Seasonal Flu: What Every Parent Needs to Know

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 elect for Pediatric Chest Medicine NetWork of the American College of Chest Physicians and past chair of the Asthma Coalition of Long Island.  She is the Nassau Pediatric Society Representative to NYS AAP Chapter 2.)

Fourth Child in NYC Dies of Seasonal Flu: What Every Parent Needs to Know

This week as the news of the fourth pediatric death in New York City hit the press, parents are asking what they can do to protect their children.  They turn to their pediatricians to put these findings into perspective, address concerns and to offer actionable strategies to modify risk factors.

This year’s flu season has been particularly severe and is likely to last several more weeks, possibly months.  The Centers for Disease Control have consistently recommended universal immunization against influenza for children ages 6 months and above through adulthood highlighting that children under age 5 years, particularly those under age 2 years as well as pregnant women, the elderly and those with chronic medical illnesses are at increased risk for flu related complications and hospitalizations.

Governor Cuomo declared a statewide influenza public health emergency on January 25, 2018.  As a result pharmacists are temporarily permitted to administer flu vaccines to children between 2 and 17 years of age.  Promotional campaigns can be seen throughout the state on print, social and other media sources.  Free flu shots are now available at multiple locations.

We know that the best defense against the seasonal flu is influenza immunization.  Immunization should begin as soon as the vaccine is available in the Fall.  This is especially important for those children between ages 6 months through 8 years who are receiving the vaccine for the first time because they will need to receive 2 doses given at an interval of about 28 days.  Protection for infants who are too young to receive the flu shot (<6 months) is best offered by immunizing parents, older siblings and caretakers as well as avoiding sick contacts.  Immunization against seasonal flu is now considered standard of care for all health care professionals.  They receive the flu vaccine not only for themselves but to protect the children they care for in offices, hospitals and community.

There are still a few stragglers, a few non believers, a few who were too busy to have their children immunized.  As long as influenza is prevalent in your community, it is not too late to get a flu shot.

The Centers for Disease Control supports this decision with the following findings:

  • The flu shot minimize the risk of contracting the flu by approximately 1/3
  • Flu season is likely to last several more months and could even stretch into May
  • The flu shot carries a low risk of significant side effects
  • There are no effective alternatives

What else can parents can parents do to protect their children and help to limit the spread of influenza?

  • Avoid contact with people who are sick
  • Keep your child home if they are sick
  • Practice healthy habits:
    • Cover your cough and sneezes
    • Wash your hands often
    • Avoid touching your eyed, nose and mouth
  • Be sure your child’s school and daycare centers have provisions to
    • Separate sick children from the rest of the group while they are waiting to be picked up
  • If you think your child may have the flu contact your pediatrician. Antivirals, such as Tamiflu, work best if given within 48 hours of symptom onset.

Additional information on flu surveillance and current recommendations for both parents and providers can be accessed at www.cdc.gov.


Influenza 2017-18

Leonard Krilov, MD, FAAP

Leonard Krilov, MD, FAAP

Asif Noor, MD, FAAP

Asif Noor, MD, FAAP

Influenza outbreaks are unpredictable.  This year’s flu season has hit the entire country hard.  Influenza activity spiked earlier than expected this year.  It is widespread and already associated with 37 pediatric deaths nationwide.  Over the past month newsflashes of healthy children succumbing to flu are depicting an alarming situation.  The impact is comparable to the 2009 H1N1 Pandemic in terms of its rampant spread.

As a pediatrician you play a crucial role during such an outbreak.  Not only do you treat the flu stricken children, you transform into an advocate for flu prevention through vaccination.  In this blog we address the two common issues faced by the pediatricians, i) understanding the effectiveness of this year’s flu vaccine, and ii) when to consider oseltamivir for treatment.

What are the circulating strains in New York State?  Influenza virus belongs to the orthomyxoviridae family and has two clinically significant antigenic types: influenza A and B.  Influenza A is further subtyped based on the nature of surface proteins, the hemagglutinin (HA) and neuraminidase (NA) which are spike-like projections from the surface.  Genetic mutations in the HA antigen and to a lesser extent NA antigen are responsible for the severity and epidemic potential of outbreaks.  This season the main circulating strain is influenza A H3N2 (77%), followed by H1N1 (15%), and influenza B (8%) based on testing at the New York State Department of Health, Wadsworth Center.

What strains are in the flu vaccine?  The composition of the flu vaccine is reviewed annually and updated based on the circulating influenza strains.  Influenza vaccine for this season includes: A/Michigan/45/2015 (H1N1)pdm09-like virus, A/Hong Kong/4801/2014 (H3N2)-like virus, and B/Brisbane/60/2008-like virus.  The quadrivalent vaccine containing two influenza B viruses contain the above three viruses and a B/Phuket/3073/2013-like virus.

How is the effectiveness of flu vaccine measured?  The effectiveness of the flu vaccine depends upon the match between the vaccine strain and the circulating strain.  The estimate is, however, calculated by the number of cases prevented by the flu vaccine.  This year the circulating H3N2 strain is similar to last year’s strain and is included in the vaccine.  The reason H3N2 strain is still the predominant virus responsible for the flu outbreak is due to its ability to undergo constant mutations of the genetic material, known as antigenic drift.  It can change from one season to another and even during the same season.  This phenomenon is particularly true if the predominant strain is H3N2 and if the vaccine production is egg-based (less stable vaccine).  The vaccine effectiveness studies since 2009 have shown that when the vaccine and circulating virus are well matched the flu vaccine provides better protection against influenza B and influenza A H1N1 as compared to H3N2. Thus the severe and widespread nature of flu activity this year is likely a result of the predominant H3N2 strain which underwent drifting.

