Swathi Khrishna

Sonali Bora

Many primary care providers are on the front lines of fielding questions and identifying symptoms of psychiatric illness in children and adolescents in the community setting.  We have put together a quick guide that addresses some common questions and concerns on how to refer non-emergent psychiatric concerns to community outpatient resources and avoid unnecessary and costly ED visits

What kind of services are and are not available to children with psychiatric/behavioral complaints in the ED?

Psychiatric assessments in the medical ED setting are brief and focused.  They are not full psychiatric evaluations and are not meant to provide new diagnosis or start new medications.   They are simply a crisis assessment to evaluate for the child’s safety and the safety of others. If a patient is deemed unsafe to self or others, they will be transferred to a primary psychiatric facility for further treatment.  It is an assumption of many community providers that patients with psychiatric complaints must first be directed to a medical facility for “medical clearance”.  In fact, all psychiatric facilities are emergency receiving facilities and have the resources to provide medical clearance and directly accept healthy patients with behavioral and psychiatric complaints.  Most psychiatric hospitals perform psychiatric assessments 24/7,  and can place a patient on a 1013 or admit them voluntarily. Psychiatric facilities can also refer families to outpatient or lower levels of care if inpatient psychiatric hospitalization is not warranted. PLEASE NOTE CHOA DOES NOT HAVE INPATIENT PSYCHIATRY SERVICES.

What  intensive outpatient treatment options  are available for patients not in crisis?

Some psychiatric facilities offer Partial Hospitalization Programs (PHP) and Intensive Outpatient Programs (IOP). A PHP is a nonresidential treatment program that is hospital-based. The program provides diagnostic and treatment services on a level of intensity similar to an inpatient program, but on less than a 24-hour basis.

An IOP Program offers group and individual services for 10-12 hours each week and allows individuals to participate in daily activities like school or work.

What outpatient resources are available in my area?

The Georgia Crisis Access Line (GCAL) is the first line referral for patients with medicaid or CMO’s looking for mental health services in Georgia.  GCAL can refer for emergency and routine psychiatric services and can be reached at 1-800-715-4225.   Patient or providers may search for community mental health providers in their area based on location and age group at  This is an online database of community mental health providers maintained by GCAL.  Providers can also ask parents, to look up mental health providers on their insurance provider’s website.

CHOA’s Behavioral Health Initiative Line (404-785-DOCS) is also available for community providers to ask general questions about psychiatric medications and management of symptoms on an outpatient basis.

What patients should I always send to the Medical ED first?    

Ingestions, psychiatric symptoms with coexisting medical symptoms ( i.e. fever, viral/bacterial illness, abnormal labs) and first break psychosis should  be directed to medical ED first.

Sedation Services at Children Healthcare of Atlanta

David Banks, MD

In the late 1990’s, as pediatric MRI imaging services came of age, pediatric hospitals were faced with a growing need for quality pediatric sedation services. Many institutions met this need initially by assembling experienced nurses and having them manage the sedations.  By the early 2000’s, the nurse-run services were being replaced by physician services, as the Joint Commission developed new standards for deep sedation services.  In compliance with Joint Commission standards, both Children’s campuses Scottish Rite and Egleston developed physician run sedation services.  Pediatric Sedation Services (PSS) was developed on the Scottish Rite campus by the PEMA physician group, and Children’s Sedation Services (CSS) was formed as a combined effort by the critical care and pediatric emergency medicine teams at the Egleston campus.  Both PSS and CSS have grown in volume and scope of services and, as a system, represent one of the largest pediatric procedural sedation services, performing over 11,000 cases per year.  

Services Provided

The sedation services at CHOA provide predominantly “deep sedation,” where the requirements for completing a study involve the patient lying completely still, typically for imaging studies such as MRI, CT, nuclear medicine/PET imaging, or for Auditory Brainstem Response (ABR) hearing studies.  We also provide deep sedation for difficult or painful procedures, commonly referred to as “procedural sedation,” where the patient not only needs to be deeply asleep, and reasonably still, but also have the pain of the procedure appropriately managed.  Deep procedural sedation is provided in multiple areas across the system, including the AFLAC Cancer Centers (bone marrow studies or lumbar punctures for intrathecal chemotherapy,) the emergency departments (fracture reduction, abscess drainage, complex wound management), and interventional radiology (difficult LPs, PICC line placement, percutaneous drainage of appendiceal abscesses).  Deep sedation services account for approximately 95% of the sedation services’ consultations.

In some situations, moderate sedation is appropriate to meet the patient’s needs. One example would be an older patient undergoing lumbar puncture for intrathecal chemotherapy.

