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.

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 !

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 1^st 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.

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

Eve Meltzer-Krief MD, FAAP

(Dr. Eve Meltzer-Krief MD, FAAP is a pediatrician in Huntington and member of the NYS AAP Chapter 2 Legislative Committee and Suffolk Pediatric Society.)

I am a pediatrician and I work, reside and am a parent in Suffolk County.  On behalf of my patients and my children, I urge the Suffolk County Legislature to pass the proposed bill that will ban the sale of most flavored e-cigs and flavored nicotine in our county.

E-cigarette use is one of the leading public health issues affecting teens today with a 75% increase in use among teens in the last year alone.  E-cigarette and liquid nicotine use is rampant here in Suffolk County.Kids are vaping in school hallways, classrooms and bathrooms and are sharing devices with friends.  It is odorless and smokeless and and the vaping devices resemble pens, usb drives and battery chargers making their use easily concealed.

This issue is of huge concern to parents who are worried about their children.  Most of the teens simply do not know the potential harm they are causing themselves and the potential addiction they are putting themselves at risk for.65% of teens who vape are not even aware that the products contain nicotine.  Therefore, it is our responsibility to protect them.

Clearly the fruity and dessert flavored products with colorful packaging are meant to target youth and we know that kids who start vaping are more likely to try cigarettes.  We know that the nicotine in all these products is not safe, is addictive, can harm the developing brain and is associated with addiction to other drugs.  In addition the chemicals in the vapor can cause irreversible lung damage and contains potential carcinogens and heavy metals.

According to the American Academy of Pediatrics, the flavors, design and marketing of the nicotine products appeal to youth and normalize and glamorize nicotine product use.  E-cigs and liquid nicotine are addicting a new generation of youth to nicotine and are reversing more than fifty years of progress in tobacco control.

As far as I’m concerned, with youth being the primary target of these flavored products, their sale should be completely banned from the market.  We have the ability to do that here in Suffolk County with the proposed legislation.  We have a responsibility to do everything in our power to make it as difficult as possible for youth to get their hands on these products.

I can say with absolute certainty that pediatricians and parents throughout Suffolk County would welcome and be extremely grateful if this bill was passed and I urge the legislature to do so.

Eve Meltzer-Krief MD, FAAP

(Dr. Eve Meltzer-Krief MD, FAAP is a pediatrician in Huntington and member of the NYS AAP Chapter 2 Legislative Committee and Suffolk Pediatric Society.)

Last week the NRA quite arrogantly called doctors ‘self-important’ and advised them to “stay in their lane” with respect to gun violence.  They were responding to a recent policy paper by the American College of Physicians that called firearm violence a public health crisis and outlined policies that would reduce injuries and death.

As a pediatrician, I can confidently say that this is, in fact, our lane.  Pediatric Emergency Physicians and trauma surgeons try to save the lives of the nearly 1300 children under 18 that die from gunshot wounds every year and they care for the 5,790 children who are injured yearly.  Firearm related death is one of the top three causes of death among American youth, a rate much higher than any other high-income country.  Gun violence is a public health crisis and should be treated as such.  Just as car seats and seat belts have reduced death and injury from motor vehicle accidents, the implementation of evidence-based gun safety legislation could reduce death and injury from gun violence.

A recent study showed that stricter gun laws at the state level cut the number of deaths in children due to gun injuries in half. The study also found that states with no child access prevention laws had four times as many childhood suicides by guns as compared to states with safe storage or gun lock laws.  Furthermore, states with background checks for guns and ammunition also had dramatically fewer numbers of children dying from gun violence.

Such research supports the idea that gun violence must be treated like the public health crisis it is.  More CDC supported research that is currently discouraged by the Dickey amendment must be allowed to take place to prevent the tragic, senseless and preventable loss of life physicians see every day.

Shetal Shah, MD, FAAP

Eve Meltzer-Krief 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.  Dr. Eve Meltzer-Krief MD, FAAP is a pediatrician in Huntington and member of the NYS AAP Chapter 2 Legislative Committee and Suffolk Pediatric Society.)

