# **IHS PEDS NOTES**

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

## **June, 2000 Volume 16 Bill Green, Editor**

***Reach Out and Read recently received a \$2 million grant to extend
their Pediatric reading programs to minority and underserved
populations, including Indian health care sites ...*** There are already
over a dozen sites at IHS and tribal clinics, recently including ours,
with a strong commitment to expand significantly from their national
office. As part of the AAP Spring meeting in Boston I attended an
outstanding presentation on Literacy Promotion in Primary Care and spoke
to ROR national medical director Perri Klass, M.D. who along with the
ROR staff would be more than happy to answer any specific inquiries
617/638-3380, <perri.klass@bmc.org>. Many of you may have attended ROR
workshops by Lori Byron, M.D. at the Phoenix meeting a year ago or
January at the Combined Councils. There are three components: (1) during
well-child visits pediatricians and other clinicians encourage parents
to read aloud to their children and provide tips and guidance, (2)
clinicians then give a new, age-appropriate book to every child between
6 months and 5 years and (3) volunteers read aloud to children in clinic
waiting rooms. Research on this program presented at the meeting,
including one poster including Indian children, show a potentially
favorable impact on reading behaviors and language acquisition of
participants that will need to be validated in more comprehensive
studies (see Pamela High et al, "Literacy Promotion in Primary Care
Pediatrics: Can we make a Difference?" April, 2000 Pediatrics, 105, (4)
pp. 927-934.) The application process is simple and essentially supports
the purchase of books; the involved health provider can be a family
physician, nurse practitioner, anyone providing well-child care.
Publication and dissemination of more Indian specific books is also an
achievable goal as the number of sites expands. I encourage you to take
advantage of this expanded opportunity!

***7-Valent Conjugate Pneumococcal Vaccine is approved but awaits
adoption by Vaccines for Children and specific guidelines for use*...**
"PCV7" ( Prevnar) was accepted by the PHS Advisory Committee on
Immunization Practice in February as a 2, 4, 6 and 12 to 15 month
schedule based on a large study of 38,000 children in Northern
California where the vaccine achieved over 90% overall efficacy. With
invasive pneumococcal disease rates in studied Indian populations 5 to
24 times higher than the general population this vaccine has been
eagerly awaited. Unfortunately, with a list price of \$58 [a
dose]{.underline} it is cost prohibitive for many Indian care sites
though probably still cost-effective---a March JAMA article actually
questioned cost-effectiveness for the general population at this price!
The ongoing study of vaccine efficacy in Navajo and Apache children
continues at present because the seven vaccine serotypes were less
prevalent than anticipated and community clustering may impact on
significance, according to lead investigator Kate O'Brien, M.D. who
presented update on the study May 14^th^ at the AAP Spring meeting.
Despite Internet allegations there is no credible scientific evidence
that this vaccine is associated with type 1 Diabetes, which in contrast
to Type 2 Diabetes, has been and remains rare in Indian children. A
favorable trend of 10 to 15% decrease in otitis media in vaccine
recipients with recurrent otitis in the Kaiser study shows promise but
needs to be studied prospectively. There is also essentially no data to
guide policy makers for recommendations in older age groups than those
specifically studied. Meanwhile, the relatively inexpensive and
available 23-valent Unconjugated Pneumovax "23 PS" remains an option for
children over two with high-risk conditions and living situations---see
the September, 1999 PEDIATRICS statement for additional guidance. The
new statement currently being prepared for release by the AAP Redbook
Committee contains language specific to "high" and "moderate" risk AI/AN
populations, and because of low prevalence of the seven PCV7 serotypes
will recommend in certain situations combining PCV7 with a 23 PS booster
to broaden coverage.

***Two new textbooks can help clinicians learn skills to practice
evidence-based pediatrics...***"Evidence Based Pediatrics and Child
Health" edited by Virginia Moyer, (British Medical Journal Books, 2000)
is the first book I have found that attempts to provide guidance on how
to use evidence-based data bases such as the Cochrane Library and
evaluate articles from medline on your own to answer important clinical
questions. The first part is essentially a primer on how to frame
questions, search for evidence and evaluate results using basic
epidemiological and statistical concepts with specific pediatric
examples. The second section deals with evidence for routine practices
such as well-child care, obesity and injury prevention, highly relevant
in our population. The final section discusses selected common
conditions such as the febrile infant, asthma, ADHD. The authors of
articles in sections 2 and 3 "show their" work, i.e. exactly what search
strategy they used. Updates will be available at a designated website.
The second text, "Evidence-Based Pediatrics" Feldman, (BC Decker, 2000)
is a more conventional textbook using evidence-based articles to review
a broader list of common conditions and is accompanied by a searchable
CDROM.

