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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)


 

Concussion Research

Khalida Itriyeva, MD

Khalida Itriyeva, MD

Conducting Concussion Research with the Help of New York AAP Chapter 2: A Model of Partnership

Dr. Khalida Itriyeva, MD FAAP

(New York Chapter 2 of the American Academy of Pediatrics includes several medical centers with training programs.  In addition to co-sponsoring residency research presentations through our affiliated Brooklyn, Queens and Nassau Pediatric Societies, our chapter can be utilized as a resource to aid members interested in research.  Here Dr. Khalida Itriyeva, MD FAAP discusses how she partnered with NY AAP Chapter 2 to conduct a research project on the management of concussions in primary care which was subsequently presented at a national meeting.)

Concussions, a form of mild traumatic brain injury, are a “hot topic” in sports and medicine, with current studies focusing on the link of repeated concussions on the development of chronic traumatic encephalopathy and other long-term sequelae.  Mild concussions are common in young athletes, and pediatricians see many of these patients in their practices.  Guidelines and recommendations on diagnosis and management of concussion are constantly evolving and come from multiple organizations, resulting in varying practices among providers.

The Committee on Youth and Adolescence (COYA) of New York AAP Chapter 2 sought to survey local primary care pediatricians on their attitudes and practices regarding concussion after reviewing an article by Zonfrillo et al1 in the December 2012 issue of Pediatrics.  Sampling pediatricians in the Philadelphia area, the authors found a majority of providers were referring concussion patients to specialists for reasons such as inadequate time or resources, comfort level, and setting.  They also found that providers had barriers in providing neurocognitive assessments, most notably due to inadequate time and training.

Were the issues and barriers in treating concussions in the primary care setting similar in our area?

The COYA conducted a survey of pediatricians in AAP Chapter 2 to determine whether our pediatricians would present with similar responses.  The COYA membership worked to modify and adapt the same survey used in the original article.  Partnering with AAP New York Chapter 2, we were able to disseminate our questionnaire electronically to all members on their chapter membership email list serve.

We found that most pediatricians were seeing patients with concussion and the majority of providers did feel comfortable educating families about the diagnosis of concussion and recommending the appropriate time to resume school and activities. A little over half (57.4%) of respondents were familiar with the New York State Education Department concussion guidelines.

Yet despite this familiarity with concussion, its symptoms and recommendations from the New York State Education Department (NYSED), most providers were referring some or all of their concussion patients to specialists, most commonly neurologists.  Reasons for referral included lack of comfort with management of concussion, lack of time or resources, and inappropriate setting for follow-up.  The majority of providers (87.1%) also identified completing a neurocognitive assessment as a barrier, most commonly secondary to lack of training.

Most respondents (84.3%) also answered that they would be interested in a webinar for CME credit focused on concussions.

Concussion Poster

Concussion Poster

The abstract for our study was accepted for poster presentation at the Society for Adolescent Health and Medicine 2016 Annual Meeting in Washington, D.C. in March.  Our poster also won 2nd place in the Educational Outcomes Research category at the Northwell Health 2016 Academic Awards Day at the Feinstein Institute in June.  In the future, we hope to develop a webinar for CME credit on concussion diagnosis and management for primary care pediatricians.

A link to NYSED “Guidelines for Concussion Management in the School Setting” is listed in the references below.  The guidelines state that any student suspected of having sustained a concussion must be taken out of the physical activity immediately, and cannot return to physical activities until he/she has been symptom free for a minimum of 24 hours and cleared by a medical provider to initiate a gradual return to play.

The SCAT3TM is a standardized tool that pediatricians can use in their practices to evaluate a patient who has suffered a concussion.  This tool may aid the pediatrician in determining whether an athlete is ready to begin a gradual return to physical activities.

Partnering with our local AAP Chapter was crucial to conducting this work.  Without their input, we would not have been able to send the survey to as many pediatricians and wouldn’t have adequately assessed the local practices regarding concussion management.  Further the Chapter benefitted by allowing us to identify a knowledge gap in the local pediatric community – a gap we hope to address in the creation of our webinar.  We hope this description of how we worked with the local AAP chapter will convince other academic programs to reach out to their local chapters to engage them in mutually-beneficial scholarly work.

