**NORTHWEST PORTLAND AREA**

**MATERNAL CHILD HEALTH NEWSLETTER**

**December 2000, #4**

**Cliff O'Callahan, MD,PhD**

**Puyallup Tribal Health Authority, 2209 E.32nd St, Tacoma, WA 98404**

**(253) 593 0232 #478; fax (253) 593 3311; **

**[Immunization Stuff]{.underline}**

**Pneumococcal Conjugate Vaccine** (Prevnar): It is around but not all
of us have access to it yet without paying extra. Lorraine Duncan,
Vaccine For Children (VFC) Director in **Oregon**, reports that it's
available in Oregon for VFC eligible children only through the State.
Jeff Kingsbury, Senior Public Health Advisor in **Idaho** reports that
he is confident that it will be available in Idaho by December or
January. **Washington** is less clear about plans; Steve McInelly
reports that they would like to start in January but they are not sure
if it will be possible. WA is a universal vaccine state and they don't
wish to complicate things by making Prevnar available to *only* VFC
children\...but the price to immunize all is gigantic. They are,
however, required to make it available, in accordance with ACIP rules,
within 90 days of publication of the ACIP statement. The pneumococcal
conjugate ACIP statement was published in MMWR on Oct 6^th^, 2000 which
means that the vaccine should be covered by Medicaid for all
participating VFC providers by Jan 5, 2001.

**Flu Vaccine:** The flurry of emails on the IHS system alerted me to
the fact that we are not the only site that has not received the flu
shots ordered last summer, while private groups in town have got theirs.
The bottom line is that it will arrive late and let's hope that true flu
season comes in mid-January, as it has the last couple years, so that
giving it in December is still worth it. The pity is that we will
probably not get the amount ordered so universal coverage will be
thwarted! Yet another study has concluded that vaccinating preschoolers
and children is worth it (*Pediatrics* 2000;106:973-976). Mothers of
children receiving child care outside the home have double the rate of
respiratory illnesses (*Pediatrics* 2000;106:1013-1016). Next year.

**Hepatitis A:** We should all be administering the Hep A vaccine to
youth. An article in *Arch Pediatr Adolesc Med* 2000;154:763-770
concludes that in our western States it is cost effective to vaccinate
adolescents.

**Pertussis:** There are outbreaks of pertussis in the region. A study
in Israel reminds us that young vaccinated children can be asymptomatic
reservoirs in pertussis transmission, while we know that immunity wanes
or is incomplete and many teens and adults have it but are not
identified. The nasal swab cultures are successful only in the early
catarrhal phase when it looks just like a typical cold. By the time the
coughing jags begin the cultures and treatment are rarely useful. So we
need a heightened index of suspicion. The most at-risk are the infants
and there is still a risk of hospitalization and death for this
population.

**Distress with Shots:** There was an interesting article in *Arch
Pediatr Adolesc Med* 2000;154:719-724 showing that simple behavioral
interventions before immunizations reduced behavioral and biochemical
indicators of infant distress. They gave parents an information sheet
that described "visual, auditory, oral, and kinesthetic modalities" as
techniques to reduce stress. They don't give particular info and the
authors have not replied with a copy of the info sheet yet, but we have
had great success with blowing (a piece of paper or a pinwheel) in older
children. What are other sites doing to reduce the stress for child and
parent now that we often give 4 shots at a visit?

**Varicella vaccine shots:** Because the vials are frozen the stoppers
are often very hard and may dull the needle. By rubbing the stopper with
your thumb for 15 seconds it will warm it enough that the needle will
pass through easily - and cause less pain to the patient.

**Registries:** Dr Marquart passed on a letter from the Chief Medical
Officer Kermit Smith that states that it is permitted to share our IHS
clinic immunization data with State Registries. If anyone needs a copy
of that to support you in providing that info let me know.

**[Safety Issues:]{.underline}**

**Auto Safety:** The biggest killer of Native children from 1-24 years
old is the automobile. All diseases added up together don't come near to
the lethality of a car. A study in *Arch Pediatr Adolesc Med*
2000;154:606-609 told how 266 seat "checkups" in Louisiana revealed that
94% were installed incorrectly!! The three most common problems, and the
points that we should stress at every Well Child Visit in less than 30
seconds, were **1)** seat not belted in to vehicle tightly (kneel in it
when snugging seat belt), **2)** harness straps not snug (should only be
able to slip a finger under), and **3)** harness clip not at armpit or
nipple level (not at navel).

