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Cardiology Heart to Heart ❤️ with Dr. Ginnie Abarbanell · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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I'm Holly Wehmins, and this is Pediatrics Now, cases, updates,
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and discussions for the busy pediatric practitioner.
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Don't forget to click on the link in this podcast for free credit that may include
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CME, MOC, or ethics credit, depending on our topic or podcast.
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Pediatrics Now is brought to you by University Health's new Women's and Children's.
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Music.
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Hospital and the Department of Pediatrics at the UT Health Science Center.
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Joining me here in the podcast studio today back
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on the show is dr jenny abarbanel thank
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you holly you head of our pediatric cardiology division
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a cardiologist where you're on the front lines helping these children during
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heart month we're surrounded by a lot of information regarding heart health
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which is important in our pediatric patients as well as our adult patients but
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I think in the gist of that,
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sometimes we forget about those patients with congenital heart disease.
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So as our listeners know, congenital heart disease is heart defects that you're
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born with, and it is the most common birth defect of babies born across the world.
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It can be missed, and we'll talk about that, about one in about every 110 births,
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babies are affected with congenital heart disease.
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Now, does that mean that every one of those babies born has such significant
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heart disease that they need heart surgery.
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No, but we do take care of some pretty sick babies that have pretty significant heart defects.
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Our real goal is that maybe someday in the future, we'll be able to pick up
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all congenital heart disease prenatally.
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Unfortunately, we're doing better in the urban city areas at picking up congenital
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heart disease prenatally before babies are born, but in the rural communities,
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and especially among those moms who don't get very good prenatal care,
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it is still missed much more frequently than we'd like.
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We don't really know right now in the state of Texas how we're doing.
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There was a paper, it was published now, it's an older paper from 2015,
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and in the state of Texas.
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Our detection of congenital heart disease was between 20 to 30 percent.
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And I would say, again, I think my personal experience is, yes,
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we're doing pretty good here in the cities, but in the rural areas, it's pretty rough.
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That's where a lot of our babies are diagnosed with congenital heart disease after birth.
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Is telemedicine helping with that somewhat? We are hoping that someday it will.
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It's a slow process. We have managed to open a fetal echo clinic in Uvalde,
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which I think has been a good endeavor.
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It's shown us that we can do this. Hopefully it will be more on the rise in the future.
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What are some warning signs? Community pediatricians see 40 patients a day.
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There can be so much to cover in that exam room just to make sure that when
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it comes to our hearts, everything that's being covered is covered,
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like what do you recommend and what advice do you have to make sure you're not missing something?
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So I think that's, we'll just back up just a bit. So those.
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Babies that are picked up prenatally with significant congenital heart disease,
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meaning congenital heart disease where they're born blue or need heart surgery
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within the first week to two weeks of life, or even within the first six months of life,
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we usually pick them up because when they're born, there's something that will
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give us a clue that there's a problem.
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Sometimes it can be a heart murmur. And then thankfully, in all 50 states now,
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we do what's called the critical CCHD panel or screening, which is critical
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congenital heart disease screening, which is pretty simple.
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It's basically checking a pulse ox in the baby's hand and leg to see if there's
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a differential between the upper and lower extremities and pulse ox or oxygen saturations.
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And if it's abnormal, then doing a workup to figure out why.
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So that has actually really helped us from picking up some of these significant
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congenital heart defects before the babies go home. So that's really helpful.
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I would say in the general pediatrician's office, I think,
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The heart murmur that sounds really harsh or unusual, those ones,
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send them over for us to take a look at.
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Those teenagers who have chest pain with exercise, we probably should evaluate them in cardiology.
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Unusual fainting episodes, especially fainting or syncope with exercise,
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those are real big red flags.
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Or fainting without a prodrome, so what does that mean?
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And that means that before a teenager, usually it's teenagers who pass out,
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they oftentimes can have dizziness. They don't feel good. They kind of feel
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hot. They start to sweat before they pass out. That's a prodrome.
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It's more worrisome when they wake up on the ground and they don't know why
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they ended up there and didn't have any symptoms beforehand.
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So those are some of the kind of red flags I think about if I was in a general
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pediatrician's office. Yes.
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What if a child is exercising and doesn't have the prodrum? Am I saying it right?
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But the fainting did happen during exercise?
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Or did have the prodrum. That's what I mean. So let's say they're in the middle
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of exercise and they start to feel dizzy and then they pass out in the middle of exercise.