What is the estimated effectiveness of flu vaccine this year?  The vaccine effectiveness studies from 2005-2017 showed that if the vaccine and circulating H3N2 are not well matched the vaccine effectiveness is close to 23%.  Before this flu reached the Northern hemisphere, Australia had a bad flu season, in which the predominant strain was H3N2 and the vaccine effectiveness was only 10%.  It is still too early in the season to provide estimated vaccine effectiveness in United States.  The Centers of Disease Control and Prevention conducts observational studies at 5 outpatient sites across the country to measure the vaccine effectiveness.  The effectiveness implies ability of the flu vaccine to prevent infection.  It is calculated as the odds of vaccination among outpatients with influenza-like illness and laboratory confirmed influenza infection to the odds of vaccination in outpatients with influenza-like illness but are negative influenza test.

If the vaccine is not a good match to the predominant H3N2 circulating strain, should one continue to advocate for vaccination?  Yes, the match is not ideal for this year, but the antibody production from the vaccine strain will continue to provide some degree of protection against the circulating strain.  This protection might not prevent the occurrence of infection but the vaccine will reduce the probability of a further severe infection, hospitalization, and even death.

When should one prescribe antivirals?  The two classes of antivirals approved for treatment of influenza are neuraminidase inhibitors which includes oseltamivir (oral) and zanamivir (inhalation) and the adamantanes (amantadine and rimantadine; high resistance is seen).  Oseltamivir remains the treatment of choice.  It is approved for neonates as young as 2 weeks of age.  Oseltamivir’s resistance to the circulating viruses over the past few years is around 1%.  One of the limiting factors of its use in children is the associated nausea and vomiting.  The recommendations for treatment are limited to:

  1. Any child who is admitted to the hospital due to severe, complicated, or progressive respiratory disease irrespective of immunization status and duration of illness ≥48 hours.
  2. Outpatient therapy should be offered to any child at risk of complications such as children less than 2 years or underlying medical problems. Treatment should be offered to symptomatic siblings less than 6 months of age.  In addition it can be used for term and preterm infants after birth based on limited pharmacokinetics and safety data.  Best outcome is seen with early treatment started within the first 48 hours.
  3. Premavir is an intravenous formulation for treatment of influenza reserved for severe cases when oral oseltamivir cannot be used.

In this hard hit flu season, some of the other important recommendations regarding flu vaccinations are as below:

  1. The inactivated flu vaccine is recommended for children ≥6 months and older. Both trivalent and quadrivalent preparations are available.  The live nasal influenza vaccine is not recommended for this 2017-18 season due to lack of effectiveness.
  2. One should continue to offer influenza vaccination while flu activity is present in the community.
  3. The only contraindication to vaccination is a severe anaphylaxis to a prior influenza vaccination. A history of mild (hives) or severe hypersensitivity (anaphylaxis) to eggs is not a contraindication.  If there is a history of severe egg allergy then the vaccine should be administered by a healthcare worker who is able to recognize and treat anaphylaxis reactions.
  4. Prophylaxis with oseltamivir should be recommended to close contacts that are at higher risk of developing influenza complication. Prophylaxis is not recommended in infants less than 3 months of age unless the situation is judged as critical.
  5. A cell grown vaccine by the name of Flucelvax is available for children 4 years of age and above. It might provide better protection against H3N2 but the main benefit is flexibility in manufacturing.

In this particularly difficult flu season, one should continue to be an advocate for the flu vaccine to lessen the severity and extent of the outbreak.

(Dr. Leonard Krilov, MD, FAAP is Chairman of Pediatrics and Chief of the Division of Pediatric Infectious Disease at NYU Winthrop Hospital.  He is the Co-chair of the Infectious Disease Committee of the NYS AAP Chapter 2.  Dr. Asif Noor, MD, FAAP is Pediatric Infectious Disease Attending at NYU Winthrop Hospital and member of NYS AAP Chapter 2)

September 2017

Dear NYS AAP – Chapter 2 Member,

The newly elected officers of the New York State American Academy of Pediatrics (NYS AAP) – Chapter 2 would like to introduce themselves, solicit your input, and involve you in promoting child (and pediatrician) health in our region.

We will serve in these offices until July of 2019 and hope to accomplish much during that time.  Even more important is the fact that chapter membership offers multiple opportunities to network, learn new skills, contribute opinions, suggest new initiatives, educate, and advocate.

As local pediatricians in a chapter almost 70-years old, your local AAP’s credibility, combined with the expertise of its members, is in a unique position to improve the care of children in our region.  With your help, we can have even more influence in shaping the policy and future of health care in New York State.

While most of the AAP’s 10 Districts are made up of multiple states, New York and California each comprise a District.  There are three Chapters within the NYS AAP (District II), and our Chapter 2 has approximately 1,400 members from the boroughs of Brooklyn and Queens, and the counties of Nassau and Suffolk.  Chapter 3 is composed of Manhattan, the Bronx, Staten Island, and the upstate counties of Dutchess, Orange, Putnam, Rockland, and Westchester.  Chapter 1 covers the rest of New York State.