An article in *Pediatrics* 2000;106:924-929 told of a similar study in
N. Carolina where checks of 109 car seats revealed that 93.6% were
incorrectly installed. Their conclusion was that parents need to be
actually shown how to install seats. If there is a SafeKids Coalition in
your area contact them to see if they are training people to be
certified car seat evaluators. It is a 4 day course but it would be
great if a Tribal Police Officer or Community Health Nurse could provide
education and checks periodically and during community gatherings such
as Pow Wows. I know that MaryBridge in Tacoma will be hosting training
in the future. The telephone number at the Center For Childhood Safety
is 253 403-1234. I suspect there must be an equivalent in Portland.

Children from 4-9 years are still at high risk of injury and death in
MVC (the C is for crash because they don't call them "accidents"
anymore!!) because they tend to slip out of the seat belt in a crash ie.
they are too small for the shoulder belt. For that reason WA state has a
new law starting in June 2001 stating that all children up to 6 years or
60 pounds must be in a seat or booster seat. A study in *Pediatrics*
2000;106(2):333(e20) shows that only 28% of 4-9 yr olds were in a
booster, while 28% of 4 yr olds and 70% of 6-8 yr olds used lap-shoulder
belts.

There is a comprehensive up-to-date on child passenger safety principles
for pediatric providers in *Pediatrics* 2000;106:1113-1116.

**Bike Safety:** I'm sure we all have a fair share of minimal bike
injuries and the rare severe outcome. Bike related head injuries are
responsible for over 150 deaths and 45,000 nonfatal injuries yearly. We
know that helmets are highly effective but rarely worn! A report in
*Pediatrics* 2000; 106:6-9 about a program in Georgia demonstrated that
a community ***can*** change the prevalence of helmet use if it really
wants to. They did so by having the Police impound the bikes of
un-helmeted youth. Parents were able to retrieve the bikes without fines
or citations by coming to the "police station where the safety message
was reinforced to the parent and child, and helmet ownership was
verified or a helmet provided."

This intervention was done after a period of community education through
the papers, a bike fair, and school presentation. Their conclusion was
that laws regarding helmet use don't change behavior (0% use) but
community participation and enforcement do (up to 54% in 2 years).

**Violence and Risky Behavior:** I had mentioned in the last
newsletter - if you can remember back that far - about the talk at the
IHS research conference regarding multi-generational, post-colonial
PTSD. There is a very good short review in the *Lancet*
2000;355:1116-1117 on "[Research on intergenerational transmission of
violence: the next generation]{.underline}." Good references. It makes
me remember that just seeing children and their parents in clinic is
often band-aide work. The real healing of a community is through early
childhood programs, youth activities that involve healthy positive role
models (see excellent article on "[The potential role of an adult mentor
in influencing high-risk behaviors in adolescents]{.underline}", in
*Arch Pediatr Adolesc Med* 2000;154:327-331), sponsorship of needy but
motivated families, etc. I wish we could all be given a little time to
lobby our Councils and States for support of these services.

**Pediatric Emergencies in the Office:** The Amer Acadamy of Pediatrics
just came out with a commentary for us all on this in the *Pediatrics*
2000;106,2:337-338. More helpful for me is the practical article in
*Pediatrics* 2000;106:1391-1396 that found that the great majority of
emergencies seen in primary care are respiratory. They provide a nice
shopping list for what should be in our clinic to react to emergencies.
Look this one up!

**[Miscellaneous Issues]{.underline}**

**Children placed in Foster Care:** I read a very disturbing report that
clicked because it seemed quite true based on my experience clinically.
It reported that of children in foster care 91% had an abnormality in at
least one body system while 39% needed urgent referrals for medical
services at initial consultation. When screened, 53% of younger children
had one or more developmental problem, while in adolescents 12% were PPD
positive, 77% were in need of mental health referral, and of those, 15%
had indicated either a previous attempted suicide or were suspect for
suicidal ideation. Wow!

I don't feel like I'm doing a very good job at coordinating with social
services and providing a quality comprehensive screening exam for youth
on entry to foster care. What are others doing? Does anyone have a
guideline or model for this? An article in *Pediatrics* 2000;106:59-66
made me feel worse because it's conclusion was that primary care
providers just don't do a good enough job and they make the case that
all youth being placed in foster care should have a specialized
evaluation by a multi disciplinary team.

