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.)


 

Legislative Successes in New York State

Elie Ward

Elie Ward

(The New York American Academy of Pediatrics, Chapter 2, collaborates with the other two chapters to form a strong, expert and respected voice for children in our state capital.  As another legislative session continues until June, Elie Ward, MSW, Director of Policy and Advocacy for the New York State District of the American Academy of Pediatrics, provides an update on the status of issues for which pediatricians across the state strongly advocated.  Mrs. Ward is also Executive Director of Chapters 2 & 3.) 

Legislative Successes in New York State

There are seven weeks left for the state’s legislative session, but before we highlight what we still need to accomplish, let’s take a moment in these turbulent times and enjoy our major successes at the state level.

  1. Our work over the last several years and especially this year, helped get Raise the Age passed in the state budget.  Now most young people who get involved in the justice system will have their cases heard in Family Court, or a Special Youth Court, but not in Adult Criminal Court.
  2. And we can take credit, with our partners, for getting Medicaid Coverage for Donor Breast Milk for the tiniest sickest babies included in the state budget.

These are two issues that the NYS AAP has been championing for several years. Focused, consistent and strong advocacy by our members on both issues helped push them over the top this year, in an environment with multiple competing initiatives.
New State Regulations Help Adolescents

The NYS AAP also played a key role in a coalition that helped create and implement state regulations that have the potential to truly improve the lives of adolescents. New Regulations:

  • Permit Adolescents to Consent to their own HPV Immunization
  • Permit Adolescents to Access PREP as an HIV Preventive Service
  • Allow Access to Over the Counter Emergency Contraception with no age limit


Here Is What We Still Have to Do Before June 21st

We have key sponsors for our Standing Orders for Healthy Newborns legislation.  We will need your Advocacy, once we have a bill number.

We are working with key legislative leaders to move legislation Requiring Flu Immunization for Infant and Child Care attendance, A.1230.  Call your Senator & Assemblymember and let them know this is an important goal for pediatrics to keep our youngest children safe.

We have worked on the language for the “new” Child Safe Products Act, which would remove known toxic chemicals from children’s clothing, toys, furniture and accessories. I will let you know when we have a bill number so you can add your voice to our advocacy efforts.

We have filed Memos of Support for:

  • School Access to Blood Lead Levels  A.03899 / S.03941
  • E Cigs covered by Clean Air Act Requirements A. 00516/S. 0254
  • Prohibiting Sex Conversion Therapy  A.3977/S.26
  • Banning Tobacco Sales in Pharmacies  A.6956/S.543

Your calls and visits to your Senator and Assemblymember can help move these bills forward.  For E-Cigarettes and Sex Conversion Therapy, focus needs to be on the State Senate.  The Assembly has passed both.

The NYS AAP also provided comments with input from our medical professionals on many initiatives, like Cytomegalovirus enhanced testing, telehealth in schools and child care, cross state credentialing and more.

In addition, we have worked with the state to begin the implementation of Paid Family Leave.  We encourage all members to remind their patients about the availability of Paid Family Leave should they need time to care for a family member.  The very best advice you can offer is for a working Mom and/or Dad to talk to their employer about Paid Family Leave.

Statewide advocacy, along with the hard work of our Pediatric Councils, has resulted in most insurers now paying for Maternal Depression Screening.  If you are still having a problem with payment, contact your Chapter Pediatric Council representative.

The NYS AAP works throughout the year on policy development – keeping a pediatric voice at the table in areas that can and do directly impact children’s health and well-being.  Some examples include taskforces, work groups and committees focused on Value Based Payment for Children, Advanced Primary Care Statewide Stakeholders Steering Committee, State Partnership on HPV Immunization, with SDOH, ACS, ACOG, NYCDHMU, NYSACHO, Maternal Health Partnership (focusing on pre-conception health) State Immunization Advisory Council, State Early Care and Education Advisory, SDOH Breastfeeding Partnership, SDOH Antibiotic Resistance Work Group and others.  If you have a specific interest in any of these areas and can volunteer time, please contact Elie Ward at eward@aap.net.  Our members are always welcome to participate.

Now it’s time to pick your issue or issues and begin to reach out to your state representatives.  They are home in your communities each week from Thursday – Sunday.  Call, visit, e-mail.  Let them know what is important to pediatricians and why.

Whatever happens in Washington, we have a responsibility to continue to advocate for policies and targeted investments in New York State that can and will improve the lives of all of our children.