Our services also provide anxiolysis for patients undergoing minor procedures that are minimally painful but associated with significant patient stress.  Typical circumstances where anxiolysis is provided include obtaining IV access in challenging situations when the vascular access team is required and for bladder catheterization in a patient with urologic issues requiring a VCUG.

Most patients are also managed in conjunction with Child Life Services to help relieve the patient’s stress and anxiety.

Medications typically utilized by our sedation teams are:

– Deep

propofol, dexmedetomodine, methohexital, ketamine, and fentanyl

– Moderate

fentanyl and midazolam

– Anxiolysis

nitrous oxide gas


Preparing Patients and Families for Sedation

The majority of the patients that receive sedation are electively scheduled cases that are previewed well in advance of their appointment and are prescreened for appropriateness for the sedation services. Our current involves having each case reviewed by an experienced sedation nurse in advance. Families are contacted in advance to assure the patient’s appropriateness for the sedation service.  Some of these patients may be deemed to be higher risk and may be referred to the anesthesia service for management.  Specific conditions that may result in referral to the anesthesia service include:

  • Difficult airway
  • Patients with a Z score of >2.5 for BMI for age (patients whose comparative weights are overweight for age based on an international standard scale)
  • Laryngomalacia or stridor at rest
  • Poor airway tone
  • Excessive secretions, GERD
  • Chronic lung disease resulting in O2 requirement of ventilator support
  • Congenital heart disease with R to L shunts or pulmonary hypertension
  • Certain metabolic disorders
  • Patients with significant medical complexity

After screening, families are then given pre-procedure instructions that include arrival time, a discussion of NPO times, and instructions on whether to take the morning dose of routine medications on the day of the procedure. For purely elective procedures, families are encouraged to reschedule if the child is ill just before or at the time of the scheduled procedure.

NPO Guidelines:

Heavy, greasy meal                8 hours

Solids, milk/formula               6 hours

Breastmilk                              4 hours

Clear liquids                            2 hours


Be Selective.  Weigh All the Risks

Sedation is not without short term and long-term risks.  As sedationists, we are comfortable managing the well-known short-term risks of deep sedation, including depressed respiratory drive, hypoxemia, and loss of airway tone with subsequent airway obstruction.  These events occur in approximately 1 in 20 deep sedations, and the sedation team is prepared to manage them.  However, if the case is truly elective, and the patient is at greater risk on the day of the procedure due to respiratory illness or other medical issues, then rescheduling for 3 or 4 weeks later may allow the study to be obtained with less risk.

Long term risk of deep sedation and anesthesia is still unclear.  Recent studies demonstrate that pups of multiple species exhibit neuro-developmental delay following prolonged or repeated exposure to propofol, ketamine, sevoflurane, or halothane. Large human population studies associate cognitive delay later in life in children that experienced multiple anesthetic exposures prior to age 3 years. However, there is no direct link demonstrating harm from deep sedation/anesthesia in human studies.

As a result of these studies, in December 2016, the FDA issued a Drug Safety Communication warning that “repeated or lengthy use of general anesthetic and sedation drugs during surgeries or procedures in children younger than 3 years or in pregnant women during their third trimester may affect the development of children’s brains.”

Interpreting animal studies that appear to demonstrate harm from sedation and anesthetic agents is difficult, as the methodologies and logistics of performing these studies are quite challenging.  Drawing conclusions from large human population studies is also fraught with difficulty, as there is no way to assess the effects of potential co-morbidities and surgical complications in patients receiving multiple anesthetics. In an attempt to keep this all-in perspective, it is crucial to remember that there are numerous studies delineating the deleterious effects on children of inadequate sedation or incomplete pain management during difficult or painful procedures. And we have all seen the devastating effects of delayed diagnosis of certain serious medical conditions.

The Society for Pediatric Sedation has been at the forefront of research in the field of pediatric sedation since its inception in 2007.  I recommend visiting the SPS website- and for more information regarding this research.

With all this in mind, please judiciously consider what sedated test you order. Is it necessary or will the results change your patient care?  As providers of healthcare to children, we should all be certain that any study or procedure that has been prescribed for any child is truly indicated, and that the risk-benefit ratio for potential short and long-term risks of harm has been carefully assessed.

For questions or concerns about ordering imaging studies and sedation services for all the CHOA facilities, contact:  404-785-2787 (Monday-Friday)

On weekends or after hours, you may contact the departments directly: 404-785-1487 for Egleston and 404-785-4698 for Scottish Rite.

Thank you for choosing Children’s and entrusting your patients to us.


