What We Are Doing



Dear Representative,

As a constituent and member of the local American Academy of Pediatrics (AAP) Legislative Committee, which represents over 500 pediatric healthcare providers in Nassau, Suffolk, Queens and Brooklyn, I write to request co-sponsorship of HR 5486, the CHILD NICOTINE POISONING PREVENTION ACT. The bill would allow for child-proof packaging on liquid nicotine cartridges, thus preventing children from accessing this drug, which can be highly toxic to young children.  As children’s health experts and advocates, we are concerned about the significant increase in nicotine poisoning that is occurring nationwide with the widespread introduction of electronic cigarettes.

In October of 2014, we wrote to your predecessor, former Rep. Tim Bishop, asking for co-sponsorship of this life-saving bill and we now ask for your influence to help protect Long Island’s children.  The measure passed the U.S. House Committee on Energy and Commerce Subcommittee on Commerce, Manufacturing and Trade last month and co-sponsorship of this proposed legislation would provide critical support toward passage.

The liquid nicotine used to refill e-cigarettes is highly toxic to young children. High doses of nicotine disrupt central nervous system functioning and is a deadly poison (1, 2) Symptoms of poisoning include nausea, vomiting, diarrhea, hallucinations, headaches, seizures and coma. Introduced by your colleague Rep. Elizabeth Etsy in 2014, the bill would require these packages to maintain the same child safety standards used for household cleaner and prescription drugs.

The rate of liquid nicotine poisoning in children is increasing at epidemic rates. The Centers for Disease Control report upwards of 2400 calls to poison control centers related to liquid nicotine by February of 2014. Recently, that call total has increased to 3,783 (3).  This represents a sharp increase from the one call per month in 2010 (4). According to the California Poison Control System, approximately 40% of these phone calls result in Emergency Room referrals (5).

The tobacco industry targets young children, placing them at higher risk for nicotine poisoning (6).  It is well known that 80% of adult smokers being using nicotine prior to 15 years of age (7,8). This has made children the target for nicotine marketing by tobacco companies.

The use of bright color packaging and flavorings such as bubblegum, cotton candy and gummy bear are designed to appeal to children. Given this attraction, many young children are attracted to the packaging and may play with its contents, increasing the likelihood of nicotine ingestion or absorption through the skin, both of which can lead to poisoning.  Sadly, New York was a national leader in tragedies caused by liquid nicotine. A toddler in Fort Plains, New York was the first child to die from liquid nicotine poisoning caused by ingesting just one liquid refill.

That event motivated the New York State Legislature to pass a state law in 2014 providing for these child-packaging protections. We ask you to toward bringing the same protections to all children across the country by supporting a broader federal law.

Liquid nicotine cartridges are incredibly potent sources of toxic nicotine.  Pharmacologic studies on nicotine demonstrate the average cigarette contains 10-15mg of nicotine, with roughly 1mg transferred systemically. While electronic cigarettes can deliver the same amount of drug, their dependence on vaporized liquid nicotine requires the e-cigarette to utilize a highly concentrated solution.

Commercial liquid nicotine refills vary in concentration from 24mg-100mg in one milliliter of fluid.  Ingestion of a 30ml vial would result in a dose of 3000 mgs of nicotine, which in a toddler can easily produce toxicity (5).  A recent report in the New England Journal of Medicine details symptoms of liquid nicotine poisoning due to the 1-3 milliliters of fluid in a single e-cigarette device (9, 10).

Child-proof packaging is a proven, evidenced-based, method of reducing poisonings with over 50 years of public health data supporting its benefit (11, 12).  The introduction of child-proof packaging for over-the-counter medicine such as aspirin and acetaminophen drastically reduced accidental overdoses due to these medications and is considered a significant public health advance (13).  Aspirin-related mortality reduced by 34% between 1973 and 1990 with improvements and expansion of child-proof packaging requirements (14).

A Consumer Products Safety Commission Survey demonstrated that from 1964-1992 the introduction of child-proof packaging reduced the rate of fatalities up to 45% and reduced the rate of oral prescription medication-related death by 1.4 million (12).

Given the need for this medication is well defined and the remedy of child-proof packaging a proven public health measure, we ask for your sponsorship of HR 5486.  The CHILD NICOTINE POISONING PREVENTION ACT will provide a vital safeguard to protect the health of children in the context of concentrated liquid nicotine e-cigarette refills, a new, emerging toxic threat to our patients.

I urge you to make the health and well-being of children one of your top priorities by co-sponsoring this legislation and building upon last year’s discussion of this matter.

