Defining and Promoting Pediatric Pulmonary Health: Equitable Family and Community Partnerships.

Optimizing pulmonary health across the lifespan begins from the earliest stages of childhood and requires a partnership between the family, pulmonologist, and pediatrician to achieve equitable outcomes. The Community Pediatrics session of the Defining and Promoting Pediatric Pulmonary Health workshop weaved together 4 community-based pillars with 4 research principles to set an agenda for future pediatric pulmonary research in optimizing lung and sleep health for children and adolescents. To address diversity, equity, and inclusion, both research proposals and workforce must purposefully include a diverse set of participants that reflects the community served, in addition to embracing nontraditional, community-based sites of care and social determinants of health. To foster inclusive, exploratory, and innovative research, studies must be centered on community priorities, with findings applied to all members of the community, particularly those in historically marginalized and minoritized groups. Research teams should also foster meaningful partnerships with community primary care and family members from study conceptualization. To achieve these goals, implementation and dissemination science should be expanded in pediatric pulmonary research, along with the development of rapid mechanisms to disseminate best practices to community-based clinicians. To build cross-disciplinary collaboration and training, community-academic partnerships, family research partnerships, and integrated research networks are necessary. With research supported by community pillars built on authentic partnerships and guided by inclusive principles, pediatric lung and sleep health can be optimized for all children and adolescents across the full lifespan in the community in which they live and thrive.

Early Childhood Caries in Indigenous Communities.

The oral health of Indigenous children of Canada (First Nations, Inuit, and Métis) and the United States (American Indian and Alaska native) is a major child health disparity when compared with the general population of both countries. Early childhood caries (ECC) occurs in Indigenous children at an earlier age, with a higher prevalence, and at much greater severity than in the general population. ECC results in adverse oral health, affecting childhood health and well-being, and may result in high rates of costly surgical treatment under general anesthesia. ECC is an infectious disease that is influenced by multiple factors, but the social determinants of health are particularly important. This policy statement includes recommendations for preventive and clinical oral health care for infants, toddlers, preschool-aged children, and pregnant women by primary health care providers. It also addresses community-based health-promotion initiatives and access to dental care for Indigenous children. This policy statement encourages oral health interventions at early ages in Indigenous children, including referral to dental care for the use of sealants, interim therapeutic restorations, and silver diamine fluoride. Further community-based research on the microbiology, epidemiology, prevention, and management of ECC in Indigenous communities is also needed to reduce the dismally high rate of caries in this population.

American Indian and Alaska Native infant and pediatric mortality, United States, 1999-2009.

OBJECTIVES: We described American Indian/Alaska Native (AI/AN) infant and pediatric death rates and leading causes of death. METHODS: We adjusted National Vital Statistics System mortality data for AI/AN racial misclassification by linkage with Indian Health Service (IHS) registration records. We determined average annual death rates and leading causes of death for 1999 to 2009 for AI/AN versus White infants and children. We limited the analysis to IHS Contract Health Service Delivery Area counties. RESULTS: The AI/AN infant death rate was 914 (rate ratio [RR] = 1.61; 95% confidence interval [CI] = 1.55, 1.67). Sudden infant death syndrome, unintentional injuries, and influenza or pneumonia were more common in AI/AN versus White infants. The overall AI/AN pediatric death rates were 69.6 for ages 1 to 4 years (RR = 2.56; 95% CI = 2.38, 2.75), 28.9 for ages 5 to 9 years (RR = 2.12; 95% CI = 1.92, 2.34), 37.3 for ages 10 to 14 years (RR = 2.22; 95% CI = 2.04, 2.40), and 158.4 for ages 15 to 19 years (RR = 2.71; 95% CI = 2.60, 2.82). Unintentional injuries and suicide occurred at higher rates among AI/AN youths versus White youths. CONCLUSIONS: Death rates for AI/AN infants and children were higher than for Whites, with regional disparities. Several leading causes of death in the AI/AN pediatric population are potentially preventable.

Human papillomavirus vaccination practices among providers in Indian health service, tribal and urban Indian healthcare facilities.

