*"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 sholve@tcimc.ihs.gov

IHS Child Health Notes

August 2006

# Quote of the month

*"Of course, it is important to be a good listener -- but it also pays
sometimes, to be a little deaf"*

Yiddish Proverb for newlyweds

**Articles of Interest**

Outcomes among newborns with total serum bilirubin levels of 25 mg per
deciliter or more. N Engl J Med. 2006 May 4;354(18):1889-900\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=pubmed>

Neonatal hyperbilirubinemia\--what are the risks?\
N Engl J Med. 2006 May 4;354(18):1947-9.

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

An assessment of neurodevelopmental outcome in 140 infants at term or
near term with total serum bilirubin levels \> 25mg/dl. 130 patients had
bilirubin levels \> 25 mg/dl and \<30 mg/dl while 10 infants had
bilirubin levels \> 30 mg/dl. 135 patients were treated with
phototherapy alone and 5 patients received exchange transfusions.

No patient had kernicterus. There was no increase in the number of
patients with abnormal neurological findings on exam or documented
diagnoses of neurological abnormalities compared to control infants.
Patients with positive direct antiglobulin tests had lower scores on
cognitive tests but no more neurologic or behavioral problems.

**Editorial Comment**

This study is reassuring that bilirubin levels of \< 30 mg/dl are
unlikely to put an infant at risk for kernicterus or adverse neurologic
outcome. The one subgroup at higher risk are those with hemolytic
disease and these patients should be treated more aggressively with
phototherapy and exchange transfusion if indicated. This is consistent
with the newest AAP guidelines on hyperbilirubinemia from 2004.

The editorial also notes that the biological risk for hyperbilirubinemia
is genetically based. It is already known that the risk is higher in
Asians and also in American Indians of the southwest. American
Indian/Alaskan Native infants in general may be at higher risk than the
general population for hyperbilirubinemia and deserve our extra
attention.

For further reading:

Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks
of Gestation Pediatrics 2004 114: 297-316

<http://aappolicy.aappublications.org/cgi/content/abstract/pediatrics;94/4/558>

Jaundice in Navajo neonates.\
Clin Pediatr (Phila). 1992 Dec;31(12):716-8.

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

Exaggerated jaundice in Navajo neonates. The role of bilirubin
production.\
Am J Dis Child. 1986 Sep;140(9):889-90.

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

**Infectious Disease Updates**.

Rosalyn Singleton, MD, MPH

 

**Vaccine: Update on New Recommendations**

There have been so many new vaccine recommendations pouring out of the
Advisory Committee on Immunization Practices (ACIP) that I decided a
general update was in order (I can barely keep these all straight and
this is my job!):

1.  **Menactra®** (meningococcal conjugate) vaccine was in the news
    because of a vaccine shortage. The ACIP recommends deferring the
    doses in 11-12 year old and concentrating on the 15 year olds and
    college freshmen entering dorms.
    <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm55d520a1.htm?s_cid=mm55d520a1_e>
    We are changing the RPMS forecasting in late summer so that it only
    forecasts for 15 year olds.

2.  **RotaTeq®** (rotavirus) vaccine provisional recommendations have
    been published:
    <http://www.cdc.gov/nip/recs/provisional_recs/rotavirus-child.pdf>
    RotaTeq is recommended as a 3 dose oral vaccine for children 6-32
    weeks. The first dose must be given before 13 weeks of age, or you
    don't start the series, and the last dose must be given by 32 weeks
    of age. The unique forecasting for this vaccine will be included in
    the late summer RPMS patch.

3.  **Gardasil®** (Human papillomavirus -- HPV) vaccine is licensed for
    9-26 year old females and the ACIP has recommended HPV vaccine for
    routine vaccination of 11-12 year olds with catch-up for older ages.
    <http://www.cdc.gov/od/oc/media/pressrel/r060629.htm>. Gardasil will
    be eventually covered under Vaccine for Children Program; however,
    we are still waiting for news of a federal contract for this vaccine
    (anticipated in Fall) and ACIP recommendations have not yet been
    published.

4.  **Varicella vaccine** -- the ACIP just voted for a routine 2^nd^
    dose of Varicella to be given at school entry (4-6 years of age).
    This recommendation will be included in the RPMS forecasting in the
    late summer RPMS Immunization patch.
    <http://www.cdc.gov/od/oc/media/pressrel/r060629-b.htm>

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

Doug Esposito, MD

**[Article]{.underline}**

Mental disorders among parents/caretakers of American Indian early
adolescents in the Northern Midwest. *Soc Psychiatry Psychiatr
Epidemiol*. 2006 Jun 15; \[Epub ahead of print\]
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=16779502&query_hl=1&itool=pubmed_DocSum>

**Summary**

This study employed a culturally modified version of the University of
Michigan Composite International Diagnostic Interview (UM-CIDI) to
investigate the 12-month and lifetime prevalence of five DSM-III-R
diagnoses among 861 Northern Midwest American Indian and Canada First
Nations parents and caretakers of 10-12 year-old children. The five
conditions assessed were alcohol abuse, alcohol dependence, drug abuse,
major depressive disorder, and generalized anxiety disorder. Prevalence
rates were then compared to rates reported from studies of a Northern
Plains and a Southwest American Indian culture, and to the general U.S.
adult population. The authors discuss their findings in the context of
the inherent difficulties faced when studying small, culturally
distinct, and often geographically isolated Native populations in the
U.S. and Canada. They scrutinize method variance as a possible source
for divergent prevalence rates for some psychiatric disorders reported
in studies of different cultural groups.

