Recipient of the Julius B. Richmond Center of Excellence Visiting Professorship

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.)

This year’s award for the Julius B. Richmond Center of Excellence Visiting Professorship went to NYS AAP Chapter 2 serving the Pediatric Societies of Brooklyn, Queens, Nassau and Suffolk.  The award, funded through a grant from the Flight Attendant Medical Research Institute brings together tobacco control experts with pediatric organizations and training programs throughout the country. We were honored to host Dr. Karen Wilson as our visiting professor.  Dr. Wilson is the Debra and Leon Black Division Chief of General Pediatrics and Vice Chair for Clinical and Translational Research for the Department of Pediatrics at the Icahn School of Medicine at Mount Sinai.

In a series of three sessions over 200 community and academic pediatricians, fellows, residents and students had the opportunity to learn more about the impact of targeted marketing and deleterious health effects of e-cigarettes on adolescents, the impact of second and third hand smoke exposure and motivational interviewing to engage appropriate parents in smoking cessation discussions. There is clear evidence at all ages and developmental stages that exposure to tobacco is harmful.  Prenatal exposures have been associated with preterm birth, low birth weight and sudden infant death. During childhood increase rates of asthma, ear infections and pneumonia are well described.  There is no safe lower limit for tobacco smoke exposure.  Pediatricians are encouraged to advocate for smoke free environments for all children.

Tips for pediatricians to share with parents include:

  • Set a good example by not smoking
  • If you are a smoker, there are effective strategies to help you succeed in stopping
  • Keep your home and care smoke free
  • Work with your school and child care to keep play areas smoke free

While teen use of traditional cigarettes is declining, electronic cigarettes are on the rise. Targeted marketing, addition of flavors and the misconception that electronic cigarettes are a “safe alternative” contribute to changing trends.  Also known as e-cigs, e-hookahs, vapes, mods and ENDS (electronic nicotine delivery systems) these devices are not regulated and can contain nicotine, carcinogens and other toxic chemicals.  Nicotine is highly addictive and has harmful effects on adolescent brain development as well as to pregnant women and developing fetuses.  Multiple studies have shown that teens who use e-cigarettes are at higher risk for regular tobacco use in the future.

Key messages for pediatricians to share with parents and teens:

  • E-cigarettes are not a safe alternative to traditional tobacco products
  • There is no safe lower limit for exposure to nicotine in children
  • Teen users have a higher risk of nicotine addiction and higher rates of becoming long term tobacco smokers
  • Advocate for inclusion of e-cigarettes in tobacco free school legislation and prohibition of use in outdoor areas and locations where children may be present
  • Support ban on promotion and sale of e-cigarettes to children
  • Talk to your teen

Legislative Wins & Losses 2018; School Health Form

Elie Ward, MSW

Elie Ward, MSW

(Mrs. Elie Ward, MSW is the Director of Policy, Advocacy, and External Relations for NYS AAP Chapters 1, 2 &3.  She provides an update on the status of issues for which pediatricians across the state strongly advocated.) 

The New York State Legislature left Albany on June 20th.  Despite a chaotic and highly dysfunctional session, we were able to secure several high value victories for the children and families of New York.

NYS AAP Priority Legislation that Passed:

  • Standing Orders legislation, allows Nurses in the delivery room to admit a healthy newborn to the regular nursery without calling a pediatrician at home who has not seen the newborn. This was a high priority for our members.
  • Indoor Tanning Prohibition for all young people under the age of 18
  • Maternal Depression screening in pediatrics & primary care now covered by Commercial Insurance
  • Medically Necessary Donor Breast Milk for the tiniest, most medically fragile newborns now covered by Commercial Insurance
  • Sex Trafficking of a Child legislation was strengthened to include stronger penalties for perpetrators and stronger protections for child victims
  • CMV Testing Added to Universal Newborn Testing Under Specific Circumstances included CMV testing as part of universal newborn testing, if the newborn fails a hearing test, and requires a specific test for CMV as defined by the AAP

We and our partners were not able to move:

  • Statewide Lead Screening and Lead Action Level to 5 mg/l: The current statewide Action Level is 10mg/l which is above the CDC recommendation. But we have made progress with our coalition advocacy and as a result several key legislators who want to start working on moving the bill have reached out to start meeting as soon as early August. Memo of Support
  • Extreme Risk Protection Orders (ERPO) which allows a family member or other close friend to identify a person who is at risk and allows a judge to remove weapons from that person for a specified period of time.
  • Safe Storage of Fire Arms: Requires safe storage of all guns and stipulates exactly what safe storage means. Includes penalties. Memo of Support
  • Tobacco 21: Requires tobacco purchase age statewide to move to 21. Many counties have already moved in this direction, but a statewide approach would help protect all New York young people from being introduced to smoking too early.