PURPOSE: The human papillomavirus (HPV) vaccine is of particular importance in American Indian/Alaska Native women because of the higher rate of cervical cancer incidence compared to non-Hispanic white women. To better understand HPV vaccine knowledge, attitudes, and practices among providers working with American Indian/Alaska Native populations, we conducted a provider survey in Indian Health Service, Tribal and Urban Indian (I/T/U) facilities. METHODS: During December 2009 and January 2010, we distributed an on-line survey to providers working in I/T/U facilities. We also conducted semistructured interviews with a subset of providers. RESULTS: There were 268 surveys and 51 provider interviews completed. Providers were more likely to administer vaccine to 13-18-year-olds (96%) than to other recommended age groups (89% to 11-12-year-olds and 64% to 19-26-year-olds). Perceived barriers to HPV vaccination for 9-18-year-olds included parental safety and moral/religious concerns. Funding was the main barrier for 19-26-year-olds. Overall, providers were very knowledgeable about HPV, although nearly half of all providers and most obstetricians/gynecologists thought that a pregnancy test should precede vaccination. Sixty-four percent of providers of patients receiving the vaccine do not routinely discuss the importance of cervical cancer screening. CONCLUSIONS: Recommendations for HPV vaccination have been broadly implemented in I/T/U settings. Vaccination barriers identified by I/T/U providers are similar to those reported in other provider surveys. Provider education efforts should stress that pregnancy testing is not needed before vaccination and the importance of communicating the need for continued cervical cancer screening.

Venomous spiders, snakes, and scorpions in the United States.

Venomous bites and stings are complex poisonings that have local and systemic effects. Mild envenomations can be treated with supportive care. Severe envenomations can be treated definitively with species-specific antivenom, although the use of these products has potential risk of immediate and a more delayed onset form of hypersensitivity reactions. Consultation with a toxicologist is recommended to help guide therapy. Field treatments such as tourniquets and incision likely cause more harm than benefit and should be avoided.

Impact of immunizations on the disease burden of American Indian and Alaska native children.

American Indian and Alaska Native (AI/AN) people have suffered disproportionately from infectious diseases compared with the general US population. As recently as 25 years ago, rates of hepatitis A and B virus, Haemophilus influenzae type b, and Streptococcus pneumoniae infections were as much as 10 times higher among AI/AN children compared with the general US child population. In the past quarter century, routine use of childhood immunizations for hepatitis A and B viruses has eliminated disease disparities for these pathogens in AI/AN children, and significant decreases have been demonstrated for H influenzae type b, S pneumoniae, and pertussis. Nevertheless, certain infectious diseases continue to occur at higher rates in AI/AN children. The reason for continued disparities is most likely related to adverse living conditions such as household crowding, lack of indoor plumbing, poverty, and poor indoor air quality. Although tremendous strides have been made in eliminating disparities in infectious disease among AI/AN children, further gains will require addressing disparities in adverse living conditions.

Trends in otitis media and myringtomy with tube placement among American Indian/Alaska native children and the US general population of children.

BACKGROUND: Otitis media (OM) morbidity in American Indian and Alaska Native (AI/AN) children is historically higher than that in other US children. METHODS: Outpatient visits and hospitalizations listing OM as a diagnosis and outpatient visits listing myringotomy with insertion of tubes as a procedure among AI/AN children <5 years of age from the Indian Health Service National Patient Information Reporting system for 2003-2005 were analyzed. Outpatient visits and hospitalizations with OM for the general US child population were analyzed using the National Hospital Ambulatory Medical Care and National Ambulatory Medical Care Surveys for 2003-2005, and the 2003 Kids' Inpatient Database, respectively. RESULTS: The OM-associated outpatient visit rate for AI/AN children <5 years of age (89 per 100 children/yr) for 2003-2005 was less than that reported for 1994-1996 (138); however, the rate increased for Alaska region (158 to 181). The OM outpatient visit and myringotomy with insertion of tubes rates (181 and 2.6 per 100 children/yr, respectively) for AI/AN children in Alaska were higher than rates for children in each of the other IHS regions and rates for US children (63 and 1.8 per 100 children/yr, respectively). The OM outpatient visit rates for AI/AN infants (184), especially in the Alaska region (334), were higher than the rate for US infants (84). CONCLUSIONS: The OM-associated outpatient visit rate in AI/AN children <5 years of age has decreased but remains higher than that of the US general child population; however, the rate increased in the Alaska region, where a limited decline in invasive pneumococcal disease has been demonstrated. The ongoing disparity in OM outpatient visit rates among AI/AN children, especially Alaska Native children, indicates a need for new prevention measures, including expanded-valency pneumococcal conjugate vaccines, to reduce OM morbidity.

