Maternal Child Health ‹ Child Health Notes ‹ May 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
May 2012
Quote of the month
“The great tragedy of science is the slaying of a beautiful hypothesis by an ugly fact.”
Thomas Huxley
Articles of Interest
Effectiveness of adenoidectomy in children with recurrent upper respiratory tract infections.
Tribal and Indian Urban Health Facilities
BMJ 2011; 343 doi: 10.1136/bmj.d5154
http://www.bmj.com/content/343/bmj.d5154
Acute upper respiratory tract infection is a common diagnosis in children in primary care. Upper respiratory tract infections (URIs) not only affect children’s health but also account for a large proportion of annual healthcare expenditure and high indirect costs for the family and society. An estimated 20% of children experience recurrent upper respiratory tract infections, and some of these children are referred to the ear, nose, and throat surgeon for procedures. The goal of this study was to assess the effectiveness of adenoidectomy in children with recurrent upper respiratory tract infections.
Children were randomized to either immediate adenoidectomy or watchful waiting. The primary outcome measure was the number of URIs per person year calculated from data obtained during the follow-up period.
During the median follow-up of 24 months, there were 7.91 episodes of URIs per person year in the adenoidectomy group and 7.84 in the watchful waiting group (difference in incidence rate 0.07, 95% confidence interval -0.70 to 0.85). No relevant differences were found for days of upper respiratory tract infections and middle ear complaints with fever in episodes and days, nor for health related quality of life. The prevalence of URIs decreased over time in both groups.
Editorial Comment
Recurrent URIs occur in one of five children and predisposes to complications such as otitis media and sinusitis. A frequent number of children are referred to ENT surgeons for upper airway surgery though there is no evidence that such interventions are beneficial. Interestingly, the adenoidectomy rate is more than three times higher in the Netherlands, where this study was done, than in the US. This study confirms that surgical intervention offers no benefit over watchful waiting. It also confirms what most of us already suspected: URIs are mostly self limited and decrease in frequency with increasing age. Sometimes the best thing to do, is to do nothing.
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Infectious Disease Updates
Rosalyn Singleton, MD, MPH
Hospitalizations for Lower Respiratory Infections in American Indian and Alaska Native children: Improving but still a Disparity
In 1999-2001 the lower respiratory tract infection (LRTI) hospitalization rate in American Indian/Alaska Native (AI/AN) children < 5 years was 1.4 fold higher than same aged children in the general US population. Nearly a decade later, in 2006-2008, LRTI rates have decreased 32% in both the AI/AN and general US child populations; however, the rate difference remains about the same. LRTI’s comprise nearly half of all hospitalizations for AI/AN children compared with one-fourth of hospitalizations for the general US child population. Highest rates of LRTIs were seen in the Alaska and Southwest AI/AN regions, especially in children. The LRTI rate in Alaska and Southwest AI/AN infants was three times the US rate. The disparity was most pronounced for pneumonia in infants – especially in Alaska.
Why are LRTI’s a big deal? In many IHS/tribal facilities, LRTIs (mainly pneumonia and bronchiolitis) are the leading causes of pediatric hospitalization. In addition to significant acute illness, LRTIs result in significant long-term morbidity in the form of chronic recurrent wheezing in infancy. Pneumonias can lead to chronic suppurative lung disease (including bronchiectasis) in older children. While rarely seen in healthy US children, bronchiectasis is common among western Alaska Native children (10-20/1000 births) who also experience the highest AI/AN pneumonia rates (nearly 10 fold higher than the US child population).
Reasons for inequities in LRTI hospitalization rates include household crowding, lack of running water, indoor air pollutants such as wood smoke, inadequate ventilation and low parental educational level. There are several exciting projects and studies addressing these issues in Indian Country, including a woodstove change out study among Nez Pierce, indoor air quality studies among Alaska Native and Canadian Inuit children, Cold Climate housing research, bronchiectasis research with Australia and New Zealand, and evaluations of villages receiving piped running water.
Do you have a great project or personal experience to share? We’d like to hear from you.