Because AAP members from New York City are split between Chapters 2 and 3, look for increased collaboration between the Chapters through our Committees and initiatives that further our agenda in New York City and the surrounding metropolitan area.

Now a little about us:

NYS AAP – CHAPTER 2 OFFICERS & STAFF

Steven J. Goldstein, MD, FAAP

Steven J. Goldstein, MD, FAAP

President
Steven J. Goldstein, MD, FAAP
sjg34@cornell.edu
Follow Chapter 2 on Twitter @NYSAAPCH2
Follow me on Twitter @SteveGoldstei10I am a general pediatrician with offices in Brooklyn and Queens.  In my
work as Chair of the Pediatric Council I advocate for children’s
healthcare coverage and for fair payment for pediatric services.  I
believe that a healthy future for our nation and a competitive workforce
in the global marketplace depends on raising our children in safe
environments with adequate nutrition, educational opportunities, and
quality pediatric healthcare.

Shetal Shah, MD, FAAP

Shetal Shah, MD, FAAP

Vice President
Shetal Shah, MD, FAAP
shetaldoc@hotmail.comI am a practicing neonatologist and Professor of Neonatology and
Pediatrics at Maria Fareri Children’s Hospital/New York Medical
College.  My interests include neonatal immunology (particularly
immunizations), stem cell therapy and neonatal healthcare policy.  My
work with the AAP started when I wanted to help pass a law in NYS to
promote influenza immunization.  My work with the local AAP Chapter
showed me the power of dedicated individuals to institute change.  We have had much success, but there is still work to do!

Robert Lee, DO, FAAP

Robert Lee, DO, FAAP

Secretary
Robert Lee, DO, FAAP
robertlee.do@gmail.comI am an academic pediatrician and Associate Residency Program
Director at NYU-Winthrop Hospital.  As Co-Chair of the new Foster
and Kinship Care Committee, I advocate for children exposed to toxic
stress.  I will help develop quality educational programs and work to
engage the members with the goal of improving children’s health
through policy, advocacy, and education.

Sara Kopple, MD, FAAP

Sara Kopple, MD, FAAP

Treasurer
Sara E. Kopple, MD, FAAP
SaraKopple@gmail.comI am a general pediatrician and Assistant Professor of Clinical
Medicine at The New York-Presbyterian/Queens Medical Center.  My
interests include early childhood development, legislative advocacy,
and medical education.  I believe our role as pediatricians in the
community is to advocate and provide a voice for children and
families on an individual and population level.

Jessical Geslani

Jessica Geslani

Executive Director
Jessica Geslani
jgeslani@aap.orgOn July 1, 2017, Jessica Geslani assumed her new position as
Executive Director of the Chapter.  She will also serve Chapter 3,
facilitating our joint initiatives.We welcome Jessica to her new responsibilities.

Elie Ward

Elie Ward

Director of Policy, Advocacy & External Relations
Elie Ward, MSW
eward@aap.netElie Ward also transitioned into a new position in July, and we
welcome her efforts to represent the members of the District both in
Albany and New York City.  She will also assist in Grant
Management for the Chapters.

GET INVOLVED IN THE NYS AAP – CHAPTER 2!

Do you have a particular interest, specialty or passion within Pediatrics?  Do you perceive the need for an educational program we have not addressed?  Our Committees welcome new members and new ideas.  The Committees, their Chairs, and contact information are listed here: http://ny2aap.org/chapter-committees/.

Send an introductory email to us or to a Committee Chair and join with us and pursue your interest or passion!

We will be publicizing a number of events of interest to our members in the coming weeks, and hope you will join in.  The AAP’s National Conference and Exhibition was in Chicago this year, from September 15 to 19, and fulfilled its promise to be a great way to network, learn, and develop our skills.  The NCE is in Orlando next year, and the NCE site can be reached here: http://aapexperience.org.

We are on social media.  Please sign up for Chapter 2’s Twitter account @NYSAAPCH2 to get a daily, 140-character dose of the work we do each day to make our region a healthier place for children and a more practice-friendly environment.  If you need help creating a Twitter account, contact Jessica Geslani at jgeslani@aap.org.

The Officers of the Chapter look forward to working with you in the coming years.  Please let us know what you need and how we can engage you in our vital work.

Sincerely,
Steve Goldstein
Shetal Shah
Robert Lee
Sara Kopple


 

Bright Futures

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 NYS AAP Chapter 2 Secretary and Co-Chair of the Foster/Kinship Care Committee.  He is a member of the Middle Childhood Expert Panel for the Bright Futures Guidelines, 4th Edition.)

 

What is Bright Futures?

Bright Futures

Bright Futures

Bright Futures is a set of principles, strategies, and tools that are theory based, evidence driven, and systems oriented that can be used to improve the health and well-being of all children through culturally appropriate interventions that address their current and emerging health promotion needs at the family, clinical practice, community, health system, and policy levels.

Bright Futures is a national health promotion and prevention initiative, led by the AAP and supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau.  The book, Bright Futures Guidelines, 4th Edition, is the core of the Bright Futures tools for practice and provides theory-based and evidence-driven guidance for all preventive care screenings and health supervsion visits.  The Bright Futures Tool and Resource Kit that accompanies the book is designed to assist pediatricians in planning and carrying out health supervision visits.  It contains numerous charts, forms, screening instruments, and other tools that increase practice efficiency and efficacy.  According to Joseph Hagan, MD, FAAP (Bright Futures Co-Editor), “The Periodicity Schedule tells us what should be done in a well visit, I believe Bright Futures tells us how to do it well.”

