FALL 2019
Dedicated to the Health of Arizona Children
PEDIATRIC DIGEST
Resolving to Improve Child Health: How Arizona members may influence the American Academy of Pediatrics’ (AAP’s) national agenda by submitting resolutions to address pediatric issues of importance.
A LOOK INSIDE A Message from National AAP:
08
Eliminating Religious and Other Non-Exemptions to Vaccinating Children
10
Asylum Seeker Care in Tucson
22
Providing Guidance on School Response to E-Cigarette Use by Students
Your Voice Through the Resolution Process—Page 6
AzAAP President’s Report
W
e have dedicated this issue of the Pediatric Digest to the topic of the top 10 resolutions selected at the national AAP’s Annual Leadership Forum (ALF) this past March. We will discuss the process of creating a resolution, discussing it among leadership and voting on it at ALF. The voting members at the ALF are given the
opportunity to select their top 10 and these resolutions then are presented to the board of the AAP for consideration as a top priority of the leadership. All resolutions are advisory to the Board of Directors and are not binding.
ALF is one of the highlights of the year for the AAP and the leadership of the various chapters around the country and Canada. We come together to discuss the various issues facing the children and pediatricians of
Gretchen Hull’s
President’s REPORT
our districts and how the Academy may be able to help guide us and the country. The discussions are rich and vibrant, truly one of the most exciting times for us to come together and discuss issues for which we are all passionate about. The variety of perspectives is great and listening to the various perspectives has definitely changed my mind many times.
Top 10 Resolutions of 2019:
Dr. Hull is AzAAP’s President and has served on the Board of Directors for the past 15 years, as well as been involved on several committees and task forces. She practices at Tucson Central Pediatrics—Arizona
Community Physicians.
Eliminating Religious Exemptions to Vaccinating Children Family Separations at the Border: Safeguarding Children’s Health Limitation of Prior Authorization Requirements for Medications Continuity of Medicaid Benefits When Recipients Move Access to Evidence-Based Treatment for Children and Adolescents with Neurodevelopmental Disorders Beyond Autism
Affordable Insulin Access for All Children with Diabetes Revising the AAP Guidelines on Gun Safety Anticipatory Guidance Drowning Prevention Recommendation Statement and Education Providing Guidance on School Response to E-Cigarette Use by Students Public Education About Intramuscular Vitamin K Administration at Birth
As is apparent above, the variety of issues are vast, but all are pertinent to us in our practices. In this issue, we will hear from Arizona pediatricians and other professionals about their perspective on these various resolutions. I hope that someday you too have an opportunity to attend the ALF and experience for yourself the passion of our leaders to improve the health and well-being of our children and pediatricians.
Sincerely,
Gretchen Hull, MD, FAAP AzAAP President
Pediatric Digest, Fall 2019 Page 2
Supporting Pediatric Professionals in Creating Change
In this Issue:
ANNE STAFFORD, MA | AzAAP CHIEF EXECUTIVE OFFICER The Arizona Chapter of the American Academy of Pediatrics has always had a strong voice in advocating for the health and well-being of children and for the practice of pediatrics. This is done in many ways; through our advocacy committee, our child health committees, our work with the media and community outreach, and at the AAP Annual Leadership Forum every March.
The Annual Leadership Forum is attended by chapter presidents, chapter vice presidents, chapter executive directors, nationally appointed committee chairpersons, council chairpersons, section chairpersons, guests, and chapter/national staff. The Arizona Chapter president and vice president attend and represent the voice of our members, bringing forward the issues that Arizona pediatricians and pediatric sub-specialists are facing, as well as their suggestions and ideas for change through the resolution process.
Anne Stafford, MA, AzAAP Chief Executive Officer
Resolutions are the process for the members of the Academy to use to give input into Academy policy and activities. This process allows any member of the AAP to submit an idea for a new policy, a change to an existing one, or ask the Academy to consider an operations change that will affect the local chapter or its members. While this process may feel intimidating to a first-time resolution writer, national AAP and the Arizona chapter provide many resources to guide our members and help create a strong catalyst for change.
AzAAP is helping to lead the way for our District in organizing and submitting clear and concise resolutions. We host a resolution-sharing project management site for all District VIII leaders to review local resolutions prior to the final draft being submitted to AAP. This helps members refine their resolution and gain support from other chapter leaders before it even gets to the Annual Leadership Forum for discussion or voting.
AzAAP is hoping all of our members will consider submitting resolutions this year to elevate the voice of Arizona pediatricians at a national level. Here are some things to remember as you consider this process:
November 1st is the deadline to submit your resolution to national AAP
All resolutions must be in the template format – please contact AzAAP if you
page 6 A Message from National AAP: Your Voice Through the Resolution Process page 7 Advocacy Committee: Update on “Top 10 Resolutions Topics” page 8 Eliminating Religious and Other Non-Exemptions to Vaccinating Children page 10 Asylum Seeker Care in Tucson page 12 A Parent’s Perspective Prior Authorization Requirements for Medications page 13 Get Involved in AzAAP: Create Change by Joining Our Member Committees page 14 Neurodevelopmental Disorders Beyond Autism page 16 Affordable Insulin Access for Children with Diabetes, Call to Action page 19 Drowning Prevention: Updated Guidance for Pediatricians and Parents page 22 Providing Guidance on School Response to E-Cigarette Use by Students page 23 Editor’s Note
need the template or have other questions
Consider co-authoring a resolution with a specialist or Chapter leader to build a strong, well drafted resolution
Remember - no issue is too small to submit as a resolution; If it’s important to you, it’s probably important to your colleagues and fellow AAP members
While not every resolution gets passed and makes it way to the national AAP Board of Directors, the process in itself allows the AzAAP board and staff members to learn about what issues our members are facing and what Pediatric Digest, Fall 2019 Page 3
changes you would like to see. It also allows us to collect information and feedback from other states on how they address similar issues so we can best support our members.
Supporting pediatric professionals is a priority for AzAAP.
Use the resolution process as a way to ensure that
your voice is heard and the Chapter and National AAP know what is important to you. Help us move in the right direction for Arizona children and pediatric professionals.
Sincerely,
Anne Stafford, MA AzAAP Chief Executive Officer
WHO CAN SUBMIT RESOLUTIONS? Resolutions may originate from:
Individual members of the AAP (voting fellows) Chapters Committees Councils Sections Districts
WONDERING IF YOUR RESOLUTION IDEA BEEN SUBMITTED BEFORE? Review the resolution database : The purpose of the resolution database is twofold; 1) The database is a quick reference for looking up past resolutions; and 2) The database allows members who are thinking about developing a new resolution to review past resolutions on the same subject and learn about AAP activities on the topic. In many cases an author may find that their issue is already being addressed. Instructions:
Go to the ALF Main page (https://collaborate.aap.org/alf/Pages/home.aspx) Log in with your MyAAP credentials. To the right of the page, under “Looking for a Past Resolution”, click in the search box to search for any resolution.