References

  1. Zonfrillo MR, Master CL, Grady MF, Winston FK, Callahan JM, Arbogast KB. Pediatric providers’ self-reported knowledge, practices, and attitudes about concussion.  Pediatrics.  2012 Dec;130(6):1120-5. doi: 10.1542/peds.2012-1431.
  2. http://www.p12.nysed.gov/sss/schoolhealth/schoolhealthservices/ConcussionManageGuidelines.pdf
  3. http://bjsm.bmj.com/content/47/5/250/T1.expansion.html

 

Advocacy

 

Elie Ward

Elie Ward – Director of Policy and Advocacy for the New York State District of the American Academy of Pediatrics and Executive Director of Chapters 2 & 3

(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 ended this 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.) 

Your hard work of visits, calls and e-mails to our state leaders did make life better for children and families across New York State this year.

Two major wins that will have a positive impact on the lives of millions of children across the state are:

  1.  Increase in Minimum Wage
    This year, working in coalition with many organizations across the state, we can claim victory on passing one of the largest increases in the Minimum Wage in the country.  Increasing the Minimum Wage is the most direct and effective way to address child poverty.  Here in New York State we took a giant step this year with minimum wage moving to $15 downstate and incrementally from $12.50 to $15 dollars upstate as the economy allows.  This legislated increase will do more the address child poverty across our state than any other option available to our state government.  Our voices, which focused on the direct positive impact on children across the state, made a difference in this campaign.
  2. Paid Family Leave
    Again, working in a large coalition, we were able to get a generous and real Paid Family Leave program passed in NYS.  Families will now be able to take care of family needs at challenging times, birth, adoption, serious illness, and not worry about losing their jobs or losing all of their income.  Paid Family Leave is a crucial family support service that is important to all families as they struggle with balancing the complex needs of financial support for families to keep stable and the emotional social needs of taking care and building strong bonds to keep families together.  Paid Family Leave is a pro-family initiative that has finally come to NYS. Again, our voices, which focused on the impact on early brain and child development and early bonding strengthened the arguments in favor of Paid Family Leave.

Other legislative victories include passage of:

Insurance Coverage of Donor Breast Milk for high risk premature babies weighing less than 3.5 lbs, whose Moms for various reasons cannot breastfeed, or supply their own milk.

Minor’s Consent to HPV Immunization addresses conflict between Minor’s Consent Law and Immunization Law.  Passage of this legislation bridges the conflict and allows Minors to Consent to their own HPV immunizations.

Crib Safety and Safe Sleep This legislation requires the State Department of Health and the State Department of Consumer Affairs to clearly inform parents about the dangers of drop side cribs, recalls of unsafe cribs and provide information about safe sleep options for newborns and infants.  Implementation of the legislation will create more voices talking to parents about the importance of safe sleep, amplifying pediatric counseling at well baby visits.

We also were able to secure Executive Orders to Raise the Age of Criminality in NYS to 18 and to deny any coverage for Conversion Therapy in NYS.   Although we are appreciative of the Executive Orders on these two issues, we will continue to advocate for legislation, so the protections afforded cannot be challenged.

In addition, although we did not get our legislative fix for the Maternal Depression Screening payment challenge, we are being advised that the Department of Health will be coming out with a regulatory fix that will allow pediatricians to bill the screening to the child.   It is anticipated that we will see this fix before Labor Day.

Key Legislative Initiatives That Did Not Become Law This Year Include:

  • E-Cigarettes Added to the Indoor Clean Air Act
  • Child Safe Products Act
  • Gun Safe Storage
  • Collective Bargaining Rights for Physicians

But we will be back next year and will fight again for budget and legislative protections for the children and families of New York.   As you all know, advocacy is a long term process, what we don’t get one year, we can and will get the next year or the year after that.

Our goal, to improve the health and well being of all the children in New York motivates us to be consistent and strong in raising our voices for children.  When we win we celebrate.  When we lose, we take a breath and then plan how to come back and win.  That’s Advocacy!!!


International Medicine

Sam Bangug MD FAAP

     The American Academy of Pediatrics’ Motto is “Dedicated to the Health of ALL Children,” — not just those in the United States.  Locally, our international health committee works to help represent global childhood health issues across Long Island.  Working with multiple Filipino organizations and partially sponsored by New York Chapter 2 of the American Academy of Pediatrics, Dr. Sam Bangug MD FAAP organized and participated last spring in a 3-day international medical mission in his home country of the Phillipines. 