What’s New in the Fourth Edition?

The Fourth Edition builds upon previous editions with thoroughly revised and updated content that reflects the latest research.  Because of the science of early brain development,  adverse childhood events (ACEs) and toxic stress, environmental and social determinants of health, the AAP has adopted an eco-bio-developmental model of human health and diseases (Figure).  Bright Futures incorporates this new science into the development of a new health promotion theme: Promoting Lifelong Health for Families and Communities.  It provides a current review of the science of development and insight for how this science might be applied in our practices and clinics.  For most visits, pediatricians are encouraged to ask about topics such as food insecurity, domestic violence, substance use, housing situations and other issues that may affect a family’s health.  In addition, there are major updates to several adolescent screenings including: cervical dysplasia; depression; dyslipidemia; hearing; vision; tobacco, alcohol, and drug use.

How is New York State using Bright Futures?

The New York State Department of Health (DOH) is leading the implementation of Bright Futures.  DOH has worked with many state partners to ensure that Bright Futures Guideline is the primary resource for preventive services and health care supervision.  DOH began by working with NYS Medicaid office to infuse Bright Futures into the Medicaid provider handbook.  Specifically, the handbook includes the Periodicity Schedule, which DOH updates to match any changes made by the AAP.  Next, DOH shared the Bright Futures Guidelines with other state agencies, demonstrating their relevance to the agencies’ work and generally increasing awareness of Bright Futures.  DOH also shared the Bright Futures Guidelines with the Office of Mental Health for use with children and youth with emotional health issues.  The use of Bright Futures across these agencies allows state programs to communicate using a common language.

The NYS AAP Chapter 2 and 3 Pediatric Council have worked with individual insurance providers to explain the importance of Bright Futures recommended services, such as developmental screening, in sustaining child health and to ensure providers receive insurance payments for services recommended by Bright Futures.

 How can Pediatricians implement Bright Futures into their Practices?

Many pediatricians have asked whether it is really possible to implement the recommendations in Bright Futures Guidelines in daily clinical practice.  The answer is Yes!  Carrying out Bright Futures means making full use of all the Bright Futures materials. For pediatricians who wish to improve their skills, Bright Futures has developed a range of resources and materials that complement the Bright Future Guidelines.  The Bright Futures Tool and Resource Kit allows pediatricians who wish to improve their practice or services to efficiently and comprehensively carry out new practices and practice change strategies.  The Bright Futures tools also are compatible with suggested templates for the electronic health record (EHR).

  • Bright Futures Previsit Questionnaire, which a parent or patient completes before the pediatrician begins the visit. When the questionnaire is completed, the family’s agenda, and many of the child’s strengths, screening requirements, and intervention needs, is highlighted.
  • Screening tools, such as standardized developmental assessment tests and screening questionnaires that allow pediatricians to screen children and youth for certain conditions at specific visits.
  • Bright Futures Visit Chart Documentation Form, which corresponds to the Bright Futures Guidelines tasks for that visit and the information that is gleaned from the parent questionnaire. It reduces repetitive charting and frees the pediatrician for more face-to-face time with the child or youth.
  • Bright Futures Preventive Services Prompting Sheet, which affords an at-a-glance compilation of work that is done over multiple visits to ensure completeness and increase efficiency.
  • Parent/Child Anticipatory Guidance Materials, which reinforce and supplement the information discussed at the visit.

For more information about how to implement Bright Futures recommendations click here.


Policy Agenda for Pediatricians & Children in Nassau County

Dear NYS AAP – Chapter 2 Member,
     As the Executive Officers of your local Chapter of the American Academy of Pediatrics (AAP), we work to make life better for children and to support pediatrics in our region, across the state, and nationally. Our work often involves meeting with elected officials to advocate for initiatives that will impact the children we care for and the practice of Pediatrics.
     In January, Laura Curran will take office as the new Nassau County Executive. She is sympathetic to the causes we espouse and we reached out to her staff to develop a policy agenda for the pediatricians and children in Nassau County.  We are asking for your input in developing this policy agenda.  Your suggestions will be compiled and considered for this agenda.
     Please email Jessica Geslani, the Chapter Executive Director, at jgeslani@aap.org with your suggestions. They will be compiled and reviewed.
    As a member of your the local AAP Chapter (NYS AAP – Chapter 2), we hope you see opportunities such as this as providing additional value to your Chapter membership and as a means to impact your local practice.
     The Chapter, in conjunction with partners across Nassau County, has been successful in promoting the Tobacco 21 initiative to the individual towns to reduce exposure to first- and second-hand smoke and vapor. Only the Town of Oyster Bay still allows sales of tobacco and e-cigarettes to those under 21 and we are still working with them. Tobacco Free Kids estimates we can reduce the days of life lost in the U.S. by 4.2 million if the initiative is adopted nationwide. We care for the children of Nassau County and the Pediatricians we serve.
     The Chapter Officers are available to address your concerns and questions. We invite you to visit the Chapter website www.ny2aap.org and follow us on Twitter @NYSAAPCH2.
     Please don’t hesitate to contact us.
Sincerely,
Steven J. Goldstein, MD, FAAP, President | SJG34@Cornell.edu | Twitter: @SteveGoldstei10
Shetal Shah, MD, FAAP, Vice-President | Shetaldoc@hotmail.com | Twitter: @NICUBatman
Rob Lee, DO, FAAP, Secretary | rlee@aap.org
Sara Kopple, MD, FAAP, Treasurer | SaraKopple@gmail.com

Infant Mental Health

Marcy Safyer, PhD, LCSW-R, IMH-E

Marcy Safyer, PhD, LCSW-R, IMH-E

What is Infant Mental Health and Why is it Important?

