*"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

July 2008

# Quote of the month

*"If you rest, you rust.*"

Helen Hayes

**Article of Interest**

Cardiovascular Monitoring of Children and Adolescents with Heart Disease

Receiving Medications for Attention Deficit/Hyperactivity Disorder: A
Scientific

Statement from the American Heart Association Council on Cardiovascular
Disease in the Young Congenital Cardiac Defects Committee and the
Council on Cardiovascular Nursing

*Circulation* 2008;117;2407-2423; originally published online Apr 21,
2008;

[[http://circ.ahajournals.org/cgi/content/full/CIRCULATIONAHA.107.189473/DC1]{.underline}](http://circ.ahajournals.org/cgi/content/full/CIRCULATIONAHA.107.189473/DC1)

**Cardiovascular Monitoring and Stimulant Drugs for Attention-Deficit
Hyperactivity Disorder - Policy Statement of the American Academy of
Pediatrics**

Published online on May 28, 2008

<http://www.aap.org/new/ecg-adhd.htm>

**American Academy of Pediatrics/American Heart Association
Clarification of Statement on Cardiovascular Evaluation and Monitoring
of Children and Adolescents with Heart Disease Receiving Medications for
ADHD**

Published online on June 3, 2008

<http://americanheart.mediaroom.com/index.php?s=43&item=422>

In late April the American Heart Association (AHA) released new
guidelines for children receiving stimulant medication for Attention
Deficit Hyperactivity Disorder (ADHD) The AHA recommended that all
children beginning treatment with stimulant medications, and those
already on stimulant medication, should have an electrocardiogram (ECG)
to search for occult heart disease that could place them at increased
risk for sudden cardiac death. This recommendation caused anxiety in
many parents and frustration in many psychiatrists and pediatricians.

The AHA recommendation has significant procedural and financial
implications. It is estimated that 2.5 million children are receiving
stimulant medication now. Obtaining an ECG on each one would entail
significant costs. For some patients a further barrier was the
suggestion that the ECG should be reviewed by a practitioner experienced
in reading pediatric ECG. This would limit the reading of these studies
to pediatric cardiologists and a small subset of pediatricians.

Within a month the American Academy of Pediatrics (AAP) fired back. The
AAP published its own policy statement on stimulants and ADHD on May 28,
2008. Highlights included.

-   Sudden Cardiac Death (SCD) in persons taking medications for ADHD is
    a rare event occurring at rates no higher than in the general
    population of children and adolescents

-   Stimulant medication can cause mild elevations of blood pressure and
    heart rate but there is no evidence they increase the risk of SCD

-   There is no evidence that the routine use of ECG screening before
    beginning medication for ADHD treatment would prevent SCD.

-   Substantial evidence exists concerning the efficacy and safety of
    ADHD treatment with stimulant medications.

-   Requiring an ECG before stimulant treatment could create a barrier
    to timely therapy. Limiting children's access to effective treatment
    for ADHD could have serious implications, because there are
    substantial risks of not treating ADHD.

The AAP recommended that the cardiac evaluation of children taking
stimulant medication should not change from their previous policy in
2000. The recommendations were as follows:

1\. The AAP continues to recommend a careful assessment of all children,
including those

starting stimulants, using a targeted cardiac history (e.g., patient
history of previously

detected cardiac disease, palpitations, syncope, or seizures; a family
history of sudden

death in children or young adults; hypertrophic cardiomyopathy; long QT
syndrome) and

a physical examination, including a careful cardiac examination.

2\. Given current evidence, the AAP encourages primary care and
subspecialty physicians to continue currently recommended treatment for
ADHD, including stimulant medications, without obtaining routine ECGs or
routine subspecialty cardiology evaluations for most children before
starting therapy with these medications.

To resolve confusion between the two professional societies the AAP and
AHA issued a joint statement on June 3, 2008. The relevant portion is
listed below:

-   Obtaining a patient and family health history and doing a physical
    exam focused on cardiovascular disease risk factors are recommended
    by the AAP and AHA for assessing patients before treatment with
    drugs for ADHD.

-   It is reasonable for a physician to consider obtaining an ECG as
    part of the evaluation of children being considered for stimulant
    drug therapy, but this should be at the physician's judgment, and it
    is not mandatory to obtain one.

-   Treatment of a patient with ADHD should not be withheld because an
    ECG is not done

**Editorial Comment**

The AAP statement of May 28, 2008 is reasonable guidelines that
practitioners should embrace. Patients should be screened by history for
potential cardiac risk factors and have a physical exam that focuses on
cardiovascular system. Patients with known or suspected heart disease
may need an ECG and further specialty evaluation.

**Infectious Disease Updates**.

Rosalyn Singleton, MD

**Teen Vaccines: How are we doing?**

Since 2005, three new vaccines have been licensed and recommended
specifically for teens: Tdap, HPV and meningococcal conjugate vaccine.