Type a keyword, date, author name, or title to search for a resolution.*
*All resolutions dating from 1995 to the present will appear in your search. This will help you determine whether or not a resolution is still needed.
Pediatric Digest, Fall 2019 Page 4
A Message from National AAP Your Voice Through the Resolution Process
R
esolutions afford AAP members the opportunity to provide input regarding Academy efforts to address important child health issues. All resolutions are advisory to the Board of Directors. Resolutions should be as specific as possible and ask the Academy to act on a particular issue that is not already addressed in AAP policies or programs. Submitted
resolutions fall into 5 categories - advocacy, health care finance, practice, education, or AAP governance and operations.
Jonathan Faletti Manager of Chapter Programs,
Resolutions give member leaders, chapter presidents and vice presidents, and chairpersons of national
American Academy of Pediatrics
committees, councils, and sections, the opportunity to hear important child health topics impacting members-at-large. At the Annual Leadership Forum (ALF), a meeting held every March, national AAP leaders debate the resolutions and vote to adopt or not adopt all submitted and approved resolutions. After the voting concludes, member leaders then rank the resolutions in order of importance, and an annual Top Ten list is formed. Resolutions in the Top Ten receive an expedited response from the Board of Directors, and those responses are published in the July issue of AAP News. Click here for the Top Ten article for the 2019 Resolutions.
All other adopted resolutions are sent to internal AAP groups (committees, councils, sections, and appropriate staff groups) to respond to the resolutions in a timely manner. These responses are reviewed and approved by the Board of Directors. The Chapter Forum Management
2020 ALF Dates March 12-14, 2020 AAP Headquarters at the Westin Chicago Northwest
Committee Members and AAP staff relay the responses to resolution authors. The responses for all resolutions are also compiled into a disposition document and widely dispersed to authors and member leaders.
Interested in writing a resolution? Click here for guidelines for resolutions, and click here for the resolution template. Submit your resolution to Charles Pruitt, MD, FAAP, District VIII Chapter Forum Management Committee Member at Charles.Pruitt@hsc.utah.edu and copy Jonathan Faletti, Manager Chapter Programs at jfaletti@aap.org. Any questions, please contact Jonathan.
Pediatric Digest, Fall 2019 Page 6
School Safety: Although Governor Ducey included school safety as a priority this year, the legislature never introduced his plan and failed to pass a variety of bills regarding firearms on campus
Advocacy Committee
and the creation of a Safe
Update on “Top 10 Resolutions Topics”
budget, however, included
BY MARY RIMSZA, MD, FAAP | TUCSON, AZ During the 2019 legislative session the AzAAP Advocacy committee addressed many of the Top Ten Resolution topics including vaccine
School Plan Task Force. The
Mary Ellen Rimsza, MD, FAAP
$20 million a year for schools
Chair, AzAAP Advocacy Committee,
to hire more school resource
Medical Director, AzAAP Child
officers and counselors, and
Fatality (CFR) Review
the legislature enacted a requirement that schools
exemptions, family separation at the border, school safety, and ecigarettes.
adopt policies for reporting suspected crimes or threatening conduct. The good news is that Superintendent of Public Instruction Kathy
Vaccine Exemptions: While we would have loved to work on eliminating personal and religious exemptions to vaccines this year, no bill to personal exemptions was given a hearing. Instead, your advocacy committee needed to work on defeating a trio of bad vaccine bills introduced by Representative Barto and Senator Boyer including:
HB2470 Vaccination Religious Exemptions: This bill would have added a religious exemption to the school vaccine requirements. HB2472 Vaccinations- Antibody Titer: This bill would have mandated that doctors inform parents that antibody titer tests are an option in lieu of receiving a vaccination and that there are exemptions available for the state requirements for attending school. HB2471 Informed Consent: This bill would have required
Hoffman announced that she would create the Safe School Plan Task Force even without legislative direction to do so, and would bring forward the Task Force recommendations to the legislature. We hope to have a representative on this task force and plan to weigh in on its recommendations.
E-cigarettes: This year there was a passionate debate between tobacco and vaping companies and health advocates, including the AzAAP Advocacy Committee, regarding the regulation of E-cigarettes. We sought stronger limitations on minors’ ability to access tobacco and e-cigarette products while the tobacco industry tried to override local regulations on the use of tobacco. This dispute resulted in a stalemate and no bills on E-cigarettes were enacted. We will be taking up this issue again next year.
physicians to provide parents the manufacturer's full vaccine package insert for each vaccine administered.
I would like to thank Lauren Valdiviezo and all of our chapter members who helped us advocate for Arizona's children during the
I am happy to report that all three of these bad vaccine bills were defeated and in the process we raised public awareness about the dangers of low vaccination rates on Arizona communities.
past year by calling their legislators, writing letters and weighing in on bills via the RTS system. If you would like to join the advocacy committee or have any questions/comments regarding legislative matters, please feel free to contact me.
Family Separation at the Border: Your AzAAP Advocacy committee supported SB1247 sponsored by Senators Brophy-McGee and Carter to address concerns regarding care provided for children in residential care facilities such as Southwest Key. The new law provides more oversight of these facilities including staff background checks on any residential facility that cares for children and requires these facilities to be compliant with state rules and regulations for residential facilities including inspections by Arizona Department of
Mary Ellen Rimsza, MD, FAAP Chair, Advocacy Committee Mary.Rimsza@gmail.com Lauren Valdiviezo Staff, Director of Member and Constituent Services Lauren@azaap.org
Health Services. Pediatric Digest, Fall 2019 Page 7
Eliminating Religious and Other Non-Exemptions to Vaccinating Children A.D. JACOBSON, MD, FAAP | PHOENIX, AZ The state of Arizona is one of only 17 states which
What can you do to help
allows for exemption, from child care through 12th
decrease exemption rates:
grade school requirements, that includes personal belief, religious, and medical exemptions. Many states now are having legislative ways to improve our herd immunity such as to eliminate or constrain the use of non—medical exemptions. This last year the Arizona legislature put forth several bills that would actually expand the state’s exemptions until Governor Ducey vetoed the bills.
