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

Deng Hsaio P'ing

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 steve.holve@tchealth.org

IHS Child Health Notes

June 2008

# Quote of the month

*"Anger is contagious.*"

Sandra Cisneros

**Articles of Interest**

Identification and Evaluation of Children with Autism Spectrum
Disorders. *Pediatrics* 120: 5; 1183-1213 November 2007

Management of Children with Autism Spectrum Disorders. *Pediatrics*
120:5; 1161-1182 November 2007

These two clinical reports published in *Pediatrics* in November 2007
provide a complete summary for the clinician on autism spectrum
disorders (ASDs). The review last month highlighted the identification
and evaluation of children with autism spectrum disorders. The review
this month will describe management strategies.

**Summary**

Autism Spectrum Disorders (ASDs) are not rare with an estimated
frequency in Europe and North America of 1/150 births. Given this
frequency most primary care providers will care for several patients
with this disorder.

ASDs, like other neurodevelopmental disorders are generally not curable
but can benefit from management like other chronic diseases. The goal is
to minimize the deficits associated with ASD such as speech impairment
and social interactivity while maximizing the potential of patients to
function independently.

There are a variety of modalities used to treat ASDs. Relatively few of
these have been rigorously evaluated. The most work has been done with
applied behavior analysis, a form of behavior modification. Studies have
shown improvement in IQ measurements, academic performance, and social
adaptiveness. For interventions to be effective they need to be
intensive and sustained which is defined as one on one teaching for a
minimum of 25 hours/week.

Medical management is also discussed. Seizures occur in 20-40% of
children with autism and treatment is based on the same principles used
to treat other children with epilepsy. Challenging behavior, especially
behaviors that include aggression or self-injurious may benefit from a
trial of medications. SSRIs have been used for the past decade. Recently
Risperidone® has been licensed by the FDA for use for symptoms of
irritability and aggression in children with ASDs.

Lastly, a large number of biological and non-biological treatments have
been offered for treatment of ASDs. Appropriately designed trials have
show no benefit for treatment for the following; dimethlyglycine,
vitamin B6, magnesium, secretin, auditory integrative training and
facilitated communication. Many other treatments have not been
rigorously evaluated but are offered to patients; these include
immunotherapy, chelation, anti-fungals, various elimination diets and
complementary and alternative medicines. The physician's job is to help
families use the best evidence to choose therapies with proven benefit
and avoid therapies with potential risks.

**Editorial Comment**

There is no cure for ASDs. Medical therapies for ASDs are limited but
may be of benefit for specific indications. Educational interventions
have the most potential but require personnel who are familiar with ASDs
and can devote intensive time treatment. There is good evidence that
children need intervention as soon as the diagnosis of ASD is
entertained and that the intervention needs to be intensive with a
minimum of 25/hours a week. This kind of expertise and intensive
treatment could be made available through Head Start or public schools.
The reality in many rural settings is that these patients may struggle
to get the services they need. The physician's job is to be an advocate
at the school for needed services.

**Infectious Disease Updates**.

Rosalyn Singleton, MD, MPH

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

Michael L. Bartholomew, MD

In a moment of unconscious communication Drs. Singleton and Bartholomew
both submitted reviews on the same article. This study below
demonstrates that the persistence of substandard housing and plumbing
accounts for at least some of the continuing disparity in infectious
disease burden for AI/AN children. As physicians we often focus on
medical determinants, such as vaccines and antibiotics, and may overlook
many of the other important factors in health.

Hennessy TW, Ritter T, Holman RC, Bruden DL, Yorita KL, Bulkow L, Cheek
JE, Singleton RJ, Smith J. The Relationship Between In-Home Water
Service and the Risk of Respiratory Tract, Skin, and Gastrointestinal
Tract Infections Among Rural Alaska Natives. *American Journal of Public
Health* May 2008 Vol 98 No. 5

http://www.ncbi.nlm.nih.gov/pubmed/18382002?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

Modern water and sanitation services have long been known to be
important in improving health and reducing the transmission of
infectious diseases. During the first half of the 20^th^ century,
multiple surveys attempting to assess the health status of American
Indians and Alaska Natives (AI/AN) cited a lack of water and waste
disposal services as significant causal factors to the high rates of
infectious diseases among AIs and ANs.^1^ In 1959, The Indian Sanitation
Facilities Act (P.L. 86-121) authorized the Indian Health Service to
provide water and sanitation services to homes and communities. Since
its inception, the impact on Native Health has been dramatic with
reductions in morbidity and mortality from infectious diseases among
AI/ANs.

