# **IHS PEDS NOTES**

### **A Newsletter for American Indian/Alaska Native Child Health**

## **November, 1999 Volume 15 Bill Green, Editor**

***"Immunizations for Native American Children" in the September 1999
issue of Pediatrics highlights important differences in immunizing
strategy in Indian/Alaska Native infants and children...***

Sponsored jointly by the Committee on Native American Child Health and
the Committee on Infectious Disease of the American Academy of
Pediatrics, this statement has been under preparation for several years,
and incorporates recent AAP recommendations to limit thimerosal or
mercury exposure to youngest infants with some specific exceptions. Some
of the conclusions: PRP-OMP HIB conjugate vaccine (Pedvax and COMVAX) is
the preferred initial immunizing dose for prevention of invasive
Haemophilus Influenzae B disease. Hepatitis A vaccine should be a
routine immunization for all AI/AN children at age 2, and catch-up
immunization for older children should be considered. Pneumovax should
be considered at age 2 years in communities where increased risk of
invasive pneumococcal disease has been demonstrated. The conjugate
pneumococcal vaccine will be a priority for use in our infants when
released, possibly as soon as next year. Hepatitis B vaccine is also a
priority in our infants and children; the text discusses whether to
modify the previous schedule of immunization at birth based on both
community and population risk.

I urge everyone [to read the complete statement carefully]{.underline},
including the disclaimer at the bottom of the first page:
"recommendations in this statement do not indicate an exclusive course
of treatment or serve as a standard of medical care. Variations, taking
into account individual circumstances, may be appropriate." My
particular thanks to Rosalyn Singleton for preparing initial drafts of
the statement and the hard work of the two committees to come to this
consensus. (PEDIATRICS, Vol. 104 No. 3 September, 1999, 564-567.) The
September issue also contains the statements on thimerosal and
suspension of oral rotavirus vaccine because of recent increased cases
of intussusception in immunized infants.

***Over one million teens in the United State are addicted to gambling
according to the National Gambling Impact Study Commission Report....***

The congressionally mandated study found that 5 million Americans suffer
from pathological gambling, and 1.1 million adolescents ages 12 to 17 or
5% of the total 20 million American teenagers engage in severe
pathological gambling each year. Quotations from several pediatricians
formerly on the AAP CONACH were featured in the article of August 1999
AAP news, reflecting concern of the committee members of the possible
impacts on Indian children.

"It's not easy to identify adolescent gamblers: they are smart,
energetic and highly motivated...may enjoy and early "winning phase"
before the bottom drops out...and mounting losses lead to a "desperation
phase" that leaves may at risk for suicide." Key symptoms of
pathological gambling include stealing money or other valuables from the
home; withdrawal form ordinary activities; exaggerated displays of
gambling winnings; school truancy; and lying about one's whereabouts,
according to Elizabeth George, executive director of the non-profit
Minnesota Council on Compulsive Gambling. Although Indian gaming
operations have allowed economic development for many tribes who have
often used revenues to improve health, education and housing for tribal
members, health providers and families need to recognize these negative
impacts and screen adolescents for pathologic gambling in their
practice. The AAP will be publishing a parent/patient education brochure
in the near future, developed with the assistance of CONACH. The entire
National Gambling Impact Study Commission report is available at
www.ngisc.gov/

***Asthma rates in children are rising rapidly, particularly in minority
groups including Indian Children...***

A 1990 review of respiratory disease found asthma to be "rare" in
Indians. However, in a 1995 school based parent survey in Jemez we found
12.3% reported prevalence vs. 5% in national NHANES surveys. At Ft.
Peck, Montana Roman Hendrickson, James Bresette and Julie Bemer have
recently found over 17% prevalence among the Assiniboine and Sioux
children in their service unit, indicating that this high prevalence is
not unique to the Southwest. Nationally since 1984 asthma has increased
80% among schoolchildren and 160% among preschoolers. Deaths from asthma
in children under 18 have nearly tripled in the past 15 years. Asthma is
currently the most common chronic disease of children; the most common
cause of missed school days and places children at increased risk for
academic problems and school failure. In 1997 the second expert panel on
the management of asthma for the NIH published updated guidelines for
the diagnosis and management of asthma, including diagnostic and
therapeutic recommendations for children.

