*"It doesn't matter if the cat is black or white as long as it catches
mice."*

Deng Hsaio P'ing 1904-1997

This a page for sharing "what works" as seen in the published literature
as well as what is done at sites that care for American Indian/Alaskan
Native children. If you have any suggestions, comments or questions
please contact Steve Holve, MD, Chief Clinical Consultant in Pediatrics
at sholve@tcimc.ihs.gov

IHS Child Health Notes

June 2006

# Quote of the month

*"Science is facts; just as houses are made of stone, so is science made
of facts; but a pile of stones is not a house and a collection of facts
is not necessarily science."*

Henri Poincare (1854-1912)

**Articles of Interest**

A randomized, controlled trial of removable splinting versus casting for
wrist buckle fractures in children. Pediatrics. 2006 Mar;117(3):691-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=pubmed>

Wrist buckle fractures are commonly seen in pediatric patients in both
emergency departments and pediatric clinics. The standard treatment in
the United States is to place these children in a short arm cast for 2
to 4 weeks. In Britain many patients are placed in a removable splint.

This study was a randomized controlled trial for children 6 to 15 years
of age with a buckle fracture of the wrist. Patients received either a
short arm cast or a removable plaster splint for three weeks. There was
no difference in pain our fracture healing. Children with the splint had
better physical functioning and less difficulty with activities of daily
living at 2 and 3 weeks post injury.

**Editorial Comment**

Buckle wrist fractures are commonly seen and treated by primary care
physicians in the Indian Health Service if for no other reason than few
of our rural clinics have easy access to orthopedists. This study
confirms what most people knew intuitively; that these fractures heal
promptly. This study also confirmed what many of us knew from
experience; that these fractures heal so rapidly in children that many
patients will remove their own casts off before 3 weeks and never return
for follow-up. In this study 40% of children had stopped wearing their
splint most of the time by 14 days and by 20 days almost 85% had stopped
wearing their splint. If both treatments are equal we should use the
least restrictive choice. A commercially available preformed splint
would likely work as well as a plaster splint and be much quicker in a
busy clinic.

Screening for developmental dysplasia of the hip: recommendation
statement.\
Pediatrics. 2006 Mar;117(3):898-902.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=pubmed>

Screening ultrasounds of the hip in newborns were going to make
unrecognized developmental dysplasia of the hip (DDH) a thing of the
past. It hasn't worked out that way.

The United States Preventive Services Task Force looked at the
risk/benefits of screening tests for DDH. They felt that screening
ultrasounds have a high false positive rate. Surprisingly, they also
found there was not sufficient evidence to recommend physical exam
screening for DDH given the high rate of spontaneous resolution of DDH
in well infants. There is no controlled trial demonstrating better
outcomes in a population screened for DDH.

**Editorial Comment**

The American Academy of Pediatrics and the Academy of Family Practice
continue to recommend physical exam screening for DDH. It seems prudent
to perform a physical exam of the hips at well child visits until 6
months of age.

**Infectious Disease Updates**.

Rosalyn Singleton, MD, MPH

**Mumps Outbreak hits the Midwest**

Through May 10^th^ 3,268 mumps cases have been reported to CDC from 12
states in the United State's largest mumps outbreak in years. The
outbreak started in Iowa in Dec. 2005. The strain of mumps virus is the
same one that has caused an ongoing outbreak in the United Kingdom. The
majority of the cases are in 2-dose MMR recipients and the predominant
age group is 18-24 years. This isn't unusual since mumps is occurring in
a highly vaccinated population. About 80% of persons who have received 1
MMR dose can be considered protected and 90% after 2 doses. Since no
vaccine is 100 percent efficacious, most cases of disease in a highly
vaccinated population will happen in individuals that have been
vaccinated.

The main outbreak control measure is immunization of persons not fully
vaccinated. In an outbreak, fully vaccinated is defined as 2 doses of
MMR for persons aged 1-49 years and 1 dose of MMR vaccine for persons
aged 50 years and older. During an outbreak, health-care facilities
should consider recommending 2 doses of MMR vaccine to unvaccinated
health-care workers born before 1957 who do not have other evidence of
mumps immunity.

