*"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

March 2007

# Quote of the month

*"Our capability to prevent and treat disease seems to exceed our
willingness to apply our interventions."*

C. Everett Koop, Former Surgeon General of the United States

**Articles of Interest**

Double burden of iron deficiency in infancy and low socioeconomic
status: a longitudinal analysis of cognitive test scores to age 19
years.\
Arch Pediatr Adolesc Med. 2006 Nov;160(11):1108-13.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17088512&query_hl=2&itool=pubmed_docsum>

Middle class Costa Rican infants who had chronic iron deficiency had
lower cognitive scores than their counterparts with normal iron stores.
This gap was not reduced by later supplementation of iron stores in
childhood. The gap in cognitive performance persisted even when these
children were followed out to 19 years of age. The difference in
cognitive performance was even greater when low income Costa Rican
infants with iron deficiency were compared to their counterparts with
sufficient iron. In low income children who were iron deficient, the gap
in cognitive performance actually increased over time even if their iron
stores were repleted in early childhood. These results suggest the value
or preventing iron deficiency in infancy.

**Editorial Comment**

Some things can't be undone. Congenital hypothyroidism will result in
permanent cognitive deficits unless treated by 3 weeks of age; later,
adequate treatment cannot fully reverse this injury. The article above
suggests that iron deficiency in infancy may have permanent cognitive
effects that cannot be reversed with later iron therapy.

Every effort to prevent iron deficiency should be made. Breastfed
infants should receive iron fortified cereal starting at 4 months of
age. If there is any concern that a breastfed infant is not receiving
sufficient iron they should receive iron supplements. These are most
easily given as iron drops at 1 mg/kg/d of elemental iron beginning at 6
months of age and until 12 months. Breastfed pre-term and low birth
weight infants should be supplemented with elemental iron at 2mg/kg/d
beginning at 1 month of age and until 12 months of age. Non
breastfeeding infants should receive only iron fortified formula.

All infants should be screened for iron deficiency anemia at 9 months.
This is earlier than the previous recommendation to screen at 12 months
but will allow for earlier detection of anemia and earlier iron
repletion if needed.

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

Doug Esposito, MD

**Editorial Comment**

Please forgive me, but this month I would like to diverge a little from
my usual M.O. I would like to take a short journey away from Indian
Country and travel the literature specifically related to the foreign
country. Of course, many of the same health and socioeconomic issues
facing the developing world are in force in Indian Country, so it won't
be such an exotic vacation after all. Anyway, I promise to ultimately
make a point that is relevant to Indian child health, so please bear
with me.

The February 2007 issue of the *American Journal of Public Health* is
devoted to the topic of international child health priorities. There are
several really interesting and timely entries that are worth exploring.
There is even an article entitled "Changing the Child Labor Laws for
Agriculture: Impact on Injury,"^1^ a topic once very near and dear to my
own heart. Unfortunately, I cannot really link its relevance to Indian
child health, so I will simply mention it in passing. Also, for anyone
interested in understanding a piece of the insanity that controls public
health policy making in this country, you should have a look at
"Paternalism and Its Disconnects: Motorcycle Helmet Laws, Libertarian
Values, and Public Health."^2^ OK Doug, time to move on!

The opening editorial introduces this topical issue by laying out an
important argument.^3^ Victora states "It is widely known that 10% of
the world's expenditure in health research is for the conditions
accounting for 90% of the global burden of disease," the so-called
"10/90 gap in funding." Of course, this funding scheme makes no rational
sense when one considers that "two thirds of the more than 10 million
annual deaths in children could be prevented by universal coverage with
off-the-shelf, low-cost interventions." The bottom line? We are not
spending enough to develop efficient and effective systems of health
care delivery and heath system access/utilization, much to the detriment
of child survival and the public health. For a more detailed
mathematical discussion of this topic, the reader is referred to Leroy
et al, "Current Priorities in Health Research Funding and Lack of Impact
on the Number of Child Deaths per Year."^4^

To bring the topic home, Wolf discusses related issues in "Potential
Health and Economic Consequences of Misplaced Priorities" in *JAMA*.^5^
He makes the argument that policy decisions should be based on
principles of public health more than is the tendency in contemporary
America.

So, what does this all mean for us? I knew you would ask that question.
The reader might remember my comments in the December 2006 issue of the
*IHS Child Health Notes*.^6^ In that issue, I reviewed an article
reporting the preliminary results of a study of a paraprofessional home
visitation program designed to improve outcomes for Native American
children born to adolescent mothers.^7^ The preliminary effectiveness of
this model, I said, challenges us to rethink the longstanding model of
public health nursing as it is practiced in the IHS and consider how a
paraprofessional model might be incorporated into our programs. Needless
to say, a multitude of barriers exist that deter innovation when it
comes to how health and preventive services are delivered, not the least
of which is funding.

In speaking to the authors of this paper, they describe that very few
grants are available to fund either new models of service delivery or
methods to improve what already exists. Of course, billions of dollars
are available out there to investigate new technologies: "\...of the
scarce research funds aimed at reducing child mortality, 97% were
directed at the development of new technologies, such as drugs,
vaccines, or laboratory diagnostics. Only 3% were spent on operational
research to determine how to best deliver existing interventions to
mothers and children who need them most."^3^ Are you surprised to learn
that there appears to be a "10/90 gap in funding" issue in the United
States, too?

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**References**:

1\. Marlenga B, Berg RL, Linneman JG, et al. Changing the child labor
laws for agriculture: impact on injury. *Am J Public Health*.
20007;97(2):276-82.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17194860&query_hl=1&itool=pubmed_docsum>

2\. Jones MM, Bayer R. Paternalism and its discontents: motorcycle
helmet laws, libertarian values, and public health. *Am J Public
Health*. 2007;97(2):208-17.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17194856&query_hl=4&itool=pubmed_docsum>

3\. Victora C. Editor's choice: addressing international child health
priorities. *Am J Public Health*. 2007;97(2): 203.
[http://www.ajph.org/cgi/search?andorexactfulltext=and&resourcetype=1&disp_type=&sortspec=relevance&author1=victora&fulltext=%22addressing+international+child+health+priorities%22&pubdate_year=&volume=&firstpage](http://www.ajph.org/cgi/search?andorexactfulltext=and&resourcetype=1&disp_type=&sortspec=relevance&author1=victora&fulltext="addressing+international+child+health+priorities"&pubdate_year=&volume=&firstpage)

4\. Leroy JL, Habicht JP, Pelto G, et al. Current priorities in health
research funding and lack of impact on the number of child deaths per
year. *Am J Public Health*. 2007;97(2):219-23.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17194855&query_hl=6&itool=pubmed_docsum>

5\. Woolf SH. Potential health and economic consequences of misplaced
priorities. *JAMA*. 2007;297(5):523-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17284703&query_hl=1&itool=pubmed_docsum>

6\. IHS Child Health Notes, December 2006.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN1206.doc>

7\. Barlow A, Varipatis-Baker E, Speakman A, et al. Home-visiting
intervention to improve child care among American Indian adolescent
mothers: a randomized trial. *Arch Pediatr Adolesc Med*.
2006;160(11):1101-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17088511&query_hl=1&itool=pubmed_DocSum>