*"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

**December 2007**

# Quote of the month

*"Good artists copy, great artists steal."*\
Pablo Picasso

**Articles of Interest**

U.S. Food and Drug Administration Public Health Advisory:
Nonprescription cough and cold medicine use in children. August 15, 2007

<http://www.fda.gov/cder/drug/advisory/cough_cold.htm>

The FDA issued a public health advisory on non-prescription cough and
cold medicines in children. Highlights included:

-   Parents should not use cough and cold products in children \< 2
    years unless instructed by their physician

-   Parents should use only a dropper or dosing cup or dosing spoon
    provided with the medication

-   Parents should administer only the specified amount of medication

**Editorial Comment**

It will soon be cough and cold season. All parents want to make their
children feel better. The FDA advisory suggests that non-prescription
cough and cold medicines have significant risks and little benefit and
their use should be limited.

This advisory follows a CDC report in January of 2007 that reported on
infant deaths associated with cough and cold medications.

<http://www.cdc.gov/od/oc/media/mmwrnews/2007/n070111.htm>

There is no evidence that non-prescription medication alleviates cough
and cold symptoms in children. There is now good evidence that there are
risks with these medications, especially in younger children and
infants. Most of the serious morbidity and mortality related to
inappropriate dosing hence the FDA warning to consult a physician and an
emphasis on correct measuring of medication.

A final word on treatment of colds for this winter. A recent literature
review looked at treatment of cold symptoms with zinc. Zinc lozenges and
nasal sprays are available as non-prescription medications. There is a
perception that zinc is a natural remedy and less toxic. The review
found little evidence that zinc improved cold symptoms. There were
several reports of anosmia with use of intranasal zinc. Again, the best
remedy for a cold is rest, anti-pyretics, fluid and maybe chicken soup.

Treatment of naturally acquired common colds with zinc: a structured
review.

Clin Infect Dis. 2007

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17682990&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

**Infectious Disease Updates**.

Rosalyn Singleton, MD, MPH

**Vaccines Shortages: PedvaxHIB®**

Merck & Co., Inc. has reported that PedvaxHIB® is unavailable for
shipment. Based on the latest information, Merck expects PedvaxHIB®
(PRP-OMP) to be available sometime in the first quarter of 2008. Merck
reports that the exact timing is dependent upon resolution of a
manufacturing issue. There are currently adequate amounts of ComVax®
(PRP-OMP/Hepatitis B) to meet historical demand, but not to meet
additional demand. Updates of vaccine availability may be found at:
[[http://www.cdc.gov/vaccines/vac-gen/shortages/default.htm#chart]{.underline}](http://www.cdc.gov/vaccines/vac-gen/shortages/default.htm#chart)

IHS has made an official request to CDC that American Indian/ Alaska
Native (AI/AN) children be prioritized for PedvaxHIB® vaccine, citing
the 2006 Redbook statement:

*\"Before availability and public use of conjugated Hib vaccines, the
incidence of invasive Hib disease was up to 10 times higher among young
AI/AN children compared with the general US population. Because of the
high risk of invasive Hib disease within the first 6 months of life in
many AI/AN infant populations, the Indian Health Service (IHS) and the
AAP recommend that the first dose of Hib conjugate vaccine contain
polyribosylribitol phosphate-meningococcal outer membrane protein
(PRP-OMP) as a single-antigen vaccine or in a combination vaccine with
other antigens. The administration of a PRP-OMP-containing vaccine leads
to more rapid seroconversion to protective concentrations of antibody
within the first 6 months of life, and failure of use has been
associated with excess cases of Hib disease in young infants in this
population\....Thus for clinics that serve predominantly AI/AN children,
it may be prudent to use only a PRP-OMP Hib vaccine.\"*

CDC has tentatively agreed to prioritize PedvaxHIB® for AI/AN children;
however we are waiting for final language. If you currently use
PedvaxHIB® we recommend that you do the following:

1.  Check with your state VFC program re: PedvaxHIB® and ComVax® supply

2.  We will send the CDC prioritization language as soon as it is
    finalized so that you can work with your state VFC program to
    continue administering PedvaxHIB®

3.  If supply is limited at the moment, we recommend that you use
    PedvaxHIB® or ComVax® for the primary series (first two doses) if
    possible.

