# **IHS PEDS NOTES**

### **A Newsletter for American Indian/Alaska Native Child Health**

## **January 2002 Volume 19 Bill Green, Editor**

#### Now online with links: <http://www.ihs.gov/MedicalPrograms/MaternalChildHealth/ChildHealth.asp>

*The Special Interest Group (SIG) in Indian Health within the American
Academy of Pediatrics (AAP) Section on Community Pediatrics (SOCP) met
during the NCE in San Francisco and has developed a proposed 4-part
vision statement to guide activities for the coming year....*

The 4 parts are:

1.  Provide a forum for pediatricians and other health providers that
    serve Alaska Native/American Indian children to share successes and
    to attempt to meet needs during a time of profound change in the
    organization of Indian health care, including provision of both
    rural and urban health care.

2.  Sponsor educational programs at AAP meetings that highlight the
    unique aspects of providing comprehensive health care to American
    Indian/Alaska Native children.

3.  Support the work of the AAP Committee on Native American Child
    Health (CONACH) through the dissemination of information about new
    policy statements and advocacy issues, collaboration in development
    of educational programs, and assistance in nominating new members to
    serve on the committee.

4.  Attempt to link SIG members in mentoring or consulting relationships
    to address problems specific to local or regional care of Native
    American children.

Selection for a steering committee has been completed. Thanks to the
efforts of Harold Margolis, DO, and the support of Jeff Goldhagen, MD,
and Peter Simon, MD, MPH, a proposal to have a SIG-sponsored workshop
entitled "A Community Intervention to Prevent Obesity: The Native
American Headstart Obesity Initiative" has been included in the proposed
SOCP program for the 2002 National Meeting (NCE) in Boston. Indian child
health providers and other interested AAP and non-AAP members are again
encouraged to join the SIG and make this our home for Indian child
health within the AAP! For information about how to join, contact Wendy
Nelson at 847/434-7789 or [**wnelson@aap.org**](mailto:wnelson@aap.org).
Comments about the vision statement and future priorities are welcome.

*The National Highway Safety Traffic Administration (NHSTA) encourages
us to talk to families about the proper use of car seats in a time of
increased use of automobile travel...* Specific information about the
November campaign can be found at
[**http://www.nhtsa.gov/people/injury/airbags/BucklePlan/New/
november_announcement.htm**](http://www.nhtsa.gov/people/injury/airbags/BucklePlan/New/ november_announcement.htm).
Despite improvement in recent years, death from unintentional injury
and, specifically, motor vehicle crashes remains 50% to 100% higher in
Indian children, and at least half these deaths could be prevented by
proper restraint. Ben Hoffman, MD, formerly at Gallup Indian Medical
Center and now at UNM Department of Pediatrics, developed a community
coalition to improve car seat use that involved car seat installation
clinics, coupons for purchase of seats at cost, and cooperation with law
enforcement and merchants, which resulted in significant increase in use
after intervention. It has been estimated that 4 out of 5 car seats are
used incorrectly, and Ben found the 5-day certification class held by
NHSTA to be challenging but also a catalyst that helped develop the
community coalition. The National Safe Kids Campaign handout details
some of the points in proper selection and installation of car seats and
is available at
[**http://www.nhtsa.dot.gov/people/injury/childps**](http://www.nhtsa.dot.gov/people/injury/childps).
In an era of concern about airplane hijacking and bioterrorism, we need
to continue to address the proven risks of death to Indian children
through unintentional injuries and motor vehicle accidents by promoting
proper child passenger restraint. Contact me at
[**WGreen@abq.ihs.gov**](mailto:WGreen@abq.ihs.gov) or Ben Hoffman at
[**bhoffman@salud.unm.edu**](mailto:bhoffman@salud.unm.edu) for more
information about the Gallup "Got Belts" program.

*The Neonatal Resuscitation Program has a new teaching CD-ROM that
accompanies its latest teaching manual and is an outstanding step to
more interactive learning...*Included in the CD-ROM are video clips of
live resuscitation scenarios, equipment demonstrations, and interactive
screens (eg, a delivery room in which you can click on and examine
various equipment). The audio and visual reinforcement greatly aids the
learning process, and I recommend those involved in neonatal
resuscitations test-drive this new program, which hopefully will become
a model for other advance life support modules.

