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Heather Brumberg, MD, MPH, FAAP

Shetal Shah, MD, FAAP

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

(Dr. Shetal Shah, MD, FAAP is a neonatologist at Maria Fareri Children’s Hospital.  He is NYS AAP Chapter 2 Vice President and Chair of the Legislative Committee.  Dr. Heather Brumberg, MD, MPH, FAAP is Director of Regional Neonatal Public Health Programs and Medical Director of the Lower Hudson Valley Perinatal Network.  She is NYS AAP Chapter 3 President.)

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

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

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

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

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

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

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

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

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

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

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

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

Dear Editor,

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

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

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

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

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

Steven J. Goldstein, MD, FAAP

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

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

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

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

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

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

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

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

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

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

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

Mary Cataletto, MD, MMM, FAAP

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

(Dr. Mary Cataletto, MD, MMM, FAAP, FCCP is a pediatric pulmonologist and Associate Director of Pediatric Sleep Medicine at NYU Winthrop Hospital.  She is chair elect for Pediatric Chest Medicine NetWork of the American College of Chest Physicians and past chair of the Asthma Coalition of Long Island.  She is the Nassau Pediatric Society Representative to NYS AAP Chapter 2.)

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

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

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

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

Please watch for these special programs.

Mary Cataletto, MD, MMM, FAAP

(Dr. Mary Cataletto, MD, MMM, FAAP, FCCP is a pediatric pulmonologist and Associate Director of Pediatric Sleep Medicine at NYU Winthrop Hospital.  She is chair elect for Pediatric Chest Medicine NetWork of the American College of Chest Physicians and past chair of the Asthma Coalition of Long Island.  She is the Nassau Pediatric Society Representative to NYS AAP Chapter 2.)

Fourth Child in NYC Dies of Seasonal Flu: What Every Parent Needs to Know

This week as the news of the fourth pediatric death in New York City hit the press, parents are asking what they can do to protect their children.  They turn to their pediatricians to put these findings into perspective, address concerns and to offer actionable strategies to modify risk factors.

This year’s flu season has been particularly severe and is likely to last several more weeks, possibly months.  The Centers for Disease Control have consistently recommended universal immunization against influenza for children ages 6 months and above through adulthood highlighting that children under age 5 years, particularly those under age 2 years as well as pregnant women, the elderly and those with chronic medical illnesses are at increased risk for flu related complications and hospitalizations.

Governor Cuomo declared a statewide influenza public health emergency on January 25, 2018.  As a result pharmacists are temporarily permitted to administer flu vaccines to children between 2 and 17 years of age.  Promotional campaigns can be seen throughout the state on print, social and other media sources.  Free flu shots are now available at multiple locations.

We know that the best defense against the seasonal flu is influenza immunization.  Immunization should begin as soon as the vaccine is available in the Fall.  This is especially important for those children between ages 6 months through 8 years who are receiving the vaccine for the first time because they will need to receive 2 doses given at an interval of about 28 days.  Protection for infants who are too young to receive the flu shot (<6 months) is best offered by immunizing parents, older siblings and caretakers as well as avoiding sick contacts.  Immunization against seasonal flu is now considered standard of care for all health care professionals.  They receive the flu vaccine not only for themselves but to protect the children they care for in offices, hospitals and community.

There are still a few stragglers, a few non believers, a few who were too busy to have their children immunized.  As long as influenza is prevalent in your community, it is not too late to get a flu shot.

The Centers for Disease Control supports this decision with the following findings:

• The flu shot minimize the risk of contracting the flu by approximately 1/3
• Flu season is likely to last several more months and could even stretch into May
• The flu shot carries a low risk of significant side effects
• There are no effective alternatives

What else can parents can parents do to protect their children and help to limit the spread of influenza?

• Avoid contact with people who are sick
• Keep your child home if they are sick
• Practice healthy habits:
  • Cover your cough and sneezes
  • Wash your hands often
  • Avoid touching your eyed, nose and mouth
• Be sure your child’s school and daycare centers have provisions to
  • Separate sick children from the rest of the group while they are waiting to be picked up
• If you think your child may have the flu contact your pediatrician. Antivirals, such as Tamiflu, work best if given within 48 hours of symptom onset.

Additional information on flu surveillance and current recommendations for both parents and providers can be accessed at www.cdc.gov.

