Infantile hemangiomas (IHs) occur in as many as 5% of infants, making them the most common benign tumor of infancy. Most IHs are small, innocuous, self-resolving, and require no treatment. However, because of their size or location, a significant minority of IHs are potentially problematic. These include IHs that may cause permanent scarring and disfigurement (eg, facial IHs), hepatic or airway IHs, and IHs with the potential for functional impairment (eg, periorbital IHs), ulceration (that may cause pain or scarring), and associated underlying abnormalities (eg, intracranial and aortic arch vascular abnormalities accompanying a large facial IH). This clinical practice guideline for the management of IHs emphasizes several key concepts. It defines those IHs that are potentially higher risk and should prompt concern, and emphasizes increased vigilance, consideration of active treatment and, when appropriate, specialty consultation. It discusses the specific growth characteristics of IHs, that is, that the most rapid and significant growth occurs between 1 and 3 months of age and that growth is completed by 5 months of age in most cases. Because many IHs leave behind permanent skin changes, there is a window of opportunity to treat higher-risk IHs and optimize outcomes. Early intervention and/or referral (ideally by 1 month of age) is recommended for infants who have potentially problematic IHs. When systemic treatment is indicated, propranolol is the drug of choice at a dose of 2 to 3 mg/kg per day. Treatment typically is continued for at least 6 months and often is maintained until 12 months of age (occasionally longer). Topical timolol may be used to treat select small, thin, superficial IHs. Surgery and/or laser treatment are most useful for the treatment of residual skin changes after involution and, less commonly, may be considered earlier to treat some IHs.

Vision screening is crucial for the detection of visual and systemic disorders. It should begin in the newborn nursery and continue throughout childhood. This clinical report provides details regarding methods for pediatricians to use for screening.

Physician health and wellness is a critical issue gaining national attention because of the high prevalence of physician burnout. Pediatricians and pediatric trainees experience burnout at levels equivalent to other medical specialties, highlighting a need for more effective efforts to promote health and well-being in the pediatric community. This report will provide an overview of physician burnout, an update on work in the field of preventive physician health and wellness, and a discussion of emerging initiatives that have potential to promote health at all levels of pediatric training.Pediatricians are uniquely positioned to lead this movement nationally, in part because of the emphasis placed on wellness in the Pediatric Milestone Project, a joint collaboration between the Accreditation Council for Graduate Medical Education and the American Board of Pediatrics. Updated core competencies calling for a balanced approach to health, including focus on nutrition, exercise, mindfulness, and effective stress management, signal a paradigm shift and send the message that it is time for pediatricians to cultivate a culture of wellness better aligned with their responsibilities as role models and congruent with advances in pediatric training.Rather than reviewing programs in place to address substance abuse and other serious conditions in distressed physicians, this article focuses on forward progress in the field, with an emphasis on the need for prevention and anticipation of predictable stressors related to burnout in medical training and practice. Examples of positive progress and several programs designed to promote physician health and wellness are reviewed. Areas where more research is needed are highlighted. Pediatrics 2014;134:830-835 INTRODUCTIONPhysician health and wellness is an issue garnering national interest because of the high prevalence of burnout in medical practitioners and trainees. Burnout takes a steep toll on physicians and has negative effects on patients and health care systems. 1 Research advances detailing the detrimental effects of chronic stress, including impaired immune function, inflammation, elevation of cardiovascular risk factors, and depression, 2-9 are directly relevant to pediatric practitioners and create a need for organized efforts to address physician health and well-being in the pediatric community. The purpose of this report is to provide an update on the issue of physician health and wellness with regard to how they relate to pediatricians. Rather than reviewing programs already in place to address substance abuse and other serious conditions in distressed physicians, this report focuses on forward progress in the field, with an emphasis on the need for prevention and anticipation of predictable stressors related to burnout in medical training and practice. Although specific recommendations are beyond the parameters of this report, examples of positive progress and national programs to promote physician health and wellness will be reviewed. BURNOUT: THE ANTITHESIS ...