*National Shortages of Vaccines have forced interim changes in
immunization schedules, particularly in suspending the fourth and even
fifth DTaP dose in some states and reserving Prevnar (PCV7) for children
under 2 years of age....*Currently there are no national recommendations
for suspending the fourth DTaP dose, although states such as New Mexico
and Minnesota already have taken this step. Sites should check with
their states. Spot shortages are projected to continue for at least 3 to
4 months. Aventis Pasteur is expected to join the current single
manufacturer (GlaxoSmithKline) in supplying vaccine to the Centers for
Disease Control and Prevention (CDC) in the second quarter of next year.
On September 14, 2001, the CDC issued recommendations for priority use
of Prevnar only in children less than 2 years of age and children 2 to 5
years of age with high-risk medical conditions. American Indian and
Alaska Native children, despite increased risk, fall into the "moderate"
rather than "high" risk category (see CDC guidelines MMWR). Immunization
with PPV 23 or unconjugated PNEUMOVAX is a less attractive but approved
interim alternative for children older than 2 years of age; efficacy for
any of these vaccines including PREVNAR has never been studied in these
older children. The shortage in PREVNAR is projected to be over by
spring 2002.

*The Clinical Practice Guideline: Management of Sinusitis in the
September issue of* Pediatrics *provides specific definitions and
treatment algorithms for children*

*1 to 21 years of age...* Diagnosis of acute bacterial sinusitis is
based on clinical criteria of children presenting with upper respiratory
symptoms that are either "severe" (temperature of at least 102
accompanied by purulent nasal discharge for at least 3 to 4 days in a
child who appears ill) or "persistent" (nasal or postnasal drip lasting
longer than 10 to 14 days, daytime cough, or both). Physical exam and
imaging studies are not usually helpful, and CT scans should be reserved
for those for whom surgery is being considered. Antibiotics are
recommended for management of children diagnosed using the above
criteria, although this is based on limited data of 5 controlled
randomized trials and 8 case series. Optimal duration has not received
systematic study; the review suggests that antibiotic therapy be
continued until the patient becomes asymptomatic and then be
administered an additional 7 days. A useful management algorithm for
uncomplicated acute bacterial sinusitis appears on page 804 of the
article.

*Recent evidence-based reviews question the benefits of antibiotics and
myringotomy in the treatment of acute otitis media in children...*

Our longstanding faith in these treatment modalities that has been based
on prevailing practice and literature has been challenged by recent,
more careful review of the evidence. In a 2-part article in the August
2001 issue of *Pediatrics*, Glenn Tanaka, et al, at USC performed a
systematic review of the literature on the role of antibiotics in the
treatment of uncomplicated otitis media. Of 3491 citations reviewed,
only 80 studies had appropriate criteria as either randomized control
trials or cohort studies. Children with AOM not treated with antibiotics
experienced a 1 to 7 day clinical failure rate of 19% with "few
suppurative complications; treatment with amoxacillin reduced the
clinical failure rate to 7%. The researchers concluded that "the
majority of uncomplicated cases of AOM resolved
spontaneously...Amoxacillin confers a limited therapeutic benefit. There
is no evidence to support any particular antibiotic regimens as more
effective in relieving symptoms." In the second part, "Research Gaps and
Priorities for Future Research," they further conclude that "despite the
large body of literature on AOM, its quality is uneven and its findings
are not generalizable."

In an article in the October 2001 *Archives of Pediatric and Adolescent
Medicine*, Pichichero and Poole present data on the accuracy of
pediatricians and ENT physicians in assessing otitis media and
performance of tympanocentesis during a series of CME courses conducted
in 35 cities. The overall correct diagnosis of AOM vs otitis media with
effusion (OME) or normal ear was 50% for pediatricians and 73% for ENTs;
the main error was overdiagnosis of AOM. However, with training
tympanocentesis was "optimally performed" by 83% of pediatricians and
89% of ENTs. In an accompanying editorial, "Should Watchful Waiting Be
Used More Often in Otitis Media," Sandi Pirozzo, points out that the
diagnostic inaccuracy would result in 50% of myringotomies performed for
inappropriate indications (OME rather than AOM) and that 15% of these
might be harmed by improper technique on an immobile study mannequin.
The study did not examine whether myringotomy is an effective treatment
for acute OM, with only 1 RCT and 1 case series in the literature.

