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August 1, 2013

By Damon Dixon, MD, a Native American physician and third-year pediatric cardiology fellow at the University of Minnesota Amplatz Children’s Hospital

As the fellow liaison to the Committee on Native American Children Health (CONACH), I had the opportunity to participate in the annual legislative visit to Washington DC. The agenda for the legislative meeting involved discussions on Native American child health issues, an opportunity to meet with U.S. representatives and senators and sponsorship of a congressional briefing.

CONACH is an AAP National Committee that develops policies and programs to improve the health of Native American Children. The members are committed to increasing the awareness of health care issues facing Native American children and advocating for legislation that ensures Native American children have access to high quality health care. CONACH also conducts annual pediatric consultation visits to Indian Health Service (IHS) and tribal health care facilities to promote the development of programs that support healthy lifestyles and optimal physical, mental and social health in Native American children.

IHS is a comprehensive community-oriented health care delivery system that serves American Indians and Alaska Natives (AI/AN). The IHS was established by treaties and trust agreements to provide basic health care needs to AI/AN by the U.S government. AI/AN have longstanding treaty rights with the U.S. government that guarantee federal provision of health care services, dating all the way back to the constitution. IHS serves 2.1 million American Indians and Alaska Natives (AI/AN) and is the primary source of basic health care services on Indian reservations.

Meeting in downtown Washington, D.C. at the Sofitel Hotel, CONACH members discussed several issues, including actions to improve medical providers’ recruitment and retention, coalition building with other health professional groups, updates on Reach Out and Read (ROR) programs on IHS clinics and updates on Area IHS health care facilities. The meeting was highlighted by a teleconference meeting with current IHS Director Dr Yvette Roubideaux. Dr.

Roubideaux discussed the current state of affairs and reviewed IHS’s four priorities, which are commitments to strengthen partnerships with tribes, bring reform to the IHS, improve the quality and access to care, and ensure that its work is transparent, accountable and fair.

AI/AN children suffer from significant health disparities compared to other children in the general population. A Native American child born today has a life expectancy four years shorter than that of the general population; moreover the rate of obesity and Type 2 diabetes is epidemic in Indian Country. IHS provides primary preventative care to a vulnerable population with unique health care needs.

Members of CONACH also had the opportunity to meet with U.S. Congressional representatives to discuss and advocate for federal policies that would protect AI/AN children from budget cuts under sequestration. The AAP also sponsored a Hill briefing on the importance of transportation infrastructure and transportation safety issues on the Indian reservations. Motor vehicle crashes are the leading causes of injury-related deaths for Native American 19 years old and younger.

The AAP has collaborated with the IHS for 48 years and has played an important role in the improvement of Native American health care. CONACH is an example of the AAP commitment to expanding its efforts to raise the status of Native American children’s health. Being a member of CONACH has strengthened my commitment to the IHS and has rekindled my passion for advocacy.

Linda Thompson, MD and John Tobin, MD are retiring this summer after nearly 40 years as pediatricians at Hennepin County Medical Center (HCMC) where they’ve cared for underserved children and taught physicians who care for them. They have trained more physicians and medical professionals in primary care pediatrics than perhaps anyone else in Minnesota through their pediatric continuity clinics, everyday instruction to medical students and residents rotating through HCMC, and continuing education presentations.

What advice would you give to a young pediatrician?

Tobin: The costs are substantial, but the rewards considerable. You may be greeted with unabashed enthusiasm by a child, then criticized for being late or intrusive by the parents of another. Educational costs may be the same as those of colleagues going into more highly paid specialties, but the remuneration will not compare to theirs. You may make a difference in the life of the next Mozart or Einstein!

Thompson: Be prepared for hard work, long hours and a fair amount of worrying; this is the necessary price we pay for a life of fulfillment and enjoyment seeing kids grow and develop. Always listen to parents as carefully and empathetically as you can, bearing in mind that children sometimes hold the truth more so than their parents. Learning how to talk directly to children at a very young age is also important in order to provide optimal care. Read as much as time allows.

What are the biggest changes you have seen occur in your career affecting pediatric care and the health of children?

