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MNAAP Newsletter

Minnesota Pediatrician is published quarterly (February, May, August and November) and is written by pediatricians for pediatricians. The newsletter is mailed and emailed to over 1,000 members.

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June 13, 2019

Firearm-related fatalities are the third leading cause of death among children in the U.S., taking about 1,300 young lives annually. Several thousand children are injured by firearms yearly, and as many as 4 percent of children have witnessed a shooting in the past year causing immeasurable psychological trauma.

But what can we, as pediatricians, do to protect children from gun violence?

We can give very specific guidance to parents on how to safely store guns (if owned) and how to talk to their children about firearms. We can advocate for policies that have a track record for decreasing gun violence. This is an issue “in our wheelhouse” that we are equipped, and obligated, to address.

As pediatricians, we are in a unique position to rise above the partisan debate and advocate for children in the office, in our communities, and in our capitol.

Guidelines for Safe Firearm Storage

A 2018 study from the Journal of Urban Health found that 4.6 million U.S. youth live in homes with at least one loaded, unlocked firearm. Safe gun storage prevents accidental injuries and suicides. States with laws that require handguns to be locked have 68 percent fewer firearm suicides per capita than states without such laws, even after controlling for confounding variables. Share with parents and caregivers:

  • Hiding a gun in a drawer or closet is not safe storage
  • Firearms should be stored in a locked cabinet, gun vault or safe and/or secured with a gun-locking device (e.g.cable lock).
  • Ammunition should be stored and locked separate from firearm

Messaging for Children

  • Ask children to problem-solve at well check appointments: What would you do if you were playing at a friend’s house and found a gun? What if it looked like a toy?
  • The message you can share with children is: Stop. Do NOT touch the gun. Don’t let anyone else touch it. Even if the gun looks like a toy, don’t touch it because some real guns may look like toys. Go tell an adult.

Legislative Advocacy

Reducing firearm violence is one of MNAAP’s legislative priorities. The chapter advocates for policies that can protect children, including:

  • Background checks universally applied to all gun sales
  • Laws requiring waiting periods that create an important window for gun purchasers to reconsider their intentions and prevent impulsive acts of violence, particularly suicide
  • Minimum age for purchasing a firearm should be 21 years old
  • Safe storage laws can mandate safety requirements such as a locked container or gun lock

Additionally, since the federal assault weapons ban expired in 2004, banning assault weapons and large capacity ammunition magazines is an important area of policy to prevent mass shootings.

 

About the Author

Nadia Maccabee-Ryaboy, MD, FAAP, is a pediatric hospitalist at Children’s Minnesota. She serves on MNAAP’s child safety workgroup.

 

A teenage patient who has been coming to you her entire life is brought in by her parent, who is concerned with
the teen’s complaints of stomachache, fatigue, and loss
of appetite. The teen denies having intentions of losing weight, and her BMI is still above 50 percent. However, her weight has dropped significantly enough that she has steeply fallen off her growth curve, and she hasn’t had a period for five months. When a patient like this presents to your clinic, an eating disorder needs to be on your mind. In primary care, we are well-positioned to identify eating disorders early and intervene. We just need to ask.

Eating disorders in children and adults frequently go undetected for lengthy periods of time. This is a concern because early intervention is robustly linked to positive prognosis in these deadly illnesses. Pediatricians have the perfect vantage point to initiate intervention with children and adolescents with eating disorders. This is because patients often present first in primary care, usually with nonspecific concerns such as stomachaches, fatigue, depression, amenorrhea, or unexplained weight loss. When pediatricians screen for eating disorders, we are often able to identify them earlier and support families in seeking appropriate care.

Eating disorders are typically considered mental health issues which manifest physical changes. In children and teens, however, it may be more appropriate to think of eating disorders as physical conditions with mental health side effects.

Intervention in a primary care setting can also reduce the risk of patients failing to follow up with specialty care, which is another barrier to intervention for eating disorders. When a primary care provider diagnoses an eating disorder it can reduce some of the stigma of having an illness, because it recasts it as a medical issue, rather than a mental health issue. Additionally, pediatricians often have long-standing relationships with families as trusted medical experts.
This relationship can help parents feel supported as they struggle to take action to address their child’s disorder.

