News for St. Louis Children s Hospital s Attending and Referring Medical Staff. see page 8

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1 WINTER 2018 DOCTOR SDIGEST News for St. Louis Children s Hospital s Attending and Referring Medical Staff Young Athlete Center Specializes in Treating Sports-Related Injuries see page 8 2 Breaking the Cycle of Violence 3 One Donor Liver, Two Recipients: A Split That Saves Lives 5 Medical Team Performs Rare in Utero Spina Bifida Surgery 10 Spotlight: SLCH Critical Care Transport Team For more information, contact HELP (4357) or Childrens_Direct@bjc.org 1

2 DOCTOR S DIGEST News for St. Louis Children s Hospital s Attending and Referring Medical Staff Breaking the Cycle of Violence by Supporting Its Young Victims SHARE YOUR IDEAS Should you have ideas or suggestions you would like brought before the Children s Medical Executive Committee (CMEC), contact one of your CMEC private physician representatives: John Galgani, MD jgalgani@essehealth.com Karla Keaney, MD karlakeaney@gmail.com Jennifer Arter, MD arter@wudosis.wustl.edu John Cole, MD jccole3@sbcglobal.net Kevin Murphy, MD northwestpediatric@sbcglobal.net _ LET US HEAR FROM YOU If you have comments or suggestions regarding Doctor s Digest, or if you would like to share information about your activities as a physician, contact: Jennifer Pickett Marketing and Communications St. Louis Children s Hospital 4590 Children s Place Suite 6203 Mailstop fax: Jennifer.Pickett@bjc.org _ Joan Magruder President John Galgani, MD Medical Staff President Andrew White, MD Medical Staff President-Elect _ 2 Doctor s Digest Winter 2018 _ Erica and her mentor, Genai Houser. (photo: Gara Dyson) She suffered a concussion, sustained injuries to her back, and her eye took quite a beating. But those surface wounds told only part of Erica s story, one that is all too familiar to the people in Erica s life. In fact, Erica s harrowing experiences of living through or frequently witnessing acts of violence made her eligible for SLCH s donor-funded Victims of Violence program. With more than $500,000 in funding from the Hauck Family Foundation, the hospital s Victims of Violence program grew out of a pilot study showing that mentoring young victims of violence in ways to avert another attack reduced the likelihood of a repeat visit to the emergency department. Many of the children who have been the victim of interpersonal violence will go on to initiate violence toward others, leading to unsafe communities and further injury and death, says Margie Batek, MSW, LCSW, Victims of Violence program director. The goal of this program is to curb the reoccurrence of interpersonal violence in the lives of children who have been shot, stabbed, assaulted or involved in domestic violence and Fit for Confinement evaluations. Genai Houser, one of the program s social workers at SLCH, became Erica s mentor. Houser worked diligently with Erica to gain her trust, meeting with her regularly at a mutually agreed upon safe spot near Erica s home or school in a neighborhood much like Houser s own as a child. After being assaulted by several classmates in the girls restroom of her high school, Erica, age 17, was treated in the emergency department at St. Louis Children s Hospital (SLCH). I always felt fortunate that no one in my family was directly impacted by violence, Houser says, but we definitely were surrounded by it. One time, a man was shot and died on Houser s front porch. You can almost become numb to the violent acts you see every day, Houser says. Most of the kids we work with think of it as a normal part of life. Our challenge is to help them understand that it isn t and that there are actions they can personally take to avoid the escalation of violence and keep themselves safe. The program, which recently added social workers at Barnes-Jewish, SSM Health Saint Louis University and SSM Health Cardinal Glennon Children s hospitals, requires a minimum of six sessions with a Victims of Violence mentor. Along the way the mentors communicate with school personnel, deputy juvenile officers, court personnel, police officers and community agency staff who may be involved with the child. Already traumatized by the shooting death of her father, Erica began opening up. Houser helped her process her loss and move beyond conflicts of the past. Because Erica was resistant to returning to school, Houser encouraged her to get her G.E.D. and pursue training to be a medical assistant. I m not an easy person to know, Erica says. I don t trust a lot of people, but Ms. Houser never gave up on me. For more information about the Victims of Violence program, call Children s Direct at HELP (4357).

