School Vaccination Exemptions Should Be Only for Medical Conditions

Shetal Shah, MD, FAAP

Shetal Shah, MD, FAAP

Dr. Shetal Shah, MD, FAAP is a neonatologist at Maria Fareri Children’s Hospital.  He is NYS AAP Chapter 2 Vice President and Chair of the Legislative Committee.  This op-ed was published on northjersey.com on May 9, 2019.

Forty years ago, the United States eradicated endemic polio.  It was a cooperative, national effort to eliminate a major public health threat, made possible by a lifesaving vaccine, an army of healthcare professionals and by parents who chose to vaccinate their children — many waiting in line for hours.  Vaccines are considered one of the world’s greatest health achievements and are the main reason current parents of young children don’t remember polio, rubella, diphtheria and until recently, measles.  Prior to the creation of measles vaccine over a half-century ago, approximately 3-4 million US cases occurred annually, resulting in thousands of hospitalizations, cases of lifelong disability and hundreds of childhood deaths.

New York is again facing outbreaks of measles.  Almost 700 cases have been reported nationally the largest since the disease was considered domestically eradicated — largely from clusters of unvaccinated children in Brooklyn and Rockland County.  The number of infected keeps rising.  In a single week in April, 78 new cases were reported.

Washington State is also facing an outbreak and cases of measles span 22 states.  Since 2001, over 100 measles outbreaks have occurred, including the 2014 episode centered on Disneyland.

Pediatricians foresaw the return of vaccine-preventable diseases because each week, we spend hours discussing the importance of vaccination to increasingly skeptical parents who, fueled by misinformation as well as unsubstantiated claims nurtured on the internet, cite greater concerns about the vaccines than the diseases they prevent.

When vaccination rates decrease, the return of measles, (or pertussis, or mumps) is inevitable.  Parental refusal of vaccines is now so prevalent the World Health Organization declared it a “Top Threat to Global Health” this year, alongside HIV/AIDS and poor access to medical care.  While measles has captured the public’s attention, there have been 426 cases of mumps this year, approximately 300 in March alone.  Pertussis outbreaks occur so often they are now considered medically “routine.”

Worse than the suffering these diseases can cause (5 children have required intensive care from measles complications) is having the public health tools to prevent these illness and not using them.  This is why the New York State Legislature should pass bills A.02371/S.02994 and eliminate all non-medical exemptions to vaccination for school attendance.

New York State allows parents to obtain religious exemptions from vaccination and more parents are getting them. Though most major religions support immunization – rates of religious exemptions in the state are now high enough to weaken population immunity levels (herd immunity) that almost 300 schools in the state are at risk. Moreover, what is often overlooked is the general population vulnerability of these diseases in immune compromise individuals such as those suffering with cancer, and others with impaired immune defense mechanisms such as AIDS as well as those with true contraindications who cannot be immunized.

Though New York, unlike 17 other states, does not allow for a philosophical exemption (a wish to not be immunized simply because one is against vaccination), it is clear religious exemptions are often truly philosophical ones dressed in religious doctrine.  Having reviewed applications for religious vaccination exemptions, it’s clear many parents are trying to opt out of vaccination by co-opting religious texts – sometimes from multiple religions which parents state they do not follow.

Since religious exemptions are granted by local school boards, some parents feel if they complain enough, or threaten to sue, schools will relent.  This process also makes school boards de facto courts of faith, dissecting which exemptions are rooted in religious conviction and which are not – a job school officials do not want and are often unqualified for.

In the wake of this year’s measles cases, Washington State is attempting to learn from the outbreak.  A bill to restrict exemptions to vaccination passed the state’s Senate.  The question is, can New York learn the same lesson?

This measure, sponsored by Legislators Dinowitz and Hoylman enjoys widespread support from physicians, public health groups, healthcare workers and parents of school-age children.  If passed, the bill would put New York on equal footing with West Virginia and Mississippi – two states which have not experienced widespread outbreaks and with California – which despite having measles next door in Oregon has to date been spared a major repeat of its 2014 experience.

Regrettably, a small, well-organized group of opponents have harassed legislators and pediatricians, both in person and on social media. Their tactics not only are reprehensible and in some cases dangerous.  These groups have overtaken town halls and disrupted public events.  Protestors surrounded the car of New York State Senator Kevin Thomas, who supports the bill — and refused to leave, requiring the Senator to call the police.  Assemblyman Dinowitz has been told by anti-vaccine activists, according to a report, that they hope his “grandchildren get autism.”

Pediatricians support this bill because allowing only medical exemptions is a proven way to increase immunization rates and protect all children from vaccine-preventable diseases.  Since all kids who get immunized don’t generate an immune response sufficient to protect themselves, ALL parents should support this bill as a way to protect ALL our state’s children.  It eliminates school boards from becoming arbiters of vaccination exemptions – which leads to different standards in each district – and places authority to grant exemptions in the hands of physicians.

These epidemics should motivate legislators to understand the importance of strengthening our public health infrastructure.  If they fail to recognize the medical and epidemiological facts behind immunization and the policies which keep rates of vaccination high, then another outbreak is certain.


Legislators Need to End Most Vaccine Exemptions

Eve Meltzer-Krief MD, FAAP

Eve Meltzer-Krief MD, FAAP

(Dr. Eve Meltzer-Krief MD, FAAP is a pediatrician in Huntington and member of the NYS AAP Chapter 2 Immigration and Legislative Advocacy Committees.)

NYS Legislators: Please Support Bill that Will Allow Only  Medical Exemptions to Vaccination, S.02994 and A.02371

Vaccination has been the most important and impactful scientific achievement of modern times.  Yet because of misinformation fueled by social media, there remain pockets of unvaccinated children whose parents hide behind a cloak of religious exemption as protection from unfounded fears.  There are, in fact, no major religions that prohibit vaccination.  Sadly, these parents have put not only their own children at risk but the communities in which their children live, play and attend school.  The current measles outbreak is evidence of what happens when children go unvaccinated.

Measles is a highly contagious virus.  The current outbreak has now infected 695 people in 22 states.  Measles can lead to pneumonia, a brain infection called encephalitis, deafness, a prolonged immunocompromised state, and a rare complication called SSPE or subacute sclerosing panencephalitis that can occur years after infection and is fatal.  In 1962, the year before the measles vaccine was available, 3-4 million people were diagnosed with measles, 48,000 were admitted to hospitals and 500 people died.  By the year 2000, measles had been eliminated from the United States because of the vaccine.  However because of growing numbers of parents choosing not to vaccinate their children, we have begun to see increased outbreaks in recent years, with this year’s being the largest since the disease was eliminated nearly twenty years ago.

Particularly susceptible to serious illness in these outbreaks are infants under one year old who have not yet been vaccinated, and immunocompromised children and adults who are receiving or have recently received chemotherapy and other immunosuppressives to treat cancer and chronic diseases.

Vaccines save lives.  The Hib vaccine has virtually eliminated disease caused by Haemophilus Influenzae B which before its introduction in the late 1990’s affected 25,000 children yearly, causing meningitis, paralysis, blindness, pneumonia and a severe life-threatening respiratory illness called epiglottis.  Since the introduction of the Prevnar vaccine in 2000 there has been a dramatic decline in rates of meningitis, blood infections and other invasive life threatening disease caused by pneumococcal bacteria.

