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

Deng Hsaio P'ing

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 steve.holve@tchealth.org

IHS Child Health Notes

May 2008

# Quote of the month

*"If you are late, you are a thief of my time.*"

Anonymous

**Articles of Interest**

Identification and Evaluation of Children with Autism Spectrum
Disorders. *Pediatrics* 120: 5; 1183-1213 November 2007

Management of Children with Autism Spectrum Disorders. *Pediatrics*
120:5; 1161-1182 November 2007

These two clinical reports published in *Pediatrics* in November 2007
provide a complete summary for the clinician on autism spectrum
disorders (ASDs). This month's review will highlight the first article
that covers identification and evaluation of children with autism
spectrum disorders. The review next month will describe management
strategies.

The authors emphasize that ASDs are not rare. The most recent
epidemiology shows that 1/150 children in Europe and North America have
an ASD, which is a 10-fold increase in the past few decades. Much debate
has focused on whether the increased diagnosis of ASDs represents a true
increase in disease and how this may relate to immunizations, especially
the MMR vaccine and mercury containing vaccines.

Good evidence show that the increase in diagnosis is due to expanded
diagnostic criteria and diagnostic "substitution". The disease category
of autism also now includes Asperger syndrome and pervasive development
disorder-not otherwise specified making the disease now a spectrum
disorder with a much broader range of presentations. Secondly, many
children who were previously given a diagnosis of "mental retardation"
or "emotional disturbance" and even "speech impairment" are now more
appropriately place in the ASD.

There is an excellent discussion on etiology. The evidence for/against
vaccines as a potential cause of ASDs is reviewed. Often overlooked is
that 10% of ASD are part of identified medical conditions such as
fragile X, Down Syndrome, phenylketonuria and FAS. The heritable nature
of ASD is emphasized in that there is a 5-6% recurrence risk of ASD in
subsequent siblings.

Primary care providers are the key to identifying patients with ASD at
an early age. The value of ongoing surveillance for delays in speech or
emotional connectedness is reviewed. Screening using an ASD specific
screening tool is recommended at ages 18-24 months and for any child in
whom the diagnosis is entertained. If the diagnosis of ASD is felt
likely then referral to a specialist who works with ASD is suggested
along with enrollment in an early intervention program.

**Editor's Note**

This one article summarizes the literature of ASD for clinicians and
supplies an algorithm for surveillance and screening that is
straightforward. ASD is surprisingly common and it is our job to
identify those children who may benefit from early intervention and
structured programs at school. For many of us in remote, rural
communities the first problem is how to obtain specialty consultation to
confirm a diagnosis. The second and more formidable barrier to be
discussed next month is how to find treatment services.

**Infectious Disease Updates**.

Rosalyn Singleton, MD, MPH

Vaccine Safety Concerns: The Price of Vaccine Success?

The Vaccine Court under the National Vaccine Injury Compensation Program
recently awarded made a judgment in favor of parents of a child with
autism. This has occurred despite the fact that HRSA and CDC and the AAP
and Institute of Medicine have all reviewed the scientific information
concerning the allegation that vaccines cause autism and have found no
credible evidence to support the claim. Paul Offit offered perspective
on how the court could make this award on behalf of a child with autism
and an underlying mitochondrial disorder.

**Opinion: Inoculated Against Facts**\
**By Paul A. Offit**, **Infectious Disease**, **Children's Hosp
Philadelphia**\
***New York Times*** **March 31, 2008**\
<http://www.nytimes.com/2008/03/31/opinion/31offit.html?_r=1&oref=slogin>

When the vaccine court was established in 1986 a preponderance of
scientific evidence was required for compensation. Because no one could
sue vaccine makers without going through this special court, the number
of lawsuits against vaccine makers fell drastically. The system worked
fine until a few years ago, when vaccine court judges turned their back
on science by dropping preponderance of evidence as a standard. Now,
petitioners need merely propose a biologically plausible mechanism by
which a vaccine might cause harm --- even if their explanation
contradicts published studies. In 2000, when Hannah was 19 months old,
she received five shots against nine infectious diseases. Over the next
several months, she developed symptoms of autism. Subsequent tests
showed that Hannah has a mitochondrial disorder and this contributed to
her autism. An expert who testified in court on the Polings' behalf
claimed that the five vaccines had stressed Hannah's already weakened
cells, worsening her disorder. Without holding a hearing on the matter,
the court conceded that the claim was biologically plausible.