Leonard Krilov, MD, FAAP

Asif Noor, MD, FAAP

Influenza outbreaks are unpredictable.  This year’s flu season has hit the entire country hard.  Influenza activity spiked earlier than expected this year.  It is widespread and already associated with 37 pediatric deaths nationwide.  Over the past month newsflashes of healthy children succumbing to flu are depicting an alarming situation.  The impact is comparable to the 2009 H1N1 Pandemic in terms of its rampant spread.

As a pediatrician you play a crucial role during such an outbreak.  Not only do you treat the flu stricken children, you transform into an advocate for flu prevention through vaccination.  In this blog we address the two common issues faced by the pediatricians, i) understanding the effectiveness of this year’s flu vaccine, and ii) when to consider oseltamivir for treatment.

What are the circulating strains in New York State?  Influenza virus belongs to the orthomyxoviridae family and has two clinically significant antigenic types: influenza A and B.  Influenza A is further subtyped based on the nature of surface proteins, the hemagglutinin (HA) and neuraminidase (NA) which are spike-like projections from the surface.  Genetic mutations in the HA antigen and to a lesser extent NA antigen are responsible for the severity and epidemic potential of outbreaks.  This season the main circulating strain is influenza A H3N2 (77%), followed by H1N1 (15%), and influenza B (8%) based on testing at the New York State Department of Health, Wadsworth Center.

What strains are in the flu vaccine?  The composition of the flu vaccine is reviewed annually and updated based on the circulating influenza strains.  Influenza vaccine for this season includes: A/Michigan/45/2015 (H1N1)pdm09-like virus, A/Hong Kong/4801/2014 (H3N2)-like virus, and B/Brisbane/60/2008-like virus.  The quadrivalent vaccine containing two influenza B viruses contain the above three viruses and a B/Phuket/3073/2013-like virus.

How is the effectiveness of flu vaccine measured?  The effectiveness of the flu vaccine depends upon the match between the vaccine strain and the circulating strain.  The estimate is, however, calculated by the number of cases prevented by the flu vaccine.  This year the circulating H3N2 strain is similar to last year’s strain and is included in the vaccine.  The reason H3N2 strain is still the predominant virus responsible for the flu outbreak is due to its ability to undergo constant mutations of the genetic material, known as antigenic drift.  It can change from one season to another and even during the same season.  This phenomenon is particularly true if the predominant strain is H3N2 and if the vaccine production is egg-based (less stable vaccine).  The vaccine effectiveness studies since 2009 have shown that when the vaccine and circulating virus are well matched the flu vaccine provides better protection against influenza B and influenza A H1N1 as compared to H3N2. Thus the severe and widespread nature of flu activity this year is likely a result of the predominant H3N2 strain which underwent drifting.

What is the estimated effectiveness of flu vaccine this year?  The vaccine effectiveness studies from 2005-2017 showed that if the vaccine and circulating H3N2 are not well matched the vaccine effectiveness is close to 23%.  Before this flu reached the Northern hemisphere, Australia had a bad flu season, in which the predominant strain was H3N2 and the vaccine effectiveness was only 10%.  It is still too early in the season to provide estimated vaccine effectiveness in United States.  The Centers of Disease Control and Prevention conducts observational studies at 5 outpatient sites across the country to measure the vaccine effectiveness.  The effectiveness implies ability of the flu vaccine to prevent infection.  It is calculated as the odds of vaccination among outpatients with influenza-like illness and laboratory confirmed influenza infection to the odds of vaccination in outpatients with influenza-like illness but are negative influenza test.

If the vaccine is not a good match to the predominant H3N2 circulating strain, should one continue to advocate for vaccination?  Yes, the match is not ideal for this year, but the antibody production from the vaccine strain will continue to provide some degree of protection against the circulating strain.  This protection might not prevent the occurrence of infection but the vaccine will reduce the probability of a further severe infection, hospitalization, and even death.

When should one prescribe antivirals?  The two classes of antivirals approved for treatment of influenza are neuraminidase inhibitors which includes oseltamivir (oral) and zanamivir (inhalation) and the adamantanes (amantadine and rimantadine; high resistance is seen).  Oseltamivir remains the treatment of choice.  It is approved for neonates as young as 2 weeks of age.  Oseltamivir’s resistance to the circulating viruses over the past few years is around 1%.  One of the limiting factors of its use in children is the associated nausea and vomiting.  The recommendations for treatment are limited to:

1. Any child who is admitted to the hospital due to severe, complicated, or progressive respiratory disease irrespective of immunization status and duration of illness ≥48 hours.
2. Outpatient therapy should be offered to any child at risk of complications such as children less than 2 years or underlying medical problems. Treatment should be offered to symptomatic siblings less than 6 months of age.  In addition it can be used for term and preterm infants after birth based on limited pharmacokinetics and safety data.  Best outcome is seen with early treatment started within the first 48 hours.
3. Premavir is an intravenous formulation for treatment of influenza reserved for severe cases when oral oseltamivir cannot be used.