 

Healthcare Reform Must Prioritize Children and Avoid Fixed Payments

Shetal Shah, MD, FAAP

Shetal Shah, MD, FAAP

(As healthcare reform continues at a fast pace, Chapters have been working to highlight the potential impact proposals within the American Health Care Act will have on children.  Given Medicaid’s vital role in providing health insurance to children, protecting its budget from policies that would result in restricted enrollment or decreased services has become a national American Academy of Pediatrics’ priority.  Here, two active AAP members from neighboring chapters, Drs. Shetal Shah and Heather Brumberg, outline how measures to “Block Grant” or instill “Per-Capita Caps” on the Medicaid program will affect children.  This blog post was originally published as an Opinion-Editorial piece in Tulsa World, a prominent newspaper in Oklahoma.  It is available here.)

By SHETAL SHAH MD FAAP and HEATHER BRUMBERG MD MPH FAAP

At a time when national healthcare can change with a tweet, politicians seeking to “Repeal and Replace” the Affordable Care Act (or Obamacare) are proposing to weaken our children’s healthcare safety net.  President Trump aims to convert Medicaid to a Block Grant System which gives states a fixed dollar limit to fund their entire Medicaid program.  Features of this plan also appear in House Speaker Paul Ryan’s proposal, “A Better Way.”  Auditions for potential replacements of healthcare reform have also included these provisions.

We experience the Affordable Care Act each day.  As pediatricians who care mostly for infants in the Medicaid program, this fiscal maneuver will hurt children, decreasing their access to preventive care.  It also ignores the intangible benefits children experience when they have stable health insurance.

Children in the Medicaid program receive advantages aside from better health.  Rates of child poverty are epidemic, and include 1 in 5 children.  Poverty impacts the brain development of growing children, leading to increased rates of distractibility and longer times to learn new tasks.  Studies illustrate impoverished children have differences in parts of their brain which affect emotions, decision-making, and language.  As a strategy to elevate kids out of poverty, Medicaid yields significant benefits.  Data from the Georgetown University Center for Children and Families shows children with Medicaid grow up to be healthier adults, and achieve greater economic success than if they had periodic coverage.

Medicaid is the nation’s largest child health insurance program.  Expansion of Medicaid under the Affordable Care Act means the program now covers almost 30 million children.  This has led to the lowest rate of uninsured children (4.8%) EVER.  Children are over-represented in the Medicaid program, comprising only 20% of the population but almost 50% of Medicaid beneficiaries.

Though popularly conceived as a social handout, the parents of our infant patients often work 2 jobs apiece as janitors, waiters and daycare attendants, but still can’t earn enough to phase out of the program.  Since children are healthier than adults, pediatric Medicaid recipients incur only 20% of Medicaid costs, mostly in preventive care like immunizations, lead and autism screening.

A key factor of Medicaid is its economic adaptability.  States share the costs of new enrollees with the federal government, so they are encouraged to enroll as many children as are eligible, including my newborn patients.  During the “Great Recession” 3.7 million people moved to Medicaid.

However if converted to a Block Grant system, or per-capita cap program, states will bear the costs for new enrollees or increased children’s healthcare on their own.  Unlike the federal government, 45 states have balanced budget amendments, which mean they cannot take on debt to provide children with healthcare in times of economic recession.

This backward step for children’s health insurance leads to reduced coverage, unnecessary obstacles meant to deter families from enrolling their children in Medicaid and limited physician payments – all of which reduce access to care and literally sicken a third of our nation’s kids.  Practically, that means “addicted” babies born to opiate-exposed mothers don’t get home visits by nurses to ensure they are thriving.  It means new mothers won’t see lactation consultants to support breastfeeding.  A Block Grant program would mean premature babies, at risk for cerebral palsy, won’t be able to see a neurologist.  It will mean long waits for parents of autistic children to see specialists.

Even if you don’t receive Medicaid, cuts could affect you.  The School Superintendent’s Association notes that should block grants be implemented, services benefitting all children will be cut first.  These include school-based vision and hearing screening and fewer nurses in schools.

How much funding are states expected to lose?  Block Grant programs are not new, and had those proposals been implemented, states would have had to cut $76.6 billion dollars over a 10-year span by slashing child enrollment and refusing necessary services.

