Breaking barriers in pediatric surgery … and beyond
Any surgery can be challenging and come with risks. But when that surgery involves children, it comes with a unique set of things the surgery team has to consider that are very different from adults. Dr. Kanika Bowen-Jallow delves into how those differences impact both the surgical team and patient outcomes.
Meet the speaker
Host: Hello and welcome to Cook Children's Doc Talk. Today we're talking about the challenges of pediatric surgery with Dr. Kanika Bowen-Jallow. Before we get started, just a little background about Dr. Bowen-Jallow. When she was just six years old, she received a Playschool doctor's kit, and it was them that she knew she would grow up to be a doctor. Today Dr. Bowen-Jallow is board certified in both general and pediatric surgery, and is a practicing pediatric surgeon with Cook Children's Health Care System. She has received numerous accolades and recognitions throughout her career. Most recently, she was recognized by the American Pediatric Surgical Association for breaking barriers and making history as the ninth black female pediatric surgeon in the entire U.S. A distinction that gained national and international attention. In fact, Good Morning America called her a trailblazer. She is also a certified member of the American Pediatric Surgical Association, a fellow of the American College of Surgeons, a fellow of the American Academy of Pediatrics and board certified by the American Board of Surgery in both general surgery and pediatric surgery. She's also involved in several national committees that address the need for excellent comprehensive pediatric surgical care. And if that's not enough, she's an associate professor of pediatric surgery and is actively involved in research for childhood obesity, which includes many grant awards, NIH fellowships, 35 manuscripts, 37 published abstracts among many other achievements. Oh, and she's married and the mother of two very busy children. Welcome Dr. Bowen-Jallow.
Dr. Bowen-Jallow: Thank you.
Host: In addition to your doctor's kit, I understand your favorite game as a child was Operation. So the groundwork for surgery was laid early. What was it that really inspired you to become a surgeon?
Dr. Bowen-Jallow: Well, you know, it really started from my parents and their involvement. They've always been supportive in anything that I wanted to do. And it wasn't always a surgeon. Sometimes it was an ER doctor, sometimes it was a lawyer, but no matter what it was, they always told me that I could aspire to do that. And they always encouraged me throughout all of those different interests that I had. In addition, they provided books. So I've read a plethora of books on how it is to be different types of physicians, so ED physicians and surgeons, and neurosurgeons. And so they really provided the fertilizer for my growth in that aspect.
Host: So initially, you were planning on going into adult surgery, but ultimately chose pediatric surgery, which you've been known to say happened by accident, the best accident ever. So what happened to change your course?
Dr. Bowen-Jallow: Well, like I said, throughout my younger years, and even into medical school, I thought neurosurgeon, cardiac surgeon, and then I had decided on plastic surgery. And that really was what my goal was at the end of medical school. And so I was doing all of these classes and preceptorships so that I could get letters to do plastic surgery. And as it turns out, the only elective that I could get was a pediatric surgery rotation. I couldn't even get general surgery. And I said, Well, I don't even like kids. Like, I don't want to do that one. And they said, Well, this is it, you need to do this one or you know, you don't get anything. And so I said, Well, of course I'll do it no, sounds great. And I did it. And after the first day or two I was completely sold. The kids were wonderful, seeing how they bounced back from any surgeries, seeing how quickly they were discharged, seeing, you know, differences in pain and tolerance and all of those things. It just made me know that this is what I wanted to do for the rest of my life. So I just completely changed course, I started interviewing for places that had a good reputation for getting residents and fellows into pediatric surgery. And the rest is history, as they say.
Host: So what ultimately drew you're here to Cook Children's?
Dr. Bowen-Jallow: Well, I really wanted to be at a freestanding Children's Hospital with all of the services and that come along with that. And I really wanted to treat children and at a freestanding Children's Hospital you really get that that is the most important thing is the health of the child. And so that was the main reason that I came to Cook Children's. In addition, I was really interested in building my own team. So I do a lot of leadership courses. I think it's so important to have a healthy, happy team around you and knowing that I could build that is what brought me to Cook Children's.
Host: So any kind of surgery can be challenging and comes with risks. But when that surgery involves children, it comes with a unique set of things the surgery team has to consider that are very different from adults, can you delve into how those differences impact what you and your team do every day?