HIV Screening Recommendations in Adolescents

Lauren Middlebrooks, MD








What an illness
My life is meaningless
You make my life lifeless
You make me hopeless
What an illness

You don’t care who you kill
It old and young
Big and small
Bad or good
What an illness

The sky was blue
Now its black
People hate each other
Because of you HIV/AIDS
What an illness

By SN, Primary school KaNyamazane, South Africa

As depicted in the poem above, written by a young child living with HIV in South Africa, HIV and AIDS has carried a reputation deeply rooted in fear, shame, and distrust.  Stigmas have impacted patient disclosure, provider discussion, and have limited early screening and diagnosis of at risk populations1. Once thought of as a disease only extending across international borders, Georgia is now ranked #5 in the United States (U.S.) for some of the highest rates of HIV in our nation.  The rising rates in downtown Atlanta specifically, have been compared to rates of HIV in third world countries, such as “Zimbabwe, Harare or Durban2.”  As if these statistics aren’t alarming enough, adolescents and young adults, ages 13-24, accounted for 22% of all new HIV infections in the U.S. in 2015—that’s roughly 1 in every 5 young people affected by this virus3.  In a 2005 Youth Risk Behavior Surveillance System assessment (YRBS), almost half of high school students surveyed nationwide reported having had sexual intercourse, yet only 11% had ever been tested for HIV4.  Adolescents and young adults quickly became an at-risk cohort, and in response to this new epidemic, the Centers for Disease Control and Prevention (CDC) made national recommends in 2006 for routine, opt-out HIV testing beginning at 13 years of age.  Interestingly, prior studies concluded not only that many clinicians had poor knowledge of these recommendations made over 10 years ago, but that the prevalence of HIV testing did not significantly change amongst high school students between the 2005 and 2015 YRBS’s.

Adolescents and young adults have the most challenges in links to primary care, mainly due to limitations in transportation, health insurance, and concerns for breeched confidentiality.  As a result, approximately 60% of HIV-positive adolescents remain unaware of their status.   Of adolescents who did see a primary provider, only half of primary care physicians even touched on sexual content, and the average amount of time discussing a sexual history was 36 seconds5.  It is our duty as providers to have open conversations with each one of our adolescent patients regarding their sexual history, preferences and practices.  It is also important that they understand the results will remain confidential and that every effort will be made to contact the patient directly with any new positive results. Per official recommendations, all patients 13-64 years of age are recommended to have at least one HIV test in their lifetime.  Persons who frequent high prevalent settings, including homeless shelter, prisons, and adolescent clinics, along with persons engaging in risky sexual behavior (multiple sexual partners, MSM, sex in exchange for money, substance abusers), may be tested at least once per year, or as frequent as every 3-6 months.

The most sensitive and specific tests for HIV are 4th generation antigen-antibody tests.  This is highly encouraged over others as it will more accurately capture true positives as soon as 4 weeks after exposure.  Positive tests should be relayed in person, not over the phone, and those patients can be referred to the Grady Ponce Center for further management and treatment.

Together we can normalize HIV screening in the adolescent and young adult population, reduce stigma associated with HIV/AIDS, and assist in managing this public health crisis.

For more information on the Grady Ponce Center, please visit:

or Contact Ponce Clinic Nurse-Deborah Ferris-404-516-4340 for any additional questions


  1. 2017 August 29. HIV Stigma and Discrimination.  Retrieved from:
  2. Huddleson D. Atlanta HIV Epidemic Compared to Third World Countries. WSB-TV 2 Atlanta 2016. Retrieved from:
  3. Health TGDoP. HIV Surveillance Fact Sheet, 2014. 2016
  4. Laura Kann P, Tim McManus, MS, William A. Harris, MM, Shari L. Shanklin, MPH, Katherine H. Flint, MA, Joseph Hawkins, MA, Barbara Queen, MS, Richard Lowry, MD, Emily O’Malley Olsen, MSPH, David Chyen, MS, Lisa Whittle, MPH, Jemekia Thornton, MPA, Connie Lim, MPA, Yoshimi Yamakawa, MPH, Nancy Brener, PhD, Stephanie Zaza, MD. Youth Risk Behavior Surveillance-United States 2005. Center for Disease Control and Prevention Morbidity and Mortality Weekly Report 2006;55(SS-5):19-22
  5. Alexander, S. C., Fortenberry, J. D., Pollak, K. I., Bravender, T., Davis, J. K., Ostbye, T., Shields, C. G. (2014). Sexuality Talk During Adolescent Health Maintenance Visits. JAMA Pediatrics, 168(2), 163.doi:10.1001/jamapdiatrics.2013.4338















The new way to test poop! The GI PCR or FilmArray Gastrointestinal Panel


Deborah Bloch, MD

Mark Gonzalez, MD

Craig Shapiro, MD

FilmArrayTM Gastrointestinal Panel?