The term Infant Mental Health (IMH) is a slight misnomer and also includes Early Childhood Mental Health.  IMH can be understood as the developing capacity of a 0-5 year old child to experience, regulate and express emotions, form close and secure interpersonal relationships and explore the environment and learn within the psychological balance of the parent-infant relational system, as well as larger family, community and culture without serious disruption caused by harmful life events (National Zero to Three, 2004).

Recent neuropsychological research has shown that infants are born with their brains wired to be engaged in important nurturing and protective relationships.  They come into the world with remarkable capacities to establish and regulate these relationships.  Infants are surprisingly competent and endowed with predispositions toward attachment promoting behaviors.  They are not the “blank slates” they were once thought to be.  Infants possess an amazing repertoire of social and emotional capacities that are designed to give their parent information about their well-being and to actively behave in ways that modify and regulate the behavior of their parents.  The infant’s capacities to execute these signaling behaviors have roots across developmental domains.  In turn, infants seek emotional responsiveness from their parents and become distressed when it is not forthcoming.

Although the infant’s contribution to the relationship with his parent is great, it cannot be separated from the context of the parent.  The infant-parent relationship will suffer when infants fail to display behaviors or characteristics which elicit responsive caregiving as can be the case with babies who are premature, drug-exposed, or have developmental challenges.  Sometimes it is parents who cannot modify their expectations because their early life was characterized by unmet needs, abandonment and maltreatment, or because current stressors like maternal depression, mental illness or domestic violence are present.

Infant Mental Health-Developmental Practice (IMH-DP) is an interdisciplinary field that represents a dramatic shift in clinical practice.  IMH-DP focuses on the development of 0-5 year olds within the context of the early parent-child relationship as the foundation for healthy social-emotional, cognitive, language and even physical development.  IMH-DP offers ways of conceptualizing early disruptions in the attachment process, and of organizing interventions.  Its focus is on the mental health and relational dimensions of development that unfold in the context of other related domains of development, all of which are intimately and inextricably interlaced in infancy.  Thus the thrust of IMH-DP must be both developmentally and trauma informed.

At the Adelphi University Institute for Parenting and within the IMH-DP Master’s Degree program, multidisciplinary IMH specialists work within the context of the parent-child relationship to strengthen parental capacity while promoting both an understanding of the needs of young children and their parents’ unique ability to meet those needs.  In addition, IMH specialists work in a range of settings with care providers, preschool teachers and pediatricians, to name a few, as consultants to help address young children’s needs from a relationship-based perspective.  The dimensions of service aim to meet the needs of families on multiple levels and in many settings and include a service continuum that includes both prevention and intervention.  This comprehensive and intensive approach integrates a range of methods and services that include: developmental and trauma screening for children; depression, anxiety and trauma screening for parents; emotional support; developmental/parent guidance; early parent-child relationship assessments; dyadic (parent-child) psychotherapy; advocacy; and concrete assistance.  The Institute applies theoretically sound evidence-based approaches to clinical practice to support and enhance relationships between parents and their 0-5 year olds.  We aim to address early identification and assessment of children at-risk for developmental and mental health problems, strengthen attachment quality between young children and their parents and improve developmental trajectories through specialized dyadic services for at-risk populations of 0-5 year olds and their parents.

Pediatricians play a key role in the identification of high-risk children and families, provision of developmental guidance, referral of families to intervention resources and serving as a consistent touchpoint in the continuity of care.  The non-stigmatizing, health-oriented perspective of pediatrics makes pediatricians a safe and supportive port-of-entry for difficult-to-engage families facing the challenge of identification and referral.  Pediatricians can serve as critical links between the medical community, the mental health and developmental service systems and early care and education programs to promote integration of service delivery.

The Institute for Parenting at Adelphi University and its graduate program in IMH-DP can serve pediatricians as a resource for early identification, direct treatment services, mental health consultation to early care and education, coordinating child-serving resources in the community and a source of awareness information and expertise about infant mental health and developmental practice.

You can refer families with 0-5 year old children for services through the Institute of Parenting, if you are concerned that a child is has behavioral or developmental challenges, a family history of trauma or current traumatic events (i.e., child maltreatment, intimate partner violence, ongoing medical concerns/frequent hospitalizations, changes in family structure, loss of a close family member, or parental mental health and substance abuse issues), a parent suffering from Postpartum Mood and Anxiety Disorders (PMADs), or an impaired parent-child attachment relationship. Services are available to both English speaking and Spanish speaking families.  Referrals can be made by contacting Stacy Kurtz, PsyD at (516) 877-3911 or skurtz@adelphi.edu.