     Here he recounts his experiences leading a team of physicians in a provincial hospital in Isabela a province located 200 miles north of Manila, and a place where the majority of patients live below the poverty line. 

The Philippine Islands are well known for their natural beauty and friendly people.  However, despite hosting the fastest growing economy in Asia, access to healthcare can be difficult in more remote regions of the country.

Drawing on resources from the Association of Philippine Physicians of New York, the local chapter of the American Academy of Pediatrics, the Isabela National High School Alumni International group as well as other ethic organizations — Dr. Jose Quiwa and I organized our third annual medical mission to Ilagan Isabela, a province with high rates of poverty and poor access to healthcare.

This is where I was born and how I “give back” to those in my home country.

The medical mission catered to all dental, medical, and surgical needs, including free cataract surgeries. Dr. Jose Quiwa, Secretary of the Queens Pediatric Society and another AAP NY Chapter 2 member led the pediatric contingent.  Other volunteers include internal medicine physicians and ophthalmologists, four nurses and 25 volunteers.  We were also assisted by both local doctors and dentists and a pharmacist.

As a pediatrician, it was especially fulfilling to care for the children and to provide services which families had often been waiting months for.  Over the three days, a total of 2,200 patients were seen, 782 were pediatric.  Common medical problems encountered included anemia, malnutrition, pneumonia, diarrheal disease and dental carries.  Our surgeons repaired several hernias and operated on a patient with a thyroglossal duct cyst.

Patients wait to see a physician the Filipino clinic.

Patients wait to see a physician the Filipino clinic.

Among the many patients was a 9 month old named Mark with hydrocephalus whose family had been waiting for over three months to get an appointment at the Children’s Hospital in Manila.  One of the mission physicians, a retired neurosurgeon from California was able to schedule surgery for the patient a week after he presented to the mission clinical staff. By the time volunteers returned to New York, we heard Mark’s surgery was a complete success.

Despite the issues we often face navigating the medical bureaucracy for our patient here, there are so many aspects of care we take for granted.   Here, however, these practical issues add multiple layers of complexity which make providing care difficult.  A patient with a hernia was initially unable to receive surgery because expense anesthetic medications must be paid for in advance and his family could not afford it.  Our organization, partially funded by the NY Chapter 2, was able to underwrite the expense so the boy could be operated on while the surgeon was in the region, less he had to wait another year for his repair.

Another woman whose infant had diarrheal illness held her child’s intravenous (IV) fluid bottle in her hands for her baby’s entire hospitalization because the hospital ran out of IV poles.

New York AAP Chapter 2 members, Dr. Jose Quiwa MD FAAP (R) and Dr. Sam Bangug MD FAAP (L)

New York AAP Chapter 2 members, Dr. Jose Quiwa MD FAAP (R) and Dr. Sam Bangug MD FAAP (L)

The number of patients seen and the timeliness of care given made the mission successful.  It could not have been achieved without the support of the generous donors and volunteers who selflessly provided their time and services. Queens based Physicians and American Academy of Pediatrics Chapter 2 International Committee Co Chairs Drs G. Sabogal and S. Patel help approach the Chapter about use of funds to support the mission and AAP Chapter 2 President Dr. J Abularrage authorized funding for the project as part of Chapter’s mission to uplift the health and conditions of ALL children.

Plans are underway for a fourth mission in February of 2017 and volunteers are currently being actively sought.


Decreased Government Support for Children’s Research Short Changes Kids

Shetal Shah, MD, FAAP

Shetal Shah, MD, FAAP

FINDING CURES FOR THE INCURABLE: Decreased Government Support for Children’s Research Short Changes Kids

(A version of this post originally ran as an Opinion-Editorial piece the Buffalo News on May 29, 2016 and can be found at: http://www.buffalonews.com/opinion/viewpoints/nation-must-invest-in-scientific-research-to-cure-the-incurable-20160529)

Tomorrow’s cures will be realized only if we prioritize them today.  Science is our best weapon against both emerging infectious, such as Zika virus, and chronic diseases like type 2 diabetes.  Well-established environmental dangers such as lead poisoning pose a disproportionately large risk to children despite clear evidence of harm and cogent, but ignored, mitigation plans.  The notion that a ounce of prevention equals more than of pound of cure has never been more applicable and underscores the imperative to accelerate research that helps doctors prevent disease or treat the sick or injured.

