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

Jack Levine, MD, FAAP

Jack Levine, MD, FAAP

Dr. Levine is a pediatrician at Kew Gardens Hills Pediatrics and an Executive Committee member of the National AAP Section on Developmental Behavioral Pediatrics. 

Project TEACH has been working with pediatric practices in New York State since 2010. The project, funded by the New York State Office of Mental Health, has supported and strengthened the critical role that New York State pediatric primary care providers (PCP’s) can play in the early identification and treatment of mild-to-moderate mental health concerns for children ranging in age from 0 to 21.
One component of the Project TEACH /NYS American Academy of Pediatrics partnership in 2019 is a series of monthly newsletters touching on topics of concern to pediatricians and to parents.
2020 is the perfect time to begin screening for postpartum depression in the pediatric primary care setting! The American Academy of Pediatrics (AAP) recently published an extensive and comprehensive policy on “Incorporating Recognition and Management of Perinatal Depression into Pediatric Practice.” According to the AAP, pediatric providers can 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. Pediatric providers see new mothers earlier and more frequently than other physicians, giving multiple opportunities to assess and screen parental mental health.
Perinatal Mood and Anxiety Disorders: Different 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 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
  • Cognitive deficits
  • Less language stimulation
  • Less play time
  • Less reading stimulation
  • Less engagement with mother
School problems
Sleep problems
Mental health concerns
  • Social withdrawal
  • Fussy, irritable
  • Poor self control, impulsivity
  • Anxiety/depression
  • Attachment disorders
  • Aggression
Poor safety: car seats, plug covers, sleep
Over/under use of health care and ER
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 to 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!  Screening at one month, 2 months, 4 months and 6 months is recommended in the new AAP policy. Additional screening at 2 weeks and one year 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. The Survey of Well-Being of Young Children (SWYC) is a screening instrument that assesses a broad range of issues including maternal depression (PHQ-2 and EPDS), other family risk factors and child development and behavior.
Remember: Whenever inquiring about postpartum depression there must be a determination of suicide intent and safety of the mother and infant.
What 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.
Providers can use Project TEACH’s Maternal Mental Health Initiative (MMHI) – https://projectteachny.org/mmh/ for direct access to expert psychiatrists in maternal mental health, and for assistance with linkages to care and supports in the community. You can also access training – including two online trainings, “Diagnosis and Treatment of Depression during Pregnancy” and “Screening and Treatment of Postpartum Depression.”
Resource material, like the flyer shown here, 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. Resource material should be available for immediate referrals. 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 MF, Yogman MW, Mattson G, et al; AAP Committee on Psychosocial Aspects of Child and Family Health. Incorporating Recognition and Management of Perinatal Depression Into Pediatric Practice. Pediatrics. 2019;143(1):e20183259PHQ-2
  2. S. Kurtz, J Levine, M. Safyer. Ask the Question: Screening for Postpartum Mood and Anxiety Disorders in Pediatric Primary Care. Curr Probl Pediatr Adolesc Health Care. 2017: 47(10) 241-253.
  3. PHQ-2 download: https://brightfutures.aap.org/Bright%20Futures%20Documents/PHQ-2%20Questionnaire.pdf
  4. PHQ-2 scoring: https://brightfutures.aap.org/Bright%20Futures%20Documents/PHQ-2%20Instructions%20for%20Use.pdf
  5. PHQ-9 download: https://projectteachny.org/wp-content/uploads/2017/09/phq9_adult.pdf  
  6. Edinburgh Postnatal Depression Scale download: https://projectteachny.org/wp-content/uploads/2017/09/Edinburgh_Postnatal_Depression_Scale.pdf
  7. Survey of Well-Being of Young Children: https://www.floatinghospital.org/the-survey-of-wellbeing-of-young-children/overview

 

Dealing with Climate Grief

Steven J. Goldstein, MD, FAAP

Steven J. Goldstein, MD, FAAP

(Dr. Steven J. Goldstein, MD, FAAP is a pediatrician in Brooklyn and Queens.  He is the immediate past president of the NYS AAP Chapter and serves as co-chair of its Pediatric Council and Committee on Environmental Health)

