**MATERNAL CHILD HEALTH UPDATES: JANUARY 2000. #1**

Cliff O'Callahan, MD, PhD, the MCH guy. Puyallup Tribal Health Authority

253-593 0232 x478. Fax593 3311.

**[INTRO:]{.underline}** Hello to all, and I hope you had a very happy
Holiday season! I am the newly ordained regional MCH contact. The
position is not funded so I won't have the ability to visit you all or
invest too much time, but I thought that if I jot down some of the info
that comes across my desk that is pertinent to us in Indian country, and
disseminate it on a periodic basis, it might be helpful. To improve the
communication sharing I would be willing to receive and include in this
newsletter ideas and stories of experiences and programs that you think
would be helpful to other NW Native clinics.

I would hope that as local MCH coordinators you could further spread the
info from these newsletters to the other providers. I feel that the
communication and sharing between us could be a valuable way for us to
improve our services.

**[1) SIDS:]{.underline}** I trust that we are all teaching new parents
to place their children to sleep on their backs or sides and avoiding
thick fluffy material in the crib or bed. That's the essence of the Back
to Sleep program. There's been a lot in the Peds press about this topic:
the most relevant for us is Dr Dee Robertson's article in MMWR where he
demonstrated that the Infant Mortality and the SIDS rate for Native
babies in OR, ID, and WA has decreased phenomenally since 1985 to where
it is almost at the non-Native rates now. This can be found at
[[http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/00056637.htm]{.underline}](http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/00056637.htm)
and summarized by:

**[GROUP 1985-88 1993-96]{.underline}**

Native Infant Mortality 20 7.7 per 1000 live-born births

Non-Native Infant Mort 9.6 6.3

Native SIDS 8.9 3.0

Non-Native SIDS 2.5 1.4

MMWR also published info in October 48(39);878-882 1999 showing that in
13 states Native moms had decreased their tendency to place infants on
their belly by 23.0 - 42.5%. The Amer Acad of Pediatrics has also been
active: the Committee on Injury published a statement in Oct 1999 on
safe transportation of newborns at hospital discharge. An article in the
May issue of Pediatrics discussed that the leading cause of injury
deaths for infants under 12 months was due to suffocation caused by
beds, bedding, pillows, plastic bags, or co-sleeping with folks.

Our challenge is to decrease these trends by having Community Health
Nurses, clinic nurses, and providers all remind parents about infant
placement, the pros and cons of co-sleeping, avoiding co-sleeping on
couches and soft surfaces, etc. If we have input at hospitals where our
families deliver, ask them to review and implement the AAP policy (Child
Death Review work has revealed SIDS/suffocation deaths in infant seats
improperly installed at more than a 45% angle so that the infants head
flops over and chokes).

**[2). Immunizations:]{.underline}** The AAP Committee on Native
American Child Health (CONACH) published a statement in the September
issue of Pediatrics 104(3)564-567, 1999. All immunization coordinators
should have a copy! Recommendations summarized:

**a)** The preferred **first** **[HIB shot]{.underline}** given is
PRP-OMP *Haem* conjugate (PEDVAX HIB) because it has much higher
seroconversion rates. Important because Native infants tend to get
invasive disease earlier and more often. Subsequent doses can be with
any kind. Unfortunately, we take what the Health Dept gives us.

On Dr Efflers suggestion, I contacted Steve MacNally, the vaccine
purchaser for the State of WA. He knows of the recommendations but the
price of vaccines is the major driver of decisions: PedVaxHib is very
expensive despite its three dose schedule. He is not convinced that
there is a significantly higher rate of invasive Hib disease in young
Native children.

**b)** Make **[Hep A]{.underline}** a routine vaccination at 2 years
WCC. We do get this free from Health Dept as a Native-oriented site and
have been doing this. Mr MacNally reports that WA state is trying to get
money to provide it for ALL children in the State.

**c) [Hep B]{.underline}** for all! Many sites have been holding off on
Hep B with thimersol until infants are 6 months, unless mom has
hepatitis. The *mercury-free* stuff is here so lets start catch up!!

**d)** **[Pneumococcal 23-valent polysaccharide]{.underline}** vaccine,
single dose, at 2 yrs age for children 2-4 years old in areas of risk
for invasive pnuemococcal disease. Each unit will have to determine that
from their experience in clinic and hospital.

**e)** Combine **[HIB and Hep B]{.underline}** if possible to decrease
number of shots. Regardless, a recent article in Archives Peds 153, Dec
1999, reported that parents overwhelmingly complied with provider
recommendations for multiple shots.

**[3). Unintentional Injury:]{.underline}**

The Amer Acad Peds Committee on Native American Child Health recently
came out with a review of *"The Prevention of Unintentional Injury Among
American Indian and Alaska Native Children" in Pediatrics
104(6),1397-1399, 99.* Highlights:

Of the 700,000 Native children 0-18 yrs, the mortality rate of 52.3
deaths/100k /yr between 1992-94 was almost twice the US rate!

Fatality rates for Native children in:

motor vehicle occupant injuries is 3 times higher

pedestrian-motor vehicle collision deaths is 4 times higher

drowning is 2 times higher

fire and burn injury is 2.8 times higher

They make some nice observations and recommendations (one of which is
NOT to compare rates between Native and Non-Native\...I just did the
above to get your attention!).

An article in *Injury Prevention 1999;5:119-123, "Injury
Hospitalizations among American Indian Youth in Washington"* is also
interesting. Traffic related injuries and death are very high: risks
including rural driving, alcohol, and no seat belt use. Fire and flame
injuries were disproportionally high. Rates for **in**tentional injuries
(self inflicted) and assaults were higher than State; most strikingly
higher in areas of general assaults, child maltreatment, and firearms.

A paper in *Pediatrics 104;4:878-884, 1999* demonstrates that there is a
significant association linking violence exposure, lack of parental
monitoring, and television-viewing habits with elementary and middle
school children's self reported violent behaviors.

For **all** American Indians and Alaskan Natives from 1-24 years old
between 1994-1996, Unintentional Injury, Motor Vehicle, and Homicide
were in the ***first four*** leading causes of death, and Suicide was
the other once they reached 10 years old.

The conclusion from all of this is that we all need to be aware of these
facts, communicate them to our colleagues and Tribal Councils, and work
in unison to somehow address issues of violence reduction, improved car
restraint/pedestrian laws, smoke detector prevalence, and suicide. One
of the ways that we can become aware of our particular risks in a region
is by sitting on the Child Death Review Board for the county or region.
Sometime soon the EpiCenter at the NPAIHB will be able to give us much
more accurate region or tribe specific rates of illness or injury or
death by using the Tribal Registry Project.

I am writing a letter to the Tribal Police thanking them for their
wonderful work and encouraging them to further stress the importance of
infant, toddler, booster seats and belts, bike helmet use etc as they
drive about! I'll let you know how that goes!!

**4). School-Based STD testing:**

I'd like to bring up something that is pertinent to our urban clinic and
you will have to determine if it is a problem in your region. We have
been seeing a lot of teenage STDs, most especially chlamydia. Medical
and Community Health staff have always been involved in hepling do the
sexuality/HIV/STD/contraception discussions in the middle and high
school. Last school year, with the help of the NPAIHB's Stop Chlamydia!
Project, we also provided free urine chlamydia screens at school and
clinic. Only about 30 students at school and 17 at clinic took us up on
it, but it is a powerful technique (no painful urethral swab or need to
convince a teen to get a pelvic) that I think can be helpful to those of
us working with our teens.

A recent paper in *Pediatrics 104;6:1281-, 1999* describes a great
strategy for educating and testing students repeatedly in school that
seems to have some impact. The disadvantage of the test is its
price\...but the long term costs of PID, infertility, tubal pregnancies
etc might outweigh the initial lab cost. Francine Romero, PhD is the
Stop Chlamydia! person (503) 228 4185.

**5). Lice!!!:**

I'm sure none our your sites have a problem with lice, but just for your
info!\...

They have proven that many lice are now resistant to permethrins.
Malathion has been resurrected to combat the critters. The alcohol base
may sting and it's reported to be stinky (and flammable!), but very
effective.

We are trying to push using a home-made LiceOut. Pharmacy buys
lubricating jelly (Surgell) in gallon containers and repackages it,
although they are looking into bulk buying LiceOut. Generous amounts in
the hair suffocate some adults (?) and it is easier to comb out the
nits - but one really needs a metal comb. Department of Social and
Health Services (DSHS) will now reimburse \$12.71 for a metal comb under
"nit comb=non durable medical equipment" code 0172A, and at 65% for the
lice goop under "antiseptic - non durable equipment" code of 0158A.

NEXT TIME: Antibiotic resistance and Abx, Fluoride, corneal abrasions,
mental health access?