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Maternal Child Health ‹ Child Health Notes ‹ January 12

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

January 2012

Special Notice
Infectious Disease Updates
Recent Literature on American Indian/Alaska Native Health

Quote of the month

“The art of medicine consists in amusing the patient while nature cures the disease.”
Voltaire

Special Notice

Community Access to Child Health (CATCH) grants of up to $12,000 for pediatricians and $3,000 for pediatric residents are available to work collaboratively with local community partners to ensure that all children have medical homes and access to health care services.

The AAP Committee on Native American Child Health has partnered with CATCH in the funding of its Native American child health grants for projects that benefit American Indian/Alaska Native (AI/AN) children. Indian Health Service (IHS) and tribal 638 family physicians and community family physicians serving Native American children may apply in partnership with a pediatrician. According to the IHS Manual, IHS physicians may accept grants less than $100,000 and no approval is required from area or headquarters. In 2011 three AI/AN clinics were awarded CATCH grants so chances of a successful application are quite good.

For more information visit http://www.aap.org/catch/implementgrants.htm, e-mail catch@aap.org, or call 847/434-4916. The deadline to apply is January 31, 2012.

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Infectious Disease Updates
Rosalyn Singelton, MD, MPH

New guidelines for management of infants and children with community-acquired pneumonia

American Indian/Alaska Native children experience hospitalization rates for pneumonia that are 2-fold higher than the US general child population. The Pediatric Infectious Diseases Society and Infectious Diseases Society of America just published new guidelines for management of community-acquired pneumonia (CAP) which are important for AI/AN providers to review:

When does a child with CAP require hospitalization?

Respiratory distress (e.g. tachypnea, retractions, grunting, flaring, apnea, , SaO2 <90% )
Infants 3-6 months old with suspected bacterial CAP
Children w/ suspected CAP caused by organism with increased virulence (e.g. MRSA)

What lab and imaging tests should be used in a child with suspected CAP?

Blood cultures should be obtained in hospitalized children and those failing to improve
Repeat blood cultures to document resolution should be obtained if S. aureus bacteremia.
Sensitive/ specific tests for rapid diagnosis of Flu/ respiratory viruses should be used in evaluation of children with CAP, and may avoid antibiotic therapy.
Routine CBC is not necessary in outpatients but may be useful in severe pneumonia.
Acute-phase reactants can’t determine viral vs. bacterial CAP but may be useful in inpatient
CXRs not necessary for outpatient CAP, but should be obtained for severe/ hospitalized CAP.
Follow-up CXRs should be done in children who fail to improve, or progress within 48-72 hours

Which antibiotics should be used for outpatient CAP?

Antibiotics not routinely required for preschoolers with CAP; majority are viral pathogens
Amoxicillin should be used as first line therapy for previously healthy, immunized infants and preschoolers with mild/moderate CAP, and for school aged children for S. pneumonia.
Macrolides for children with findings compatible with CAP caused by atypical pathogens.
Influenza antiviral therapy ASAP to children with mod/severe CAP consistent with Flu.

What antibiotics should be used for inpatient CAP?

Ceftriaxone/cefotaxime for hospitalized children not fully immunized, or in regions where high-level penicillin resistance for S. pneumoniae, or children with empyema.
Ampicillin or Penicillin G can be used in regions with lack of high-level penicillin resistance.
Combination therapy with macrolide + B lactam for child with suspected M pneumonia.
Vancomycin or clindamycin should be provided for infections consistent with S. aureus

Clin Infect Dis. 2011 Oct;53(7):e25-76. Epub 2011 Aug 31

Return to top of page

Recent Literature on American Indian/Alaska Native Health

Jeff Powell, MD, MPH

Council on Communications and Media; Media Use by Children Younger Than 2 Years; Pediatrics Vol 128 (No. 5), 1040-1045

This month’s Child Health Notes AI/AN Literature review marks a bit of a departure: rather than focus on new research specific to AI/AN youth, I will use this space to highlight an important AAP Policy Statement: “Media Use by Children Younger Than 2 Years.” This Statement is published in the November 2011 Pediatrics journal, and written by the AAP Council on Communications and Media. I have chosen to focus on this Policy Statement because of the pervasive and large health impacts media consumption has on our children. In addition, excessive media use and exposure is a public health problem that primary care systems and providers can play a role. We have the capacity to raise these issues in prevention programming and routine preventive health care visits. Currently, only 15% of parents report that their pediatrician discusses media use with them. This Policy Statement provides an argument that pediatricians should discuss media use with every child.

