle Children’s: These are diagnoses of tumors or other lesions in the middle of the head. The cranial base is also sometimes called the skull base. Diagnoses can include nasal dermoids, orbital tumors, cholesterol granulomas, craniopharyngiomas, schwannomas, paranasal sinus tumors, pituitary adenomas, inverted papillomas, neurofibromas, angiofibromas, glomus tumors, esthesioneuroblastomas and cerebrospinal fluid (CSF) leaks.

Read full post »

Namita Singh

What causes inflammatory bowel disease (IBD)? How has our understanding of it changed over time?

Dr.  Namita Singh, physician, Seattle Children’s: IBD is a multifactorial chronic disease. It is due to the overly active immune response to gastrointestinal (GI) enteric bacteria in genetically susceptible individuals, triggered by environmental factors. More than 200 genetic loci have been identified as playing a role in IBD, with some (i.e., NOD2) being associated with more progressive disease. Using our understanding of the inflammatory pathways affected in IBD, newer medications have been developed targeting these various pathways. The enteric bacteria, or GI microbiome, is known to be very different in IBD — with less diversity — than in healthy non-IBD patients. There has been an increase in IBD incidence worldwide over the past decade, suggesting a large impact in environmental factors rather than genomic shifts. For example, immigrants from countries with a lower prevalence of IBD assume a much higher risk when they immigrate to the United States, and their children even more so. The fastest-growing population is the pediatric Crohn’s disease population, and we are seeing IBD in very young patients as well.

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