Dr. Bowen-Jallow: Absolutely. So because we deal with pediatrics and children, you really have to pay attention to their parents, because a lot of times those kids are so young that they're nonverbal, or maybe they're nonverbal for other reasons. And so really, the parents, you have to take into account their emotional state their investment, you know, their expectations. And so we spend a lot of time dealing with that to make the parent comfortable, because if the parents not comfortable, then the child isn't going to be comfortable. I really tried to treat every child like it's my child. And I get asked that question quite frequently. But what would you do if it was your child? So it makes my job very easy in that respect.
Host: What are some of the risks that babies children, adolescents, and even some young adults may have? And why? What are the causes?
Dr. Bowen-Jallow: That's a great question. You know, it's kind of funny this week, I was actually putting together a trauma presentation. And in that we talked about ATV accidents, MVC accidents, drownings, and so these don't just apply to children, they apply to adults. Now there are things that are very specific to children, like at certain ages, are they in their car seat properly? Do the parents know how to install it properly? And things like that, but those are all things that cross lines of age, as well, as you know, the mental health crisis, I mean, that is applicable to both adults and pediatrics. And we've seen that in the spikes and ED visits for adults and adolescents.
Host: The NIH Library of Medicine has no shortage of articles on the added risks of surgery in overweight and obese children ages two to 18. This is a big concern among surgeons with patients of all ages, but maybe especially among pediatric patients, what are those risks?
Dr. Bowen-Jallow: There's a plethora of risks. Just a couple are, you know, your increased risk of skin infection, which is increasing your post op infection risks, increased anesthesia risks, and some centers actually have a BMI weight limit, even among pediatric patients who are having surgery. So everybody acknowledges that it's extremely important. It's something to take note of and it can affect their outcomes.
Host: A 2019 British article stated that lack of data on obesity and measuring BMI and children can lead to unknown surgical risks. Is that a concern here in the U.S. as well? And if so, what's being done to address this?
Dr. Bowen-Jallow: Absolutely. Obesity increases pulmonary risks, as well as cardiac, endocrine, associated with cancers. I mean, the list just goes on and on and on. And so we definitely have that concern in the U.S., and that's being addressed through the innovation of new programs to try to target these groups and help them.
Host: So are there BMI measuring protocols?
Dr. Bowen-Jallow: Yes, there are, especially at pediatric hospitals. Most hospitals, you have to enter a height and weight, which gives you the BMI and in some electronic records, it'll pop up that you need to address the issue of obesity. Now, that is not in all but certainly something that I think that is valuable, and really can help the PCP when they've got so much already to do to focus on and say I at least need to raise this issue today.
Host: And what are some of the difficult surgeries you've seen? And are they mostly related to obesity?
Dr. Bowen-Jallow: It's really not that the difficult surgeries are related to obesity, it's that obesity makes difficult surgeries even harder is what I would say about that. So it does impact outcome because it does make the surgery itself more difficult.
Host: And so how do you address this as a pediatric surgeon with the patient and the family and maybe even the primary care physician?
Dr. Bowen-Jallow: Well, if it's pertaining just to surgery, you know, we always give the risks of surgery. But if we know that that risk is increased, and a patient that has obesity, we tell them that. You know, if you're trying to get an incision back together, and the patient has a extremely obese BMI, it is highly likely that that wound may dehisc, which means in our language fall apart. And so they really need to know that. Now, it's not the time to go into what they can do to lose weight before surgery. But it's certainly you need to have people informed and that just goes to their expectations about what can happen during the process and after the process.
Host: As mentioned earlier, Good Morning, America called you a trailblazer for overcoming color barriers as a female surgeon, but that's not the only trail you've blazed. Let's talk about your research and what you've discovered in regards to weight related issues in pediatric surgery. What led you into this research?
