Minnesota Chapter of the American Academy of Pediatrics

Robert Jacobson, MD, FAAP

By Robert M. Jacobson, MD, FAAP, president of MNAAP
In case you haven’t heard, MNAAP received the 2014 Outstanding Large Chapter of the Year award in March at AAP’s Annual Leadership Forum. AAP has been awarding chapters for their performance since 1964. Of its 66 chapters, 18 are defined as large. Minnesota is among those 18. We’ve won the award twice before, most recently in 2010 under the leadership of Anne Edwards, MD.

What made MNAAP stand out from other chapters?
I would argue that the infrastructure, relationships, and membership efforts that won us the award in 2009 led to our recognition again in 2013. Frankly, we have not changed our approach to chapter leadership and activity since then. Perhaps we have matured some processes. Of course we would hope so, but what appear to be critical factors in our success remain unchanged.
By infrastructure, we mean our organization with contract staff, committees, and work groups. Our work groups are key to driving advocacy, education, and outreach as well as our ability to address collaborations and membership. We aim for 3 or 4 work groups whose work is based on our annual member surveys that drive our strategic planning. Our work groups thus come and go&#8211;forming, transforming, and dissolving, depending on the issues we pursue with our strategic plans.
Our next round of strategic planning takes place this summer under the leadership of incoming President Sue Berry, MD. As a result we will have a different set of work groups for the coming 2 years. The strategic planning gives us the flexibility to maximize our limited resources.
By collaboration, we mean our continued efforts to work closely with allies for children’s health around the state, including not-for-profit organizations, parent groups, and professional organizations as well as state government offices and agencies. We also pursue support from our own national AAP as well as other national resources that can support our work.
MNAAP&#8217;s legislative priority this year has been the restoration of the Minnesota’s newborn screening program. We have put the lion’s share of our resources in leading and shepherding legislation to restore the program. As a result of this focus, we have had to rely on our collaborators to take the lead with other issues this year.
But our work with collaborators extends far beyond legislative advocacy. We pursue grants with them, we invite them to participate in our work groups, and we execute educational efforts with them.
Without their collaboration, we would be a smaller, less successful, less productive chapter.
By membership efforts, we mean our focus on the inclusiveness of our organization. We strive to represent all pediatricians across the state. To do that, ideally, all pediatricians should belong to our chapter. We work to keep our dues affordable and include at no charge trainees as well as retirees.
Our focus on trainees is driven by our need to prepare for the future and to utilize the energy they can bring now. Our focus on retires is driven by our respect for what they have already contributed as well as what their acquired experience and wisdom can now teach us.
And we regularly reach out to non-members. We hold events that are open to members and non-members alike. We strive to be useful and accessible.
But, for us, membership is not about reaching a certain number. It&#8217;s about including, supporting and engaging as many pediatricians as possible. We must seek to include in our leadership and work groups and membership individuals who represent pediatrics across the state, across cultures, across organizational types, across specialties, across training programs, and across patient populations. That means reaching outside of our comfort zones and engaging those we know less well and who may very well disagree with us on various approaches or outcomes. But we will be a stronger organization for pursuing our continued efforts at membership diversification and inclusiveness.
Winning such an award is a great honor, but we cannot relax. We have to ask how we are going to stay relevant, focused, and solvent. I’d argue that we maintain our current infrastructure, cultivate our collaborations, and continue to reach out for new members and work to deserve the ones we have.
Our work, of course, requires member input as well as participation. Our success depends on it. It always has and it always will.

Word from the President: Celebrating Large Chapter of the Year

By Pamela Heggie, MD, FAAP, IBCLC, Fairview Children’s Clinic, Minneapolis and Robert M. Jacobson, MD, FAAP, Mayo Clinic, Rochester and MNAAP President
A recent article published in the journal Social Science and Medicine made headlines and was widely quoted in blogs, email list-serves and Facebook: &#8220;Is Breast Truly Best? Estimating the Effects of Breastfeeding on Long-term Child Health and Wellbeing in the United States Using Sibling Comparisons&#8221; (Colen, 2014). This article raised questions about the long-term benefits of breastfeeding on health outcomes for children.