     Committed pediatricians address the problems and consequences of gun violence, hunger, homelessness, immigration status, healthcare coverage, and anti-vaccine sentiment daily, and there is progress, albeit slow, on many fronts.  But there is an over-riding issue with little progress being made that will affect all of us, and children disproportionately, and is inescapable on the daily news.  I am referring to Climate Change.
     As large portions of California burned, and now as Australia sees unprecedented destruction, there are daily reports that the early predictions of the effects of climate change were underestimates, and the response of our country (and others as well) to both these issues seems feeble at best.  And lest pediatricians think that in their locales the effects of climate change are going to be a long time coming, witness the respiratory issues in states adjacent to the wildfires, the rising sea levels in Miami and other coastal locales necessitating raising the streets, and the almost daily reports of extreme weather events both here and abroad-including flooding, tornadoes, high winds, and drought.  This global change will result in island nations that, if trends continue, will no longer exist or lose vast amounts of land due to rising seas.  And the slow northward march of tropical diseases previously unknown in North America will change how we practice medicine.  The devastation of pines in northern habitats killed by a blight that now overwinters successfully due to rising temperatures affects whole ecosystems.  These seemingly distant examples of climate change will cumulatively affect all of us and our patients, no matter where we live or practice.
     If these occurrences weren’t worrisome enough, we are also faced with a rollback of protections for clean air, water and food by an administration that fosters business interests over public health ones.  And this denial of science is not limited to our country.  This past week the Australian Prime Minister denied the role of climate change in the wildfires and pledged to support the coal industry (Washington Post).  In the US, the administration discounts daily the role of science in public policy, and those at the head of the EPA and other governmental organizations charged with protecting the public interest, including once sacrosanct National Parks, now protect the fossil fuel industry  ( NY Times).  Chipping away at the protections designed to protect future generations put in place by previous administrations and slowly replacing advocates for children and the future with advocates for fossil fuels is the new normal.  Two examples: Dr. Ruth Etzel, a pediatrician and epidemiologist well-known to many of us was removed from her position as head of the EPA’s Office of Child Protection in 2018 and efforts to undermine protections against asbestos exposure were detailed by Dr. Phil Landrigan in August in the New England Journal of Medicine .
     The psychological effects of climate change issues on children and families is profound, and only adds to the burden of already existing stressors.  Some populations, like the Inuit and Pacific Islanders, are already dealing with these issues on a daily basis as rising seas and melting ice threaten their way of life, their physical and mental health and their futures.  These issues and how to help our patients build resilience are addressed in a report from the American Psychological Association and ecoAmerica (Access the report here).  The report details recommendations we can use to help individuals, communities and leaders to foster resilience, action, and mental health.
     Undoubtedly there are children and families under our care that are worried and stressed by this issue-experiencing what has come to be known as Climate Grief.  I am proposing that we discuss these global issues at office visits and see this as an opportunity to educate and enlist families in adjusting their lifestyles, building resilience, and advocating for the future not only of themselves, but also the planet.
     I believe that pediatricians should make it a priority to learn more about environmental health, climate change, and ecology.  Joining the AAP Council on Environmental Health and working with the Chapters on their new initiative to raise consciousness about climate change will add our voices to the national conversation and help us chart the future for ourselves and future generations.

Gun Violence: What is Our Role as Pediatricians?

Sanjivan V. Patel, MD, FAAP

Sanjivan V. Patel, MD, FAAP

(Patel Sanjivan, MD, FAAP is Chairman of the Department Of Pediatrics and Director of Newborn services and NICU at Wyckoff Heights Medical Center.
Nguyen-Thao Tran, DO, PGY2 is a Pediatric resident at Wyckoff Heights Medical Center)

Gun violence is recognized as a public health crisis with devastating effects on children, adolescents, and young adults.  Death caused by firearms is the third most common cause among children aged 1 to 17 years (1).  Furthermore, the United States leads the industrialized world in youth homicide and suicide rates (2).  What are the circumstances surrounding firearm-related injuries and deaths in children, and what exactly are we as Pediatricians doing to combat this crisis?

According to data from the Centers for Disease Control and Prevention (CDC) from 2002 to 2014, approximately 1,300 children die and 5,790 are hospitalized for gunshot wounds each year in the United States (1, 2).  Nearly half of these were due to homicides where younger children were bystanders in a violent conflict between intimate partners.  One-third of firearm-related injuries among adolescents and young adults are triggered by relationship problems with family, friends, or intimate partners.  Underlying mental health factors such as depression, developmental, and behavioral problems are also key contributors.  The remaining deaths were due to unintentional firearm deaths which are frequently due to unsafe storage of guns (1, 2).

In response to the rising youth violence prevention movement, the AAP issued guidelines and recommendations stressing the importance of Pediatricians becoming familiar with Connected Kids: Safe, Strong, Secure (2, 3).  This nationally-accepted program is a comprehensive effort by the AAP that serves as a primary care violence prevention protocol.  It serves as a clinical guide, provides 21 information brochures for parents and patients, and offers training materials that are accessible online for healthcare providers.

As Pediatricians we routinely have front-line access to our young patients with co-morbid mental health problems and those with involvement in high risk or violent behaviors (2).  It has been shown in a randomized, controlled study by Barkin et al that when pediatricians take the time to discuss gun issues during clinical care visits, patients and their families follow-through with their pediatrician’s recommendations on gun safety (3, 4).

The implementation of this anticipatory guidance and screening during routine health maintenance examinations touches on the importance of fostering resilient factors “that enable children and young adults to adapt successfully to stress, including exposures to violence (2).”  It is essential to note that when we take the time to advocate and provide support for early parenting behaviors in areas that help their child build interpersonal skills, peer relationships, staying safe, healthy dating, bullying prevention, firearms and media violence, and mental health, among other topics; children develop greater resilience early-on and more successfully, safely, effectively, and healthfully navigate and handle conflicts.

The AAP encourages pediatricians to routinely ask questions to screen for firearms in the home of their patients.  If present, we should counsel regarding safe gun storage (storing the unloaded gun in a locked safe, storing ammunition separately, etc.) or gun removal.  An adolescent’s access to firearms is usually obtained illegally through a family member or friend.  A recent cross-sectional study by Timsina et al found that the National Instant Criminal Background Check System (NICS) by itself does not decrease gun-carrying behaviors in adolescents.  However, they found that in states where universal background checks on all gun purchases are combined with the implementation of NICS, there is a reduction in adolescents having access to guns (6).  Our purpose as Pediatricians is to educate and ensure the safety as well as the health of our children and to not infringe on the Constitutional right to bear arms (5).

Overall, youth morbidity and mortality due to firearms is preventable with Pediatricians’ collective efforts to educate and advocate.  We need to educate and advise our patients on gun safety.  We need to advocate at the federal level for policies and legislation on violence prevention and mental health surveillance and resources that is pro-child health and safety (5).

References:

  1. Fowler KA, Dahlberg LL, Haileyesus T, et al. Childhood Firearm Injuries in the United States. Pediatrics. 2017; 140(1): e20163486.
  2. American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. Role of the Pediatrician in Youth Violence Prevention. Pediatrics 2009;124;393.
  3. Palfrey JS, Palfrey S. Preventing Gun Deaths in Children. NEJM 2013;368;5.
  4. Barkin SL, Finch SA, Ip EH, et al. Is office-based counseling about media use, time-outs, and firearm storage effective? Results from a cluster-randomized, controlled trial. Pediatrics 2008l;12(1)2:e15-e25.
  5. Jones N, Nguyen J, Strand NK, et al. What Should Be the Scope of Physicians’ Roles in Responding to Gun Violence? AMA Journal of Ethics 2018; 20 (1):84-90.
  6. Timsina LR, Qiao N, Mongalo AC, et al. National Instant Criminal Background Check and Youth Gun Carrying. Pediatrics. 2020;145(1):e20191071.