Despite wide availability of this guide and an abbreviated "Practical
Guide for the Diagnosis and Management of Asthma", [it is evident that
children are often not diagnosed and not treated
effectively]{.underline}**.** The panel advocates categorizing patients
into "steps": step 1 "mild intermittent", step 2 "mild persistent", step
3 "moderate persistent", and step 4 "severe persistent", based on days
and nights with symptoms, and peak flow and peak flow variability. Both
"Quick Relief" and "Controller" medications should be used for all
asthma over step 1. Educating families about the inflammatory nature of
the disease, identification and avoidance of specific triggers, and
proper use of MDIs including spacers are important components to
success. Home peak flow monitoring and written action plans for more
severe disease are advocated by the guide, though peak flow monitoring
has not been conclusively demonstrated to be effective. "Pediatric
Allergy and Asthma: The Complete Course for Primary Care Providers" is
an excellent annual AAP course that provides up to date information in
plenary, workshop, and point/counterpoint formats. I presented
information from this and other sources at the April 1999 IHS Primary
Care Conference, "A Primary Care Approach to Childhood Asthma" which I
would be happy to share. The NIH guidelines "Practical Guide" is NIH
publication \# 97-4053, also available from GlaxoWellcome, website
(www.glaxowellcome.com). The September issue of AAP News highlights the
important issue of access to inhalers during school hours and has some
of the current statistics cited above.

***Evidence-based medicine needs to be applied in pediatric clinical
care...***

Evidence-based medicine has been defined as "the process of
systematically finding, appraising, and using contemporaneous research
finding as the basis for clinical decisions. " Ideally it integrates
individual clinical experience with the best available external clinical
evidence. On a practical level, there is a growing body of resources in
print, CD-ROM, and on the web that attempt to organize the medical
literature to answer clinical questions. Some important resources
include the Cochrane Library www.cochrane.org that publishes a database
of systematic reviews and critical assessments and structured abstracts
of good systematic reviews published elsewhere. The Agency for Health
Care Policy and Research, USPHS has created 12 evidence based practice
centers and has collaborated in a National Guideline Clearinghouse at
www.guideline.gov. The clearinghouse offers structured abstracts of
guidelines, tabular comparisons of abstracts generated "on the fly" by
user, "hot links" to full text when possible, and syntheses of guideline
on similar topics. A pediatric website that offers a comprehensive
introduction and compendium of evidence based medicine is found at
http://PedsCCM.wustl.edu/EBJ/EG Resource.html. This is a critical care
website maintained by Adrienne Randolph, MD from Childrens Hospital
Harvard Medical School and Barry Markowitz, MD St. Louis Childrens
Hospital, Washington University School of Medicine, and offers "hot
links" to literature on evidence-based medicine, statistics,
meta-analysis and the Pediatric Critical Care Medicine Evidence Based
Journal Club.

***Clinical Guidelines for Type 2 DM in children and adolescents are
under development by the American Academy of Pediatrics and American
Diabetes Association...***

Kelly Moore from IHS and Sheila Gahagan from CONACH are part of national
workgroups addressing this important issue. Many diagnostic standards
will probably be adapted from those currently developed for adults. The
American Academy of Family Physicians and American Diabetes Association
recently published a systematic evidence based review of "The Benefits
and Risks of Controlling Blood Glucose Levels in Patients with Type 2
Diabetes Mellitus". Two large well-designed prospective studies, the
Diabetes Control and Complications Trial (DCCT) in 1993 in Type 1
Diabetes, and in 1998 the United Kingdom Prospective Diabetes Study
Trial (UKPDS) in Type 2 Diabetes have convincingly shown that treatment
can decrease morbidity from microvascular and neuropathic complications
of diabetes. UKPDS showed that the 10 year incidence of microvascular
complications was 25% lower in patients who were intensively treated
with diet and medications than in those receiving conventional
treatment. The intensive medication regimens combined different oral
agents and insulin to achieve better control; no specific regimen was
superior.