-   Tdap -- for 11-18 year olds with [\>]{.underline}5 years since last
    Td vaccine,

-   HPV -- 3 doses for 9-26 year old females

-   Meningococcal conjugate (Menactra®, MCV4) -- for 11-18 year olds

CDC published the first estimates of national vaccination coverage among
teens aged 13-17 years in U.S.-2006 in Aug. 2007
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5634a3.htm>

Among 13-17 year olds, 10.8% had received 1 dose of Tdap and 60.1% had
received 1 dose of Td or Tdap since age 10 years; 11% had received
meningococcal vaccine. According to recent CDC data, 23% of females aged
13-17 years had received 1+ doses of HPV vaccine.

Indian Health Service started reporting Adolescent Immunization rates
for American Indian and Alaska Native adolescents 13-17 years of age
from IHS/contract facilities in 12/31/07. Adolescent coverage data from
12/31/07 and 3/31/08 are presented here:

![](media/image1.wmf){width="5.001388888888889in" height="3.74375in"}

Comments: The initial Indian Health Service adolescent vaccine coverage
rates for new vaccines compare favorably with national coverage rates;
however, the national rates reflect an earlier time period. These rates
reflect a robust delivery system; however, it will be challenging to
administer 2^nd^ and 3^rd^ doses in a timely manner to teens. Providers
can pull up lists of teens due for their 2^nd^ or 3^rd^ HPV doses in the
RPMS Immunization Package by running a list of girls who have "received
HPV vaccine" and are "due for HPV vaccine".

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

Michael L. Bartholomew, MD

Murphy TV, Syed SB, Holman RC, Haberling DL, Singleton RJ, Steiner CA,
Paisano EL, Cheek JE. Pertussis-Associated Hospitalizations in American
Indian and Alaska Native Infants. *J Pediatr*. 2008;152:839-43.

<http://www.ncbi.nlm.nih.gov/pubmed/18492528?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum>

Before the introduction of the pertussis vaccine in the 1940s, the US
incidence of pertussis was approximately 150 cases per 100,000
population or roughly 175,000 cases per year^1^. By the 1980-90's the
incidence declined to approximately 1 case per 100,000 population. Since
1980, the incidence of pertussis has steadily increased. Waning immunity
in the adolescent and adult populations are felt to be contributing
factors to this increase^2^.

This study investigates the burden of pertussis in American Indian and
Alaska Native (AI/AN) infants from 1980 to 2004 and 2000 to 2004 through
the analysis of discharge/hospitalization data from the Indian Health
Service (IHS)/Tribal health care system. Infant pertussis
hospitalizations were examined by sex, age group (infants less than 6
months and 6-11 months) and IHS region (Northern Plains, Southern
Plains, Southwest, and Alaska). Rates of infant pertussis
hospitalizations for 2000-2004 were compared to the pertussis
hospitalizations of the general U.S. infant population in 2003.

In IHS, there were 483 infant pertussis hospitalizations between 1980
and 2004. This equals an annual pertussis hospitalization rate of 132.7
per 100,000 AI/AN infants (95% CI = 121.3 to 145.2). The highest numbers
of hospitalizations were in infants less than 6 months of age (427
hospitalizations); equaling a rate of 234.5 per 100,000 infants. Rates
in males and females were similar by age. The Southwest region had the
highest rate (187.9 per 100,000) of pertussis hospitalizations as
compared to Alaska (92.0), Northern Plains (103.3) and the Southern
Plains (87.8).

In comparison, the average annual pertussis hospitalization rate for
AI/AN between 2000 and 2004 was higher than the 2003 general US infant
population pertussis hospitalization rate (100.5 vs. 67.7).
Additionally, Alaska (156.9) and Southwest (130.9) regions had higher
hospitalization rates than the Northern (59.1) and Southern (59.2)
Plains during the same time period.

The authors concluded that the burden of pertussis is greatest in AI/AN
infants less than 6 months of age predominantly those residing in the
Southwest and Alaska regions. Despite levels of immunization rates equal
or slightly less than the general population, environmental and social
influences likely contribute to the higher disease burden in the AI/AN
population; similar to what is seen with respiratory syncytial virus
infections in Alaska Native infants^3^. Prevention of pertussis by
timely administration of DTaP at 6 to 8 weeks of age and promotion of
Tdap vaccination in adults and adolescents are strongly encouraged.

Reference:

1.  Centers for Disease Control and Prevention.
    <http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/pert.pdf>

2.  American Academy of Pediatrics. Pertussis. In: Pickering LK, Baker
    CJ, Long SS, McMillan JA, eds. *Red Book: 2006 Report of the
    Committee on Infectious Diseases.* 27^th^ ed. Elk Grove Village, IL:
    American Academy of Pediatrics; 2006:498-520.

3.  Holman RC, Curns AT, Cheek JE, Bresee JS, Singleton RJ, Carver K,
    Anderson LJ. Respiratory syncytial virus hospitalizations among
    American Indian and Alaska Native infants and the general United
    States infant population. *Pediatrics* 2004 Oct;114(4):e437-44.