The Society for Pediatric Research and the American Academy of Pediatrics highlighted Seven Great Achievements in Pediatric Research last year.  These breakthroughs include curing children from cancers previously considered terminal, saving the vast majority of the almost 1 in 9 babies born prematurely, and virtually eliminating HIV/AIDS transmission from mothers to infants.  Immunization prevents approximately 43,000 early deaths in vaccinated U.S. children vaccinated.  These achievements are the result of a long-standing, federal commitment to scientific funding to benefit children.  The National Institutes of Health (NIH) budget increased steadily for over 32 years to support this work, annually increasing by 2.9%, and actually doubled between 1996 and 2004 – a time period spanning both Republican and Democratic presidencies.

Since then, funding has remained stagnant, while inflation costs for research have not, reducing the amount of scientific research that can be done.  According to testimony provided by NIH Director Francis Collins, NIH has lost 22% of its purchasing power since 2003.  The result is the worst climate for federally funded research in a generation. Researchers have had to cut back, close their laboratories, or find other employment opportunities, delaying the development of treatments and cures that could help people worldwide.

Young investigators have been especially affected by these financial constraints.  When NIH grant applications are considered, established investigators – whose prior experience with grants and solid track-record of publications – have an advantage in obtaining renewals of existing grant funds.  Young investigators who are beginning their careers must compete for an ever-limited number of NEW grant funds.  This creates a disincentive for bright, enthusiastic, talented scientists to pursue a career in medical research.  In a statement published by the Associated Press, Dr. Collins, commenting on young investigators, said they find themselves in the worst financial environment in half a century.

According to the American Academy of Pediatrics, the percentage of NIH principal investigators 36 and younger was approximately 3% in 2010, down from 18% in 1982 (reference? There are primary sources for this claim).  Not surprisingly, the number of established investigators over the age of 66 has increased steadily over the same time span.  Over the next decade the United States is at risk of relinquishing its preeminent position as the world leader in biomedical research.

Congress is finally returning to the idea that when it comes to science, you get what you pay for.  Last year, it provided its largest budget increase to the NIH in twelve years, raising the funding level by $2 Billion, but not enough to cover the cost of the inflation over the past several years. In particular, dramatic constraints in NIH funding  short changes children, who make up 20% of the population but to whom far less than 20% of the funding is directed.  To create cures for today’s lethal diseases, a sustained, long-term commitment to science is imperative.  This commitment must be immune to partisan whims, the talons of budget hawks and the election cycle.

While biomedical research has always enjoyed bipartisan support, the support is particularly strong now as many in Washington, Republican, Democrat and Independent alike, agree that NIH funding levels must continue to increase. This year, the research advocacy community is asking Congress to raise the NIH funding level to $34.5 Billion for the next fiscal year

Congress will soon vote on a budget which contains this $34.5 Billion funding level.  We hope this will resume a long tradition of research support.  Now more than ever, we need to invest in tomorrow’s cures.  Lets replace fear with hope!

Dr. Shetal Shah, MD FAAP is Secretary and Legislative Chairman of New York State (District II), Chapter 2 (Long Island) of the American Academy of Pediatrics.  The views represented are his own.  Follow him on Twitter @NICUBatman


Legislative Conference

We Care for Kids and We Vote

Last month, pediatricians rallied on Capitol Hill in Washington D.C as part of the 25th Annual American Academy of Pediatrics Legislative Conference.  The meeting focused on ensuring support of the Child Nutrition Integrity and Access Act, which would reauthorize funding for critical children’s nutrition programs such as summer feeding programs, school lunches and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

Three members from New York AAP Chapter II representing Brooklyn, Suffolk and Nassau were supported by the chapter to attend the conference, learn critical advocacy skills and meet with our federal representatives to remind them of the importance of these programs for children in our region.