The investigators reviewed infant feeding histories within families and compared the long-term health outcomes of siblings within the same family. In particular they focused on families with siblings who had discordant feeding types where one sibling was breastfed and the other bottle-fed. The investigators compared the outcomes of these siblings over time, looking at 11 variables, including body mass index, asthma, obesity, and additional behavioral and academic outcomes. The study found that overall the breastfed children scored better than the bottle-fed children in 10 out of 11 health outcomes when all children were combined.
Yet when the investigators compared siblings in the same family–one breastfed and the other not, they found no statistically significant differences. They suggest that it is familial factors such as home environment, socio-economic status, race, and work status of mother that influence health outcome more than infant feeding type. The investigators conclude that breastfeeding has no long-term benefits.
However, the study is deeply flawed. When looking at the methods and the way the study was conducted, we note that the investigators fail to consider the duration of breastfeeding. The investigators included children in the breastfed group who may have received any amount of breastfeeding. Even breastfeeding prior to discharge from the hospital following delivery would have sufficed. The AAP recommends breastfeeding over formula feeding when possible and exclusive breastfeeding for six months before the introduction of solids. The study did not compare infants fed exclusively with breastmilk for six months with infants fed exclusively with formula for six months. The reader is left wondering how many of the discordant siblings were both basically formula-fed the entirety of their infancy.
This shortcoming of the study ignores the robust body of literature demonstrating a dose response relationship between breastmilk and health outcome. Multiple studies reported by the Agency for Healthcare Research and Quality (AHRQ) and noted in the 2011 Surgeon General’s Call to Action to Support Breastfeeding show that exclusive breastfeeding and a longer duration of breastfeeding improve health in a number of areas, including reduced risk for obesity, diabetes, infection, sudden infant death syndrome, necrotizing enterocolitis, and other health outcomes.
In addition, the investigators do not define &#8220;bottle-feeding.&#8221; The investigators appear to assume that a bottle-fed infant was given formula, but many mothers who choose not to nurse give breastmilk to their baby by bottle. By including babies who received breastmilk in the bottle-fed group, differences due to breastmilk versus formula would be lost.
Another limitation of this study is that it only addresses long-term effects (4 -14 years) when looking at potential benefits of breastfeeding versus bottle feeding. It ignores the early short-term benefits of breastfeeding so important in preventing illness in a baby’s first year of life, including reduction in sudden infant death syndrome, necrotizing enterocolitis, pneumonia, otitis media, and diarrhea.
Finally, the investigators disregard the benefits of breastfeeding on maternal health. Women who breastfeed have much lower rates of obesity, heart disease, and cancer and these effects last a lifetime for the mother. In addition, breastfeeding mothers often note the cost and time savings of breastfeeding.
The authors claim their results show that the benefits of breastfeeding are &#8220;overstated.&#8221; We disagree, given the many limitations of this study. Often the headlines from controversial studies like this one are confusing for families in our practices. So what shall we tell parents about breastfeeding?
The AAP 2012 Statement on Breastfeeding and the Use of Human Milk gives clear guidance to us and to the families we provide care for: Pediatricians should recommend exclusive breastfeeding for about 6 months, followed by continued breastfeeding to at least 1 year as complementary foods are introduced. The AAP statement goes on to say that &#8220;Given the documented short- and long-term medical and neurodevelopmental advantages of breastfeeding, infant nutrition should be considered a public health issue and not only a lifestyle choice.&#8221;