Why are children especially vulnerable to Medicaid funding cuts?  Despite being the most cost-effective population to insure, children suffer excessively in times of fiscal crisis.  Since children are 0% of the vote, and their lost preventive care is less visible than reducing payments for adult acute care like health attacks and strokes, our newborn infants are the main course on the financial menu.

One night in our unit slept 2 babies.  One infant’s mother was a professional from a wealthy suburb, the other baby’s mother cleaned rooms in a local hotel and took 2 buses each night to be with her ill newborn.  A well-funded Medicaid program gives each of these babies a chance to reach their full potential.

Obamacare has flaws.  It made no improvements in malpractice reform, did not curtail the unconscionable costs of prescription drugs, fails to provide universal coverage to all children, does not substantially fund comparative outcomes research which could save billions and increased taxes in certain income brackets.  Efforts to “Repeal and Replace” would be better spent in addressing these issues instead of jeopardizing healthcare for 30 million children.

The babies need us, but are we there for them?

(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.)


Screening for Postpartum Depression and Anxiety: A Perfect Pediatric Opportunity!

Jack Levine, MD, FAAP

Jack Levine, MD, FAAP

(Recent efforts by the American Academy of Pediatrics, New York, Chapter 2, as well as other pediatric advocates, have worked to make screening for postpartum depression in the pediatric office more convenient.  Two years ago, the New York State Legislature passed a bill expanding pediatric scope of practice in the state to specifically include screening for this common condition.  However, regulation and insurance issues were interpreted as requiring a separate chart for the mother solely for this screening, which impeded many practices from implementing this important work.  Last year, your chapter worked with a coalition to ensure maternal postpartum depression can be included in the infant’s chart.  In this blog post, Dr. Jack Levine, MD FAAP, Chairman of Developmental Behavioral Pediatrics/Children with Disabilities Committee for AAP NYS Chapter 2 and an Executive Committee member of National AAP Section on Developmental Behavioral Pediatrics, provides insights into how, why and when to screen.)

2017 is the perfect time to begin screening for postpartum depression in your office!  According to the American Academy of Pediatrics, pediatricians can now use CPT code 96161 and bill with the infant’s visit.  New York State Medicaid billing guidance can be found at https://www.health.ny.gov/health_care/medicaid/program/update/2016/aug16_mu.pdf.  Pediatricians see new mothers earlier and more frequently than other physicians, giving us multiple opportunities to assess and screen parental mental health.

Perinatal Mood and Anxiety Disorders: The new Terminology

Anxiety is a common characteristic of mothers’ feelings both during and after pregnancy and is very common in postpartum depression. Additionally depression can effect up to 20% of pregnant woman.  Along with “baby blues” and postpartum depression and anxiety disorders there is also psychosis, obsessive-compulsive disorder and PTSD.   Fathers may also develop postpartum depression.

Why screen?

Postpartum depression is common (8%-25%) and in some low income populations may include close to 50% of all new mothers! It is the most common cause of infant toxic stress in the United States.  There are significant and highly detrimental effects to developing infants (Table 1).  Screening helps us assess the baby’s environment and to establish a positive helpful relationship with the family.

Table 1. Effects of Postpartum Depression on Infants

Decreased breastfeeding

Failure to thrive

Developmental delay

Mental health concerns

Social withdrawal

Fussy, irritable

     Cognitive deficits      Poor self control, impulsivity
     Less language stimulation      Anxiety/depression
     Less play time      Attachment disorders
     Less reading stimulation      Aggression
     Less engagement with mother Poor safety: car seats, plug covers, sleep
School problems Over/under use of health care and ER
Sleep problems Difficulty managing health conditions

What to ask at every visit?

Assessing the risk factors for postpartum depression should be part of every well visit (Table 2). Maternal history of mood disorders and/or anxiety is an important risk factor and should be carefully assessed.  Discontinuation of anti-depressant medication during pregnancy is a particularly important risk factor.

Table 2. Risk Factors for Postpartum Depression

Psychosocial Risk Factors

  • Poverty
  • Maternal chronic illness
  • History of depression, anxiety, mood disorder, substance abuse
  • Adolescent pregnancy
  • Social isolation
  • Stressful life events, miscarriage

______________________________

Infant behavior

  • Decreased activity
  • Increased crying
  • Poor feeding
  • Failure to thrive
  • Sleeping problems
  • Increased accidents

 

Maternal behavior (observed or expressed by mother, father, grandparents)

  • Depressed affect
  • Sleeping more or trouble sleeping
  • Lack of enjoyment of usual activities/avoidance of usual activities
  • Withdrawal from family
  • Neglect of newborn or other children
  • Questions reflecting self-doubt/ severe anxiety
  • Inaccurate expectations of behavior and/or development
  • Punitive child rearing attitudes or discipline
  • Irritable/disruptive in office/frequent visits

______________________________

Infant risk factors

  • Prematurity
  • Congenital problems
  • “Vulnerable child” syndrome
  • Fussy temperament

 

When should I screen and what tools are available?