If you have any additional questions or wish to discuss this issue further, please do not hesitate to contact the Long Island Chapter of the American Academy of Pediatrics.


District II (New York State), Chapter 2, American Academy of Pediatrics


  1. Benowitz NL. Nicotine addiction. N Engl J Med. Jun 17 2010;362(24):2295-2303.
  2. Solarino B, Rosenbaum F, Riesselmann B, Buschmann CT, Tsokos M. Death due to ingestion of nicotine-containing solution: case report and review of the literature. Forensic Sci Int. Feb 25 2010;195(1-3):e19-22.
  3. Hassink, S. “Pediatricians Applaud House Action on Children Nicotine Poisoning Prevention Act,” American Academy of Pediatrics, Press Release 7/23/2015.
  4. Chatham-Stephens K, Law R, Taylor E, et al. Notes from the field: calls to poison centers for exposures to electronic cigarettes–United States, September 2010-February 2014. MMWR Morb Mortal Wkly Rep. Apr 4 2014;63(13):292-293.
  5. California Poison Control System. “Child resistant packaging of electronic cigarette devices and refill liquid containers containing nicotine to prevent childhood.” Comments to the Food and Drug Administration. Docent FDA-2014-N-0189.
  6. Brown J, Luo W, Isabelle L, Pankow J. Candy Flavorings in Tobacco. NEJM 5/7/14. Electronic Publication Ahead of Print. Available at: http://www.nejm.org/doi/full/10.1056/NEJMc1403015
  7. The scientific basis of tobacco product regulation. WHO Technical Report Series no. 945. Geneva: World Health Organization, 2007 (http://www.who.int/tobacco/global_interaction/ tobreg/9789241209458.pdf).
  8. American Academy of Pediatrics, Richmond Center of Excellence. Handout on E-Cigarettes. Available at: http://www2.aap.org/richmondcenter/pdfs/ECigarette_handout.pdf
  9. Bassett RA, Osterhoudt K, Brabazon T. Nicotine poisoning in an infant. N Engl J Med. Jun 5 2014;370(23):2249-2250
  10. Etter J, Bullen C. Electronic Cigarette: User Profile, Utilization, Satisfaction and Perceived Efficacy. Addiction. 2011; 106(11): 2017-2028.
  11. Poison Prevention Packaging: A Guide for Healthcare Professionals. 2005. Consumer Products Safety Commission.
  12. Rodgers G. The Safety of Child Resistant Packaging for Oral Prescription Drugs: Two Decades of Experience. JAMA 1996;275:1661-1665.
  13. Rodgers G. Let’s Welcome a New Generation of Child-Resistant Packaging. Contemp. Peds. 1997:57-72.
  14. Rodgers G. The Effectiveness of Child- Resistant Packaging for Aspirin. Archives of Peds Adolesc. Med. 2002;156:929-933.Go to top


American Academy of Pediatrics
District II, Chapter 2 Long Island, NY
(917) 940-2262


Dear Representative,

As a constituent and member of the local American Academy of Pediatrics (AAP) Legislative Committee, which represents over 500 pediatric healthcare providers in Nassau, Suffolk, Queens and Brooklyn, I write to request CO-SPONSORSHIP of HR 1462, “To Combat the Rise of Prenatal Opioid Use and Neonatal Abstinence Syndrome.”  The legislation, introduced by your colleagues Representatives Katherine Clark and Steve Stivers is bipartisan and has a companion bill in the Senate introduced by Senators Mitch McConnell and Bob Casey.

The measure would help to combat the increasing rate of opioid abuse among pregnant women, which causes neonatal abstinence syndrome (NAS) in their newborn infant. As a neonatologist, we see the effects of this neonatal condition, caused by in utero exposure to opioids, daily.  The symptoms of NAS include seizures, excessive wakefulness, diarrhea, poor weight gain and other symptoms of narcotic withdrawal.   Exposure to these drugs early in prganancy is associated with cardiac and intestinal birth defects (1).

Opioid use in pregnancy is increasing across the nation. Not only is the number of pregnant women who receive narcotic prescriptions rising, but so is the number of prescriptions they receive during the pregnancy.  A recent Centers for Disease Control report noted the percentage of pregnant women who received narcotic prescriptions from 2005-2011 was approximately 15%, but now is as high as 27%-41% depending on insurance status and geographic region. In the northeast, roughly 1 in 5 women receive narcotics during gestation (2).

