*"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

May 2006

# Quote of the month

*"It ain't what people don't know that's so dangerous, it's what people
know that just ain't so."*

Will Rogers\*

\*Editor's Note -- Yes, this was also the quote last month, but it is so
good, and so germane to this month's reviewed articles, that I am using
it again.

**Articles of Interest**

Controlled delivery of high vs. low humidity vs. mist therapy for croup
in emergency departments: a randomized controlled trial.\
JAMA. 2006 Mar 15;295(11):1274-80.

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

-   Humidified air doesn't improve croup scores -- end of story

**Editorial Comment**

Everyone knew that humidity improves croup -- especially your
grandmother. Humidity has long been used as a treatment for croup: from
boiling kettles and sitting in the shower at home to blow-by humidity
and mist tents in hospital. Mild croup often waxes and wanes
spontaneously. Telling parents to go in the shower or turn on the
humidifier gave pediatricians something to say and parents something to
do while waiting spontaneous improvement to occur.

The authors of this study are taking away our placebo.

They gave humidity every chance to succeed: they even optimized water
particle size so that water vapor would reach the subglottic space,
something that regular humidified air doesn't do. All for naught.
Humidified air provided no statistical or clinical improvement. The
authors also point out that there is some downside to humidity,
especially croup tents, which make it difficult to monitor ill children.
The authors do recommend proven treatments such as steroids and inhaled
epinephrine.

**Article of Interest**

Fluoroquinolone use in children.\
Pediatr Infect Dis J. 2006 Mar;25(3):257-8.

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

-   Quinolones have been associated with cartilage damage in beagle pups

-   Babies are not beagles but most physicians were reluctant to use
    this class of antibiotics in children despite their proven efficacy

-   A review of multiple studies with thousands of children shows no
    link in humans between quinolones and joint injury.

**Editorial Comments**

For years they told us that beagle pups got cartilage damage from
quinolone antibiotics and that no baby could be guaranteed joint safety.

This review highlights the effectiveness of this class of antibiotics
and possible pediatric uses. The authors suggest that there are
instances in which quinolones may be the best antibiotic for your
patient: *Pseudomonas* infections, complicated otitis media, resistant
gram negative infections and multi-drug resistant meningitis.

**Infectious Disease Updates**.

Rosalyn Singleton, MD, MPH

**Which Hib Vaccine?**

Invasive *Haemophilus influenzae* type B (Hib) disease occurred at a
higher rate and younger ages in many American Indian/Alaska Native
populations before Hib vaccine. Now Hib vaccine has led to
near-elimination of Hib disease in the United States, but there are
lessons to remember.

Because of the high risk of Hib disease within the first 6 months of
life, the AAP Redbook Committee recommended that the first dose of Hib
vaccine be given as PRP-OMP (PedvaxHIB®, Merck Inc.) PedvaxHIB® results
in rapid seroconversion to protective antibody concentrations after the
first dose. After the first dose of Hib vaccine any brand of Hib vaccine
may be administered. To avoid the confusion, and to minimize the number
of vaccinations, it may be easiest to use PevaxHIB to complete a series
of 3 injections. While most IHS and tribal sites are using PedvaxHib®
routinely, there are some sites that use ActHib®. If you are one of
these sites, you can contact your state about switching to PedvaxHib®.
If you encounter problems, contact Amy Groom, IHS Immunization
Coordinator at <Amy.Groom@ihs.gov>.

What has happened to Hib disease rates in indigenous children? Hib
disease has plummeted in Alaska Natives from 309 to 5.6/100,000; however
this rate still looks higher than the current U.S. rate of
0.2/100,000.0. A similar rate (6.7/100,000) has been reported in
Australian aboriginal children.

Bottom line: The rate of Hib disease in AI/AN children is now very low
and the numbers of cases in AI/AN children are very small. PedvaxHIB®
offers the best protection against Hib disease -- especially for the
first dose.

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

Doug Esposito, MD, MPH

**[Article]{.underline}**

A controlled, household-randomized, open-label trial of the effect that
treatment of *Helicobacter pylori* infection has on iron deficiency in
children in rural Alaska. *J Infect Dis*. 2006 Feb 15;193(4):537-46.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16425133&query_hl=2&itool=pubmed_docsum>

**Summary**

Last month, I reviewed a paper reporting an association between iron
deficiency and active *H. pylori* infection in school-age Yupik children
residing in western Alaska
(\<<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN406.doc>\>).
The following paper reports the outcome of the treatment arm of that
study, and seeks to determine if treatment of *H. pylori* infection is a
useful intervention for pediatric iron deficiency in this and other
populations.

The authors conducted a controlled, household-randomized, open-label
trial of treatment of *H. pylori* infection in those children previously
found to be iron deficient. The control group received a 6 week course
of iron sulfate therapy, while the intervention group received an
identical course of iron sulfate plus a 2-week course of triple *H.
pylori* therapy. Re-evaluation of iron status and *H. pylori* infection
via urea breath testing occurred at 2, 8, and 14 month intervals. Those
children in the treatment group still found to be infected at the 2
month interval received a 2-week course of quadruple *H. pylori*
therapy.