#1
Probably the most important thing you
can do is to have a conversation with parents. Be a good listener and find out what is their rationale
A.D. Jacobson, MD, FAAP, Medical
– the most common reasons are usually:
Director, Division of Developmental
A. Compliance – belief that vaccines are
Disabilities (DDD) - State of Arizona,
unnecessary.
Chairman, Board of Directors, The
B. Convenience – barriers to access
Arizona Partnership for
C. Confidence – concern about vaccine safety/side Presently, I believe that it is undisputed that Arizona has the most lenient immunization policies and lax enforcement of any state, and the problem is now getting worse with the total exemptions rising from 2.3% in 2005
“By using, at least,
D. Calculation – Weighing the pros/cons of
D. The best complete reference for parents (and
vaccinating.
pediatricians as well) is the paperback book: “Vaccines and Your Child” - separating fact from
some of the strategies in this brief article, I truly believe that Arizona
to 26.7% in 2019.
pediatricians can Non-medical exemptions
make a difference
are all dangerous and put
in our vaccine
individuals at risk for
culture.”
Immunization (TAPI)
effects.
You can give them medical facts about vaccines
fiction. Authored by Paul A. Offit, M.D. and
such as: The World Health Organization lists
Charlotte A. Moser.
reduction in immunization rates and loss of herd immunity as one of the top 10 threats to public
Bad information is out there on the Internet and
health in the world. You also may find that some
many parents have trouble forming accurate
parents do not like scientific facts. I suggest then,
opinions when much of the information is
to use behavioral modules such as personal
misinformation and/or debunked conspiracy
statements that “I always vaccinate my own
theories. Listed below is a sampling of Anti–
children and I want yours to be protected too.”
Vaccine Groups on the Internet:
#2
contracting potentially debilitating and deadly infectious diseases. Other than the Dutch Reformed Church, there does not appear to be a formal anti— vaccine doctrine in any of the major religions around the world. In fact, most mainstream religions support the use of vaccines.
Provide good information parents can
Pennsylvania Parents For Vaccine Awareness
B. TAPI Website (whyimmunize.com) C. CHOP (vaccine.chop.edu)
The Alliance for Informed Choice in Vaccination
use: A. CDC (cdc.gov)
National Vaccine Information Center
Concerned Parents For Vaccine Safety
AAP RESOLUTION RANKED #1 Eliminating Religious Exemptions to Vaccinating Children RESOLVED, that the Academy develop a toolkit that highlights successful chapter strategies for the purpose of helping chapters work with their state legislators to eliminate/reduce exemptions that have allowed immunization refusals.
Pediatric Digest, Fall 2019 Page 8
Citizens For Healthcare Freedom Vaccine Information Resource Center Coalition For Informed Choice PAVE: People Advocating Vaccine Education Future Generations
according to the CDC vaccine schedule is the standard of care for all pediatricians. There is no scientific evidence that spacing vaccines will help the body’s immune system.
VOICE: Vaccinations – Offering Individuals Choice and Education
I am sure you all know that vaccinating children
Vaccination Alternatives Natural Community Information Network Ohio Parents for Vaccine Safety Healthy Alternatives Michigan Opposing Mandatory Vaccinations
#3
Contact your legislator in your district
Arizona had a pilot program last year that offered parents seeking personal vaccine exemptions for their children, a science – based online curriculum about vaccines in the diseases they prevent. But after a backlash from parents, including some who said they don’t vaccinate their children, the state
AzAAP LAUNCHES NEW SAFE
canceled the program. ADHS now has the module,
SLEEP FOR BABY CAMPAIGN
still in pilot mode and an evaluation plan will be in
and voice your concerns.
place after the school assessments are done in
#4
November, 2019. Always nurture the provider – patient
relationship.
There are several factors that are putting
#5
Arizona’s school–children at risk, including the
#6
Educate yourself and office medical staff.
legislature, pervasive mistrust of accurate science, Don’t forget missed opportunities in your
practice.
#7
and a lack of consistent easily accessible science – based information about vaccines for parents. By using, at least, some of the strategies in this brief
Send reminders to parents about
preventative appointments and missed or delayed
article, I truly believe that Arizona pediatricians can make a difference in our vaccine culture.
campaign page at:
AzAAP.org/SafeSleep
AzAAP provides free posters to providers, practices, and hospitals, to encourage parents to practice safe sleep and prevent sleep-related tragedies. Request printed posters from Leadership@azaap.org or download the digital version via the webpage.
vaccines.
#8
states vaccine policy, politics in the Arizona
Visit AzAAP’s new Safe Sleep for Baby
Address vaccine hesitancy with parents
starting with the prenatal visit.
#9
Discuss vaccines in each well
child visit every vaccine the child will receive specifically for that day, and possible side effects when appropriate.
Pediatric Digest, Fall 2019 Page 9
Asylum Seeker Care in Tucson RICHARD WAHL, MD, FAAP| TUCSON, AZ Casa Alitas (“House of Wings”)
The number of families with children increased dramatically this past
was opened in 2014 by Catholic
October, with over 400 individuals suddenly released by ICE over the
Community Services of Southern
course of a few days. Casa Alitas opened a centralized emergency
Arizona as a “safe house” in
shelter in the gymnasium at St Pius X Church, and quickly organized
central Tucson to provide
a fairly large number of community volunteers to provide all
temporary housing for families
necessary services for these new arrivals, including food, shelter,
who had been detained at the
clothing, transportation, and medical care.
Mexican border by the Border Richard Wahl, MD, FAAP, Department of Pediatrics, University of Arizona —Tucson
Patrol (BP) and released as
A corner of the gym was designated the “medical area”, with 3 tables
“asylum seekers”. These
and a few chairs set up. The initial medical team consisted of
families are permitted to enter
volunteer faculty and residents from the UA Dept. of Pediatrics, but
the U.S. legally after clearance
quickly expanded to include community pediatricians as well as
by the BP and Immigration and Customs Enforcement (ICE), and must
faculty and residents from Emergency Medicine, Family Medicine,
have family elsewhere in the continental U.S. who are legal residents
Internal Medicine, and OB/GYN.
and able to purchase a bus ticket for the “asylum seekers” to reach their sponsoring family.