Good evidence-based outpatient care for eating disorders exists, but it is frequently very hard for patients to access. Family-Based Treatment (FBT) is considered the first line evidence-based outpatient treatment for treating adolescent eating disorders, however, fewer than 100 practitioners worldwide are certified in this method. Most of those who are certified are located near a major metro area, which limits rural patients’ ability to access treatment. Mayo Clinic has developed and piloted a modified version of FBT for delivery in primary care, by a primary care provider. This intervention is called Family-Based Treatment for Primary Care (FBT-PC). This interdisciplinary program allows for the comprehensive management of both psychological and medical factors at a single location and has the potential to improve access to eating disorder care for anyone with a primary care provider.

In early 2017, two pediatricians and one family medicine nurse practitioner at the Mayo Clinic received training in FBT-PC. All providers in the pilot program were volunteers and saw FBT-PC patients as part of their standard clinical practice. Providers received four hours of initial training led by two clinical psychologists who specialize in the treatment of adolescent eating disorders, one of whom is FBT-certified. The content of the training consisted of FBT interventions that focus on weight restoration and normalization of eating by empowering parents to take charge of refeeding their child through monitored meals. Throughout the pilot, providers participated in monthly hour-long FBT-PC case consultation meetings with the psychologists and had the ability to consult with them in between sessions as well.

Results from a pilot study of FBT-PC suggest the intervention is suitable for implementation in primary care settings and was associated with significant improvement in patient BMI percentile after three months. The rate of weight gain was comparable to that recommended in standard FBT. Providers had success engaging caregivers or parents, and retaining families in treatment. These findings suggest that additional study of the FBT-PC intervention is warranted, and confirms the idea that primary care is a feasible and potentially effective setting to implement eating disorder care for young patients.

Pediatricians are dedicated to the sustained health and wellbeing of their patients. The standard practice of reserving eating disorder interventions for specialists, and failing to involve primary care in the treatment ignores the powerful role pediatric providers can play in helping young patients get care. By shifting the paradigm and arming pediatric providers with the evidence-based tools they need to help families of children and adolescents with eating disorders, there is the potential to increase early intervention and improve patient outcomes.

 

Jocelyn Lebow, PhD, LP, is a clinical psychologist at Mayo Clinic and is certified in Family-Based Treatment.

Cassandra Narr, APRN, CNP, MSN, Angela Mattke, MD, FAAP, Janna Gewirtz-O’Brien, MD, FAAP, Marcie Billings, MD, FAAP, Robert Jacobson, MD, FAAP, and Leslie Sim, PhD, of Mayo Clinic collaborated on this article.

 

The much-anticipated warm weather and activities are upon us. I live in Duluth, so when we start to see ships passing under the Aerial Lift Bridge it’s official: Spring is here! I am pleased to report that advocacy has been the driver of a great deal of energy in the Minnesota Chapter of the AAP these past few months. We had a robust attendance of more than 140 at our Pediatricians’ Day at the Capitol this year. Having the opportunity to learn more about our legislative priorities and meeting with Minnesota lawmakers enriches our advocacy experience, and the engagement was palpable this year. The Minnesota State Capitol has been literally buzzing with activity. It was a vigorous legislative session in 2019 with over 5,000 bills introduced. Thousands of those failed to meet deadlines, but many have made it through the relevant policy committees in the House and Senate. I want to acknowledge and thank all the pediatricians who have given testimony in the hearings for several relevant bills. We have a “deep bench” of participants and have been able to call on them with short notice.

In addition, many pediatricians have been speaking up at their local city councils on behalf of Tobacco 21 ordinances in the metro area and in greater Minnesota. Tobacco 21 ordinances would raise the purchase age for tobacco products to 21 and can help prevent or delay nicotine addiction. The pediatricians who are sparking conversation and encouraging change are the “boots on the ground” folks. You have been very influential in getting these ordinances passed. There are many pediatricians across the state that apply advocacy in their practice, schools, and communities. I thank you for your dedication and tireless efforts. I am currently reading a book about Eunice Kennedy Shriver, who lived a life emblematic of advocacy.
Even though she lived in the shadow of her politically accomplished brothers, she had a fervor for advocacy that resulted in the formation of the Special Olympics. She was described as impatient, insistent and formidable, qualities that led to a lasting legacy of social justice. It is with that same persistence and passion that we will continue to speak up and speak out on behalf of all children and families of Minnesota.