In this hard hit flu season, some of the other important recommendations regarding flu vaccinations are as below:

1. The inactivated flu vaccine is recommended for children ≥6 months and older. Both trivalent and quadrivalent preparations are available.  The live nasal influenza vaccine is not recommended for this 2017-18 season due to lack of effectiveness.
2. One should continue to offer influenza vaccination while flu activity is present in the community.
3. The only contraindication to vaccination is a severe anaphylaxis to a prior influenza vaccination. A history of mild (hives) or severe hypersensitivity (anaphylaxis) to eggs is not a contraindication.  If there is a history of severe egg allergy then the vaccine should be administered by a healthcare worker who is able to recognize and treat anaphylaxis reactions.
4. Prophylaxis with oseltamivir should be recommended to close contacts that are at higher risk of developing influenza complication. Prophylaxis is not recommended in infants less than 3 months of age unless the situation is judged as critical.
5. A cell grown vaccine by the name of Flucelvax is available for children 4 years of age and above. It might provide better protection against H3N2 but the main benefit is flexibility in manufacturing.

In this particularly difficult flu season, one should continue to be an advocate for the flu vaccine to lessen the severity and extent of the outbreak.

(Dr. Leonard Krilov, MD, FAAP is Chairman of Pediatrics and Chief of the Division of Pediatric Infectious Disease at NYU Winthrop Hospital.  He is the Co-chair of the Infectious Disease Committee of the NYS AAP Chapter 2.  Dr. Asif Noor, MD, FAAP is Pediatric Infectious Disease Attending at NYU Winthrop Hospital and member of NYS AAP Chapter 2)

Robert Lee, DO, FAAP

(Dr. Robert Lee, DO, MS, FAAP is a pediatrician and Associate Pediatric Residency Program Director at NYU Winthrop Hospital.  He is NYS AAP Chapter 2 Secretary and Co-Chair of the Foster/Kinship Care Committee.  He is a member of the Middle Childhood Expert Panel for the Bright Futures Guidelines, 4^th Edition.)

What is Bright Futures?

Bright Futures

Bright Futures is a set of principles, strategies, and tools that are theory based, evidence driven, and systems oriented that can be used to improve the health and well-being of all children through culturally appropriate interventions that address their current and emerging health promotion needs at the family, clinical practice, community, health system, and policy levels.

Bright Futures is a national health promotion and prevention initiative, led by the AAP and supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau.  The book, Bright Futures Guidelines, 4th Edition, is the core of the Bright Futures tools for practice and provides theory-based and evidence-driven guidance for all preventive care screenings and health supervsion visits.  The Bright Futures Tool and Resource Kit that accompanies the book is designed to assist pediatricians in planning and carrying out health supervision visits.  It contains numerous charts, forms, screening instruments, and other tools that increase practice efficiency and efficacy.  According to Joseph Hagan, MD, FAAP (Bright Futures Co-Editor), “The Periodicity Schedule tells us what should be done in a well visit, I believe Bright Futures tells us how to do it well.”

What’s New in the Fourth Edition?

The Fourth Edition builds upon previous editions with thoroughly revised and updated content that reflects the latest research.  Because of the science of early brain development,  adverse childhood events (ACEs) and toxic stress, environmental and social determinants of health, the AAP has adopted an eco-bio-developmental model of human health and diseases (Figure).  Bright Futures incorporates this new science into the development of a new health promotion theme: Promoting Lifelong Health for Families and Communities.  It provides a current review of the science of development and insight for how this science might be applied in our practices and clinics.  For most visits, pediatricians are encouraged to ask about topics such as food insecurity, domestic violence, substance use, housing situations and other issues that may affect a family’s health.  In addition, there are major updates to several adolescent screenings including: cervical dysplasia; depression; dyslipidemia; hearing; vision; tobacco, alcohol, and drug use.

How is New York State using Bright Futures?