Dr. Bowen-Jallow: Well, actually, I didn't start off having an interest in obesity it kind of segued into it as I went through my career. So my first passion, and it's still there, is in pediatric health care disparities. And a lot of times people think, "Oh, well, there's no discrimination, or there's no bias when we deal with pediatrics." And there are numerous studies that show that that just is not true. First impressions are everything. And if you have unconscious bias, then you're going to apply that to your patients. So that was really my first love. But then I was going to a conference where they were talking about pediatric bariatric surgery, and I was looking at all the graphs that were being projected. And it was quite stark that the individuals that were receiving bariatric surgery was not the population that was most affected by obesity, which really bothered me. And I actually went up to that speaker after the conference and said, "You know, I noticed this slide. Can you tell me more about that? Or what's going on with that? And why weren't we really talking about that too?" And I was told, "Well, nobody really wants to get into that." And so never tell somebody that that's your passion. That's not something I want to get into. So then I got into it. And I was like, why is this isn't right, this isn't fair. And then came the journey into obesity.
Host: Dr. Don Wilson developed the Risk Evaluation to Achieve Cardiovascular Health clinic program here at Cook Children's, also known as REACH, the program seeks to identify early risk factors, both genetic and acquired for children, and then to develop individualized programs to reduce the risks associated with overweight and obesity. How do you see programs like this helping to reduce a child's risk of heart disease or diabetes, but also improving surgical outcomes?
Dr. Bowen-Jallow: I am all for any program that raises the awareness about obesity, the treatments, the nutrition, all of the mental health, everything that goes into this is so vital. And so by helping the children through that program, it helps surgeons because if we can get kids down to a healthy BMI, then it makes their outcomes even better. And so I love to see all the programs that are going around the country right now, because of the epidemic of obesity.
Host: As mentioned, obesity can increase a child's risk of heart disease and or diabetes. Which segues into this next question, what other disease risks do children and teens with obesity face?
Dr. Bowen-Jallow: Being ostracized by their community, the mental health issues that are associated with obesity are well documented, due in part to that ostracization of the community. They get orthopedic issues, neurologic issues, the list just goes on and on.
Host: So that not only impacts them when they come in for surgery. But Can those things also lead to additional surgeries?
Dr. Bowen-Jallow: That's a great question. In terms of outcomes, we know that if we talk about ortho outcomes, a lot of orthopedic surgeons will not do certain types of surgeries on adolescents, if their BMI is above 35, or 40, because of the high failure rate after surgery. So it absolutely can impact their outcomes and if they even get offered the surgery.
Host: So if you have a patient that is referred for any type of surgery, who is obese, and maybe already experiencing complications from that, how do you address the risks with the patient and or family? And do you have to delay the surgery?
Dr. Bowen-Jallow: From a general surgery standpoint, we see a lot of obesity when it comes to gallbladder disease. And a lot of patients that are obese have gallbladder disease. And so when they come to the clinic, you know, we're getting their blood pressure and all of those things. And I have actually had to delay surgery to get a adolescent patient, their high blood pressure under control, I had to actually send them to a pediatric nephrologist, who started medications and had to take about a month to get that blood pressure under control. And so it really highlights how this at a young age is affecting their health.
Host: So and of course, the family is one of the most critical components of the team to ensure the child has the support, they need to be as healthy as they can prior to the surgery. How do you address this? And how can a primary care physician also address this issue with families?
Dr. Bowen-Jallow: Well, this is so important to engage our primary care physicians. They are the first line of defense. And so you know, it's hard talking about obesity, you know, the communication with the family with the parent that were poor, historically, it's been more to talk down to the patients like why are you letting them eat this? Why are you giving them this food? instead of knowing the why behind it? And I think motivational interviewing is really important in terms of coming to the parent in a different kind of way. And so instead of saying you need to do this, you need to do this, you need to do that. It's well, how do you feel about this? What do you think if you were meant to make maybe just a small change? And there's a very different receptiveness when you talk to parents in that way.
Host: And for those who continue to struggle with weight what can primary care physicians, and really the health care system in general, do to help assure there are more long term success stories?
Dr. Bowen-Jallow: We know that long term success has been proven with bariatric surgery and with accredited bariatric programs. And so I think it's really important for people to know what those guidelines are, and what the accredited programs for pediatric are in the area. So I think that's the first step. And right now, the American Academy of Pediatrics has already, a couple years ago now, put out a statement that pediatric bariatric surgery is indicated, it's warranted, we should be doing more of it. And we should not be selecting based on socioeconomic status.
Host: So what do you base it on?