The FilmArrayTM Gastrointestinal Panel is a rapid test (~2 hr turnaround time) offered by the CHOA microbiology lab for detection of common gastrointestinal pathogens (see Figure 1), which includes bacteria, viruses and parasites. Because of the comprehensiveness of the panel, in most cases stool culture, ova and parasite (O&P) examination, and antigen testing for Adenovirus 40/41, Rotavirus, Cryptosporidium spp. and Giardia lamblia no longer need to be ordered (see Figure 1 for additional information)


When should I order the FilmArrayTM Gastrointestinal Panel?

The panel should be ordered for a patient of any age with diarrhea (> 3 unformed stools in a 24 hour period who is not on a laxative) for whom you are worried about infection with a GI pathogen that may impact patient management or isolation practices. Testing should not be performed on formed stool. Please contact the microbiology lab (404-785-6426) or the ID consult service (404-785-DOCS) with any additional questions.


  • Fever and frankly bloody/mucusy diarrhea (if concern for C diff, also send stool for C diff toxin – not included in GI PCR panel)
  • Prolonged diarrhea>7 days (or before referral to GI for evaluation)
  • Travel-related diarrhea (if persistent or red flags; if concern for worms, also send stool for ova/parasites)
  • Immunocompromised patient – if concern for non-viral etiology
  • IBD patients- newly suspected or unusual change in stools in established IBD pt

What do the results mean?

For non-severe or prolonged (<7 days) illnesses caused by many of the pathogens detected (e.g. EAEC, EPEC, STEC, non-typhoidal Salmonella, all viral pathogens, Giardia lamblia and Cryptosporidium species), treatment is supportive; however, for patients in certain age groups, and patients with certain comorbidities or immunocompromising conditions, antimicrobial treatment may be indicated.

Because the FilmArrayTM Gastrointestinal Panel detects nucleic acids, it cannot differentiate active infection from treated infection or colonization; this must be done by correlating clinical symptoms. Results can remain positive for weeks or months after an infection especially in young children and immunocompromised patients.

Figure 1. Reported pathogens on the FilmArrayTM Gastrointestinal Panel at CHOA and which reflex to culture.

Should I also order a stool culture to get antimicrobial susceptibility results?

When testing is performed in the CHOA microbiology laboratory, a stool culture order is not necessary as positive panels will automatically reflex to culture, and if the isolate is recovered antimicrobial susceptibility testing will be performed when appropriate (Figure 1).

Should I order an O&P examination? What about for patients who drink and use well water?

O&P examinations should be ordered if you suspect a parasite other than those listed on the panel (e.g., for patients who returned from travel abroad). It should be noted that the top parasitic causes of well water contamination are Giardia and Cryptosporidium, which are tested for on the panel. Maximal sensitivity for parasite detection by O&P examination requires up to three stool specimens collected over a 7-10 day period.\

Should I order C. difficile toxin testing separately?

Yes, but it is not typically recommended for children under 2 year of age due to high rates of colonization. 

Should I reorder the FilmArrayTM Gastrointestinal Panel to test for cure?

No. Nucleic acids detected on the panel may remain positive for an indeterminate amount of time, and the FilmArrayTM Gastrointestinal Panel should only be ordered on unformed stool.


Caring for Our Transgender Patients: The Basics

By Atsuko Koyama

Chief Complaint: Rash

Andrew is a 16-year-old transman (female-to-male, FTM) presenting with a red, painful rash of his bilateral inner thighs. On exam, you note an area in the inguinal region concerning for cellulitis. Upon questioning him alone, he reports that he began using a “STP” device 2 weeks ago. “What is a STP device?” He answers that it is a stand-to-pee device that he straps on with a waist harness in order to urinate standing, as other males do. STP devices are used by some FTM who have not had bottom surgery. They can cause skin irritation/breakdown if ill-fitting.

Transgender youth

Transgender is an umbrella term for those whose gender identity (a person’s sense of their own gender as male, female, or some other gender) differs from their biologic sex (typically assigned at birth based on chromosomes or anatomy). Population estimates for transgender youth is not well defined. One study estimates that 0.7 to 3.2% of 13 to 18 year olds identify as transgender.1 A study from 2017 estimated that 1 in every 250 adults are transgender. 2

What’s in a name? Definitions.

