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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

We Care for Kids and We Vote

Last month, pediatricians rallied on Capitol Hill in Washington D.C as part of the 25^th 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.

(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.

2. 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.

3. 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.

(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.

(Sens. D. Stabenow (D-MI) & P. Roberts (R-KS) address pediatricians at the 25^th 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.

(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/

2. 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

3. 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.

4. 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.

5. 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.

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.)

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).

• HPV Champion Toolkit – AAP.org
  www.aap.org – This toolkit has the best resources available to help you educate other healthcare professionals and discuss HPV vaccination with parents.

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.

David Fagan, MD, FAAP

BULLYING: WHAT PEDIATRICIANS, CAREGIVERS AND PARENTS NEED TO KNOW

From parental vaccination and smoking cessation to mental health screenings and checking for food insecurity, general pediatricians are required to do more and more with less and less time.  This month’s INSIGHTs Into CHILD HEALTH discusses practical ways pediatricians can screen for bullying, why it is important and how to best help children who may be reluctant to discuss these issues.

Chapter 2 (Brooklyn, Queens, Nassau and Suffolk) of the New York State American Academy of Pediatrics organizes an annual Anti-Bullying Conference to inform and educate middle school children about bullying.

The fact is that because the prevalence of bullying is so high, every pediatrician (regardless of practice), teacher, parent or adult who works with children will encounter a bullied child.  Here is what we can do to identify children who have been bullied, why the stakes are so high for the child and what we can do to help them.

How do we define bullying?

“The biggest misconception in this country is that bullying is “normal” behavior.  “Kids being kids and that it really is no big deal,” – that quote is from Dr. Joseph Wright, lead author of the AAP’s 2009 Policy Statement on the Role of the Pediatrician in Youth Violence Prevention.  Bullying is unwanted, aggressive behavior among school aged children that involves a real or perceived power imbalance.  It is a form of aggression in which 1 or more children repeatedly and intentionally intimidate, harass, or physically harm a victim who is perceived as indefensible.  Bullying includes verbal bullying, social bullying, physical bullying and cyber bullying.

What are the signs of bullying?/ What are the long-term effects of bullying?  

Victims may present with school phobia, depressive and suicidal symptoms, vague somatic complaints, malingering, nightmares or disordered sleeping.  While older, popular images of bullying bring to mind a school bully beating up smaller kids for lunch money, the most commonly recorded health outcomes associated with bullying are psychosomatic.  Much less common are physical injuries.

What can pediatricians do to see if kids are being bullied?  

Asking about bullying is one of the pediatrician’s (or anyone who works with children) best ways to help bullied children.  Pediatricians should try to routinely screen children and teens for bullying during well visits.  Pay special attention to vulnerable children (those with Attention-Deficit Hyperactivity Disorder, special needs, and extreme shyness).

Elicit some information from either the parent or the patient.  Ask parents what they are most happy about or proud of in their child’s life and follow this with an open-ended inquiry into areas of trouble.  Gentle probing of a child’s school performance, school attachment, and peer relationships can provide an opportunity to discuss conflict resolution or bullying.

Some things you might ask:

• Have you been in any pushing or shoving fights? – (If the answer is yes, it is important to determine what role the child is playing: instigator, bully, bullied, or bystander.)  Focus on helping the child and the parents deal with the situation.
• What do you usually do to avoid getting into a fight?
•  Are you afraid of being hurt by any other children?
•  Do you feel bullied by other children?
•  If you see other children in fights or being bullied, what do you do?

Pediatricians should encourage parents to talk to their children about bullying even if their child isn’t being bullied, isn’t a bully or witness to bullying.

What community resources are there for pediatricians who notice someone is being bullied?

All pediatricians should know about the New York State Dignity for All Students Act (DASA) which went into effect July 2012.  DASA bans harassment and discrimination against students based on their sexual orientation, gender identity and expression, race, color, weight, national origin, ethnicity, religion or disability.  The law requires NYS school districts to adopt anti-bullying policies and mandates each district appoint a staff member per school to implement anti-bullying techniques and methods.