"There is no evidence that children with mitochondrial enzyme
deficiencies are worsened by vaccines," Salvatore DiMauro, a professor
of neurology at Columbia who is the nation's leading expert on the
disorder, told me. Indeed, children like Hannah Poling who are
especially susceptible to infections are most likely to benefit from
vaccines.

The vaccine court should return to the preponderance-of-evidence
standard. But much damage has already been done by the Poling decision.
Parents may now worry about vaccinating their children, more autism
research money may be steered toward vaccines and away from more
promising leads and, if similar awards are made in state courts,
pharmaceutical companies may abandon vaccines for American children.

Below are some additional links for more information on vaccine safety:

<http://www.cdc.gov/vaccinesafety/concerns/thimerosal.htm>

<http://www.immunize.org/safety>

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

Michael L. Bartholomew, MD

Letourneau RJ, Crump CE, Bowling JM, Kuklinski DM, Allen CW. Ride Safe:
A child Passenger Safety Program for American Indian/Alaska Native
Children. *Maternal and Child Health Journal* 2008 Mar 14. \[Epub ahead
of print\]

<http://www.ncbi.nlm.nih.gov/pubmed/18340516?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum>

The motor vehicle related death rate in AI/AN children is nearly 2 ½
times higher than the overall US rate. Data from the 2002 National
Highway Traffic Safety Administration (NHTSA) show that almost 40% of
children under 5 who died in car crashes were unrestrained. Less is
known about the use of child safety restraints in AI/AN populations
though available information suggests very low rates of restraint use in
AI/AN infants and children.

In January 2008, the NHTSA released *Child Restraint Use in
2007-Demographic Results^1^.* Their analysis indicates that the US child
restraint use for children less than 12 months of age was estimated at
98%, while children aged 1-3 years was 96%. For children aged 4-7 years,
the estimated restraint use was 85%. Interestingly, the NHTSA grouped
AI/AN into an "Other-Non-Hispanic" demographic along with Native
Hawaiian and Pacific Islander due to insufficient numbers. The 2007
NHTSA child restraint use estimates for "Other Non-Hispanic" for
infants, children 1-3 years, and children 4-7 years were 100%, 95% and
87% respectively. It is painfully apparent that these results do not
reflect the child restraint use in Indian Country and is largely
misleading.

This new study attempts to define rates of restraint use among AI/AN
children before and after implementation of a car safety seat
educational intervention program. The program called Ride Safe is an
evidenced-based injury prevention program designed to increase child
safety seat use in children ages 3-5 years who are enrolled in 14
different AI/AN Head Start Programs.

Fourteen AI/AN Head Start sites in six different states implemented Ride
Safe over four academic school years. The Ride Safe program included
education of Head Start staff, and parents, distribution and
installation of child safety seats, child safety seat certification
training, and study training and support. Results show that initially
Ride Safe was an effective intervention. After implementation of the
Ride Safe Program, children were 2 to 3 times more likely to be observed
in a child safety seat. Unfortunately this increase was not sustained
over the length of the intervention. Additionally, the rate of child
safety seat use ranged from 29.8% to 70.8%, with an overall car seat use
rate of 47.5%. This rate is "far below" the 2006 NHTSA published car
seat use rates for infants and children.

Despite the lack of sustainability, the Ride Safe program did produce
some positive outcomes. During the study period, 2,916 car seats were
provided. 78 Head Start staff obtained child passenger safety seat
certification training and 1,744 parents/family members and 358 Head
Start staff participated in educational sessions. Parental reasons for
not using child safety seats became known, thus allowing for program
improvement by focusing on these areas.

Reference:

1.  Glassbrenner, D., & Ye, T. Child Restraint Use in 2007-Demographic
    Results. Traffic Safety Facts Research Note DOT HS 810 897, National
    Highway Traffic Safety Administration, National Center for
    Statistics and Analysis {online} January 2008