*"It doesn't matter if the cat is black or white as long as it catches
mice."*

*Chinese Proverb*

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

**January 2008**

# Quote of the month

*"Logic is an organized procedure for going wrong with confidence and
certainty."*\
C. F. Kettering

**Articles of Interest**

Stephen S. Hall. Small and Thin: The controversy over the fetal origins
of adult health. *The New Yorker*, November 19, 2007

<http://www.newyorker.com/reporting/2007/11/19/071119fa_fact_hall>

Weight in infancy and death from ischemic heart disease.

[Lancet.](javascript:AL_get(this, 'jour', 'Lancet.');) 1989 Sep
9;2(8663):577-80

Mother\'s weight in pregnancy and coronary heart disease in a cohort of
Finnish men: follow up study.

[BMJ.](javascript:AL_get(this, 'jour', 'BMJ.');) 1997 Oct
4;315(7112):837-40

Trajectories of growth among children who have coronary events as
adults.

[N Engl J Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2005
Oct 27;353(17):1802-9

The belief that maternal health in pregnancy can have life long effect
on chronic illnesses in their offspring has gone from heresy to
orthodoxy in the past 20 years. The driving force behind this theory is
David Barker, who was featured recently in an article in *The New
Yorker.* Dr. Barker's original hypothesis was based on population
studies in England. It was confirmed by similar work in Finland. This
epidemiologic work has found correlates in the new field of epigenetics
which postulates that environmental factors can produce permanent
changes in the activity of genes. Birth effects are not predestination
but they do have measurable effects over a population. Dr. Barker argues
we need to put more emphasis on maternal nutrition as a cost effective
intervention for future health.

**Editorial Note**

What do skinny children born to skinny, poorly nourished mothers in
England in the early 20^th^ century have to do with AI/AN children
today? Studies have shown that the children at greatest risk for
coronary heart disease as adults are not fat babies: it is thin babies
who gain unusual amounts of weight after birth. This perfectly describes
infants born 20 to 40 years ago as many AI/AN populations went in one
generation from under nutrition to over nutrition. We now have an
epidemic of diabetes and coronary heart disease in young adults. It is
unclear what will be seen 20 years from now in the current group of
large for gestational infants being born to overweight mothers. We can
only be sure that there will be epigenetic effects.

**Infectious Disease Updates**.

Rosalyn Singleton, MD, MPH

**2008 Childhood Immunization Schedule: Few changes planned.**

There were numerous changes to the Childhood (0-6 year) and Adolescent
Immunization Schedules in 2007. Few additional footnote changes are
proposed for the 2008 schedule:

1.  Hep B -- "If mother is HBsAg-negative, the birth dose can be delayed
    in rare cases with providers order and copy of mother's negative
    HBsAg lab report in infant's medical record"

2.  Pneumococcal vaccine -- "At ages 24-59 months administer 1 dose of
    PCV to incompletely vaccinated healthy children and 2 doses of PCV
    at least 8 weeks apart to incompletely vaccinated children with
    certain high risk conditions. Administer Pneumovax to children 2
    years and older with certain high-risk conditions"

3.  Meningococcal vaccine -- "Administer Menactra to children aged 2-10
    years with terminal complement deficiencies or anatomic or
    functional asplenia or HIV infection"

4.  Influenza vaccine --

    a.  Yearly for children 6-59 months, close contacts of children 0-59
        months

    b.  Yearly for children 5 years + with certain risk factors

    c.  FluMist can be used in healthy children 2 years and older (with
        out asthma or recurrent wheezing)

    d.  Give 2 doses (separated by at least 4 weeks) to children \<9
        years receiving Flu vaccine for the first time; or who were
        vaccinated for the first time last season but only received 1
        dose.

Summary: The biggest new change is that Menactra, currently recommended
for 11-18 year olds, will be recommended for children down to 2 years of
age with certain high risk conditions. Depending on the supply and
finances, ACIP may eventually expand Menactra to one dose for any child
2-18 years.

You can download the new schedules in January at:
<http://www.cdc.gov/vaccines/recs/schedules/>

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

Doug Esposito, MD

**[Article]{.underline}**

[Singleton RJ, Holman RC, Yorita KL, Holve S, Paisano EL, Steiner CA,
Glass RI, Cheek
JE.](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17984807&ordinalpos=14&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum)
Diarrhea-Associated Hospitalizations and Outpatient Visits Among
American Indian and Alaska Native Children Younger Than Five Years of
Age, 2000-2004. *Pediatr Infect Dis J*. 2007;26(11):1006-1013.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17984807&ordinalpos=14&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum>

**Editorial Comment**

This study scrutinizes IHS hospital discharge and outpatient visit data
for diarrhea in children \<5 years of age for calendar years 2000 --
2004, inclusive. Hospitalization and outpatient visit rates
(events/10,000 population) were constructed using the 2004 IHS
service-population as the denominator, with statistical adjustments
applied to earlier years. The data were analyzed on a regional basis;
for the AI/AN population, Northern Plains, Southern Plains, Southwest,
East, Alaska, and West designations were used while the general U.S.
population was regionalized using Northeast, Midwest, South, and West.
Additional analysis was made based on age (\<12 months and 1 -- 4
years), sex, and diarrhea etiology.