There was no statistically significant improvement in iron deficiency
with treatment and successful resolution of *H. pylori* infection in the
population studied. The authors contend that, at this time, "a strategy
of testing for and treating *H. pylori* infection in patients with
isolated iron deficiency or mild anemia may not be appropriate in this
and other disadvantaged populations worldwide\..." The authors point out
that their study was designed to determine the effect of treatment or
resolution of *H. pylori* infection on iron deficiency, not necessarily
whether *H. pylori* infection was causal of iron deficiency (please see
my review of the subject last month), though such a relationship of
causality might actually be present. Additionally, their study did not
carry sufficient statistical power to uncover small effects, or
differences between subgroups of study participants. Of course, further
study is recommended.

**Editorial Comment**

It is commendable that this negative-effect study was published. As many
of you know, studies reporting a positive-effect are published with much
greater frequency than those reporting a negative or neutral-effect
(known as positive-outcome or publication bias). This unfortunate
reality creates an overall prejudice in the published literature, which
must be recognized when critically reviewing a subject. It is not that
these negative-effects are not uncovered. It is simply that such studies
are just not submitted or accepted for publication as frequently as
their positive counterparts, resulting in a less robust body of data on
a subject than otherwise might be available.

That there was no statistical effect found in the current study calls
into question the whole notion that treatment for *H. pylori* infection
will improve iron status in co-affected individuals. There are a number
of studies out there reporting such an effect, but most of these studies
are either small or methodologically flawed in some significant way. In
a recent personal communication with Dr. Baggett, one of the authors of
the Alaska study, he suggests: "I think it\'s worth reading the paper,
because I don\'t think negative results in this study disprove an
association\--just suggests that treating the Hp in school-age children
may not improve the iron deficiency."

For me, this and other published articles on *Helicobacter pylori*
reveal how little we know about this organism and its pathophysiology,
diagnosis, and treatment in children. The clinical conundrum it presents
is significant, and considerably frustrating. Hopefully, as more and
more carefully designed studies are conducted and reported, we will be
able to develop rational and effective protocols for identifying and
treating *H. pylori* infection and its sequelae in our pediatric
patients, especially in those kids presenting with abdominal pain or
unexplained or unsuspected iron deficiency.

**Previously Reviewed Article**

Endemic iron deficiency associated with *Helicobacter pylori* infection
among school-aged children in Alaska. *Pediatrics*. 2006
Mar;117(3):e396-404. Epub 2006 Feb 1.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16452320&query_hl=9&itool=pubmed_DocSum>

**[Article]{.underline}**

Effect of a National Vaccine Shortage on Vaccine Coverage for American
Indian/Alaska Native Children. *Am J Public Health*. 2006
Apr;96(4):697-701.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16507733&query_hl=5&itool=pubmed_docsum>

**Summary**

In 2001-2002, the US experienced a shortage in 5 of the 8 vaccinations
routinely recommended for children, including DTaP, varicella, MMR,
pneumococcal conjugate, and Td vaccines. Studies have shown that
regional and private versus public sector variability in access to and
coverage of DTaP occurred during this shortage. It has been recommended
that such inequities be remedied.

The authors of this article used the robust vaccine reporting system
present in IHS to investigate disparities in coverage of AI/AN children
with DTaP 4 (the fourth in the recommended 5 dose series) as a result of
the national shortage. They found that among children covered in the IHS
immunization reports, there was a 14.8% overall decline in receipt of
DTaP 4 as compared to a 1.8% decline for the general US population and a
6% decline for children receiving their immunizations from public
clinics. Interestingly, they identified a surprisingly wide variability
in declining immunization rates when IHS was stratified by region (4.5%
in Alaska to 26.5 % in the Southwest).

The authors suggest that the inequities in vaccine distribution
identified specifically for IHS parallel the findings from other studies
of the US population in general. There appeared to be a maldistribution
of vaccine to rural areas, public clinics, and the southern United
States during the period time of vaccine shortage. They suggest further
evaluation of the vaccine distribution system and that more equitable
distribution procedures and practices need to be implemented on a
national, state, tribal, and local level.

**Editorial Comment**

I believe the results of this study speak for themselves. In the US,
there exists a well characterized inequity in distribution of
therapeutic and preventive medical resources. This situation is in
desperate need of attention. The only question that remains is whether
we as a society and a nation have the will to do what desperately needs
to be done?

**[Article]{.underline}**

Improving Access to Health Care Among New Zealand\'s Maori Population.
*Am J Public Health*. 2006 Apr;96(4):612-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16507721&query_hl=1&itool=pubmed_docsum>

**Editorial Comment**

The similarities between the plight of the Maori and that of North
American indigenous populations are striking. Statistical trends and the
ever widening disparities in health status appear to have parallel
roots. "In particular, it has been argued that the continuing
disparities in health between Maoris and non-Maoris represent evidence
that Maori health rights are not being protected as guaranteed under the
treaty and that social, cultural, economic, and political factors cannot
be overlooked in terms of their contribution to the health status of
this group." Sound familiar?

This is an article worth reading for those who wish to examine
cross-national parallels of health disparities and socio-economic
struggles of native populations worldwide (or aboriginals, as the
British Commonwealth countries are fond of saying).

.