An observational study of the association of fluoride varnish applied during well child visits and the prevention of early childhood caries in American Indian children.

OBJECTIVES: To determine if fluoride varnish applied at well child care visits would decrease the prevalence of dental caries in a group of American Indian children at high risk for early childhood caries. METHODS: This was an observational study in an American Indian community. Starting in 2002 all children received fluoride varnish applications at well child care visits at 9, 12, 15, 18, 24 and 30 months. The Head Start class of 2003 served as historical controls and students in 2004 and 2005 had increasing number of fluoride varnish treatments. All children entering Head Start from 2003 to 2005 had dental exams to determine the number of decayed, missing and filled surfaces (dmfs) present. The number of dmfs for each child was correlated with the number of fluoride varnish treatments received. RESULTS: Children with 4 or more treatments had 15.5 dmfs (95%CI 10.8-20.4) versus children with no fluoride varnish treatments who had 23.6 dmfs (95%CI 19.5-25.8) for a 35% decrease in overall caries. Children who received 1, 2 or 3 treatments showed no significant difference in dmfs when compared with children who had no fluoride varnish applications. CONCLUSIONS: Fluoride varnish applied at well child care visits can reduce early childhood caries in American Indian children. Consideration should be given to making fluoride varnish more available to American Indian and Alaska Native children at well child visits. These findings may be applicable to other children who are at increased risk for early childhood caries.

Diarrhea-associated hospitalizations and outpatient visits among American Indian and Alaska Native children younger than five years of age, 2000-2004.

BACKGROUND: Diarrhea accounts for many hospitalizations and outpatient clinic visits among children. American Indian and Alaska Native (AI/AN) children have experienced a greater infectious disease burden compared with the general U.S. population of children, although diarrhea-associated hospitalization rates have declined among AI/AN children. METHODS: Hospital discharge and outpatient visit records with a diagnosis indicating a diarrhea-associated diagnosis were evaluated for AI/AN children <5 years of age, using the 2000-2004 Indian Health Service Direct and Contract Health Service Inpatient Data and outpatient visit data from the Indian Health Service National Patient Information Reporting System, and for the general U.S. population of children <5 years of age using the Kids' Inpatient Database for 2003 and National Ambulatory data for 2000-2004. RESULTS: For 2000-2004, the diarrhea-associated hospitalization rate was similar for AI/AN children and U.S. children <5 years of age (65.9 and 79.3 of 10,000, respectively), but the rate among AI/AN infants was nearly twice the rate among U.S. infants (262.6 and 154.7 of 10,000, respectively). The rate of diarrhea-associated outpatient visits among AI/AN children was higher than for U.S. children (2255.4 versus 1647.9 of 10,000, respectively), as a result of the high rate among AI/AN infants compared with U.S. infants (6103.5 and 2956.3 of 10,000, respectively). CONCLUSIONS: Although the diarrhea-associated hospitalization rate in AI/AN children <5 years old has declined to levels comparable with that of all U.S. children, the rate for AI/AN in infants remains higher than for U.S. infants. The diarrhea-associated outpatient visit rate for AI/AN children was higher than for U.S. children. Ongoing evaluation of hospitalization and outpatient data is important to understand the impact of rotavirus vaccine among AI/AN children.

Athabascan brainstem dysgenesis syndrome.

We report a new disorder with diverse neurological problems resulting from abnormal brainstem function. Consistent features of this disorder, which we propose should be called the Atabascan brainstem dysgenesis syndrome, include horizontal gaze palsy, sensorineural deafness, central hypoventilation, and developmental delay. Other features seen in some patients include swallowing dysfunction, vocal cord paralysis, facial paresis, seizures, and cardiac outflow tract anomalies. All affected children described are of Athabascan Indian heritage, with eight children from the Navajo tribe and two patients who are of Apache background. The disorder can be distinguished from the Moebius syndrome by the pattern of central nervous system findings, especially the sensorineural deafness, horizontal gaze palsy, and central hypoventilation. Recognition of children with some features of Athabascan brainstem dysgenesis syndrome should prompt investigation for other related abnormalities. Published 2003 Wiley-Liss, Inc.