Watchful waiting rather than antibiotic treatment has been adopted in
entire populations, such as the Netherlands. An article in the
November/December 2001 issue of the *Journal of the American Board of
Family Practice* describes differences in practices in the US, Great
Britain, and the Netherlands, using the International Primary Care
Network and Ambulatory Sentinel Practice Network: " The Dutch avoid
antimicrobials unless fever and pain persist, the British use them for 5
to 7 days, and the Americans use them for 10 days." These differences in
practice were supported by data in the review that also noted that the
Dutch children presented initially with more severe symptoms, possibly
because of parental attitudes and their care-seeking behavior. "The
consequences of the Dutch approach to AOM care and care-seeking behavior
were reduction in the development of antimicrobial resistance and
costs...Adopting Dutch guidelines restricting the use of antimicrobials
for AOM in the United States would result in annual savings of about
\$185 million."

*The AAP Committees on Attention-Deficit/Hyperactivity Disorder (ADHD)
and Quality Improvement have issued a Clinical Practice Guideline:"
Treatment of the School-aged trial with Attention Deficit/Hyperactivity
Disorder," published in the October 2001* Pediatrics*.* This supplements
the "Diagnosis and Evaluation" guideline published more than a year ago.
(See the June 2000 newsletter issue in the archives.) As in the previous
guideline, recommendations are qualified with strength of evidence and a
consensus strength of recommendation: ADHD should be recognized as a
chronic condition; the treating physician, child, family and school
should collaboratively specify target outcomes; stimulant medication
and/or behavior therapy should be recommended to improve target
outcomes; and there should be periodic, systematic follow-up directed at
target outcomes. When selected management has not met target outcomes,
original diagnosis and treatments should be reevaluated, including
adherence and presence of coexisting conditions. The guideline includes
useful treatment algorithms and a well-referenced discussion of the use
of stimulant medication and effective behavioral techniques. The AAP
also has recently published an information pamphlet for families about
understanding ADHD.

*Ken Fleshman, MD, MPH, received the Native American Child Health
Advocacy Award at the 2001 AAP NCE in San Francisco...* He was granted
this award for his work in developing innovative public health
approaches to solve American Indian and Alaska Native health problems
during 30 years of IHS pediatric practice from Southern Arizona to
Alaska. In his acceptance speech at the SOCP reception, Dr Fleshman
stressed the importance of using knowledge of local epidemiology of
health problems to collaboratively develop community-based
interventions.

*Judy Thierry, DO, a pediatrician and CO, has been selected as Chief of
Maternal Child Health at Headquarters...* In her IHS career, Judy has
been a busy clinician at Albuquerque Indian Hospital; a Clinical
Director at ACL hospital, with a term as head of the National Council of
Clinical Directors and member of the IHS Executive Leadership Group; and
currently is completing a Masters in Public Health at Johns Hopkins. She
is thus uniquely qualified to provide leadership on MCH issues at the
national level. My thanks to the CONACH and other groups that strongly
advocated that this position be filled.