3 One Donor Liver, Two Recipients: A Split That Saves Lives Drs. Doyle and Chapman reunite with Synthia and Gabriella, who share a liver. (photo: Tim Parker) Seventeen times during the past two years at St. Louis Children s (SLCH) and Barnes-Jewish hospitals, one donor liver has saved the life of one child and one adult. Called split-liver transplants, the latest occurred in August, when 2-year-old Gabriella received one-third of a donor liver and adult patient Synthia received the remaining twothirds. It is a procedure made possible by the uncanny ability of the liver to regenerate, and pediatric and adult liver transplant programs that, after more than 30 years, are among the oldest and most experienced in the country. ALLOCATING DONOR LIVERS The allocation of a donor liver is a complicated process. In simple terms: The donor liver is classified by blood group; each blood group has its own list of people awaiting transplant, with those who are sickest at the top. Pediatric donor livers generally are offered to pediatric and adolescent patients first. Adult donor livers go into the pool for both adults and children. Through a scoring process that determines the greatest need, an adult donor liver may be allocated to a pediatric patient. When this occurs, I assess the donor liver based on its size and the age of the donor. We only split young, healthy livers to ensure excellent function for both recipients, says Washington University pediatric surgeon Majella Doyle, MD, surgical director of liver transplantation at SLCH. In addition, the pediatric patient needs to be a certain size because older and larger children need either a half or full liver. Once Dr. Doyle determines that the liver can be split and that her pediatric patient is the right size to receive one-third of the liver, she contacts the transplant surgeon at Barnes-Jewish Hospital (BJH) to see whether there is a patient who fits the adult criteria for receiving a split liver. Again, the adult needs to be of a certain size since the transplanted portion of liver will be smaller and not suited for a larger person, explains Dr. Doyle. In addition, because of a slight increase in the risk of complications, the adult patient needs to be healthy enough to withstand the surgery. For the adult, that surgery involves using vessels from the donor to reconstruct the artery and sometimes veins since the bulk of vessels from the donor liver are transplanted into the pediatric patient. continued on page four For more information, contact HELP (4357) or Childrens_Direct@bjc.org 3

4 Donor Liver continued from page three The liver is amazing because it is the only organ that can be partially split and then regenerate. It doesn t grow back into the shape of a normal liver; it just grows in the shape that it is, says Dr. Doyle. In the adult, it regenerates to a size suitable for carrying out its vital roles in the human body. In the pediatric patient, it grows as the child grows. LIVER TRANSPLANT PROGRAM SUCCESS With its long history, the Liver Care and Transplant Center at SLCH is among the most successful in the United States, with three-year survival rates of more than 90 percent, consistently above the national average. In addition to split-liver transplants, its pediatric liver transplant surgeons are skilled at whole liver, segmented/reduced liver and living donor transplants. One aspect that makes our program so unique is that we do transplants on very small babies, which can be incredibly challenging, requiring great focus and intensity. Forty-nine percent of patients we transplant are under 2 years of age; the youngest was just 10 days old, says Dr. Doyle. We often receive referrals from other hospitals because some programs don t feel comfortable performing liver transplants on smaller children. She adds, Our liver transplant team consists of transplant surgeons, transplant hepatologists, pediatric nurse practitioners, transplant coordinators, pharmacists, nutritionists, a child psychologist and a social worker. These are the experts who review all information with families whose child has liver disease. After a full, frank and extensive discussion, the team develops comprehensive pre-transplant and peri-transplant care plans, guaranteeing the best care possible. To learn more about the Liver Care and Transplant Center at SLCH, call Children s Direct at HELP (4357). 4 Doctor s Digest Winter 2018 Transplant Services at SLCH St. Louis Children s Hospital is one of the top pediatric transplant centers in the country, with programs dedicated to lung, heart, heart/lung, liver, kidney and bone marrow. Highlights for each include: Lung transplant 1990 program established More than 440 lung transplants performed through 2017 Patients drawn from across the world, including Israel, Mexico, Japan, Saudi Arabia, Canada and Australia Heart transplant 1986 program established More than 460 heart transplants performed through 2017 One of the largest and most active pediatric heart transplant programs in the country Heart/lung transplant 1993 first heart/lung transplant 19 heart/lung transplants performed through 2017 Liver transplant 1985 program established More than 300 liver transplants performed through 2017 Expertise in split-liver, whole liver, segmented/reduced liver and living donor transplants Kidney transplant 1970 program established More than 310 kidney transplants performed through 2017 One of the few programs in the country with expertise to perform transplants for children under 1 year of age Bone marrow transplant 1991 program established 632 bone marrow transplants performed through 2017 The first bone marrow transplant program in St. Louis created exclusively for children Youngest bone marrow transplant recipient 26 days old Longest-surviving bone marrow transplant patient 26 years 97 percent survival at 100 days post-transplant for autologous (self) transplants 90 percent survival at 100 days post-transplant for allogeneic (related and unrelated) transplants