There are many terms you may hear when discussing gender. Transgender can refer to an individual or a larger community, and it is an umbrella term for those whose gender identify differs from their biologic sex and from conventional notions of gender. Alternatively, cisgender is someone whose gender identity DOES match up with our cultural notions about gender. Gender identity: A personal conception of oneself as male, female, both, or neither, experienced in self-awareness or behavior. Gender expression: A person’s outward expression of gender. Gender dysphoria: Discontent a person may feel about the biological sex they were assigned at birth.

Gender and sexuality

Gender and sexuality can be viewed on a spectrum and considered fluid rather than being binary entities. They are not either/or concepts. One can be biologically male, identify with a feminine gender identify (as female), and can be attracted to and have sexual relationships with males, females or both. Gender play is a passing interest that involves playing out different gender-typical roles. Gender nonconforming youth behavior is more persistent, consistent and insistent. It is cross gender expression, wanting other gender body parts, or not liking one’s gender or body.

Transgender youth, mental health, and healthcare access

Transgender adolescents have a 2 to 3-fold increased risk of depression, suicidality, anxiety, and mental health treatment. 3 Given these risks, it is important to understand that identifying as transgender is not in and of itself a mental health disorder. It is social stigma, familial rejection, and social isolation that contribute to the higher rates of mental health issues. Research shows that with acceptance and access to healthcare to help transition, youth are protected from gender dysphoria and reactive depression. 4 Lack of access to accepting and transgender friendly health care services is also a barrier to health for transgender youth. One study revealed that 52% of patients who presented to an ER experienced trans-specific negative experiences, while another showed that 13% of transgender patients were denied equal treatment in an ER setting due to their gender identity/expression. 5,6 

How should we communicate with our patients? Language is important so that we can communicate with our transgender patients in a way that is respectful and affirming.

Conversations can start with something as simple as asking, “Do you feel more like a girl, boy, neither, both?” “What name or pronoun fits you/do you prefer?” When examining a patient, use non sex-specific terms. Going back to the initial patient vignette, one may say to Andrew, a FTM teen, “I need to perform a genital exam,” instead of “I need to perform a vaginal” exam. Use the word “chest” vs. “breast,” “genital” vs. “vaginal or penile.” When speaking with transgender patients, ask questions necessary to assess the issue, but avoid unrelated probing. “What’s your anatomy and what surgeries have you had? I need to know this information in order to best treat you.” If you have a patient who presents with a broken finger, it is unnecessary to ask about their reproductive anatomy.

What might we expect from a patient who is transitioning?

Chief complaint: Chest pain, shortness of breath, and URI symptoms

Jenny is a 17-year-old transwoman (male-to-female, MTF) on estrogen therapy. She has a PMH of moderate persistent asthma. What is her risk of a pulmonary embolus?

Phenotypic transitioning occurs in phases: reversible, partially reversible, irreversible, and surgical. The reversible portion of transition includes the adoption of preferred gender hairstyles, clothing, play, perhaps a new name and suppression of biologic gender puberty using GnRH analogues (defined below). The portions of the reversible phase that do not involve suppression of puberty will sometimes occur before the age of ten. Some children may begin GnRH analogues at around age 12 or 13, when they are still Tanner Stage 2, and initiate hormones several years later. GnRH analogues lead to fully reversible changes, provide extra time for psychotherapy and a relief of their gender dysphoria. They prevent secondary sex characteristics that would have required more invasive intervention later. Partially reversible changes are brought about with hormone therapy, which is offered in most centers around age 15 or 16, and irreversible changes with surgery, typically not before age 18.


All medications have potential side effects and risks, and it is important for providers on the front lines in primary care and urgent/emergency care know what those potential risks are. However, it is important to frame the risks and benefits of treatment for transgender youth in light of the risks of depression, anxiety, and suicide that youth without treatment face. Studies support the mental health of trans youth being much improved with appropriate, early access to health care including the medications discussed below.

GnRH analogues stop puberty. There are few side effects aside from injection pain and withdrawal bleed if menstruating. Estrogens induce the development of female secondary sexual characteristics. The greatest risk for estrogen therapy is the 20-45 fold increase of venous thromboembolism (VTE). 2-6% of hormonally treated MTF patients experience a VTE. Other lower risk, possible complications include prolactinomas, pituitary adenomas, hypertension, hypertriglyceridemia causing pancreatitis, gall bladder and liver disease, and the potential biological female risk of breast cancer. Anti-androgens reduce the effects of endogenous male sex hormones. Most pertinent are spironolactones causing hyperkalemia, hypotension, or ataxia. Testosterone induces the development of male secondary sexual characteristics. Risks include hepatotoxicity, insulin resistance, weight gain, decreasing high-density lipoproteins (HDL), increasing triglycerides and homocysteine levels, and polycythemia. There is a theoretical risk of breast cancer and endometrial cancer (testosterone is aromatized to estrogen), so patients who have chest or genital symptoms need workup appropriate to their anatomy.