Dr. Marcy Safyer, PhD, LCSW-R, IMH-E® IV-C is Director of Institute for Parenting at Adelphi University and Co-Director of Adelphi University Infant Mental and Developmental Practice (IMH-DP) Training Program.  She is the President of the New York State Association for Infant Mental Health.  She is a member of the NYS AAP Chapter 2 Foster/Kinship Care Committee.


Help Me Grow

Elizabeth Isakson, MD, FAAP

Elizabeth Isakson, MD, FAAP

Help Me Grow- Long Island: Helping You Help Promote Developmental Health

Watching development naturally unfold, seeing parents discover the amazing feat of a growing human being, are perhaps two of those greatest joys of general pediatrics.  It is during the first five years of a child’s life that pediatricians see families and patients the most, and it is during this time that your guidance, assistance and knowledge not only identifies problems but promotes healthy development.

The path of child development is neither straight nor narrow.  Children vary widely, sometimes leap ahead or fall behind.  One challenge that gets in the way of the joy by accompanying families on their journey is the difficulty in detecting developmental problems early; then successfully linking those families to appropriate services.  For example, you suspect an issue in language development and refer the parent for early intervention services, only to find out six months later that the child didn’t make it to the evaluation, or they were evaluated and found ineligible.  It is as if we have determined that the only thing possible to promote developmental health is Early Intervention – and if a child is ineligible nothing else needs to happen.

Docs 4 Tots

Docs 4 Tots

Docs for Tots has been working with 6 health centers in Nassau County to ensure that they had best practice in place for developmental screening.  Working with the health centers through a quality improvement framework, together we ensured that the practices were screening with a valid tool 95%-100% of the time.  The AAP recommends universal developmental screening with a valid tool at the 9, 18, and 30 (or 24) month visits.  Screening was only the start; once valid screening was initiated, children were identified and needed to be connected to services.  Many barriers exist to connecting children to services – cultural or linguistic barriers, transient phone numbers, and residences that make follow-up difficult, parental ambivalence, etc.  Our work was with safety net health centers, serving children whose social determinants of health and experience of ongoing stress put them at an increased risk for developmental issues.  They could benefit the most for access to developmental supports and amelioration.  Screening could only go so far for these families and providers – consistent and targeted care coordination was needed.

That’s how we came to learn about Help Me Grow (HMG), a community impact model designed to identify children at risk for developmental problems that builds upon existing resources to support early detection of developmental concerns, celebrate the growth of young children, and link families to the supports and services that help children thrive from birth to age five.  Its core components include child health care provider outreach, community outreach, a centralized access point for screening and care coordination, and data collection.  Set to launch in early 2018, Help Me Grow – Long Island (HMG-LI) is a partnership that will serve all families under the age of five, providing integration and coordination among the many excellent resources on Long Island. As a pediatrician, you can get involved by:

  • Learning about HMG-LI and offering it as a resource to parents
  • Receiving free support to improve developmental screening in your practice
  • Utilizing HMG-LI to handle referrals to a full range of available services that support development

Pediatricians play a key role in child development.  They are but one asset in a community of multiple supports for families with young children.  Help Me Grow builds a system that connects the existing resources to the existing needs.  It starts to ensure that everyone’s good intentions lead to good results.  By improving partnerships and connections between the families, the medical community, and early childhood services, we can make a lasting impact in the lives of young children.

Dr. Elizabeth Isakson, MD, FAAP is a pediatrician and public health practitioner with 15 years experience with Columbia-Presbyterian Medical Center, the National Center for Children in Poverty (NCCP), and the New York Zero-to-Three Network (NYZTT).  She is the Executive Director for Docs for Tots.


Access 4 Kids

Christina Kratlian, MA

Christina Kratlian, MA

SOPT Advocacy Campaign 2017-18: Access 4 Kids

Access to healthcare and the ability to visit a physician is essential in improving and determining children’s health across the country. As the healthcare debate continues to evolve, we have seen thousands of pediatricians across the country take a stand to defend all children’s right to health care. Recognizing the crucial importance of access to quality medical care for children, the AAP’s Section on Pediatric Trainees annual advocacy campaign will focus on advocating for improved access to healthcare for all children, regardless of their medical conditions, living situation, country of origin, or preferred gender or sexual orientation.

The Access 4 Kids campaign will focus its efforts on four populations of children, including:

  1. Children Living in Foster Care or Group Homes
  2. Immigrant Children (defined as children who are foreign-born or children born in the United States who live with at least one parent who is foreign-born)
  3. Children and Youth Identifying as Lesbian, Gay, Bisexual, Transgender, Questioning, or Queer (LGBTQ)
  4. Children with Special Health Care Needs
Access 4 Kids

Access 4 Kids

The Access 4 Kids campaign aims to be fluid to allow for changing legislation at the state and national level to dictate our advocacy efforts, primarily using social media to respond to current political events. However, the campaign will have a defined quarterly structure, including:

  • A variety of educational resources to help trainees understand the intricacies of each specific population and how to best address their health care needs in the clinic and hospital setting.
  • An interactive webinar within each quarter with a prominent physician well-versed in the health care needs of each population of children.
  • A call to action at the end of each quarter to emphasize the work done across the country and to promote improved access to care at the community, state, and national level. The campaign will highlight the work already being done and new projects that have taken place on a Google map so everyone can share in the amazing advocacy efforts of their fellow trainees. Included in these efforts is a platform for residents and fellows to submit essays about their own experiences and the experiences of the patients that they care for daily.