Minnesota Hospitals Act to Support Breastfeeding
Many hospitals throughout Minnesota are focusing on ways to improve breastfeeding rates and support infant feeding choice so that all families can reach their infant feeding goals. Some hospitals have chosen to pursue the Baby-Friendly Hospital Initiative as a way to help families get off to the right start with breastfeeding. The Baby-Friendly Hospital Initiative not only helps to increase overall rates of breastfeeding, it also reduces racial and ethnic disparity in breastfeeding rates.
The Baby-Friendly Hospital Initiative is a program developed in 1991 by the World Health Organization and UNICEF in an effort to reduce worldwide child mortality and improve health outcomes for mothers and babies. The initiative focuses on ten evidence-based hospital and birthing center practices that have been shown to increase the rates of breastfeeding regardless of race, ethnicity, income, language, or family constellation. The &#8220;10 Steps to Successful Breastfeeding&#8221; describe these evidence-based practices in detail. Hospitals pursuing Baby-Friendly designation must undergo a rigorous certification process including an on-site visit from the certifying agency.
The ten steps of the Baby-Friendly Hospital Initiative were endorsed by the AAP in 2009. Baby-Friendly hospitals provide care that emphasizes best practice in infant feeding, while helping ALL families reach their infant feeding goals. Hospitals provide breastfeeding support for mothers who plan to breastfeed and instruction about safe formula feeding for mothers who choose to formula feed their babies. No mother is ever &#8220;forced&#8221; to breastfeed.
There are currently 20,000 Baby-Friendly hospitals and birthing centers worldwide in 150 countries, but as of 2013, only 6.9% of US birth hospitals were certified Baby-Friendly. In Minnesota, two hospitals are Baby-Friendly: the University of Minnesota Amplatz Children’s Hospital and Austin Medical Center (Mayo Clinic Health System). Regions Hospital in St. Paul and Hennepin County Medical Center (HCMC) in Minneapolis are participating in a grant program from the Centers for Disease Control and Prevention called Best Fed Beginnings, which is designed to increase the number of Baby-Friendly hospitals in the country. Regions and HCMC joined 88 other hospitals throughout the country on a fast track Baby-Friendly journey as part of this grant program.
As of January 2014, 16 out of 97 Minnesota maternity care hospitals have declared intention to work on becoming Baby-Friendly hospitals. Despite this progress, 73.5 percent of women giving birth in Minnesota start out breastfeeding but less than half are still breastfeeding at 6 months and only 23.5 percent are exclusively breastfeeding (CDC, 2013), falling short of the AAP’s recommendation to exclusively breastfeed for 6 months. Also, according to recent data from the Minnesota Women, Infant and Children’s nutrition program (WIC), significant racial and ethnic disparities persist in breastfeeding rates throughout Minnesota (WIC, 2012).
The Baby-Friendly Hospital Initiative helps to create health equity in infant feeding, emphasizing cultural competence and equal access to best practice maternity care and lactation support regardless of race, ethnicity, income, family structure or language.
Be on the look-out for more Baby-Friendly hospitals in Minnesota! Maybe you can take the lead at your hospital to improve health equity in Minnesota for mothers and babies!
The 10 Steps to Successful Breastfeeding
1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
2. Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding within 1 hour of birth.
5. Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.
6. Give newborn infants no food or drink other than breast milk, unless medically indicated.
7. Practice rooming-in—allow mothers and infants to remain together—24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no artificial nipples or pacifiers to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