I was heartened a bit by the guideline in *Pediatrics*
2000;106:1145-1150 on Developmental Issues for Young Children in Foster
Care. They give us some direction of what to do and when. Share this one
with your Children's Services team.

**Croup**: A number of studies have shown that children who continue to
have stridor at rest and/or respiratory distress after a trial of cool
mist often benefit from a ***single*** dose of ***orally*** administered
dexamethasone. People were giving 0.6 mg/kg but studies have shown that
even 0.15 mg/kg is equally effective (Pediatr Pulmonol 1995;20:362-368).
It even tastes good, but do not give to children with varicella! The
recent *Pediatrics* 2000;106:1344-1348 demonstrated that oral works as
just as well as IM.

**Oral Rehydration Solution:** Lots of issues for providers and parents
regarding rehydration solutions. The only solution given in most ER's is
IV normal saline, not oral, despite the fact that it's proven to be as
good. It takes more education and doctor/nurse time though, and is not
as billable or interventionalist enough for most ER staff. Not great for
parent empowerment!

Another issue is that of parents using Pedialyte equivalents for all
kinds of things rather than for dehydration due to diarrhea (not
vomiting or just not drinking). The electrolye composition makes it
ideal for stool loss but bad for "not eating and drinking."

Yet another is that most providers feel that parents wouldn't like to be
given a little packet of ORS salts to be made at home over a big fancy
bottle of Pedialyte,, or equivalent. That's all hogwash, a study in
*Arch Pediatr Adolesc Med* 2000;154:700-705 reports. Caretakers were not
only happy to take packets over bottles but were ***more satisfied***
with how the packet solution worked!! We have no excuse except to look
into getting some!!

**Asthma issues:** A couple of very good studies have demonstrated that
giving albuterol to children with acute exacerbation of their asthma via
a metered dose inhaler plus spacer device is just as effective as
nebulizing it (*Pediatrics* 2000;106:311-317 and *J. Pediatr*
1999;135:22-27). One caveat is that 2-10 or more puffs need to be given.
That has implications for our acute care clinics, ER's, office visits,
and home therapy. It can be cheaper, is much quicker, and is more
transportable.

If spacers are too expensive for some clinics then another report proved
that the use of a sealed 500mL soft drink bottle is almost as effective
as an Aerochamber (67 vs 74% change in peak expiratory flow after a
dose) !! You make a hole in the side or base for the inhaler, cover the
top when actuating the inhaler, and then bring it to the mouth, seal,
and breath. *Lancet* 1999;354:979-982.

**Fetal Alcohol Syndrome:** There is an updated statement by the
American Academy of Pediatrics on FAS and it's less severe counterparts
that used to be called Fetal Alcohol Effect but are now ***alcohol
related neurodevelopmental disorder*** (ARND) and ***alcohol related
birth defects***. It can be found in *Pediatrics* 2000;106,2:358-360.
There is less data on the effects of crack and methamphetamine.

**Otic Suspensions and Tympanostomy Tubes:** I just learnt something
very important from an article in *Otolaryngol Head Neck Surg*
2000;122:330-333. (No I don't read this journal but saw a commentary in
the AAP Grand Rounds, which is good, by the way). They demonstrated that
if we do not teach parents to apply tragal pressure after putting in
antibiotic ear drops in children with ear tubes then it's fairly useless
because the drops will not just jump through the PE tubes! So providers
and pharmacists, we need to teach the basics: warm the solution to body
temp, lay the child's head to the side, instill drops, and squish down
the tragus (the knob towards the front of the ear canal entrance)
moderately firmly in order to push the suspension into the middle ear.
Try it yourself to feel the pressure change. Now maybe those drops will
work!!

**SIDS: **We are doing a good job educating people in our region about
SIDS prevention. Here are some more tips. A study in *JAMA*
2000;283:2135-2142 reports that getting the message out about Back To
Sleep by multiple sources (doctor, nurse, TV, radio, newsletters etc)
increases the chance that a child will sleep supine. In *JAMA*
1998;280:341-346 they showed that the presence of a grandmother in the
home *increased* the risk twofold! It wasn't long ago that we did teach
parents to put them on their bellies. Perhaps elder-oriented educational
messages need to be developed in our communities.