Depressive symptoms peak at 6 weeks, 2-3 months and 6 months.   “Baby blues” usually resolve by two weeks so that earlier screening may over identify, but post-partum depressive symptoms  can be delayed or persist for up to one year or longer!   Screen at 2 weeks, 2 months, 6 months and one year.  One month and 4 month screens can be added.  The Patient Health Questionnaire (PHQ-2, PHQ-9) or the Edinburgh Postnatal Depression Scale (EPDS) are commonly used, readily available, well researched, easy to administer, free, and have been translated into many languages (See References).

The EDPS has 10 questions and includes both anxiety and suicidal intent. The PHQ-2 is brief and contains only two questions.  The PHQ-9 (which also includes suicidal intent but not anxiety) can be given alone or with the PHQ-2 to determine the extent of depression.

Remember: Whenever inquiring about postpartum depression there must be a determination of suicide intent and safety of the mother and infant.

depressionWhat are available resources?

Treatment for postpartum depression must include both treatment for the mother and the mother-infant dyad. Reassurance and parent education can be provided along with specific referrals.  Medication is usually not needed but can be provided by obstetricians, internists or psychiatric providers.  A pediatric office should have plans available for the rare event of emergency referral (911) or in case of safety issues. Resources and guidance for both providers and parents are available through the Postpartum Resource Center of NY www.postpartumny.org and Postpartum Support International www.postpartum.net. Programs are available at most local hospitals in the Chapter 2 area.   Resource material should be available for immediate referrals (See Figure).  Appointments should be confirmed in the pediatric office and frequent follow-up provided. Early treatment results in the best outcomes for mother and baby and should be obtained as quickly as possible (within a day or two).

Identifying and treating postpartum depression are effective ways to ensure optimal early infant brain development – which is after all, why we all do what we do!!!

References:

  1. Earls, M et al. Clinical Report: Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice. Pediatrics. 2010;126(5):1032–1039. Reaffirmed December 2014)
  2. PHQ-2 download: http://health.utah.gov/mihp/pdf/PHQ-9%20two%20question.pdf
  3. PHQ-9 download: https://www.cappcny.org/home/media/phq9_adult.pdf
  4. Edinburgh Postnatal Depression Scale download: https://www.cappcny.org/home/media/Edinburgh_Postnatal_Depression_Scale.pdf

Dr. Levine is a pediatrician at Kew Gardens Hills Pediatrics and practices Developmental -Behavioral Pediatrics at Nassau University Medical Center.  He is Chairman of the AAP Chapter 2 Developmental Behavioral Pediatrics/Children with Disabilities Committee and an Executive Committee member of the National AAP Section on Developmental Behavioral Pediatrics.  Follow him on Twitter: @doctoj


Minor Consent for Human Papillomavirus Vaccination

Nina Suresh, MD

Nina Suresh, MD

“Minor Consent for Human Papillomavirus Vaccination”

(The local AAP Chapter is heavily involved with advocacy efforts in Albany, over the past several years, our voice has been critical in expanding paid family leave, ensuring parents are offered Tetanus, Diphtheria and Acellular Pertussis vaccine, and combating exemptions to vaccination prior to school entry [to name a few].  This month’s blog post outlines the case for supporting a proposal to allow minors to consent for Human Papilloma Virus Vaccination.  Last year, the bill was referenced as “New York State Bill S.2712/A.1528,” and though it did not pass, it is expected to be re-introduced when the legislature convenes next January).

by Nina Suresh, MD

This year alone, almost 300 women in New York State will die from cervical cancer (1).  On average, 2,400 New York State residents are diagnosed with cancers associated with human papillomavirus (HPV) each year[1]. Virtually every single sexually active person will become infected with the virus at some point during his or her lifetime, and HPV causes almost all cases of cervical cancer, over 80% of anal cancers, and over 50% of vaginal, penile, and oropharyngeal cancers (2).

Fortunately, acquisition of the most virulent strains of HPV can be prevented with the HPV vaccine, recommended by the CDC for both boys and girls ages 9 to 26 years.