Is Breastfeeding Still Best? MN Hospitals Make Changes to Support it

By Robert M. Jacobson, MD, FAAP&#8230;
What were the top ten events for our chapter in 2013? What would such a list look like, and what would we learn from it?
I ended up making such a list to help with our year-end reporting. At the end of 2013, our chapter submitted its annual chapter report for the national organization. The report details MNAAP’s accomplishments for the year. It’s a Herculean task of cleaning out the stables of the year gone by and trotting out accomplishments for a national audience. We ask the leaders of our workgroups and committees to participate in the reporting as well. 
Each of us on the board would probably list different things. Perhaps many items would overlap but the order would vary greatly. My own top ten list includes the following:
1. Updated School and Daycare Immunization Rules. The successful adoption of the updated Minnesota School and Daycare Immunization Rules in August had been a long time coming. Katherine Cairns, our executive director, and I began meeting as representatives of the chapter in 2012 with the immunization rules task force that the state assembled. Dr. Dawn Martin, chair of the MNAAP Immunization work group, kept members informed of the updates at meetings and in the newsletter. We finalized that work in the spring of 2013 and waited with apprehension for the period of public notification and comment. In a tense administrative hearing this summer, I spoke on behalf of our chapter in support for the proposed rules, which included new vaccine requirements for Rotavirus, Hepatitis B, Hepatitis A, Tdap, Varicella, and Meningococcus. Our efforts paid off when the administrative judge ruled in favor of MDH, allowing the rules to become effective in September of 2014. 
More info at www.mnaap.org/immunizations.htm
2. Pediatricians’ Day at the Capitol. This well-attended event involved more than 100 pediatricians meeting with legislators and successfully brought both of our state’s pediatric residencies together to participate in this show of legislative advocacy. The enthusiasm of the pediatricians-in-training was energizing and carried us through a rocky legislative season that saw the tabling of the anti-bullying bill we pushed as well as the tabling of our efforts to stay the destruction of the newborn screening test data along with the blood spots themselves. The MNAAP’s efforts at the Capitol in regards to tobacco, however, were hugely successful as the MNAAP and our coalition partners 
advocated for – and won – a historic increase in the 
tobacco tax, a change that will result in far fewer adolescents smoking.
More info at www.mnaap.org/pedsdayatthecapitol.htm
3. Investments in Health and Education. We advocated for the successful approval of the state health budget with its support for pediatric and adolescent mental health as well as the approval of the state’s investment in early childhood education and the critical congenital heart disease testing requirement.
4. Successful Education Programs. Our Hot Topics in Pediatrics Conference, held the day of our annual meeting, successfully brought together nearly 150 attendees for our programming on obesity and motivational interviewing.
5. Dynamic Annual Dinner. Those in attendance won’t soon forget the 2013 annual dinner where our keynote speaker, Dr. Piero Rinaldo, spoke so passionately for the return of Minnesota Newborn Screening to where it was just several years ago: the best in the country and the world with so much promise for the future. 
More info at www.mnaap.org/annualmeeting2013.html
6. New and Improved Website. We rolled out our new web presence in 2013. While it is easy to take a web site’s appearances and functionality for granted, we know that our organization depends on the ease of communication. Our web pages are central to our organization’s ongoing conversation across the state. 
More info at www.mnaap.org/
7. Collecting Member Feedback. Every year we conduct an all-member survey. It is a big event for us because it provides our members a chance to weigh in on a variety of topics in a relatively easy format. We worked hard to make that survey user friendly. In the months to come, the survey responders will see we’ve taken their responses seriously and will direct our work going forward. 
View results at svy.mk/1cc1RKk
8. Maintenance of Certification Programs. Last year we saw our first enrollees in all of our MOC 4 programs. We have three underway—in pediatric obesity, medical homes, and immunizations. It’s a concerted effort that our board of directors took so seriously as to assign the effort to each of our work groups to make these MOC 4 experiences happen.
We also are seeking permission—new this year—to begin offering MOC 2 credit. We are in the process of submitting a grant that would support our development of an MOC 2 experience regarding HPV vaccine communication.
More info at www.mnaap.org/moc4.htm
9. Vaccine Hesitancy Training. The previous year our chapter obtained a grant to teach pediatricians the CASE approach to vaccine hesitancy, and we brought that teaching this year to Saint Cloud’s CentraCare CME programming as well as to the University of Minnesota’s pediatric residency program. In addition, we published the technique in Minnesota Medicine as well. 
More info at www.mnaap.org/immunizationsed.htm
10. Increased membership. We held a number of events to improve membership in the AAP at the chapter level, including a special mailing to all pediatric specialists across the state. That along with our concerted efforts to support our medical schools’ pediatric interest groups garnered us new members across the spectrum of pediatric professionals. 
This year we topped 1,000 members—our best year yet.
That’s my ten. What did I learn from making that list? First, our chapter’s success completely depends on pediatricians coming together to volunteer their time, interest, and wisdom. Second, our chapter’s resources including its staff consultants, if not especially them, can turn ideas into reality. And, third, if that’s what we accomplished last year, just imagine what we can do in the years to come!

A Look Back at MNAAP’s Highlights in 2013

By Robert M. Jacobson, president of MNAAP&#8230;
I hope you take the time to read the front-page article about the destructive changes that have occurred to Minnesota’s newborn screening program. It’s the leading issue for our chapter this year in terms of advocacy. It rose to the top for three reasons: a clock-ticking sense of urgency, the large number of children who will be impacted, and the lack of other organizations willing to take the lead.
Occasionally our colleagues ask why we aren’t focusing more attention to injury prevention, gun control, child sex trafficking, responsible sex education, or other hot-button issues. My response is that we are careful to prioritize which efforts we best lead and which efforts we join coalitions our fellow pediatric advocates’ best lead. We only have so many resources. We have limited lobbying time, consultant support, and volunteer person-power. Last legislative season we pursued legislation related to anti-bullying, early brain development, newborn screening, and access to care. We have work groups and committees that drive each of those efforts.