The Access 4 Kids campaign will strive to educate and empower pediatricians-in-training to advocate on a community, state, and national level for access to quality health care for all of America’s children during this important time. The campaign urges trainees to get involved and help address inequities for some of our country’s most vulnerable children. Please reach out to the co-chairs with any questions, and then join all trainees as we open the health care door for all children!

For kids,

Rachel Lieberman, MD
Christina Kratlian, MA
Access 4 Kids Co-Chairs
SOPTAccess4Kids@gmail.com

(Christina Kratlian is a fourth year medical student at Albany Medical College.  She is the SOPT District II Medical Student District Representative and co-chair for the Access4Kids campaign.)


Musings on Humanism, Medicine, and Medical Education

Ron Marino, DO, MPH, FAAP

Ron Marino, DO, MPH, FAAP

“The future isn’t what it used to be.”
                                             —Yogi Berra

Medicine is a noble profession; it is a human service profession, the goals of which are to support and enhance health, cure disease and infirmity, and comfort the afflicted.  However, numerous factors have affected how medicine is taught and practiced in the 21st century.  Medicine has moved from a cottage industry to a massive medical industrial complex that constitutes an ever-increasing percentage of all economic activity in the United States.1  The pharmaceutical industry has created markets through direct-to-consumer advertising, and it seems that both physicians and patients have come to consider drugs central to patient-physician encounters.  In my experience, patients have become consumers who have high expectations for miraculous outcomes, and attorneys are ubiquitous and willing to explore potential malpractice in almost any situation where the clinical outcome was disappointing to the patient.  Meanwhile, at the earliest steps of a medical career, education is long and expensive, leaving most young physicians in 6-digit debt by the time they graduate.2,3  These economic realities impact young physicians’ career paths.2

I have worked as a medical educator for more than 35 years, and I see very clear changes in who physicians are, what they know and value, and how they are educated and practice medicine.  I have found that the possession of scientific knowledge has been elevated to a place of supremacy in discriminating a superior physician from an average one and has, in my opinion, wrongly become the emphasis of what we want and need in our students.  Cognitive information-based diagnostic and therapeutic approaches are important, but physicians may be losing sight of the humans who are experiencing the symptoms.  It is Sir William Osler who has been credited with saying, “It is more important to know what kind of patient has the disease than what kind of disease the patient has.”  Perhaps in the 1800s that was true.  Today, a balance seems more tenable.  Physicians must develop scientific knowledge to serve their patients’ best interests, and although knowledge and diagnostic acumen are necessary, they are insufficient qualities in excellent physicians.

Our current love affair with evidence-based medicine deifies data and minimizes the importance of relationship-based care, as well as ignores the reality that medical scientific information is merely a click away.  I have witnessed faculty clamor for more didactic time to essentially “fill the bucket” of medical students’ brains.  Meanwhile, I watch students move quickly from lecture to lecture, focusing on acquiring knowledge and passing written examinations.  I fear this misplaced emphasis will neither foster lifelong learning nor develop the ethics and values so critical to physicians.  As Albert Einstein was attributed with saying, “Not all that counts can be counted, and not all that can be counted counts.”

As physical examination skills fade into history, physicians become more dependent on high-cost, high-technology laboratory imaging and procedures to diagnose diseases and heal patients.  Yet, in my years of experience, a thoughtful conversation with a patient coupled with a skilled examination may both diagnose and heal in a cost-effective manner that is satisfying to both the patient and the physician.

Where does one learn the art of speaking with patients and using clinical examination skills?  I believe that senior physicians mentoring junior physicians through an ongoing relationship-based process models what the patient-physician relationship can be and serves as a vehicle to transmit our dying art.

Perhaps some of today’s medical students do not want an ongoing relationship with their patients; perhaps they simply want to develop a technical skill that is marketable, helps people, and affords them a nice lifestyle.  Perhaps some medical students want to practice the calling of longitudinal humanist care.  How will they know and decide what kind of physician they want or do not want to be?  Third-year medical students are asked to create their fourth-year curriculum, which sets the trajectory for graduate medical education, before they experience enough clinical rotations to have a clear sense of personal direction.  Perhaps medical schools should provide some combination of workshops, guidance counseling, and personality inventory in the first and second years to help medical students clarify their visions and values as they prepare to make choices that will have enduring significance.

The number of options available to medical school graduates boggles the mind—from administration to roles that involve technologically probing the body in so many ways, from medical physics and surgery to neuro-ophthalmology and, oh yes, primary care.  For those who are drawn to providing compassionate and ongoing care for humans, I hope there will always be a place.  I hope that the changes in the culture of medicine in our society never replace the patient-centered physician.

References

  1. The Effect of Health Care Cost Growth on the U.S. Economy. Washington, DC: US Dept of Health and Human Services; 2008.  http://aspe.hhs.gov/health/reports/08/healthcarecost/report.pdf.  Accessed February 4, 2013.
  2.  Research Department American Association of Colleges of Osteopathic Medicine. AACOM 2011-12 Academic Year Survey of Graduating Seniors Summary Report. Chevy Chase, MD: American Association of Colleges of Osteopathic Medicine; 2012.  http://www.aacom.org/data/classsurveys/Documents/AACOM%202011-12%20Graduating%20Seniors%20Survey%20Summary%20Report.pdf. Accessed February 4, 2013.
  3. Medical Student Education: Debt, Costs, and Loan Repayment Fact Card. Washington, DC: Association of American Medical Colleges; October 2012.  https://www.aamc.org/download/152968/data/debtfactcard.pdf.  Accessed February 4, 2013.