The Statement summarizes relevant recent literature and lays out several key points. Central to the discussion are the ideas that: 1) the use of “educational” media for children under 2 years of age is inappropriate; 2) the exposure of large amounts of “background” media (e.g. the TV is constantly on) is harmful to early child development; 3) young children develop far more effectively while doing non-media child activities (anything from unstructured play to reading with an adult); and 4) heavy media exposure, including the use of TV in children’s sleeping areas, is likely to have negative health and developmental consequences.

Taking a look at the first concept, above, the AAP is discouraging all media use for children less than 2 years of age. The statement reviews literature on the ability of very young children to “learn” from video material specifically designed to teach young children. They reveal that these video resources have not been shown to benefit development, and that they are likely harmful to child language development. In addition, there may be a negative effect of TV exposure to the attention spans of very young children. The statement clearly describes some of the developmental reasons that video media is not helpful for “teaching” young children 0 to 2 years of age.

Background media is another significant concern, and there is a growing body of literature of how harmful this is. When adult caregivers watch television or other video media, there will often be children in the same space. This has the impacts of reducing the amount of direct engagement, and in particular the amount of “talk time,” when caregivers directly speak to children. In addition, children exposed to heavy amounts of background media have been shown to be more distractible and to have poorer abilities to sustain independent free play. All of these factors impact development for the worse.

So then the question becomes, “how else should my child be spending time when I am busy working at home?” The answer, it seems, is they should spend their time doing just about anything else. Unstructured free play is proven to improve problem-solving skills, and creativity. Direct engagement with children is proven to improve language development. Reading to children is proven to improve language skills and increasing the likelihood that children will learn to read. When adult caregivers are busy working at home while supervising children, they can simply provide a safe environment and allow the children to play freely. Even playing on the floor with nesting measuring cups is a learning opportunity for a very young child.

Finally, the statement reviews what is known about health and developmental consequences of heavy media use among very young children. While the literature is limited, what is known is that media use has negative effects. Impacts on sleep are one area highlighted in the statement. The very large proportion of children under ONE with a TV in their bedroom (nearly 20%) are at risk for increased bed-time resistance, delayed onset of sleep, and shorter sleep durations. Developmental studies have shown negative short term impacts of media use on language development, and concerning mixed results on attention spans.

Screen Free Week / TV Free Week / Digital Detox Week is April 30th to May 6th, 2012. Consider promoting this week, and consider talking to all our patients year round about the importance of regulating young children’s media exposure.