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

Doug Esposito, MD

**[Article]{.underline}**

[Holve
S.](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17957458&ordinalpos=8&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum)
An Observational Study of the Association of Fluoride Varnish Applied
During Well Child Visits and the Prevention of Early Childhood Caries in
American Indian Children. *Matern Child Health J*. 2007 Oct 24; \[Epub
ahead of print\]
<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17957458&ordinalpos=8&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum>

**Editorial Comment**

This observational study evaluates the efficacy of a fluoride varnish
application strategy in a rural reservation community. Early Childhood
Caries (ECC), the most common chronic disease of childhood, disparately
afflicts American Indian/Alaska Native kids at an alarming six fold
greater rate than their white counterparts. Although many healthcare
workers and families have the perception that this condition is little
more than a minor annoyance whose effects are perhaps purely cosmetic,
ECC is frequently debilitating and negatively and significantly impacts
child wellbeing. Documented and preventable consequences of ECC include
increased caries in permanent teeth, hospitalization, increased
emergency room visits, increased treatment costs, impacts on optimal
child development (especially height, weight, and speech), lost school
days, impacts on educational attainment, and decreased quality of life.
Carious teeth surely hurt! ECC is an important and prevalent disease
that has received little attention from pediatricians until fairly
recently.

This study demonstrates that four or more applications of fluoride
varnish in early childhood can reduce the burden of dental caries in a
very high-risk population of children. Applications targeted the 9, 12,
15, 18, 24, and 30 month well child visit. Beyond the demonstrated
reduction in "decayed, missing, or filled surfaces" (dmfs) score that
was used as the study outcome, fluoride varnish applications in the well
child visit setting are known to be quick and efficient from both a time
and manpower perspective, and in some states, represent a fully billable
service.

Please, please, please implement a fluoride varnish program soon in your
practice setting, if you haven't already. We pediatricians, in
partnership with our pediatric dentist colleagues and in combination
with new and promising strategies on the horizon, will likely have the
capacity to one day eliminate ECC as a health disparity in American
Indian/Alaska Native children. We must position ourselves to be able to
implement these new strategies as soon as they become available. The
universal application of fluoride varnish in AI/AN children, although
not perfect, is an important step in the right direction. At a minimum,
you will be doing your individual patients and families an important
service. But, the greater goal is the elimination of those pesky and
tenacious health disparities!

**Additional Reading**:

[Hale
KJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Hale KJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus);
[American Academy of Pediatrics Section on Pediatric
Dentistry](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="American Academy of Pediatrics Section on Pediatric Dentistry"%5BCorporate Author%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Oral health risk assessment timing and establishment of the dental home.
[*Pediatrics*.](javascript:AL_get(this, 'jour', 'Pediatrics.');) 2003
May;111(5 Pt 1):1113-6.

<http://aappolicy.aappublications.org/cgi/reprint/pediatrics;111/5/1113.pdf>

**[Article]{.underline}**

[LaRowe TL, Wubben DP, Cronin KA, Vannatter SM, Adams
AK.](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17875253&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum)
Development of a culturally appropriate, home-based nutrition and
physical activity curriculum for Wisconsin American Indian families.
*Prev Chronic Dis*. 2007 Oct;4(4):A109.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17875253&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum>

**Editorial Comment**

Using the community participatory research model, the authors describe
the development and implementation of a home-based intervention
targeting childhood obesity. This program seeks to bring about lasting
lifestyle changes related to improved nutrition and increased physical
activity among Head Start children and their families living on three
Wisconsin American Indian reservations.

The project employs community mentors to deliver a culturally specific
curriculum to children at an age critical to the development of lasting
food preferences and physical activity patterns. Through the alteration
of the child's home environment, the researchers seek to impact health
outcomes (obesity) through the promotion of durable positive health
behaviors. Specific behaviors being targeted include: "1) increasing
fruit and vegetable intake; 2) increasing physical activity; 3)
decreasing consumption of candy, soda, and other sweetened beverages;
and 4) decreasing television viewing time." Makes sense, right?

Only recently implemented, it will be interesting to see the effect of
this 12 month project. Depending on the strength and durability of the
effect, this program might be appropriately adapted for use in other
American Indian communities. Stay tuned.

# Announcements from the AAP Indian Health Special Interest Group 

Sunnah Kim, MS **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>

11/17/07njm