This study investigates the relationship between modern sanitation
services (in-home water services and wastewater disposal services) and
hospitalization rates for respiratory, skin, and gastrointestinal tract
infections in rural Alaska villages. Between 2000 and 2004, in-home
water and waste disposal services were surveyed and analyzed in rural
villages within defined regions in Alaska. Water service data for one
region (Region A) was further examined on a village level. Additionally,
regional and village level (Region A) hospitalization rates for
infectious gastroenteritis, pneumonia or influenza, RSV among children
less than 5 years, skin or soft tissue infection, and methicillin
resistant *Staphylococcus aureus* (MRSA) infections were obtained and
compared.

Overall, in-home water service was present in 73% (range 57%-100%) of
homes while 71 %( range 55%-100%) of homes had wastewater services. This
is in comparison to the 99.4% of homes in the United States with modern
sanitation services. Unevenly distributed, 61% of homes had in-home
water service within Region A (designated a low service area). Thirty
percent of the population (less than 10% of homes) within Region A lived
in homes that lacked modern sanitation. The largest town had 99.5% of
homes with in home water service, accounting for 23% of the Region A's
population.

Regional hospitalization rates differed by water service level. Children
less than 5 years of age living in low service regions were 3.4 times
more likely to be hospitalized for RSV than children living in high
service regions (95%CI=3.0,3.8). This trend can also be seen in all ages
with pneumonia or influenza (RR=2.5; 95% CI= 2.4, 2.7)), skin or soft
tissue infections (RR=1.9; 95% CI=1.8, 2.1)), and MRSA infections
(RR=4.5; 95% CI=3.6, 5.7)). Hospitalization rates between high and low
service regions for infectious gastroenteritis showed no difference.
This may be related to the adequate availability of safe drinking water
to all homes, low temperature of the water and nutritional status of the
population. Within Region A, hospitalization rates for lower respiratory
tract infections (LRTI), pneumonia, and RSV among infants were the
highest in villages where less 10% of homes had in-home water service.
Significant trends of decreasing rates of hospitalizations of infants
with LRTI and LRTI with pneumonia, skin and soft tissue infections,
*Staphylococcus aureus* infections and MRSA infections were seen with
increase proportions of homes with in-home water service.

Despite the inability to draw casual conclusions, the results strongly
suggest an association between water service and infectious disease.
In-home water service is an important public health intervention. The
authors conclude from the results of this study that the simple
intervention of providing modern water and sanitation to all homes in
rural Alaska villages would significantly improve health of Alaska
native children. The same can be said for all homes on tribal lands.

Reference:

1.  Galloway JM, Goldberg BW, Alpert JS. 1999. *Primary Care of Native
    American Patients: Diagnosis, Therapy, and Epidemiology*. Boston:
    Butterworth-Heinemann

**Editorial Comment by Dr Singleton:**

The study, published American Journal of Public Health, demonstrated
that RSV hospitalization rates (Relative Rate \[RR\] = 3.4 in children
\<5 years), pneumonia and influenza hospitalization rates (RR=2.5), and
skin or soft tissue infection rates (RR=1.9) were higher in Alaska
regions with low levels of water service than those with high levels of
service. Diarrheal disease hospitalizations were uncommon and rates were
similar throughout Alaska; each village has a supply of potable water.

Lack of clean water and wastewater disposal may contribute to
respiratory and skin infections by making hand washing and body hygiene
more difficult because families are conserving water for cooking and
drinking. In many other parts of Indian Country, the lack of in-home
water service is similar to rural Alaska. This study highlights the
importance of addressing non-medical household determinants of health
through construction of in-home sanitation services. Providing these
basic services has the potential to reduce respiratory, skin and
diarrheal diseases, through availability of adequate amounts of potable
water for consumption and hygiene.