Childhood diarrhea hospitalization rates for the general U.S. population
were examined using the 2003 Kids' Inpatient Database (KID). Comparison
outpatient visit data for the general U.S. population derived from the
2000 -- 2004 National Ambulatory Medial Care Survey (NAMCS) and the
National Hospital Ambulatory Medical Care Survey (NHAMCS). Age-specific
rates were constructed using 2003 U.S. census and U.S. natality data.

It appears that AI/AN children \<5 years of age had similar or slightly
lower rates of hospitalization for diarrhea than the general U.S.
population \[65.9 (95% CI: 63.8 -- 68) vs. 79.3 (95% CI: 74.9 --
83.6)/10,000\], while rates of diarrhea hospitalization for AI/AN
infants were almost two-fold higher \[(262.6 (95% CI: 252.3 -- 273.3)
vs. 154.7 (95% CI: 145.6 -- 163.8)/10,000\]. Also of note is that the
hospitalization rate for AI/AN infants was 10 times the rate for 1 -- 4
year-old AI/AN children! This difference was not as striking among the
general U.S. population. Higher rates of outpatient visits for diarrhea
were found for AI/AN children \<5 years of age \[2255.4 (95% CI:
2245.1--2265.7) vs. 1647.9 (95% CI: 1398.4 --1897.4)/10,000\], with
infants being seen at about twice the rate of the general U.S.
population.

The pattern of diarrhea-associated hospitalization and outpatient visits
for AI/AN children varied by region, but the regions of highest and
lowest burden did not completely match. Overall, hospitalization rates
were highest in the Southwest and in Alaska and lowest in the Northern
and Southern Plains while outpatient visit rates were highest for the
East and the Southwest and lowest for the Southern Plains and the West.
Please refer to the article itself for details of these differences and
the regional variability based on age group. Seasonal variation occurred
for both in and out-patient events and mimicked what might be expected
based on the known epidemiology of viral etiologies (especially
rotavirus) of childhood diarrhea.

Given that these data reflect IHS hospital discharge and outpatient
visit data, some inherent peculiarities exist that might reasonably be
expected to have underestimated hospitalization rates overall and to
have possibly impacted the variability observed by IHS region. For
example, in regions where hospitalizations occur mainly outside the IHS
or contract facilities (e.g. the Northern and Southern Plains),
hospitalization rates would be expected to be biased lower (i.e. the
disparity between AI/AN children and the general U.S. populations is
actually worse than it appears). Additionally, differences in hospital
admission criteria, health care seeking patterns, diagnosis and coding
issues, and issues with the denominator (user population) all could
serve to skew the rate estimates. These issues are discussed by the
authors both in the current article and in another article employing an
identical methodology to investigate rates of hospitalization for a
different condition.^1^ Finally, given that AI/AN groups are known to be
very diverse and not uniform with regard to traditions, lifestyle,
health behaviors, socioeconomic factors, and others, variability in
health status and health outcomes is to be expected. American
Indian/Alaska Native is a highly diverse racial designation which is
reflected in the health statistics of individual band and tribal
designations.

Although disparities in diarrhea still exist and are possibly even
greater than demonstrated by this study, one cannot argue the impressive
progress that has been made over the years with regards to the burden of
diarrhea among AI/AN children. Substantial credit for this progress
belongs to the IHS itself and to the dedicated individuals that have
worked with and within the system to accomplish so very much with so
very little.^2^ These improvements are certainly the result in large
part of the targeted deployment of the same basic public health
interventions that have so positively impacted health status throughout
the world, namely safe water systems, improved sanitation, and better
hygiene practices.

According to the authors, further improvements and reductions in
diarrhea-associated hospitalization and outpatient visit rates,
especially for infants, might be expected as a result of the newly
available rotavirus vaccine. That, however, remains to be seen. At a
minimum, continued deployment of technologies known to be effective
should be a focus of our efforts. Significant proportions of AI/AN
populations still lack basic systems of safe and available water and
sanitation that most of us take for granted. Additionally, components of
poverty that are widely know to adversely affect susceptibility and
transmission of infectious disease (e.g. overcrowding, unhygienic living
environments, nutritional integrity), must continue to be targeted. To
me, disparities in diarrhea reflect basic and unacceptable societal
inequities. Until we as a society address these fundamental facts,
health equity and the complete elimination of health disparities will be
a long time in coming.

**References**

1\. Singleton RJ, Holman RC, Cobb N, Curns AT, Paisano EL. Asthma
Hospitalizations Among American Indian and Alaska Native People and for
the General US Population. *Chest*. 2006;130(5):1554-62.

> <http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17099037&query_hl=1&itool=pubmed_DocSum>

2\. Forty years in partnership: the American Academy of Pediatrics and
the Indian Health Service. *Pediatrics*. 2006 Oct;118(4):e1257-63.

> <http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17015514&query_hl=1&itool=pubmed_DocSum>

**Additional Reading**

[Holman RC, Parashar UD, Clarke MJ, Kaufman SF, Glass
RI.](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=9917491&ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum)
Trends in diarrhea-associated hospitalizations among American Indian and
Alaska native children, 1980-1995. *Pediatrics*. 1999;103(1):E11.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=9917491&ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum>