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March 7, 2019

A bill to promote the benefits of immunization will be heard in the House Health and Human Services Policy Committee on Friday, March 8.

Please take 1 minute to contact your House member and urge them to support this effort to increase immunization rates. Our voice needs to be louder than those contacting legislators with anti-vaccine rhetoric.

In short, HF 1182 would provide funding to the Minnesota Department of Health and community-based organizations to promote the benefits of immunization for those communities most at risk. The education efforts would be focused upon geographic areas or populations experiencing or at risk of experiencing an outbreak of a vaccine-preventable disease.

Talking points:
  • Vaccines prevent serious illness and save lives. Yet misinformation about vaccines is all too common, leading many parents to opt out of vaccines and put children and others at risk.
  • States with more permissive vaccination laws, such as Minnesota, are at increased risk for outbreaks of vaccine-preventable disease.
  • Data from the Minnesota Department of Health shows that several communities and schools have high rates of non-medical exemptions. In Wadena County, for example, 13 percent of Kindergartners are entering school without required vaccinations.
  • Targeted education is needed to counter myths and falsehoods about vaccination, especially in communities with high rates of non-medical exemptions.

Please take 1 minute to contact your House member and urge him or her to support HF 1182. 

1. Enter your home address to find your MN House member: https://www.gis.leg.mn/iMaps/districts/

2. Send him or her a brief email using the language above. Feel free to personalize or modify. Copy debilzan@mnaap.org so we can track outreach.

Another option is a quick call saying, “I’m a constituent in your district and pediatrician calling to convey my support for HF 1182, a bill to help provide education to communities with low vaccination rates.”

 

 

August 12, 2022

It’s more complicated than you might think.  Obviously, it starts at birth.  Well, not exactly.  We all know that there is a child being created for several months before we pediatricians get directly involved.  So don’t forget about supporting the health, nutrition, and medical care of young women–even BEFORE they become pregnant.  We can influence the next generation for the better before they even exist.

But our involvement really kicks in at birth — sometimes right down to the second in the delivery room.  This newborn child, with a new edition of the most powerful brain on the planet, can do essentially nothing without adult care, nurture, and eventually guidance.  So “early childhood education” is really parent (and grandparent) education — our stock-in-trade!  And we can also do better educating and supporting the child-care workforce — those dedicated and underpaid educators who are now needed by most families.  Remember: a single remark to a new parent can have a lasting impact.

And how long does this “early childhood” period extend?  More about that next week!

In fall 2021, the chapter adopted Early Childhood concerns as one of its top strategic priorities for the years 2022, ’23, and ’24. This decision changed our Early Childhood Caucus into the Early Childhood Working Group, still co-chaired by Krish Subrahmanian, MD, FAAP; Nathan Chomilo, MD, FAAP; and Roger Sheldon, MD, FAAP. The group has been working on legislation and on other projects.

One of the group’s goals is to keep chapter members informed. The work group is actively enlisting help in spreading the word about the needs of early childhood and family education, and the needs of childcare in general for the prenatal to three age group.

The work group will be providing you with the knowledge and opportunities to assist the chapter in improving the early childhood situation state-wide. They welcome your questions and suggestions for topics to include. Additional members of the working group are also needed. Please send your reactions, suggestions, questions and your offers of assistance to: Roger Sheldon (rogeugshe@gmail.com) or Mary Meland (melandmh@gmail.com).

Current work group members include:

Ada Alden

Gigi Chawla, MD, MHA, FAAP

Nathan Chomilo, MD, FAAP

Dale Dobrin, MD, FAAP

Chad Fahning

Faith Kidder, NP

Kath Kulus, MD, FAAP

Adam Langenfeld, MD, PhD, FAAP

Brian Lynch, MD, FAAP

Mary Meland, MD, FAAP

Christian Nagel, MD, FAAP

Nancy Ott, MD, FAAP

Roger Sheldon, MD, FAAP

Krishnan Subrahmanian, MD, FAAP

Pafoua Vang

August 11, 2022

Meg Bensignor, MD, FAAP

With a 95 percent increase in type 2 diabetes (T2DM) incidence in youth aged 10-19 years from 2001 to 2017, T2DM clearly is not just a disease of adulthood anymore. (1) It is also apparent that T2DM is not the same disease in adolescents as it is for adults. Firstly, T2DM in adolescents is a much more aggressive disease than in adults, characterized by rapid impairment of insulin secretion with up to 80 percent pancreatic β-cell function loss at the time of diagnosis. (2-6)  Additionally, medications that typically work well for adults are not as effective in adolescents. For example, despite treatment with metformin and lifestyle management, about half of adolescents with T2DM required insulin therapy in a median treatment time of 11.5 months, which is a much higher failure rate than adults. (7-11)  Two other medications commonly used in adults (dipeptidyl peptidase-4 inhibitors and sodium-glucose cotransporter-2 inhibitors) were recently found to not improve diabetes control in adolescents as they were with adults. (12, 13, 14)  On top of this, diabetes-related comorbidities occur early in youth with about a 60 percent cumulative incidence of any microvascular complication (retinopathy, diabetic kidney disease, hypertension, dyslipidemia, or nerve disease) in a mean of diagnosis length of 13 years. (15)

The American Diabetes Association (ADA) recommends to start screening at age 10 years or the start of puberty, whichever is sooner. (16) Screening is typical done with a hemoglobin A1c (HbA1c), which can be quickly obtained in an office setting. Any patient should be screened annually if they have a BMI > 85th percentile for age and sex and have a maternal history of diabetes or gestational diabetes, a first or second degree relative with T2DM, or signs of insulin resistance (acanthosis nigricans,  skin tags, hypertension, dyslipidemia, history of small-for-gestational-age status, and polycystic ovarian syndrome). (16) However, is important to note that diabetes type cannot be diagnosed by signs of insulin resistance or BMI alone as 35-50 percent of youth with type 1 diabetes can also have overweight or obesity. (17) Obtaining diabetes auto-antibodies to exclude type 1 diabetes is recommended for all suspected cases of youth with diabetes before labeling a patient as having T2DM. (16)

Once T2DM is diagnosed with an HbA1c > 6.5 percent, a fasting glucose > 126 mg/dL, or a random glucose > 200 mg/dL with symptoms of polyuria, polydipsia, or unintentional weight loss, treatment with metformin should be started immediately along with lifestyle management. (16) A trial of lifestyle treatment alone without anti-diabetes pharmacotherapy is not recommend. Furthermore,  insulin therapy initiation and referral to a pediatric endocrinologists should be done if the HbA1c > 8.5 percent.16 Although still limited, there are expanding treatment options for pediatric T2DM, including two injectable glucagon-like peptide-1 receptor agonists recently FDA approved for the use of patients > 10 years (weekly exenatide extended-release and daily liraglutide 1.8mg). (18,19)

Staying vigilant of a T2DM diagnosis in youth is imperative as delayed diagnosis and treatment initiation can lead to diabetic ketoacidosis or hyperglycemic hyperosmolar syndrome, and poor long-term glycemic control in an already remarkably aggressive disease. (20)


About the Author

Meg Bensignor, MD, FAAP,  is an Assistant Professor in the Department of Pediatrics and in the Division of Endocrinology and Diabetes at the University of Minnesota as well as a Core Faculty in the University of Minnesota Center for Pediatric Obesity Medicine. She is a board-certified obesity medicine specialist and a pediatric endocrinologist, specializing in type 2 diabetes in youth. Dr. Bensignor’s area of research involves evaluating the effects of eating patterns on obesity risk and appetite, in addition to novel and effective treatments for youth with Type 2 Diabetes and obesity. She is part of the multidisciplinary team, which includes diabetes nurse educators, a dietician, and a social worker, that make up the Pediatric Type 2 Diabetes Clinic at the University of Minnesota/MHealth.


References

  1. Lawrence JM, Divers J, Isom S, et al. Trends in Prevalence of Type 1 and Type 2 Diabetes in Children and Adolescents in the US, 2001-2017. JAMA. 2021;326(8):717-727.
  2. Elder DA, Woo JG, D’Alessio DA. Impaired beta-cell sensitivity to glucose and maximal insulin secretory capacity in adolescents with type 2 diabetes. Pediatr Diabetes. 2010;11(5):314-321.
  3. Elder DA, Hornung LN, Herbers PM, Prigeon R, Woo JG, D’Alessio DA. Rapid deterioration of insulin secretion in obese adolescents preceding the onset of type 2 diabetes. J Pediatr. 2015;166(3):672-678.
  4. Bacha F, Pyle L, Nadeau K, et al. Determinants of glycemic control in youth with type 2 diabetes at randomization in the TODAY study. Pediatr Diabetes. 2012;13(5):376-383.
  5. Group TS. Effects of metformin, metformin plus rosiglitazone, and metformin plus lifestyle on insulin sensitivity and β-cell function in TODAY. Diabetes Care. 2013;36(6):1749-1757.
  6. Michaliszyn SF, Mari A, Lee S, et al. β-cell function, incretin effect, and incretin hormones in obese youth along the span of glucose tolerance from normal to prediabetes to type 2 diabetes. Diabetes. 2014;63(11):3846-3855.
  7. Brown JB, Conner C, Nichols GA. Secondary failure of metformin monotherapy in clinical practice. Diabetes Care. 2010;33(3):501-506.
  8. Consortium R. Metabolic Contrasts Between Youth and Adults With Impaired Glucose Tolerance or Recently Diagnosed Type 2 Diabetes: II. Observations Using the Oral Glucose Tolerance Test. Diabetes Care. 2018;41(8):1707-1716.
  9. Turner RC, Cull CA, Frighi V, Holman RR. Glycemic control with diet, sulfonylurea, metformin, or insulin in patients with type 2 diabetes mellitus: progressive requirement for multiple therapies (UKPDS 49). UK Prospective Diabetes Study (UKPDS) Group. JAMA. 1999;281(21):2005-2012.
  10. Barnes NS, White PC, Hutchison MR. Time to failure of oral therapy in children with type 2 diabetes: a single center retrospective chart review. Pediatr Diabetes. 2012;13(7):578-582.
  11. Zeitler P, Hirst K, Pyle L, et al. A clinical trial to maintain glycemic control in youth with type 2 diabetes. N Engl J Med. 2012;366(24):2247-2256.
  12. Jalaludin MY, Deeb A, Zeitler P, et al. Efficacy and safety of the addition of sitagliptin to treatment of youth with type 2 diabetes and inadequate glycemic control on metformin without or with insulin. Pediatr Diabetes. 2022;23(2):183-193.
  13. Shankar RR, Zeitler P, Deeb A, et al. A randomized clinical trial of the efficacy and safety of sitagliptin as initial oral therapy in youth with type 2 diabetes. Pediatr Diabetes. 2022;23(2):173-182.
  14. Tamborlane WV, Laffel LM, Shehadeh N, et al. Efficacy and safety of dapagliflozin in children and young adults with type 2 diabetes: a prospective, multicentre, randomised, parallel group, phase 3 study. Lancet Diabetes Endocrinol. 2022;10(5):341-350.
  15. Bjornstad P, Drews KL, Caprio S, et al. Long-Term Complications in Youth-Onset Type 2 Diabetes. N Engl J Med. 2021;385(5):416-426.
  16. Draznin B, Aroda VR, Bakris G, et al. 14. Children and Adolescents: Standards of Medical Care in Diabetes-2022. Diabetes Care. 2022;45(Supplement_1):S208-S231.
  17. Hamman RF, Bell RA, Dabelea D, et al. The SEARCH for Diabetes in Youth study: rationale, findings, and future directions. Diabetes Care. 2014;37(12):3336-3344.
  18. AstraZeneca. Bydureon BCise (exenatide extended-release) approved in the US for the treatment of type 2 diabetes in pediatric patients ages 10 years and older. 2021; ttps://www.astrazeneca-us.com/media/press-releases/2021/bydureon-bcise-exenatide-extended-release-approved-in-the-us-for-the-treatment-of-type-2-diabetes.html. Accessed November 24, 2021, 2021.
  19. Bacha F. FDA approval of GLP-1 receptor agonist (liraglutide) for use in children. Lancet Child Adolesc Health. 2019;3(9):595-597.
  20. Alemzadeh R, Ellis J, Calhoun M, Kichler J. Predictors of metabolic control at one year in a population of pediatric patients with type 2 diabetes mellitus: a retrospective study. J Pediatr Endocrinol Metab. 2006;19(9):1141-1149.

 

August 9, 2022

Looking Inward to Inspire Change

As a physician, the medical director of the Children’s Minnesota Simulation Center, and a mother of four – I am deeply committed to addressing the inequities that have sat just beneath the surface of clinical bedsides nationwide for far too long. This is why I collaborated with Brittany Dahlen, clinical education specialist at Children’s Minnesota, to develop a cutting-edge, hands-on training course to help our providers take an inner-look at themselves and their personal biases. My team created an immersive training program that reinforces our organization’s continued commitment to health care equity and improving patient outcomes through an interactive course called: The Role of Bias in De-escalation. 

The Role of Bias in De-escalation Training Course

In 2020 – just months after George Floyd’s murder and the civil unrest that followed – Children’s Minnesota launched The Role of Bias in De-escalation. This interactive training program now puts health care professionals face-to-face with live actors portraying parents of kids in high-stress medical situations. Participants include nurses, physicians, advanced practice providers, allied health professionals, and members of Children’s Minnesota’s Executive Leadership Team. Professional actors are recruited from our community, and represent Children’s Minnesota’s diverse patient population. 

Training courses often unfold at our simulation center inside Children’s Minnesota’s Minneapolis hospital campus, which is less than two miles from where George Floyd was killed. Here, participants have the opportunity for self-reflection and to identify personal biases during interactive encounters with an actor. Actors are given scripted dialogue to choose from centered around the same highly-emotional exchanges health care professionals have during real clinical situations. However, unlike the actors, the participants’ responses are completely unscripted. Personal biases are most likely to surface when emotions are escalated. Instructors closely monitor these exchanges between the health care professional and actor. Instructors then offer bias mitigation tactics, tools and strategies, when necessary, to the group of participants. A few bias mitigation strategies taught in the program include emotional regulation, partnership building and perspective taking. 

The Course’s Success

Since Children’s Minnesota first launched The Role of Bias in De-escalation course, more than 200 Children’s Minnesota employees have completed this groundbreaking training with  97 percent of participants reported using bias mitigation strategies at the bedside within the first six months of completing their simulation training. 

After each course, learners are asked to evaluate and comment on their experience through a survey. One participant wrote:  “I have had many difficult but important conversations about bias with my coworkers as a result of this class, and have felt personally empowered with some of the strategies to deconstruct my bias and work towards anti-racism.” 

Children’s Minnesota has always taken great pride in ensuring our organization is deeply rooted in health care equity. The Role of Bias in De-escalation course serves as another tangible action we’ve taken towards our mission to champion the health of all kids and families.


This article was authored by Samreen Vora, MD, with Children’s Minnesota and was provided to Minnesota Pediatrician by Children’s MInnesota (a MNAAP annual sponsor). 

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