Older Blogs

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.