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In the middle of exercise, that would still make me worried.
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But let's say they're sitting in class and they stand up and all of a sudden
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they have all of those symptoms and then they pass out.
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That's a lot less worrisome than passing out in the middle of exercise.
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Okay. So no matter what, if a child passes out while exercising,
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that should be evaluated.
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Yes. Same with chest pain with exercise. And even though a lot of times,
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I know in our Pediatrics Now for Parents episode, which is meant to be one less
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thing that pediatricians need to say in the exam room.
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So we have an episode on the topics we're talking about now in Pediatrics Now for Parents.
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But a lot of times it's really not concerning the chest pain during exercise.
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It could be a lot of things, but it does need to be checked out.
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It should be checked out.
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And most of the time, it's good to not alarm families because in all reality,
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we all worry about the sudden death in athletes or sudden death in our teenagers.
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It's a really sad thing when it happens. And we pray that it never happens,
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but unfortunately it does. But the good thing is, is that that only happens like 0.1% of the time.
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So 99.9% of the time, it's going to check out to be chest pain with exercise,
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but normal cardiac evaluation.
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And the same with fainting, it's usually syncope is not something to be concerned about?
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Usually with syncope, yes, especially, well, only if it's at exercise,
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I would be concerned about it.
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If a significant startle response and somebody passes out or passes out during
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swimming, that's also one of the red flags.
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Passing out to an alarm clock or somebody scares you and you pass out,
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those are kind of red flags.
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But the things that are less of red flags are the I stood up too fast,
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I felt dizzy, I walked a few feet, and then I passed out.
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That's a lot less concerning to me. Or I'll hear all kinds of stories.
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I think teenagers, the number one places they pass out, they pass out in church.
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They pass out in choir because I think they're standing and they lock their
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knees and they're tired.
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And in church, I think it's a combination of things. I think they don't eat
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breakfast. They're probably a little bit dehydrated.
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It's sit down, stand up, sit down, stand up. The other things,
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other places that kids pass out, too hot of a shower.
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Some boys will pass out when they're urinating. more in the girl population
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than the boy population. But if they're getting their hair done for prolonged
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periods of time, they can pass out during that process as well.
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And all of those times just depends on what the alarm factor is and if there's
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other things that are concerning.
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Most of the time, those are not concerning episodes of fainting.
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But the thing to kind of think about as a practitioner out there is that a lot
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of things that you want to make sure have to do with your history before you
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even get to your physical.
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So for example, just getting a good history of what happened when they passed
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out or what happened when they were getting chest pain.
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But then also knowing past medical history, for example, do they have a history of Kawasaki disease?
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Do they have a history of congenital heart disease? And then family history too.
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So sudden cardiac death in the family. Oftentimes I'll ask questions like,
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are there unusual drownings, single car accidents that are unusual,
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anybody who died in their sleep?
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And I usually kind of paraphrase it in younger people.
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Because, you know, if grandma and grandpa, if they actually die in their sleep
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when they're 85, that's very different than the father dying in their sleep when they're 35.
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The buzzer goes off or an alarm clock.
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And then someone fainting, that being alarming, is that long QT?
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Yeah, that's something you can see in long QT. Okay.
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I think the other thing, just to kind of get on something that's one of my kind
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of interests, if you will, is cardiac neural development.
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And I think a lot of general pediatricians and general practitioners don't really know.
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But our babies that we do heart surgery on before six months of age,
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or if they have prolonged cyanosis for a prolonged period of time,
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are at risk for neurodevelopmental delays.
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And I think it's good for the regular practitioner to know this as well.
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There was a recommendation and guideline that came out in,
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I think it was 2012, and it was just updated in 2024, so last year,
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that all of those kids should have some type of screening either in their pediatrician's
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office or by another practitioner to look for deficits so that they can get
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either early childhood intervention or help in school.
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And, you know, what it looks like is, especially as they get older,
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some issues with ADHD and executive function, they can have some learning differences
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so they can have some struggles with reading and math in school.
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And I think not enough people realize that these two things are associated with
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each other and something just to be thinking about.
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If you have a child in your clinic that, say.
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You know, on the extreme example, has hypoplastic left heart syndrome and has
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had three heart surgeries, oftentimes I think parents and us as providers,
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we're like, yay, you're alive, you're doing okay.