Dr. Bowen-Jallow: You base it on. So first of all, it's a six month program. They go through the program where they see a dietician, a surgeon, a nutritionist, exercise, physiologist, a mental health specialist, because all of these things go together. And so an accredited program has all of those things. The referral is, for pediatricians and our PCPs, are BMI of 35 with a comorbidity, or BMI of 40 with no comorbidity. So once you reach that point, you don't even have to think about it, the referral just should just be an automatic send in, if the family is amenable to hearing it, because as I said, it's a six month program. They come, they get evaluated, they learn what it really means to be involved in that kind of process.
Host: I recently read that the USDA Food and Nutrition Service is focused on improving nutrition in school based meals. So I have a question. But I also know you have a personal story about your son related to this topic. So I'll ask the question and let you decide if you want to tell the story first, or answer the question first.
Dr. Bowen-Jallow: So I'll tell the story first, being someone that is so interested in obesity and nutrition and fitness in schools and all of those things that come with, you know, receiving a good education. I was surprised because my son eats the school lunch. You know, I'm a working mom, I know they have options there. I packed in a healthy snack for him every day. And the way that schools work now is that you had to give your credit card, you log it in on the internet, like everything else, and they deduct the money once they go through it. And I had noticed that a lot of money was getting deducted from my credit card for the elementary school lunch. But I have a child that's in the 99th percentile for height he has been since he was two months old. And so he eats a lot. He eats more than I eat. I mean, he will eat you out of house and home. So I said okay, well, he's hungry, he's growing, it's fine. Well, I get a message from the teacher asking if it was okay, because every morning he would come in for breakfast. But in addition to breakfast, apparently they have a market there where they can buy whatever they want to. So every morning he was going in and having his breakfast, and then he was getting his Gatorade, not the sugar free one. And then he was getting a couple of rice krispie treats. And he was getting fruit roll ups. And he was taking all of this stuff back to his classroom, and trying to eat it before class started in the morning. And I said, Excuse me. And the list that I got from the teacher who was an excellent teacher, she literally listed out every single thing my son had bought this morning, and I don't even think I listed at all, what I just told you. I was astounded. But once again, then we're having behavior issues. But now I know why he's having behavior issues, because he's hopped up on like, 10 times and sugar intake he should be having. And so that story right? There just highlights the disconnect that I think we have with schools right now. And actually, when I talked to the teacher afterwards, and was asking her she was like, honestly, I'm not even supposed to say anything. Because we have from the higher ups have told us if there's no restrictions, and we shouldn't be bringing it up. And I thought that that was insane. But then what was even more insane was when I tried to go through the process to limit him because you can limit based on you know, one dairy product, only one dessert, it took a couple days for me to get through that process. And all I could think about was I'm a working mom. But what if I'm a working mom with two jobs, and I don't get a chance to call the school during school hours. And I don't have the capability and the resources like I have to stay on someone until it gets done. And so it really just highlights that difference in socioeconomic status, and how that plays into the health and the healthy choices that our kids have.
Host: So here's the question as a physician who sees the complications in kids due to poor nutrition, what role should schools play? How do we ensure that schools and other organizations actually take some responsibility for the health of kids by providing better choices?
Dr. Bowen-Jallow: Well, I wish I could say that there's an easy answer to this question and there ... but there just isn't. There's a difference between private schools, there's a difference between public schools, there are actually mandates from the government about what they have to have in schools and what they don't have to have in schools. And depending on which administration there is, sometimes those come and sometimes those go. But the voices that always get heard are the voices of the parents. And so within your school district, you just have to, with the PTO, with everybody, band together and say, No, we shouldn't be offering anything other than diet coke in the school, we should be offering where at lunch, they can get a low calorie drink, it shouldn't always have to be juice and things like that, and what actually adds to our nutritional value. Yes, we should offer fruit with every meal. And no, we shouldn't let a six year old walk through the lunch line and get 10 different things on his plate. So I mean, there are things that we can do. But I think it's really going to be at the parental level, because there's just too much big business in food.
Host: Some of the biggest health issues are related to the disparities in access to healthy food and health care and the role that plays in a child's diet and weight issues. What can the healthcare world do to reduce challenges and stumbling blocks.