Vaccines are scientifically proven to be safe and effective and have saved tens of millions of lives over the past several decades.  Parents today are lucky to live in a time when we do not have to live in fear of our children contracting serious and deadly diseases.  However the current outbreak has demonstrated that if parents fall prey to misinformation and fail to properly vaccinate their children they put their own children at risk as well as the most vulnerable among us.

The American Academy of Pediatrics representing 67,000 pediatricians across the country is advocating for an end to state laws that allow people to refuse vaccination of their children on religious or philosophical grounds.  I urge NYS legislators in the Senate and Assembly to pass S.02994 and A.02371.  This bill will allow only medical exemptions to vaccination.  I implore our legislators to believe science and to protect children and at risk residents in our state.

I implore parents and community members who understand the importance of vaccination to ask their NYS legislators to support the bill.   It is always tragic when children die or develop devastating long term consequences from disease.  However the most tragic of those are cases that are entirely preventable.  Let us not fail our children.  Let us not fail those among us who are immunocompromised, who are too young to get vaccinated or who are undergoing treatment that prevents them from getting vaccinated.  These individuals, parents and children live in fear during outbreaks such as we are experiencing now.  Let us not deny them the protection they need and are entitled to.


The Return of Measles to a Neighborhood Near Yours

Steven J. Goldstein, MD, FAAP

Steven J. Goldstein, MD, FAAP

(Dr. Steven J. Goldstein, MD, FAAP is a pediatrician in Brooklyn and Queens. He is president of the NYS AAP Chapter and serves as co-chair of its Pediatric Council and Committee on Environmental Health. This blog post was originally published in AAP Voices on April 30, 2019)

The outbreak of measles in New York City brings back vivid memories more than half a century old.  I was 5 years old and was very ill, with a terrible cough, dry lips, crusted eyes, extensive rash, and high fever.  My pediatrician visited while I was sick, and he was a welcome sight.  I had terrible light sensitivity and spent most of the time in a semi-dark room.

Only in medical school did I learn that I had exhibited classic measles symptoms: cough, coryza, and conjunctivitis with photophobia, fever and rash.  The virus infected more than three-quarters of a million people and killed hundreds in the United States that year, a decade before the measles vaccine would become available.  Fortunately, I escaped serious complications of the disease.

I think the experience helped influence me to become a pediatrician.  Not a reason to contract measles, though.

As I age, I am less patient waiting for positive change as I realize the work of individual pediatricians to make the world a better place is time-limited.  This is one reason I am incensed by the return of measles to the neighborhoods where I practice.  As of April 29, there have been 423 confirmed cases of Measles in Brooklyn and Queens.  The vast majority of patients, roughly 84 percent, are infants, children and teens.

Vulnerable communities targeted with vaccine misinformation

My Brooklyn office serves a largely Chasidic clientele, with a melting pot of families from other backgrounds.  My Queens office patients are reflective of one of the most diverse communities in the US.  We first noticed a troubling trend in the Brooklyn office.  Starting in late 2017, there was a significant drop-off in babies and children coming in for well visits and immunizations.

An anti-vaccine group calling themselves PEACH (Parents Educating and Advocating for Children’s Health) in the ultra-Orthodox community of Lakewood, New Jersey sent out an illustrated, 40-page booklet filled with false information about vaccines.  Targeting isolated and fundamentalist communities, where the science of immunizations is not well known and accepted, is a known tactic of the anti-vaccine activists.

A helpful publication from the Hudson Valley Health Coalition that countered the misinformation with facts was distributed by the New York City Department of Health and supported by the CDC.  Our immunization rates dropped nevertheless, and it was the rare visit that did not engender a long discussion about vaccine risk, efficacy, and timing.  Long discredited claims of a possible MMR immunization and autism link were revived, and questions about the need for vaccines against “eliminated diseases” arose.

The ultra-Orthodox community in Brooklyn has seen measles before.  In 2013, an unimmunized child returned from London incubating measles, resulting in 58 cases in New York City.  Forty-five of the affected patients were eligible to receive vaccine but had not.

The toll of outbreaks on the health care system & practices

The costs to society of outbreaks such as these, which divert funds from worthy initiatives, are not trivial.  The costs to the Department of Health in the 2013 outbreak were calculated to be about $400,000.  According to federal estimates, the direct and indirect costs of each case of measles can run as high as $142,000.

As I write this, the ongoing spread of measles from Brooklyn causes worry about the possible spread to other municipalities, especially with recent holidays when many families traveled long distances.  The question of how to protect very young children remains, other than advising families not to travel and isolating them as much as possible.  But what about someone inadvertently bringing measles into our office, hospital, ED, or clinic?  This should be of major concern to all of us, because it has implications for structuring our schedules and patient encounters.

Facilities must close for two hours after measles is diagnosed because of the continued contagion of virus in the air.  Suspected cases also disrupt practices. Last week in Queens, we saw a 2 1/2 year old child with history of one MMR vaccine who attended a childcare nursery in Brooklyn, near to an affected community.  He’d had 4 or 5 days of fever and then developed a rash, so we had to consider measles.

We learned two days later from his lab work that the polymerase chain reaction was negative.  It was not measles.  Still, the burden on staff to check the immunization status of each child in the office those days and if needed, to contact their families, was huge.  Because of the time frame and age, some children would need immune globulin prophylaxis or vaccine, and might need to be quarantined for up to 28 days.  Newborns might have been exposed. I lost sleep.

The return of measles has the potential to profoundly influence the way we, in the affected communities, practice pediatrics.  We were extremely unhappy about the possibility that a child in our office might have exposed others.  Pediatricians will need to consider measles immunity, the possibility of measles in the pre-rash stage, and the incubation period when scheduling patients, and attempt to isolate susceptible patients from others if the epidemic spreads.

Wild measles: trampling families’ freedom from disease

Because of the spread of measles to the Detroit community, with 50 cases documented at last count, my own daughter has decided to forego daycare for her new baby and will hire a nanny to minimize the infant’s chance of getting the disease.

One argument the anti-vaccine community makes is that by insisting on immunization, we are infringing on individual freedoms.  What about the rest of the world that stands to suffer, with risk of death or disability, because of measles spread by vaccine refusers?  Wild measles is the gift that keeps on giving, with subacute sclerosingpanencephalitis (SSPE), a fatal, late onset measles complication, a real possibility.  Some of us think, given the number of cases so far, that there will be a major spike in SSPE in a few years.  Measles is not a benign disease.

This issue — the inability of young children and others susceptible to infectious diseases — is a cogent argument for the passage of bills eliminating all but medical exemptions for vaccines.  New York is considering this issue and other states should as well, joining California, West Virginia and Mississippi.  The most recent estimates suggesting that for every 1000 cases of measles, one or two patients die, it is clearly a public health issue.

In the meantime, as pediatricians fighting on the front line of outbreaks, we are faced with a new normal as we continue to factor measles into our decision-making when booking and seeing patients to protect our most vulnerable patients.  Most importantly, we continue our efforts to educate families about the dangers of measles–and how the decision not to vaccinate affects everyone around them.


April 2019

Steven J. Goldstein, MD, FAAP

Steven J. Goldstein, MD, FAAP

Dear NYS AAP – Chapter 2 Member,

There is a lot going on in Pediatrics in New York State, around the world, and in the Chapter. This month’s newsletter highlights issues and events that should be of interest to you. We especially need your help and attention in dealing with the measles epidemic and in helping to pass our legislative priorities in Albany. One of our legislative goals is to end all vaccine exemptions except for legitimate medical reasons. Three other states have already accomplished this, and NY can as well, with your advocacy. Please read on, advocate, and join us for our upcoming events.

Steven J. Goldstein, MD, FAAP
President, NYS AAP – Chapter 2
SJG34@Cornell.edu

Measles Grows in Brooklyn

The number of measles cases in Brooklyn has increased dramatically in the past few weeks and some of us have been dealing with this in our offices, clinics, and ED’s. Chapter 2 has been in contact with the NYC DOH and a link to their measles page is posted on the Chapter’s home page.

An MMR vaccine should be given at 6 months of age in affected communities to offer early protection, but does not count towards the doses needed for school attendance. Any child with one MMR given on or after their first birthday may get a second dose 28 or more days later. This second dose will complete the series and is to capture the 3-5% of children who did not develop immunity with their first injection. I personally have seen measles in the office in the past weeks and the problem is compounded by not knowing who is in the 4-5 days pre-rash phase but nevertheless spreading disease in the office. The city has guidelines posted for post-exposure prophylaxis and the DOH will pick up swabs and blood for testing. Recommendations are to close the office/exam rooms for 2 hours after someone with measles has visited. We now prescreen our visits so that anyone with fever and rash is met outside the office so as not to expose others. There is a lot to say about this issue. For those of you in other communities, keep your eyes open. There were 2 cases in Queens last week.

Here are some good resources for dealing with the anti-vax/hesitancy issue and measles:

Pending Vaccine Legislation in New York State Worthy of Your Support

The bills listed below are a priority for us and we may have more influence in view of the measles issue.  The newly elected legislature is sympathetic to pediatric issues, so please express your opinion to your representatives by phone, letter, email, or even better, in person at their local office.  Click the links below to view the NYS AAP’s Memo of Support for each one:

Free CME Dinner Program – May 9th
“What Happens in Childhood Does Not Stay in Childhood: Why this is true and what we should do!

EVENT: “What Happens in Childhood Does Not Stay in Childhood: Why this is true and what we should do!”
PRESENTED BY: NYS AAP – Chapter 2
WHEN: May 9, 2019 from 6:30pm – 9:00pm
WHERE: NYU Winthrop Hospital | 101 Mineola Blvd. | Research and Academic Center, Conference Room G-18, Section A | Mineola, NY 11501

OVERVIEW:
At this CME dinner program for Chapter members, Dr. Andy Garner, co-author of “Thinking Developmentally: Nurturing Wellness in Childhood to Promote Lifelong Health,” will discuss the lifelong effects of childhood adversity/toxic stress and give pediatricians an evidence-based road map for building a healthier future for the next generation.

Register HereREGISTRATION FEE:

$10 Refundable Fee: NYS AAP – Chapter 2 or 3 Members (this fee will be refunded to Chapter members who attend)
$40: Non Member Pediatricians (this fee can be applied to Chapter dues)

AGENDA:

6:30pm Reception/Exhibit Hour

7:30pm Welcome and Introductions
Steven J. Goldstein, MD, FAAP
President, NYS AAP – Chapter 2

7:35pm What Happens in Childhood Does Not Stay in Childhood: Why this is true and what we should do!
Andrew Garner, MD, PhD, FAAP
Clinical Professor of Pediatrics
CWRU School of Medicine
Cleveland, OH

Objectives:

  • Explain the significance of recent advances in the basic sciences of development (e.g., epigenetics, developmental neuroscience)
  • Describe the ecobiodevelopmental model of disease and wellness, some of its advantages, and a few of the implications for medicine
  • Define relational health and at least three components of a public health approach to build relational health

8:30pm Questions & Answers with Panelists
Moderator: Steven J. Goldstein, MD, FAAP
President, NYS AAP – Chapter 2

Ellen J. Feldman, LCSW-R, CCTP
Supervisor of Education and Training
Child Abuse Prevention Services (CAPS)
Roslyn, NY

Andrew Garner, MD, PhD, FAAP
Clinical Professor of Pediatrics
CWRU School of Medicine
Cleveland, OH

Joaniko Kohchi, MPhil, LCSW, IMH-E® (IV-C)
Director, Institute for Parenting
Adelphi University
Garden City, NY

Jack M. Levine, MD, FAAP
Executive Committee, AAP Section on Developmental and Behavioral Pediatrics
Chair, NYS AAP – Chapter 2 Committee on Developmental-Behavioral Pediatrics/Children with Disabilities

Sandra Pensak, MA
Adjunct Lecturer and Field Supervisor
Queens College, CUNY
Flushing, NY

9:00pm Adjourn

ACCREDITATION STATEMENT:
This activity has been planned and implemented in accordance with the Accreditation Requirements and Policies of the Medical Society of the State of New York (MSSNY) through the joint providership of the Westchester Academy of Medicine and the NYS American Academy of Pediatrics Chapter 2. The Westchester Academy of Medicine is accredited by MSSNY to provide Continuing Medical Education for physicians.

The Westchester Academy of Medicine designates this live activity for a maximum of 1.5 AMA PRA Category I Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

FOR MORE INFORMATION:
Contact Jessica Geslani, Executive Director, at jgeslani@aap.org or 516-326-0310

Are You an Early Career Physician Looking for a Mentor?

We are excited to announce the launch of our Early Career Physician Mentoring project. We will be pairing our Early Career Physicians (<10 years out of training) with seasoned pediatricians in our area. We have amazing mentors including AAP local and national leadership who are ready to be paired with YOU for one on one mentoring!

Sign up online to be a Mentee.  Any questions? Contact: Dr. David Fagan, Chapter 2’s Mentoring Committee Chair, at dfagan@northwell.edu, or our Executive Director, Jessica Geslani, at jgeslani@aap.org.

The 2020 Census

As the Census approaches, please keep in mind that counting every child is important. More about this issue will be coming from the National AAP.

The Casey Foundation’s 2018 KIDS COUNT® Data Book warns that the 2020 census is mired in challenges that could shortchange the official census count by at least 1 million kids younger than age 5.  This discrepancy would put hundreds of millions of federal dollars at risk and, in doing so, underfund programs that are critical for family stability and opportunity.

To help spread the word, Nassau and Suffolk County high school students can participate in the Health & Welfare Council of Long Island’s 2020 Census Logo Design Contest. Entries are due by May 15th.

Wellness Radio Show

Tune into a VoiceAmerica.com radio show on wellness topics by Dr. Vidisha Patel, daughter of our Wellness Committee Co-Chair, Dr. Ishvar Patel.

RESOURCE: New York State Medicaid Managed Care (MMC) Pharmacy Benefit Information Center.

 

Having trouble figuring out which ADHD drug or inhaled steroid is covered for your patient?

The New York State Medicaid Managed Care (MMC) Pharmacy Benefit Information Center is a website that is designed to provide easy access for members and providers looking for information on the drugs and supplies covered by different Medicaid health care plans. While pharmacy benefits and participating pharmacies vary among health plans, all plans maintain their own web sites and customer service call centers.

Visit the website here: https://mmcdruginformation.nysdoh.suny.edu/

Chapter 2 Committee Openings

Our Committees are actively seeking your involvement and ideas!  There are openings and opportunities to make a difference in the following committees:

  • Disaster Preparedness
  • Environmental Health
  • Legislative
  • Membership and Diversity
  • Mentoring Committee (Mentors and Mentees wanted)
  • Parents (suggest a parent to work with us)
  • Pediatric Council
  • Prevention of Family Violence
  • Quality Improvement

View our full list of committees and contact information here.  Still don’t see your interest?  Talk to us about starting a new committee!

NATIONAL AAP NEWS – Presidential Elect Candidates

The National AAP National Nominating Committee has selected Dr. Lee Savio Beers of Washington, D.C., and Dr. Pamela K. Shaw of Kansas City, Kan., as candidates for AAP president-elect.

Additional information about the candidates, including profiles and position statements, will be published in upcoming issues of AAP News and online at www.aap.org/election.  Voting will begin September 7 and ends September 21, 2019.

 

We’ll help you pursue your passion within Pediatrics!

Send us an email describing your interest and we will connect you with the right people to get you involved.

Please contact me or our Executive Director, Jessica Geslani, at jgeslani@aap.org

Follow Chapter 2 on Twitter: @NYSAAPCh2

My best,
Steve Goldstein, Chapter President SJG34@Cornell.edu | Twitter: @SteveGoldstei10

and the Officers:
Shetal Shah, Vice President shetaldoc@hotmail.com | Twitter @NICUBatman
Robert Lee, Secretary rlee@aap.net
Sanjivan Patel, Treasurer sapatel@wyckoffhospital.org

Electronic Cigarettes Among Young People

Mary Cataletto, MD, MMM, FAAP

Mary Cataletto, MD, MMM, FAAP

(Dr. Mary Cataletto, MD, MMM, FAAP, FCCP is a pediatric pulmonologist and Associate Director of Pediatric Sleep Medicine at NYU Winthrop Hospital. She is chair of the Pediatric Chest Medicine NetWork of the American College of Chest Physicians and past chair of the Asthma Coalition of Long Island. She is Editor in Chief of Pediatric Allergy, Immunology and Pulmonology. She is the Nassau Pediatric Society Representative to NYS AAP Chapter 2.)

Published Online: March 8, 2019

Citation: US Respiratory & Pulmonary Diseases. 2019;4(1):Epub ahead of print

The Use of Sweetened and Flavored Electronic Cigarettes Among Young People—a Growing Concern

Electronic cigarettes (e-cigs) are often promoted as a safe alternative to conventional tobacco-based cigarettes and as an aid to smoking cessation.  The use of sweet and fruit-based flavorings, as well as targeted marketing strategies to attract teens, have resulted in a significant uptake in the use of these products in middle and high school students in the US.1 Potential customers can select from a vast array of flavoring options, and access information about e-cigs via social media and other online sources, as well as traditional marketing communication channels and face-to-face interaction with vape shop employees. The availability of sweetened and flavored brands has heightened their appeal for young people. However, despite substantial increases in e-cig consumption, little is known about the long-term health consequences of their use.

In an expert interview, Mary Cataletto discusses these issues, as well as a recent position statement of the Forum of International Respiratory Societies (FIRS) on the use of e-cigs in youths.

1. How prevalent is the use of electronic cigarettes in children and adolescents?

Based on the 2017 National Youth Survey published by the US Food and Drug Administration, 2.1 million American middle and high school students had used e-cigs in the past 30 days.1 E-cig use has surpassed the use of conventional tobacco cigarettes in this age group and they are the most commonly used tobacco product in middle and high school students.2

2. What role do flavorings play in adolescent electronic cigarette use?

The majority of youths, defined as between 12–17 years old, report that flavored e-cigs were their initiation into tobacco products, citing the availability of flavors and the ability to mix their favorite flavors as important factors.1–4 Adolescents who preferred more flavors used more e-cigs. Multimedia advertising promotes ‘natural’ flavors and aromas, so it is not surprising that flavors have also been reported as the main reason that teens continue to use them.5 There are thousands of flavors of e-cigs on the market (over 7,500 flavors estimated in 2014).6 The availability of multiple choices in flavors and the option to mix your own flavorings may help to maintain the novelty of e-cigs for teens and promote increased use. Fruit and sweet flavors are the most popular in youths. In a recent study by Kroemer at al., the addition of a sweet taste was shown to potentiate the reinforcing effects of nicotine.7

3. What has been the adult experience with flavored electronic cigarettes as an aid to smoking cessation?

Adult smokers are also influenced by flavorings, and the dual use of e-cigs and conventional tobacco is not uncommon.8 Many adults prefer menthol or tobacco flavor as they start to quit smoking, although sweet flavors become more popular as they continue to use e-cigs.3–4 It remains unclear whether e-cigs are an effective aid to smoking cessation.

4. Why is the use of sweetened electronic cigarettes among minors a controversial issue?

There is no safe amount of nicotine exposure, and e-cigs are not a safe alternative to conventional tobacco cigarettes.9 Many youths believe that e-cigs are safer and more socially acceptable.10 While more research is needed, it appears that the sensitization to nicotine in e-cigs promotes conventional tobacco use as the nicotine cravings increase. Few users recognize that they are a likely gateway to conventional tobacco cigarettes. The brain continues to develop throughout adolescence and is particularly vulnerable to the addictive effects of nicotine.9 The adverse effects of e-cigs include those ascribed to nicotine itself, the contents of the aerosol (vapor), or to the temperature modification of the content.11

The sale of both e-cigs and conventional tobacco products are banned to minors in the US, yet the 2017 US National Youth survey reported that approximately 2.1 million middle and high school students had used e-cigs in the past 30 days.1

5. What is being done to discourage the use of these products among minors?

FIRS issued a position statement on e-cigs and electronic nicotine delivery systems use in youth. FIRS reflects a collaboration of professional organizations and respiratory experts; it is made up of nine international societies: the American College of Chest Physicians, American Thoracic Society, Asian Pacific Society of Respirology, Asociación Latinoamericana de Tórax, the European Respiratory Society, the International Union Against Tuberculosis and Lung Disease, the Pan African Thoracic Society, the Global Initiative for Asthma and the Global Initiative for Chronic Obstructive Lung Disease.

They recommended:

  1. To protect youths, [electronic nicotine delivery systems] should be considered tobacco products and regulated as such, including taxation of electronic cigarettes and supplies. The addictive power of nicotine and its adverse effects in youths should not be underestimated.
  2. Considering the susceptibility of the developing brain to nicotine addiction, the sale of electronic cigarettes to adolescents and young adults must be prohibited by all nations, and those bans must be enforced.
  3. All forms of promotion must be regulated and advertising of electronic cigarettes in media that are accessible to youths should cease.
  4. Because flavorings increase rates of youth initiation, they should be banned in electronic nicotine delivery products.
  5. As electronic cigarette vapor exposes nonusers to nicotine and other harmful chemicals, use should be prohibited in indoor locations, public parks, and places where children and youths are present.
  6. While their health risks are increasingly recognized, more research is needed to understand the physiological and deleterious effects of electronic cigarettes.
  7. Routine surveillance and surveys concerning combustible and electronic cigarette use should be carried out in many settings to better understand the scope and health threat of tobacco products to youths in different countries and regions.’ [sic]12

In conclusion, it is clear that flavorings can influence initiation and contribute to the ongoing use of e-cigs. Nicotine is an addictive substance, and preteens and teens are particularly vulnerable. Legislation and enforcement of existing restrictions to targeted marketing to teens, sale to minors, as well as restriction of sweet and fruit flavorings, are important steps to protect the future health of our children. Additional studies are needed to further evaluate the safety and efficacy of e-cigs as an aid in smoking cessation.13

______________________________________________________________________________

  1. Wang TW, Gentzke A, Sharapova S, et al. Tobacco product use among middle and high school students – United States, 2011–2017. MMWR Morb Mortal Wkly Rep. 2018;67:629–33.
  2. US Food & Drug Administration. Youth tobacco use: National Youth Tobacco Survey. 2018. Available at: fda.gov/TobaccoProducts/PublicHealthEducation/ProtectingKidsfromTobacco/ucm405173.htm (accessed January 22, 2019).
  3. Huang LL, Baker HM, Meernik C, et al. Impact of non-menthol flavors in tobacco products on perceptions and use among youth, young adults and adults: a systematic review. Tob Control. 2017;26:709–19.
  4. Harrell MB, Weaver SR, Loukas A, et al. Flavored e-cigarette use: characterizing youth, young adult, and adult users. Prev Med Rep. 2017;5:33–40.
  5. Centers for Disease Control and Prevention. Quick facts on the risks of e-cigarettes for kisd, teens, and young adults. 2018. Available at: cdc.gov/tobacco/basic_information/ecigarettes/Quick-Facts-on-the-Risks-of-E-cigarettes-for-Kids-Teens-and-Young-Adults.html?s_cid=osh-stu-home-slider-004%20 (accessed January 22, 2019).
  6. Zhu SH, Sun JY, Bonnevie E, et al. Four hundred and sixty brands of e-cigarettes and counting: implications for product regulation. Tob Control. 2014;23 Suppl. 3:iii3–9.
  7. Kroemer NB, Veldhuizen MG, Delvy R, et al. Sweet taste potentiates the reinforcing effects of e-cigarettes. Eur Neuropsychopharmacol. 2018;28:1089–102.
  8. Kasza KA, Ambrose BK, Conway KP, et al. Tobacco-product use by adults and youths in the United States in 2013 and 2014. N Engl J Med. 2017;376:342–53.
  9. Schraufnagel DE. Electronic cigarettes: vulnerability of youth. Pediatr Allergy Immunol Pulmonol. 2015;28:2–6.
  10. Pepper JK, Ribisl KM, Brewer NT. Adolescents’ interest in trying flavored e-cigarettes. Tob Control. 2016;25:ii62–6
  11. Lodrup Carlsen KC, Skjerven HO, Carlsen KH. The toxicity of e-cigarettes and children’s respiratory health. Paediatr Respir Rev. 2018;28:63–7.
  12. Ferkol TW, Farber HJ, La Grutta S, et al. Electronic cigarette use in youths: a position statement of the Forum of International Respiratory Societies. Eur Respir J. 2018;51:pii:1800278.
  13. Farsalinos K. Electronic cigarettes: an aid in smoking cessation, or a new health hazard? Ther Adv Respir Dis. 2018;12:1753465817744960.

March 2019

Steven J. Goldstein, MD, FAAP

Steven J. Goldstein, MD, FAAP

Dear NYS AAP – Chapter 2 Member,

As a Chapter, and in cooperation with Chapters 1 and 3 as the NYS AAP (District II), we have been involved in governmental affairs and initiatives in New York City, Long Island, Albany, and in Washington that will benefit the children we serve and society as a whole. We are proud to share these efforts, and other important information with you.  Please see below for details.

Steven J. Goldstein, MD, FAAP
President, NYS AAP – Chapter 2
SJG34@Cornell.edu

 

DON’T MISS THE NYS AAP’S ANNUAL ADVOCACY DAY!

REGISTER ONLINE here!

 

WHEN:

 

 

 

Tuesday, March 19, 20198:00am Breakfast
9:00am Morning Session Begins
12:00pm Lunch, followed by Scheduled Visits with Legislators
3:30pm Adjourn

WHERE:

 

University Club
151 Washington Ave.
Albany, NY 12210
WHO: This event is for members of the NYS AAP – Chapters 1, 2 & 3.  There is no charge to attend.

WHY:

 

Come to the State Capitol and Advocate for Kids and Pediatricians! Meet Key Legislators and State Agency Decision Makers. Meet with Your Assemblymember & Your Senator to educate them about the important issues in children’s health and well being.

 

Advocacy for Gun Violence Prevention

On February 25th in New York City, Governor Andrew Cuomo, with House Speaker Nancy Pelosi at his side, signed landmark legislation known as the “Red Flag Bill” creating a mechanism for ERPO, Extreme Risk Protection Orders in New York State.  This bill allows teachers and administrators to request that guns belonging to individuals seen as unstable or as a threat be confiscated pending a hearing in order to protect students and society.  The Chapter has been advocating for ERPO legislation for years.  Members of Chapters 2 and 3 were in attendance at this historic signing.

On March 4th we received word that the NY State Senate and Assembly passed Gun Safe Storage legislation.  Elie Ward, our Director of Policy, Advocacy & External Relations, played a role in crafting this landmark achievement, which was bolstered by the unceasing advocacy efforts of Chapter members.

But there is more to be done!  Our advocacy on Funding for Research about gun violence prevention at the state and federal levels is ongoing.  We need your voice!

Chapters 2 and 3 recently joined with Chapter 1 to create a statewide committee to address gun violence prevention in New York. If you would like to get involved, please email our Executive Directors: Chapters 2 & 3, Jessica Geslani at jgeslani@aap.org, and Chapter 1, Chris Bell at cbell@mcms.org.

Chapter 2 Legislative Committee Member Dr. Eve Krief is in the white coat and to the right of Governor Cuomo

Chapter 3 Member and Co-Chair of the joint Chapters Gun Violence Prevention Committee, Dr. Nina Agrawal, is in the white coat to the left of the Governor, pictured with members of New Yorkers Against Gun Violence.

 

National AAP President Dr. Kyle Yasuda (left) and Chapter 2 VP Dr. Shetal Shah (right) flanking Senator Charles Schumer’s Legislative Aides at appointment in February advocating for gun violence prevention legislation.