Tobin: Unquestionably, the continued development newer and more effective vaccines. Also, the Electronic Medical Record. There is now a premium placed on uniformity instead of molding the content of a visit to meet the needs of the child and family. Accompanying this is more and more requirement for measurable tasks with undocumented benefits.

Thompson: New vaccines and the virtual elimination of vaccine-preventable diseases; the disappearance of Reyes syndrome after the link with aspirin was shown; improvements in imaging techniques; advances in neonatal and pediatric intensive care; introduction of surfactant to prevent hyaline membrane disease; the explosion in medical genetics; and the increase in the proportion of women in medicine.

What are the biggest obstacles/challenges you foresee for pediatric care and children’s health in the future?

Tobin: Money. In this country we give lip service to the idea that children are important, but do not act on that principle. Witness the disparity between health care dollars spent on the end of life (much of it futile) and on the first years of life. Whether we speak of immunizations, nutrition, education, or drug development, children in the U.S. get short shrift.

Furthermore, private insurers have little incentive to provide more support, as they almost certainly will not be paying for the consequences of, say, obesity, for an individual child as an obese adult in the decades to come.

Thompson: Children’s mental health services need to improve; incentives for more people to train in child psychiatry and behavioral pediatrics and more collaborative efforts with schools, including preschools and day care centers, might help in this effort.

Racial disparities in health care access also need to be addressed. The quality of social services and the educational system are huge factors in determining children’s health. We as pediatricians need to partner with other professionals and not assume that we can solve all the problems facing children and families on our own.

What are highlights of your pediatric career? Your legacy?

Tobin: Time after time, the highlight of the week is my Continuity Clinic with University of Minnesota Pediatric residents. They have taught me far more than I have them! The fact that these residents and others have told me that they have learned the value of truly listening to what the parents have to say would unquestionably be my legacy.

Thompson: For 20 years I was the primary care doctor for NICU graduates at HCMC, often following them into their teenage years. I attended many funerals during those years and witnessed much sadness as well as some triumphs. During the past 27 years I have also worked with child abuse cases and have seen the development of this field culminating in the approval of child abuse pediatrics as a subspecialty by the ABP in 2009. Educating young pediatricians in Continuity Clinic has also been a great joy and has led to many long-term friendships for which I feel very privileged.

By Leslie King-Schultz, MD, MPH, chief resident, Mayo Clinic Pediatric Residency program

More than three-quarters of Minnesota children age 0-5 are enrolled in childcare centers. As with the rest of the population, this demographic is also experiencing a rise in the rate of obesity. In fact, among low-income preschoolers, 30 percent are considered overweight or obese. As concerned pediatricians-in-training, the University of Minnesota and the Mayo Pediatric Residency programs teamed up to improve physical activity in daycare centers in Minneapolis and Rochester through the Move2Grow project, funded by a Healthy Active Living grant from the American Academy of Pediatrics. Most pediatric residents have limited knowledge of childcare environments and the challenges that childcare providers face in offering high quality care, including adequate physical activity opportunities. This project afforded residents the chance to become familiar with childcare centers in the context of promoting child health. Using pediatric obesity as a platform for community engagement, the project aimed to develop residents’ skills in advocacy, inspire interest in life-long activism, and impact child health on a community level.

Through the Move2Grow project, leadership teams of residents and faculty from each program in partnership with the Minnesota Chapter of the AAP identified childcare centers in each community interested in improving physical activity within the center. The University of Minnesota chose four distinct centers in different regions of the city. The Mayo residency partnered with the largest Head Start center in Rochester. Teams of residents visited the centers periodically throughout the academic year, serving as coaches for the teachers in the classroom to achieve the goals they set at the start of the year. At Mayo, residents also visited the centers to observe and participate in a typical day. At each site, the residents helped lead a parent night to share the messages about healthy lifestyles including adequate physical activity with parents. Additionally, the residents helped craft new physical activity policy statements for the centers to incorporate into their existing policies.

In total, 51 residents from both programs participated in the project. In comparing pre and post-survey responses, residents reported increased confidence in counseling families regarding physical activity guidelines. They also demonstrated increased self-efficacy with regards to community engagement and policy activities with more residents feeling prepared to work at the community level to impact child health. In addition, more residents reported interest in public health, health policy, and community advocacy after participating in the project. Overall the centers really enjoyed having residents in the classrooms. The residents were most helpful in sharing resources with the teachers to help parents improve activity levels at home. The teachers felt the parent nights were very helpful, with fun shared by all.

Pediatricians have a responsibility to promote child health not only at an individual level, but also at a community level. The Move2Grow project gave pediatric residents in Minnesota a better understanding of the childcare setting and its important role in supporting child well-being. The project began relationships between residents and childcare centers which will continue to grow with new projects in coming years. At the same time, residents gained important skills to become stronger and more confident child advocates through community engagement in their future careers.

By Charles Oberg, MD, FAAP, program director of the Maternal and Child Health program at the University of Minnesota and practicing pediatrician at Hennepin County Medical Center

In the June issue of Pediatrics, the AAP Committee on Community Pediatrics released a policy statement titled “Providing Care for Children and Adolescents Facing Homelessness and Housing Insecurity.” The statement provides an important framework for thinking about the context of homelessness in our practices. It outlines both the antecedents of homelessness as well as the health, developmental, educational and social adverse outcomes of a child being raised in a transitory or less than permanent home environment. The statement concludes with a series of recommendations for the pediatrician to be cognizant of resources that might assist them in the care and management of these children.

What is the magnitude of this problem? The National Center on Family Homelessness recently released a report titled “America’s youngest outcasts 2010” and places the number of homeless children at 1.6 million children or close to 1 in 45 children. The center estimates that Minnesota had 15,898 homeless children. This is substantially less than the 337,105 in Texas, the state with the largest number of homeless children. However, for each of these children this housing instability can severely affect their life trajectory. A more recent study was conducted by the Amherst H. Wilder Foundation in 2012, which intermittently surveys the homeless population in Minnesota. It estimated there were 10,214 homeless adults, youth, and children statewide in 2012. This was a 6 percent increase over the 2009 survey. Surprisingly, the results show that nearly half (46 percent) of all homeless persons in the state of Minnesota were 21 years of age or younger. This included 3,546 children with their parents and 1,151 youth who were homeless on their own.

The table provides a listing of statewide resources designed to decrease the burden that homelessness places on a family. The list provides a description of services as well as contact information that might assist in the coordination of care for this vulnerable population.

The AAP and the Committee on Community Pediatrics should be applauded for their efforts to re-familiarize us with this most extreme form of risk for an infant, child or adolescent. The recent dialogue on Toxic Stress and Adverse Childhood Events emphasizes the importance of this risk. The contributing factor of homelessness such as parental unemployment, mortgage foreclosure, poverty, mental illness, substance abuse and/or domestic violence are magnified when a family slips into a homelessness, exponentially worsening the adverse health outcomes for children. As pediatricians, we should be familiar with these invaluable resources that might assist us in our coordination of care and to provide linkages to essential community services for these vulnerable families and their children.

Policy Statement on Care for Children Facing Homelessness and House Insecurity, Council on Community, Pediatrics, 2013; 131: 1206

The National Center on Family Homelessness, America’s Youngest Outcasts 2010: state report card on child homelessness. Available at:

Gerrard M, Shelton E, Pittman B, and Owen G: Initial findings: Characteristics and trends of people experiencing homelessness in Minnesota,
2012 Minnesota Homeless Study, Amherst H. Wilder Foundation, 2012

Caring for Homeless Children Resource Table

By Dave Aughey, MD, FAAP, Medical Director, Adolescent Medicine, Children’s Hospitals and Clinics of Minnesota

Chlamydia genital infections are the most commonly reported infectious diseases in Minnesota. The burden of infection is most common among sexually experienced adolescents and young adults. Substantial health disparities exist — with the prevalence among blacks more than 10 times that of whites. Chlamydia prevalence in 14-29 year olds is 2.5 times greater than in 25-39 year olds. In 2012, Greater Minnesota had the largest increase in chlamydia — more than double the rate increase in the Twin Cities. Nationally, among 14-19 year old females, chlamydia prevalence is 6.8 percent overall (4.4 percent for whites vs. 16.2 percent for blacks).