In the workshop on this subject attended by mostly academic
pediatricians there was tension between universal application of
presumably evidence-based practice guidelines in teaching centers vs
teaching students and residents the critical skills of assessment on
their own. Although traditional textbooks remain useful repositories of
basic anatomic and descriptive information they are simply too quickly
out of date for most therapy questions. Unfortunately pediatric practice
is filled with treatments that are based on tradition or expert opinion
and evidence-based studies are simply unavailable. Hopefully these early
attempts to fill this gap will be supplemented by better well-designed
randomized control trials in pediatric care. (see also Gary Onady,
"Evidence-Based Medicine", May 2000, Pediatrics, 105 95), pp. 1176-1177,
which is a response to a recent commentary).

***Practice Parameter on Attention Deficit with Hyperactivity published
in May, 2000 PEDIATRICS attempts to qualify expert panel opinion with
assessment of the quality of evidence...*** ADHD has been in the news
recently with ongoing debate about under Vs over diagnosis of the
condition in young children. This clinical practice algorithm developed
by a consensus panel systematically reviewed evidence for six
recommendations that are also organized as a flow sheet. The touchstone
for a diagnosis requires meeting specific DSM-IV criteria in more than
one setting as well as evaluation for coexisting conditions such as
anxiety or depression and learning disabilities. At a Spring Meeting
workshop on the guidelines Heidi Feldman, MD presented a "Clinicians
Tool Kit for the Diagnosis and Management of ADHD of the School-Aged
Child" that conveniently includes work-sheets and rating scales that can
be incorporated into the patient record, as well as information sheets
for parents and teachers and medication dosing. Diagnosis under age 6
was felt to be problematic because of significant overlap of
developmentally appropriate "ADHD behaviors" in this age group, possibly
requiring specialist consultation. For appropriately diagnosed children
age 6 to 12 medication response can be documented in over 70%.
Approaching the diagnosis in this rigorous fashion can help avoid errors
of inappropriate selection of children for treatment. (see Pediatrics
May 2000, 105 (5) pp. 1158-1170.)

***Recently IHS Headstart published a report, "Healthy Children, Healthy
Families, and Healthy Communities: A Focus on Diabetes and Obesity
Prevention"*** which concisely summarizes available evidence and
recommends a blueprint for planning specific program interventions. An
excellent current reference, Mary Story, et al, "The Epidemic of Obesity
in American Indian Communities and the need for Childhood
Obesity-Prevention Programs", 1999 American Journal of Clinical
Nutrition, 69 (suppl): 747S-754S is included in the index. Contact
Cheryl Wilson at 505-248-4182, <cheryl.wilson@mail.ihs.gov> if you would
like a copy. Applications for funding for pilot projects are going out
to IHS Headstarts this summer. Recent research in obesity highlights the
association of early adiposity rebound at age 5 and subsequent obesity
(see Ahmad Dorosty et al, "Factors Associated with Early Adiposity
Rebound", May 2000 Pediatrics, 105(5) pp1115-1118), providing impetus
for a targeted intervention in this age group. Evidence-based research
on the efficacy of interventions is limited, but the rationale for a
community-based, generic public-health approach is thoroughly discussed
in the report. The May issue of the British Medical Journal contains an
important article on using the Body Mass Index in "Establishing a
standard definition for child overweight and obesity worldwide:
international survey", (Timothy Cole, et al, BMJ 320, pp. 1-6.). This
article attempts to use data from six large nationally representative
cross sectional growth to link adult cut-off points, 25 kg/m2 for
overweight and 30 kg/m2 for obesity, with BMI centiles for children age
2 to 18 and has a convenient table on page 4. Late breaking news:
long-awaited U.S. updated growth charts from the National Center for
Health Statistics that [include BMI centiles]{.underline} were just
released last week and are available at www.cdc.gov/growthcharts.

***Distinguishing between otitis media with effusion and acute otitis
media has important treatment implications...***The December 1999 issue
of Pediatric Infectious Disease Journal (18 (12) pp1115-1151) has a
supplement "Acute Otitis Media: A Treatment Paradigm for the New
Millennium", a collection of articles by Infectious disease specialists
including a review of consensus guidelines developed by CDC in 1998.
"The CDC-AAP principles of judicious use of antimicrobial agents
distinguish AOM as a treatable disease from the persistent middle ear
effusion (OME). OME after therapy of AOM is expected, may persist for
weeks to months and does not require immediate use of antimicrobial
agents." Diagnosis of AOM requires documentation of middle ear effusion
by pneumatic otoscopy if possible and signs or symptoms of acute
illness. Although the policy in some Western European countries is to
withhold antibiotics unless children "remain ill" after 1 to 3 days of
observation, the specific criteria for withholding or treating remain
poorly defined as well as outcomes. Immediate treatment at least for
children younger than 2 is therefore recommended.

