*"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

March 2009

# Quote of the month

*"*A drug is a substance that when injected into a guinea pig produces a
scientific paper."

Anonymous*.*

**Article of Interest**

**Quality of Care for Common Pediatric Respiratory Illnesses in United
States Emergency Departments: Analysis of 2005 National Hospital
Ambulatory Medical Care Survey Data**

Jane F. Knapp, Stephen D. Simon, and Vidya Sharma

Pediatrics 2008; 122: 1165-1170.

<http://pediatrics.aappublications.org/cgi/reprint/122/6/1165>

The goal of this paper was to measure US emergency department care of
pediatric asthma, bronchiolitis and croup as there are clear "best
practices" for each of these conditions.

Physicians prescribed steroids in only 69% of the patients with
moderate-severe asthma and only 31% of croup visits. Physicians ordered
chest radiographs in 72% of children with bronchiolitis visits and
prescribed antibiotics for 53% of children diagnosed with bronchiolitis.

The authors conclude that physicians treating children with asthma,
bronchiolitis and croup are under using known effective treatments and
overusing ineffective therapeutic and diagnostic treatments.

Editors Comments:

Surprisingly, despite well-publicized guidelines for these common
respiratory illnesses physicians still fail to meet best practices
almost half the time. What accounts for the gap between guidelines and
the bedside? This study reminds us that we need to place the more effort
on making sure the simplest things are done correctly.

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

Michael L. Bartholomew, MD

Singleton RJ, Holman RC, Plant R, Yorita KL, Holve S, Paisano EL, Cheek
JE. Trends in otitis media and myringtomy with tube placement among
American Indian/Alaska native children and the US general population of
children. *The Pediatric Infectious Disease Journal*. 2009
Feb;28(2):102-7.

<http://www.ncbi.nlm.nih.gov/pubmed/19131901?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum>

Otitis media continues to be a prevalent disease affecting children
within the United States. Prior to the introduction of 7-valent
pneumococcal conjugate vaccine (PCV7), estimates of OM visits accounted
for over 24 million visits annually with surgical intervention ranging
from 1-7% of affected children.^1,2,3^ Post licensure surveillance
studies of PCV7 have shown a reduction of OM visits and myringotomy with
insertion of tubes (MIT) procedures ^2,3,4^. With limited data on the
occurrence of OM and MIT among American Indian/Alaska Native children
since the introduction of PCV7, the authors explored the recent
epidemiology and burden of OM and MIT procedures among AI/AN children
less than 5 years of age between 2003-2005.

For 2003-2005, the OM-associated outpatient visit rate for AI/AN
children less than 5 years of age was higher (89 per 100 children/year)
than the general US population of 62.7 per 100 children/year. This rate
represents a decrease from previous reported rates for AI/AN children in
1994-1996 (138 per 100 children/year)^1^. Regionally, Alaska had the
highest OM-associated outpatient visit rate; followed by the Northern
Plains, Southwest, and West regions. Additionally, the Alaska region was
the only region to show an increase in OM outpatient visit rate from
previous reported years of 1994-1996 (158 to181 per 100 children per
year). Each IHS region had higher rates than the general US population.
AI/AN infants accounted for approximately 33% of OM-associated
outpatient visits and had a higher rate than AI/AN children ages 1-4
years. OM-associated outpatient visit rates for AI/AN infants were
double that of the US general infant population.

AI/AN children also had a higher annual OM-associated hospitalization
rate than the US child general population in 2003 (675 vs. 617 per
100,000) The majority of outpatient MIT procedures occurring at
IHS/Tribal facilities occurred in the Alaska region. The AI/AN rate for
outpatient MIT procedure was higher in the Alaska region (2.6 per
100/year) than any other IHS region and the general US population (1.8
per 100/year).

This study is not without limitations. The 10-fold difference in MIT
procedure rates for Alaska and the remainder of the IHS regions may be a
result of direct access to surgical interventions in Alaska (Otitis
Media Project in Alaska) or MIT procedures being preformed at
non-IHS/tribal facilities in other IHS regions. The AI/AN population
(active IHS/Tribal user population) used is an estimate and is not
representative of all AI/AN children in the United States.

OM continues to be a significant cause of morbidity among AI/AN
children. Despite decreases in OM-associated outpatient visits,
OM-associated hospitalizations, and MIT procedures among American Indian
populations in other IHS regions, Alaska region demonstrates an increase
in OM associated morbidity among Alaska Native children. The authors
conclude that these findings may suggest a decreased impact of PCV7 on
non-invasive *Streptococcus pneumoniae* infections in Alaska Native
children and the need for expanded-valency pneumococcal conjugate
vaccine in this population.

References:

1.  Curns AT, Holman RC, Shay DK, et al. Outpatient and hospital visits
    associated with otitis media among American Indian and Alaska Native
    children younger than 5 years. *Pediatrics* 2002;109(3)e41.

2.  Zhou F, Shefer A, Kong Y, Nuorti JP. Trends in acute otitis
    media-related health care utilization by privately insured young
    children in the United States, 1997-2004. *Pediatrics*. 2008
    Feb;121(2):253-60.

3.  Grijalva CG, Poehling KA, Nuorti JP, Zhu Y, Martin SW, Edwards KM,
    Griffin MR. National impact of universal childhood immunization with
    pneumococcal conjugate vaccine on outpatient medical care visits in
    the United States. *Pediatrics*. 2006 Sep;118(3):865-73.

4.  Poehling KA, Szilagyi PG, Grijalva CG, Martin SW, LaFleur B, Mitchel
    E, Barth RD, Nuorti JP, Griffin MR. Reduction of frequent otitis
    media and pressure-equalizing tube insertions in children after
    introduction of pneumococcal conjugate vaccine. *Pediatrics*. 2007
    Apr;119(4):707-15.