Most genital chlamydia infections in males and females are asymptomatic or have minimal, intermittent symptoms. Important sequelae include cervicitis, Bartholin abscess, epididymitis and urethritis (in both genders). In females, chlamydia can ascend to the upper genital tract resulting in pelvic inflammatory disease (PID), fallopian tube fibrosis and scarring, tubal factor infertility, ectopic pregnancy and chronic pelvic pain. Chlamydia is the leading preventable cause of infertility.

Genital chlamydia infections are readily diagnosed using nucleic acid amplification tests (NAATs). For screening, a vaginal swab (collected by the clinician or by the patient) for females, and a first-void urine specimen for males, is preferred. Though some clinics conduct urine tests for females, vaginal swab has a higher sensitivity.

The cornerstone of chlamydia prevention is regular screening. Annual screening is recommended for all sexually active females 25 years and younger. Risk factors for additional screening include recent onset of sexual activity and having a new sex partner, or more than one partner. The U.S. Preventive Services Task Force designates annual screening as an A-rated preventive service as screening has been shown to decrease the prevalence of chlamydia and PID. Despite being rated as one of the top ten most beneficial and cost-effective preventive services, it is also among the most underutilized. In Minnesota in 2009, screening rates were 43 percent among eligible females enrolled in commercial health plans and 57 percent among the Medicaid population.

Routine screening is not currently universally recommended for males but should be considered in settings with a high prevalence of chlamydia or based on sexual risk assessment (history of STDs, lack of condom use, multiple partners, other high risk behaviors).

Clinical Pearls

  • Uncomplicated genital chlamydia infections (asymptomatic patient with a positive test or cervicitis, urethritis) are treated with 1 gm of azithromycin as a single dose, or 100 mg doxycycline twice a day for 7 days. Abstinence from all sexual activities is recommended (not even with a condom) until after 7 days of completed treatment AND until 7 days after partner(s) are treated.
  • 10-15 percent of untreated Chlamydia may result in PID. Note that azithromycin is not adequate treatment for PID.
  • Reinfections, usually from untreated partners, are common. Chlamydia-infected males and females should be retested about 3 months after treatment.
  • Test-of-cure is generally not recommended. It takes about 3 weeks for chlamydia DNA/RNA to clear the genital tract after treatment. Retesting before 3 weeks may result in a false-positive result.
  • Sexual partners of those who have tested positive for Chlamydia should be treated as a “Chlamydia-Contact.” Treating the male partners of infected females is critical for preventing repeat infections in females. Treatment should occur regardless of the absence of symptoms or a negative test.
  • Persistent symptoms (dysuria, vaginal discharge or burning) or findings (cervicitis, pyuria) can be from re-infection from untreated partners (the most common cause), co-infection (trichomoniasis) or treatment failure.

Although most adolescents have heard of chlamydia, lack of adequate knowledge and misconceptions are common as is fear of getting tested. The asymptomatic nature of most chlamydia infections may discourage testing because “How can I have chlamydia if I feel fine?” and “Even so, how can it cause harm if there aren’t any symptoms?” Messages about testing need to focus on the positive dimensions of being tested (being responsible about being sexual, protecting your partner, getting early treatment).

Chlamydia conundrums
There is increasing concern about medication-related treatment failures. A recent small study in males found that azithromycin was only 77 percent effective in eradicating chlamydia versus 95 percent for doxycycline. Other studies have noted cure rates of 81-90 percent for azithromycin and 99-100 percent for doxycycline. More studies are needed, and treatment recommendations have not changed.

Limited studies on the natural history of chlamydia have noted that spontaneous resolution occurred in 18 percent of STD clinic patients in the interval between screening and returning for treatment of a positive test.

National Chlamydia Coalition:
AAP’s Chlaymydia training resources: visit AAP website
Center for Young Women’s Health:
AAP Healthy Children

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