Transgender youth flourish

Research shows that transgender people report numerous positive aspects related to successful transitioning. 7 Familiarizing yourself with local resources (medical, mental health, peer and parent support groups) and learning more about transgender youth will help to create a more supportive health care system for trans youth and their families for successful transitioning.

Last words from experts in the field of transgender care

  • Lack of trans friendly health services, transphobia, and real or perceived prejudice and discrimination lead to mental health disorders and undertreatment of medical conditions.
  • Transgender kids need love and acceptance by family, school, and community, like all teens.
  • Using incorrect names or pronouns and misgendering IS a big deal to patients, and we all need to help systems counteract or eliminate this.


Local Physicians Accepting Referrals of Transgender Youth

  1. Comprehensive care of transgender youth: David Levine, MD, Morehouse Healthcare, 1800 Howell Mill Rd, Atlanta, Georgia 30318, 404) 756-1400
  2. Comprehensive care of transgender youth: Isabel Lowell, MD, MBA QMed,Website:, Email:, Office phone: 404-445-0350
  3. For medications only: Leonidas Panagiotakopoulos-CHOA Endocrinology-404-785-KIDS


Provider Resources 


  1. Herman JL, et al. “Age of Individuals Who Identify as Transgender in the United States.” The Williams Institute, UCLA School of Law. January 2017.
  2. Meerwijk EL, et al. “Transgender Population Size in the United States: a Meta-Regression of Population-Based Probability Samples.” Am J Public Health, 2017;107:e1-8.
  3. Reisner SL, et al. “Mental Health of Transgender Youth in Care at an Adolescent Urban Community Health Center: A Matched Retrospective Cohort Study.” J Adolesc Health. 2015;56:274-79.
  4. Ryan C, et al. “Family Acceptance in adolescence and the health of the LGBT Young Adults.” J Child Adolesc Psychiatr Nurs. 2010;23:205-13.
  5. Bauer GR, et al. “Reported Emergency Department Avoidance, Use, and Experiences of Transgender Persons in Ontario, Canada: Results From a Respondent-Driven Sampling Survey.” Ann Emerg Med. 2014;63:713-720.
  6. Grant, JM et al. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.
  7. Riggle, ED et al. “The Positive Aspects of Transgender Self-Identification.” Psychol Sex, 2011;2:147-58











CHOA Constipation Guideline

By Beesan Agha, MD








Constipation is a common problem throughout childhood and affects up to 30 percent of children and accounts for an estimated 3 to 5 percent of all visits to pediatricians.1 Early intervention is key to avoid complications such as anal fissures, stool withholding, fecal incontinence (encopresis), and psychosocial consequences. This guideline represents a collaboration of several specialties including pediatric emergency medicine, urgent care, and gastroenterology with the goals of:

  • Understanding the diagnostic criteria for functional constipation
  • Being aware of red flags that may indicate organic causes of constipation
  • Establishing a uniform process for the evaluation and management of constipation
  • Decreasing utilization of abdominal x-rays to diagnose constipation

Patients >1 month of age who meet the diagnostic criteria for functional constipation are included in the guideline.

Diagnostic criteria for functional constipation must include TWO or more of the following:

  1. Two or fewer defecations per week
  2. At least one episode per week of incontinence after the acquisition of toileting skills
  3. History of retentive posturing or excessive stool retention
  4. History of painful or hard bowel movements
  5. Presence of a large fecal mass in the rectum
  6. History of large diameter stools which may obstruct the toilet

Functional constipation is responsible for more than 95% of cases of constipation in healthy children one year and older.2 Although constipation is common, it is still important to evaluate children and be diligent to identify the few that have organic causes of constipation. Some red flags that should raise your suspicion to a possible organic cause include:

  • Midline dimple; Tuft of hair over lower back
  • New onset lower limb weakness/motor delay
  • Signs of systemic illness: fevers, mouth sores, joint pain, rash
  • Weight loss
  • First passage of meconium after 48 hours of life
  • Persistent abdominal distension/vomiting
  • Bloody diarrhea
  • Bilious emesis
  • Failure to thrive, Malabsorption
  • Tight rectum gripping finger; explosive stool/air from rectum upon withdrawal of examining finger
  • Family history of Hirschsprung’s disease

The treatment of functional constipation begins with determining whether the patient has fecal impaction. If fecal impaction is determined by a digital rectal exam it recommended the patient receive a glycerin suppository for children <1 year of age and a soap suds enema for children >1 year of age. Enema dosing can be found in the guideline.