Quality measures are used for a variety of purposes in health care, including clinical care improvement, regulation, accreditation, public reporting, surveillance, and maintenance of certifi cation. Most quality measures are 1 of 3 types: structure, process, or outcome. Health care quality measures should address the domains of quality across the continuum of care and refl ect patient and family experience. Measure development for pediatric health care has a number of important challenges, including gaps in the evidence base; the fact that measures for most conditions must be agespecifi c; the long, resource-intensive development process; and the national focus on measure development for adult conditions. Numerous national organizations focus on the development and application of quality measures, including the Pediatric Quality Measures Program, which is focused solely on the development and implementation of pediatric-specifi c measures. Once a quality measure is developed for use in national measurement programs, the organization that develops and/or "stewards" the measure may submit the measure or set of measures for endorsement, which is recognition of the scientifi c soundness, usability, and relevance of the measure. Quality measures must then be disseminated and applied to improve care. Although pediatric health care providers and child health care institutions alike must continually balance time and resources needed to address multiple reporting requirements, quality measurement is an important tool for advancing high-quality and safe health care for children. This policy statement provides an overview of quality measurement and describes the opportunities for pediatric health care providers to apply quality measures to improve clinical quality and performance in the delivery of pediatric health care services.

Appropriate visual assessments help identify children who may benefit from early interventions to correct or improve vision. Examination of the eyes and visual system should begin in the nursery and continue throughout both childhood and adolescence during routine well-child visits in the medical home. Newborn infants should be examined using inspection and red reflex testing to detect structural ocular abnormalities, such as cataract, corneal opacity, and ptosis. Instrument-based screening, if available, should be first attempted between 12 months and 3 years of age and at annual well-child visits until acuity can be tested directly. Direct testing of visual acuity can often begin by 4 years of age, using age-appropriate symbols (optotypes). Children found to have an ocular abnormality or who fail a vision assessment should be referred to a pediatric ophthalmologist or an eye care specialist appropriately trained to treat pediatric patients.

The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffi rmed, revised, or retired at or before that time.

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent. The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

BackgroundCraniofacial arteriovenous malformation (AVM) is a challenging disease to eradicate, often requiring the combination of embolization and reconstructive surgery. The tortuosity of distal feeding arteries and the presence of abundant collaterals make it difficult to obliterate the nidus with transarterial embolization. In this small case series, we report curative transvenous embolization of craniofacial AVM under transient arrest of arterial inflow.Materials and methodsFour patients with craniofacial AVMs (two in the scalp, one in the face and one in the forehead) were embolized transvenously with Onyx. In all cases, the dominant feeding arteries were first embolized with Onyx to reduce arterial inflow. The major draining veins were then accessed transfemorally or via direct puncture. Detachable coils were placed in the venous pouches to further obstruct outflow from the AVM nidus. After arterial inflow was completely stopped with the placement of a tourniquet on the head or inflation of a balloon catheter in the external carotid artery, we injected Onyx into the venous pouch to retrogradely fill the entire AVM nidus. Follow-up angiograms were performed 1 year later.ResultsAngiographic cure was achieved in all four patients. The mass effect from the Onyx cast was not disfiguring. No patient had skin necrosis or a visible black mark on the skin. The first two patients underwent surgical removal of the Onyx cast which was scheduled before embolization. The next two patients declined surgery because they were not bothered by the Onyx cast. No recurrence was found at the 1 year follow-up angiogram.ConclusionHead and neck AVM can be safely cured with transvenous embolization using Onyx.Abstract P-018 Figure 1Angiogram of a facial arteriovenous malformation before and after embolization.Abstract P-018 Figure 2Transvenous embolization with Onyx after partial coiling and transient occlusion of the external carotid artery with a balloon (A). Onyx cast showing the nidus and numerous small feeders (B).