While national events consume the news prior to the upcoming midterm elections, it is important to remember that there is a lot at stake for children in this election.  Voting outcomes at the state and county levels of government can impact the health and well-being of children in our communities.

As pediatricians and volunteers with the local chapter of the American Academy of Pediatrics, we frequently meet with policy makers on behalf of our region’s children.  As we prepare to enter polling stations next month, we must remember that our votes are the only voice that our kids have.

Pediatricians immunize children every day against common and deadly diseases.  However each year, illnesses once forgotten are returning.  Earlier this month, New York saw several cases of measles.  Vaccine preventable diseases like whooping cough and influenza are now commonplace.  Last season was the worst flu epidemic in a decade, with 128,000 cases in New York.

Six children died.

Yet last year the New York State Legislature strongly entertained relaxing immunization requirements for children in public schools, where these infections are easily spread.  Only vigorous protest by the medical community and parent groups helped defeat the bill (but just barely).  State legislators also did not pass a bill which would strengthen day care influenza vaccination requirements, despite evidence that this measure protects young children and their adult parents from being hospitalized with influenza.  Data from New Jersey and Connecticut, which have enacted the same law, show that  these policies improve the health of our toddlers and boost vaccination rates in a population of children highly vulnerable to flu.

Use of electronic cigarettes is another epidemic – mostly targeting teenagers.  Roughly 10% of 8th graders have vaped in the past month, and among 12th graders, the rate is 16%.  Though New York City, Long Island and several suburban counties have raised the age to purchase tobacco to 21 years, there is no state legislation protecting our teens.

Raising the age of tobacco purchasing to 21 years has been shown to reduce teen vaping and smoking by 50%, and already exists in California, Hawaii, New Jersey, Massachusetts, Oregon and Maine.  However our state has been inactive on this issue for at least a decade.

Appealing liquid flavors in nicotine, like bubble gum, cotton candy and banana split, are clearly marketed to children and facilitate addiction.  A recent survey found these flavors perpetuate vaping in almost half of all kids who use these products.  To remove this “on-ramp” to childhood nicotine addiction, large cities like San Francisco have banned the sale of flavored e-cigarette liquids.  But locally, no major municipality or county has taken similar actions, despite the existing public health data.  Teen e-cigarette use is linked to subsequent marijuana use, and as New York State is poised to legalize marijuana next year, these protections will only become more important.

Seven children die from gun violence every single day.  Since the tragedy in Parkland, Florida, there have been over 100 mass shootings.  While these tragic events dominate headlines, people forget that 89% of accidental shooting deaths in children occur at home.

In the wake of the Sandy Hook Elementary School shooting, New York State enacted several common-sense measures to prevent gun violence.  But our state does not mandate that guns at home be stored safely and away from children.  This “safe-storage” proposal has the strongest public health evidence supporting its ability to keep children safe from firearms in the home.  The federal government estimates roughly one-third of accidental deaths by guns could be prevented with this one simple law.  Though this bill has been introduced annually for several years, it has been opposed by “gun-rights” advocates who claim that a requirement to purchase a container to safely store the firearm constitutes a “tax” on gun ownership.

Three years after the mass public health disaster in Flint, Mich., which exposed thousands of children to toxic levels of lead, New York State laws on childhood lead poisoning remain outdated.  Your vote could determine if lead-exposed children have access to critical health services.  Currently the threshold lead level to test a child’s home and water in New York State is double the level recommended by the Centers for Disease Control.

Though the American Academy of Pediatrics notes that there is no safe level of lead, a bill will be introduced next year to make our state regulations current with the latest science on toxicity.  Such measures are the only way to make sure what happened in Flint does not happen here.

As pediatricians, we ask that children be at the top of your agenda when you vote.  We urge parents and state leaders to invest in programs and policies that keep children, families and communities safe and healthy.  Voting for kids is a small act that can have a profound influence on the health of our state’s children.  Pediatricians across the country have been distributing ‘Prescriptions to Vote’ like the one pictured, urging parents to ‘Vote Kids.’  We owe it to our children to vote with their interests in mind.