DASA further mandates administrators report incidents of bullying or bias-based harassment to the New York State Department of Education.  So if you have a patient who is being bullied, you should call the school and ask as the child’s pediatrician, “What is the school doing about the situation?”

Shetal Shah, MD, FAAP

ANTI-VACCINE COMMENTS HARM PUBLIC AND PRIVATE HEALTH

For pediatricians, it was déjà vu all over again.

Almost 6 months since a measles epidemic that began in California ended, sickening almost 150 – mostly un-immunized people with a disease that was eliminated in the United States over 15 years ago, three years removed from a whooping cough outbreak in Washington State and after another record year of California whooping cough cases, the public health utility of vaccines is again in the news.

As presidential hopefuls continue campaign efforts to earn our trust, it is worthwhile to remember what happened earlier this year when they shared a nationally-televised stage. Comments made by high-profile political figures about the safety and timing of vaccination again brought the issue of immunization safety to the forefront of public interest.

Then last month, an article in the Proceedings of the National Academy of Sciences (partially funded by the National Autism Association and Autism advocacy group SafeMinds) found no autistic behaviors in monkeys given vaccines. Microscopically, the brains of these animals also did not resemble those of autopsy specimens of children who had autism.

As a pediatrician who cares for sick children and works to keep healthy children healthy, doubt about vaccine safety is concerning because it nurtures misinformation about immunization, leading to potentially even more outbreaks of vaccine-preventable disease across the country.

As both a physician and a parent of two fully immunized children, I am disturbed about the hijacking of medical fact for political purposes and its interference with our partnership with parents in maintaining their child’s health.

Vaccines are safe and do not cause autism. A 2007 study published in the New England Journal of Medicine found no association between vaccines, the mercury-based preservative thimerosal contained within them and autism after testing over 40 different neuropsychiatric measures. Nine studies over more than a decade and sponsored by the Centers for Disease Control (CDC) – found no link between autism and immunization.

The Autism Self Advocacy Network states that perpetuating claims of a link between immunization and autism distracts “from real and pressing issues facing the autistic community.”

The Vaccine Schedule is safe, well tested and the only scientifically-based regimen to administer vaccines safely and effectively. The landmark 2013 Institute of Medicine report entitled, “The Childhood Immunization Schedule and Safety,” found “no evidence that the schedule is unsafe.” Any other calendar of vaccination should be considered experimental by traditional methods of scientific rigor.

Vaccines save lives. Last year the CDC, reported childhood vaccination prevents 322 million cases of disease (roughly the US population), 732,000 deaths (approximately the population of Detroit) and saved over 1.38 Trillion Dollars (roughly the Gross Domestic Product of Spain) in healthcare costs over the first few years of life. It is precisely these facts that led the Institute of Medicine to declare vaccines the “most effective and safe public health intervention to prevent serious disease and death.”

The CDC named vaccination one of the ‘Ten Great Public Health Achievements’ of the last century. The Society for Pediatric research, in partnership with 4 other leading child health organizations including our 60,000-member American Academy of Pediatrics, highlighted ‘Life saving Immunizations’ as one of the ‘7 Great Achievements of Pediatric Research.’

Vaccination prerequisites, such as requirements that children receive certain vaccines prior to school entry or that health care personnel are current with immunizations are not a political issue. These requirements are the only scientifically-tested means of attaining immunization rates which are high enough so those who are medically incapable of receiving vaccinations – such as children being treated for cancer – are also protected via herd immunity.

While the percentage of vaccinated children required to achieve herd immunity varies with each disease, the policy evidence clearly indicates that relaxing such standards, such as creating state-based “philosophical exemptions” to immunization, encourage outbreaks of vaccine-preventable disease.

Unfounded concerns over administration of “too many vaccines,” has potentially contributed to lower than target goals for vaccines against tetanus, whooping cough, 2 types of Hepatitis, several bacterial infections, infectious diarrhea, cancer-causing strains of Human Papilloma Virus and influenza – the most common vaccine-preventable disease. Low rates of vaccination coverage for these infections prevent the medical community from fulfilling the full public health promise of immunization.

Pediatricians and parents want the same things: the best care for their children and to protect them from harm. Immunizations given at the right time are one part of a national child health strategy that works best when parents’ questions about vaccination are answered by pediatric physicians and we all cooperate in the shared goal of keeping your child well.