*I will be stepping down as Chief Clinical Pediatric Consultant as of
December 31, 2001...*The past 6 years have gone by quickly, and I have
enjoyed the opportunity to meet with many outstanding child health
providers throughout the Indian Health Service and urban and tribal
programs, as well as IHS "graduates" volunteering on CONACH and other
AAP committees dedicated to the health of Indian children. Despite the
changes in administration of Indian health programs, I feel there
remains a need for ongoing communication and sharing that I have tried
to encourage through this newsletter, the semi-annual IHS Pediatricians
conference, and the new Special Interest Group. Kelly Moore, MD, FAAP,
recently has been selected by Chief Medical Officer Craig Vanderwagen to
replace me as the new Pediatric Chief Clinical Consultant, pending
agency approval. As many of you know, Kelly has been particularly active
in developing standards for the care of children with Type 2 diabetes
and has helped plan the last 3 IHS Pediatrician conferences. She brings
a wealth of clinical and administrative experience from working in the
Phoenix, Navajo, and Billings Areas ---currently, she is Chief Medical
Officer for the Billings Area, as well as an active member in the
American Indian Physicians. Her impressive CV of service, professional
organizations, and original articles does not sufficiently reflect her
patience, wisdom, and quiet but vigorous commitment to improving the
health of Indian children that I have come to know and value in the past
6 years. Contact her at
[**kelly.moore@mail.ihs.gov**](mailto:kelly.moore@mail.ihs.gov).

*David Grossman reports on recent CONACH activities....*

The AAP Committee on Native American Child Health continues to meet
bi-annually, alternating sites between Washington, DC, and Indian
country. The CONACH continues to use its DC meeting to advocate for
improved funding of Indian health programs, particularly those with
likelihood of improving children's health and quality of life.

We met most recently in December 2001 in Window Rock, AZ, the capital of
the Navajo Nation. Prior to our meeting, 3 teams conducted 3 independent
consultation visits at Fort Defiance, Shiprock, and Winslow. The teams
were warmly greeted in all the service units, and deeply impressed with
the enthusiasm and commitment demonstrated by the pediatricians and
other child health providers at the sites.

Each site will receive a written document recognizing the strengths of
the service unit, and the opportunities that exist to make changes based
on the input from the in-depth interviews. The CONACH views these
consultation visits as a mechanism to provide closer ties between the
AAP and pediatricians working in Indian communities, as well as an
important 'witnessing' that must occur to remain credible advocates at
state and federal levels.

The CONACH will soon release the results of an in-depth review of
optimal strategies to screen, and treat and prevent Type II diabetes.
Led by CONACH member Sheila Gahagan, MD, FAAP, the report was funded by
the IHS as a means to improve pediatric capabilities in battling this
increasing problem.

The CONACH is excited by the development of an Indian Health Special
Interest Group (SIG) within the AAP Section on Community Pediatrics. The
SIG will provide common ground for all of us with an interest in Indian
and Native health to convene, share our work, and educate our
colleagues. If you would like to join this group, please contact Wendy
Nelson at 800/433-9016, ext 7789, or
[**wnelson@aap.org**](mailto:wnelson@aap.org).

We will miss Bill Green on the committee, who has proven to be a staunch
ally and advocate. Bill kept the committee continually challenged and
imbued us all with his can-do spirit. Kelly Moore is also a good friend
of the committee and will provide us with the kind of gentle wisdom that
is often needed in our efforts. Welcome Kelly!

One final reminder: We are excited to conduct our work with the full
enthusiasm of the AAP Board and the AAP Department of Community
Pediatrics. Your membership in the AAP helps to sustain these efforts.
If you don't belong, PLEASE do join and participate in our mission. Call
the AAP Membership Department at 800/433-9016 or visit the AAP Web site
at <http://www.aap.org/>, to join!

**FAX COVER SHEET**

TO: William F. Green, MD [wgreen@abq.ihs.gov]{.underline}

801 Vassar NE FAX: 505/248-7698

Albuquerque, NM 87106 phone: 505/248-4000

FROM:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ phone:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ E-mail address:

FAX: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Dear Bill,

YES, I want to join the Special Interest Group in Indian Health, Section
on Community Pediatrics! Please send me the necessary application forms.

I have the following comments on this newsletter and suggestions for
future topics:

I have visited the child health page at: [www.ihs.gov/MedicalPrograms/
MaternalChildHealth/ChildHealth.asp](http://www.ihs.gov/MedicalPrograms/MaternalChildHealth/ChildHealth.asp)
and have suggestions for content or links to this page:

The following pediatricians or practitioners need to be added to your
mailing list: (You can also E-mail or fax these changes to Ana Garcia at
the American Academy of Pediatrics at
[**agarcia@aap.org**](mailto:agarcia@aap.org) or 847/228-6432.)