The next surge of newly released asylum seekers from ICE came several weeks later. The gym was no longer available. We set up an
Between 2014 and October 2018, the number of these releases
emergency shelter in a south side Tucson motel, and duplicated all
remained relatively small but steady, and amounted to approximately
services available at Pius X. Once again, the waves of new arrivals
7000 individuals released in Tucson. A small network of shelters were
varied greatly week by week, with a return to the motel necessary at
opened in Tucson by a variety of local churches and community
different times throughout the fall and winter.
groups. We were rather unexpectedly offered the use of the former Benedictine Monastery on County Club Road in late January of this year. We moved in, and were able to
AAP RESOLUTION RANKED #2 Family Separations at the Border: Safeguarding Children’s Health RESOLVED, that the Academy support child-parent psychotherapy that is developmentally appropriate and targeted towards the multiple layers of reunification for families affected by immigration policies, and be it further RESOLVED, that the Academy support families potentially affected by immigration policies by developing guidelines for safe medical record documentation to decrease risk of deportation, and by creating a Family Preparedness toolkit detailing the documents and items needed in the event of sudden deportation.
Pediatric Digest, Fall 2019 Page 10
accommodate the increasing numbers of new arrivals. We quickly were assisted by over 400 local volunteers, with an additional 100+ medical volunteers helping out. Between January and August 2019, over 10,000 asylum-seekers were provided services by Casa Alitas at the Monastery.
Medical volunteers meet with all new arrivals for an initial screening process. While we were initially most concerned about active TB infection and measles, we have not yet identified a case of either. We have seen a steady stream of varicella, and have isolation rooms set up. Spread of varicella within a family seems to be less likely in tropical climates than in more temperate ones, and most adults in
Central America appear to lack immunity to varicella. In consultation with Peds ID and the Pima County Health Dept., we have started to treat active cases with acyclovir to reduce the period of contagion, and provide acyclovir prophylaxis for parents of children with active varicella.
Many of our new arrivals experience some combination of exhaustion, dehydration, and gastrointestinal upset, as well as psychological sequelae of traumas experienced while traveling north. Many women arrive with complications of pregnancy and need for obstetric services. We have needed to hospitalize several children with pneumonia, acute dehydration, helminthiasis, and one with leukemia (previously diagnosed in Guatemala). We were able to administer 500
Timely attention to the psychological symptoms related to
doses of influenza vaccine this past year. We provide care for chronic
physical threats and/or sexual assault suffered in the country of
illnesses, and attempt to assist with chronic medications (often
origin or while en route to the U.S.
confiscated on detention). We also try to setup ongoing medical care referrals for individuals with chronic medical concerns in their
bus ride is medically contraindicated
destination cities.
The AAP has committed to focusing on advocating for these children by
Funds to provide airline travel for families for whom a 3 to 4 day
Arrangement of appropriate medical follow-up in destination
developing guidelines for safe medical record documentation for
cities for those with significant identified health concerns by
immigrant children. In this way they hope to create a “Family
creating a database of U.S. medical centers able to provide care
Preparedness Toolkit” that details documents and items needed in the
to this uninsured high-risk population
event of sudden deportation. While I appreciate the Academy’s efforts to enter into this important space with this resolution, I respectfully
As we now need to leave the Benedictine Monastery, we are opening
submit the following as higher priorities:
the new Casa Alitas Welcome Center in space provided by Pima County. We have a continuing and ongoing need for medical and
Reassurance for families in their primary language upon release
nursing volunteers. Please do let me know if you would like to help
from custody that they are able to remain safely in the U.S. in
out.
their sponsor’s city until a decision is made at their next court hearing
Richard Wahl MD, FAAP Department of Pediatrics
Identification and treatment of any health concerns requiring
University of Arizona
immediate attention including active infections (TB, varicella,
rwahl@email.arizona.edu
hepatitis), physical trauma, and sequelae of neglecting chronic medical conditions while in transit
Identification and immediate treatment of symptoms related to exhaustion, dehydration, sudden change to an extremely different diet, crowded detention conditions and the extreme temperatures of holding cells
Pediatric Digest, Fall 2019 Page 11
A Parent’s Perspective Prior Authorization Requirements for Medications DAWN BAILEY | PHOENIX, AZ
A
s a parent of a child with complex medical needs, there are many areas to navigate within healthcare, and prior authorizations for medications is one of the more challenging and frustrating ones. Prior authorizations can be required yearly, monthly with each refill, every time there is a dosage change or when a new or generic version is made available.
Depending on the type of health plan, commercial and/or Medicaid/Medicare, these requirements vary creating confusion for families, providers, and pharmacies. When we leave a doctor or specialist visit with an updated plan of care that includes a new or updated prescription, we expect to go to the pharmacy, have that filled and begin treatment. However, with many of our medications, a prior authorization is required and so the chaos begins. Chaos in trying to keep track of or chase down where the request, documentation and decision is. Chaos in finding a
AAP RESOLUTION RANKED #3
pharmacy willing to work with prior authorizations. I have
Limitation of Prior
the luxury of a pharmacy that is willing to put in the work
Authorization Requirements
for our prior authorizations, but many families are not so
for Medications
fortunate. At times pharmacies will refuse to fill the
Dawn Bailey, Family Engagement Specialist, Office for Children with Special Healthcare Needs, Arizona Department of Health Services (ADHS), Bureau of Women’s and Children’s Health
prescriptions because they do not have the resources to keep up with the ongoing need for prior
RESOLVED,
authorizations. And if those prescriptions were sent electronically, there is an added challenge in finding a different pharmacy to fill and subsequently transferring the script or getting a new one sent.
that the Academy advocate to
It can take days or sometimes a week before this is sorted out, resulting in a delay in care, or
the Centers for Medicare and
families giving up all together.
Medicaid Services (CMS), state Medicaid agencies and private
For the many times I have endured this process, rarely has our doctor changed their mind and
insurers for change in policies
modified the prescription. To me, this is burdensome, only to eventually get the original script filled.
to reduce requirement for
In the meantime, we have delayed care to a child, created more administrative work within the
prior authorization for on-label
healthcare system and added a few more gray hairs for this mom. Although my perspective is for a
medications for children, and
child with chronic and complex medical needs, we need to be mindful of all levels of health issues,
be it further
whether acute or chronic and ensure we are addressing all aspects of healthcare needs. Furthermore, while this resolution is for medications prescribed for on label use, I believe we need to look further at
RESOLVED,
all medications for children. Those with chronic or medically complex needs often use medications for off label use and will continue to experience these same challenges and delay in care.
that the Academy advocate to the Centers for Medicare and
Perhaps consistent and understood requirements for prior authorizations makes sense for the initial
Medicaid Services (CMS), state
prescription fill and to ensure quality, but existing requirements for new authorizations each time a
Medicaid agencies and private
dose is adjusted or for ongoing monthly refills is neither efficient nor effective. In my experience, I
insurers to cease the common
have yet to see these requirements truly improve care, reduce overall costs, improve patient
procedure of forcing patients
experience, and/or improve provider experience. When considering the Triple or Quadruple Aim, I
who are stable on an on-label
believe we are missing the mark with the current prior authorization process. And for what benefit
medication to change their
exactly?
treatment to a medication which may not be
Dawn Bailey, Family Engagement Specialist
therapeutically equivalent.
Arizona Department of Health Services Dawn.Bailey@azdhs.gov
Pediatric Digest, Fall 2019 Page 12
GET INVOLVED IN AzAAP
CREATE CHANGE BY JOINING OUR MEMBER COMMITTEES Access to Care—addresses issues that
support members through training and
and makes recommendations to the Board;
impact access to care for uninsured and
technical assistance
educates the general membership about legislative issues, and communicates
underinsured children in Arizona; strive to educate health care professionals on
Pediatric Emergency Medicine—
AzAAP’s official positions regarding
community resources, develop partnerships
defines and promulgates best practices that
legislative issues; members might also be
between existing organizations working
address the unique needs of infants,
tapped to testify on issues of importance in
towards improving access to care, and
children, and adolescents in the access to
front of legislative committees
support legislation that promotes improving
and delivery of pediatric emergency care, as
access to care; reviews and evaluates
well as in disaster preparedness programs
Pediatric Council—discuss pediatric
AzAAP access to care efforts including the
and activities
issues with payers; focused on educating health plans about child health and issues of
Medical Services Project (MSP) program
Adolescent Health—addresses the
importance to the practice of pediatrics;
Obesity and Food Insecurity—
special health care needs of adolescents and
communicate the needs of pediatric
working collaboratively with other
promotes the pediatrician as their optimal
practices with the medical directors of major
community organizations and businesses in
source of health care; monitors and makes
health plans to advocate for more
the state, this committee helps develop
policy recommendations to the Board of
appropriate coverage for pediatric services
solutions and provide input on ways Arizona
Directors on issues surrounding vital
and claims adjudication
families can live more healthy lives and
adolescent health issues
Fund Development—focused on
prevent lifelong health issues brought on by
Child Fatality Prevention—Using
diversifying the revenue streams of the
data from the Child Fatality Review (CFR)
organization, as well as contributing to the
Early Literacy—promotes early literacy
which explores the causes and contributing
overall sustainability and success of AzAAP
initiatives within Arizona to increase the rate
factors associated with Arizona child deaths
programs and key priorities
of children entering school ready to learn;
to identify recommendations to reduce
strive to increase public awareness of the
preventable fatalities of children; work to
Continuing Medical Education
importance of early literacy on child
develop and create campaigns that influence
(CME)—ensures education programs
development including the Reach Out and
child health, safety and protection
remain evidence-based and include current
obesity and food insecurity
recommended guidelines; providing
Read (ROR) program, and focuses on the unique relationship between parents and
Finance—monitors the organization’s
oversight for the accreditation of the CME
medical providers to develop essential early
financial management and makes policy
program; recommending new directions
literacy skills
recommendations to the AzAAP Board of
and/or initiatives for AzAAP continuous
Directors on financial matters and asset
learning opportunities
Developmental Screening—works to
management
Other Opportunities
ensure that all children receive optimal developmental screenings and are assessed
Advocacy—works as a conduit between
Contact us, and we will be happy to help
and provided services when needed;
AzAAP and the Arizona Legislature regarding
align your interests with an AzAAP program,
evaluate screening tools to ensure members
statewide issues surrounding child health
committee, project, or workgroup: 602-532-
have to most up to date methods and
and pediatric practices; monitors legislation
0137; leadership@azaap.org.
Pediatric Digest, Fall 2019 Page 13
Neurodevelopmental Disorders Beyond Autism CATHERINE RILEY, MD, FAPP | TUSCON, AZ Applied Behavioral Analysis (ABA)
ABA involves instructional strategies and systematic use of the environment to
is devoted to assessing and
address two key areas: 1. teaching effective and necessary skills, and 2. shaping
treating socially significant
behavior to minimize challenging behaviors while also promoting optimal
behaviors to produce behavioral
behaviors that improve functioning (Will and Hepburn 2015). Children with a large
and developmental improvements
variety of diagnoses deserve improved access to this type of treatment/
(Cooper, Heron & Heward, 2007).
intervention.
Certainly, this aim can be applied to individuals with developmental
Children with genetic disorders (Down Syndrome, Fragile X, Williams Syndrome,
disabilities and/or behavioral
Prader Willi Syndrome, etc.) often struggle with language skills, cognitive skills,
challenges that do not fall within
noncompliance, self-injury, anxiety, and off-task behavior. ABA programs can
the autism spectrum.
expertly target all of these areas to promote skill acquisition while also improving behavior.
The American Academy of Pediatrics has selected: “Access to
It has long been recognized that ABA based treatments are proven effective for
Evidence-Based Treatment for
children with autism as well as other developmental disabilities.
Children and Adolescents with
Catherine Riley, MD, FAAP, Developmental Behavioral Pediatrician, Clinical Associate
Neurodevelopmental Disorders
priority deserving attention and advocacy.
AZAAP Medical Director Early Brain and Child Development
Disabilities, the oldest and largest interdisciplinary organization of professionals concerned with intellectual disability and related disabilities, designated ABA-based
Professor, University of Arizona Department of Pediatrics
The American Association on Intellectual and Developmental
Beyond Autism” as an area of
The resolution states: “that the
procedures for the treatment of behavioral problems with
Academy advocate for access to
individuals with intellectual disability and related disorders as
evidence-based behavioral
"highly recommended" (Rush & Frances, 2000).
treatment including home and community-based Applied
Behavioral Analysis and other evidence-based positive behavior support programs for children and adolescents with a broad range of neurodevelopmental disorders, not just for those with a diagnosis of autism spectrum disorder”.
The American Academy of Child and Adolescent Psychiatry concluded: “ABA techniques have been repeatedly shown to have efficacy for specific problem behaviors, and ABA has been found to be effective as applied to academic tasks, adaptive
Comprehensive early behavioral interventions that target language, motor, play skills, and socioemotional development has been shown to be highly effective at
living skills, communication, social skills, and vocational
remediating deficits present in children with a variety of developmental disorders.
skills” (Volkmar et al., 2014). Both of these statements from prominent organizations highlight the importance of ABA based treatments to improve functional skills and minimize
AAP RESOLUTION RANKED #5 Access to Evidence-Based Treatment for Children and Adolescents with Neurodevelopmental Disorders Beyond Autism
challenging behavior.