Algorithms for antibiotic treatment have changed in the era of drug
resistant strep pneumoniae; amoxacillin remains initial drug of choice
but higher dosing 80 to 90 mg/kg, and consideration for use of
amoxacillin/clavunate if antibiotics were administered within the past
month. Ten-day course is recommended for children under 2 but shorter 5
to 7 day course can be considered for children over that age.
Unfortunately resistance to sulfa/trimethoprim by DRSP is often higher
than that for amoxacillin, which limits its usefulness as an
alternative. Further treatment for treatment failures is more
controversial, and includes higher dose amoxacillin/clavunate (80-90
mg/kg amoxacillin that [requires new formulation or extra amoxacillin
dosing to keep clavunate at 6.4 mg/kg/day!]{.underline}), ceftriaxone,
cerfuoxime, clindamycin, and/or tympanocentesis. Suggested algorithms
appear on page 1153 along with a full discussion of the rationale for
the conclusions.

Because of the high spontaneous resolution rate of AOM and lack of
locally documented DRSP many Indian care clinicians may be reluctant to
change treatment algorithms at present. Yet DRSP is increasing
everywhere it is looked for, and I would recommend obtaining cultures,
monitoring pneumococcal resistance in your clinics, and becoming
familiar with these current consensus diagnostic and therapeutic
strategies.

***Jim Flaherty in Tuba City reports on resources available to upgrade
EMS programs....***Beginning in FY 2000, the Maternal and Child Health
Bureau has entered into an inter-agency agreement with the IHS to
facilitate the promotion of the goals of the EMSC program. As you likely
know, the EMSC program has enjoyed continued and increasing funding over
the last16 years. The Program is primarily a grant program aimed at
three eligible recipients within states and territories: EMS bureaus,
MCH Bureaus or medical schools. There are different categories of
grants; most states at this point have received generations of grants,
and are presently in the partnership or continuation phase. Although
American Indian, Alaska Native and Hawaiian Native children are
specifically mentioned as special populations targeted to benefit from
EMSC programs, neither IHS service units nor Tribal health programs are
eligible to directly receive grant funds. Dave Short, a graduate of the
IHS Injury Prevention Fellowship program, completed an EMSC needs
assessment of Tribal EMS Programs by phone survey in 1998 and 1999, at
the request of Headquarters. About half of existing Tribal EMS programs
responded, and the findings were consistent. The majority identified
that training and equipment (including computers and web access) were
their most pressing needs. One of my goals is to facilitate or directly
provide this training and equipment by working with Tribal EMS programs
and their respective state EMS Bureaus. (To date, I have had limited
requests to facilitate or provide EMSC training in response to my letter
soliciting such requests.) The EMSC Program has many resources available
to you, your prehospital providers, and emergency department staffs.
Primary among them is the National Resource Center located in Silver
Spring, MD. The NRC has a highly knowledgeable and professional staff
with extensive contacts in every state, and in all federal agencies
which pertain to the EMSC Program goals. The phone number of the NRC is
(301) 884-4927, the web site is www.ems-c.org, and the e-mail address is
info@emscnrc.com. One of the many activities which the NRC coordinates
is the Partnership For Children program. By contracting with fifteen
professional organizations (e.g., AAP, ACEP, Emergency Nurses
Association, American Pediatric Surgical Association), the NRC involves
them in planning and implementing EMSC goals and activities consistent
with the Program\'s Five Year Plan. The broad goal of the EMSC Program
is to improve the spectrum of emergency care and services for all
children. As the physician liaison to the IHS, I am available to you, my
fellow IHS pediatricians, as a resource to make these improvements for
our patients. Call me. Jim Flaherty, MD, Navajo Area EMS Medical
Director Emergency Department, Tuba City Indian Medical Center (520)
283-2960 (office/Voice mail) 283-2406 (page), 283-24089(fax), or
jflaher1@tcimc.ihs.gov

# ***David Grossman, MD, MPH provides update of CONACH activities...***

Greetings from the Committee on Native American Child Health of the
American Academy of Pediatrics. I wanted to update you on some committee
issues and projects.