The New York State Department of Health (DOH) is leading the implementation of Bright Futures.  DOH has worked with many state partners to ensure that Bright Futures Guideline is the primary resource for preventive services and health care supervision.  DOH began by working with NYS Medicaid office to infuse Bright Futures into the Medicaid provider handbook.  Specifically, the handbook includes the Periodicity Schedule, which DOH updates to match any changes made by the AAP.  Next, DOH shared the Bright Futures Guidelines with other state agencies, demonstrating their relevance to the agencies’ work and generally increasing awareness of Bright Futures.  DOH also shared the Bright Futures Guidelines with the Office of Mental Health for use with children and youth with emotional health issues.  The use of Bright Futures across these agencies allows state programs to communicate using a common language.

The NYS AAP Chapter 2 and 3 Pediatric Council have worked with individual insurance providers to explain the importance of Bright Futures recommended services, such as developmental screening, in sustaining child health and to ensure providers receive insurance payments for services recommended by Bright Futures.

 How can Pediatricians implement Bright Futures into their Practices?

Many pediatricians have asked whether it is really possible to implement the recommendations in Bright Futures Guidelines in daily clinical practice.  The answer is Yes!  Carrying out Bright Futures means making full use of all the Bright Futures materials. For pediatricians who wish to improve their skills, Bright Futures has developed a range of resources and materials that complement the Bright Future Guidelines.  The Bright Futures Tool and Resource Kit allows pediatricians who wish to improve their practice or services to efficiently and comprehensively carry out new practices and practice change strategies.  The Bright Futures tools also are compatible with suggested templates for the electronic health record (EHR).

• Bright Futures Previsit Questionnaire, which a parent or patient completes before the pediatrician begins the visit. When the questionnaire is completed, the family’s agenda, and many of the child’s strengths, screening requirements, and intervention needs, is highlighted.
• Screening tools, such as standardized developmental assessment tests and screening questionnaires that allow pediatricians to screen children and youth for certain conditions at specific visits.
• Bright Futures Visit Chart Documentation Form, which corresponds to the Bright Futures Guidelines tasks for that visit and the information that is gleaned from the parent questionnaire. It reduces repetitive charting and frees the pediatrician for more face-to-face time with the child or youth.
• Bright Futures Preventive Services Prompting Sheet, which affords an at-a-glance compilation of work that is done over multiple visits to ensure completeness and increase efficiency.
• Parent/Child Anticipatory Guidance Materials, which reinforce and supplement the information discussed at the visit.

For more information about how to implement Bright Futures recommendations click here.

Marcy Safyer, PhD, LCSW-R, IMH-E

What is Infant Mental Health and Why is it Important?

The term Infant Mental Health (IMH) is a slight misnomer and also includes Early Childhood Mental Health.  IMH can be understood as the developing capacity of a 0-5 year old child to experience, regulate and express emotions, form close and secure interpersonal relationships and explore the environment and learn within the psychological balance of the parent-infant relational system, as well as larger family, community and culture without serious disruption caused by harmful life events (National Zero to Three, 2004).

Recent neuropsychological research has shown that infants are born with their brains wired to be engaged in important nurturing and protective relationships.  They come into the world with remarkable capacities to establish and regulate these relationships.  Infants are surprisingly competent and endowed with predispositions toward attachment promoting behaviors.  They are not the “blank slates” they were once thought to be.  Infants possess an amazing repertoire of social and emotional capacities that are designed to give their parent information about their well-being and to actively behave in ways that modify and regulate the behavior of their parents.  The infant’s capacities to execute these signaling behaviors have roots across developmental domains.  In turn, infants seek emotional responsiveness from their parents and become distressed when it is not forthcoming.

Although the infant’s contribution to the relationship with his parent is great, it cannot be separated from the context of the parent.  The infant-parent relationship will suffer when infants fail to display behaviors or characteristics which elicit responsive caregiving as can be the case with babies who are premature, drug-exposed, or have developmental challenges.  Sometimes it is parents who cannot modify their expectations because their early life was characterized by unmet needs, abandonment and maltreatment, or because current stressors like maternal depression, mental illness or domestic violence are present.

Infant Mental Health-Developmental Practice (IMH-DP) is an interdisciplinary field that represents a dramatic shift in clinical practice.  IMH-DP focuses on the development of 0-5 year olds within the context of the early parent-child relationship as the foundation for healthy social-emotional, cognitive, language and even physical development.  IMH-DP offers ways of conceptualizing early disruptions in the attachment process, and of organizing interventions.  Its focus is on the mental health and relational dimensions of development that unfold in the context of other related domains of development, all of which are intimately and inextricably interlaced in infancy.  Thus the thrust of IMH-DP must be both developmentally and trauma informed.