Vaccine Exemptions

Sometimes the work that you don’t see is important.  Vice President Shetal Shah and Legislative Committee Member Eve Krief visited NY State Senator Monica Martinez to discuss her bill to streamline applications for vaccine exemptions.  Subsequently, she agreed to rewrite the bill and have us review it.  The Chapters and National AAP believe that the only vaccine exemption should be for legitimate medical reasons.

Drs. Shah and Krief with aides of State Senator Martinez

Updates on Immigration Issues

  • Decision Reversed to Move an ICE Facility to the Nassau University Medical Center – Nassau County Executive Laura Curran reversed her decision to move an ICE facility to the Nassau University Medical Center, a move that could inhibit families from seeking healthcare for their children.  The Chapter sent a strongly worded protest within 24 hours of her initial decision, contributing to her reversal.
  • Congressman Jerry Nadler Opens Hearings on Family Separation – “In our first immigration-related hearing this Congress, the Judiciary Committee will finally hold this Administration accountable for its indefensible and repugnant family separation policy, and for the injuries it has inflicted on thousands of children and families.”
    Congressman Nadler’s remarks linked here are worth reading.  He refers to the AAP’s work on family separation.
  • Kids on the Line – An ongoing investigation into family separation and the treatment of migrant children.

 

Chapter 2 Membership Committee – Call for Members!

Juan C. Kupferman, MD

Juan C. Kupferman, MD

 

As Membership Committee Chair, I would like to invite you to join the Committee to brainstorm about new ideas to increase our membership and improve the experience of our current members. Plans for a first dinner meeting at a restaurant are underway.

I am a strong believer in teamwork and look forward to collaborating with you and hearing your ideas! Please join me!

My best regards,
Juan C. Kupferman
JKupferman@maimonidesmed.org

 

RECORDED WEBINAR – “Don’t Be Lost in Transition:
Prepare & Efficiently Transfer Youth With and Without Special Health Care Needs to Adult Medical Care”

Many pediatricians feel unprepared to help their patients transition to adult medical care.  Click this link to watch an excellent introduction to the issue with valuable resources from Drs. Sophia Jan of Chapter 2 and Lynn Davidson of Chapter 3.  The webinar took place on February 28th and is worthy of your attention.

Annual Leadership Forum

The AAP Annual Leadership Forum, where resolutions and policy suggestions from AAP members are discussed and voted on, takes place in mid-March at AAP headquarters in Itasca, Illinois.  Chapter 2 has a number of resolutions that will be considered and has been nominated for the Outstanding Chapter Award in the Large Chapter category.  We’ll keep you posted as the ALF progresses.

Here is a link to the entire roster of ALF Resolutions.
Chapter 2 initiated resolutions may be found here and are listed below:

  • “Public Education About Intramuscular Vitamin K Administration at Birth” by Shetal Shah
  • “Revising the AAP Bright Futures Guidelines on Gun Safety Anticipatory Guidance” by Jennifer Grad, Dani Holmes and Christian Pulcini
  • “Expansion of Options for Publications as Membership Benefits” by Jack Levine
  • “Chapter Membership for Executive Committee Members of AAP National Sections, Councils, and Committees” by Steve Goldstein

 

New NYS School Health Examination Form Implementation Update

  • New NYS School Health Examination Form Implementation Year Memo – The memo linked here communicated that the NYSED is working with medical providers through their professional organizations (such as the NYS AAP) to develop a format that can be utilized in electronic health record systems.  Until further notice you should continue to accept any health exam form received.  The NYSED will disseminate information in the coming months regarding changes to the form along with when it will be required.  Stay tuned for updates!

 

CDC Request for Measles Outbreak Support

From January 1 to February 21, 2019, 159* people from 10 states (CA, CO, CT, GA, IL, NJ, NY, OR, TX, and WA) have been reported as having measles.  Five outbreaks (defined as 3 or more linked cases) have been reported, in Rockland County, New York; Monroe County, New York; New York City; Washington; Texas; and Illinois.  Of these outbreaks, 2 outbreaks are ongoing from 2018.  CDC urges healthcare professionals to ensure that all patients are up to date on MMR vaccine, including before international travel.

What Should Clinicians Do?

  • Discuss the importance of MMR vaccine with parents.  Listen and respond to parents’ questions.  When parents have questions, it does not necessarily mean they won’t accept vaccines.  Sometimes, they simply want your answers to their questions.
  • Ensure all patients are up to date on measles, mumps, rubella (MMR) vaccine: 1) – Children need 2 doses of MMR: one dose at 12-15 months and another dose at 4-6 years. 2). Before any international travel, infants 6-11 months need 1 dose of MMR vaccine, children 12 months and older need 2 doses separated by at least 28 days, and teenagers and adults who do not have evidence of immunity against measles need 2 doses separated by at least 28 days.
  • Consider measles in patients presenting with febrile rash illness and clinically compatible measles symptoms (cough, coryza, and conjunctivitis), and ask patients about recent travel internationally or to domestic venues frequented by international travelers, as well as a history of measles exposures in their communities.
  • Promptly isolate patients with suspected measles to avoid disease transmission and immediately report the suspect measles case to the health department.
  • Obtain specimens for testing from patients with suspected measles, including viral specimens for genotyping, which can help determine the source of the virus.  Contact the local health department with questions about submitting specimens for testing.

For more information, including guidelines for patient evaluation, diagnosis and management, visit: https://www.cdc.gov/measles/hcp/index.html

We’ll help you pursue your passion within Pediatrics!  Send us an email describing your interest and we will connect you with the right people to get you involved.  Please contact me or our Executive Director, Jessica Geslani, at jgeslani@aap.org

Follow Chapter 2 on Twitter: @NYSAAPCh2

My best,
Steve Goldstein, Chapter President  SJG34@Cornell.edu | Twitter: @SteveGoldstei10

and the Officers:
Shetal Shah, Vice President  shetaldoc@hotmail.com | Twitter @NICUBatman
Robert Lee, Secretary  rlee@aap.net
Sanjivan Patel, Treasurer  sapatel@wyckoffhospital.org


 

Measles Crises as Vaccine Refusals Rises

Asif Noor, MD, FAAP

Asif Noor, MD, FAAP

Dr. Asif Noor, MD, FAAP is a Pediatric Infectious Disease Specialist at NYU Winthrop Hospital and he co-chairs the Infectious Disease Committee of the NYS AAP Chapter 2)

It’s 5:00 p.m. on a Friday evening and I was about to finish seeing the last patient at our ID clinic.  My colleague informs me that she got paged for a consult regarding an infant with fever and a rash. The concern is measles. It is an infection which was declared eliminated from the United States about 18 years ago. Several communities in New York are now grappling with it. We struck up a conversation about our experience with measles. As millennial pediatricians, we were able to recall plenty of false alarms but not many true measles cases.  My iPhone buzzes!  There is a message on “Physician Dad’s Group” on Facebook.  One of the physicians witnessed a cancer patient, who survived cancer, now succumbed to measles.  This brought in mixed feelings of frustration and devotion to immunization.