The Immunization Exemption Crisis

 

Ron Marino, DO, MPH, FAAP

Ron Marino, DO, MPH, FAAP

 (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.)

I Found Religion, Then Lost It: The Immunization Exemption Crisis

The New York State Legislature passed regulations in June 2019 removing the religious exemption for vaccination of children entering the school system in 2019.  This appropriate Public health policy, supported by AAP Chapter 2 and numerous other advocates for child health, has given rise to new and creative approaches in the anti-vax community.  Parents are confronted with the prospect of home schooling or exclusion from school if they do not comply with the legislation which is founded on the CDC’s immunization schedule.  The legislation also provides that medical exemptions will be consistent with currently published CDC contraindications and precautions.  As Medical Director for a variety of school systems, medical exemption requests come to my attention for validation.  Somehow parents are finding doctors willing to write exemption requests that are not consistent with CDC guidelines.  When I respond to the school administration that the exemption request is not based on current evidence based recommendations the fireworks begin.  School administrators have been verbally abused, my phone rings off the hook from parents, some doctors call to plead their case; I even received a call from a state assembly person who voted for the legislation asking me to make an exception for her constituent!

Colleagues, please do not write exemption requests that are not consistent with published guidelines!!  There may be some situations that are grey and require discussion, however it is clear that some licensed medical practitioners are writing clearly inappropriate and unsubstantiated medical exemptions.  Ultimately this will place the practitioner at risk and will not prevent the student from being subject to the immunization regulations.  Currently the New York State Department of Health is dealing with requests that need secondary review.  I am sure they are receiving lots of questions.  Parents should know that they can appeal the exemption denial to the state education Department, in the interim they may request a brief stay of the requirement.

We are clearly, as a Society, victims of our great success with immunizations.  Parents no longer see the diseases and have lost fear of what might be if their child contracted the disease and replaced it with distrust of the medical establishment and government.  We need only look back 30-60 years to epidemics of polio, measles, and invasive bacterial diseases to recognize the benefit that immunizations have given us.  Parents of the 1950s clamored to have their children immunized and that effort resulted in a much healthier population.  Every licensed physician in New York State should think carefully before providing a bogus, inappropriate, and professionally unethical immunization exemption request.  Medical Directors and the state office of professional misconduct are watching.  We must take a strong stand to be part of the solution and not part of the problem.


2019 Legislative Session Update: WHAT WE ACCOMPLISHED!

Elie Ward

Elie Ward

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.

As you may have read or heard, this year’s legislative session has been extremely productive. I am very pleased to report that it has also been very productive and positive for the children of New York.  Many of our key legislative priorities, like the repeal of Religious Exemption to Immunization, Lowering Blood Action Level from 10 mg/dl to 5 mg/dl, and passage of a Gun Safe Storage Act, were achieved.  In addition, we had several significant legislative successes in the areas of child safety, the environment, and further curbs of tobacco access for young people.

The following is a summary of our victories in the legislative arena.  Many of our bills which passed both houses still need to be signed by the Governor.  Most have been agreed to and the Executive has indicated that they will be signed.  If we encounter resistance or an assault by opponents, such as the chemical industry fighting the Child Safe Products Act, I will let you know, and we will activate our Advocacy Action Alert system.

But for now, enjoy the fruits of your labor. We couldn’t have done this without the active participation of you, our members, as well as the close support and coordination from our partners in medicine, public health, early childhood development, child safety, child well-being, and environmental health.  Our friends and supporters in the legislature and in the Executive were also helpful.

Together we raised a strong and multi-focused voice for the children of New York. Here is what we accomplished:

  • 2371a/S.2994a: Medical Exemption Only for Immunization – Passed both Houses and signed by Governor all in one day!
  • 2686/S.2450: Gun Safe Storage – Passed both Houses
  • 0558/S.02833: Tobacco 21 (No one under 21 can purchase tobacco products) – Passed both Houses
  • 00217a/S.3788a: Crib Bumpers (Crib bumpers cannot be sold in NYS) – Passed both Houses
  • 7371/S.5341: Kids Safe Products (Banning & disclosure of dangerous chemicals in children’s products) – Passed both Houses
  • 576/S.1046: Conversion Therapy (No longer legal in NYS) – Passed both Houses and signed by Governor
  • 2477/S.5343: Chlorpyrifos Ban – Passed both Houses
  • 164/S.2387: Period Products Disclosure – Passed both Houses
  • 6295/S.4389: 1,4 Dioxane Ban – Passed both Houses

I will keep you informed as these bills move forward. In addition, there are several other bills directly related to children’s health and well-being that we will be watching that may move toward the Governor’s Office.