Dr. Bowen-Jallow: And this really gets back to the heart of the matter in terms of knowing your audience, knowing that the situation is not created equal. And so this speaks to really about food deserts, which are a huge issue. I mean, if you can't walk to a grocery store, then where are you walking to in a crunch. You're walking to the gas station. There's nothing ... hardly ever anything healthy at the gas station, as we all know from road trips. Quality of food, once again, at the gas station you're not going to get any quality fruit, no quality vegetables. So depending on where you live, you are going to be severely hampered by this. Quality food pantries. I mean, I've been to several food pantries, some are great, some are doing the best that they can, and the ones that they are doing the best that they can can't really offer fruits and vegetables. You know, we're not just saying that a potato is a vegetable at this point. And so it's really important though, to partner with these organizations that are already up and running in the community and successful. And that's one way that schools can really impact because they can be sending flyers home to parents in everybody's backpack, so you're not singling anybody out, that says here's the local food pantry, here is a place that offers discounts on fruits and vegetables. And so really getting that word out there.
Host: We've talked a lot about the challenges of pediatric surgery, particularly those related to weight. But there's been a lot of breakthroughs and advancements in treatments and technologies for kids undergoing surgery. What are some of the most exciting things that have happened recently and are happening now.
Dr. Bowen-Jallow: For me, it's the way that minimally invasive surgery has come forth in leaps and bounds in terms of the pediatric aspects. So adult surgeons are always the first one to get the toys, and we call them toys in the or where it's like the new thing that cuts down your OR time, you know, it does it 10 times better than the last instrument that you had. And those things are slow coming to pediatrics for the most part. But just within my time and training and being practicing as staff, the instruments that we use now, the things that make surgeries go quicker, and thus less anesthesia time. And thus quicker return to recovery, smaller incisions, those are the things I really get excited about. So if you want to call those toys, I call them toys, but any device that cuts down your OR time, that cuts down the recovery. And I'm a big proponent of minimally invasive surgery with the small incisions which have already been shown for faster recovery back to your baseline activity. Another thing that I'm really interested in and passionate about is robotic surgery. And although it hasn't found its application in small children yet, we're certainly using it in that obese population. Because as we talked about surgery on the obese patient is harder, the strain that it puts on your back is a lot and so to be able to use the robot in that manner so that you can sit down and you know, I want to be able to practice for the next you know, 3040 years, you know, I want my back to stay intact. And so that's one of the things that I find fascinating that we're starting to get into that adolescent realm.
Host: So what's on the horizon for pediatric surgery?
Dr. Bowen-Jallow: I think integrative medicine, telehealth is basically where medicine is going. People lead extremely busy lives. They want to be able to talk to a physician see a physician and not have to drive the 45 have minutes to the doctor's appointments. And don't even get me started when you're looking for a specialty appointment, the time that might be a three month waiting list and it might be two hours away. And so I think telehealth is really going to be a part of integrative medicine, especially in schools. And I think the more physicians and health care providers that can get into schools, and really talk to them on a basic fundamental level about the health of children, that that impacts everyone, and is a positive impact for everyone. So I love, as you know, if you've seen any of the other things that I do, I actually am going to a school tomorrow to give a talk on pediatric surgery to a high school to try to get them engaged. And so it makes a huge difference about getting into that environment and starting it early. But not only with the children, but also with the the teachers and the administration.
Host: And is there anything else that you would want to say to primary or referring physicians?
Dr. Bowen-Jallow: What I would say about primary and referring physicians for anything within pediatric surgery, and the ones in my area know, that everybody has my cell phone number. Everybody calls me, they text me is that, if you don't know, no problem asking because that's going to make things easier for you. It's easier for the patient. Even if it comes to things like that, you know, a surgeon might have a specialty in so clearly one of my specialties is pediatric obesity. So I've taken courses on that on motivational interviewing. I've taken the class to be board certified in obesity medicine, and there are people that even go beyond my knowledge in it, but always feel free to reach out.
Host: Dr. Bowen-Jallow, it has been a great pleasure to talk to you today. Thank you so much for taking the time out of your extremely busy schedule.
Dr. Bowen-Jallow: It's been a pleasure.
Host: We're so glad you could join us today. If you'd like to learn more about this program or any program at Cook Children's, please visit us at Cook Children's dot org