This suggests but does not prove that early diagnosis and intensive
treatment in children and adolescents may significantly decrease their
lifetime complications and disease burden from diabetes. Hopefully the
guidelines under development will provide a framework for how to
proceed, acknowledging that at present we simply don't have the evidence
to decide which specific treatment approach is best. [Involving
adolescents and families in individual treatment decisions, as
emphasized by Amy Hyde this spring at the IHS Pediatric Conference, is
critical for success.]{.underline} The CDC has a website that has
current information about epidemiology of diabetes in Indian children:
www.cdc.gov/diabetes/. Some preliminary diagnosis and treatment
recommendations for adolescents and children are expected soon in an
upcoming issue of Diabetes Care.

***Dorothy J. Meyer, CNM, MPH is recipient of this year's Native
American Child Health Advocacy Award presented by AAP President Joel
Alpert at the Annual Meeting in DC in October...***

Dot, as most of us know her, has demonstrated outstanding leadership in
child health policy for the Phoenix Area over the past 13 years as MCH
coordinator. She has served on two sub-committees of the Arizona Child
Fatality Review, systematically periodically reviewed well-child care
and more recently child diabetes care at Phoenix Area sites, provided
training for all health providers in diagnosis of child sexual abuse,
and generally provided an exemplary model program of maternal child
health coordination. She has also sponsored annual meetings in child
health for the entire Phoenix area, and most recently has helped me by
providing virtually all the coordination for the two national IHS
Pediatricians meetings in 1997 and 1999. To quote Kelly Moore, "Dot
performs outstanding well child care reviews and offers her time and
services to review any MCH area of interest at any site that requests
it. She has been instrumental in the success of the Arizona
fetal/infant/child mortality review and has provided follow-up services
to service units sometimes when they weren't even aware of a death. She
has shown tremendous pediatric advocacy in her concerns about child
abuse and child protection team functioning. I could go on and on..what
a great tribute to a remarkable career."

***David Grossman reports on CONACH activities and his vision for future
Committee priorities....***

As the new chair of the American Academy of Pediatrics Committee on
Native American Child Health, I am truly excited and honored to work
with you all on our mission of improving the health of American Indian
and Alaska Native children in North America. Lance Chilton, our former
chair, left giant footsteps behind. Lance served on various iterations
of CONACH for 14 years, leaving a legacy of tremendous accomplishment
and permanence for CONACH. His many contributions will forever be
remembered by our colleagues. Lance is moving on to become the
Vice-President of the New Mexico AAP chapter, where he can further exert
his influence on behalf of Indian children. We also lost tremendous
expertise when Jon Jantz and Joann Bodurtha left our committee in July.
Jon and Joann were also "long-termers", each bringing their own special
expertise and enthusiasm to CONACH. No doubt that they, too, will
continue to carry the cause in other ways.

With departing members, we also gained fresh talent on the committee.
George Brenneman "re-joined" the committee as a regular member after
serving as a liaison the past several years. George is a retired IHS
pediatrician who used to head up the national Maternal Child Health
branch of HIS and now works with the Hopkins Center for American Indian
and Alaska Native Health. He also works as a locums for several Indian
health sites. Indu Agarwal is a neonatologist from Fargo North Dakota
who has been active in the CATCH program of the Academy, and has worked
extensively with the Spirit Lake Nation on many different health
programs. James Jarvis is a pediatric rheumatologist of Mohawk
extraction from the University of Oklahoma School of Medicine who has
been active in working with Indian communities on chronic and rheumatic
diseases. Vincent (Vinny) Biggs is a pediatrician in private practice
from Amherst, Massachusetts who formerly practiced in Shiprock.
Remaining with the committee are Bernadette Freeland-Hyde (Phoenix) and
Sheila Gahagan (Ann Arbor).