So far, Wisconsin sites in the Bemidji Area are the main IHS sites
affected by this outbreak. CDC recommends that a blood specimen for IgM,
and buccal swab and/or urine for culture or PCR be collected from all
patients with clinical features compatible with mumps. Isolation
procedures consist of droplet precautions for 9 days after onset of
parotitis. Daily updates on this outbreak are available on the CDC
website at: <http://www.cdc.gov/nip/diseases/mumps/default.htm>

**Recent literature on American Indian/Alaskan Native Health**

Doug Esposito, MD, MPH

**[Article]{.underline}**

A Nationwide Population-Based Study Identifying Health Disparities
Between American Indians/Alaska Natives and the General Populations
Living in Select Urban Counties. *Am J Public Health*. 2006 Mar 29;
\[Epub ahead of print\]

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16571711&query_hl=10&itool=pubmed_DocSum>

**Summary**

The authors report results of a study designed to assess the health
status of the urban American Indian/Alaska Native population served by
urban Indian health organizations (UIHOs). Data from the 2000 US census
and the National Center for Health Statistics were used.

As you might imagine, health data collected on a national level
demonstrates significant disparities for AI/AN groups as compared to the
general US population. This is true for the urban as well as for the
general AI/AN population. The authors also document significant
disparities in socioeconomic status. They show that AI/AN people living
in UIHO areas are about twice as likely to be poor, unemployed, and to
not have a college education. Rates of AI/AN children living in poverty
were found to be highest; almost twice that of the comparison groups and
approximately 10 percent higher than adult AI/ANs. It was found that
approximately 20% of the 400,000 AI/AN births happening nationwide
between 1991 and 2000 occurred in urban areas covered by UIHOs. Other
interesting and important statistics are reported in this article, and
should be accessed directly by any interested individuals.

Some study findings were not easily explained, and require additional
investigation. Lower rates of low birth weight were found for both urban
and nationwide AI/AN populations than for the comparison groups.
However, rates of prematurity were slightly higher. The authors suggest
that this is perhaps somehow related to higher rates of diabetes among
AI/AN groups, but such a statement seems a little "premature" to me!
Additionally, the birth rate for AI/ANs living in UIHO service areas was
about one fourth that of the general US population, although the birth
rate for the general AI/AN population nationwide was similar to that of
the general US comparison group. The authors posit that this could be
due to mobility factors of the maternal AI/AN population at large,
whereby deliveries are occurring outside of the UIHO area of residence.
Are these women moving back to Reservations to have their babies?

The authors make several suggestions that they believe would result in
reductions in health disparities. They contend that disparities in
access to care are paramount to the plight of the urban AI/AN
population. Other studies have definitively documented that urban AI/ANs
are less frequently insured and less frequent users of primary health
care. Under funding of urban Indian health programs also appears to be
important. The authors point out that "\...although UIHOs are the
primary health care venue for urban American Indians/Alaska Natives, who
represent 60% of the nationwide AIAN population, IHS allocations for
these organizations represent 1% of the total IHS budget." They call for
urgently needed leadership "to refocus and unify the system into a more
cohesive and coherent national health care initiative" to address a
"fragmented and decentralized" urban AI/AN health system.

Finally, data collection on urban AI/AN populations is problematic.
Difficulties exist due to racial misclassification and a lack of a
formal mechanism to track urban AI/AN health statistics and
demographics. The authors suggest that the adoption of standardized
racial classification schemes would help to more accurately track the
needs of this underserved population. Further research in a number of
areas, of course, is needed.

**Editorial Comment**

Relatively few studies exist documenting the health status of urban
AI/ANs, even though as many as 60% of the Native American population
nationwide reside in urban areas. The results of the current study
mirror findings from other studies of urban AI/AN children, some of
which are listed below. The plight of the urban Indian is an important
issue, only made worse by the apparent continuing migration of AI/AN
people to urban centers and the continued dissolution of funding for
AI/AN health programs. Achieving the goal of eliminating health
disparities by the year 2010 as set forth in *Healthy People 2010* is
appearing more and more of an impossibility to this writer. What do you
think?

**Additional Reading**

Perinatal and infant health among rural and urban American
Indians/Alaska Natives.\
*Am J Public Health.* 2002 Sep;92(9):1491-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12197982&query_hl=5&itool=pubmed_docsum>

Disparities in infant health among American Indians and Alaska natives
in US metropolitan areas. *Pediatrics*. 2002 Apr;109(4):627-33.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11927707&query_hl=5&itool=pubmed_docsum>

Health status of urban American Indians and Alaska Natives. A
population-based study. *JAMA*. 1994 Mar 16;271(11):845-50.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8114239&query_hl=5&itool=pubmed_docsum>

Measuring disparity among American Indians and Alaska Natives; who\'s
counting whom? *Med Care.* 2003;41(5):579-81.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12719680&query_hl=65&itool=pubmed_DocSum>