ABA based interventions are not diagnosis specific. Because ABA programs are structured and individualized, this approach can be applied for use
RESOLVED,
with any developmental disorder in children, as long as developmentally appropriate goals are identified
that the Academy advocate for access to evidence-based behavioral
and targeted.
health treatment including home and community-based Applied
While ABA has been scientifically proven to be an
Behavioral Analysis (ABA) and other evidence-based positive behavior
extremely useful intervention for children with
support programs for children and adolescents with a broad range of
autism, children with a multitude of other diagnoses
neurodevelopmental disorders, not just for those with a diagnosis of autism spectrum disorder.
Pediatric Digest, Fall Page 14
can certainly benefit from the same intensive behavioral interventions. Therefore, the application
of ABA based interventions should not be limited solely for individuals with autism spectrum disorders.
It is appropriate and vitally necessary that the AAP advocate for access to evidence-based ABA treatment for children with a broad range of neurodevelopmental disorders, not just for those with a diagnosis on the autism spectrum.
References:
Cooper, J.O., Heron, T.W., & Heward, W.L. (2007) Applied behavioral analysis (2nd ed.). Columbus, OH: Merrill.
Rush, A. J. & Frances, A. (Eds.) (2000). Expert consensus guideline series: Treatment of psychiatric and behavioral problems in mental retardation [Special issue]. American Journal on Mental Retardation, 105, 3.
Volkmar, F., Siegel, M., Woodbury-Smith, M., King, B., McCraken, J., State, M., & the American Academy of Child and Adolescent Psychiatry Committee on Quality Issues (2014). Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder. Journal of American Academy of Child and Adolescent Psychiatry, 53, 237-257.
Will, E., Hepburn, S. (2015). Applied behavior analysis for children with neurogenetic disorders. International Review of Research in Developmental Disabilities, 49, 229-259.
Affordable Insulin Access for Children with Diabetes, Call to Action TALA DAJANI, MD, MPH, FAAP | MESA, AZ Like atmospheric oxygen, humans can not survive without insulin. Parents of children who live with diabetes now not only have to be concerned with parenting a child with a condition that requires minute to minute management, hyperglycemia, hypoglycemia, finger pokes, injections, meal planning, carb counting, buying and organizing diabetes supplies, but now they have to contend with paying for and acquiring life-saving insulin. Over the past decade, insulin and diabetes supplies prices have grown exponentially (graph 1). 1
Graph 1
Pediatric Digest, Fall 2019 Page 16
As an American phenomenon, insulin prices have risen in other countries to a much lesser
AAP RESOLUTION RANKED #6
degree (graph 2) leading a 5 year old boy in
Affordable Insulin Access for All Children with Diabetes
Gilbert, Arizona to lobby congress.
2, 3
Indeed,
the generic lispro insulin meant to provide a
RESOLVED,
more affordable option, remains elusive to Arizonans.4 Likewise, the rising prices have led
that the Academy advocate for policies that promote affordable access
patients and families to rationing the drug thus
to analogue insulin for all pediatric patients with diabetes.
increasing morbidity and mortality risks.
5
While patients continue to struggle to afford this life saving medication, pharmacy benefit management (PBM) systems have negotiated with pharmaceutical manufacturers for rebates. 6 This has led to consistent increase in list price to accommodate the rebates. Rebate savings are not passed down to the consumer resulting in rising profits for PBM and manufacturers.6
Graph2
Tala Dajani, MD, MPH, FAAP, Assistant Professor of Clinical Science Medicine, Board Certified Pediatric Endocrinologist, Diplomate, American Board of Pediatrics, In fact, after the Congressional meeting was convened by the U.S. House of Representatives Committee on Energy & Commerce Oversight and Investigations Subcommittee in early April of 2019, Rep. Frank Pallone, D-NJ, chairman of the House committee noted that both
A.T. Still University of Health Sciences, School of Osteopathic Medicine in Arizona
manufactures, and PBMs are pointing fingers at each other:
“When the manufacturers have been criticized for raising their prices, they point the finger at the PBMs. When the PBMs have been questioned about their practices, they often point their finger back at the manufacturer. We’re left with no accountability. For the millions of people who are suffering in this system, these back and forth arguments are frustrating and, frankly, unacceptable. Everybody seems to be coming out ahead here except for the patient.”7
Pediatric Digest, Fall 2019 Page 17
The time has come to mitigate the exploitative financial profit of those individuals living with chronic disease. With America’s health system’s business approach, the top priority is profit. As is the case with all providers, those of us caring for patients need to continue to step up and advocate for this very vulnerable population. Through this crisis, we can delineate ways to overcome and find a win-win solution that results in both profit and affordable access to lifesaving medications.
References: 1. The GoodRx List Price Index Reveals the Rising Cost of All Diabetes Treatments – Not Just Insulin. https://www.goodrx.com/blog/goodrx-list-price-index-rising-cost-ofdiabetes-treatments/ Website accessed 7/8/19. 2. The human cost of insulin in America. By Ritu Prasad. BBC News. https://www.bbc.com/news/world-us-canada-47491964 Website accessed 7/8/19. 3. 5-year-old Arizona boy lobbies Congress for diabetes funding. https://www.azcentral.com/story/news/local/gilbert/2019/07/15/gilbert-boy-grant-leonard-lobbies-congressdiabetes-funding-juvenile-diabetes-research-foundation/1730863001/ . Website accessed 7/6/19. 4. Cheaper insulin 'nowhere to be found' in Arizona, pharmacies and advocates say. Stephanie Innes, Arizona Republic Published 6:00 a.m. MT June 24, 2019 | Updated 4:36 p.m. MT June 27, 2019. https://www.azcentral.com/story/news/local/arizona-health/2019/06/24/arizona-consumers-struggle-find-cheap-new-insulin-made-elililly/1479464001/ 5. The human cost of insulin in America. By Ritu Prasad. BBC News. 14 March 2019. https://www.bbc.com/news/world-us-canada-47491964 6. The Insulin Racket. NATALIE SHURE JUNE 24, 2019 https://prospect.org/article/insulin-racket 7. PBMs, drugmakers both to blame for rising insulin prices, legislators say at hearing by Jacqueline Renfrow | Apr 11, 2019 8:31am. https://www.fiercehealthcare.com/payer/ house-subcommittee-questions-drug-companies-rising-insulin-prices
YOU DON’T WANT TO MISS THIS!
Pediatrics in the Red Rocks Mark your calendars NOW to attend the 2020 Pediatrics in the Red Rocks Conference taking place June 26-28. Plan to escape to the Hilton Sedona Resort at Bell Rock and earn CME and MOC credit amidst the spectacular beauty of the magnificent red rock formations surrounding Sedona. AzAAP's CME Committee is already hard at work planning and preparing for next year's meeting. Expect a variety of hot topics and distinguished speakers with more information being sent in the coming months. As always, AzAAP members will be offered discount and special rates on registration and overnight accommodations.
Save the Date! Escape to the Beauty of the Red Rocks! June 26-28, 2020
Pediatric Digest, Fall 2019 Page 18
DROWNING PREVENTION:
Updated Guidance for Pediatricians and Parents JEFFREY C. WEISS, MD, FAAP | PHOENIX, AZ According to the CDC, drowning
1
killed almost 1,000 US children
3
(1.11 per 100,000 population) in
and swim skills;
2017. For the period 2013-2017, the
water competency, swim lessons,
highest drowning death rates were in white
4
boys 0-4 years old (3.44 per 100,000),
jackets;
American Indian children 0-4 years old
adult supervision and use of life
(3.58 per 100,000), and African American
5
adolescent boys (4.06 per 100,000). For
and
the same period, Arizona was ranked 8th highest state in drowning deaths, with 130
6
child and adolescent drowning deaths
the importance of bystander CPR.
pool fences and physical barriers;
never leave a child alone (or in the
care of another child) near water;
2
be aware of drowning risks in the
home (i.e., bath seats, toilets, buckets);
3
always provide close, constant, and
attentive supervision and know how to recognize a child in distress, perform a rescue and provide CPR;
the drowning chain of survival and
(1.44 per 100,000). For children 0-4 years
4
install a 4-sided isolation fence with a
self-closing and self-latching gate around
old, Arizona’s drowning death rate was
Many of the 2019 policy statement’s
home pools;
ranked 4th highest (4.00 per 100,000).1
recommendations for parents are similar to those published in the previous policy
5
This year, in conjunction with the release
statement in 2010. Parents are
their children water safety rules and
of a revised AAP policy statement,
encouraged to:
swimming skills;
learn to swim themselves and teach
“Prevention of Drowning”, the national American Academy of Pediatric leadership adopted a resolution that supports
AAP RESOLUTION RANKED #8
“promotion of the policy statement and the
Drowning Prevention Recommendation Statement and Education
development of new educational materials and media which can be used to educate
RESOLVED,
pediatricians, residents, medical students, and parents about drowning prevention”2.
that the Academy update or reaffirm, using new data, and the vigorously
The 2019 Prevention of Drowning policy
promote, the Prevention of Drowning policy statement, and be it further
statement includes new information about:
1
RESOLVED, populations at increased risk
(including those with underlying medical
that the Academy produce new educational materials and media updates
conditions such as epilepsy and autism);
based upon the Prevention of Drowning policy statement which can be
2
used to educate pediatricians, residents, medical students, and parents racial and sociodemographic
about drowning prevention.
disparities in drowning rates;
Pediatric Digest, Fall 2019 Page 19
and swim skills for populations that have not
WHY:
historically had access to high-quality
life jacket when boating so he doesn’t
affordable swimming programs.
drown.
Although I am a hospitalist now, I was a
HOW:
primary care pediatrician for most of my
approved, child size life jackets at John’s
career. I know that it is extremely difficult
Sporting Goods on 5th Street. Other
to fit all the AAP anticipatory guidance
parents tell me the people at John’s know
recommendations into a typical office visit.
how to fit kids properly and their prices are
At an Ambulatory Pediatric Association
good too.
Be sure your son uses a
You can buy Coast Guard
meeting many years ago, I was exposed to Bandura’s Social Learning Theory3, which
I don’t have good scientific proof that this
suggests that behavior change occurs more
Social Learning Theory approach will be
Jeffrey C. Weiss, MD, FAAP,
when people are taught HOW to do
effective for drowning prevention, but it
Pediatric Hospitalist, Phoenix
something rather than being told WHY they
does make sense to me that these HOW
Children's Hospital and Professor of
should do it. Giving people the DETAILS of
messages could be incorporated into a time
how to do a particular behavior that will
saving handout. If I were still in outpatient
make them safer or healthier, especially in
practice, I’d say something like: “Because
the context of STORIES about HOW
you live in Arizona and your child is 2 years
OTHER PEOPLE LEARNED to do it, can be
old, he is in a high-risk group for drowning.
particularly powerful. Here are some
The AAP wants me to give you some
relevant examples:
information about drowning prevention, so
Clinical Pediatrics, University of Arizona School of Medicine
6
use US Coast Guard approved life
jackets when boating or, for young children
our practice has created this handout that
or non-swimmers, near any body of water; and
7
WHY: select swimming sites with lifeguards.
contains detailed information about what Get a pool fence so your
kid won’t drown.
you can do. Please read it over carefully and let me or my nurse know if we can answer any questions for you.” If you try
The new policy statement indicates that
HOW:
pediatricians are expected to know the
installed beautiful, reasonably priced pool
drowning prevention, I would love to hear
leading causes of drowning in their location
fences for several of my patients. They tell
your thoughts and see the handout you
so that they can give appropriate guidance
me they now have great peace of mind.
create. I can be reached at
to parents. Parents of children with special
Here’s the phone number.
jweiss@phoenixchildrens.com.
Joe’s Construction has
Good luck!
health care needs should get drowning prevention advice targeted especially to them. Parents of adolescents should be
WHY:
warned specifically about increased risks
she won’t drown.
around water when drugs or alcohol are
Teach your kid to swim so
HOW:
parents to warn children not to overestimate
learned to swim at Little Fish Swim School.
their swimming skills. Finally, the policy
Parents tell me the teachers are great,
statement encourages CPR training for high
parents are very involved in the program,
school students. Of course, the policy
and the price is reasonable. Here’s their
statement encourages pediatricians to work
website.
laws regarding pool fences, boating, and life jackets. Pediatricians can also help support programs that encourage water competency
Pediatric Digest, Fall 2019 Page 20
References: 1. Centers for Disease control and Prevention.
involved. Pediatricians should also advise
with other groups in the community to pass
this type of approach to counseling about
Many kids in our practice
WISQARS. https://www.cdc.gov/injury/wisqars/ index.html 2. American Academy of Pediatrics. https:// www.aap.org/en-us/my-aap/alf/Documents/ alf_2019_top_ten_resolutions.pdf 3. Bandura A. Self-efficacy: Toward a Unifying Theory of Behavior Change. Psych Rev 1977; 84:191-215
Member Benefit: Making it Easier to Advocate! Make Your Voice Heard
Request to Speak (RTS) is an online system that Arizona's lawmakers use to collect feedback on
pending legislative bills. The RTS system is an excellent tool that pediatric professionals can use to make their voices heard and advocate on important issues that affect the health and well-being of Arizona children and families. You may create an account in-person using a special kiosk at the state Capitol. AzAAP realizes it is not easy for all our members to make a trip to the state Capitol to create an account in-person using a special kiosk, especially if you live far from Phoenix. To make this process easier and to promote participation from our statewide membership, AzAAP can create a RTS account for you to access remotely. Request an RTS form by emailing Leadership@azaap.org.
