*"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

April 2006

# Quote of the month

*"It ain't what people don't know that's so dangerous, it's what people
know that just ain't so."*

Will Rogers

# Articles of Interest

Hearing thresholds and tympanic membrane sequelae in children managed
medically or surgically for otitis media with effusion.\
Arch Pediatr Adolesc Med. 2005 Dec;159(12):1151-6.

Long-term sequelae of ventilating tubes: implications for management of
otitis media with effusion**.** [[Arch Pediatr Adolesc
Med.]{.underline}](javascript:AL_get(this, 'jour', 'Arch Pediatr Adolesc Med.');)
2005 Dec;159(12):1183-5

-   A 10 year follow-up of children who were randomized to either
    medical or surgical treatment for persistent otitis media with
    effusion (OME)

-   Surgical treatment was with ventilating tubes which were removed
    after 12 months

-   Medical treatment was with low dose sulfisoxazole for 6 months

-   The risk of long term tympanic membrane abnormalities (sclerosis,
    retractions, perforations) was 4.4 times higher in the group which
    had ventilation tubes placed

-   Hearing thresholds were 2.1 to 8.1dB higher in children who had
    undergone placement of tubes

-   The risk of mild permanent hearing loss (\>15dB) was 3.3 times
    higher in the group which received ventilating tubes

-   Parental reports of hearing and speech and school success were equal
    in both groups

Editorial Comment

Ventilating tubes (VT) have long been considered an acceptable treatment
for persistent OME. The AAP "Clinical Guidelines on "Otitis Media with
effusion" published in 2004 list OME \> 4 months as one possible
indicator for surgical placement of VT. This recommendation is based on
a decrease in the number of days with effusion and improved hearing
levels of 6 to 12 dB in children while VT remain in place.

VT may provide the short term physiologic benefits described above but
they do not demonstrate any long-term benefit in terms of functional
outcomes in normal children with OME. Children with OME followed to age
5 years have similar outcomes in hearing and speech whether they have
had medical therapy or surgical therapy in their younger years.
Unfortunately, as the above study shows, VT placement is likely to
result in a much greater risk of permanent tympanic membrane damage and
functional hearing loss in children.

The 2004 AAP guideline does stress in other sections that "watchful
waiting" may be an acceptable plan for asymptomatic children with OME.
Given the potential harm of VT it seems prudent to only recommend
surgical treatment for children with high risk conditions (Down syndrome
or cleft lip), documented speech delay or significant hearing loss which
is usually defined as \> 40dB. In these groups the risk/benefit ratio
will favor surgical intervention in spite of the documented long-term
risks.

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

Doug Esposito, MD

**Articles of Interest**

Redeeming Hollow Promises: The Case for Mandatory Spending on Health
Care for American Indians and Alaska Natives. *Am J Public Health*. 2006
Feb 28; \[Epub ahead of print\]
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16507732&query_hl=1&itool=pubmed_DocSum>

**Summary**

The authors describe in detail the federal funding process for Indian
health programs as compared to other government health programs. They
discuss the "discretionary" funding structure of AI/AN programs, and
compare that with "mandatory" spending for Medicare and Medicaid,
presenting the shocking (but not surprising) statistics of under
funding. In 1999, according to the Level of Need Funded Workgroup of the
IHS, funding occurred at 54% of what was needed. Several recommendations
are made that if enacted, would, in the authors' opinion, significantly
narrow the funding gap and by extension, allow for meaningful reductions
in AI/AN health disparities. These include treating funding for AI/AN
health programs as "mandatory" rather than "discretionary,"
automatically adjusting funding for inflation in order to preserve
purchasing power, and making funding rates for AI/AN programs comparable
to other government programs. Caution is offered, reflecting pessimism
surrounding the present political climate and the will and ability of
Congress to address this problem in any meaningful or productive way.

**Editorial Comment**

I believe that this is a landmark paper, written by lawyers with health
policy backgrounds, who appear to be motivated by a passion for social
justice. Although the data is not new or earth shattering, a uniquely
cogent, well organized, and logical argument calling for changes in the
funding structure for Indian Health is made that even I can follow!
Hopefully, this article will find its way into the hands of the right
people, and help to change the minds of our legislators. Please read
this article, and pass it along. Everyone associated, even loosely, with
AI/AN Health should have an opportunity to become familiar with the
content of this report.