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	Maternal Child Health ‹ Child Health Notes ‹ January 12 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 January 2012 Special Notice Infectious Disease Updates Recent Literature on American Indian/Alaska Native Health Quote of the month “The art of medicine consists in amusing the patient while nature cures the disease.” Voltaire Special Notice Community Access to Child Health (CATCH) grants of up to $12,000 for pediatricians and $3,000 for pediatric residents are available to work collaboratively with local community partners to ensure that all children have medical homes and access to health care services. The AAP Committee on Native American Child Health has partnered with CATCH in the funding of its Native American child health grants for projects that benefit American Indian/Alaska Native (AI/AN) children. Indian Health Service (IHS) and tribal 638 family physicians and community family physicians serving Native American children may apply in partnership with a pediatrician. According to the IHS Manual, IHS physicians may accept grants less than $100,000 and no approval is required from area or headquarters. In 2011 three AI/AN clinics were awarded CATCH grants so chances of a successful application are quite good. For more information visit http://www.aap.org/catch/implementgrants.htm, e-mail catch@aap.org, or call 847/434-4916. The deadline to apply is January 31, 2012. Return to top of page Infectious Disease Updates Rosalyn Singelton, MD, MPH New guidelines for management of infants and children with community-acquired pneumonia American Indian/Alaska Native children experience hospitalization rates for pneumonia that are 2-fold higher than the US general child population. The Pediatric Infectious Diseases Society and Infectious Diseases Society of America just published new guidelines for management of community-acquired pneumonia (CAP) which are important for AI/AN providers to review: When does a child with CAP require hospitalization? Respiratory distress (e.g. tachypnea, retractions, grunting, flaring, apnea, , SaO2 <90% ) Infants 3-6 months old with suspected bacterial CAP Children w/ suspected CAP caused by organism with increased virulence (e.g. MRSA) What lab and imaging tests should be used in a child with suspected CAP? Blood cultures should be obtained in hospitalized children and those failing to improve Repeat blood cultures to document resolution should be obtained if S. aureus bacteremia. Sensitive/ specific tests for rapid diagnosis of Flu/ respiratory viruses should be used in evaluation of children with CAP, and may avoid antibiotic therapy. Routine CBC is not necessary in outpatients but may be useful in severe pneumonia. Acute-phase reactants can’t determine viral vs. bacterial CAP but may be useful in inpatient CXRs not necessary for outpatient CAP, but should be obtained for severe/ hospitalized CAP. Follow-up CXRs should be done in children who fail to improve, or progress within 48-72 hours Which antibiotics should be used for outpatient CAP? Antibiotics not routinely required for preschoolers with CAP; majority are viral pathogens Amoxicillin should be used as first line therapy for previously healthy, immunized infants and preschoolers with mild/moderate CAP, and for school aged children for S. pneumonia. Macrolides for children with findings compatible with CAP caused by atypical pathogens. Influenza antiviral therapy ASAP to children with mod/severe CAP consistent with Flu. What antibiotics should be used for inpatient CAP? Ceftriaxone/cefotaxime for hospitalized children not fully immunized, or in regions where high-level penicillin resistance for S. pneumoniae, or children with empyema. Ampicillin or Penicillin G can be used in regions with lack of high-level penicillin resistance. Combination therapy with macrolide + B lactam for child with suspected M pneumonia. Vancomycin or clindamycin should be provided for infections consistent with S. aureus Clin Infect Dis. 2011 Oct;53(7):e25-76. Epub 2011 Aug 31 Return to top of page Recent Literature on American Indian/Alaska Native Health Jeff Powell, MD, MPH Council on Communications and Media; Media Use by Children Younger Than 2 Years; Pediatrics Vol 128 (No. 5), 1040-1045 This month’s Child Health Notes AI/AN Literature review marks a bit of a departure: rather than focus on new research specific to AI/AN youth, I will use this space to highlight an important AAP Policy Statement: “Media Use by Children Younger Than 2 Years.” This Statement is published in the November 2011 Pediatrics journal, and written by the AAP Council on Communications and Media. I have chosen to focus on this Policy Statement because of the pervasive and large health impacts media consumption has on our children. In addition, excessive media use and exposure is a public health problem that primary care systems and providers can play a role. We have the capacity to raise these issues in prevention programming and routine preventive health care visits. Currently, only 15% of parents report that their pediatrician discusses media use with them. This Policy Statement provides an argument that pediatricians should discuss media use with every child. The Statement summarizes relevant recent literature and lays out several key points. Central to the discussion are the ideas that: 1) the use of “educational” media for children under 2 years of age is inappropriate; 2) the exposure of large amounts of “background” media (e.g. the TV is constantly on) is harmful to early child development; 3) young children develop far more effectively while doing non-media child activities (anything from unstructured play to reading with an adult); and 4) heavy media exposure, including the use of TV in children’s sleeping areas, is likely to have negative health and developmental consequences. Taking a look at the first concept, above, the AAP is discouraging all media use for children less than 2 years of age. The statement reviews literature on the ability of very young children to “learn” from video material specifically designed to teach young children. They reveal that these video resources have not been shown to benefit development, and that they are likely harmful to child language development. In addition, there may be a negative effect of TV exposure to the attention spans of very young children. The statement clearly describes some of the developmental reasons that video media is not helpful for “teaching” young children 0 to 2 years of age. Background media is another significant concern, and there is a growing body of literature of how harmful this is. When adult caregivers watch television or other video media, there will often be children in the same space. This has the impacts of reducing the amount of direct engagement, and in particular the amount of “talk time,” when caregivers directly speak to children. In addition, children exposed to heavy amounts of background media have been shown to be more distractible and to have poorer abilities to sustain independent free play. All of these factors impact development for the worse. So then the question becomes, “how else should my child be spending time when I am busy working at home?” The answer, it seems, is they should spend their time doing just about anything else. Unstructured free play is proven to improve problem-solving skills, and creativity. Direct engagement with children is proven to improve language development. Reading to children is proven to improve language skills and increasing the likelihood that children will learn to read. When adult caregivers are busy working at home while supervising children, they can simply provide a safe environment and allow the children to play freely. Even playing on the floor with nesting measuring cups is a learning opportunity for a very young child. Finally, the statement reviews what is known about health and developmental consequences of heavy media use among very young children. While the literature is limited, what is known is that media use has negative effects. Impacts on sleep are one area highlighted in the statement. The very large proportion of children under ONE with a TV in their bedroom (nearly 20%) are at risk for increased bed-time resistance, delayed onset of sleep, and shorter sleep durations. Developmental studies have shown negative short term impacts of media use on language development, and concerning mixed results on attention spans. Screen Free Week / TV Free Week / Digital Detox Week is April 30th to May 6th, 2012. Consider promoting this week, and consider talking to all our patients year round about the importance of regulating young children’s media exposure.

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