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But we forget to ask, well, how are you doing in school?
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How are you doing from a developmental standpoint? Because they can have issues with that.
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And we know that if you get some early childhood intervention or some help at
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school, you can really change the trajectory of a child's life as well as when they become an adult.
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Okay, so anything else you want to say there? Most pediatricians know what milestones
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that kids should be reaching at certain times from a developmental standpoint.
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But, you know, paying attention to those and not being like,
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oh, they're delayed because they have heart defect.
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Let's just wait and see if you see those delays to send them in to get evaluated
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so they can get services.
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And then I think in the school age kids, a lot of times we get really busy and
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we kind don't ask about how they're doing in school.
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And I think that's an important thing, especially in these patients that have
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significant congenital heart disease and have had heart surgery,
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asking them, well, how are they doing in school?
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And not really just being like, oh, okay, but like really asking them,
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are you struggling in school?
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Are you getting extra help? And trying to dive into that and see if there's
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ways that we can help them if they need extra help.
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Like how can we get them extra testing, all that kind of stuff if they need it.
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But there's different things at school, for example, from what's called a 544 plan and an IEP.
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So IEP stands for Individual Education Plan, where the school,
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if you have certain diagnoses and testing, they can provide extra services.
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So I think just being aware that our kids do struggle with that.
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And then I think just being aware that this does affect the children that are
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growing up now who have congenital heart disease.
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There was a study, this came from 2023, and looked at adults with congenital
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heart disease who were ages 40 to 53 after they'd had surgery as a child.
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And so in the study, they were looking at 50-year-old people,
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so looking back on their life.
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And when you compare those that had congenital heart disease to those in the
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general population, Those that congenital heart disease actually had lower educational
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levels, lower occupational levels, lower employment rates than those that did not.
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And over time, they felt more often physically restricted because of their congenital
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heart disease, felt more often disadvantaged due to their congenital heart disease.
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And if you think if you could change some of those trajectories,
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like, for example, when we talk about things, we know that.
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That some of our studies have shown that kids who have congenital heart disease
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are two times likely to receive special education services, and it probably
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should be even higher than that.
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They can have increased significant school absences, worse academic outcomes
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compared to their peers.
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So we just know that they have these issues. And I think oftentimes our general
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practitioners and those that are out in the clinic,
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why would you know this unless you listen to a podcast like this,
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or we as cardiologists help to make sure that people are aware of these issues.
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And Jenny, thank you so much for bringing that up, because you wouldn't necessarily
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think that with a child who has had heart problems, that this affecting the whole big picture.
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Right. And it's interesting when you start thinking about this,
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because a lot of different researches happen, like why would they,
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it's their heart, not their brain.
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But they've looked at fetal brains in those that have congenital heart disease
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prenatally compared to normal.
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And the fetal brains aren't normal. And so even in development,
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because the blood flow secondary to the congenital heart defect isn't the same
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as the theory is that the brain doesn't develop the same.
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And then they've looked at different brains of those that have congenital heart
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disease to those that are normal after delivery. And again, they're not the same.
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And so then you take those that have significant kagellar heart defects and
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you do a surgery in the first week or two weeks of life where you put them on
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cardiopulmonary bypass, all of those things.
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We know that those things ultimately can't be good for the developing brain either.
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So all of those things can compound and can lead to some of these developmental
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delays or cognitive delays that we can see in these kids.
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Now, what I tell families is that this does not equal, right?
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Not every child who has a significant congenital heart defect might have all
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of these things, but I think we need to be aware that this is something that
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we see in this population.
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Thank you so much, Ginny. Is there anything else you want pediatric practitioners to know?
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I think that that covers a lot of different things.
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I think we've talked about, you know, congenital heart disease and sort of my
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one passion is the cardiac nodal development aspects.
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And I think the other thing to
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start thinking about is not really from necessarily the heart perspective,
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but one of the things that I also just am interested in and how do we further
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the agenda is how do we get the services for our kids that they need for early
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childhood intervention and then how do we get better services in our school.
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Now that's a whole big issue for our society,
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but I think ultimately it's something that we need to continue to keep trying
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to push so that we can get all those services for kids like the kids I take
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care of who have these significant congenital heart defects.
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For developmental pediatricians, there can be a very long waiting list,
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and it can be tough to get in.
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We have something called the Now Clinic. Have you heard of the Now Clinic here?
