*"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

October 2006

# Quote of the month

*"He has never been known to use a word that might send a reader to a
dictionary"*

William Faulkner (about Ernest Hemingway)

**Articles of Interest**

Early prednisone therapy in Henoch-Schonlein purpura: a randomized,
double-blind, placebo-controlled trial. JPediatr. 2006 Aug;149(2):241-7.

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

The authors report a randomized, double-blind, placebo-controlled trial
of prednisone in the treatment of Henoch-Schonlein Purpura (HSP). They
excluded patients who had hematuria or proteinuria at presentation.
Patients received prednisone (1 mg/kg/day for 2 weeks with weaning over
the following 2 weeks. Patients who received prednisone had reduction of
intensity of abdominal and joint pain. Prednisone did not prevent the
development of hematuria or proteinuria but abnormal urinalyses resolved
in 61% of the treated patients compared to 34% of the placebo patients.
There was no difference in the small number of treated versus untreated
patients who developed severe nephritis that required renal biopsy.

**Editorial Comment**

To paraphrase Homer Simpson's description of the power of donuts;
"Steroids, is there nothing they can't do." The longstanding debate on
steroid use in HSP has been hampered by the relative infrequency of the
condition. Assembling a patient series of adequate size for a placebo
controlled trial is an achievement in itself. Prednisone appears to
decrease abdominal and joint pain and was associated with more prompt
resolution of hematuria and proteinuria. Unfortunately, prednisone did
not decrease the small number of patients who developed severe
nephritis. Since this is the major sequelae of HSP this is very
disappointing. Bottom line: Steroids could be prescribed for HSP for
symptomatic relief but is not likely to affect long term renal outlook.

Physician documentation of neonatal risk assessment for perinatal
infections.\
J Pediatr. 2006 Aug;149(2):265-7.

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

The author looked at documentation on the newborn record of maternal
status of hepatitis B, syphilis, *Chlamydia* and group B streptococcus.
Over half of the infants lacked documentation in their charts though for
most this included negative reports of hepatitis B, syphilis and
Chlamydia. The author speculated that many physicians know the test is
negative and do not feel the need to record negative findings in the
chart. However, 5% of the positive GBS results and 1% of positive
*Chlamydia* results were not documented in the infant's chart suggesting
that this information was overlooked. The author suggests that nurseries
need to establish systematic processes to ensure that information from
the mother's record is transferred to the physician caring for the
infant.

**Editorial Comment**

*Res ipsa loquitur* *.* (It speaks for itself).

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

Douglas Esposito,MD, MPH

**[Article]{.underline}**

The Alaska *Haemophilus influenzae* type b experience: lessons in
controlling a vaccine-preventable disease. *Pediatrics*. 2006
Aug;118(2):e421-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16882783&query_hl=1&itool=pubmed_docsum>

The Arctic Investigations Program of the CDC has been conducting
surveillance of invasive *Haemophilus influenzae* in Alaska since 1980.
This data, combined with U.S. census data from 1980, 1990, and 2000 were
used to calculate Hib infection rates in children \< 10 years of age.
Case rates from before and after implementation of universal Hib
vaccination are compared. Data from vaccination registries, case
reviews, and previously conducted Hib carriage studies in Alaska were
also analyzed for this report.

Drum roll please! Since implementation of the universal Hib vaccination
campaign in 1991, an estimated 479 cases of invasive Hib disease have
been prevented in Alaska Native children less than five years of age.
Average annual attack rates for that age group fell from 309.4 cases per
100,000 population pre-vaccine to just 5.4 cases per 100,000 population
in 2001-2004; a decrease of over 98%! Please refer directly to this
important article for a complete and valuable discussion of all the
results. The bottom line is that the Hib vaccination campaign represents
one of the most successful and important vaccination initiatives in U.S.
history.

**Editorial Comment**

Thanks to the incredible efforts that lead to the development and broad
distribution of the Hib vaccine, in my eleven-plus years as a
pediatrician, I never encountered a case of invasive Hib until just a
couple of years ago. Today, it\'s a wonderfully rare occurrence! Having
now observed first-hand the ravages of this disease, I hope never to see
it again, and due to this particular success story, I likely never will!
Hats off to our own Rosalyn Singleton and the CDC Arctic Investigations
Program for chronicling the benefits of Hib vaccine for the Alaska
Native population!

Thanks also for demonstrating that, despite a dramatic decrease in
incidence, Alaska Native populations still suffer much higher rates of
this terrible disease than does the general Alaska and U.S. population.
As stated conspicuously in the last line of the abstract and in the last
two lines of the report: \"Household crowding, poverty, unemployment,
and lack of indoor plumbing\...are each more prevalent among rural
Alaska Native persons than persons living in urban Alaska. Equity in
disease rates may not be achieved in indigenous populations with the
current vaccines unless other factors contributing to disease
transmission are addressed.\" For minority populations living in the
U.S., observed health disparities are inextricably interwoven within
socioeconomic disadvantage and racial prejudice. For those of you who
are regular readers of my reviews, you get the picture!

**Additional Reading**

Experience with the prevention of invasive *Haemophilus influenzae* type
b disease by vaccination in Alaska: the impact of persistent
oropharyngeal carriage. *J Pediatr.* 2000 Sep;137(3):313-20.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=10969253&query_hl=4&itool=pubmed_docsum>

**[Article]{.underline}**

QuickStats: infant mortality rates, by maternal
race/ethnicity\-\--United States, 1995 and 2003. *MMWR Morb Mortal Wkly
Rep*. 2006 Jun 23;55(24):673-6.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5524a6.htm?s_cid=mm5524a6_e>

**Editorial Comment**

Click on the link and review! Infant mortality (death in individuals \<1
year per 1,000 live births) for American Indian/Alaska Native mothers
ranks second highest in the U.S., surpassed only by the rate for
non-Hispanic blacks. The infant mortality rate for non-Hispanic blacks
in 2003 was 13.61, followed by the AI/AN rate of 8.73.  This compares
poorly to the overall U.S. rate of 6.84." instead of "The infant
mortality rate for non-Hispanic blacks in 2003 was 14.65, followed by
the AI/AN rate of 9.04.  This compares poorly to the overall U.S. rate
of 7.57. In 1998, the U.S., one of the richest nations on the planet,
ranked 28^th^ among industrialized nations in infant mortality according
to the March of Dimes
(<http://www.marchofdimes.com/files/international_rankings_1998.pdf>).
International comparison of infant mortality is controversial, and
reporting bias probably does contribute some to the observed
differences. However, few experts would argue that we don't have a real
problem here at home. In fact, it would appear that uniquely American
styles of socioeconomic disparities, racism, and unequal access to care
and supportive services contribute to our poor international showing.
Will we ever be able to effectively eliminate these deplorable and
embarrassing disparities?

For a more thorough presentation of the infant mortality data in the
U.S. for 2003, please refer to the first citation below. The last two
citations will be interesting to anyone wanting to learn more about our
international infant mortality ranking.

**Additional Reading**

Infant mortality statistics from the 2003 period linked birth/infant
death data set. *Natl Vital Stat Rep*. 2006 May 3;54(16):1-29.

Infant Mortality and Income in 4 World Cities: New York, London, Paris,
and Tokyo. *Am J Public Health*, 2005 Jan;95(1):86-90.

<http://www.ajph.org/cgi/content/abstract/95/1/86>

Comparing international infant mortality rates. *CMAJ*. 2000 Sep
5;163(5):497-8.

<http://www.cmaj.ca/cgi/reprint/163/5/497>