Measles is highly contagious.  It is a serious infection and can lead to death among the vulnerable population: young children and the immunocompromised.  On the contrary, the measles vaccine is highly effective.  The first MMR vaccine, developed by Maurice Hillman and colleagues, was widely distributed beginning in 1968.  By 1981 measles cases reduced by 80%.  An outbreak of measles in the vaccinated group children in 1989 led to the recommendation of a second dose of MMR in all children which further reduced measles cases.  The Americas were declared measles free in 2000 after a 12 month period with 0 reported cases.  This was all made possible by pairing of a safe and effective vaccine with an efficient vaccination program.

Measles has reappeared. Since 2000, the annual number of cases ranged from 37 in 2004 to 667 in 2014.  A few months into 2019 and we already have 127 confirmed cases nationwide.  This time it’s not an outbreak in a Disneyland theme park, rather the affected children are from our neighborhoods in New York.  Since October 2018 there have been 90 cases of measles in Brooklyn, 138 cases in Rockland County, and 64 cases in Clark County, Washington State.  There is a strong possibility that the millennial pediatricians might encounter measles which was once declared eliminated before they even entered medical school.

The two plausible elements responsible for measles flare up are 1) unvaccinated infected foreign travelers and 2) unvaccinated people.  Let’s see how both of these factors are contributing to the recent surge in measles cases:

Firstly, air travel has shrank the globe into a village.  Measles outbreak in one part of the world can reach our neighborhood in less than 24 hours. In 2014, a large outbreak in Orange County, California was imported from a case of measles in the Philippines where there was an ongoing epidemic.  The current, 2018-19 explosion of measles in the United States started with travelers returning from local outbreak regions in Israel and the Ukraine.  Limiting travel of someone with measles is an unrealistic control strategy because the disease can be contagious 4 days before and 4 days after rash onset.  Screening for prodromal viral symptoms and rash on this large scale is not possible by non-medical personnel at the air ports.  Spread is inevitable!  Sporadic measles cases from travelers will continue until measles is eradicated worldwide.

Secondly, unvaccinated pockets of people are highly susceptible to this contagious virus. Sure enough the ground zero in the ongoing measles outbreaks are communities with unimmunized children.  There has been a gradual rise in unvaccinated children over the past 18 years. For example in Clark County only 76.5% of kindergarteners were vaccinated against measles, whereas 95% need to be vaccinated for herd immunity. This vacuum created by the unvaccinated provides the perfect recipe for spread of measles.

The tyranny of anti-vaccination is primarily parental refusal.  As a pediatrician we need to understand the most common reasons to allow informative conversation in a timely fashion:

Religious: Majority of the parents base their choice of not vaccinating their children on religious backgrounds.  No mainstream religion is against vaccination.  Vaccines indeed serve to protect human life and respect the principles of not harming self or public.

Link to Autism: Some parents are concerned about autism and MMR.  This claim was propagated in the flawed The Lancet article by Andrew Wakefield, which became the most infamous retractions in history of science.  Multiple follow-up studies did not find any such association.

Vaccine safety: Few parents express great concern of vaccine safety due to vaccine components, i.e. thimerosal.  These components were removed from the vaccines more than a decade ago and current vaccine are safer to administer.  Some parents fear that overwhelming their child’s immune system with too many vaccinations at one time has negative outcomes.  Again, this belief does not have any scientific evidence.

Personal beliefs: Some parents make it a matter of freedom of choice based on philosophical reasons.  Such freedom should never harm the most susceptible and defenseless amongst us.

Parents who refuse vaccines should be advised that New York State law prohibits unimmunized children from attending school during outbreaks.  Parents should be encouraged to read the applicable law(s). Information on religious, philosophical, and nonmedical exemptions for immunization are available online (http://vaccinesafety.edu/cc-exem.htm).

As a pediatrician we have dual responsibility of medical care and vaccine advocacy during this ongoing measles outbreak.  In addition to the infected child at risk, there is also a societal cost for investigating the potentially large number of those exposed to the index case.

Medical care: We need to be vigilant and consider measles in a child presenting with fevers and rash if they are unvaccinated.  A careful history of exposure to a case of measles and recent foreign travel from an endemic region should be obtained.  Any suspected case should be placed under airborne precautions in a negative pressure room (hospitalized). Measles infection can be confirmed by using RNA PCR by at least nasopharyngeal swab and serum.  New York State laboratory at Wadsworth can perform the PCR assays.  A positive IgM can also be used to confirm the cases however it has low positive predictive value.  IgG can be used for case confirmation with a 4 fold rise in acute and convalescent titers.  There is no antivirals, however vitamin A should be given to all children admitted with measles to the hospital.

Vaccination: We should continue to be a passionate advocate for MMR vaccination.  During this outbreak setting, if there is an exposed case, administer MMR vaccine if unvaccinated, or if history of single dose, provided ≥ 28 days have elapsed after the first dose.  Infants’ ≥ 6 months of age should be given MMR if they are living in the currently affected communities in Rockland County, Brooklyn or Clark County.  This however will not be counted towards the 2 dose MMR series.

Our infant luckily just had roseola.  It did serve as a reminder to stay on guard for a measles case in the current outbreak situation and be a voice for vaccines in contempt of parental refusals.


Witnessing History in Albany

Eve Meltzer-Krief MD, FAAP

Eve Meltzer-Krief MD, FAAP

(Dr. Eve Meltzer-Krief MD, FAAP is a pediatrician in Huntington and member of the NYS AAP Chapter 2 Immigration and Legislative Advocacy Committees.)

My alarm went off at 4:45am.  I got dressed and neatly folded my white coat into my bag, got into my car, and drove to the train station where I waited in the cold on the dark, deserted platform in Huntington, Long Island.  I was catching a train from NYC to Albany where dozens of other advocates were gathering from across the state, advocates including other physicians and moms and including individuals who had lost loved ones to gun violence.  We were all coming together to support the historic passage of gun safety legislation in New York State.

For some, like myself, it was our first time at the Capital watching Senate and Assembly proceedings.  For all of us, it represented the culmination of phone calls, letters, rallies and visits to legislative offices advocating for common sense gun legislation for our children.

As pediatricians, we know the impact that gun violence has on children in our country.  Nearly 1,300 children under 18 years old die from gunshot wounds every year and 5,790 are injured yearly.  Firearm related injury is the third leading cause of death among American youth.  A recent study showed that half as many children die from gun injuries in states with stricter gun laws compared to states with more lax gun laws.  Pediatricians know that gun violence is a healthcare epidemic for children in our country.

The pediatricians who were in Albany to witness the passage of the important gun safety bills stood up in applause along with Linda Beigel Schulman who lost her son to gun violence at Parkland and who burst into tears as one by one the gun safety measures were declared state law.  We watched as the Senate passed the Extreme Risk Protection Order bill and passed a law that will give up to 30 days to complete background checks.  They banned bump stocks and passed a bill preventing teachers from carrying guns.  They created regulations for gun buyback programs and passed a bill that allowed out of state mental health records to be reviewed before obtaining gun permits.  Common sense gun safety legislation.

Pediatricians also look forward to the passage of safe gun storage legislation that would require guns to be stored unloaded in a locked box separate from ammunition.  Studies show that 70% of childhood gun injuries, deaths and suicides would be prevented if the family weapon was locked up and unloaded.  Pediatricians from the NYS AAP also advocate for the establishment of a Gun Safety Research Institute in NY that would allocate funding for evidence based gun safety research and lead to recommendations for future gun safety measures.