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(From R to L: NYS AAP members Drs. Yishan Cheng, Gopi Desai and Sara Kopple, with Jamie Poslosky of the AAP)

The Senate Agricultural Committee recently unanimously passed the Child Nutrition Integrity and Access Act of 2016, which renews funding for the following child nutrition programs:

  1. The AAP is particularly interested in maintaining adjunctive eligibility, which automatically qualifies families for WIC if they receive Medicaid. Currently ~75% of WIC patients are enrolled through this route. The AAP also supports extending eligibility through age 6yrs for those not yet enrolled in kindergarten to prevent a nutritional gap in kids not yet in school and benefitting from school nutrition programs.
  1. School based meals. The current legislation reflects a compromise reached in the Senate on scientifically-based nutrition standards for school meals, which 98% of school s are meeting. Opponents argue that if the nutritional standards are too high, children won’t eat the food and thus money will be wasted.  However, data from the Rudd Center for Food Policy and Obesity show children are in fact eating more fruits and vegetables since the new standards were implemented.   The AAP also would like to preserve the “Community Eligibility Provision,” which allows schools in high poverty areas to provide free breakfast and lunch to ALL students, simplifying the enrollment process and decreasing the stigma of requiring school-based food services.
  1. Summer meals. Impoverished children are at greater risk for hunger during the summer months. Only about 15% of children who rely on free or reduced-price school lunch have access to meals in the summer.  The AAP supports increasing access to nutritional assistance in the summer months.

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(AAP President at NY Chapter 2 native, Dr. Benard Dreyer addresses conference attendees.)

However, the proposal is stalling before the full Senate and the House of Representatives.  As the input of pediatricians is critical to the re-authorization process, conference attendees heard from Senators Jon Tester (D-MT), Debbie Stabenow (D-MI) and Pat Roberts (R-KS) about the importance of being strong pediatric advocates.  One major theme of the conference was the need for continuous dialogue with our legislative offices.  It is critical that advocacy not begin and end with this legislative experience.  The goal is establish ourselves as the KEY CHILD HEALTH EXPERTS for our Congressional representatives.

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(Sens. D. Stabenow (D-MI) & P. Roberts (R-KS) address pediatricians at the 25th Annual Legislative Conference earlier this month.)

We then met with staff members from the offices of Senator Charles Schumer, Senator Kirsten Gillibrand, and Congresswoman Carolyn Maloney, emphasizing the importance of supporting this childhood nutrition legislation to ensure it receives a full Senate vote and to help the bill progress in the House of Representatives.

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(Drs. Yishan Cheng, Gopi Desai and Sara Kopple at Congressional Offices on Capitol Hill earlier this month)

Since the Senate has a working bill in place, it is important for all New York Pediatricians to call upon their Representatives in the House to act swiftly.  Members of the Chapter’s advocacy committee have met with several key representatives in our AAP Chapter on this issue including Reps. Gregory Meeks, Grace Meng, Lee Zeldin, Steve Israel, Pete King and Kathleen Rice.

Dr. Mona Hanna-Attisha, who gained national attention as the chief pediatric advocate for children affected by lead-contaminated water in Flint, MI also attended the conference as a luncheon keynote speaker, inspiring us to speak up and act on behalf of children. She emphasized the need for ongoing support for families affected by the Flint tragedy to ensure comprehensive long term care for affected children.

Her lesson to us all: You are the expert on kids. You are not alone in advocacy. Be prepared.

We also attended several advocacy skill-building workshops, including Speak up for Kids at the Ballot Box: Advocating for Children in an Election Year. There we learned about the importance of encouraging everyone to vote in this very important election. Some ideas everyone can take home are:

  1. Start planning now – Make sure you and your friends are registered to vote. If you’re not sure, this is a great website to check your status: https://voterlookup.elections.state.ny.us/
  1. If you’re not registered, check your state’s registration policies so that you don’t miss any deadlines. This is the information for New York: http://www.elections.ny.gov/VotingRegister.html
  1. Ensure you have time off from work to vote. If you’re a resident, work with your program director to find coverage so that everyone who can and wants to vote is able.
  1. Encourage those in your community to vote! You can set up a voter registration table in your clinic waiting room and encourage parents to vote; you can do the same at a local health fair as well.
  1. Use social media to encourage friends and colleagues to vote too!

The National American Academy of Pediatrics will be using its social media resources to encourage pediatricians to vote this year.  The Chapter will be amplifying this message via its social media, internet and email resources.  On Election Day, the Academy will encourage pediatricians to post photos of themselves voting to Twitter.


 

Yoga and Meditation in Pediatric Practice

Ron Marino, DO, MPH, FAAP

Ron Marino, DO, MPH, FAAP

THE POTENTIAL ROLE OF YOGA AND MEDITATION IN PEDIATRIC PRACTICE

Over the past several years, there has been increased attention to issues of physician burnout and a need from physicians to provide non-pharmacologic tools to help patients deal with emotional and physical issues.  New York Chapter 2 of the American Academy of Pediatrics is dedicated to both these principles and supports a group of pediatricians who actively promote Yoga and Meditative Practice.  Dr. Ron Marino has lectured at national meetings about the importance of Yoga as a tool for both pediatric practice and physician health.  He shares his knowledge with “INSIGHTS INTO CHILD HEALTH.”