5 The 25-week-old fetus underwent a three-hour surgery that included a pediatric cardiologist, adult and pediatric surgeons, anesthesiologists, a neonatologist, a clinical pharmacist and a skilled team of operating room support staff. (photo: Timothy Mudrovic) Collaborative Medical Team Performs Rare in Utero Spina Bifida Surgery In October, Washington University surgeons and physicians from St. Louis Children s and Barnes-Jewish hospitals collaborated to perform a prenatal closure of a myelomeningocele in a 25-week-old fetus with spina bifida. In total, 35 medical professionals took part in the rare surgery that was the first of its kind at the Washington University medical campus. This was a significant event that has the potential for benefiting families throughout the Midwest, says Michael Bebbington, MD, MHSc, director of the Fetal Care Center of Barnes-Jewish Hospital (BJH), St. Louis Children s Hospital (SLCH) and Washington University School of Medicine. Rather than traveling long distances, this advanced care now is available closer to home. Spina bifida occurs when the fetus spinal canal remains open along several vertebrae in the lower or middle back. This causes the membranes surrounding the spinal cord and some nerve fibers to protrude, forming a sac on the baby s back. The condition may cause physical and neurological problems to the lower limbs, bowel and bladder, as well as hydrocephalus, for which a ventricular shunt is usually needed. In years past, the standard of care for treating myelomeningocele was to perform neurosurgery, usually within 24 to 48 hours after birth. The procedure involved repositioning the exposed tissue back into the spinal column and covering it with muscles and skin. In recent years, however, evidence has shown that in some cases fetal surgery for myelomeningocele may improve continued on page six For more information, contact HELP (4357) or Childrens_Direct@bjc.org 5

6 Spina Bifida continued from page five neurological outcomes. That was the finding of the Management of Myelomeningocele Study (MOMS), a randomized, multicenter clinical trial sponsored by the National Institutes of Health comparing the outcomes of prenatal surgery with postnatal surgery. The results of the trial were published in the New England Journal of Medicine in February The MOMS trial showed that for a select group of fetuses, in utero surgery can result in three major benefits, says Dr. Bebbington, who participated in the clinical trial when he was at the Children s Hospital of Philadelphia. One is that the high-brain herniation occurring as a result of the lesion is reversed, meaning the cerebellum migrates back up into a more normal position. Second, the need for shunting because hydrocephalus is decreased by 50 percent compared to postnatal surgery. Finally, neurologic function may improve by up to two levels, which for some children means the difference between walking and not walking. According to Washington University neonatologist Barbara Warner, MD, co-director of the Fetal Care Center, a variety of problems can arise when children need shunting. Among these is shunt malfunction that requires revision surgery, a constant source of worry for parents. Eliminating the need for shunting is a significant improvement for patients with spina bifida and their parents and greatly enhances these children s lives, she says. CAREFUL, HIGHLY SELECTIVE EVALUATION The MOMS trial established particular inclusion/exclusion criteria that determine pregnant mothers and their fetuses eligibility for prenatal repair of myelomeningoceles. Among these are: For fetuses (inclusions) Open neural tube defect between T1 and S1 Evidence of a chiari malformation, the condition in which brain tissue extends into the spinal canal Singleton pregnancy between 19 and 25 weeks Normal karyotype For mothers (exclusions) Factors that may increase risk for preterm labor and delivery; e.g., short cervix, uterine abnormalities, placenta previa, prior spontaneous preterm deliveries Major medical conditions such as diabetes, or infectious diseases that may be transmitted to the fetus during surgery Body mass index of more than 35 If the various initial criteria are met, families undergo an extensive evaluation, including specialized ultrasound study and a fetal MRI. The families then meet with Dr. Bebbington to review the results of the study, what that means for the developing fetus, and all the options for ongoing care. If they are good candidates for open fetal surgery, the next step is meeting with the pediatric neurosurgeon, pediatric surgeon, A total of 35 medical professionals from Children s and Barnes-Jewish hospitals collaborated in the surgery. (photo: Timothy Mudrovic) 6 Doctor s Digest Winter 2018