Singleton RJ, Holman RC, Folkema AM, Wenger JD, Steiner CA, Redd JT. Trends in lower respiratory tract infection hospitalizations among American Indian/Alaska Native children and the general US child population. J Pediatr 2012; epub before print
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Recent Literature on American Indian/Alaska Native Health
Jeff Powell, MD, MPH
Disparities in Infant Mortality and Effective, Equitable Care: Are Infants Suffering from Benign Neglect? ; Annual Review of Public Health 2012. 33:75-87
For this months’ CHN literature review, another article focusing on infant mortality caught my attention. This article, available to federal and tribal staff via the NIH library, provides a broad perspective on disparities in Infant Mortality. While the March review provided concrete data on the static disparity in Alaska Native infant mortality, this review highlights infant mortality trends among all U.S. populations. By way of jumping to the conclusion, the article raises important questions about what is being done to impact Infant Mortality disparities among Native Americans and other U.S. populations.
As the title implies, these authors are challenging health systems and those of us working within them, to seriously address whether we are providing Effective, Equitable Care. The article offers several examples of how clinical care, and the research that drives it, is progressing unjustly in this country.
First, the overview: Infant Mortality data (including neonatal and postneonatal infants) show broad disparities. American Indian and Alaska Native infants have the second highest rate of death. The disparities reveal highly variable rates between ethnicities. Infants born to Asian/Pacific Islander mothers have one of the lowest infant mortality rates known. Immigrant Mexican women have infants at very low risk of dying, while Puerto Rican infants have a high mortality rate (similar to Non-Hispanic black Infants). Table 1 and Figure 1 in the article review cause specific and overall infant mortality.
The authors’ detailed consideration of cause-specific mortality provides an opportunity to reflect health care delivery equity. For example, in 2005, Non-Hispanic black infants had an astonishingly high rate (305 per 100,000 babies) of death related to low birth weight (the rate for Non-Hispanic while babies was 76/100,000). Further, despite major medical advances, the trends over time do not reflect improvement in this gap. The question becomes, are the medical advances (and the research that drives them) the wrong interventions to address disparities? Or, do the advances simply magnify inequities in access to quality healthcare? For example, progesterone therapies during pregnancy have helped prevention of later-term premature deliveries for white women, but have had much less positive impact for black women. Non-Hispanic black women have much higher rates of inadequate early prenatal care, and have much higher rates of very preterm deliveries (factors that make progesterone therapy less effective). So in the context of inequitable health care access and higher risk of Non-Hispanic black very preterm infants, the Infant Mortality gap widens.
Turning to consider American Indian and Alaska Native infants, the top causes of death are congenital malformations and sudden infant death syndrome (SIDS). Congenital malformations are a troubling disparity, reflected by the relatively small evidence base for prevention discussed in this article. Folate consumption has been shown to have improved significantly in the past 20 years, yet disparities persist. I personally do not know whether Native American women’s Folate consumption has been fully evaluated.
SIDS disparities raise further questions about the effective, equitable care needed to close the gaps. The authors here demonstrate twenty year mortality trends (Figure 3, 1989 to 2009). While the SIDS prevention “Back to Sleep” campaign is broadly credited with distinct and rapid reductions in SIDS deaths, mortality disparities persist. Our March review showed that Alaska Natives did not benefit broadly from this campaign. So the question becomes, why has the SIDS campaign not provided more in terms of infant death prevention? For perspective, Table 1 shows that AI/AN SIDS rates are the highest among any group (112 per 100,000 infants, which is twice the rate of all races combined, more than 4 times the rate of Asian/Pacific Islander infants). The major intervention for SIDS has been a culturally neutral (if not culturally un-informed) approach with the back-to-sleep campaign. I have wondered for many years, if Navajo newborns and infants traditionally use cradleboards and, in my experience, rarely if ever are placed on the stomach, why should the standard “back to sleep “ campaign be effective for our community here in Shiprock, NM? Is it likely (and I think the persistent SIDS disparities point to this), that we are missing potentially effective interventions?
If we expect these disparities to go away, we need some additional approaches. This article pushes us to consider key questions: are we guilty of benign neglect? Have we accepted the current state of healthcare delivery as sufficient? Have we accepted the status quo of inaction in the face of this disparity? The authors conclude that infant mortality disparities will not improve until society commits to finding interventions that support women, infants, and their families in health care and community settings. This broad support demands significant progress in research (e.g. community based, culturally relevant, participatory) and intervention strategies (e.g. preconception and interconception care reflecting the socio-ecological determinants of health) targeting AI/AN infant mortality. Benign neglect, of preventable infant mortality, is not an acceptable option.
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