SUMMER 2017
Dedicated to the Health of Arizona Children
PEDIATRIC DIGEST
AzAAP Strategic Priority: Quality of Care & Child Safety AzAAP is committed to providing members with opportunities to develop strategies for continuous assessment and improvement in quality of care and child safety. GUEST AUTHOR: Mrs. Cindy McCain
A LOOK INSIDE 3
Adolescent Health Expert Leads Critical Priority Area
6
New Committee Responding to Findings in Child Fatality Review
21
Improving Outcomes for Ill and Injured Children
puts a spotlight on human trafficking— Page 14
AzAAP President’s Report I
was honored to represent and speak about the Arizona Chapter at the American Academy of Pediatrics
(AAP) annual leadership forum (ALF) in Schaumburg, Illinois in March. One opportunity was during the
process through WHICH OUR CHAPTER WAS NAMED THE MEDIUM SIZE OUTSTANDING CHAPTER which
includes chapters from the US and Canada! The award is a shared success due to the work of our dedicated members and chapter committees, devoted board members, our amazing staff, those who care for children in Arizona, and our community partners who support our vision to improve the health and well-being of all Arizona children.
I was proud to discuss our remarkable achievements in many areas over the last 2 years especially the chapter Agenda for Children which includes a focus on key chapter initiatives in three priority areas
John Pope’s
President’s REPORT
including poverty and child health, early brain and child development, and quality of care and child safety. This issue is dedicated to the quality of care and child safety pillar where we have some excellent programs that were highlighted at the ALF meeting. The award review committee praised the success of the unique Pediatric Prepared Emergency Care Program (PPEC) and the Child Fatality Review report preparation and follow up which have featured articles this quarter.
Dr. Vinny Chulani MD, MSED, FSAHM of Phoenix Children’s Hospital is the medical director for quality of
Dr. Pope is AzAAP’s President and has
care and child safety for the AZAAP. He oversees initiatives including child fatality review, pediatric disaster
served on the Board of Directors for the past
and emergency preparedness including the PPEC program, care coordination, and newborn screenings as
6 years as well as involvement on several
well as the RECENTLY BOARD APPROVED ADOLESCENT HEALTH COMMITTEE.
committees and task forces. He is the Chief Medical Officer for the HonorHealth Scottsdale Shea Medical Center.
In this issue, we will hear about the various chapter quality and safety programs as well as evolving issues with adolescents, human trafficking, newborn screening and infant safety, and new ideas around care coordination.
We look forward to our 40th annual PEDIATRICS IN THE RED ROCKS CONFERENCE in June where we will reconnect, learn, and celebrate our successes including our outstanding chapter award!
Sincerely,
John A. Pope, MD, MPH, FAAP AzAAP President
To contact our Board of Directors with questions or concerns, email Leadership@azaap.org.
Pediatric Digest, Summer 2017 Page 2
AzAAP Medical Director Message:
In this Issue:
A Look at Quality of Care and Child Safety VEENOD CHULANI, MD, MSED, FSAHM | PHOENIX, AZ Dear AzAAP Colleagues,
Adolescents are a tremendously underserved population in contemporary models of health service delivery in the United States. The National Academy of Sciences- Institute of Medicine report, Adolescent Health Services: Missing Opportunities highlights gaps in the ways we deliver care to adolescents and provides recommendations on how to best strengthen and improve health services for youth. The American Academy of Pediatrics and the Society for Adolescent Health and Medicine have also each outlined essential criteria critical for quality care adolescents given their unique developmental characteristics. These criteria include visibility, affordability, confidentiality, and coordination of care, among others. As one of just over 600 adolescent medicine specialists in our country of 42 million youth, I feel that I can best serve the Chapter by taking it where it has not historically been by bringing quality considerations in the care of adolescents within our Quality of Care and Child Safety Priority Area. This also includes highlighting the needs of the underserved among the underserved - Lesbian, Gay, Bisexual and Transgender and Questioning (LGBTQ) Youth, homeless and runaway adolescents, and commercially sexually Veenod Chulani MD, MSED, FSAHM, Medical Director, Homeless Youth
exploited youth being among them. Since assuming this role, the Executive Committee has adopted resolutions to expand the
Outreach, Section Chief, Adolescent
Agenda to include Quality of Care for Adolescents and to broaden
Medicine, Phoenix Children’s Hospital,
its view of critical child safety issues to include human trafficking.
Phoenix, AZ
There is an incredible amount of momentum around improving health care services for adolescents and for the most vulnerable
among them both locally and nationally. It is an honor and a privilege to lead and represent the Chapter in these initiatives and to be a part of making a lasting impact on the health and well-being of Arizona’s youth.