Currently there are no widely-accepted standards for diagnosis and treatment of infants with this condition. As newer synthetic opioids become approved for pregnancy, there also exists a substantial gap in our knowledge and understanding of how opiate exposure affects the developing infant in utero.  Medical science’s lack of full understanding of this condition ultimately undermines our ability to diagnose and treat this newborn condition.

Physician and public education is also required surrounding the need for appropriate prescription use during pregnancy and treatment options for those who currently abuse opioids while pregnant.

The proposed legislation would improve the care of the babies born to these infants by directing the Department of Health and Human Services to make standardized recommendations for diagnosis and treatment of this condition, coordinate federal research efforts and improve data collection via state health agencies and departments.

This legislation has significant cost benefits to the healthcare system. Infants with NAS can spend several weeks in the hospital receiving treatment, and given the increasing nature of the condition, medical costs in programs such as Medicaid are likely to increase.  A study in the Journal of the American Medical Association indicated that infants with NAS costs 500% more than the average hospital birth (3).

Creation of standardized recommendations for these infants would have medico-legal benefits as well. Malpractice is a pressing issue in New York State, which does not enjoy the favorable tort reforms, and both obstetricians and neonatologists remain among the specialties with the highest malpractice premiums.  Standardization of care for neonatal abstinence syndrome may delineate a standard of care for physicians who treat this disease. Physicians who follow these guidelines may be less likely to be sued.  And if a claim is filed, physicians may be able to take advantage of “safe harbor” practices in their defense.

For the reasons outlined above, the bill enjoys widespread support in the medical community. In addition to receiving support from the American Academy of Pediatrics, the measure is endorsed by both the national American College of Obstetricians and Gynecologists and the March of Dimes – the largest advocacy organization dedicated to newborn health.

As you continue the process of deliberation, we ask you to keep these points, and the position of the members of our organization in mind.  WE ASK YOU TO COSPONSOR HR 1462 AND SUPPORT THE HEALTH OF OUR DISTRICT’S NEWBORNS.


District II (New York State), Chapter 2, American Academy of Pediatrics


  1. Broussard C, Rasmussen S, Reefhuis J et al. Maternal treatment with opioid analgesics and risk for birth defects J Obstet Gynecol 2011;204:314.e1-11.
  2. Ailes E, Dawson A, Lind J et al. Opioid Prescription Claims Among Women of Reproductive Age — United States, 2008–2012. MMWR Jan 2015 Vol. 64(2) pg. 37-41.
  3. Patrick S, Schumacher R, Benneyworth B et al. Neonatal Abstinence Syndrome and Associated Health Care Expenditures: United States, 2000-2009 JAMA. 2012;307(18):1934-1940.

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American Academy of Pediatrics
District II, Chapter 2
Long Island, NY
(917) 940-2262



Dear Representative,

As a constituent and member of the local American Academy of Pediatrics (AAP) Legislative Committee, which represents over 500 pediatric healthcare providers in Nassau, Suffolk, Queens and Brooklyn, I am writing to request co-sponsorship of HR 1859, the ENSURING CHILDREN’S ACCESS TO SPECIALTY CARE ACT.

This bipartisan bill — introduced by your colleagues Rep. Joe Courtney and your New York Congressional Delegation colleague Rep. Chris Collins – would allow for pediatric sub-specialists to be included in the National Health Service Corps loan repayment program.  This program, created by the Public Health Service Act, would provide education debt relief and for pediatric sub-specialists who work in underserved areas after completing their medical training. This bill not only has the potential to improve healthcare access for children across the country, but WILL HAVE SUBSTANTIAL LOCAL IMPACT in New York City and Long Island.

As widely covered in the news media, the total amount of educational debt held by students is now estimated at 1.2 trillion dollars. Medical students and physicians hold a disproportionate share of educational debt. Nationally the cost of a medical education has far surpassed inflation.  According to the American Association of Medical Colleges, the median cost of a four-year medical school education for a student in the Class of 2015 ranges from $225,000 to almost $300,000 (1). Not surprisingly the median educational debt for a medical school graduate is now $180,000. Ten percent of graduates have a combined undergraduate and medical graduate debt burden of over $300,000 (2).

This financial stress informs a medical school graduate’s choice of which career to pursue (3-5). According the Bureau of Labor and Statistics, pediatricians are at the lowest end of the physician income spectrum, with a median income (across ALL levels of experience) of $163,350 (6).  These conditions have contributed to a disparity in the geographic distribution of pediatricians (7).  Failure to renew Medicaid Parity – a provision in the Affordable Care Act which paid pediatricians at the same rate (for equal work) as adult physicians caring for Medicare patients – further contributed to geographic mal-distribution of child health physicians.