Another risk factor for SIDS was being in day care, where 20.4% of
deaths occur. Someone from each clinic could check whether the day cares
in their area are truly aware of the position guidelines, or provide a
poster or something. I understand the staff turnover in most day care
facilities is enormous and that must be a risk factor. Article in
*Pediatrics* 2000;106:295-300.

This concept of *increased* risk when "other" people caring for a child
put them to sleep on their tummy is born out in a recent study of 157
SIDS cases in Quebec. It seems the risk is ***much*** higher when
infants who are used to being on their backs are suddenly laid on their
tummy. Pediatrics 2000;106:1476,e86.

**Native Radio:** There is a wonderful radio station that is run by
Native people for Natives in Alaska and the lower states. AIROS is
played over the airwaves in some areas but we can all access it off the
internet too at http://airos.org. I am hoping to convince our staff to
have it played over the speakers in parts of the waiting room. They have
a weekly Wellness Edition on Fridays at 1 pm and music and talk formats
24 hours a day!

**Books for Children:** I've mentioned the Reach Out and Read program
before. That's where providers give a new book to children from 6 months
through 5 years at their Well Child Visits. To supplement the
book-giving for other visits and older youth I've looked around and
discovered that Half Price Books gives a LOT of books away to non-profit
groups. I have stocked all our waiting room bookshelves to overflowing
with children and teen books. If there is one in the area, get yourself
on the list to get books!!

**Teens and Contraception:** A revealing article in the *BMJ*
2000;321:461-462,486-489 notes that the vast majority (93%) of teens who
got pregnant before they were 20 years of age had not only visited their
doctor in the previous year, but discussed contraception (71%), and had
got a contraception method (50%)! For some reason, though, they got
pregnant! The editorial with this article challenges us to become better
developing rapport with our teen patients and educating them well. What
astonishes me is that 50% of these sexually active teens were not on
birth control after a visit where they brought it up with their doctor.
Are we so busy that ***we*** become the obstacle to preventing
pregnancies?

**Obesity and Diabetes etc:** The potential to be overwhelmed is looming
as we have more youth who are obese with acanthosis and insulin
resistence, teetering on the edge of the diabetes abyss. What
suggestions can we make to families? One study compared the effect of
increased activity to targeting and reducing sedentary behaviors such as
sitting to watch TV, playing video games, and talking on the telephone.
The effect was about equal at reducing their weight over 24 months and
increasing their physical work capacity. *Arch Pediatr Adolesc Med*
2000;154:220-226. The downside was that it took a lot of work from a
coordinated team of health professionals to do this.

As we bring up the issue of obesity and family history for diabetes we
need to remember how sensitive this can be for our youth. A study of
3^rd^ grade students in N. California revealed that obesity itself, or a
high BMI, does not predict depressive symptoms. That's good to know.
However, "overweight concerns," especially in females, was strongly
associated with depressive symptoms regardless of their BMI. *Arch
Pediatr Adolesc Med* 2000;154:931-935.

If mothers do not see their children as obese they are not as compelled
to make changes. A study in *Pediatrics* 2000;106:1380-1386 reveals that
obesity is more common in mothers with less education. Those moms did
regard themselves as overweight but *did not* view their obese children
as overweight! So we have to use tact and patience in bringing this up
and convincing them to make preventive changes. Good luck to us!!

I almost overlooked the most exciting report which is about teaching
preschool children how to focus on their internal signals and regulate
their eating. ***This may be one of the most important and do-able
preventive interventions if it bears out*** in other communities.
*Pediatrics* 2000;106:1429-1435.

**Growth Charts: **The new growth charts that incorporate BMI are
available through the AAP at 888 227 1770 for about \$50 for 100 of each
of the 4 series, or download the original free at
www.cdc.gov/growthcharts

**Suicide:** There is a very good article in *Arch Pediatr Adolesc Med*
2000;153:573-580 entitled "Suicide Attempts Among American Indian and
Alaska Native Youth." It comes from old, 1990, data but the truths are
timeless. I guess what I liked was that they identified protective
factors that we could strive to promote, such as the ability to discuss
problems with friends and family, emotional health, and family
connectedness. They recommend a good wellness screen for all teens
because it would pick up the risk factors - alcohol, marijuana, and
other drug use; past or present physical or sexual abuse (especially in
males), family and school connectedness (*Pediatrics*
2000;106:1017-1021); and suicidal ideation.