*"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

September 2006

# Quote of the month

*"Never eat more than you can lift"*

Miss Piggy

**Articles of Interest**

Intake of sugar-sweetened beverages and weight gain: a systematic
review.\
Am J Clin Nutr. 2006 Aug;84(2):274-88.

<http://www.ajcn.org/cgi/content/full/84/2/274>

The authors reviewed English language articles from 1966 -- 2005 on the
relationship of consumption of sugar sweetened beverages and the risk of
weight gain. Findings from large cross-sectional studies with long
periods of follow-up show a positive association with greater intake of
sugar sweetened beverages and weight gain in both children and adults.
Short- term feeding trials in adults also support an induction of
positive energy balance and weight gain with sugar sweetened sodas. The
authors believe the weight of epidemiological and experimental evidence
supports the need for public health strategies to discourage consumption
of sugary drinks.

Obesity\--the new frontier of public health law.\
N Engl J Med. 2006 Jun 15;354(24):2601-10.

<http://content.nejm.org/cgi/content/extract/354/24/2601>

The law can be a powerful instrument of public health. The authors
mention decreased lead exposure, improved workplace safety, the mandate
of seatbelts and airbags and even increased immunization rates as the
result of legislation and litigation. One of the newest targets of
public health law is obesity.

Increased regulation or taxing of food raises issues about the
appropriate balance between personal freedoms and the potential public
health benefits. The authors do an excellent job of pointing out that
such regulations were rejected in the past. They go on to show that
restrictions on food advertising now are far more likely to be accepted
given the documented increase in obesity. Various pending legislation
and litigation around food advertising, distribution and taxation are
discussed.

**Editorial Comment**

These two articles complement one another: Identification of a problem
and a set of possible solutions. Beyond one-on-one counseling of
patients (which appears to be fairly ineffective) what public health
strategies involving courts or legislatures might work? An interesting
angle is that tribes are sovereign nations and have the power to set
their own laws and taxes. A Navajo Nation tax on soda pop? A Hopi Nation
tax on any soda \> 12 ounces? An Apache ban Twinkies®? Or would this
lead to bootlegging of Big Gulps® and Twinkies®? There are lots of
intriguing possibilities. Read the articles and dream.

**Infectious Disease Updates**.

Rosalyn Singleton, MD, MPH

 

**Outpatient visits associated with otitis media and Tympanostomy tube
placement among young American Indian and Alaska Native children in the
age of Pneumococcal conjugate vaccine.**

**Rosalyn J. Singleton, Robert C. Holman, Krista L. Yorita, James E.
Cheek,**

Outpatient visit rates with otitis media (OM) and with tympanostomy (PE)
tube placement were evaluated in American Indian and Alaska Native
(AI/AN) children.

*Methods.* Records for all outpatient visits with OM listed as one of
the diagnoses and with myringotomy and insertion of tube listed as a
procedure for AI/AN children \<5 years of age were obtained from the
Indian Health Service National Patient Information Reporting system for
2000-2004. Rates for OM visits were obtained for the general population
of US children by using the National Ambulatory Medical Care Survey.

*Results.* Outpatient visit rates associated with otitis media for AI/AN
children \<5 years old (97/100/year) in 2000-2004 were less than those
previously reported for 1994-1996^1^ (138); however, the rate remained
higher than that for the US population in 2000-2004 (71, 95% confidence
interval 64-77). The OM visits rate for AI/AN infants \<1 year of age
(204) were more than twice as high as that for US infants (93). The OM
visit rate in AI/AN children varied by region, and was highest for the
Alaska region (157 for children \< 5 years of age) and lowest for the
Oregon and Washington Areas (76 for children \< 5 years of age). . The
PE tube placement rate for AI/AN children \<5 years of age also varied
by region; the rate was highest for the Alaska region (23/1,000/year)
and low (0.5 to 2.2) for each of the other regions.

*Comment*: The OM outpatient visit rate in AI/AN children, as well the
rate for the general population of US children, has decreased since
routine Pneumococcal conjugate vaccination. The rate of OM and PE tube
placement for AI/AN children varied widely by region; the PE tube
placement rate may be affected by the OM rates, as well as availability
of and referrals to otolaryngologists.