Sadly, the situation is often worse for pediatric subspecialists, who undergo additional years of post-medical graduate training beyond the 3 required for pediatrics before entering the workforce.  However, despite this increased training, many pediatric sub-specialists are paid equally or less than the general practitioner colleagues – an aspect of pediatric healthcare which differs significantly from adult medicine (8).

This system discourages physicians from entering pediatric sub-specialty fields such as child neurology and behavioral pediatrics and has resulted in wait times of several weeks or more and long commutes for parents to seek care for their children who suffer from serious illnesses.  According to the American Board of Pediatrics, there are only 270 certified pediatric rheumatologists and only 40 pediatric toxicologists in the NATION. (7).

Locally, our region is not immune to the pediatric subspecialist shortage and these physicians are hesitant to practice in areas which feature our high cost of living.  Despite having a population of over 1.5 million people, there is only ONE pediatric rheumatologist in the county.

Though approximately 1 in 150 children are diagnosed with autism or autism-like disorders, Brooklyn and Queens are designated as “medically-underserved areas” for many pediatric subspecialties, including child psychiatrists, neurologists and behavioral specialists according to the Health Resources and Services Administration (9).  In areas of Nassau County, waiting times to see specialists for conditions related to child mental health disorders, can approach several months, particularly for patients on Medicaid.

The Ensuring Children’s Access to Specialty Care Act (H.R. 1859), addresses these workforce problems by incentivizing pediatric subspecialists to practice in underserved areas by rendering them eligible for the National Health Service Corps loan repayment program.  This program provides loan repayment and scholarship opportunities for providers who serve two years in a high need or underserved areas.  This bill will motivate more pediatricians to pursue subspecialty training by mitigating educational debt issues and provide critical health access to children who are often out of reach of pediatric subspecialty care.

Simply, put.  This bill is a WIN FOR CHILDREN AND PEDIATRICIANS.

I urge you to make the health and well-being of children one of your top priorities by co-sponsoring this legislation and by seeking out colleagues on the House Energy and Commerce Committee. If you have any additional questions or wish to discuss this issue further, please do not hesitate to contact the Long Island Chapter of the American Academy of Pediatrics.


District II (New York State), Chapter 2, American Academy of Pediatrics


  1. American Association of Medical Colleges, Medical Student Education: Debt, Costs, and Loan Repayment Fact Card. October 2014.
  2. American Association of Medical Colleges, Physician Education Debt and the Cost to Attend Medical School: 2012 Update, February 2013.
  3. Cull WL, Yudkowsky BK, Shipman SA, Pan RJ. Pediatric training and job market trends: results from the American Academy of Pediatrics third-year resident survey, 1997-2002. Pediatrics 2003;112:787-92.
  4. Freed GL, Dunham KM, Jones MD Jr., McGuinness GA, Althouse LA. Longitudinal assessment of the timing of career choices among pediatric residents. Arch Pediatr Adolesc Med 2010;164:961-4.
  5. Compton MT, Frank E, Elon L, Carrera J. Changes in US medical students’ specialty interests over the course of medical school. Gen Intern Med 2008;23:1095-100.
  6. US Bureau of Labor Statistics Data: Available at: http://www.bls.gov/oes/current/oes291065.htm
  7. Althouse LA, Stockman JA. The Pediatric Workforce: An Update on General Pediatrics and Pediatric Subspecialties Workforce Data from the American Board of Pediatrics. Journal of Pediatrics 2011; 159(6):1036-1040.
  8. Freed GL, Dunham KM, Switalski KE, Jones MD Jr., McGuinness GA, Research Advisory Committee of the American Board of Pediatrics. Recently trained pediatric subspecialists: perspectives on training and scope of practice. Pediatrics 2009;123(suppl 1):S44-9.
  9. Health Services Research Administration Data. Available at: http://muafind.hrsa.gov/index.aspx

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American Academy of Pediatrics
District II, Chapter 2
Long Island, NY
(917) 940-2262



Dear Representative,

As a constituent and member of the local American Academy of Pediatrics (AAP) Legislative Committee, which represents over 500 pediatric healthcare providers in Nassau, Suffolk, Queens and Brooklyn, I write to request co-sponsorship of HR 3235, the BRINGING POST-PARTUM DEPRESSION OUT OF THE SHADOWS ACT.  Introduced by your colleagues Rep, Katherine Clark, and Rep. Ryan Costello, the bill is bipartisan, and aims to expand awareness, screening and treatment for postpartum depression – a common, treatable but highly stigmatized condition.