 

 (Dr. Ron Marino, DO, MPH, FAAP is a pediatrician and Associate Chairman and Director of General Pediatrics at NYU Winthrop Hospital.  He is co-chairman of the Yoga and Meditation Committee of the New York State (District II), Chapter 2 (Long Island) of the American Academy of Pediatrics.)


Medicaid Must Be Saved

Shetal Shah, MD, FAAP

Shetal Shah, MD, FAAP

(As healthcare reform continues at a fast pace in the US Senate, Chapters have been working to highlight the impact proposals within the Better Care Reconciliation Act will have on children.  Given Medicaid’s vital role in providing health insurance to children, protecting its budget from impacting children, particularly those with disabilities, is a vital national American Academy of Pediatrics’ priority.  Here, two active AAP members from neighboring chapters, Drs. Shetal Shah and Heather Brumberg, discuss the importance of a strong Medicaid program on children in New York and children’s hospitals.  More importantly, they highlight how Medicaid reductions will result in decreased access to subspecialists for ALL children, irrespective of insurance status.  This blog post was originally published as an Opinion-Editorial piece in The Journal News, a prominent newspaper in Westchester.  It is available at: http://www.lohud.com/story/opinion/contributors/2017/06/21/medicaid-cuts-hurt-babies-lifetime-outcomes-valley-view/414018001/

MEDICAID MUST BE SAVED TO ENSURE THE HEALTH OF CHILDREN

By SHETAL SHAH MD FAAP and HEATHER BRUMBERG MD MPH FAAP

As the landscape of healthcare reform shifts rapidly, it’s clear the federal Medicaid Program – the nation’s largest insurer of children – is in jeopardy.  Over the next two weeks, the United State Senate will debate a version of the American Health Care Act, also known as the “ObamaCare Repeal,” which drastically endangers the care of children.  The House of Representatives version of this bill defunded Medicaid by $834 Billion over 10 years and President Trump’s recently released budget was even more drastic – calling for $1.3 Trillion dollars in cuts over the next decade.

As pediatricians and neonatologists, we know firsthand such measures would be devastating to the critically-ill babies we care for, over 70% of which receive Medicaid coverage.  These babies are among the most gravely-ill in New York State, often weighing less than 3 soda cans.  There are roughly 3,300 of these babies born each year in our state.  They are at risk for heart, lung, intestinal and eye disease as well as cognitive delays.  The care our team provides saves their lives and gives them the best chance at growing up to be healthy adults.  But these treatments are made possible by health insurance programs like Medicaid.

Nationally, Medicaid is fundamentally integrated into child health, covering 40% of all children, including 1.78 Million kids in New York.  In our area, more than a third of children rely on Medicaid for healthcare.  That number is expected to grow.  Data from the University of Pennsylvania suggests the combination of higher annual contributions and increased deductibles for family plans will result in even more children from working class families ($49,200 for a family of four) shifting to public insurance.

Children depend on Medicaid.  Pediatricians depend on Medicaid to ensure that every child, no matter what tax-bracket they were born into, has access to the care they need.   Without this strong child health insurance program, our babies born more than a trimester early, or born to mothers addicted to opioids won’t have access to the care they need.  Other children won’t have access the life-saving vaccinations, autism screening and other preventive healthcare.  This leaves parents dependent on the emergency room for their children’s care, increasing costs and causing unnecessary suffering for children who could have had mild conditions treated by a pediatrician before they got worse.

Even if your children’ aren’t in the program, your family will be affected.  Since Medicaid covers so many kids, local children’s hospitals, including ours, disproportionately rely on Medicaid payments.  Without those funds, hospitals will reduce personnel, which impacts all hospitalized children, regardless of insurance status.  Medicaid funds also support school nurses, and allow hospitals to afford more physicians who provide mental health care and treatment for behavioral problems – increasing the ability of all kids to see specialists.

Economically, Medicaid also covers a great share of children with special health care needs, including children with cancer, sickle-cell disease and cystic fibrosis.  It’s estimated Medicaid saves $2,800 per child annually.  Without this support, these children will receive uncompensated care by a hospital; increasing the charges for private insurers who ultimately relay those costs to their beneficiaries via increased premiums.

Reductions in Medicaid funding, often labelled as reducing “entitlements” are shortsighted and ignore the demonstrated societal cost savings of insuring children’s health.  These proposals also ignore the long-term effects of having a healthy childhood.  Healthy children become more successful adults.  Throughout childhood, kids who receive Medicaid are more likely to complete college, pay more taxes and grow to healthier adults.  Sadly, this 18 year period doesn’t coordinate well with election timelines, putting Medicaid under threat.

Children are 0% of the vote and 100% of our future.  As parents, we know there is nothing we wouldn’t do for our children.  Medicaid has been there for our poorest children, allowing them to stay healthy.  It’s time for pediatricians and parents to be there for Medicaid.

(Dr. Shetal Shah is the Legislative Secretary and Secretary for the American Academy of Pediatrics, District 2, Chapter II.  Dr. Heather Brumberg is Vice-President of the American Academy of Pediatrics, District 2, Chapter III.)