Upon discharge the patient will receive education on appropriate dose and home use of miralax to continue the treatment of constipation as an outpatient. These recommendations are included below:

1-3 years old

Cleanout: Take 1 capful (17 grams) Miralax every day for 3 days in 8 oz. of juice

Maintenance: On day 4 take ¼ capful (4.25 grams) Miralax daily in at least 4 oz. of any liquid

If stools are too liquid, decrease Miralax to 1/8 capful but do not stop taking  

4-5 years old

Cleanout: Take 2 capfuls (34 grams) Miralax every day for 3 days in 16 oz. of juice Maintenance: On day 4 take ¼ capful (4.25 grams) Miralax daily in at least 4 oz. of any liquid

If stools are too liquid, decrease Miralax to 1/8 capful but do not stop taking

6-11 years old

Cleanout: Take 7 capfuls (119 grams) Miralax for 1 day in 32 oz. Gatorade

Maintenance: On day 2 take ½ capful (8.5 grams) Miralax daily in at least 4 oz. of any liquid

If stools are too liquid, decrease Miralax to 1/4 capful but do not stop taking

12 years and older

Cleanout: Take 14 capfuls (238 grams) Miralax for 1 day in 64 oz. Gatorade

Maintenance: On day 2 take 1 capful (17 grams) Miralax daily in at least 8 oz. of any liquid

If stools are too liquid, decrease Miralax to 1/2 capful but do not stop taking

  • Encourage fluid intake (especially during cleanout)
  • Referral to PCP in 2 weeks. Continue maintenance dosing until seen by PCP

The constipation guideline can be accessed on CHOA Physician Portal:

Under clinical excellence clinical practice guidelines

  1. Epidemiology of childhood constipation: a systematic review.

Van den Berg MM, Benninga MA, Di Lorenzo C

Am J Gastroenterol. 2006;101(10):2401.

  1. Prevalence, symptoms and outcome of constipation in infants and toddlers.

Loening-Baucke V

J Pediatr. 2005;146(3):359


Joining Forces-the NEW ALL CHOA Emergency Department Newsletter

Welcome to the new newsletter including ALL Emergency Departments of Children’s Healthcare of Atlanta. This newsletter now includes collaboration from the Emergency Department of Scottish Rite. The information included in this newsletter combines the efforts of the two largest groups of pediatric emergency medicine physicians in the Atlanta Metro area.  The Division of Pediatric Emergency Medicine at Emory University and Pediatric Emergency Medicine Associates (PEMA). Emory Physicians staff the Hughes Spalding and Egleston EDs while PEMA physicians staff Scottish Rite and 7 other pediatric emergency departments throughout the metro area including one hospital in Chattanooga, Tennessee.  We are continuing to expand our outreach and collaborative efforts to all metro Atlanta area physicians who care for children including Emergency Medicine, Pediatric and Family Medicine Physicians.  Please feel free to forward this newsletter link to your colleagues. Don’t hold onto this valuable information pass it on. Sometimes with growing and merging  we can experience some delays thus we recognize this newsletter is delayed in publication.  Stay tuned in the next few months as our website will move to a new location and we will be offering continuing medical education.  Also check out this article on Medbytes-Partnering to Improve Pediatric Emergency Medicine Care here is the link that is accessible to those with md portal access-


Please enjoy this quarter’s newsletter articles on summer safety tips and new  information on the effects of acetaminophen. Finally, see below the history of PEM (Pediatric Emergency Medicine) in Atlanta including the history of Emory Pediatric Emergency Medicine and Pediatric Emergency Medicine Associates.


The Story of Pediatric Emergency Medicine in Atlanta

By Thuy Bui

By Wendy Little









Children’s Healthcare of Atlanta is one of the largest and busiest pediatric healthcare systems in the United States. The three CHOA emergency departments collectively encounter over 220,000 visits per year and the hospitals, with their full complement of pediatric subspecialty providers, care for some of the sickest and most medically complex patients in the state and the region.

While specialized pediatric healthcare in Atlanta dates back to the early 1900s, there were no pediatric emergency departments and no pediatric emergency specialists in Atlanta until the mid-1980’s.  The growth of emergency medical care for children in Atlanta over the past 30 years has been phenomenal!