1.  **Legislation/Advocacy:** The committee's last meeting was held in
    Washington, D.C. in February 2000. As you may know, we now hold
    every other meeting there to facilitate our advocacy efforts with
    Congress. We work closely with the Washington AAP office during this
    meeting. The big issues legislatively are the elevation of the
    Director of the Indian Health Service to an Asst. Secretary level
    and the passage of the Indian Health Care Improvement Act (IHCIA).
    The appropriations issue is an ongoing issue for us since the
    president's budget is first introduced in February. Currently, our
    efforts will be directed toward assisting with the revisions of the
    IHCIA, supporting the director elevation, and in creating a new
    infrastructure for maternal and child health. We are also working
    toward improving our advocacy efforts by staying in touch with AAP
    members who have an interest in Indian Health. As you know, federal
    employees cannot lobby Congress but tribal employees may be able to;
    and physicians who have exited the Indian Health Service certainly
    can. We hope to get help educating key congressional representatives
    about Indian Health issues.

2.  **Diabetes:** A subcommittee of CONACH chaired by Dr. Sheila Gahagan
    is writing a guide on Type II diabetes for primary care clinicians
    caring for children. This guideline will build upon the joint
    AAP/ADA statement that appeared last month in Pediatrics and will
    focus primarily on diagnosis, treatment and prevention. This is
    being written primarily for Indian health clinicians but should have
    broad applicability with other ethnic groups. Other members of the
    Task Force include George Brenneman, Indu Agarwal, and Kelly Moore.

3.  **Recruitment/Retention:** On another front, we are continuing to
    look into the disparity in salary levels for pediatrician
    commissioned officers, compared to other primary care specialties.
    This issue was taken up on our behalf with the Director of
    Commissioned Personnel and the Director of the Indian Health
    Service. We will continue to pursue this.

4.  **Consultation** visits: Our next consultation visits will be in the
    Phoenix Area in the Fall of 2000. We hope to visit several programs
    and provide some feedback on MCH programming and service delivery,
    as well as to learn about what's working in your institutions.

I hope you'll stay in touch with us, and let us know of your concerns
and needs. You can reach our AAP committee staff person, Ms. Ana Garcia
by email at <nativeamerican@aap.org> or by phone at 1-800-433-9016, ext.
4739. I am available at <navajo@u.washington.edu>.

***The National Diabetes Prevention Center in Gallup is hosting a
conference on Type 2 Diabetes in Children August 28 to 31.*** Contact
1-888-590-NDPC for more information or visit their website at
<http://hsc.unm.edu/ndpc>.

***Plans for the biennial Indian child health conference in 2001 are
already underway...***On the "FAX BACK" form on the back of the
newsletter are a list of suggested topics, rating scale, and space to
suggest additional topics. [Your input is vital if the conference is to
continue to be relevant to our practice!]{.underline} This year the
American Academy of Pediatrics and Oklahoma University will be
collaborating and providing staff support thanks in part to the
enthusiastic advocacy of Dr. James Jarvis, CONACH member and Pediatric
Rheumatologist in Oklahoma. Tentative dates for the conference are
around September 19 to 21, 2001 in Oklahoma City---please indicate if
you prefer Wednesday through Friday or starting later but including some
weekend days. Please FAX back to me and I will forward to the planning
committee.

FAX COVER SHEET

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

PHS Indian Hospital FAX: 505-248-4088

801 Vassar NE phone: 505-248-4000

Albuquerque, NM 87106

FROM: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ PHONE:

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

FAX: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ E MAIL ADDRESS:

Dear Bill,

I would suggest the following topics for the September, 2001 meeting in
Oklahoma:

I prefer \_\_workshops \_\_\_lectures \_\_\_some of each

Wednesday through Friday\_\_ Thursday through Saturday\_\_

On a list of some suggested topics below, rate your level of interest
(1=high,

2=medium, 3=low)

\_\_Current approaches to dx and rx of Asthma

\_\_Type 2 Diabetes diagnosis and management

\_\_Control of invasive Streptococcal pneumoniae disease in AI/AN
children

\_\_Tobacco use and abuse, treatment strategies

\_\_IGA Nephropathy, implications for the workup of hematuria

\_\_ evidence-based pediatrics/use of the internet resources

\_\_management of common adolescent GYN problems

\_\_rheumatologic diseases in AI/AN children

\_\_prevention, diagnosis and management of fetal alcohol exposure

\_\_practical care of neurologically impaired child

\_\_rational use of antibiotics in an era of antibiotic resistance

\_\_obesity prevention

\_\_practical dysmorphology with emphasis on conditions more common in
AI/AN

\_\_diagnosis and management attention deficit, pervasive developmental
disorder and autism

\_\_violence prevention

\_\_impacts of gambling on children

\_\_workshop on literacy promotion: lessons of experience so far

Topics for the next newsletter:

You should send copies to these new IHS, tribal, or urban health care
pediatricians/nurse practitioners: