*"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

December 2005

# Quote of the month

*"The thing that impresses me the most about America is the way parents
obey their children"*

The Duke of Windsor

**Articles of Interest**

Antibiotic treatment of children with sore throat.\
JAMA. 2005 Nov 9;294(18):2315-22.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=pubmed>

Antibiotic prescribing in general practice and hospital admissions for
peritonsillar abscess, mastoiditis, and rheumatic fever in children:
time trend analysis.\
BMJ. 2005 Aug 6;331(7512):328-9. Epub 2005 Jun 20.

<http://bmj.bmjjournals.com/cgi/content/full/331/7512/328>

**Summary**

In children with sore throat 15-36% have pharyngitis caused by group A
B-hemolytic strep (GABHS). This national survey showed that antibiotics
were prescribed in 53% of sore throat encounters, in excess of the
maximum expected prevalence of GABHS. Performance of a rapid test for
GABHS occurred in only about half of the visits but when performed was
associated with a lower prescribing rate for diagnoses associated with
pharyngitis. It was also noted that inappropriate antibiotics (broad
spectrum macrolides and second generation cephalosporins) were
prescribed in almost 30% of cases.

The second article describes the potential downside of decreased
antibiotic use. The United Kingdom made a concerted effort to decrease
overuse of antibiotics by general practitioners and from 1993 to 1999
the prescription of antibiotics fell 34%. The authors report a slight,
but measurable increase in mastoiditis in children \< 4 years during the
time in which antibiotic prescriptions declined. They estimate that
2,500 children with otitis media would have to be treated to prevent one
case of mastoiditis.

**Editorial Comment**

It is clear that indiscriminate antibiotic use leads to increased
antimicrobial resistance. It is less clear that a zeal to reduce
antibiotic use could lead to a rare, but measurable, increase in serious
bacterial infections. The first article suggests that physicians in the
United States continue to over prescribe antibiotics for sore throat in
children. A simple step would be to adhere to published guidelines:
perform a rapid GABHS and treat only those patients who test positive.
The second article hints that British restraint in antibiotic use may
have rare, but serious consequences. Each physician will have to balance
these competing goals in his/her practice.

I would also recommend the British article as it is a master of brevity
-- only 3 pages including graphs. If only more writers could emulate
their style.

**Infectious Disease Updates**.

Rosalyn Singleton MD MPH

Pneumococcal Disease in children: Will serotype replacement erase the
gains from PCV7?

Since introduction of pneumococcal conjugate vaccine (PCV7), reports
have shown significant decreases in both invasive pneumococcal disease
(IPD) and antimicrobial resistant IPD in children \< 2 years as well
among persons from older age groups (presumably from decreased
transmission). The December edition of Vaccine highlights Alaska's
experience through 2003.^1^ After vaccine introduction, vaccine-type IPD
rates declined by 91% in Alaska Native children \< 2 years old, and by
40% in adults. There was also a decline in IPD with decreased
susceptibility to penicillin, erythromycin, or Septra. The one black
cloud in this bright story is a recent increase in the rate of
non-vaccine serotype IPD in Alaska Natives leading to an increase in
overall IPD from 37% (2001-3) to 59% (2004-5) of pre-vaccine levels.
Surveillance among Navajo/Apache children has not shown an increase in
non-vaccine type IPD. Since 20-35% of IPD was non-vaccine type before
vaccine, the decrease in overall IPD (60-70%) since PCV7^2^ has not been
as dramatic as Hib. However, PCV7 has been effective in preventing
vaccine type IPD and we should optimize its use. The dilemma is whether
an increase in non-vaccine type IPD will begin to erase the gains made
against IPD through PCV7 use. Continued surveillance in Alaska and
Navajo/Apache is critical to determine if these increases will persist
or be seen in other areas. If so, we anticipate new pneumococcal
conjugate vaccines with expanded serotype coverage (eg. 9-valent), or
vaccines based on antigens common to all pneumococci.

1.  Hennessy TW et al. Impact of heptavalent pneumococcal conjugate
    vaccine on invasive disease, antimicrobial resistance and
    colonization in Alaska Natives: progress towards elimination of a
    health disparity. Vaccine 2005; 23:5464-5473.

2.  Whitney CG et al. Decline in Invasive pneumococcal disease after the
    introduction of protein-polysaccharide conjugate vaccine. N Engl J
    Med 2003;348:1737-46.

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

Doug Esposito, MD

Restraint use among northwest American Indian children traveling in
motor vehicles.\
*Am J Public Health*. 2005;95(11):1982-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16195522&query_hl=1>

**Editorial Comment**

You guessed it! Northwest American Indian children are inadequately
restrained, and the reasons appear to be multiple. In this survey, 41%
of children eligible to be in a safety seat were completely
unrestrained, while rates for inadequate or improper restraint use were
also unacceptably high (about 30% overall). Of course, AI/AN children
bear a disproportionately higher burden of motor vehicle injury and
death, at too many times the rate of the general U.S. population. We
certainly can, and must, do better!

