Maternal Child

Maternal Child Health ‹ Child Health Notes ‹ February 09

IHS Child Health Notes

"It doesn’t matter if the cat is black or white as long as it catches mice."

- Deng Hsaio P’ing 1904-1997

This is 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 steve.holve@tchealth.org

February 2009

Quote of the month

“A house uncleaned is better than a life unlived.”
Rebecca West

Articles of Interest

Paracetamol (acetaminophen) plus ibuprofen for the treatment of fever in children (PITCH): randomized controlled trial BMJ 2008;337:a1302 http://www.bmj.com/cgi/content/abstract/337/sep02_2/a1302

Goals The goal of this English study was to investigate whether paracetamol (acetaminophen) plus ibuprofen are superior to either drug alone for increasing time without fever. Participants were children between 6 months and 6 years of age with axillary temperatures of at least 37.8°C and up to 41.0°C. The primary outcomes were the time without fever in the first four hours after the first dose was given and the proportion of children reported as being normal on the discomfort scale at 48 hours. Secondary outcomes were time to first occurrence of normal temperature, time without fever over 24 hours, and adverse effects.
Results Paracetamol plus ibuprofen were superior to paracetamol for less time with fever in the first four hours (55 more fever free minutes) but no better than ibuprofen alone. For less time with fever over 24 hours, paracetamol plus ibuprofen were superior to paracetamol alone and to ibuprofen alone (4.4 hours and 2.5 hours longer, respectively). Combined therapy cleared fever 23 minutes faster than paracetamol alone but no faster than ibuprofen alone. No difference was found between the three therapies for discomfort or other symptoms. Adverse effects did not differ between groups.
Conclusion Parents, nurses, pharmacists, and doctors wanting to use medicines to maximize the time that children spend without fever should use ibuprofen first and consider the relative benefits and risks of using paracetamol plus ibuprofen over 24 hours.

Editorial Comment
The greatest rivalries never have a definitive conclusion. Think of Pepsi® versus Coke® or Bud lite® versus Miller lite®. Tylenol ® and Motrin® used to belong in that group but there is increasing evidence that ibuprofen is a superior agent for fever reduction with faster onset of action and longer relief of fever.

Clinicians may still prefer Tylenol® because of familiarity and its overall excellent safety profile. However, ibuprofen does seem to perform better with fever reduction and might be the better first choice with acetaminophen to be added if needed. Which ever agent is used clinicians do need to give explicit instructions on dosage and frequency of administration. In this trial, in which standardized instructions under research conditions were given, over 10% of children still received extra doses of medication.

Editorial Comment
Infectious Disease Updates.
Rosalyn Singleton, MD

2009 Immunization Schedule: What’s new?
Happy New Year! There are only minor changes in the 2009 Immunization Schedule:

Rotavirus: change in maximum age for the first dose (14 weeks 6 days)
Routine annual influenza vaccination is now recommended for all children 6 months through 18 years.

School-aged children typically have the highest rates of infection and are a major source of transmission during community outbreaks. Data from school-based programs show decreased school absences and flu-like illness with vaccine.

A shorter interval than 5 years may be used Td and Tdap for persons aged 10-18 years “when pertussis immunity is needed”

They leave it up to the provider to determine if pertussis immunity is needed. There is data on intervals between Td and Tdap as short as 18 months without unacceptable increase in side effects.

Hib vaccine is not contraindicated among persons 5 years and older at increased risk for invasive Hib disease.
Catch-up vaccination with HPV vaccine is clarified. Second and third doses should be administered 2 months and 6 months after first dose (minimum intervals still 4 weeks between dose 1 and 2 and 12 weeks between dose 2 and 3) even when doing catch-up in older teens. Third dose should be given at least 24 weeks after first dose.

Find the new schedule on-line at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5751a5.htm?s_cid=mm5751a5_e

Recent literature on American Indian/Alaskan Native Health
Michael L. Bartholomew, MD
Forster JL, Brokenleg I, Rhodes KL, Lamont GR, Poupart J. Cigarette Smoking Among American Indian Youth in Minneapolis-St. Paul. American Journal of Preventative Medicine. 2008;35(6S):S449-S456.
http://www.ncbi.nlm.nih.gov/pubmed/19012838?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

Despite recent indications that tobacco use among youths across the nation continues to decline,1,2,3 tobacco use in youth continues to be an issue in both urban and rural/reservation locations. Tobacco use, as well as alcohol use, at an early age is predictive for use of other and more potent drugs4. Tobacco addiction onset often occurs in childhood. Most adults, who currently smoke, started before 19 years of age. In 2006, The National Survey on Drug Use and Health reported the ethnic group with the highest rate of smoking cigarettes within the past month to be American Indian youth aged 12-17 (21.2%).