Pediatric Digest, Fall 2019 Page 21
middle schoolers who reported a decrease from 4.3% to 2.1%. Unfortunately, the progress of our recent past has fallen in the shadow of a burgeoning e-cigarette market, an alarming trend that is occurring both nationally and in Arizona. While TV and radio advertising for tobacco have been prohibited, print ads and an increasing presence of nicotine-containing e-cigarette products on the internet have rapidly increased youth exposure to these products. From 2011 to 2014, e-cigarette advertising spending increased from $6.4 million to $115 million annually. In the same time, reported e-cigarette use among middle schoolers increased from 1% to 4% and among high schoolers from
Providing Guidance on School Response to E-Cigarette Use by Students
2% to 13%!
R. NICHOLAS STAAB, MD, FAAP, MSPH
the Arizona Department of Health Services (ADHS) developed
ARIZONA DEPARTMENT OF HEALTH SERVICES
In 2018, 3.6 million US middle and high school
students reported recent use of e-cigarettes that is 4.9% of middle school students and 20.8% of high school students.
In the setting of e-cigarette marketing trying to renormalize nicotine use, in 2015 the American Academy of Pediatrics released its policy statement on Public Policy to Protect Children From Tobacco, Nicotine and Tobacco Smoke to help guide our concerted effort to protect our youth from harmful addiction to nicotine.
In response,
several key initiatives to provide education to adolescents about the dangers of e-cigarettes. In 2019, the ADHS launched an aggressive marketing campaign called “Facts over Flavor� (https://
The reduction of cigarette smoking and thus nicotine exposure to our
factsoverflavor.com) which primarily uses social media aimed at
youth has been a great accomplishment of the past 10 years. From
dispelling the purported safety of vaping compared to smoking
2011 to 2018 high school students reporting current cigarette use
cigarettes that many youth and their parents believe. ADHS has also
dropped from 15.8% to 8.1%. A similar trend was shown among
developed a peer-based, tobacco education program called Students Taking a New Direction
AAP RESOLUTION RANKED #9
or STAND (http://www.standaz.com). Having
Providing Guidance on School Response to E-Cigarette Use by Students
just completed their 10th annual summer conference, this group of young advocates is
RESOLVED,
prepared to start the school year armed with the knowledge and skills to help spread the message
that the Academy develop evidence-based materials and best practice
to their peers of the harm of e-cigarettes.
guidelines to allow pediatricians to better provide guidance to patients,
Currently there are 36 high school coalitions in
parents, communities, and local schools on ways to deter e-cigarette
the state.
use, along with effective and ineffective responses to e-cigarette use on school campuses.
Among the 10 resolutions developed at this year's national AAP conference is providing
Pediatric Digest, Fall 2019 Page 22
guidance on school response to
Editor’s Note
e-cigarette use by
JODI CARTER, MD, FAAP | PHOENIX, AZ
students. A zerotolerance At its heart, this issue is about
approach to
advocacy. It is impossible to read
discipline has
this issue cover to cover and not
been shown to be
develop a profound respect for
ineffective at
the dedicated advocates in our
changing habits.
midst.
Instead, a progressive
The hope is that this issue will
discipline approach with an informed intervention strategy using
inspire the reader to take a bold R. Nicholas Staab, MD, FAAP, MSPH, Medical Director, Bureau of
step – commit to advocating for the health and wellbeing of
Epidemiology & Disease Control,
children through the AAP
Arizona Department of Health
Resolution Process. This
resources like
Services
opportunity is open to all AAP
Jodi Carter, MD, FAAP, AzAAP Secretary of the Board of Directors, AzAAP Pediatric
Facts over Flavor
Fellows and the Arizona Chapter
and STAND would likely be much more effective in combating the
of the AAP staff are here to
challenge we face. All actors engaged in this effort to reduce vaping
support any Fellow with a
in youth must be able to identify who is vaping and target their
resolution idea through the
interventions. In Arizona, we know that males vape at higher rates
process. As President Barack Obama once said, “Change
than females and white youth vape more than Latinos or African
will not come if we wait for some other person or…some
Americans. With that in mind, pediatricians, parents and educators
other time. We are the ones we’ve been waiting for. We
need to be asking their adolescents about their use, exposure and
are the change that we seek.”
Digest Editor
knowledge regarding e-cigarettes. With the resources we already have available in Arizona through Facts over Flavor and STAND we can extend the messaging to reach our youth before experimentation and certainly before habit.
Questions: Questions and concerns pertaining to the newsmagazine can be
References: 1.
directed to Leadership@azaap.org or 602-532-0137.
Centers for Disease Control and Prevention. Vital Signs: Tobacco Product Use Among Middle and High School Students – United States, 2011-2018. Morbidity and Mortality Weekly Report, 2019;68(06) [accessed 2019 Aug 7].
2.
Centers for Disease Control and Prevention. Vital Signs: E-cigarette Ads and Youth. January 2016. [accessed 2019 Aug 7].
3.
U.S. Food and Drug Administration. Youth Tobacco Use: Results from the National Youth Tobacco Survey. 29 May 2019. [accessed 2019 Aug 7].
4.
American Academy of Pediatrics. Public Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke. Pediatrics, November 2015, 136:5. [accessed 2019 Aug 7].
5.
American Academy of Pediatrics. Out-of-School Suspension and Expulsion. Pediatrics, March 2013, 131:3. [accessed 2019 Aug 7].
6.
Centers for Disease Control and Prevention. High School YRBS, AZ 2017 Results. [accessed 2019 Aug 7].
Pediatric Digest, Fall 2019 Page 23
2600 North Central Avenue Suite 1860 Phoenix, AZ 85004
Free Member Benefit AzAAP Career Center Looking for a job? Searching for someone to join your practice? Find pediatric jobs and highly skilled medical professionals on the AzAAP Career Center. Members can post 6-month-spreads free of charge anytime! To place an ad, contact Leadership@azaap.org or call 602532-0137 ext. 416.
AzAAP.org/Career-Center