**[Article]{.underline}**

Endemic iron deficiency associated with *Helicobacter pylori* infection
among school-aged children in Alaska. *Pediatrics*. 2006
Mar;117(3):e396-404. Epub 2006 Feb 1.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16452320&query_hl=9&itool=pubmed_DocSum>

**Summary**

Arctic populations are known to have high rates of iron deficiency that
approximate those seen in the developing world, despite subsistence
diets relatively high in iron and low levels of intestinal parasitosis.
High rates of *H. pylori* infection are also reported in these same
regions.

In this study, the authors confirm a high prevalence of iron deficiency
(38%), iron deficiency anemia (7.8%), and active *H. pylori* infection
(86%) among approximately 700 school-age Yupik children residing in
remote western Alaska. They link as an independent variable active *H.
pylori* infection with iron deficiency and iron deficiency anemia in
these children. Although causality could not be definitively established
due to the cross-sectional study design, they conclude that *H. pylori*
infection might be an important risk factor for iron deficiency in this
population of children who should otherwise be at low risk for this
micronutrient deficiency.

Strengths of the study are large subject numbers, a high participation
rate, and a population-based, cross-sectional design. Additionally, a
validated method was used to diagnose active *H. pylori* infection, in
contrast to most other studies in children which have relied on a
serologically derived case definition. The authors point out that
serologic testing is insensitive and non-specific in children, in
addition to having an inability to differentiate between active and past
infection.

**Editorial Comment**

Yet again, an important study reporting interesting and relevant data
with broad implications for those of us serving AI/AN populations
emerges, thanks to the CDC Artic Investigations Program in Anchorage,
Alaska. What is the prevalence of active *H. pylori* infection among the
specific population of children served in you practice? I searched
PubMed briefly to find out, and identified only a couple of reports
dealing with groups other than those residing in Arctic regions. All of
these reports employed either serologic or stool antigen derived case
definitions, with the associated limitations, and had variable study
objectives. Active infection rates unfortunately were not the objective
of any of these studies. Two of these papers are cited below for the
interested reader.

It is unfortunate that few *H. pylori* investigations have been done in
other Native communities in the U.S. Given comparable levels of poverty,
crowding, sanitation, etc., that occur in the populations we all serve,
one might presume similarities in *H. pylori* epidemiology and its
association with iron deficiency. Our collective clinical experience
serves to further strengthen these suspicions. Alas, we will just have
to wait for additional studies to be done to confirm these concerns.

The authors make an important side point worth reiterating. The
diagnosis of active *H. pylori* infection in children is difficult and
fraught with significant challenges. The gold standard for diagnosis is
biopsy-proven evidence of the bacterium on stained tissue samples
obtained from endoscopic examination of the stomach and proximal
duodenum. Serologic testing is frequently used in clinical practice as a
surrogate to this invasive procedure due to its relative ease of
collection and low cost. Unfortunately, serology is highly inaccurate in
this setting. Cautious use and interpretation of results obtained from
this increasingly popular and potentially misused method is certainly
warranted.

Will treatment of *H. pylori* infected iron deficient children result in
improvement in their iron status? Two reports have been published by the
Arctic Investigations Program reporting the results of this arm of their
study, although I could not properly review them on short notice. I was
able to communicate briefly with Dr. Baggett, a co-author of both of
these reports (cited below) and learned that no effect on iron
deficiency was found after treatment of *H. pylori*. A whole host of
explanations can be posited for this finding, but the details will have
to wait until the next installment of this column. Can you wait that
long? Drum roll, please!

**Additional Reading**

*Helicobacter pylori* infection in children: recommendations for
diagnosis and treatment.\
*J Pediatr Gastroenterol Nutr.* 2000 Nov;31(5):490-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11144432&query_hl=32&itool=pubmed_docsum>

Age at acquisition of *Helicobacter pylori* in a pediatric Canadian
First Nations population. *Helicobacter*. 2002 Apr;7(2):76-85.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11966865&query_hl=34&itool=pubmed_docsum>

Transient and persistent *Helicobacter pylori* colonization in Native
American children.\
*J Clin Microbiol*. 2003 Jun;41(6):2401-7.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12791856&query_hl=36&itool=pubmed_docsum>

A controlled, household-randomized, open-label trial of the effect that
treatment of *Helicobacter pylori* infection has on iron deficiency in
children in rural Alaska. *J Infect Dis*. 2006 Feb 15;193(4):537-46.
Epub 2006 Jan 12.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16425133&query_hl=38&itool=pubmed_docsum>

A randomized trial of triple therapy for pediatric *Helicobacter pylori*
infection and risk factors for treatment failure in a population with a
high prevalence of infection. *Clin Infect Dis*. 2005 Nov
1;41(9):1261-8. Epub 2005 Oct 4.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16206100&query_hl=38&itool=pubmed_docsum>