Study subjects were from four American Indian reservations in the
Northern Midwest and five Canada First Nation reserves, all of whom
share a common cultural tradition and language. The authors report a
lifetime prevalence of 74.6% of at least one of the five conditions
assessed, with males being more likely than females to meet these
criteria. Nearly 32% of the adult parents and caretakers satisfied
criteria for two or more of the surveyed conditions. Females were almost
twice as likely as males to be without any of the five surveyed
conditions over their lifetimes in this study.

As expected, substance abuse disorder rates were high, with 49.6% of
respondents meeting criteria for alcohol abuse, 20.9% for alcohol
dependence, and 22.4% for drug abuse. Statistically significant male to
female differences were identified for alcohol dependence and drug abuse
only, with the prevalence in males exceeding females.

A lifetime prevalence of 17.1% for major depressive disorder and 4.5%
for generalized anxiety disorder was found. Both conditions were more
prevalent in females than males in this study.

Comparisons were made to the National Comorbidity Survey (NCS) and the
American Indian Service Utilization, Psychiatric Epidemiology, Risk and
Protective Factors Project (AI-SUPERPFP). These assessment tools were
similar, but not identical, to the methodology used to survey the study
population. Suffice it to say that there were inter-study differences in
prevalence rates for four of the five DSM-III-R diagnoses surveyed. A
thorough review of the methodological issues that might account for
these inter-study differences is offered, but is beyond the scope of
this review. The interested reader is encouraged to review the paper in
its entirety.

**Editorial Comment**

The findings reported by the authors of this study are WAY concerning!
The high lifetime prevalence rates for the five diagnoses surveyed
reflect the distress of our American Indian and Canada First Nations
families. And, these are only five out of the total universe of
diagnoses that might have been investigated!

Correctly, the authors state: "These findings have serious implications
for effective parenting and family functioning. The prevalence rates
also call attention to the need to improve access, identify and
eliminate cultural barriers, and improve funding for mental health
service among Northern Midwest and Canadian First Nations people." I
suggest this is true for essentially all AI/AN and Canada First Nations
populations, both rural and urban.

Last month, I reviewed an article authored by researchers from The
National Center for American Indian and Alaska Native Mental Health
Research, University of Colorado Health Sciences Center. This
institution continues to offer an important body of information
regarding the mental health status of American Indian groups. Though not
the authors of the article currently under review, they are the
originators of the AI-SUPERPFP and the litany of related reports and
articles that are extensively referenced.

The authors of this month's article pay homage to the originators of the
AI-SUPERPFP by stating "The first publications from the AI-SUPERPFP data
are radically changing the landscape of American Indian psychiatric
epidemiology by providing the first population sample that can be
compared to national psychiatric epidemiological surveys. This important
study will become the benchmark for future research on psychiatric
disorders in American Indian populations\... Researchers are now in a
position to replicate AI-SUPERPFP work with other Native cultures to
provide cumulative and comparable information that will inform policy
makers and service providers regarding potential systematic differences
in prevalence rates across cultures."

The importance of this comment cannot be overstated. There is a
cumulative value for each and every published report related to the
health of AI/AN and Canada First Nations peoples. One-by-one, greater
light is shed on the socioeconomic and health issues and disparities
burdening these populations, bringing into crisper focus exactly what
needs to be done. Someday, we will find a way to use this knowledge to
achieve equity in health status for North American Native populations
and once-and-for-all end the injustice.

**Additional Reading**

Social epidemiology of trauma between 2 American Indian reservation
populations.\
*Am J Public Health*. 2005 May;95(5):851-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=15855465&query_hl=10&itool=pubmed_docsum>

Cultural specificity and comparison in psychiatric epidemiology: walking
the tightrope in American Indian research. *Cult Med Psychiatry*. 2003
Sep;27(3):259-89.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=14510095&query_hl=8&itool=pubmed_DocSum>

Prevalence of mental disorders and utilization of mental health services
in two American Indian reservation populations: mental health
disparities in a national context. *Am J Psychiatry*. 2005
Sep;162(9):1723-32.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=16135633&query_hl=8&itool=pubmed_docsum>

# 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>

.