Post-partum depression is a common condition, affecting 10-15% of all mothers (1).  Among women from lower socio-economic backgrounds, the disease is more common, affecting up to 20% of women (2).  Across the nation, this translates to approximately 400,000 women, a disproportionate number of whom live in New York. According to the Post-Partum Resource Center of New York, 50,000 parents will be affected with post-partum depressive symptoms.

Post-partum depression is the most common obstetrical complication in the nation yet due to a combination of under-diagnosis and stigmatization associated with the condition; only 15% of women receive treatment (3).  Since post-partum depression inhibits breast feeding, and has adverse effects on maternal bonding, parenting, and the infant’s social, emotional and language development, pediatricians are a natural resource to screen and advocate for this condition (4-6).

New York State passed legislation last year that recognized the role pediatricians can play in combating post-partum depression, expanding our scope of practice to allow us to screen mothers while we care for their newborns, which have frequent medical visits in the first months of life.  Early detection is critical. Over 90% of mothers with the condition improve with treatment (7).

HR 3235 will expand on our state’s efforts by providing grants to develop programs aimed at screening for post-partum depression.  It will also afford mothers, nationwide, the opportunity to receive depression screening when they bring their child to the pediatrician, thus giving them the same benefit New York State’s mothers have received for a year. Both the Wall Street Journal and New York Times reported that in the year since the New York law was passed, significantly increased numbers of health professionals received training for evaluation and management for post-partum depression (8, 9).

Increasing the number of professionals trained in post-partum depression treatment is vital on Long Island since there is a shortage of psychiatrists who care for these patients.  Even patients with health insurance have difficulty accessing mental health services, since only 50% of psychiatrists accept private insurance, creating a vacuum for obtaining treatment and underlying support of this measure by the American College of Obstetrics and Gynecology and the American Psychological Association (10).

Given the high prevalence of post-partum depression, it’s disproportionate effects on mothers in New York, the distressing effects of this condition on infants, the increased need for screening and the high amenability to treatment we ask for your sponsorship of HR 3235 — The BRINGING POST-PARTUM DEPRESSION OUT OF THE SHADOWS ACT.

I urge you to make the health and well-being of children one of your top priorities by co-sponsoring this legislation. If you have any additional questions or wish to discuss this issue further, please do not hesitate to contact the Long Island Chapter of the American Academy of Pediatrics.


District II (New York State), Chapter 2, American Academy of Pediatrics


  1. Brett, K. Prevalence of self-reported postpartum depressive symptoms—17 states, 2004-2005. MMWR Weekly 2008, 57(14), 361-366.
  2. Grigoriadis S, Vonderporten E, Mamisashvili L et al. The Impact of Maternal Depression on Perinatal Outcomes: A Systematic Review and Meta-analysis. Clinic. Psychiatr 2013 74(4)e321-e341.
  3. McGarry, J., Kim, H., Sheng, X., Egger, M., & Baksh, L. (2009). Postpartum depression and help-seeking behavior. Journal of Midwifery & Women’s Health 2009, 54(1), 50-56.
  4. Dennis, C.L., & McQueen, K. The relationship between infant-feeding outcomes and postpartum depression: A qualitative systematic review. Pediatrics 2009, 123(4), e736- e751.
  5. McLearn, K. T., Minkovitz, C. S., Strobino, D. M., Marks, E., & Hou, W. Maternal depressive symptoms at 2 to 4 months post partum and early parenting practices. Archives of Pediatrics and Adolescent Medicine 2006, 160, 279-284.
  6. Taveras, E. M., Capra, A. M., Braveman, P. A., Jensvold, N. G., Escobar, G. J., & Lieu, T. A. Clinician support and psychosocial risk factors associated with breastfeeding discontinuation. Pediatrics 2003, 112(1 Pt 1), 108-115.
  7. Liberto t. Screening for Depression and Help Seeking in Post-Partum Women During Well-Baby Pediatric Visits: An Integrated Review. J Pediatr Health Care 2012;26, 109-117.
  8. Machalinski, A. Law Spurs Interest in Helping New Moms Deal With Depression. Wall Street Journal, May 25, 2015.
  9. Solomon, A. The Secret Sadness of Pregnancy with Depression. New York Times, May 31, 2015
  10. Bishop T, Press M, Keyhani S et al.Acceptance of Insurance by Psychiatrists and the Implications for Access to Mental Health Care. JAMA Psychiatry.2014;71(2):176-181

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