*"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 2008

# Quote of the month

*"For every complex problem there is an answer that is clear, simple,
and wrong"*

H. L. Mencken

**Articles of Interest**

Symptom profile of common colds in school-aged children.

Pediatr Infect Dis J. 2008 Jan;27(1):8-11.

Effect of honey, dextromethorphan, and no treatment on nocturnal cough
and sleep quality for coughing children and their parents.

Arch Pediatr Adolesc Med. 2007 Dec;161(12):1140-6.

**Article Comment**

The past few weeks we have been swamped in pediatric clinic with fever,
cough and runny nose. Parents' first concern is, "does my child have
pneumonia?" When my answer is "no" (which it is most of the time) the
next question is, "how long will he/she be sick?" The first article
above tries to answer that question for school aged children.

Healthy school-aged children were screened as part of a study on the
effects of viral URI on middle ear pressure. Nasal aspirates were
obtained; about half of the patients had rhinovirus recovered.
Approximately 1/3 had pathogenic bacteria such as *Moraxella* or
*Haemophilus* species. The authors gave families preprinted sheets
listing common signs and symptoms of colds.

Not surprisingly, cough and congestion were the most common symptoms.
Fever usually resolved by 4 to 5 days. What was noteworthy was that most
(73%) of patients still had some symptoms after 10 days of which 40%
still had cough. A previous study of children ages 0-3 years with colds
suggested a mean duration of symptoms of 7 days. Previous studies in
adults suggested that cold symptoms resolved by 10 days

Parents frequently return to clinic with healthy children zooming around
the exam room but concerned that their child is still coughing after 4
or 5 days of illness. This study is helpful in counseling parents about
the expected duration of cold symptoms in their children.

The second article suggests that honey may be the answer to cough and
the common cold. Investigators compared honey to dextromethorphan and
placebo and found it superior in cough suppression and improvement in
sleep quality. Possible mechanisms of action for honey to reduce cough
include antioxidant and antimicrobial effects or it may be as simple as
honey's demulcent properties. Given the recent FDA warning on cough
medications for children under age 5 years there is a cough treatment
vacuum waiting to be filled. Look for this study to be repeated to see
if the results hold up.

**Editor's Note**

Below is the last review by Dr. Doug Esposito. After a 13 year
distinguished career in clinical pediatrics in the Indian Health
Service, Doug is joining the CDC in the Epidemiological Investigation
Service. Our loss is their gain.

My hope is that at the completion of his epidemiology training he will
return to Indian Health Service. I suspect he will continue to worry,
argue, fuss and be cranky at the CDC in the same beneficial way he has
done so in Fort Defiance, Anchorage, and on these pages. Most physicians
as they mature get middle-aged, boring and predictable. Doug has
remained enthusiastic and committed about improving AI/AN health and we
and his patients are the beneficiaries of his passion.

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

Douglas Esposito,MD, MPH

**[Article]{.underline}**

[Singleton RJ, Bruden D, Bulkow
LR.](http://www.ncbi.nlm.nih.gov/pubmed/18090200?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum)
Respiratory syncytial virus season and hospitalizations in the Alaskan
Yukon-Kuskokwim Delta. *Pediatr Infect Dis J*. 2007 Nov;26(11
Suppl):S46-50.

<http://www.ncbi.nlm.nih.gov/pubmed/18090200?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum>

**Editorial Comment**

By the time you read this, it is likely that those of us working with
AI/AN kids in the lower 48 will be emerging from the depths of a pretty
rotten RSV year. How about a collective sigh of relief\...OK, everybody
together\...Whew!

Unfortunately, if history is any indication, our snow-bound colleagues
in Alaska will still be holding their breaths. They are likely to be in
the *thick* of things\...continuing to battle against RSV bronchiolitis
and thick nasal secretions for at least another couple of months! In
fact, they might not even have seen the worst of it yet!!

This report, authored by our own Ros Singleton, looks at RSV
hospitalization rates for Alaska's Y-K Delta population, assesses the
risk factors associated with RSV-related hospitalizations there,
identifies the impact of Synagis prophylaxis on high-risk Y-K Delta
infants, and documents the prolonged annual RSV season in Alaska that
simply makes me shudder (for those of you who are unaware, I was a
pediatric hospitalist at the Alaska Native Medical Center in Anchorage
for four years, and just barely made it out alive!).

Here are a few important points made in this report:

1\. The RSV hospitalization rate for Y-K Delta infants is
[five]{.underline} [times]{.underline} the rate of the general U.S.
population.

2\. The RSV season is prolonged in Alaska, with the median onset and
median offset (mid-October and late-May, respectively) being well
outside the range seen in the lower 48 (late November to late March or
early April). In fact, the median RSV season in Alaska is twice as long
as that experienced in the lower 48 (31 weeks vs. 15 weeks), with around
13% of the yearly RSV hospitalizations occurring in summer (June through
September).

3\. The median peak RSV season in Alaska occurs in late February, but
ranges from mid-December to early-May.

4\. Crowding, lack of running water and flush toilets, lack of breast
feeding, tobacco smoke exposure, and underlying medical conditions were
associated with RSV hospitalization in the Y-K Delta. Wouldn't you know
it, overcrowding and smoking rates are high and access to running water
and flush toilets low in Yup'ik Eskimo villages.

This paper expertly documents the rationale behind altering the Synagis
protocol in Alaska as compared to standard practice in the lower 48.
Additionally, factors leading to the high rates of RSV-associated
hospitalization seen in kids living in the Y-K Delta region and what
might be done to address this disparity are explored. Thanks, Ros, for
the critical insight!

**A Final Word:**

I began as a regular contributor to the *IHS Child Health Notes* back in
September, 2005. Now, after subjecting you all to more than two
and-a-half years of liberal ranting and nonstop pleas for health equity
and the elimination of health disparities among the populations we are
privileged to serve, I will be passing on the torch to two very
competent and dedicated pediatrician colleagues and friends. So, please
welcome Drs. Michael and Margaret Bartholomew to next month's *Notes*. I
know that the two of them will offer excellent reviews of superior
insight and objectivity, and perhaps even grammatical correctness and
literary appeal. With two of them splitting the job, it should be twice
as good, right?

Back in September 2005, Dr. Holve introduced me to you all with the
expectation that I would "add knowledge and breadth, and possibly wit,
to these pages." I cannot say that I have performed as billed, but I can
say that writing these notes has been fun, rewarding, and enlightening.
I am grateful for the opportunity to have been able to critically
explore the growing body of literature related to AI/AN child health in
a manner and depth that I otherwise would not have endeavored to do.

The progress that has been achieved over recent decades related to
health status gains for Native American populations has been staggering.
And, compared to other races and ethnicities in the U.S., the velocity
and magnitude of this change has no equal. This, I am convinced, is
testament to the amazing dedication and talent of you; the many
wonderful individuals and groups working in partnership with Native
American communities toward a common, necessary, and noble goal.

But, there is of course some bad news. Forward progress has stalled
recently, with health disparities persisting and in some cases, sadly
widening. The quest to achieve true health equity for Native Americans
sometimes seems impossibly distant, with so much remaining to be done.

So, I say to all of you, please continue your wonderful work and thank
you for the amazing things you do each and every day. It all truly
matters.