*"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

February 2009

# Quote of the month

*"A house uncleaned is better than a life unlived."*

Rebecca West

# Articles of Interest

# Paracetamol (acetaminophen) plus ibuprofen for the treatment of fever in children (PITCH): randomized controlled trial BMJ 2008;337:a1302 <http://www.bmj.com/cgi/content/abstract/337/sep02_2/a1302>

**Goals** The goal of this English study was to investigate whether
paracetamol (acetaminophen) plus ibuprofen are superior to either drug
alone for increasing time without fever. Participants were children
between 6 months and 6 years of age with axillary temperatures of at
least 37.8°C and up to 41.0°C. The primary outcomes were the time
without fever in the first four hours after the first dose was given and
the proportion of children reported as being normal on the discomfort
scale at 48 hours. Secondary outcomes were time to first occurrence of
normal temperature, time without fever over 24 hours, and adverse
effects.

**Results** Paracetamol plus ibuprofen were superior to paracetamol for
less time with fever in the first four hours (55 more fever free
minutes) but no better than ibuprofen alone. For less time with fever
over 24 hours, paracetamol plus ibuprofen were superior to paracetamol
alone and to ibuprofen alone (4.4 hours and 2.5 hours longer,
respectively). Combined therapy cleared fever 23 minutes faster than
paracetamol alone but no faster than ibuprofen alone. No difference was
found between the three therapies for discomfort or other symptoms.
Adverse effects did not differ between groups.

**Conclusion** Parents, nurses, pharmacists, and doctors wanting to use
medicines to maximize the time that children spend without fever should
use ibuprofen first and consider the relative benefits and risks of
using paracetamol plus ibuprofen over 24 hours.

**Editorial Comment**

The greatest rivalries never have a definitive conclusion. Think of
Pepsi® versus Coke® or Bud lite® versus Miller lite®. Tylenol ® and
Motrin® used to belong in that group but there is increasing evidence
that ibuprofen is a superior agent for fever reduction with faster onset
of action and longer relief of fever.

Clinicians may still prefer Tylenol® because of familiarity and its
overall excellent safety profile. However, ibuprofen does seem to
perform better with fever reduction and might be the better first choice
with acetaminophen to be added if needed. Which ever agent is used
clinicians do need to give explicit instructions on dosage and frequency
of administration. In this trial, in which standardized instructions
under research conditions were given, over 10% of children still
received extra doses of medication.

**Editorial Comment**

**Infectious Disease Updates**.

Rosalyn Singleton, MD

**2009 Immunization Schedule: What's new?**

Happy New Year! There are only minor changes in the 2009 Immunization
Schedule:

-   Rotavirus: change in maximum age for the first dose (14 weeks 6
    days)

-   Routine annual influenza vaccination is now recommended for all
    children 6 months through 18 years.

    -   *School-aged children typically have the highest rates of
        infection and are a major source of transmission during
        community outbreaks. Data from school-based programs show
        decreased school absences and flu-like illness with vaccine.*

-   A shorter interval than 5 years may be used Td and Tdap for persons
    aged 10-18 years "when pertussis immunity is needed"

    -   *They leave it up to the provider to determine if pertussis
        immunity is needed. There is data on intervals between Td and
        Tdap as short as 18 months without unacceptable increase in side
        effects.*

-   Hib vaccine is not contraindicated among persons 5 years and older
    at increased risk for invasive Hib disease.

-   Catch-up vaccination with HPV vaccine is clarified. Second and third
    doses should be administered 2 months and 6 months after first dose
    (minimum intervals still 4 weeks between dose 1 and 2 and 12 weeks
    between dose 2 and 3) even when doing catch-up in older teens. Third
    dose should be given at least 24 weeks after first dose.

> Find the new schedule on-line at:
>
> <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5751a5.htm?s_cid=mm5751a5_e>

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

Michael L. Bartholomew, MD

Forster JL, Brokenleg I, Rhodes KL, Lamont GR, Poupart J. Cigarette
Smoking Among American Indian Youth in Minneapolis-St. Paul. *American
Journal of Preventative Medicine*. 2008;35(6S):S449-S456.

<http://www.ncbi.nlm.nih.gov/pubmed/19012838?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum>

Despite recent indications that tobacco use among youths across the
nation continues to decline,^1,2,3^ tobacco use in youth continues to be
an issue in both urban and rural/reservation locations. Tobacco use, as
well as alcohol use, at an early age is predictive for use of other and
more potent drugs^4^. Tobacco addiction onset often occurs in childhood.
Most adults, who currently smoke, started before 19 years of age. In
2006, The National Survey on Drug Use and Health reported the ethnic
group with the highest rate of smoking cigarettes within the past month
to be American Indian youth aged 12-17 (21.2%).

Youth smoking is indeed a problem on the Navajo Nation. The 2003 Navajo
Youth Risk Behavior Surveillance System (YRBS) showed that the Navajo
Nation had a higher percentage of High School Students (38%) who smoked
cigarettes on one or more of the past 30 days compared to their
non-native high school counterparts (20%-2001 YRBS)^5^. Tobacco use is
also prevalent in Navajo Middle School children. The 2003 Navajo YRBS
data determined that 19% of middle school children have smoked
cigarettes on one or more of the past 30 days.

Higher tobacco use among native children is not only isolated to rural
settings. Foster et al reported higher tobacco use among urban Indian
youth in Minneapolis-St. Paul through a non-random cross-sectional
survey. Within the previous 30 days, nearly 37% of the surveyed Indian
youth aged 11-18 years reported recreational cigarette smoking. Nearly
49% of 16-18 year olds, 44% of 14-15 year olds, and 16% of 11-13 year
olds smoked cigarettes within the past 30 days. In comparison to the
2007 Minnesota Student Survey, the prevalence of cigarette use within
the previous 30 days among Indian youth is noticeably higher.

Though it is difficult to compare surveys, they all illustrate marked
disparities of tobacco use among Native American youth, regardless of
location: urban or rural. Interventions by primary care physicians can
be critical to the reduction of tobacco use among Native youth.
Physicians need to identify and limit the barriers that prohibit their
involvement in screening, prevention, and management of substance abuse
including tobacco.

References:

1.  Monitoring the Future Study. <http://www.monitoringthefuture.org/>

2.  National Survey on Drug Use and Health.
    <http://www.oas.samhsa.gov/nhsda.htm>

3.  Youth Risk Behavior Survey.
    <http://www.cdc.gov/HealthyYouth/yrbs/index.htm>

4.  American Academy of Pediatrics, Kulig J, and Committee on Substance
    Abuse. Tobacco, Alcohol, and Other Drugs: Role of the Pediatrician
    in Prevention, Identification, and Management of Substance Abuse.
    *Pediatrics.* 2005;115:816-821.

5.  2003 Navajo Middle and High School Youth Risk Behavior Survey
    Report. <http://www.yrbs.navajo.org/>