At the Adelphi University Institute for Parenting and within the IMH-DP Master’s Degree program, multidisciplinary IMH specialists work within the context of the parent-child relationship to strengthen parental capacity while promoting both an understanding of the needs of young children and their parents’ unique ability to meet those needs.  In addition, IMH specialists work in a range of settings with care providers, preschool teachers and pediatricians, to name a few, as consultants to help address young children’s needs from a relationship-based perspective.  The dimensions of service aim to meet the needs of families on multiple levels and in many settings and include a service continuum that includes both prevention and intervention.  This comprehensive and intensive approach integrates a range of methods and services that include: developmental and trauma screening for children; depression, anxiety and trauma screening for parents; emotional support; developmental/parent guidance; early parent-child relationship assessments; dyadic (parent-child) psychotherapy; advocacy; and concrete assistance.  The Institute applies theoretically sound evidence-based approaches to clinical practice to support and enhance relationships between parents and their 0-5 year olds.  We aim to address early identification and assessment of children at-risk for developmental and mental health problems, strengthen attachment quality between young children and their parents and improve developmental trajectories through specialized dyadic services for at-risk populations of 0-5 year olds and their parents.

Pediatricians play a key role in the identification of high-risk children and families, provision of developmental guidance, referral of families to intervention resources and serving as a consistent touchpoint in the continuity of care.  The non-stigmatizing, health-oriented perspective of pediatrics makes pediatricians a safe and supportive port-of-entry for difficult-to-engage families facing the challenge of identification and referral.  Pediatricians can serve as critical links between the medical community, the mental health and developmental service systems and early care and education programs to promote integration of service delivery.

The Institute for Parenting at Adelphi University and its graduate program in IMH-DP can serve pediatricians as a resource for early identification, direct treatment services, mental health consultation to early care and education, coordinating child-serving resources in the community and a source of awareness information and expertise about infant mental health and developmental practice.

You can refer families with 0-5 year old children for services through the Institute of Parenting, if you are concerned that a child is has behavioral or developmental challenges, a family history of trauma or current traumatic events (i.e., child maltreatment, intimate partner violence, ongoing medical concerns/frequent hospitalizations, changes in family structure, loss of a close family member, or parental mental health and substance abuse issues), a parent suffering from Postpartum Mood and Anxiety Disorders (PMADs), or an impaired parent-child attachment relationship. Services are available to both English speaking and Spanish speaking families.  Referrals can be made by contacting Stacy Kurtz, PsyD at (516) 877-3911 or skurtz@adelphi.edu.

Dr. Marcy Safyer, PhD, LCSW-R, IMH-E^® IV-C is Director of Institute for Parenting at Adelphi University and Co-Director of Adelphi University Infant Mental and Developmental Practice (IMH-DP) Training Program.  She is the President of the New York State Association for Infant Mental Health.  She is a member of the NYS AAP Chapter 2 Foster/Kinship Care Committee.

Elizabeth Isakson, MD, FAAP

Help Me Grow- Long Island: Helping You Help Promote Developmental Health

Watching development naturally unfold, seeing parents discover the amazing feat of a growing human being, are perhaps two of those greatest joys of general pediatrics.  It is during the first five years of a child’s life that pediatricians see families and patients the most, and it is during this time that your guidance, assistance and knowledge not only identifies problems but promotes healthy development.

The path of child development is neither straight nor narrow.  Children vary widely, sometimes leap ahead or fall behind.  One challenge that gets in the way of the joy by accompanying families on their journey is the difficulty in detecting developmental problems early; then successfully linking those families to appropriate services.  For example, you suspect an issue in language development and refer the parent for early intervention services, only to find out six months later that the child didn’t make it to the evaluation, or they were evaluated and found ineligible.  It is as if we have determined that the only thing possible to promote developmental health is Early Intervention – and if a child is ineligible nothing else needs to happen.