As pediatricians in New York City, we frequently see young patients who are delayed in receiving the HPV vaccine because they cannot legally consent for vaccination. We treat teenagers for sexually transmitted infections each day in our clinics. Current New York State legislation allows qualified health care professionals to provide treatment for sexually transmitted infections to minors without parental knowledge or consent. However, these same minors do not have the right, under interpretation of our current legislation, to consent for HPV vaccination, an unfortunate missed opportunity to provide them protection from both sexually transmitted infection and certain cancers.  This is particularly dangerous since the vaccine is most effective when given to children as young as 9 years old, prior to the onset of sexual activity.

Bill S.2712/A.1528, introduced by New York State Representative Amy Paulin and Senator Liz Krueger will expand a health care professionals’ scope of practice beyond treatment for sexually transmitted infection to preventative care as well, including the administration of HPV vaccine to minors with their consent alone.

HPV vaccine is effective.  In 2013, the Centers for Disease Control (CDC) showed that that since the vaccine was introduced in 2006, rates of HPV have decreased 56 percent among female teenagers 14-19 years of age.  But vaccination rates are still low.  The U.S. rates of HPV vaccination in teenage girls are lower than vaccination rates in Rwanda.  The CDC estimates that 50,000 lives could be saved if HPV immunization rates reached 80%.  Allowing minors to consent for vaccination, in the same way they consent for treatment of sexually transmitted infections, will help increase vaccination rates and provide pediatricians a teachable moment in sexual health and prevention.

As pediatricians, we strive to protect the health and welfare of our patients through effective counseling and anticipatory guidance, as well as effective preventive measures and treatment. Without all of these aspects of care, we miss significant opportunities to protect our patients. For these reasons, I support Bill S.2712/A.1528 to enable us to provide not only treatment for minors, but also safe and effective preventive care that will protect them against this deadly, cancer-causing virus.

(Nina Suresh, MD is a resident in pediatrics at NewYork-Presbyterian/ Weill Cornell Medical Center.)

REFERENCES:

  1. https://www.health.ny.gov/statistics/cancer/docs/hpv_related_cancers_and_vaccination_rates_2015.pdf
  2. National Cancer Institute at the National Institutes of Health, “HPV and Cancer,” March 2012, http://www.cancer.gov/cancertopics/factsheet/Risk/HPV

Love us and Leaf us Alone!

Lucy Weinstein, MD, FAAP

Lucy Weinstein, MD, FAAP

“Love us and Leaf us Alone!”

Led by Environmental Health Committee Co-Chair, Dr. Lucy Weinstein, MD, MPH FAAP, New York Chapter 2 of  the American Academy of Pediatrics has made significant strides in reducing noise pollution across our region.  Dr. Weinstein has worked with the committee to help enact bans on gasoline leaf blowers, often going community-to-community to meet with local and state legislators and neighborhood groups.  Here she recounts her experiences and success in reducing the environmental imprint of gasoline leaf blowers – a timely topic now that fall is here and many of us will be bagging up leaves. 

You can hear them from many blocks away. Gasoline leaf blowers are relentless and go from morning till night, seven days a week, in many of our Long Island neighborhoods.  As annoying as the sound can be, there are major health and environmental concerns associated with these devices.  Fortunately, with the help of AAP Chapter2 and other partners, our local Environmental Health Committee has worked to restrict their use in some communities in our chapter and is working to ban or reduce their use in others.

Gas leaf blowers are among the worst offenders in our garages.  Their inefficient 2- stroke engines burn an oil-gas mixture that generates high levels of toxic chemicals, and they churn up fine particulate matter at ground level, where they are easily inhaled.

Up to 30% of its gasoline is discharged unburned.  The exhaust from gasoline leaf blowers combines with sunlight to produce ground level ozone which can cause immediate respiratory symptoms and may exacerbate long-term lung disease.