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:e41

*Special thanks to Bob Holman, statistician from CDC Division of Viral
and Rickettsial Disease, Atlanta, GA.*

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

Doug Esposito, MD

**[Article of Interest]{.underline}**

Cancer in 15- to 29-year-olds by primary site. *Oncologist*. 2006
Jun;11(6):590-601.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=16794238&query_hl=11&itool=pubmed_DocSum>

**Summary**

This report represents an adaptation of a larger, more detailed 205 page
document (<http://seer.cancer.gov/publications/aya/>). According to the
authors, this is the first report detailing cancer epidemiology
specifically in the 15-29 year-old age group.

Cancer incidence and survival rates reported by the authors derive from
data collected through the Surveillance, Epidemiology, and End Result
(SEER) program of the National Cancer Institute. Population estimates
are from U.S. Census data. SEER collects data on all invasive
malignancies occurring in defined geographic areas. Although these areas
represent a relatively small portion of the entire U.S. population
(approximately 13%), they are chosen to be representative of the nation
as a whole with regard to ethnic/racial make-up. The data is then
generalized to the rest of the country. Mortality rates are derived from
analysis of data provided by the CDC's National Center for Health
Statistics (NCHS). A more detailed description of the statistical
manipulations of the data is beyond the scope of this review. For a full
description of methods, the interested reader should refer to the full
monograph referenced above.

Cancer in the 15-29 year-old population comprises only 2% of all
malignancies in the U.S. An estimated 21,400 cancer diagnoses occurred
in the year 2000 in this age group. By way of comparison, only 0.75% of
all malignancies occur prior to age 15. Due to the fact that cancer
incidence increases exponentially with age, half of all cancers in the
15-29 year age group actually occur in 25-29 year-olds. SEER reports
cancer incidence to be lowest for AI/ANs at all ages, and highest for
non-Hispanic whites in the first 40 years. African Americans/blacks have
the highest cancer incidence over age 40.

The distribution of cancer type in the 15-29 year-old age group is
unique and changes over time so that the distribution of cancer type
seen at age 15 years is very different from that seen by age 30. The
five most frequent invasive malignancies in 15-29 year-olds are
lymphomas (20%), invasive skin cancers (15%, with 76% of these being
melanoma), male genital system cancers (11%), endocrine system cancers
(11%, with 96% of these being thyroid), and female genital system
cancers (9%). These cancers account for 66% of all malignancies in this
age group. CNS cancers and leukemias account for only 6% each.
Significant gender differences exist. For females, genital system
cancers account for 18%, while lymphomas and thyroid cancers account for
17% each, melanoma 15%, and breast cancer 7% of all malignancies
(representing 74% of all female cancers in this age group). For males,
genital system cancers account for 22%, lymphomas 21%, melanoma 17%, CNS
cancers 8%, and leukemias 8% (representing 76% of all male malignancies
in this age group).

Perhaps of more interest to us pediatricians, for 15-19 year-olds, the
five most frequent malignancies are lymphomas (26%), leukemias (12%),
CNS cancers (10%), endocrine system cancers (9%, with 87% of these being
thyroid), and invasive skin cancers (8%, with 84% of these being
melanoma). These five account for 65% of all malignancies in this age
group.

Cancer incidence increased in all age groups younger than 45 years
between 1975 and 2000. However, it appears that this rise has leveled
off for 15-24 year-olds, with a decrease in incidence for 25-29
year-olds over the last five years.

With regard to mortality, the authors conclude that age-dependent cancer
death rates generally reflect the incidence profile; i.e. the more
patients diagnosed with cancer the higher the expected death rate. As
such, Native Americans are reported to have the lowest death rate from
cancer for all age groups. Trends in mortality have been positive over
time. Between 1975 and 2000, mortality due to invasive cancers has
declined in all age groups younger than 45 years. However, the rate of
reduction in mortality for African Americans/blacks was reported to be
significantly lower than the reduction observed in other racial groups.

