More than just little adults

Hospitals specially built for children used to be considered unnecessary or a luxury... but not any more.

children crowd  (photo credit: )
children crowd
(photo credit: )
When New York philanthropist Irving Schneider and his late wife Helen inaugurated the Schneider Children's Medical Center of Israel in Petah Tikva 16 years ago, critics predicted it would be a "white elephant." In 2007, this first children's hospital in Israel is busy day and night, with 52,000 children treated in its emergency department, 15,000 at in-patient wards, 8,300 undergoing surgery, 140,000 visiting out-patient clinics, 1,100 undergoing dialysis, 1,000 treated in intensive care, 500 undergoing coronary catheterization, 835 treated in the neonatal intensive care unit and 21 receiving organ transplants. And the handful of other children's hospitals and pediatric wards in the country's general hospitals still have plenty of young patients. Is there any longer a need to explain why tertiary free-standing hospitals exclusively for children are necessary? The 35,000-square-meter Petah Tikva facility is no longer the only one. While numerous medical centers call their pediatric departments a "children's hospital," they do not have a director-general of their own, and share facilities, equipment and staff with other departments. Schneider has been joined by the Meyer's Children's Hospital in Haifa's Rambam Medical Center, and Jerusalem's Shaare Zedek Medical Center has begun construction of its 6,000-square-meter Wilf Children's Hospital. According to Prof. Francis Mimouni, Shaare Zedek's chief of pediatrics (and in two years' time, when construction is completed, director of Wilf) at Tel Aviv Sourasky Medical Center (better known as Ichilov Hospital) set up the Dana Children's Hospital before Schneider opened, but it isn't fully freestanding. He added that the Hadassah University Medical Center in Jerusalem's Ein Kerem has a Mother and Child Building that is not a children's hospital, but the Hadassah Medical Organization has plans to expand its pediatric departments significantly, even though the result would also not be a free-standing pediatric facility. (The name Mimouni apparently goes with children's hospitals, as Francis's elder brother, Prof. Marc Mimouni, has been Schneider's director-general for several years, and will step down in January to be replaced by Prof. Yosef Press.) Prof. Francis Mimouni, who chaired a conference on pediatrics at Shaare Zedek earlier this month (attended by about 150 pediatricians from community clinics), told The Jerusalem Post that "it's important to have children's hospitals, even though they require a major investment. They are experts because they have so much specialization and experience. Would one prefer to be operated on by a surgeon who does two such operations a month, or two per day? In pediatric departments, a radiologist may know how to do X-rays of neonates and old people, but is not an expert at either." Decades ago, there was opposition in Israel to children's hospitals. "I wasn't here then, and I can't explain the context, but there may have been vested interests in pediatric departments to keep things the way they are." He added that children's hospitals provide not only a kid-friendly environment, but also have equipment and drugs adapted to children and their sometimes unique conditions. "We at children's hospitals do not regard kids as 'small adults.' They are different, and the difference is not just miniaturization." MIMOUNI, BORN in Algiers and trained in France and the US, left Sourasky's Lis Maternity Hospital to become chief of Shaare Zedek's pediatric division 15 months ago, after the retirement of Prof. Arthur Eidelman, who was deeply involved in planning the Wilf Hospital and Shaare Zedek's pediatric emergency department, due to open in February. The department will be 10 times larger than the existing pediatric emergency room, and larger than today's entire pediatric department. "Prof. Eidelman helped a great deal. He is very sharp, and handed over responsibility when planning for Wilf was in an advanced stage. I thank him for his major contributions.... It will set a new standard for pediatric care in Jerusalem." The emergency department will be at the entrance level in the main hospital building, and include outpatient facilities for kidney dialysis, neurology, a day hospital, departmental offices and teaching facilities. The Wilf hospital, adjacent and one floor up, will offer 35 pediatric beds, six intensive-care rooms, 15 pediatric surgery theaters, a school for children kept from their studies, and five isolation beds for patients with blood cancers. SHAARE ZEDEK director-general Prof. Jonathan Halevy managed to solicit $20 million from various philanthropists for the Wilf hospital. "Donors like giving money to pediatric hospitals, as people are more sensitive to suffering children than they are to other groups," explained Mimouni. And while the Treasury has long been opposed to building more hospitals at public expense, "we don't feel any opposition from state budget officials if we bring the money from private donors," he notes. The half-day schedule of the pediatric medicine conference in the hospital's auditorium, with lectures by a variety of pediatric specialists, highlighted the fact that while most children's illnesses involve the flu, tonsillitis and ear infections, there are many - too many - cases of serious, complex and sometimes incurable disease that should be handled only by specialists. Dr. Pnina Navon-Elkan of Shaare Zedek's pediatric rheumatology department discussed diseases that one normally views as striking the elderly, such as arthritis. Sadly, it occurs in children, even small ones, as well. The latest biological therapy