 

May 23, 2019

When I was 8 or 9 years old, I watched my younger sister, not yet 4 years old, jump off the diving board wearing her “bubble” (an inflated football shaped flotation device belted around her waist). The bubble floated to the surface; she did not. My young self swam to help her, and we both struggled. Fortunately, our father was watching. In a flash, he was in the deep end of the pool, helping us both to safety. We were lucky.

Several years ago, moments after fishing acorns out of my 9-month-old nephew’s mouth, I sprang into action, while still holding my nephew, to scoop my then 2-year-old niece out of the shallow end of the pool. Despite being told to stay on the steps, she ventured further and within moments was underwater. Another adult was supposed to be watching them both.

Swimming with my own kids at a local fitness center pool, with lifeguards and multiple other adults around, I saw yet another child slip underwater, the child’s caregiver facing another direction. I helped that child, too.

Drowning happens quickly and at unexpected times when supervision, for whatever reason, lapses. It only takes a moment. As parents, we must be vigilant, alert, responsible. As pediatricians, it is our duty to counsel parents about water safety, to practice what we preach and to lead by example. Active supervision in and around water is required to prevent drownings and is why I became a #WaterWatchdog. A #WaterWatchdog agrees to maintain constant visual contact with the children in your group, not to drink alcohol, talk on the phone, socialize or read while watching children, to keep a phone near the water for emergency purposes only, and to remain by the water until relieved by a new #WaterWatchdog.

I encourage everyone, my colleagues, friends, family members, and patients/parents to become a #WaterWatchdog. Pledge to actively supervise children in and around the water, and prevent drowning, here: https://abbeyshope.org/water-watchdog/. Together we can make a difference, and keep kids safe. Take the pledge, share and promote safety, actively watch kids and prevent drowning. #PutKids1st, always.

Christina Dewey, MD, FAAP, is a pediatrician at All About Children Pediatrics, in Eden Prairie, MN, practicing in the Twin Cities Metro area since 1999. Learn more about Dr. Dewey at allaboutchildren.net & follow her on Twitter @PedsMamaDoc. 

February 27, 2019

By Vijay Chawla, MD, FAAP; and Sylvia Sekhon, MD, FAAP

Immunization outreach group

Immunization presentation panel at Dar Al-Hijrah Mosque in Minneapolis (left to right) Wali Dirie, Imam Sheikh Abdirahman Sharif, Michelle Dittrich (MDH), Dr. Nasreen Quadri, Sabah Yusuf (interpreter), Dr. Beth Thielen, Roble Aden (foreign trained Somali physician)

The Minnesota Department of Health (MDH) identified that children of Somali descent who were 24 months of age had an MMR vaccination rate of nearly half that of their non-Somali peers: 46 percent compared to the rate among non-Somali children, which was 88 percent. During the 2017 Minnesota measles outbreak, 65 cases of measles were identified with the majority in unvaccinated persons.  U.S.- born Somali children over age 12 months accounted for 55 of the cases.

Since 2017, 37 pediatricians, med-peds physicians and pediatric residents have volunteered to provide immunization education at mosques in Minnesota and answer immunization questions of parents and elders. The outreach is part of the effort by the MNAAP Immunization Taskforce, which is committed to increasing infant, child, and teen immunization rates and decreasing barriers to vaccination.

Improving the Minnesota pediatric immunization rates is one of the four strategic priorities of the MNAAP Board for 2017-2020. New immunization outreach/education sessions at mosques started in January 2019 and are scheduled to continue through June. The hope is that by taking information to the Somali communities throughout Minnesota and by having a dialogue with parents, elders, and religious leaders in the place where they meet weekly, we might be able to change a few minds and protect all our Minnesota children.

Somali resources and tips that are used at these education sessions and are available to clinics include:

• Somali/English version of the childhood immunization schedule from MDH. Order online, at www.health.state.mn.us and searching “immunization order form”.

• Somali/English child development wheel from the Minnesota Department of Education is available free to anyone in the seven-county metro area (and MNAAP has copies to share for greater Minnesota in English, Somali, Hmong, Spanish and Karen). One side of the wheel explains what a parent can do to further child development and the other side lists what skills a child should have starting at age 3 months to age 5 years. Contact Kathy McKay at kathy.mckay@metroecsu.org and complete an order form.

While most of our mosque outreach presentations have been in a formal format with speakers sitting behind a table in front of the room, a recent group of women requested that we return to attend a women’s group at the mosque to share food and conversation and all sit together. This is a positive sign that the information is reaching those who need it.

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