As a scientist and a researcher who is actively seeking the cures of tomorrow, I can only hope my efforts have the health impact, success and safety of vaccines. Blanket statements by public figures questioning immunization safety gradually decay the public trust they seek to earn, and perpetuate a reprehensible practice of politicizing scientific inquiry.

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.

Gopi Desai, MD

WORKLOAD, NOT HOURS, CONTRIBUTE TO RESIDENT FATIGUE
Generation R: The Rushed Resident

As a medical student, I recall senior physicians commenting how current residents have it easy because of strict, 80-hour workweek limitations. These senior doctors reminisced about their training and described stretches of 2-3 days when they did not leave the hospital. As I started residency, I thought to myself, “This can’t be so bad,” compared to working 72 hours consecutively.

In an attempt to ease my anxieties I convinced myself that while residency would be challenging, it would be manageable because we had laws to limit the amount we worked.

Then reality set in – residency was far from easy. At first, I figured there were growing pains and once I became more efficient and confident, this “paradise residency,” senior doctors described would magically appear.

Now as a 3^rd year resident I have come to realize that this paradise does not exist.

My generation of trainees is challenged with cramming an increasing amount of work into a shorter amount of time. From 1990 to 2010, annual admissions to major teaching hospitals increased by almost 50%. In the same time period, residency positions grew by only 13%[1]. While physician extenders such as nurse practitioners and physician assistants have mitigated some of this increase – there is no doubt that overall workloads have increased.

As our nation collectively focuses on decreasing healthcare costs, length-of-stay is decreasing, leading to an increased turnover of patients in the hospital – many of whom have complex medical histories, complex co-morbid conditions and higher levels of acuity than even a decade ago.

Further, each of these admissions and discharges carries an exponential increase in the amount of resident-generated paperwork, much of which does not improve care but results from compliance with ever-changing insurance and medical-legal concerns.

This translates to increased volume of resident duties with less time to do it all. To cope with these realities, residents have evolved to become more efficient and to multitask. This inevitably sacrifices certain areas of medical care and training, by detracting from time that could be spent with patients or in didactics[2].

The issue of resident fatigue and burnout is not a simple one. Decreasing the amount of time spent in the hospital, with the aim to reduce medical error and resident fatigue, is a good start. However this is an insufficient intervention to tackle the complex problem at hand. Studies regarding the benefits of reduced resident work hours are inconclusive[3]^,[4]. On the other hand, studies that reduce resident workload have been associated with improved resident satisfaction, increased duty hour compliance and increased participation in educational activities[5]^,[6].

As the medical field begins to take more seriously the issues of resident burnout and fatigue, one thing is clear: it is the workload, not the work hours which needs to be addressed.

Dr. Gopi Desai, MD is a third-year pediatric resident at Weill-Cornell Medical Center and NY Presbyterian Queens and a member of the New York State (District II), Chapter 2 (Long Island) Resident Committee of the American Academy of Pediatrics.

 [1]Goitein L, Ludmerer KM. Resident workload-let’s treat the disease, not just the symptom. JAMA Intern Med. 2013 Apr 22;173(8):655-6.

[2] Block L¹, Habicht R, Wu AW, Desai SV, Wang K, Silva KN, Niessen T, Oliver N, Feldman L. In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time? J Gen Intern Med. 2013 Aug;28(8):1042-7.

[3] Choma NN, Vasilevskis EE, Sponsler KC, Hathaway J, Kripalani S. Effect of the ACGME 16-hour rule on efficiency and quality of care: duty hours 2.0. JAMA Intern Med. 2013 May 13;173(9):819-21

[4] Sen S, Kranzler HR, Didwania AK, Schwartz AC, Amarnath S, Kolars JC, Dalack GW, Nichols B, Guille C. Effects of the 2011 duty hour reforms on interns and their patients: a prospective longitudinal cohort study. JAMA Intern Med. 2013 Apr 22;173(8):657-62

[5] McMahon GT, Katz JT, Thorndike ME, Levy BD, Loscalzo J. Evaluation of a redesign initiative in an internal-medicine residency. N Engl J Med. 2010; 362(14):1304-1311.