for such inflammatory diseases has become available even for young patients. Pediatric rheumatic diseases are better understood today, she said, noting that a substance called TNF (tumor necrosis factor) is regarded as the chief mediator of inflammation. She noted that TNF can protect the body against serious infection, but if it's overactive, it can cause chronic inflammatory diseases such as juvenile arthritis, psoriasis, Crohn's disease and psoriatic arthritis. Among the new biological therapies for these are adamulimab (Humira), methotrexate plus Remicade, and etanercept (Enbrel), which can be prescribed to children. She described the case of a five-year-old boy with peripheral arthritis, lower back pain and leg atrophy and weakness who at 13 years of age weighed only 22 kilos. He was given Remicade and methotrexate in the morning when he came to the hospital on crutches. "In the evening, he played soccer for the first time in seven years. After 20 months of treatment, he grew 20 centimeters and gained over 20 kilos." Not all cases end so dramatically, said the rheumatologist. A two-month-old boy went into circulatory shock two days after getting an ordinary vaccination and suffered from fever, hypertension, enlarged coronary arteries and a lack of oxygen in his fingers. He was treated, but at 15 months suddenly refused to eat and had surgery for a perforated intestine. Finally, Remicade was tried, and within a few days his flareup subsided. While recovery is very slow, he is now in first grade, mentally normal although physically disabled. "There is no cure for these diseases," concluded Navon-Elkan, "but there 0are ways to deal with them as chronic conditions. KIDNEY FAILURE in children was described by Prof. Ya'acov Frishberg of the nephrology and dialysis institute. He said a transplant from a live (altruistic) or cadaver donor was preferable to dialysis from a child's first birthday, but that the shortage of organs forces many children to go on dialysis and thus have a much shorter life expectancy. The longer a child undergoes dialysis (in which the blood is cleaned by a machine three times a week), the shorter his life will be, and the longer he has dialysis before finally having a transplant, the lower his chances to survive the operation. Once a transplant is carried out, doctors must work hard to prevent rejection using steroids and other drugs. Infections have to be prevented. Cancer such as lymphoma, he said, is 10 times more common in children who undergo such a transplant than in children of the same age who did not have kidney failure. The risk of youngsters, especially teenagers, going on a "drug holiday" by not taking immunosuppressive drugs because they are tired of them and want to be like everyone else, is also present. The risk of cardiovascular disease among recipients is also higher, and they tend to be overweight and not to exercise, which can cause complications. Still, many transplant patients say they are grateful that it doesn't affect family life and enables them to have a family and support themselves. Young women may even get pregnant six months after a kidney transplant if their test results are favorable. Inflammatory bowel disease (IBD) is sometimes diagnosed in children and teenagers, said Dr. Dan Turner, a Shaare Zedek pediatric gastroenterologist. "We don't understand its causes very much, but we know more about genetic and environmental factors, including bacterial infections, and are able to treat it." Among the symptoms are abdominal pain, diarrhea, lower height, weight loss and delay in puberty or growth. Specialists are now able to use the Given Imaging PillCam to diagnose IBD non-invasively. "In the not-too-distant future, we will be able to take a drop of blood and put it on a chip to determine a patient's gene expression to diagnose IBD." Treatment of the condition has also improved in the past few years. "The earlier you diagnose and treat IBD, the longer the remission lasts," he said. As there is almost no IBD or asthma in the developing world, some claim that they are the result of "excessive cleanliness," in which the immune system can't cope with a sudden attack of pathogens. Turner says this may be so. Dr. Eli Picard, an expert in lung disease in children, discussed asthma - that scary inflammatory disease with episodes of wheezing, breathlessness and cough that sometimes closes the airways completely and can be fatal. The US National Institutes of Health studied whether complementary medicine can relieve it. "Homeopathy doesn't help; neither does acupuncture," said Picard. "Techniques to relieve stress may alleviate attacks, while herbal remedies not only do not help, but can even be dangerous." THE MOST "exotic" disorder discussed at the conference was Kawasaki disease, discovered by a Japanese doctor of that name in 1997 and known to only a handful of layman. Shaare Zedek pediatric infectious disease specialist Dr. Maskit Bar-Meir discussed the condition, which is characterized by acute inflammation of the arteries throughout the body. In Japan, where it seems to be most common, there are 100 cases per 100,000 children under five. Bar-Meir said there are cases in Israel, and she has treated them, but there have been no epidemiological studies here to determine exactly how many there are. "We don't know exactly what causes it, but it is probably a respiratory virus. The symptoms are a fever, a rash on the feet, conjunctivitis, enlarged lymph glands and even an irregular heartbeat, along with irritability and headaches. It can result in blood clots, coronary aneurysms and heart failure. Various drugs, including aspirin and Remicade, have been used against it." One hopes that in two years, the new children's hospital will have only easier conditions to cope with.