Docs 4 Tots

Docs for Tots has been working with 6 health centers in Nassau County to ensure that they had best practice in place for developmental screening.  Working with the health centers through a quality improvement framework, together we ensured that the practices were screening with a valid tool 95%-100% of the time.  The AAP recommends universal developmental screening with a valid tool at the 9, 18, and 30 (or 24) month visits.  Screening was only the start; once valid screening was initiated, children were identified and needed to be connected to services.  Many barriers exist to connecting children to services – cultural or linguistic barriers, transient phone numbers, and residences that make follow-up difficult, parental ambivalence, etc.  Our work was with safety net health centers, serving children whose social determinants of health and experience of ongoing stress put them at an increased risk for developmental issues.  They could benefit the most for access to developmental supports and amelioration.  Screening could only go so far for these families and providers – consistent and targeted care coordination was needed.

That’s how we came to learn about Help Me Grow (HMG), a community impact model designed to identify children at risk for developmental problems that builds upon existing resources to support early detection of developmental concerns, celebrate the growth of young children, and link families to the supports and services that help children thrive from birth to age five.  Its core components include child health care provider outreach, community outreach, a centralized access point for screening and care coordination, and data collection.  Set to launch in early 2018, Help Me Grow – Long Island (HMG-LI) is a partnership that will serve all families under the age of five, providing integration and coordination among the many excellent resources on Long Island. As a pediatrician, you can get involved by:

• Learning about HMG-LI and offering it as a resource to parents
• Receiving free support to improve developmental screening in your practice
• Utilizing HMG-LI to handle referrals to a full range of available services that support development

Pediatricians play a key role in child development.  They are but one asset in a community of multiple supports for families with young children.  Help Me Grow builds a system that connects the existing resources to the existing needs.  It starts to ensure that everyone’s good intentions lead to good results.  By improving partnerships and connections between the families, the medical community, and early childhood services, we can make a lasting impact in the lives of young children.

Dr. Elizabeth Isakson, MD, FAAP is a pediatrician and public health practitioner with 15 years experience with Columbia-Presbyterian Medical Center, the National Center for Children in Poverty (NCCP), and the New York Zero-to-Three Network (NYZTT).  She is the Executive Director for Docs for Tots.

Christina Kratlian, MA

SOPT Advocacy Campaign 2017-18: Access 4 Kids

Access to healthcare and the ability to visit a physician is essential in improving and determining children’s health across the country. As the healthcare debate continues to evolve, we have seen thousands of pediatricians across the country take a stand to defend all children’s right to health care. Recognizing the crucial importance of access to quality medical care for children, the AAP’s Section on Pediatric Trainees annual advocacy campaign will focus on advocating for improved access to healthcare for all children, regardless of their medical conditions, living situation, country of origin, or preferred gender or sexual orientation.

The Access 4 Kids campaign will focus its efforts on four populations of children, including:

1. Children Living in Foster Care or Group Homes
2. Immigrant Children (defined as children who are foreign-born or children born in the United States who live with at least one parent who is foreign-born)
3. Children and Youth Identifying as Lesbian, Gay, Bisexual, Transgender, Questioning, or Queer (LGBTQ)
4. Children with Special Health Care Needs

Access 4 Kids

The Access 4 Kids campaign aims to be fluid to allow for changing legislation at the state and national level to dictate our advocacy efforts, primarily using social media to respond to current political events. However, the campaign will have a defined quarterly structure, including:

• A variety of educational resources to help trainees understand the intricacies of each specific population and how to best address their health care needs in the clinic and hospital setting.
• An interactive webinar within each quarter with a prominent physician well-versed in the health care needs of each population of children.
• A call to action at the end of each quarter to emphasize the work done across the country and to promote improved access to care at the community, state, and national level. The campaign will highlight the work already being done and new projects that have taken place on a Google map so everyone can share in the amazing advocacy efforts of their fellow trainees. Included in these efforts is a platform for residents and fellows to submit essays about their own experiences and the experiences of the patients that they care for daily.

The Access 4 Kids campaign will strive to educate and empower pediatricians-in-training to advocate on a community, state, and national level for access to quality health care for all of America’s children during this important time. The campaign urges trainees to get involved and help address inequities for some of our country’s most vulnerable children. Please reach out to the co-chairs with any questions, and then join all trainees as we open the health care door for all children!

For kids,

Rachel Lieberman, MD
Christina Kratlian, MA
Access 4 Kids Co-Chairs
SOPTAccess4Kids@gmail.com

(Christina Kratlian is a fourth year medical student at Albany Medical College.  She is the SOPT District II Medical Student District Representative and co-chair for the Access4Kids campaign.)