It was inspiring and fulfilling to see our work lead to positive change .  I urge pediatricians to speak to their legislators about the issues they care about and to join your chapter’s legislative advocacy committee.  See you in Albany !


Where Are The Children?

Eve Meltzer-Krief MD, FAAP

Eve Meltzer-Krief MD, FAAP

(Dr. Eve Meltzer-Krief MD, FAAP is a pediatrician in Huntington and member of the NYS AAP Chapter 2 Immigration and Legislative Advocacy Committees.)

The news cycle is dizzying, exhausting and at times overwhelming.  And it is powerful.  It has the power to distort time, making days feel like weeks, weeks like months and months like years.  It has the power to shape what we know and what we care about.  And it has the power to allow tragedies of the utmost urgency and consequence to get buried and forgotten, lost in its chaotic pace.

We were all enraged last summer when we learned of the nearly 2,800 children that had been separated from their parents under this administration’s zero tolerance policy.  Their parents had brought them to this country legally seeking asylum only to have their children ripped from their arms and placed in detention centers across the country.  We learned of the cruel and immoral lengths this administration was willing to go to as a deterrent to those who would seek safety in our borders.  Public pressure and a court order have reunited most but not all of these children with their parents.

Tragically, there is a different news story that has gone mostly unnoticed about an entirely different and potentially much larger group of children.  What makes these children different is that we have no sound bite of one of them crying for the nation to hear.  We have no image of a little girl surrounded by ICE.  We have no video of children in cages.  They are invisible.

Last month DHS released a report which revealed that perhaps thousands of children had been separated from their parents during the year prior to the official announcement of their separation policy.  Furthermore, they revealed that they had no record of these children’s identities and they had failed to track them saying, “We don’t have any information on the children released prior to the court order.”  On February 1st the Office of Refugee Resettlement (ORR) released a statement saying it was not “feasible” to identify the children with the Deputy Director of the ORR, Jallyn Sualog, explaining that it would take “100 analysts, working eight hours per day for 471 consecutive days” to identify the separated children.  I wonder if Ms. Sualog would think that any amount of time and resources was too much to dedicate to finding her own children if they had been ripped from her arms.

ORR claims that the vast majority of minors are released to relatives.  But considering that the administration was taking children away from their parents – dozens of them under 5 years old and as young as 6 months, and placing them not with relatives, but in detention centers.  Can we trust that the thousands they chose not to tell us about were somehow treated more humanely?  How many children exactly did they separate from their parents before they revealed their abhorrent policy?  How old were these children?  Are they among the nearly 15,000 children this country is still holding in detention centers?  Were the separated children even old enough to know their names?

Buried in the news cycle we find child abuse, destruction of thousands of families and lifelong trauma inflicted upon children in a gross violation of their human rights.  We have dehumanized these children and we have now lost them.  We must demand that our government do everything in its power to identify and track the children they have separated.  We must demand accountability from a government responsible for these heinous crimes against children and humanity.  History will surely remember this as one of the darkest hours in our country’s history and it will judge us harshly if we remain silent.


The Impact of Legalization of Recreational Marijuana

Robert Lee, DO, FAAP

Robert Lee, DO, FAAP

(Dr. Robert Lee, DO, MS, FAAP is a pediatrician and Associate Pediatric Residency Program Director at NYU Winthrop Hospital.  He is the Chair for the AAP Section on Osteopathic Pediatricians, Secretary for NYS AAP Chapter 2, and Co-Chair of the NYS AAP Chapter 2 Foster/Kinship Care Committee.)

 “Reefer Madness” is a1936 film revolving around series of tragic events after innocent teenagers became addicted to marijuana.  It was shown to parents as a cautionary tale about the scourge called marijuana.

Today, marijuana for recreational use is legal in 10 states, and more states are considering it.  New York Gov. Andrew Cuomo has stated that the legalization of recreational marijuana is on his agenda for this year. 

What is the position of the American Academy of Pediatrics on the issue of marijuana legalization?

The legalization of marijuana has raised critical questions for pediatricians who care for children and adolescents.  In the 2015 policy statement, “The Impact of Marijuana Policies on Youth: Clinical, Research, and Legal Update,” the American Academy of Pediatrics opposes the legalization of recreational marijuana because of the potential harm to children and adolescents.  Legalization would create an industry to commercialize and market marijuana, which would be harmful for children.  Legalization would also lead to more adult use and likely lead to more adolescent use, despite attempts to restrict sales to underage youth.  It true that we do not have all the data documenting changes to child health from the legalization of marijuana in the states of Washington, Colorado and California.  Remember that it took generations, millions of lives and billions of dollar to establish the harms of combustible tobacco.  We should not consider marijuana “innocent until proven guilty,” given what already know about the harms to adolescents.

Health Effects of Marijuana

Marijuana use in pediatric populations remains an ongoing concern, and marijuana use has known medical, psychological, and cognitive side effects.  Short- and long-term recreational use in adolescents can cause:

  • Impaired memory and decreased concentrations, attention span, and problem solving
  • Alternations in motor control, coordination, judgement, reaction time and tracking ability
  • Negative health effects on lung function
  • Higher rates of psychosis is patients with predisposition to schizophrenia
  • Higher likelihood of drug dependence
  • Lower odds of completing high school or obtaining a degree
  • Increase in use of other illicit drugs
  • Increase in suicide attempts

What is the position statement of NYS American Academy of Pediatrics on New York State’s initiative to legalize marijuana for adult recreational use?

Pediatricians have special expertise in the care of children and adolescents.  Parents and legislators may call on us for expert advice.  NYS American Academy of Pediatrics has issued a position statement that is being shared with legislators, key Executive and State Agency staff and external partners.

NYS American Academy of Pediatrics strongly recommends that legislation include:

  1. Minimum age of sale should be at least 21 years of age
  2. Regulations to prevent underage sale should include at a minimum those protection in place for the sale of alcohol and tobacco to minors. Effective enforcement procedures are critical
  3. Strong regulation of retailers to prevent store locations near areas children frequent, such as parks and schools

NYS AAP recommend protections in place that include:

  1. Regulation by the NYS Department of Health to regulate potency
  2. Child proof packing of all products
  3. Outlawing of any products with appeal to children (i.e. candy)
  4. Labeling of product concerning the health risks to children
  5. Strict restriction on marketing that targets youth (i.e. use of cartoon characters)
  6. Including marijuana smoking in any clean indoor air legislation
  7. Prohibiting combustible marijuana in multi-unit housing
  8. Outlawing use of combustible marijuana in all public spaces where children may be exposed to second hand smoke

New York is likely to join the other 10 states that have legalized recreational marijuana, but as pediatricians, we need to advise legislators about the potential impact on children and adolescents.  More than 18% of NYS high schools currently use marijuana.  This number is going to increase once legalization has occurred.

Information for Parents

Marijuana: What Parents Need to Know

Legalizing Marijuana Not Good for Kids: AAP Policy Explained