Now it’s time to refocus our work for next session and onto some of the serious child and family immigration issues that are currently impacting the health and well-being of thousands of children in our country and our state.


The Southern Border and the Power of Pediatricians

Steven J. Goldstein, MD, FAAP

Steven J. Goldstein, MD, FAAP

(Dr. Steven J. Goldstein, MD, FAAP is a pediatrician in Brooklyn and Queens. He is immediate past president of the NYS AAP Chapter 2 and serves as co-chair of its Pediatric Council and Committee on Environmental Health.

The list of priorities of the current administration that have the potential to harm the children we care for and future generations is startling.  Undoing climate change protections, reversing water and air pollution caps, opening pristine lands to mining, protecting pesticide use and manufacturers, shrinking National Parks, restricting health care initiatives designed to protect children, and even back-pedaling on what constitutes a healthy school lunch are just a few of these initiatives.  Pediatricians need to be familiar with these issues so that they can raise their voices in protest and do so in an authoritative way that will influence public opinion, and ideally change the conversation.  Pediatricians can help parents and grandparents understand these important issues that will affect their children and grandchildren.  Do not underestimate the power of 67,000 pediatricians to influence public policy.

The mistreatment of children and families at the US Southern Border is ongoing and pediatricians, parents, and citizens are becoming inured to the constant news drone about the wall and the immigration issue.  The demonization of those seeking asylum at the border with subsequent pushback from the public resulted in what was supposed to be a change in policy regarding the separation of children and families.  But that has not happened at all.  Indeed, recent news reports have shed light on new issues, many kept hidden by those in charge at the border, that are putting children at risk of illness, toxic stress, and death.

As the number of those seeking asylum has risen, the ability of the government to accept and care for new applicants has been overwhelmed.  Children have been kept in facilities meant for very short stays for much longer periods of time without adequate clothing, food, or access to healthcare. Some of these facilities, meant for housing single men, can’t meet the needs of children. Many children are still sleeping in cold caged-in spaces that are never darkened, with little or no access to healthcare.  And if that wasn’t bad enough, funding for schooling and other activities for these children has been cut.  Mothers entering the US and delivering babies have been separated in the postpartum period, with nursing babies sent to other states for foster care while the mother awaits an immigration court appearance.  These babies and mothers are not criminals.

The new “Remain in Mexico” policy, with refugees forced to apply for asylum in the countries along their route before entering the US, subjects children to further food insecurity, violence, and poor living conditions as the burden of caring for them falls upon unprepared governments.

While we have been dealing with measles nationwide, mumps is now epidemic in some detention facilities with 236 cases reported as of March 2019.  One trope of the administration is that immigrants spread disease but this is untrue. Central Americans often have better immunization histories than at least some American communities.  Pediatricians know that mumps vaccine is the least effective of our vaccine arsenal, as we have seen multiple institutional epidemics in previously immunized populations.  This epidemic may be related to the close, unsanitary quarters where these children are   housed.

As this story unfolds and children and families at the border continue to suffer under intolerable conditions, many of us wonder if somehow America has lost its moral bearings and forgotten that all human beings deserve compassion and respect no matter their origin or citizenship.