I hope to accomplish several goals during my tenure as CONACH chair.
First, I hope we can establish the AAP as [THE]{.underline} leading
advocate for Indian and Native children in the United States. We are
already well on our way. Every other meeting is now held in Washington,
D.C. so that our members can make visits to members of Congress and
their staff. Thanks to Todd Askew, our Washington representative, the
AAP is well recognized as one of the leading members of the Friends of
IHS, a coalition of professional health organizations working to support
Indian health programs. From appropriations to the reauthorization of
the Indian Health Care Improvement Act, outside support is needed to
educate Congress about the needs of children and the doctors taking care
of them.

Second, we need to attract more Indian and Native pediatricians into
pediatric careers. Obviously, this is a multi-step process. Many
organizations, including the Association of American Indian Physicians
and university programs, are working hard to attract Native Americans
into medicine starting even at the high school level. We should assist
with these efforts but broaden them to trying to influence more Native
American medical students to think about pediatrics. Our committee will
be looking into ways of doing this.

Third, CONACH needs to continue to establish relations directly with
tribes and tribal organizations in its mission to improve the health of
Native American children. Increasingly, we find that our "clients" are
tribes or Native corporations, and not necessarily the Indian Health
Service. While the IHS provides support for some CONACH activities, we
must learn to relate directly to tribes and offer our expertise to them.
We will work hard on this in the coming years. Finally, you are also our
"clients". We rely on you to keep us informed, energized about how we
can help to make your job more productive and fulfilling. We will try to
establish closer ties to pediatricians and family physicians serving on
the 'front line'. We will strive to communicate with you via this
newsletter, as well as directly by telephone and mail. Please tell us
your concerns and ideas by writing CONACH at the AAP office or e-mailing
us at <nativeamerican@aap.org>. You can also follow our activities at
the AAP website ([www.aap.org](http://www.aap.org/)) in the members-only
channel (this does require AAP membership).

One final thought: our strength depends on the support of pediatricians
with the same mission, such as yourselves. Your can truly help our
mission by becoming a member of the AAP, if you have not yet joined. I
look forward to working with you. You can always drop me a note directly
at <navajo@u.washington.edu>. I look forward to hearing from you.

OTHER CONACH NEWS

-   CONACH visited the Alaska Area for consultation visits this past
    Spring. Three groups fanned out to Anchorage, Bethel and Kotzebue to
    learn more about the strengths and qualities of all of these health
    programs, and to assemble recommendations for expanded programs.
    Each time we make these visits, we are humbled by the fantastic work
    that is going on.

-   The Indian Health Service has awarded a contract to the AAP to
    develop guidelines for pediatricians on the recognition and
    treatment of Type II diabetes. Dr. Sheila Gahagan of CONACH will be
    heading up this effort for our committee.

-   Next meetings of the CONACH will be in Washington, DC in February
    2000 and Phoenix in the fall of 2000.

David Grossman, MD, MPH.

***Please e mail me or FAX back suggestions for newsletter topics.***

I am on both IHS Microsoft Exchange at
<wgreen@albmail.albuquerque.ihs.gov>, which accepts attachments, and the
venerable MAILMAN at <green.bill@ihs.gov>. Additional contact
information is on the FAX BACK form on the next page. Ana Garcia, MPA in
the Division of Community Pediatrics, AAP has graciously consented to
collate and send out this issue of the newsletter, and now is official
keeper of the mailing list. This is yet another example of how the
Academy can support us in our work. To echo David's sentiment, [this
support will only become more important in future years and I urge all
of you who are eligible to become members.]{.underline}

**FAX COVER SHEET**

TO: William F. Green, M.D. wgreen@albmail.albuquerque.ihs.gov

801 Vassar NE FAX: 505-248-4088

Albuquerque, NM 87106 phone: 505-248-4000

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Dear Bill,

I have the following information for the next newsletter or comments on
this one:

The following pediatricians or practitioners need to be added to your
mailing list: (you can also email or fax these changes to Ana Garcia at
the American Academy of Pediatrics---agarcia@aap.org. FAX 847/228-5097).