The authors report cancer survival to be best for non-Hispanic whites
and worst for African Americans/blacks in the 15-29 year-old age group.
AI/ANs had intermediate survival rates. However, AI/ANs had a more rapid
death rate in the first two years following diagnosis than non-Hispanic
whites, Hispanics, and Asians/Pacific Islanders. This high death rate in
the first two years following diagnosis was then followed by a unique
and unexplained plateau or leveling off not seen in any other ethnic or
racial group. During the 1990s, 15-29 year-old AI/ANs experienced more
than twice the death rate of non-Hispanic whites. For the age group \<15
years, AI/AN survival was worse than any other ethnic/racial group until
approximately 3.5 years after diagnosis, at which point the survival
rate met and subsequently paralleled the rate for African
Americans/blacks. Overall, AI/ANs appear to experience the second worst
cancer survival rates below 45 years of age.

Progress toward improving 1 and 5 year survival rates for 15-29 year-old
cancer patients over time has occurred, but only fractionally as
compared to older and younger age groups. Males faired far worse than
females overall.

Finally, the authors contend that the patterns and trends observed in
cancer incidence suggest the sporadic nature of cancer in 15-29 year
olds: "In general, there are relatively scant data to support either an
environmental causation or an inherited predisposition to cancer in this
age group. The vast majority of cases of cancer diagnosed before age 30
appear to be spontaneous and unrelated to either carcinogens in the
environment or family cancer syndromes."

**Editorial Comment**

Fortunately, invasive malignancies are relatively rare in the pediatric
age group. That being said, they are obviously among the most
devastating set of conditions for our patients and their families. This
report affords a valuable perspective on cancer epidemiology in young
adults.

The authors report incidence rates for invasive malignancies among 15-29
year-old AI/ANs to be the lowest of any ethnic/racial group. On the one
hand, that American Indian/Native Alaska young adults as a group seem to
be somehow protected from malignancy is encouraging. However, I don't
buy it! It is well known and has been amply reported that racial
misclassification occurs frequently among individuals of AI/AN heritage.
This racial misclassification often results in an underestimate of
disease burden. The methods employed by the authors of this report are
highly susceptible to such errors in racial classification. In fact,
SEER data and other disease registries have been extensively criticized
on this point. Additional inaccuracies arise when trying to lump
together a highly diverse ethnic/racial group such as AI/AN.

This report also suggests that AI/AN groups tend to have worse cancer
survival as compared to other ethnic/racial categories. True disparities
in cancer survival for AI/AN populations do appear to exist, and have
been reported in a number of studies employing a variety of research
methodologies. I cannot definitively say that I understand the exact
cause of these disparities, but I would wager a guess that it has
something to do with the source of most of the health disparities
afflicting vulnerable populations the world over: socially imposed
inequities and injustices in exposure and in access to resources. And
so, the struggle continues.

**Additional Reading**

Measuring the health status gap for American Indians/Alaska Natives:
getting closer to the truth. *Am J Public Health*. 2005
May;95(5):838-43.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15855463&query_hl=14&itool=pubmed_DocSum>

Childhood cancer among Alaska Natives. *Pediatrics*. 2003
Nov;112(5):e396.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=14595083&query_hl=23&itool=pubmed_docsum>

Improving American Indian Cancer Data in the Washington State Cancer
Registry using linkages with the Indian Health Service and Tribal
Records. *Cancer*. 1996 Oct 1;78(7 Suppl):1564-8.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=8839571>

# Announcements from the AAP Indian Health Special Interest Group 

Sunnah Kim, MS

**AAP Committee on Native American Child Health Receives Contribution**

The AAP Committee on Native American Child Health (CONACH) recently
received notification of a financial contribution from the estate of
Demaree Low Jackson. Little is known about Ms Jackson, other than the
fact that she was born in Nevada, and that her father worked very hard
on behalf of Native American populations in Nevada many years ago,
particularly related to education for children.

The CONACH will receive approximately \$100,000 from Ms Jackson's
estate. Members of the CONACH will be meeting in September 2006 to
discuss plans for utilizing these funds. The CONACH hopes to maximize
these funds to make a significant impact on the health of American
Indian and Alaskan Native (AI/AN) children.

We welcome your suggestions on programs that could be set up by the
CONACH. Please submit your ideas to <indianhealth@aap.org>.

**Your Opinion Matters!**

We are very interested in hearing your opinions about the Indian Health
Special Interest Group. Please take a moment to complete a brief on-line
survey: <http://www.surveymonkey.com/s.asp?u=339182157349>

We greatly appreciate your help and hope to hear from you soon!