In the late 1800s, Emma Lazarus, moved by the plight of immigrants coming to seek refuge in our great land, composed the following poem that is on display now at the base of the Statue of Liberty. It is no less relevant today:

Not like the brazen giant of Greek fame,
With conquering limbs astride from land to land;
Here at our sea-washed, sunset gates shall stand
A mighty woman with a torch, whose flame
Is the imprisoned lightning, and her name
Mother of Exiles. From her beacon-hand
Glows world-wide welcome; her mild eyes command
The air-bridged harbor that twin cities frame.
“Keep, ancient lands, your storied pomp!” cries she
With silent lips. “Give me your tired, your poor,
Your huddled masses yearning to breathe free,
The wretched refuse of your teeming shore.
Send these, the homeless, tempest-tost to me,

I lift my lamp beside the golden door!”

Pediatricians have more power than most of us know.  Speak to your patients when the opportunities arise.  Change the conversation and promote kindness, acceptance, and tolerance for all who seek refuge in our great land.  This is not over.  We can influence the future of this country and the life trajectory of countless children.


Measles as The New “Normal”

Steven J. Goldstein, MD, FAAP

Steven J. Goldstein, MD, FAAP

Dr. Steven J. Goldstein, MD, FAAP is a pediatrician in Brooklyn and Queens. He is president of the NYS AAP Chapter and serves as co-chair of its Pediatric Council and Committee on Environmental Health.

With cases of measles appearing in 23 states and counting and well over 800 cases nationwide, Americans will have to adjust to life with possible exposure to measles as the new “normal”.   This is after measles was declared eliminated from the United States in the year 2000.

People of my generation dreaded getting the measles when we were children in the 1950s, but it was a rite of passage in that pre-vaccine era along with the other childhood diseases of mumps, rubella, and chickenpox.  The worst of those illnesses, however, was measles, which can lead to pneumonia and brain infections, and the residual effects of which include immune suppression which in turn leads to a greater likelihood of illness for two to three years after the illness.  And on top of that, children who have measles under the age of two years are at increased risk for subacute sclerosing panencephalitis (SSPE), a rare complication from the virus that is fatal and begins on average six to ten years after the acute illness.  One to two deaths per thousand cases occur in those afflicted by measles.

What is different today is the greatly increased number of immunosuppressed patients living in the community.  In the fifties, patients on chemotherapy in the community were rare and immunomodulator drugs used for a wide variety of chronic diseases but which suppress the immune system did not exist.  Babies have always been at risk, as the vaccine is not usually given until one year of age.  An extra dose of vaccine can be given starting at age 6 months for exposures or travel.

But what about travel by air, or train, or bus, even within the United States, with a young child, a cancer patient, or someone on immune-suppressing drugs?  Measles is extremely contagious and hard to diagnose in the four days before the rash appears, which leads to unintended exposure in schools, places of worship, airports, and even malls.  The virus persists in the environment for up to two hours after an infected individual leaves the area.  This is just another aspect of the measles issue and has the potential to change the way we live day-to-day.

Measles made its way to the Detroit area after a visitor from Brooklyn brought the unintended guest along for the visit.  And now, after a month or so without an active case, there is once again measles in the Detroit suburbs.  Mothers of young babies in affected communities are essentially being held hostage in their homes because they are afraid to expose their children to the illness.  My daughter will drive to New York to visit with her young baby rather than risk an exposure on the short flight from Detroit.

And that brings me to what we can do to deal with this problem.  Those of us in pediatric offices, hospitals, emergency departments, and urgent care clinics are dealing with this issue every day as we must decide whether a patient that needs to be seen could spread measles to others in our health care facilities.  The bottom line is that immunization with two doses of measles vaccine gives 97% of people immunity, whereas those who have opted out of vaccination due to fear, distrust, or for whatever reason, remain at risk of contracting and spreading disease.  Those with medical reasons not to get vaccine may be at higher risk of complications and need to be protected by others having immunity (this is known as herd or community immunity) so as not to allow the illness to spread.

No major religion-in fact, no religion at all known to me-prohibits immunization, and some actively promote preventative actions.  Currently, New York State grants exemptions for school entry solely for medical and religious reasons.  There is a bill in the NYS Assembly Health Committee (A02371/S2994) that would allow for only medical exemptions to immunization in the state.  The pediatricians of New York State strongly support that bill and do not feel that it impinges on anyone’s civil rights: the law would not require vaccination, only prevent unvaccinated children from putting the other children at risk.