7 Baby Jackson was born a second time at 35 weeks on December 20, 2017 and spent 12 days in SLCH s Newborn Intensive Care Unit. (photo: Joni Reinkemeyer) pediatric anesthesiologist and a social worker. Approximately one out of every five families evaluated is identified as good candidates for the surgery. We conduct psycho-social evaluations to ensure the mothers can cope with the stress and rigors of the surgery, and that they have support people available once they are discharged from the hospital, says Dr. Bebbington. Because of the nature of the surgery, the remainder of the mothers pregnancy care changes. The moms are on bed rest, and that means having someone with them at all times to help with their needs and, most importantly, that can get them to the hospital if need be. He adds, The mothers can sometimes go back to their homes, but only if they live in close proximity to a large-enough medical center that has a specialist available to continue caring for them. Otherwise, they need to remain in St. Louis. We encourage families who have undergone open fetal surgery for myelomeningocele to return to St. Louis for delivery. Dr. Warner says those involved in the in-depth screening process act as stewards of careful evaluation of benefit. As with all surgeries, in utero myelomeningocele spina bifida surgery carries certain risks to the mother and the fetus, and we are careful to make sure the parents understand these before they make a decision, she says. Parents can be easily swayed to want to do everything for their baby, especially when new, life-changing procedures become available. In the vast majority of cases, myelomeningocele spina bifida is not a lethal congenital defect, but it can result in serious impairment and sequelae. All factors are weighed carefully before moving forward. THE SURGERY Dr. Bebbington describes the October in utero surgery as a kind of ballet, with those present knowing their role and maneuvering through the operating room. In addition to the surgeons, those present during the three-hour surgery included a pediatric cardiologist, adult and pediatric anesthesiologists, a neonatologist, clinical pharmacist and a skilled team of operating room support staff. The first step in the surgery was Dr. Bebbington and Washington University pediatric surgeons Jesse Vrecenak, MD, and Brad Warner, MD, opening the maternal abdomen and positioning the fetus inside the uterus so that the small section of the spine where the lesion was located was visible. At that point, Washington University pediatric neurosurgeons Jennifer Strahle, MD, and David Limbrick, MD, repaired the open neural tube defect, closing it with fetal skin; the amniotic fluid was reconstituted; and the maternal abdomen closed. Our multidisciplinary myelomeningocele clinic has a large number of resources we are able to deploy for our patients and their families, says Dr. Strahle. Although the success rates for this surgery are very impressive, ongoing success and sustained good outcomes for each mother and child requires ready access to care, a team that can respond to questions and changes as they arise, and guidance for families to help them anticipate milestones. Our team at Washington University is as well-prepared to do this as any institution I have seen. Following surgery, there is a four-day protocol of postoperative care because of the risks of these surgeries, in particular fetal well-being and the possibility of contractions and infection. In this case, the parents moved to St. Louis to be close to the physicians and hospitals. The closest hospitals with similar programs such as ours are in Cincinnati, Denver and Houston, says Dr. Bebbington. Our proximity should encourage physicians to recommend to families that they be evaluated at the Fetal Care Center. Beyond offering in utero surgery, we can offer a comprehensive, specialized evaluation and can help to educate families about spina bifida, what to expect and what resources are available to them. Among those resources is the large myelomeningocele clinic at SLCH. We are looking forward to carefully following babies who have undergone this in utero surgery and tracking their outcomes, says Dr. Warner. It s an exciting prospect. For more information about this case or to speak with a member of the surgical team, call Children s Direct at HELP (4357). For more information, contact HELP (4357) or Childrens_Direct@bjc.org 7