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I have not heard about the Now Clinic. So it's UT psychiatrists,
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and that's here in San Antonio, and they have Now Junior that sees kids,
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and so they help treat patients in San Antonio.
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But one of their counselors, she was a principal of a school,
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and when I was talking to her, she said that she saw how limited she was as
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a school principal and all the problems she wanted to help kids with.
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So that inspired her to go back and get training as a counselor,
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and now she works at the NOW Clinic.
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Oh, wow. So I hope to have them on the podcast soon. They have a clinic where
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they include dogs in the program, and they have pictures of the dogs on there, too.
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Oh, that's cool. Yeah, so that's a resource a lot of people might not know about,
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but it's called the Now Clinic for our San Antonio and the surrounding area listeners.
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See, we learn something new every day. Yeah.
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So you're married to Dr. Erin Abarbanel, and the two of you are co-directors
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of the Pediatric Heart Center? That is correct.
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So how is it? Tell us about being married to the love of your life and working
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with the love of your life.
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You have a close relationship all around yes we
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do we work we work together almost every single
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day we see each other at work and then we see each other
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obviously every day at home and people ask well how do you work with your husband
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and I think for us it's just been a gradual process right I finished my training
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and he started his training so we were kind of on this different path where
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we grew up with each other through our training.
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And then as we grew up together through all of our medical training,
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then as we started to work together, we'd already kind of gradually eased into
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that process through his training that followed up my training so that it just
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kind of naturally happened for us,
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which I think is probably, probably made it maybe a little bit easier for us
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because that's kind of, it was a gradual process for us.
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We didn't just wake up one day and start working together every day in the same
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field. We didn't start out that way.
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We've been married for a really long time.
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And our paths have pretty much just kind of gradually convened together to make
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it so that we work together like we do now. And you're close friends too.
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We are close friends most days. most days.
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And you have two teenage children? We do.
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We have two teenage children. Our oldest is a freshman at UTSA,
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and our youngest is a junior in high school.
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And they joke because they know it's all about the heart at our house.
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And we have a heart model that's on our mantel place that our kids have said,
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we have to have one of those when I purchased some for our clinic.
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And both my kids were like, we want one for home. So now we have one at home.
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And our pediatric practitioner listeners, of course, know the importance of a healthy diet.
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Do you want to mention just a line or two? And we have also in our Pediatrics
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Now for Parents episodes specifically about what that plate should look like.
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So you could reference that if you want to, and your patients could listen to
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Pediatrics Now for Parents.
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So it could be one less thing. Well, I think a lot of times what I tell families
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is it's just important to make healthy food choices.
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And I sort of use the plate example where half of it should be fruits and vegetables,
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the other half, a quarter should be your proteins, and then the other quarter
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should be your starches.
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But the other thing I also do talk about with some of my overweight teenage
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patients is tracking their food in a food tracker. I think that's also really helpful.
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It's very, it's not easy to do, but there's a lot of food trackers that are available now.
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And it really does help to figure out how much food you're eating.
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I think that's the other thing, talking to families.
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I don't think we have an idea of how many servings of everything that are on
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our plate. And I think that is helpful.
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But we always have to talk about exercise with our patients because we all know
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that pediatric obesity as well as obesity in the United States is on the rise.
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And so trying to encourage our patients to be as active as possible,
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which can be challenging.
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Oftentimes what I'll tell them is that, you know, with our own kids,
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we've, we made them exercise three to five times, three to at least three times
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a week. And what does that look like?
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Well, for us, it was swimming, but for others, it can look like all different things.
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And even when they didn't want to go, we actually made them go.
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But then the other thing is just making sure that you're doing the things too.
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And talking to families about how your kids are watching you.
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So exercising as a family is also really important.
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My daughter didn't want to go to swim practice the other day,
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and I just said, and it had been a long day at school, but I said,
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how about try the first, let's try the first five minutes, and then if you want
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to leave, we can go. But of course then they don't want to leave. Right.
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Well, you know, it's interesting when you bring that up because a book that
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I read a couple years ago that I really think is a fabulous book is called Atomic Habits.
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And one of the things in the atomic habits
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is breaking down the habit to the
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most the easiest first step so that
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you can establish a habit and one of
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the things that he talks about is trying to establish an exercise habit so instead
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of saying i'm gonna go do x y and z change it to i'm going to go put my exercise
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clothes on because we all know once you actually put your exercise clothes on and put your shoes on,
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you're much more liable to go do the exercise because now you've put the clothes on.