Other pollutants caused by gasoline leaf blowers read like a “Who’s Who” of toxins which adversely affects health, particularly for the young and elderly. These include:

  • Volatile organic compounds (VOCs) – including known carcinogens such as
    • Benzene
    • 1,3 butadiene
    • Acetaldehyde
    • Formaldehyde
  • Carbon monoxide
  • Nitrogen oxides
  • Particulate matter – including mold, fungal spores, insect eggs, fertilizer, heavy metals and rodent feces
    • Fine particulates which are inhaled deep into lungs, damage lung tissue, and increase the risk of cancer and premature death.
  • Carbon dioxide
  • Other hydrocarbons

According to an Environmental Protection Agency study, small lawn and garden engines account for 5%–10% of total US emissions of carbon monoxide, carbon dioxide, nitrogen oxides, hydrocarbons, and fine particulate matter. The hydrocarbon emissions from 30 minutes of running a 2-stroke leaf blower equals those produced in a 3,900-mile drive in a Ford Raptor!

Children are particularly vulnerable to these toxins because their organs are still developing, and they breathe more air per pound of body weight than adults. They are also lower to the ground and therefore inhale more pollutants released into the air by this equipment and spend more time outside. Gasoline leaf blowers are linked to asthma exacerbation, pulmonary disease, various cancers, heart attack, strokes, congestive heart failure, and increased overall mortality.

LeafblowerThese devices are also significant causes of noise pollution, which is why you can hear them six streets over in our neighborhoods.  The ears of young children are particularly susceptible to the damaging effects of the intense, high-frequency noise that gasoline leaf blowers generate. Noise has been shown to negatively affect blood pressure, to increase stress, impair communication, reduce school performance, and diminish the accuracy of complex tasks.

Gasoline leaf blowers also harm gardens and landscapes via loss of top soil and of beneficial soil microbes. They also disturb habitats of small mammals, birds and insects. It’s better for the environment to allow some leaves to remain under bushes and trees.

What are the alternatives?

Banning gasoline leaf blowers does not mean losing this landscaping tool to maintain our yards, parks and community gardens.  Today we have commercial-grade Lithium Ion battery blowers. They are a much better alternative.  Newer commercial-grade lithium battery blowers do not pollute, do not cause ground level ozone, eliminate solid waste byproducts and are much quieter.  These and manual equipment (think rakes and brooms) have been shown to be equally or nearly equally efficient and effective, and are cost-efficient. Landscapers and homeowners actually save money.  (In a test in California, a Grandma was nearly as fast and was more effective in cleaning a yard than a leaf blower!!!)
As we all become more aware of the accumulated impact of toxins in our environment and of the specific vulnerability of our children to pollutants, our committee has been working to have this equipment eliminated from local use.  Over 400 municipalities across the US have restricted or banned gasoline leaf blowers, including 16 in Westchester.

However, “Lawn Guy-land” has been slow to adopt healthier alternatives.

The Environmental Health Committee for New York Chapter 2 has been actively working to improve our region’s environmental health.  Our list of accomplishments related to reducing gasoline powered leaf blowers includes:

  • We’ve written letters of support and testified before New York City Council’s Committee on Environmental Protection in favor of legislation sponsored by a Queens city council member that would restrict the use and sale of gas lawn equipment.
  • A medical summary I wrote assisted the Medical Society of the State of NY in developing a resolution regarding the dangers of gasoline leaf blowers; the resolution passed and will be presented at the next national American Medical Association meeting. Adoption of this resolution would strengthen our cause to enact a ban of these devices across our region.
  • Brookhaven National Laboratory has agreed to consider “greener” landscape practices as a result of a presentation we gave – along with Huntington CALM (Citizens Advocating for Leafblower Moderation – to their landscape maintenance division.
  • Huntington and Stony Brook University Hospitals have agreed to restrict their use of gasoline leaf blowers based on information we provided. Northwell Health (formerly North Shore-LIJ) will have in their fall newsletter an article about the health risks of gasoline leaf blowers.
  • I’ve joined with partners such as the Environmental Health Section of the American Public Health Association to publicize this issue and am hoping to recruit more pediatricians interested in this issue to engage other community elected officials after the election.

Our Academy’s goal is “Dedicated to the Health of All Children.” This includes making changes across our local communities that positively influence child health.  In ways big and small, making sure our communities make choices that put the health and well-being of children at their forefront — and bringing information to them about the dangers of pollutants — is the core mission of our committee.  We will next bring our cause to local town councils across Long Island to further spread the word about the dangers of gasoline leaf blowers on child health.

For more information:

(Dr. Lucy Weinstein, MD, MPH, FAAP is Co-Chair of the New York, Chapter 2 Environmental Health Committee, Assistant Clinical Professor of Preventive Medicine at SUNY/Stony Brook, and consultant speaker for the Child Welfare Training Program of the Dept. of Social Welfare of SUNY/Stony Brook)