IMMIGRATION ADVOCACY FOR SEPARATED CHILDREN

We are all too acutely aware of the inhumane treatment of families and children crossing our southern borders seeking safety.

The combination of Family Separation and Zero Tolerance policies have led to more than 3,000 children, including more than 150 infants and toddlers, being placed in various care situations away from their parents.  Some of the detention facilities for children are hellish and completely inappropriate, others, like some of the New York child welfare agencies that are caring for children, are more humane, but they are no substitute for family and parent caregivers.

Everything that we are doing at the NYS AAP is focused on reunification.  Only by reunifying children and parents and keeping families out of detention can we be assured that the children and families crossing our borders are being given the rights and supports they need as they work through their asylum processes.  The National AAP is doing work every day to help push the federal government to do the right thing for these children and their families. But we in New York can do even more.

Below are links to two letters your Chapter leaders wrote to both the Governor and the Mayor of NYC alerting them to our deep concern about the care of separated children in facilities in New York and demanding that all state and city efforts focus on reunification.

In addition, many of our members attended local rallies on June 30th Demanding Reunification for All Children Separated From Their Families.

But this problem is not solved. Children are still separated from their parents and there is the continuing specter of the federal government keeping these families in detention.

Here are some ACTIONS you can take to help these families:

  • Take any part of the letters we wrote (linked above) and edit them for publication in your local newspaper under your name.
  • Contact the Legal Services Offices in your area and offer your help and expertise to those attorneys who are trying to represent separated children in court. You can offer specific health, development and emotional impacts of separation.
  • Use this link to find Volunteer Opportunities in Your Area: Stand with Immigrants.
  • Call your Congress Person and your Senator and demand they focus on the reunification of separated families.
  • This is an election year. If you are attending any candidate forums, ask about the candidates’ positions on reunification and detention of families.
  • Attend more local rallies and events. Don’t stop speaking out until the children are back with their parents and the families are released into the community to await their asylum hearings.

NEW SCHOOL HEALTH FORM UPDATE

As many of you know, the State Department of Education (SED) announced a new School Health Form about 2 months ago.  No one from the NYS AAP was involved in the creation or design of the form.  We had been talking with the SED since last November asking to see a draft of the form and asking that it be electronically linked to EHR’s.  Our requests were ignored.  No one from the NYS AAP saw the form until the form was e-mailed, causing quite a stir among our members across the state.

We contacted the SED and asked for more conversations.  At this time there is a group of pediatricians who are involved in school health and experienced in practice administration who are attempting to work with the SED to make changes to the form and to get an extension on the implementation date.

At this time no one needs to use this form until the 2019-2020 School Year.  That would take implementation, unless we can get it delayed, to sometime in 2019 depending on when you see the child for the September 2019 school year.

Here is a link to the FAQ about the form:

https://www.schoolhealthny.com/cms/lib/NY01832015/Centricity/Domain/85/FAQsChangesHealthExam.pdf 

The important thing to remember is that no school district can demand the form now.

We will report back on the progress we make working with the SED to significantly change the form, the information it requests, and how it links with existing electronic health records.


Gun Violence Prevention

Nina Agrawal, MD, FAAP

Nina Agrawal, MD, FAAP

Dr. Nina Agrawal, MD, FAAP is the Medical Director of the Child Advocacy Center at Lincoln Medical Center in the South Bronx, where she practices child abuse pediatrics and runs the Center’s Community Pediatrics residency rotation.  She is member of the NYS AAP Chapter 2 and 3 Gun Violence Prevention Committee.

NYS AAP Chapter 2 and Chapter 3 members:

For the first time since the shootings at Sandy Hook elementary school, I feel hopeful.  The next generation is standing up for kids everywhere – rural, suburban, and urban.  They are standing up for the countless children traumatized every day by gun violence – directly and indirectly.