8 Center Specializes in Treating Sports-Related Injuries The 4,000-square foot expansion is located on the 3rd floor of the Specialty Care Center. (photo: Harold Anderson) Recognizing the importance of athletics in the lives of children and adolescents today, Washington University and St. Louis Children s Hospital have established the Young Athlete Center that specializes in treating this growing patient population. Located at the St. Louis Children s Hospital Specialty Care Center at Interstate 64 and Mason Road, the Young Athlete Center offers the expertise of pediatric sports medicine and pediatric orthopedic surgery, together with specialists in physical therapy, sports psychology, nutrition, pain management and others. When needed, Washington University pediatric physicians in such areas as cardiology and pulmonology also are available for athletic-related issues. We ve treated these patients for a long time, but the Center is a dedicated approach to evaluating, diagnosing and treating young athletes, says Washington University sports medicine physician Mark Halstead, MD, who serves as the Center s co-director. We are the only program in St. Louis to provide care by three pediatric-specific sports medicine specialists myself and Dr. Terra Blatnik provide nonsurgical treatment, and my co-director, Dr. Jeffrey Nepple, is a fellowshiptrained pediatric orthopedic surgeon and sports medicine specialist. According to Dr. Nepple, today there is an epidemic of sports injuries in both boys and girls because of the emphasis placed on participating in year-round organized sports. The number of children and adolescents injured while playing sports is staggering, and many develop issues we didn t see 10 or 20 years ago, he says. As much as 50 percent of the injuries we see are related to overuse. Unlike in the past 8 Doctor s Digest Winter 2018

9 when young people played a variety of sports, today they usually concentrate on one sport and start playing it at a young age. The repeated use of sportsspecific muscle groups can take a toll on young athletes. As in all of pediatric medicine, children and adolescents are not simply small adults; rather, they have particular needs related to an athlete who is still growing. Traumatic injury to growth plates or repeated concussions can have significant consequences for the future of young athletes. For this reason, the Young Athlete Center not only offers particular expertise in treating sports injuries but also in providing athletes, their parents and their coaches with the education they need to prevent injuries while enhancing performance, says Dr. Halstead. We already have partnered with local high schools and sports clubs to conduct injury-prevention programs. Our expanded facilities will enable us to conduct similar programs within the Center. EXPANSION DESIGNED SPECIFICALLY FOR SPORTS REHAB The Young Athlete Center s 4,000- square-foot expansion opened at the end of In addition to providing room for in-house educational programs, it offers facilities specially designed for sport-specific rehab, encompassing such associated aspects as running, jumping, kicking and throwing. Drop-down nets, throwing mounds and areas covered in indoor turf and hardwood provide playing surfaces on which athletes can simulate on-field activities. A 70-foot-long running track allows patients to gain enough speed for physicians and therapists to evaluate their movement patterns and guide recommendations for improvement. Wireless 3-D motion analysis technology provides the means to visualize how athletes are moving in order to identify at-risk patterns and provide education on how to prevent injury. Return-to-sport testing ensures all athletes are prepared to resume their athletic endeavors. The long-term health benefits of staying active are well documented, and today sports play an important role in maintaining a healthy lifestyle, says Paul Jenkins, PT, MSPT, OCS, Young Athlete Center coordinator. Our goal is to keep our patients safely in the game and playing as much as they can. Adds Dr. Nepple, This additional space also provides us with the capability of conducting the research needed to continue advancing sports medicine for these patients. ACCESSIBLE CONSULTATION AND TREATMENT Keeping in mind that the Young Athlete Center s patients are children and adolescents, medical staff members are committed to making patients experience as friendly and pain-free as possible. To provide the immediate attention many sports injuries need, same-day appointments are available. Minimally invasive surgical treatment is available on site; procedures that require an overnight stay are performed at St. Louis Children s Hospital. The Center offers same-day access to comprehensive care by medical professionals trained in pediatric sports medicine, says Dr. Halstead. Our ability to quickly assess, diagnose and begin treatment is important not only for getting patients back to their sport but also for giving parents peace of mind that their kids are receiving the best care available. For more information or to speak with a member of the Young Athlete Center team, call Children s Direct at HELP (4357). Kaila Mikesch, PT, DPT, assists Young Athlete Center patient Tajah Foster-Walker as she undergoes a strict physical therapy regimen after ACL reconstruction. (photo: Gara Dyson) For For more more information, information, contact contact HELP HELP (4357) (4357) or or Childrens_Direct@bjc.org 9

