*"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

August 2007

# Quote of the month

*"Hypocrisy is the homage vice pays to virtue"*

Oscar Wilde

**Articles of Interest**

Lactose intolerance in infants, children, and adolescents.\
Pediatrics. 2006 Sep;118(3):1279-86.

<http://aappublications.org/cgi/content/abstract/118/3/1279>

Lactose intolerance is common, especially in non-white populations. The
AAP has released a summary statement based on a systematic review of the
literature.

The most important point is that while primary lactase deficiency is
common in older children and adults it is uncommon in children \< 3
years of age. Congenital lactase deficiency is extremely rare. Nearly
all infants, including AI/AN infants, should be able to have lactose in
their diets.

Transient secondary lactase deficiency after an acute viral
gastroenteritis is common and nearly always resolves rapidly. Only very
young children (\< 3 months) or malnourished children will need a
lactose free formula.

Most children, even if lactose deficient, can drink up to 8 ounces of
milk in a day without symptoms. Formal testing is not needed. A trial of
a lactose free diet followed by reintroduction of lactose containing
milk and recurrence of symptoms is sufficient to make the diagnosis.

**Editorial Comment**

We spend a lot of time worrying about cow's milk. Breastfeeding is best
but most infants should be able to drink a lactose containing formula if
needed. Older children can often drink some milk and can take partially
digested products including cheese and yogurt and pretreated milk. It is
the rare child who needs all lactose foods removed from their diet.

**Infectious Disease Updates**.

Rosalyn Singleton, MD, MPH

**Flu News**

 **2006-7 Influenza activity** in the United States peaked in
mid-February. In late May, 20 states reported sporadic activity, and 30
states reported no influenza activity. It was a mild Flu season and the
percent of deaths due to pneumonia and influenza remained below baseline
levels for the entire influenza season. Between Oct. 2006 -- May 2007,
CDC received 60 reports of influenza-associated pediatric deaths Since
October 1, 2006, of the 23,181 influenza viruses cultured, 18,392
(79.3%) were influenza A viruses and 4,789 (20.7%) were influenza B
viruses. Among the influenza A viruses, 63.5% were H1 viruses and 36.5%
were H3 viruses. Influenza vaccine is expected to be in good supply for
the 2007-8 season -- The CDC says that the US should have a record 127
million flu vaccine doses for next season.

**Live nasal flu vaccine (FluMist®)** is currently licensed only for
5-49 year olds. Two FluMist® studies were published in October in
Pediatric Infectious Disease Journal. The first indicated that FluMist®
was well-tolerated in children with asthma. The second study showed that
FluMist® was associated with fewer cases of flu from vaccines than the
Flu shot in 6-71 month old children. MedImmune Inc. has applied for an
age expansion of FluMist® down to 1 year of age.

**Bird Flu cases** among humans and birds have been declining since
January. Although WHO officials think the current cycle of the H5N1
strain is nearing an end, they remain concerned about \"pockets\" of the
disease in Indonesia, Nigeria, and Egypt. Preparing for a global
pandemic in the event that the virus mutates and passes from person to
person should still be a major priority.

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

Doug Esposito, MD

**[Article]{.underline}**

**[Article]{.underline}**

Williams JF, Storck M, American Academy of Pediatrics Committee on
Substance Abuse; American Academy of Pediatrics Committee on Native
American Child Health. Inhalant abuse. *Pediatrics*. 2007
May;119(5):1009-17

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17473104&query_hl=5&itool=pubmed_docsum>

**Editorial Comment**

This Clinical Report was jointly authored by the AAP Committee on
Substance Abuse and the Committee on Native American Child Health, and
stands as a valuable reference for those working with AI/AN children.
Unfortunately, children in the populations we serve are known to be at
elevated risk for abusing inhalants, especially the volatile
hydrocarbons. They are easy to obtain, being almost ubiquitous in homes
and the local environment. They are legal (for their intended uses),
easy to conceal, and inexpensive. Consequently, they tend to be more
widely abused by younger kids than any other substance class.
Furthermore, this problem does not respect national boundaries. First
Nations populations in Canada widely report high rates of this malady,
and I have seen first hand large numbers of Native children in both
Central and South America partaking of this form of "escape." In the
U.S., inhalant abuse occurs everywhere and among all ethnicities and
socioeconomic classes. However, it tends to be more prevalent anywhere
there is significant socioeconomic disadvantage, geographic isolation
(code for rural), and social isolation; *ergo* Reservations.

For anyone working with Native populations for any length of time, if
you haven't run into this problem yet, then you haven't been looking.
It's out there! For those of us on the Navajo Nation, all you have to do
is look around the Bashas' parking lot or in the adjacent weeds and
drainage ditches to find the ubiquitous cans of AquaNet hairspray used
to make "ocean." Although a reasonably common practice among adults,
kids partake of this concoction as well. And, its use (or misuse) can be
fatal. I've seen it!

I would encourage everyone to at least skim this article, or better yet,
read it thoroughly and in its entirety. I am sure you will find it to be
either a valuable review of or an excellent introduction to a prevalent
and dangerous problem. Please, be on the look out.

**[Article]{.underline}**

Centers for Disease Control and Prevention. Fatal Injuries Among
Children by Race and Ethnicity -- United States, 1999-2002. Surveillance
Summaries, May 18, 2007. *MMWR* 2007;56(SS-5).

<http://www.cdc.gov/mmwr/PDF/ss/ss5605.pdf>

**Editorial Comment**

The last time I wrote to you all, I reviewed an article by Pressley, *et
al*^1^ on early childhood injury.^2^ In that review, I pointed out an
important study limitation related to the racial misclassification that
occurs on death certificates and the impact racial misclassification has
on reported mortality and disease rates that are derived from death
certificate-dependent databases. The resultant effect of this bias is to
underestimate mortality and disease rates for Native Americans.

Well, as luck would have it, the very week I submitted my review to Dr.
Holve a similar study was published in the *MMWR*! In this report, the
authors referenced a CDC study that quantifies the net effect of this
error. They state that "adjusting for misclassification would increase
reported rates for AI/ANs by approximately 20.6%."^3^ Wow!!

So, what does this all mean? Injury mortality rates for AI/AN children
are significantly worse and the disparities significantly greater than
reported. This renders the progress that appears to have been made far
less impressive. Although progress is certainly being made, much remains
to be done if we are to successfully eliminate injury as a health
disparity for AI/AN children by 2010. *Healthy People 2020*, anyone?

**References**

1\. Pressley JC, Barlow B, Kendig T, Paneth-Pollak R. Twenty-year trends
in fatal injuries to very young children: the persistence of racial
disparities. *Pediatrics*. 2007 Apr;119(4):e875-84.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17403830&query_hl=4&itool=pubmed_DocSum>

2\. IHS Child Health Notes, June/July 2007.
<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/IHSchildnotesJune2007.doc>

3\. [Rosenberg
HM](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Rosenberg HM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Maurer
JD](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Maurer JD"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Sorlie
PD](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Sorlie PD"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Johnson
NJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Johnson NJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[MacDorman
MF](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="MacDorman MF"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Hoyert
DL](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Hoyert DL"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Spitler
JF](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Spitler JF"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Scott
C](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Scott C"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Quality of death rates by race and Hispanic origin: a summary of current
research, 1999. [*Vital Health Stat
2*.](javascript:AL_get(this, 'jour', 'Vital Health Stat 2.');) 1999
Sep;(128):1-13.

<http://www.cdc.gov/nchs/data/series/sr_02/sr02_128.pdf>

**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>

.