We had over 100 medical students, pediatric residents, and practicing physicians from programs all over NYC participate in the nation wide March for Our Patient’s Lives on March 24th.  Kudos to Hofstra medical students for coming out in huge numbers! (https://www.youtube.com/watch?v=eFWIXT6_IiM&feature=youtu.be)

We must continue to stand up and speak out!  As pediatricians, we are a trusted voice and can save lives.  Here’s what you can do NOW:

  1. LEARN
    1. Gun violence is a public health crisis. This is not politics.  This is about policies that keep children safe.  Gun violence is now the 2nd leading cause of death in children and is on the increase.  Every day we do nothing, 7 more children die.
    2. Gun violence is preventable. We need research and data to support effective policies.  Because of the Dickey Amendment stating that “no funds could be used by the CDC and NIH to advocate or promote gun control, we are 22 years behind in identifying evidence based solutions.  We need Congress to repeal the Dickey Amendment and appropriate $50 million to the CDC to do their job.
    3. We are promoting gun safety not gun control. This is similar to past highly successful public health campaigns such as Safe to Sleep and Motor Vehicle Safety.  Because of “Back to Sleep” and car seats, we have dramatically reduced deaths from these preventable injuries.  We need to do the same for gun violence.
  2. CONNECT
    1. We can’t do this alone. There are lots of opportunities to get involved.  Whatever you can give – a day, a week, a month – It all makes a difference.
    2. Connect with gun violence prevention advocacy groups like Moms Demand Action or the new Gun Violence Prevention Committee of NYS AAP Chapters 2 and 3.  Other groups always welcome white coats!
    3. Create dialogue with other health professionals. Offer to speak at noon conferences, grand rounds, etc.  Connect with speakers and ask them to present at your institution.
  3. ACT
    1. Raise awareness about the need for research – on a state level and on a federal level.  Most physicians don’t know about the Dickey Amendment. Repealing the Dickey Amendment has bipartisan support.  There is proposed legislation to create a NY State firearm research center.
    2. Put a face on gun violence. Tell your story about a patient or an experience.  Legislators have the stats but don’t have the front line experiences we have.
    3. June is gun violence prevention month.  June 2nd is wear orange day. Orange is the color for hunters, warning people not to shoot.  Host an event. Can be large or small.  We are happy to help you!

Stay tuned for a gun violence prevention summit in NYC on June 23rd organized by NY Docs – A coalition of advocacy groups dedicated to improving health for all.  To learn more, feel free to contact me.  We will be educating health professionals on policy advocacy and giving you the tools to take action.

Please read the attached letter from a 9 year old advocating to keep kids safe from guns.

 

In unity,

Nina Agrawal, MD
ninaagrawalmd@gmail.com


 

Why Infants and Toddlers in Daycare Need to Get the Flu Vaccine

Heather Brumberg, MD, MPH, FAAP

Heather Brumberg, MD, MPH, FAAP

Shetal Shah, MD, FAAP

Shetal Shah, MD, FAAP

This blog post was originally published as an Opinion-Editorial piece in www.lowhud.com.

(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. Heather Brumberg, MD, MPH, FAAP is Director of Regional Neonatal Public Health Programs and Medical Director of the Lower Hudson Valley Perinatal Network.  She is NYS AAP Chapter 3 President.)

Influenza has a public relations problem.  Though often perceived as a mild inconvenience, this past influenza season, commonly known as “flu,” demonstrated how serious the virus can be, infecting an estimated 34 million people nationwide and killing almost 4,000 this year.

As pediatricians in the neonatal intensive care unit, we cared for several babies whose influenza was so severe they required mechanical ventilators to help them breathe and intravenous medication to help their hearts beat stronger.  Our patients survived, but about 150 other children weren’t so fortunate.

With the increased attention this year’s flu season has received, the New York State Legislature is considering a bill (A1230a/S6346) to increase flu vaccination rates in preschoolers – the pediatric population most likely to harbor, and get seriously ill from influenza.  The bill would require infants, toddlers and young children who attend certain daycares to obtain an annual flu shot.  The measure being considered in Albany, which is similar to existing legislation in New Jersey and Connecticut, is highly effective at protecting kids from flu’s most severe complications.  In Connecticut, the regulation reduced flu-associated hospitalization in young children, and in New Jersey, preschool rates of flu immunization increased to 88 percent in the law’s first year.

The numbers from this past flu season define a public health epidemic.  In New York State, there were about 120,000 cases of influenza this past season, which doesn’t include additional undiagnosed illness.  Almost 12,000 people have been hospitalized and roughly 8,300 children under 5 years old were infected.  Eight children in our state died.  Fortunately, immunization against flu is an effective and safe means of protecting children from influenza.  Even in years when the vaccine doesn’t confer as much protection as it could — this year’s vaccine was about 30 percent effective – it still minimizes the risk of the most severe complications from influenza, including hospitalization and death.