Youth smoking is indeed a problem on the Navajo Nation. The 2003 Navajo Youth Risk Behavior Surveillance System (YRBS) showed that the Navajo Nation had a higher percentage of High School Students (38%) who smoked cigarettes on one or more of the past 30 days compared to their non-native high school counterparts (20%-2001 YRBS)5. Tobacco use is also prevalent in Navajo Middle School children. The 2003 Navajo YRBS data determined that 19% of middle school children have smoked cigarettes on one or more of the past 30 days.

Higher tobacco use among native children is not only isolated to rural settings. Foster et al reported higher tobacco use among urban Indian youth in Minneapolis-St. Paul through a non-random cross-sectional survey. Within the previous 30 days, nearly 37% of the surveyed Indian youth aged 11-18 years reported recreational cigarette smoking. Nearly 49% of 16-18 year olds, 44% of 14-15 year olds, and 16% of 11-13 year olds smoked cigarettes within the past 30 days. In comparison to the 2007 Minnesota Student Survey, the prevalence of cigarette use within the previous 30 days among Indian youth is noticeably higher.

Though it is difficult to compare surveys, they all illustrate marked disparities of tobacco use among Native American youth, regardless of location: urban or rural. Interventions by primary care physicians can be critical to the reduction of tobacco use among Native youth. Physicians need to identify and limit the barriers that prohibit their involvement in screening, prevention, and management of substance abuse including tobacco.

References:

Monitoring the Future Study
National Survey on Drug Use and Health
Youth Risk Behavior Survey
American Academy of Pediatrics, Kulig J, and Committee on Substance Abuse. Tobacco, Alcohol, and Other Drugs: Role of the Pediatrician in Prevention, Identification, and Management of Substance Abuse. Pediatrics. 2005;115:816-821.
2003 Navajo Middle and High School Youth Risk Behavior Survey Report