Question: Why should your AAP Chapter publish an article about yoga?

Answer: Because pediatricians are concerned with enhancing health and well-being and the practice of yoga is a route to this and for both patients and practitioners.  When most people hear the word yoga they think of individuals in unobtainable postures which require superhuman strength and flexibility.  This is NOT yoga!  This is one component of yoga practice.

An individual’s yoga practice may focus more on the subtle meditative aspects, the philosophical aspects, or the physical aspects.  This diversity of approaches and practice makes studying the health benefits in a traditional Western scientific way very challenging.  However there are many studies concerning mindfulness meditation and a growing body of literature about yoga as well.

Question: What are some of the medical benefits of practicing yoga that have been studied?

Answer: More studies are being published which look at both the clinical and physiologic implications of yoga and other meditative practices.  How yoga works is still being explored, but evidence is mounting that yoga practice:

  • Upregulates parasympathetic tone
  • Decreases inflammatory mediators
  • Increases immunoglobulin production
  • Enhances telomere strength

Neuro-anatomically, MRI studies suggest yoga increases pre-frontal cortex and posterior cingulate activity and is associated with a decrease in size of the amygdala.

Question: What about clinical applications in clinical practice?

Each day, general pediatricians are being asked to provide more mental health care.  While our continuing medical education has rightly focused on learning how to manage common medicines used for these conditions.  I think Yoga and Meditative Practice can have a role.  Studies regarding the clinical application of yoga for patients have been useful for:

  • Anxiety, Aggression and Pain
  • Substance abuse
  • Asthma and Irritable Bowel Syndrome
  • Depression
  • Insomnia

Question: Can Yoga help physicians dealing with issues of burnout?

Yes.  As physicians we are experiencing changing dynamics within the profession.  Daily we experience stress from a loss of autonomy, income and even societal respect.  These factors contribute to an increased burnout and feelings of depression by healthcare providers.  While there are many ways to modify burnout and support physician well-being, consistent yoga practice may help.  Physicians might consider yoga for themselves to take advantage of the health benefits.  But like any other activity yoga must be practiced consistently and mindfully.

Question: Yoga can seem intimidating, what advice do you have for someone interested, but wary?

Finding a teacher is a good place to start.  Given the remarkable diversity of offerings one may need to explore several yoga Studios and/or teachers prior to settling into a practice that’s a good fit for you. The Yoga Alliance is a certifying body that credentials teachers.  However as with many therapeutic arts, the credential may or may not yield the best experience for you.  As with therapists or personal trainers, word of mouth is also a great way to connect to a teacher.

Yoga, like medicine, is a lifetime practice.  Mindful consistent activity may yield physical and mental benefits and, in my opinion, the risk, when practiced mindfully, are worth the benefit.

(Dr. Ron Marino, DO, MPH, FAAP is a pediatrician and Associate Chairman and Director of General Pediatrics at Winthrop-University 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.)


HPV Won’t Stop Me

AAP ANNOUCEMENT BLOG POST:

As an officer in your local chapter of the American Academy of Pediatrics, I often get asked the question, “What’s the Local AAP doing about X?”  Your local AAP Chapter, New York Chapter 2 (Long Island, Queen and Brooklyn) is among the most active, dynamic and engaged chapters in the 60,000+ membership of the AAP, and our primary goal is to ADD VALUE to your practice and chapter membership.  Under the leadership of current AAP chapter president, Dr. J. Abularrage, your chapter was the FIRST EVER to convene a strategic planning meeting.  The goal of the meeting was to give EVERY member of the local AAP chapter input into how to direct our efforts.