THERE
IS NO OTHER GROUP IN OUR COMMUNITY OF CLINICIANS BETTER POSITIONED AND BETTER
QUALIFIED THAN PEDIATRICIANS TO SPEAK TO THE HEALTH SERVICE NEEDS OF ADOLESCENTS AND TO ADVOCATE FOR STRUCTURES AND SYSTEMS OF SERVICE DELIVERY THAT FULLY REFLECT AND RESPOND TO THESE NEEDS.
IF
WE DO NOT LEAD THIS CHARGE, WHO WILL?
Sincerely,
page 4 Emilie Olsen (2001-2014) page 5 Introducing AzAAP Senior Coordinator of Health Initiatives: Quality of Care and Child Safety (QCCS) page 6 New AzAAP Committee Responding to Findings in Child Fatality Review Report page 7 Partnership Between ASU and AzAAP to Assess Caregiver Sleep Education page 8 AzAAP Health Initiative: Infant Safe Sleep page 10 Quality of Care and Child Safety (QCCS) Resources page 14 Human Trafficking: Understanding a Pediatrician’s Role in Helping Child Victims page 15 Newborn Screening in Arizona: The Case for TREC Screening for SCID (Severe Combined Immunodeficiency) page 20 A Focus on Pediatric Emergency Preparedness page 21 Children Shouldn’t Be Penalized for Where They Live page 23 Safe Sleep is as Easy as ABC page 24 AzAAP Member Spotlight: Dr. Jeffrey Weiss page 26 Opioid Epidemic and Neonatal Abstinence Syndrome
Vinny Chulani, MD, MSED, FSAHM AzAAP Medical Director, Quality of Care and Child Safety Priority Area
Pediatric Digest, Summer 2017 Page 3
Being bullied can negatively impact youth in many ways. While suicides might seem extreme, Emilie is one in a growing list of youth who have taken their lives as a result of bullying especially as its reach has been extended by the use of the Internet and social media as tools for slander and intimidation. Depression and anxiety, somatic complaints, and school avoidance are common consequences. Weight-related bullying which is especially prevalent among youth is strongly associated with increased risk for body dissatisfaction and disordered eating behaviors. Research also indicates that youth who are bullied regularly perform substantially worse in school are more likely to miss, skip, or drop out of school compared to non-bullied peers.
It is important that we also consider youth who bully for whom these behaviors are symptoms of larger concerns rather than simply problematic behaviors. Research shows that youth who bully are more likely to abuse alcohol and other drugs, drop out of school and have criminal convictions as adults. There is also
Emilie Olsen (2001-2014)
mounting evidence of the links between bullying in childhood and
BY VEENOD CHULANI, MD, MSED, FSAHM
bully, early intervention to address anger, poor self-esteem, and
"GO
KILL YOURSELF
BATHROOM STALLS.
EMILIE,” SHE
HER BULLIES SCRIBBLED ON
DID. Emilie Olsen, adopted from
Southeast Asia, was ridiculed and taunted in her Fairfield, Ohio school until she could take no more. In December 2014, at age
intimate partner violence perpetration as adults. For youth who
other psychological undercurrents can prevent a lifetime of antisocial behavior.
Screening Questions for Experiences with Bullying Student
13, she put a loaded gun to her head and pulled the trigger. Her suicide death sent shockwaves throughout her rural Ohio community and made national news.
Bullying is the unwanted, aggressive behavior among youth involving a real or perceived power imbalance and is often
If children state yes or physician has concerns, proceed to ask: What are the “rules” in your school, in town sports, and at home about bullying/hazing? What really goes on? Who do you talk with about bullying? How do adults in your school and at home react to bullying?
repeated over time. Youth who bully use their positon of advantage afforded by size, strength, or status to control or harm others. Verbal and physical bullying are the most obvious forms and include teasing, name-calling, hitting, kicking, and pushing. Social bullying, also called relational bullying, involves hurting someone’s reputation or relationships such as deliberately excluding someone from groups and spreading rumors about someone.
Myriad individual, family, peer, school, and community factors can place youth at risk for being bullied by their peers. Youth who are perceived as different, specifically lesbian, gay, bisexual, or
Open with, “Sometimes kids tell me they get picked on…” then go through the BORRIS questions: Have you been Bullied or Bullied anyone anywhere? Have you Observed bullying going on? How did you Respond? Do you feel like you are Repetitively singled out as a bully or victim? Have you sent or received things over the Internet that you think may represent bullying? Do you feel Stuck in bullying situations?