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If you say, I'm going to go, you know, do something, I'm going to go work out
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for two hours, the likelihood of you doing that is really low.
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Right. That's great advice. But if you say, okay, I'm going to go put my exercise
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clothes on, then you're much more likely to go do it. That's great.
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And Dr. Dina Tom, who was recently on the show, she talks about how,
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like you, she wakes up early in the morning to exercise. I know you mentioned
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in our Pediatrics Now for Parents interview that you and your husband wake up early and exercise.
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And she says, you know, if she thinks, well, I'm too tired, well,
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exercise tired. Like she replaces it to, I'm going to exercise tired.
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I'll still feel better afterward. You know, you don't have to be.
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Usually you'll feel better. You'll feel less tired. Yeah.
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So, but it is hard. It is hard in the morning.
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And I think also just making sure, especially if you're going to do it first thing in the morning,
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that you have a plan plan of what you're going to do the night before so that
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when you get up in the morning, you're not like laying there going,
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I have to do, I don't know what I'm going to do. You have a plan.
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We exercise in the morning, but we also have this videos that we watch. And so it's pretty easy.
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You put your clothes on. For us, that's step number one.
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And then step number two is we go upstairs and you push play on the video.
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And then you really don't have to do anything except Therefore,
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follow the instructions.
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And that makes it easy for us to do it.
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Is it cardio or weights or both? A combination of both. Okay.
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Do you drink coffee beforehand? I'm just wondering. No, because no.
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Is that bad for us, our hearts? I have no idea. Okay.
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I think excess caffeine is bad for us.
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But whether you're one cup of coffee, the studies are hard to tease out what's good or what's bad.
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Do you want to mention anything about how much is too much caffeine?
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I think anything that's in excess is too much, right?
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So one to two cups of coffee is probably okay. I say that because that's what I drink.
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But if you're drinking two to three pots of coffee a day, you might want to
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rethink your habit. It's not good for your health.
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We do know that some that have underlying arrhythmia issues, it can make those worse.
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But I don't know if we actually have the data to prove one way or another.
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But when it comes to healthy eating and healthy habits, we all know that drinking
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a couple pots of coffee can be good for you because you're replacing the water
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that you should be drinking with coffee.
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And I also like to promote on Pediatrics Now having a life outside of medicine.
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And, you know, you and your family recently went on a hiking trip to Big Bend with a group.
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We did. One of the things that Erin and I have been doing over the last three
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or four years is more hiking and backpacking.
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And there's actually a local group here that we hike with here in town at Eisenhower
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Park and Harburger Park and Friedrich's Park. I love all those parks.
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And they also have some outings. So we did just recently go to Big Bend a couple
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weeks ago over, I think it was Valentine's weekend, but it was also President's
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Day weekend. The National Park.
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The National Big Bend. Went hiking with the group, camped in our little camper,
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which was a lot of fun. But we also went to Guadalupe National Park probably
26:08
about six months ago and actually camped in a little campground.
26:12
Then we backpacked and spent a night up there on the top of the peak and then came back down.
26:17
And that was a lot of fun. Those are two beautiful national parks that are in
26:20
Texas. Wow. There's only two.
26:22
But then there are a lot of state parks around here. So those people who haven't
26:26
got out to go to the state parks, just go check them out. And it's interesting
26:30
when I talk to people here, I didn't grow up in Texas, but lots of people said
26:35
that who grew up here have never been to Big Bend.
26:37
So I think it's worth checking these things out because they're in our...
26:42
Sort of back door back backyard if you will but
26:45
don't go to big ben in the middle of the summer yes that's what
26:48
i was going to say i think that's part of it i remember bringing it
26:51
up and my dad saying well it's too hot you've got to wait like four more months
26:55
because it's in the summer yeah don't go in the summer it's way too hot and
26:58
then the other thing that we have been doing recently is some off-roading we
27:03
like to go out in our jeeps and go off-roading which has been a fun thing for
27:08
the two of us to do together.
27:10
Very nice. You get outside, but it's different than hiking, sometimes terrifying,
27:15
but it definitely will push your limits a little bit depending on how adventurous
27:21
you are. Oh, it sounds great.
27:23
Do you have someone, do one of you drive or do you have a guide driving you?