Passenger safety restraint use for both children and adults in the US
has generally risen over time. This study suggests that the same trend
is not being enjoyed by northwest American Indians. In fact, this is
likely the scenario all across "Indian Country." There exists a critical
need for effective intervention. Community based public education
campaigns and child restraint laws appear to offer the greatest promise,
but providers of medical care to AI/AN children should continue to
rigorously address this issue in the clinic setting by way of
anticipatory guidance. Every little bit will help, and is well worth the
effort!

For suggestions on what works, and a whole host of other extremely
interesting and useful resources, please refer to the first link below.

Although somewhat dated and related to unintentional injury in general,
the 1999 CONACH Statement "The Prevention of Unintentional Injury Among
American Indian and Alaska Native Children: A Subject Review" is still
relevant. Other useful links are included.

**Additional Reading**

Guide to community preventive services: systematic reviews and evidence
based recommendations. Centers for Disease Control and Prevention.

<http://www.thecommunityguide.org/mvoi/default.htm>

The prevention of unintentional injury among American Indian and Alaska
Native children: a subject review. Committee on Native American Child
Health and Committee on Injury and Poison Prevention. American Academy
of Pediatrics. *Pediatrics*. 1999;104(6):1397-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10585996&query_hl=6>

Injury mortality among American Indian and Alaska Native children and
youth\--United States, 1989-1998. *MMWR Morb Mortal Wkly Rep*. 2003 Aug
1;52(30):697-701.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12894055&query_hl=11>

Motor vehicle crash fatalities by race/ethnicity in Arizona, 1990-96.
*Inj Prev*. 2003;9(3):251-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12966015&query_hl=13>

Pediatric motor vehicle related injuries in the Navajo Nation: the
impact of the 1988 child occupant restraint laws. *Inj Prev*.
2002;8(3):216-20.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12226119&query_hl=3>

Agency for Healthcare Research and Quality. Guide to Clinical Preventive
Services. Chapter 57: Counseling to Prevent Motor Vehicle Injuries.
Second Edition, 1996. <http://www.ahrq.gov/clinic/2ndcps/vehicle.pdf>

**[Article]{.underline}**

Is Pacific race a retinopathy of prematurity risk factor? *Arch Pediatr
Adolesc Med*. 2005;159(8):771-3.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16061786&query_hl=9>

**Summary**

This was a small study from a single medical center of a specialized,
though important, condition. The authors suggest that Alaska Native race
is a risk factor for threshold ROP. There seem to be parallels with
Asian race as well.

**Editorial Comment**

All limitations aside, this study reinforces the idea that neonates are
better off "in the oven" with a healthy full-term gestation. This,
obviously, is always the goal, though sometimes unattainable. With
regards to retinopathy of prematurity (ROP), longer gestations might in
fact be even more important for Asians and Alaska Natives than for other
racial groups, with regards to ocular health. All risks of such
race-specific research aside (for a detailed discussion, please see the
excellent AAP CONACH Policy Statement below; yet another example of
reasons to pay your AAP dues!) a heightened awareness of
"susceptibility" of Alaska Natives to ROP might translate into greater
diligence on the part of providers caring for these groups. We will have
to await the results of larger series to see if the conclusions of this
study in fact hold true.

**Additional Reading**

Ethical considerations in research with socially identifiable
populations.\
*Pediatrics*. 2004 Jan;113(1 Pt 1):148-51.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14702468&query_hl=13>

Susceptibility to retinopathy of prematurity in Alaskan Natives.\
*J Pediatr Ophthalmol Strabismus*. 1994;31(3):192-4.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7931954&query_hl=3>

# Announcements from the AAP Indian Health Special Interest Group 

Sunnah Kim, MS Listing of Funding Opportunities

The National Center for Medical Home Initiatives for Children with
Special Needs located at the AAP updates a list of funding announcements
on a daily basis. The list includes current funding opportunities
related to a variety of child and family health issues. This list can be
accessed at:

<http://www.medicalhomeinfo.org/grant/funding.html>

**2006 CATCH Implementation Funds - Call for Proposals**\
**Deadline:** January 31, 2006

The Community Access to Child Health (CATCH) Implementation Funds
program supports pediatricians in the initial and/or pilot stage of
developing and implementing a community-based child health initiative.
Grants of up to \$10,000 are awarded each year on a competitive basis to
pediatricians who want to initiate and develop a pilot project that
addresses the local needs of children in the community. Pediatricians
and pediatric residents are eligible to apply.

In addition, CATCH is pleased to announce a specific funding opportunity
within this 2006 Implementation Funds cycle. **CATCH will also be
offering Early Childhood Obesity grants for pediatricians who wish to
focus their interventions on obesity prevention in children from birth
to 8 years old.** More information will be provided in the Call For
Proposals for CATCH Implementation Grants. [Click
here](http://www.aap.org/catch/implementgrants.htm) for more
information.

**Locums Tenens and Job Opportunities**

If you have a short or long term opportunity in an IHS, Tribal or Urban
facility that you'd like for us to publicize (i.e. AAP Web site or
complimentary ad on Ped Jobs, the official AAP on-line job board),
please forward the information to <indianhealth@aap.org> or complete the
on-line locum tenens form at <http://www.aap.org/nach/locumtenens.htm>

.