4/15/04njm

*"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@tcimic.ihs.gov

IHS Child Health Notes

May 2004

# Quote of the month

*"It's not always easy to know what to do"*"

Sam Spade in *"The Maltese Falcon"*

# Articles of Interest -- Routine Tests in Bronchiolitis

1.Concurrent serious bacterial infections in 2396 infants and children
hospitalized with respiratory syncytial virus lower respiratory tract
infections.\
Arch Pediatr Adolesc Med. 2002 Apr;156(4):322-4.

[www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11929363](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11929363)

-Reviewed records over 7 respiratory seasons

-No positive CSF cultures

-12 positive blood cultures but all were contaminants

-1% had positive urine cultures

2\. Concurrent serious bacterial infections in 912 infants and children
hospitalized for treatment of respiratory syncyttial virus lower
respiratory tract infection

The Pediatric Infectious Disease Journal: Volume 23(3) March 2004 pp
267-269

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15014307>

-   Same author as in study #1 but now 900 more patients with
    bronchiolitis from 2000-2002

-   No positive CSF cultures, 3 positive blood cultures (0.4% ) but 10%
    positive urine cultures

-   No infants under 90 days with positive blood or CSF cultures

3\. Diagnosis and testing in bronchiolitis: a systematic review.\
Arch Pediatr Adolesc Med. 2004 Feb;158(2):119-26.
[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14757603&itool=iconabstr](../www.ncbi.nlm.nih.gov/entrez/query.fcgi%3Fcmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14757603&itool=iconabstr)

-   Rapid RSV testing is accurate but does not change treatment

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-   CXR cannot reliably distinguish between viral and bacterial disease

-   CBC counts did not affect treatment or distinguish viral from
    bacterial disease

# Editorial Comment

Never has so much testing been done to so many with so little benefit as
in bronchiolitis. Articles #1 and #2 confirm what many have suspected.
If you have a clinical presentation of bronchiolitis with rhinorrhea and
wheezing your risk of having a serious bacterial illness is almost zero.
The presence of fever, even in an infant \< 3 months does not mean CSF
and blood cultures need to be obtained if the child looks well and has
symptoms consistent with bronchiolitis. Interestingly, the studies had
wildly varying results for urinary tract infections from 1% to 10%.
Other studies reviewed have confirmed the low, low risk of meningitis or
sepsis in bronchiolitis and most have had positive urine cultures in the
1-5% range which is probably consistent with asymptomatic bactiuria
rates in females.

Similarly, study #3 shows that the frequent use or RSV tests, CBC counts
and chest x-rays adds nothing to diagnosis or therapy in clinical
bronchiolitis.

A reasonable approach is to recognize that the presence of wheezing in a
young child in winter is most consistent with bronchiolitis. Routine
sepsis work-up is not needed in a febrile infant with bronchiolitis \< 3
months unless they appear unusually ill. A chest x- ray is not needed
unless there is a concern about atelectasis. Routine CBC counts are not
needed. If any test should be done it might be a urinalysis recognizing
that positive results may represent the background asymptomatic
bactiuria rate in females. Rapid RSV testing is not needed unless it
will stop you from giving unneeded antibiotics.

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

Health service access, use, and insurance coverage among American
Indians/Alaska Natives and Whites: what role does the Indian Health
Service play?\
Am J Public Health. 2004 Jan;94(1):53-9.
[www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14713698&itool=iconabstr](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14713698&itool=iconabstr)

# Federal funding does not cover all services needed for AI/AN but shows that AI/AN had better measure of preventive care and access to care than other impoverished populations

Delivering equitable care: comparing preventive services in Manitoba.\
Am J Public Health. 2003 Dec;93(12):2086-92.
[www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14652339&itool=iconabstr](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14652339&itool=iconabstr)

-   Compared services for which there were established programs
    (immnunizations and mammography) against cervical cancer screening
    for which there is not an established program. Established programs
    showed excellent numbers across all socio-economic and ethnic
    groups. Programs that were not established had much less success in
    poorer groups and Native American. This study demonstrates that it
    is not enough to know that something is a standard -- a program
    needs to be in place to insure the standard is met.

Rheumatic disease in Native American children: opportunities and
challenge.\
Curr Rheumatol Rep. 2003 Dec;5(6):471-6. Review.
[www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14609493&itool=iconabstr](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14609493&itool=iconabstr)

-   Rheumatic diseases occur at 5-7 times the rate in Native Americans
    in the midwest as compared to caucasian populations. The authors
    work with tribes in the northern Great Plains suggests that some of
    this increase may be familial and related to founder effects.
    Something to keep an eye out for in all AI/AN. Is this increase in
    pediatric rheumatic illnesses seen in other tribal areas?

# Meetings of Interest for Child Health

## [Adolescent Health Issues in Indian Health]{.underline}

School Based Health: Donna Perry, Susie John, and others

Adolescent Issues: Steve Holve and Donna Perry

...plus Sexually Transmitted Diseases, Contraception, and more....

These are all available at the Biennial IHS Tribal and Urban (ITU)
Meeting on Women's Health and Maternity Care, August 4-6, 2004 in
Albuquerque, NM.

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#August2004>

Or contact Neil Murphy, MD for info at [nmurphy@anmc.org]{.underline}