10 Spotlight: SLCH Critical Care Transport Team For more than 30 years, the St. Louis Children s Hospital critical care transport team has provided patients with a direct route to advanced and highly specialized care, including a Level 1 pediatric trauma center. With a changing health care landscape, the team has been meeting the customer service and clinical expertise needs of pediatric, neonate and maternal-fetal patients, providing them with access to care at St. Louis Children s Hospital (SLCH) and Barnes-Jewish Hospital (BJH). The team s mission is to provide a superior patient experience by providing safe and effective care to each patient and family on every transport. The team s practice is based on advanced patient care practices established through innovation, research and education. TEAM COMPOSITION AND SERVICES Each dedicated transport team consists of two registered nurses, a paramedic and, when needed, a pilot available 24/7. The teams transport patients by specially equipped Mobile Intensive Care Units (MICUs) operated by SLCH; KidsFlight 1 and 2, EC145 helicopters; and KidsFlight 3, a Pilatus12 fixed-wing aircraft. Air operations are provided via dedicated aircrafts operated by Air Methods in partnership with SLCH. Completing more than 2,500 trips each year, the team s primary response area includes hospitals in Missouri and Illinois but also provides services across the United States and Canada. The three transport teams are based in two locations: two teams at SLCH, and one at Parkland Health Center in Farmington, Mo. These two locations allow the team to focus on a current priority, which is to be as responsive to its patients as possible by improving response times to outside hospitals. As a dedicated transport team, care is provided to both neonatal and pediatric patients up to age 18 and adult maternal fetal transports. The team is equipped to deliver all levels of advanced medical care including nitric oxide delivery, high-frequency mechanical ventilation, as well as the transport of patients on ECMO. During the last several years, transport services has expanded its offerings to include: Maternal Fetal Transport Service, offered in partnership with BJH, for pregnant women requiring specialized transport and immediate access to care. During these transports, the team consists of a high-risk obstetrical nurse, a neonate-trained nurse in the event of imminent delivery, and a paramedic. Trauma Early Launch, a program through which EMS agencies in the hospital s Missouri and Illinois service areas have the option of requesting a pediatric specialty care team via helicopter to the community hospital from which a child is being transported. The transport team nurses and paramedic are able to assist with stabilizing the patient and quickly transporting them to SLCH. RESEARCH AND EDUCATION Transport team members bring the same elite medical care currently delivered within Children s Hospital to referring facilities when they arrive at the patient s bedside. Through research projects, the processes and protocols of the transport team are continually updated and improved to meet these gold standards. This also requires continued education through several means including simulation scenarios taught by the medical directors and fellows from the NICU and PICU. The team s affiliation with Washington University School of Medicine, one of the top research facilities in the world, allows for participation in research and evidence-based practice projects. This work is instrumental to improving the medical care delivered to the patients being transported, as well as becoming the benchmark for gold standards of pediatric and neonatal patient care. To learn more about SLCH critical care transport team, call Children s Direct at HELP (4357). 10 Doctor s Digest Winter 2018

11 Medical 3-D Printing Center Opens St. Louis Children s Hospital opened a new specialized 3-D printing center in January on the Washington University medical campus. The center features three printers and specializes in medical and pre-surgical modeling for adult and pediatric patient care via direct CT image remodeling, custom parts for research and prosthetics. In addition to models of patient anatomy, custom surgical guides, templates and other tools may also be produced for use in the operating room. Engineers design models based on surgical and research needs or print directly from a client s 3-D file model. For more information and to order a model, visit StLouisChildrens.org/3DPrinting. CONTINUING MEDICAL EDUCATION Specialty Care Speaker Series Occurs on the last Tuesday of every month. Registration and light dinner begins at 5:30 p.m., followed by a one-hour presentation from 6-7 p.m. February 27, Kevin Baszis, MD Case Presentations in Pediatric Rheumatology Early Bird Rounds Occurs every Friday through mid-june from 8-9 a.m. in the St. Louis Children s Hospital executive boardroom in suite 3S-36 or online at StLouisChildrens.org/Med_Ed. 3rd Collaborative St. Louis Children s Hospital and Cox Health NICU Care Conference Fri., April 6 Springfield, MO Spring 2018 Clinical Pediatric Update Fri., April 20 Marriott St. Louis West Pediatric Telephone Triage Wed., April 25 Drury Inn, Brentwood, MO Pediatric Psychiatry for the Primary Care Provider Fri., May 4 St. Louis, MO For additional information, visit StLouisChildrens.org/Med_Ed. For For more more information, contact contact HELP (4357) or Childrens_Direct@bjc.org 11 11

12 Marketing and Communications 4590 Children s Place, Suite 6203 St. Louis, MO MS StLouisChildrens.org Non-profit Organization U.S. Postage PAID St. Louis, MO Permit No. 617 Learn more about the subjects discussed in this issue by calling Children s Direct at HELP (4357). CS_111701_2/18 12 Doctor s Digest Winter 2018