27:26
So we've done some stuff. There's what's called Hidden Falls.
27:30
It's near Marble Falls. There's an off-roading park.
27:33
We went there. And then there's one called Maris Adventures,
27:37
which is up in Palo Duro Canyon.
27:39
And we've gone up there a couple of times. Usually we end up going with a group.
27:43
So there's somebody who's like goes and helps you figure out exactly how to
27:47
drive over certain obstacles so you can get better.
27:51
But the last time we went, I got braver and braver.
27:54
So it's been a lot of fun for us.
27:57
I'm going to Yellowstone. That's our next trip. And we're going through the
28:02
park on snow coach, I guess, special tires for that.
28:06
Yeah, no, so I grew up just an hour north of Yellowstone Park,
28:09
so I grew up going to Yellowstone Park and been to Yellowstone Park in every season.
28:15
And if you're taking the snow coach, that's a lot of fun.
28:18
You'll have a good time. Are you going to Old Faithful? Yes.
28:21
Yeah. One of my childhood memories is we took the snow coach in Yellowstone
28:26
And we also snowmobiled in Yellowstone.
28:30
And there were like three people watching Old Faithful go off in the winter.
28:35
So you grew up where in Montana? A town called Livingston.
28:40
So it's about 30 minutes from Bozeman, which is one of the places people fly
28:45
in, and about an hour north of Gardner or Mammoth.
28:49
So that entrance into Yellowstone Park. And do you go back very often?
28:54
I haven't been back for several years recently, but the last time we went,
28:58
we did go to Yellowstone.
28:59
Nice. When you go, well, if you're going in the winter, you can't do it.
29:03
So if you go in the summer, though, one of the other childhood memories I have
29:06
is at the Old Faithful Lodge, the Old Lodge.
29:09
And I'm pretty sure they still have it. They have ice cream in there.
29:13
And they have huckleberry ice cream. They try to have huckleberry ice cream, which is really good.
29:17
Oh, yes. I've been there before in the summer, and it was so good. Yeah.
29:21
Yeah. Yeah, but in the winter, the big old lodge at Old Faithful actually closes
29:25
down in the winter. Oh, okay.
29:28
I know they said they're limited on food options, but. The other thing that's
29:31
cool about Yellowstone in the winter is like, it's kind of surreal,
29:34
especially if there's snow.
29:35
Because then the geysers and the hot water, they just look differently when they're in the snow.
29:40
And there's not very many people around. Less people. Yeah.
29:44
Well, and here on Pediatrics Now, we love quotes. I know, Ginny,
29:49
that you have a quote prepared.
29:50
So what's the quote to inspire our listeners? So I think the quote to inspire
29:55
listeners here is, muddy water is best cleared by leaving it alone. That's from Alan Watts.
30:03
Just think about that a little bit. Sometimes the more you muck up something,
30:08
the more muddy it becomes, where if you let it settle, it might become clear.
30:12
It's hard to think about just not doing something, you know,
30:16
when you want to fix everything.
30:18
Well, sometimes what I'll say is just give it a hot minute and see what happens before you jump in.
30:23
I think that applies to not only a professional life, and I have to tell myself
30:27
all the time, but I think in our personal lives too, right?
30:31
Sometimes just give it a hot minute, see what's going to happen.
30:35
And sometimes things fix themselves all by themselves or what you need to do
30:40
becomes more clear if you give it a moment to kind of simmer. That's great advice.
30:46
Anything else, Ginny, you want to say before we wrap up?
30:49
I think we covered a whole lot of things, but I would just say for those listeners
30:53
that you have, if they need anything, don't hesitate to reach out to me regarding
30:57
cardiac issues. I'm always here to help.
31:00
And you have a connection to the head of pediatric cardiothoracic surgery. Yeah, I kind of do.
31:07
I feel so honored to be able to be here with you today talking,
31:10
and I so admire how you are so kind to your patients and customer service all
31:17
around to your colleagues and also you're so accessible where you'll answer
31:21
the call, answer the text.
31:23
I don't know how you do it all, but I'm impressed.
31:25
Well, thank you, Holly. I definitely can't do it all, but I try my best.
31:30
Dr. Ginny Abarbanel, Head of Pediatric Cardiology at UT Health San Antonio and University Hospital.
31:36
Thank you for being here on Pediatrics Now. Thank you, Holly, for the opportunity.