[6] Thanarajasingam U, McDonald FS, Halvorsen AJ, et al. Service census caps and unit-based admissions: resident workload, conference attendance, duty hour compliance, and patient safety. Mayo Clin Proc. 2012;87(4):320-327.

Lauren Macaluso, MD, FAAP, FABM

Challenges for Breastfeeding Mothers and How to Overcome Them

Breastfeeding is the normal way to feed our babies. A mother’s breast milk is considered the BEST nutritional option for babies according to the American Academy of Pediatrics. Medical contraindications to breastfeeding are rare. Women’s bodies are MADE for breastfeeding, initiating breast development in utero with continued growth through puberty, pregnancy and after delivery. Minutes-old newborn infants have feeding reflexes, the ability to root, suck, and swallow at the breast to attain optimal nutrition, growth and protection.

Though it is a natural process, it is common for women to run into barriers breastfeeding our infants. Mothers and infants may have medical issues that can interfere with breastfeeding. Even if both mother and infant are healthy, exclusive breastfeeding may not be successful and require extra help. As a pediatrician, mother, member of both the local and national American Academy of Pediatrics and a specialist in breastfeeding medicine, here are common challenges encountered by exclusively breastfeeding women and how to overcome them.

EXPECTATIONS

Mothers often have unrealistic expectations of the breastfeeding experience. Unforeseen medical issues such as delivery by Caesarian section, premature labor or difficulty with infant weight gain sometimes occur. Keeping expectations simple and making short term goals can be helpful. Taking one day at a time and having patience and perseverance are paramount. A positive outlook and a strong support team may improve breastfeeding. In certain cases, a breastfeeding specialist, working with your infant’s pediatrician may be helpful in setting reasonable goals for breastfeeding your infant and prevent discouragement.

SUPPORT TEAM

A support team is extraordinarily important. Surrounding yourself with a team that shares your support for breastfeeding is a powerful tool in reaching your breastfeeding goal. Discuss your feeding plan with your partner, close family members, and friends during pregnancy. Consider an obstetrician, midwife and a pediatrician who are supportive of breastfeeding. Some families may benefit from a doula and/or lactation consultant at home or in coordination with the hospital staff. A breastfeeding medicine specialist who does office visits for breastfeeding moms and babies upon discharge may also suit your needs. A breastfeeding support group in your community can provide help and a social network.

EDUCATION

Empower and educate yourself so you understand what is biologically normal. Read about basics: how often to breastfeed, normal urine and stool patterns in breastfed babies, normal weight loss and gain. Observe family members or friends breastfeed if possible. Take a breastfeeding class; query friends who have breastfeed previously. Have a prenatal office visit with a pediatrician or breastfeeding medicine physician to address any issues that can impact breastfeeding.

COMMUNICATE

Address potential breastfeeding challenges as early as possible and with positive communication. Let your workplace know you plan to breastfeed and will require space and time to pump breast milk upon your return. In certain cases, companies may be required to provide you with time and a private space for breastfeeding and/or expressing breast milk. Talk about breastfeeding with your other children and let them know this is how mothers normally feed babies. Read a book together about breastfeeding and encourage them if they imitate you with their dolls so they are empowered for the future.

BE HEALTHY

Have a healthy lifestyle. Eat healthy, low fat, whole grain, nutrient dense foods and emphasize fruits and vegetables. Work exercise into (or back into) your life once medically cleared and make sure exercise is fun. Get rest as often as possible. As a mother, YOUR JOB IN THOSE FIRST FEW WEEKS AFTER DELIVERY IS BREASTFEEDING. Have support team members cook, clean and do laundry. Relax, breathe deeply, meditate or write about your feelings and experiences in a journal.

Breastfeeding is a life changing experience that has its barriers and obstacles. A strong support team, managing expectations, communicating positively, having a healthy lifestyle, and educating yourself will help you achieve your goals.

Dr. Lauren Macaluso, MD FAAP FABM is a pediatrician, breastfeeding specialist and co-chairman of the Breastfeeding Committee of the New York State (District II), Chapter 2 (Long Island) of the American Academy of Pediatrics.