  1. One theme of the strategic planning meeting was the need to work harder to promote Human Papillomavirus Virus (HPV) vaccination.  Nationally, the Centers for Disease Control report that rates of HPV vaccination are approximately 40% and 20% among adolescent females and males respectively – a rate which lags far behind the acceptance of other vaccinations (1).  Local pediatricians, just like our colleagues across the country, are having difficulty successfully promoting the benefits of HPV vaccination against the pushback and negative reactions from both parents and patients.  Reasons for vaccine refusal include parental unwillingness to accept or discuss their child’s sexual behavior, and the myth — debunked in 2012 and again in 2014 articles in Pediatrics — that receiving HPV vaccine will somehow lead to riskier sexual behavior (2, 3).  Local pediatricians are concerned that without sufficient HPV awareness, widespread HPV vaccination will not fulfill its potential in protecting our area’s children against HPV associated cancers and disease.  As January is National Cervical Cancer Awareness Month and February is National Cancer Prevention Month, we are using this post to update you on AAP efforts to promote HPV immunization.

“So what’s the AAP doing about HPV vaccination rates?”

At the National Level, the AAP has many resources available to help integrate and promote HPV awareness and immunization into your practice.  These include toolkits for your practice (https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Pages/HPV-Champion-Toolkit.aspx), Payer Advocacy materials (https://www.aap.org/en-us/Documents/payeradvocacy_hpv_recs_2015.pdf) and printable resources to help improve (and even get MOC Part IV Credit) for your HPV vaccination efforts.  For those practices with a large social medial presence, there are AAP-sponsored Facebook Messages (https://www.aap.org/en-us/Documents/hpvtoolkit_professionalFB_hpv_2015_August_2015.pdf).

However, all these efforts aim to increase vaccination rates via parental or physician outreach. As we all know, adolescents are different and thus past approaches aimed at increasing immunization rates may not work as well since those vaccinations are administered at much younger ages. Data increasingly suggests adolescents rely on social media and text messaging for healthcare information (4).

Improving education efforts around the impact of HPV has also been shown to increase a desire for teens to be immunized (5). At the local level, your AAP chapter is merging these two principles by working with adolescents and young adults to create a social media campaign aimed at increasing awareness and interest in HPV vaccination.  The hope is that if HPV immunization hesitancy stems from parents, increasing the desire for vaccination among teens will promote more conversations regarding HPV prevention and ultimately, increase local immunization rates.

To do this, we’ve partnered with Inspire Bright (http://www.inspirebright.org ), a local non-profit founded by two Syosset, Long Island sisters while still in high school.  Inspire Bright has a history of working with adolescents on relevant issues in our chapter area.  The group raised funds to purchase high school musical instruments for schools affected by Super Storm Sandy and is currently donating SAT review books to under-privileged teens in New York City.

So how do we motivate adolescents to get vaccinated against HPV?

Your AAP Chapter and Inspire Bright have created a social media campaign designed to appeal specifically to adolescents and college-age children.  Health information regarding HPV vaccination will be widely disseminated on Twitter, Facebook and Instagram.  Messages promoting cervical cancer prevention were crafted to specifically appeal to 16-21 year olds and we will be monitoring the impact of the social media’s campaign.   To appeal to this age group, we built upon the successful AAP “I ADVOCATE FOR KIDS BECAUSE . . .” campaign, which generated significant interest across many forms of social media.  Inspire Bright created placards with the phrase, “HPV WON’T STOP ME.”  Together, we brainstormed 12 key messages which will appeal to kids, who can take a picture of themselves with a chose sign and broadcast the message via Facebook, Instagram, and Twitter.

We ask chapter members to participate in the campaign by making these placards available in your waiting room.  If you are on social media, please promote our key messages to your followers. Stay tuned for updates.

REFERENCES:

  1. National, regional, state and selected local area vaccination coverage among adolescents aged 13–17 years—United States, 2014. MMWR Morb Mortal Wkly Rep 2015 / 64(29);784-792
  2. BednarczykRA, Curran EA, Orenstein WA, Omer SB. Sexual activity-related outcomes after human papillomavirus vaccination of 11-to 12-year olds. Pediatrics 2012;130(5):798-805.
  3. Mayhew A, Mullins TL, Ding L, Rosenthal SL, Zimet GD, Morrow C,Kahn  Risk perceptions and subsequent sexual behaviors after HPV vaccination in adolescents. Pediatrics. 2014;133(3):404-11.
  4. O’Keeffe GS, Clarke-PearsonK; Council on Communications and Media. The impact of social media on children, adolescents, and families.  2011;127(4):800-4
  5. Kessels SJ, Marshall HS, Watson M, Braunack-Mayer AJ, Reuzel R, Tooher RL. Factors associated with HPV vaccine uptake in teenage girls: a systematic review. 2012 May 21;30(24):3546-56.