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	Maternal Child Health ‹ Child Health Notes ‹ February 09 IHS Child Health Notes "It doesn’t matter if the cat is black or white as long as it catches mice." - Deng Hsaio P’ing 1904-1997 This is 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 steve.holve@tchealth.org February 2009 Quote of the month “A house uncleaned is better than a life unlived.” Rebecca West Articles of Interest Paracetamol (acetaminophen) plus ibuprofen for the treatment of fever in children (PITCH): randomized controlled trial BMJ 2008;337:a1302 http://www.bmj.com/cgi/content/abstract/337/sep02_2/a1302 Goals The goal of this English study was to investigate whether paracetamol (acetaminophen) plus ibuprofen are superior to either drug alone for increasing time without fever. Participants were children between 6 months and 6 years of age with axillary temperatures of at least 37.8°C and up to 41.0°C. The primary outcomes were the time without fever in the first four hours after the first dose was given and the proportion of children reported as being normal on the discomfort scale at 48 hours. Secondary outcomes were time to first occurrence of normal temperature, time without fever over 24 hours, and adverse effects. Results Paracetamol plus ibuprofen were superior to paracetamol for less time with fever in the first four hours (55 more fever free minutes) but no better than ibuprofen alone. For less time with fever over 24 hours, paracetamol plus ibuprofen were superior to paracetamol alone and to ibuprofen alone (4.4 hours and 2.5 hours longer, respectively). Combined therapy cleared fever 23 minutes faster than paracetamol alone but no faster than ibuprofen alone. No difference was found between the three therapies for discomfort or other symptoms. Adverse effects did not differ between groups. Conclusion Parents, nurses, pharmacists, and doctors wanting to use medicines to maximize the time that children spend without fever should use ibuprofen first and consider the relative benefits and risks of using paracetamol plus ibuprofen over 24 hours. Editorial Comment The greatest rivalries never have a definitive conclusion. Think of Pepsi® versus Coke® or Bud lite® versus Miller lite®. Tylenol ® and Motrin® used to belong in that group but there is increasing evidence that ibuprofen is a superior agent for fever reduction with faster onset of action and longer relief of fever. Clinicians may still prefer Tylenol® because of familiarity and its overall excellent safety profile. However, ibuprofen does seem to perform better with fever reduction and might be the better first choice with acetaminophen to be added if needed. Which ever agent is used clinicians do need to give explicit instructions on dosage and frequency of administration. In this trial, in which standardized instructions under research conditions were given, over 10% of children still received extra doses of medication. Editorial Comment Infectious Disease Updates. Rosalyn Singleton, MD 2009 Immunization Schedule: What’s new? Happy New Year! There are only minor changes in the 2009 Immunization Schedule: Rotavirus: change in maximum age for the first dose (14 weeks 6 days) Routine annual influenza vaccination is now recommended for all children 6 months through 18 years. School-aged children typically have the highest rates of infection and are a major source of transmission during community outbreaks. Data from school-based programs show decreased school absences and flu-like illness with vaccine. A shorter interval than 5 years may be used Td and Tdap for persons aged 10-18 years “when pertussis immunity is needed” They leave it up to the provider to determine if pertussis immunity is needed. There is data on intervals between Td and Tdap as short as 18 months without unacceptable increase in side effects. Hib vaccine is not contraindicated among persons 5 years and older at increased risk for invasive Hib disease. Catch-up vaccination with HPV vaccine is clarified. Second and third doses should be administered 2 months and 6 months after first dose (minimum intervals still 4 weeks between dose 1 and 2 and 12 weeks between dose 2 and 3) even when doing catch-up in older teens. Third dose should be given at least 24 weeks after first dose. Find the new schedule on-line at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5751a5.htm?s_cid=mm5751a5_e Recent literature on American Indian/Alaskan Native Health Michael L. Bartholomew, MD Forster JL, Brokenleg I, Rhodes KL, Lamont GR, Poupart J. Cigarette Smoking Among American Indian Youth in Minneapolis-St. Paul. American Journal of Preventative Medicine. 2008;35(6S):S449-S456. http://www.ncbi.nlm.nih.gov/pubmed/19012838?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum Despite recent indications that tobacco use among youths across the nation continues to decline,1,2,3 tobacco use in youth continues to be an issue in both urban and rural/reservation locations. Tobacco use, as well as alcohol use, at an early age is predictive for use of other and more potent drugs4. Tobacco addiction onset often occurs in childhood. Most adults, who currently smoke, started before 19 years of age. In 2006, The National Survey on Drug Use and Health reported the ethnic group with the highest rate of smoking cigarettes within the past month to be American Indian youth aged 12-17 (21.2%). Youth smoking is indeed a problem on the Navajo Nation. The 2003 Navajo Youth Risk Behavior Surveillance System (YRBS) showed that the Navajo Nation had a higher percentage of High School Students (38%) who smoked cigarettes on one or more of the past 30 days compared to their non-native high school counterparts (20%-2001 YRBS)5. Tobacco use is also prevalent in Navajo Middle School children. The 2003 Navajo YRBS data determined that 19% of middle school children have smoked cigarettes on one or more of the past 30 days. Higher tobacco use among native children is not only isolated to rural settings. Foster et al reported higher tobacco use among urban Indian youth in Minneapolis-St. Paul through a non-random cross-sectional survey. Within the previous 30 days, nearly 37% of the surveyed Indian youth aged 11-18 years reported recreational cigarette smoking. Nearly 49% of 16-18 year olds, 44% of 14-15 year olds, and 16% of 11-13 year olds smoked cigarettes within the past 30 days. In comparison to the 2007 Minnesota Student Survey, the prevalence of cigarette use within the previous 30 days among Indian youth is noticeably higher. Though it is difficult to compare surveys, they all illustrate marked disparities of tobacco use among Native American youth, regardless of location: urban or rural. Interventions by primary care physicians can be critical to the reduction of tobacco use among Native youth. Physicians need to identify and limit the barriers that prohibit their involvement in screening, prevention, and management of substance abuse including tobacco. References: Monitoring the Future Study National Survey on Drug Use and Health Youth Risk Behavior Survey American Academy of Pediatrics, Kulig J, and Committee on Substance Abuse. Tobacco, Alcohol, and Other Drugs: Role of the Pediatrician in Prevention, Identification, and Management of Substance Abuse. Pediatrics. 2005;115:816-821. 2003 Navajo Middle and High School Youth Risk Behavior Survey Report Return to top of page