The anti-vaccine movement sees their issue as one of personal freedom.  I see that, but society also has the right to protect itself.  I’m fine with people having the freedom not to vaccinate against their will, but not at all fine with unvaccinated children putting others at risk.  No one should have the right to spread disease to others and impede their freedom to attend school, camp, or day care, or to go shopping or to travel.

Call your NYS Assemblyman and demand that Assembly Bill 02371 to repeal religious exemptions be released from committee for open debate.


Believe The Science That Vaccinations Protect Children

Eve Meltzer-Krief MD, FAAP

Eve Meltzer-Krief MD, FAAP

Dr. Eve Meltzer-Krief MD, FAAP is a pediatrician in Huntington and member of the NYS AAP Chapter 2 Immigration and Legislative Advocacy Committees.  This op-ed was published ontimesunion.com on May 23, 2019.

 Vaccination has been the most important and impactful scientific achievement of modern times. Yet because of misinformation fueled by social media, there remain pockets of unvaccinated children whose parents hide behind a cloak of religious exemption as protection from unfounded fears.

There are, in fact, no major religions that prohibit vaccination.  Sadly, these parents have put not only their own children at risk but the communities in which their children live, play and attend school.  The current measles outbreak is evidence of what happens when children go unvaccinated.

Measles is a highly contagious virus.  The current outbreak has now infected at least 880 people in 24 states.  Measles can lead to pneumonia, a brain infection called encephalitis, deafness, a prolonged immunocompromised state, and a rare complication called subacute sclerosingpanencephalitis that can occur years after infection and is fatal.

In 1962, the year before the measles vaccine was available, 3 million to 4 million people were diagnosed with measles, 48,000 were admitted to hospitals and 500 died.  By the year 2000, measles had been eliminated from the United States because of the vaccine.

However, because of growing numbers of parents choosing not to vaccinate their children, we have begun to see increased outbreaks in recent years, with this year’s being the largest since the disease was eliminated nearly 20 years ago.  There are currently 285 schools that are underimmunized in New York that are vulnerable to outbreaks.  As the rate of individuals claiming religious exemptions continues to rise this number will only grow.  Particularly susceptible to serious illness in these outbreaks are infants who have not yet been vaccinated, and immunocompromised children and adults who are receiving or have recently received chemotherapy and other immunosuppressives to treat cancer and chronic diseases.

Vaccines save lives.  The HIB vaccine has virtually eliminated disease caused by HaemophilusInfluenzae B, which before the vaccine’s introduction in the 1980s and 1990s affected 25,000 children yearly, causing meningitis, paralysis, blindness, pneumonia and a severe life-threatening respiratory illness called epiglottis.  Since the introduction of the Prevnar vaccine in 2000 there has been a dramatic decline in rates of meningitis, blood infections and other invasive life threatening disease caused by pneumococcal bacteria.

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

The American Academy of Pediatrics, representing 67,000 pediatricians across the country, is advocating for an end to state laws that allow people to refuse vaccination based on anything other than medical exemptions.  I urge New York legislators to pass S2994 and A2371.  I implore them to believe science and to protect children and at-risk residents in our state.  I implore parents and community members who understand the importance of vaccination to ask their state legislators to support the bill.

It is always tragic when children die or develop devastating long-term consequences from disease.  The most tragic of those cases, though, are the ones that are entirely preventable. Let us not fail our children.  Let us not fail those among us who are immunocompromised, who are too young to get vaccinated or who are undergoing treatment that prevents them from getting vaccinated.  These individuals, parents and children live in fear during outbreaks such as we are experiencing now. Let us not deny them the protection they need and are entitled to.


School Vaccination Exemptions Should Be Only for Medical Conditions

Shetal Shah, MD, FAAP

Shetal Shah, MD, FAAP

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


Legislators Need to End Most Vaccine Exemptions

Eve Meltzer-Krief MD, FAAP

Eve Meltzer-Krief MD, FAAP

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

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

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

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

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

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

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

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

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