If you are involved, you know that our work groups and committees meet outside of clinic hours via teleconference and are staffed by either our executive director Kathi Cairns or our communications director Melissa DeBilzan. If you aren’t involved and you want to be active in the life of our chapter, please join one of our work groups or committees. They include the obesity, quality improvement, healthcare homes, and immunizations workgroups as well as our committees on policy and membership/communication.
What about all the other issues? What about breastfeeding, guns, nicotine and tobacco, and bike helmets? How do we pick some issues and not others?
Actually, we do take stands on these important issues outside our workgroups or committees. In addition, when we can, we partner to support another group’s taking the lead. For example, we are members of the SHIP coalition, the Raise It for Health coalition, Minnesotans for Healthy Kids, MinneMinds, and the Tan-Free Teens campaign &#8212; all of which have made significantly more headway at the Capitol in recent years than we could have on our own. We have also supported events sponsored by the Minnesota Breastfeeding Coalition and the Minnesota Safety Council. These and other organizations rely on the support and partnership of our chapter to accomplish shared goals.
We take the lead on those pediatric topics when no one else will take the lead. Recognizing that taking on too many topics limits our success in any, we aim to focus our resources on 1 to 4 topics in this way each year. They vary from year to year depending on immediacy, a compelling consensus toward specific action, and locus of responsibility. The latter refers to whether MNAAP is the one and only one to take the lead.
So what are you to do as a member if the initiative you want to pursue is not on our short list for this year? One suggestion is to communicate with our policy committee. It’s open to all members. That committee is particularly focused on making changes within the legislature. Another suggestion is to join an existing workgroup. A lot of advocacy work needs to occur outside the Capitol—with our members, with parents, and with others who care for children.
Of course, our chapter would welcome appropriate educational material to be posted on our website under resources for parents or resources for clinics. We can also get the word out through our Facebook and Twitter feed, Minnesota Pediatrician newsletter and all-member emails.
Also, you might consider applying for grants through our chapter. We have low administrative costs and our staff consultants can help you write and submit those grants. We have a great track record for such submissions.
I’d like to hear from you about the initiatives you care about most. We will be surveying our membership again this fall. That’s one way to share your thoughts. But I welcome you to write me directly as well. Take time to participate in the life of the chapter. Your participation can change how our chapter leadership views opportunities and considerations. You will make a difference.

Leading and Supporting Child Health Issues

At our annual meeting this May, we had an opportunity to put the preceding year in perspective. Our chapter accomplished a great deal in the last year. We’ve successfully obtained a grant to improve pediatric services for children in foster care and another to improve pediatric care through telemedicine and social media. We’ve achieved our largest membership ever now with close to 1,000 members. We’ve completely redesigned our web site to enhance our communications with our members as well as provide them better access to resources and news. In addition, we now offer a menu of discounted MOC 4 activities for maintenance of board certification. Finally, we have had real success with our advocacy for children.
Our highest priorities in advocacy included children’s access to care. This March our state’s health insurance exchange proposal was signed into law. As part of the goal of increasing access to care, we led efforts to instruct pediatricians across the state to sign up in time to make retroactive for the year increased primary care reimbursement increases under Medicaid. Our efforts to expand mental health services were made manifest in the Health and Human Services omnibus budget bill, the first bill to increase spending in the last six years; it specifically includes expanded services for mental health, chemical dependency, maternal depression, suicide prevention, and autism spectrum disorders therapy.
A second major priority was early brain development, and here we succeeded not only with the omnibus budget bill but also with the Minneminds financing package as part of the E-12 (early education through grade 12) bill, which dramatically expands scholarships to allow low income families access to quality education programs.
But two of our highest priorities for the year in advocacy did not fare as well.
While the Critical Congenital Heart Disease Testing Requirement did pass and was included in the omnibus bill, we were not successful in moving forward with legislation to prevent the destruction neither of the blood samples used to diagnose metabolic conditions in newborns nor of the actual documents of the results of the newborn screening. We are not giving up, however. We are already planning meetings with key allies to address this issue at the legislature again next year.
Similarly, the anti-bullying legislation that we pursued never made it out of committee. The proposal would require school districts to implement robust anti-bullying and anti-harassment policies to protect students, provide training to staff, and establish reporting protocols. It may have been killed in a legislative committee this year but we will be back next year.
Even as I write this, I am preparing to testify at an administrative hearing in the morning to fight for the updating of our state’s school and daycare rules. Given the tenor of the public comments from the anti-vaccinationists, we will be struggling to be heard and understood. But fighting for the health of our state’s children is always worth the effort, and no one ever told us it would be easy.

A Word from the President: A Year in Review

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Pediatric Physician

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BC/BE Pediatrician

We’re excited to announce an opening for a Communications Manager at the Minnesota Chapter of the American Academy of Pediatrics (MNAAP). This part-time, remote role is a unique opportunity for a communications professional with at least five years of experience, who is passionate about advancing child health through advocacy, education, and special projects.

Robert Jacobson, MD, FAAP Category