The first children’s hospital in Atlanta, Scottish Rite Convalescent Home for Crippled Children, opened its doors in 1915. Key movers behind this included orthopedic surgeon Dr. Michael Hoke (the hospital’s first medical director), philanthropist Mrs. “Bertie” Wardlaw, real estate developer Mr. Forrest Adair and the Scottish Rite Masons.  The hospital started out as two rented cottages in Decatur with 20 beds and became a full medical building housing 50 beds in 1919.  The medical facility stayed in Decatur until 1976 when it moved to its current seven-acre site in North Atlanta and became Scottish Rite Children’s Hospital.

The Henrietta Egleston Hospital for Children was founded in 1928.  Thomas R. Egleston Jr, a wealthy Atlantan, left money in his will for the founding of a children’s hospital to be named after his mother, Henrietta Egleston. The first Egleston hospital was located in Atlanta on what is now Ralph Magill Avenue.  In 1956 , Emory University donated land for an expanded facility on the Emory campus, thus beginning the long-standing relationship between Emory University and Egleston. The “new” Egleston Children’s Hospital on Clifton Road opened in 1959.

Pediatric Emergency Medicine (PEM) is a relatively new specialty with the first fellowship established in 1980.  The first board subspecialty exam, a collaboration of the American Board of Pediatrics and American Board of Emergency Medicine, was administered in 1992.  In 1998, Pediatric Emergency Medicine Fellowship became an accredited specialty.  There are just over 1700 Pediatric Emergency Medicine board certified physicians in the country and 68 in the State of Georgia.

Pediatric emergency medicine became available to the children of Atlanta in 1984. Pediatric emergency medicine pioneer, Dr. Joseph Simon, opened Atlanta’s first freestanding pediatric emergency department at Scottish Rite. It was comprised of eight exam rooms with one trauma bay and staffed by a group of four pediatric trained physicians doing 24 hour shifts.  During its first full year of operation, the department saw 5,000 patients. That same year, Egleston opened its Acute Treatment Area. It had two exam rooms and a four bed holding area. It was initially open for 9 hours overnight on weekdays and 24 hours per day on weekends, and saw approximately 8800 patients per year.  Patients could not walkin to the facility, but had to be referred by a physician. A formal emergency department opened in 1988 with 24-hour physician coverage. In 1986, Egleston was designated as a pediatric trauma center with Scottish Rite receiving its designation the following year.

The Hughes Spalding Pavilion opened in 1952 as a private hospital on the campus of Grady Memorial Hospital. Until 1992, pediatric patients were first seen in a 24-hour walk-in clinic on the second floor of Grady, staffed mainly by Emory pediatric residents. Seeing over 60,000 patients per year, wait times were notoriously long, with patients routinely waiting over 12 hours to be seen.  In 1992 , Hughes Spalding was re-opened as a dedicated pediatric facility, including an emergency department consisting of a six-bed observation room, an asthma room with chairs to accommodate approximately 10 patients, three private emergency department rooms, an urgent care/clinic area and a single resuscitation room. In 2006, Children’s Healthcare of Atlanta assumed clinical operations at Hughes Spalding.

In 1998, to help preserve and improve pediatric health care in the region, Scottish Rite Children’s Hospital and Egleston Children’s Healthcare System officially merged to become Children’s Healthcare of Atlanta.  With its assumption of responsibility at Hughes Spalding Children’s Hospital in 2006, Children’s Healthcare of Atlanta became one of the largest pediatric healthcare systems in the country.  Currently, the system’s three emergency departments (Egleston, Hughes Spalding, and Scottish Rite) manage more than 220,000 patient visits per year.

Each of the emergency departments has undergone major changes over the years. Today CHOA Egleston has 36 private patient rooms (including dedicated beds  for orthopedic and gynecologic care, as well as mental health rooms with video-monitoring capability) and four trauma bays, caring for more than 70,000 patients a year. In 2009,  CHOA Egleston became the first and only Level 1 Pediatric Trauma Center in the state of Georgia. Similarly CHOA Scottish Rite has 50 private patient rooms (including rooms dedicated for orthopedic and gynecologic care, and mental health rooms with video-monitoring capability) and four trauma bays. Designated as a Level 2 Pediatric Trauma Center, it now provides care for over 100,000 patients annually. CHOA Hughes Spalding underwent a major renovation in 2010. The updated facility includes a new emergency department with 32 private rooms (including rooms designated for orthopedic and gynecologic care, as well as mental health rooms with video-monitoring capability) and one resuscitation room, and provides care for more than 52,000 patients annually.

The variety of options and easy accessibility of pediatric emergency medicine care make Atlanta unique. This validates the need for all 3 Children’s Healthcare of Atlanta hospitals to collaborate and reach out to referring partners in the community and work together to improve children’s health in our community. The universal theme that joins us in our diversity of roles and practice is that we are dedicated to making all children better today and healthier tomorrow.