The Centers for Disease Control recommend an annual flu shot for all children and adults with rare exceptions.  Immunizing young children is paramount, because their immune systems are inexperienced, not having encountered many flu strains before.  These children are therefore more likely to get critically ill from influenza.  Children in the close confines of daycare also serve as reservoirs of disease – passing the virus to other young children, siblings, their parents and grandparents.

While preschoolers are roughly one quarter of the child population, they represented almost 40 percent of all pediatric deaths from influenza from 2004-2012.  Unfortunately, flu vaccination rates in children are shockingly low compared to other recommended vaccines.  In 2014-15, only two thirds of New York’s children received a flu shot, while greater than 90 percent were immunized against Hepatitis B.

Unfortunately, there are opponents who object to any new regulations, seeing scientific-based policies as an infringement of personal choice, combating scientific fact with passion and volume.  These arguments were made when sates introduced seat belt laws, which the National Highway Transportation Safety Administration estimates save 10,000 lives annually.  They were made when infant car seat rules were introduced, which save 250 babies per year.  Bike helmet laws, which reduce head injuries by 40 percent, prohibitions on smoking in airplanes and other vaccination rules have always been initially met with dissent, despite having roots in public health data.

Reinforcing our protection against influenza for children in daycare does not mandate flu vaccination.  Parents who choose not to immunize their child have a right to do so.  However, this right should not allow them to be in areas where disease can be easily transmitted.  This is especially true for a highly infectious disease like flu, which can infect children even before the initial child is sick.  It would also prevent passage of disease to children in same daycare who are too young to get vaccinated, like newborns.  Parents who disagree with school vaccination requirements have for years chosen to home school there children.  Similarly, parents who disagree with these medically-supported proposals can seek alternative child-care arrangements.

Immunization remains one of our country’s greatest public health success stories.  Failing to take practical steps to protect toddlers and young children from a highly infectious, potentially serious disease would represent a missed opportunity for New York State.


Cuts To Farm Bill Will Affect Hungry Children On LI

Eve Meltzer-Krief, MD, FAAP

This blog post was originally published as an Opinion-Editorial piece in the Huntington Patch.

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

Cuts To Farm Bill Will Affect Hungry Children On LI, Doctor Says

Dear Editor,

As a pediatrician I feel compelled to speak out against the proposed cuts to SNAP in the Farm Bill, H.R.2, which is currently up for a vote in the House.

SNAP is the Supplemental Nutrition Assistance Program.  It is the most effective domestic U.S. hunger safety net program and nearly half of its recipients are children.  Over one million children in New York State receive benefits from SNAP.  Cuts to SNAP will adversely affect children in the nearly 22,000 households with children that participate in SNAP right here on Long Island.

SNAP delivers critical support to vulnerable families to ensure that they can put food on the table.  Children who live in households that are food insecure are likely to be sick more often, recover from illness more slowly and be hospitalized more frequently.  Lack of adequate healthy food can impair a child’s ability to perform well in school and can lead to higher levels of behavioral and emotional problems from preschool to adolescence.

SNAP is reauthorized under the Farm Bill, legislation that renews federal agriculture, trade and nutrition programs.  At present, SNAP benefits are not enough to provide funding with the resources to obtain an adequate healthy diet, and they should not be cut further.

No child should have to struggle with hunger and food insecurity in our country.  SNAP serves as a critical support for the health and well being of children and it’s funding should not be cut in the Farm bill.


 

March For Our Lives Long Island

Steven J. Goldstein, MD, FAAP

Steven J. Goldstein, MD, FAAP

(Dr. Steven Goldstein, MD, FAAP is a general pediatrician with offices in Brooklyn and Queens.  He is NYS AAP Chapter 2 President and Chair of the Pediatric Council.)

March For Our Lives Long Island
March 24, 2018
Huntington Town Hall

It is cold out here today, but I feel warm looking at all of you here to work on this problem!  Thank you for the honor of speaking to you today.  I applaud your courage and your commitment as young people to make this time different and help to end the epidemic of gun violence that includes 18 school shootings since January 1.

I represent the 1400 member Pediatricians of Chapter 2 of the New York State American Academy of Pediatrics.  As pediatricians, we care for you when you are ill and work to keep you well.  People generally bring children and teens to see the pediatrician when they’re already sick, but doctors are also charged with fostering safety, good health, and freedom from violence.  We don’t only care for you, we also care about you.  We care about your safety, your anxiety, your families, and your future.

The American Academy of Pediatrics has a long history of supporting measures to reduce gun violence and increase safety for young people.  As long as children continue to be injured and killed by guns in this country, pediatricians will not rest in our pursuit to keep them safe.

We believe that everyone deserves to feel and be safe where they live, learn, and play.  Our lives should not be shaped by fears of gun violence.  No one should be afraid to attend school, or to go to a movie, or to a concert.

We applaud your gathering here today to urge our elected officials to act on this issue and pass comprehensive gun safety laws that ban semiautomatic assault weapons, address firearms trafficking, require stronger background checks, and encourage safe firearm storage.  We strongly oppose arming teachers.  Where guns are present, there are more, not fewer, deaths.

Some of you here today may have heard of the Dickey Amendment, an addition to a bill passed in the1990’s that, as interpreted, prevented the Centers for Disease Control from using data from its studies on gun violence to advocate for gun reform laws.  This amendment had a chilling and widespread effect, reducing the role of science in informing the country about what can be done to protect against gun violence.  Just as we learned from scientific studies about highway deaths and smoking and saved thousands of lives, we can bring science back into this conversation about guns, and learn what works to reduce gun violence, suffering, and death.  I am pleased to tell you that on March 22 we heard that the new Omnibus budget bill clarifies in one sentence that research on factors that contribute to gun violence can be conducted by the Centers for Disease Control.  You are all to be congratulated because advocacy by young people like you and pressure from parents and organizations like the Academy of Pediatrics helped make this happen.  This is a first step.

We need multiple levels of government to fund gun-related public health research to help us learn not only how to prevent the next school shooting, but also the best ways to protect toddlers from accidentally firing a gun and the most effective methods to prevent firearm-related suicides.  I am pleased to tell you that the American Academy of Pediatrics is launching a bold new research initiative to protect children from firearm injuries.  Approaching these injuries as a public health epidemic, the AAP Gun Safety and Injury Prevention Research Initiative will bring together experts from around the country to study and implement evidence-based interventions.  While this will be privately funded by the Academy with an initial investment of $500,000 from the Friends of Children and Tomorrow’s Children Endowment Fund, more government support at all levels is sorely needed to address this problem.

It is time to hold our elected leaders accountable for their inaction on gun violence issues.  I urge you to stay connected with us and with other likeminded organizations, learn more about this issue, and most important, to register to VOTE.  Go to vote.org to learn about how to do so.  Find out which candidates support our shared agenda for preventing gun violence, and if they don’t, Vote Them Out.

Please remember that as long as children continue to be injured and killed by guns in this country, pediatricians like me will not rest in our pursuit to keep you safe.  Thank you all again for all you do and will do to make life better for everyone.  Perhaps your generation will accomplish what my generation could not.


Visiting Professorship Grant

Mary Cataletto, MD, MMM, FAAP

Mary Cataletto, MD, MMM, FAAP

NYS AAP CHAPTER 2 AWARDED VISITING PROFESSORSHIP GRANT FROM THE JULIUS B. RICHMOND CENTER OF EXCELLENCE

(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.)

Chapter 2 of the New York State American Academy of Pediatrics is this year’s recipient of a Visiting Professorship grant which is awarded annually by The American Academy of Pediatrics Julius B. Richmond Center of Excellence with the generous support of the Flight Attendant Medical Research Institute.

AAP Chapter 2’s membership comes from the boroughs of Brooklyn and Queens and the counties of Nassau and Suffolk.  There are currently approximately 1400 members in the Chapter.  We share a common mission with the Julius B. Richmond Center to improve child health by eliminating children’s exposure to tobacco and secondhand smoke.  We recognize that pediatricians must advocate for a safe environment for all children.  While the use of tobacco cigarettes is decreasing in the United States, the use of electronic nicotine delivery systems has surpassed all previous use.  On Long Island our pediatricians have worked to increase the purchase age for tobacco to 21 years of age (Tobacco 21).  This has been adopted in some but not all of the communities in which we practice.  We still have work to do.

Chapter 2 leadership, in close collaboration with the Richmond Center will be working to provide our members with evidence-based programming to provide effective skills and resources for your practice.  Specifically, we are looking to provide you with a knowledge base and resources to educate children and families about emerging and alternative nicotine and tobacco products as well as electronic nicotine delivery systems.

Additional information will be sent out to the membership as soon as dates and times are finalized.  Programs will be scheduled for this spring.

Please watch for these special programs.


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)

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.