Parents
Open with, “Sometimes kids bully or are bullied, which can have a big impact on their health and functioning” then go through the WART questions: Have you Witnessed or heard about your child being picked on or picking on other kids? Have there been any recent changes in your child’s Attitude at school or home, school attendance, attention and concentration at school, grades, behavior, mood, socializing, etc.? What are the Rules in your school/town sports/home regarding bullying/intimidation/hazing? Do policies need revision in structure or in implementation? Has your child Talked with you about getting picked on at school, or seeing other kids being bullied?
transgender (LGBT) youth and youth with disabilities, are known to be at increased risk of being bullied when in unsupportive environments. Pediatric Digest, Summer 2017 Page 4
Table Reference: Buxton, D. Potter, MP, Bostic, JQ. (2013) Coping Strategies for Child Bully-Victims. Pediatric Annals; 42(4):57-61.
PEDIATRICIANS
The American Academy of Pediatrics, through The Resilience
CAN PLAY A ROLE IN BULLYING
PREVENTION AND INTERVENTION IN A NUMBER OF WAYS,
Project, has developed resources for pediatricians to effectively
BEGINNING WITH ROUTINELY ASKING ABOUT YOUTHS’
identify and care for youth who have been impacted by bullying.
EXPERIENCES IN SCHOOL. Tell me how school is going?
In an era of increasingly scarce school and community resources,
Sometimes kids get picked on at school, does this happen to
it also is especially important that we turn to programs that have
you? It is also helpful to specifically probe about being bullied
been proven effective at reducing bullying and improving school
when they present with school avoidance, attention problems,
climate. The Dion Initiative for Child Well-Being and Bullying
or psychosomatic complaints. When identified, pediatricians
Prevention (www.dioninitiative.org) is an Arizona-based resource
have the opportunity to educate parents and caregivers on how
and research program that seeks to develop and share evidenced-
to best respond and access support and resources.
based and easily replicable programs to address bullying.
Comprehensively addressing bullying and the cultures and
“WHY
climates that tend to accept, or at least tolerate, bullying will
REPORTEDLY ASKED HER FATHER AS SHE STRUGGLED
require more than individual approaches. It will require
THROUGH BEING BULLIED.
community-wide action. Pediatricians can be a part of creating
NOT THE PROBLEM.
CAN’T
I
BE WHITE LIKE YOU AND MOM?”
IT
THE
EMILY
ONCE
COLOR OF HER SKIN WAS
WAS BULLYING THAT WAS.
this change by being a resource on the issue of bullying to local schools, community leaders and the media.
Introducing AzAAP Senior Coordinator of Health Initiatives: QUALITY OF CARE AND CHILD SAFETY We are pleased to introduce Kim Zill as AzAAP Senior Coordinator of Quality of Care and Child Safety. Kim joined the team in late February of 2017. She is originally from Tennessee, but has been proud to call Arizona home for 17 years. She is alumni of The University of Tennessee- Knoxville. She earned a Bachelor of Science in Psychology and Master of Science in Health Promotion and Health Education.
With more than 20 years’ experience in maternal and child health coupled with a bit of medical sales, coordinating programming around quality of care and child safety is both an exciting and rewarding career.
In this new positon, Kim will be coordinating programming around Adolescent Health, Care Coordination, Newborn Screenings, Child Fatality Review and Prevention, Bullying and Suicide, Safe Sleep, Pediatric Disaster and Emergency Preparedness and Pediatric Prepared Emergency Care.
Kim looks forward to meeting and working with each of the Medical Directors, AzAAP members, staff and other partners to improve the health of all children residing in our state!
FOR
MORE INFORMATION ABOUT
AND
CHILD SAFETY
AZAAP’S QUALITY
HEALTH INITIATIVES, CONTACT
AT KIM@AZAAP.ORG OR
602-532-0137
EXT.
OF
CARE
KIM ZILL
409.
New AzAAP Committee Responding to Findings in Child Fatality Report KATHRYN BOWEN, MD, FAAP | TUCSON, AZ Using data from the Child Fatality Review (CFR) which explores the causes and contributing factors associated with Arizona child deaths to identify recommendations to reduce preventable fatalities of children, AzAAP Child Fatality Prevention Committee members work to develop and create campaigns that influence child health, safety and protection.
In 2015, 768 Arizona children died; 39% (301) of those deaths might have been prevented by employing known interventions and appropriate supervision. 1
The Arizona Child Fatality Review
Program (CFRP) has been providing such data and making prevention recommendations in its annual Kathryn Bowen, MD, FAAP, Chairperson, AzAAP Child Fatality Prevention Committee, Tucson, AZ
report each November for the last 23 years. The data is collected by local multidisciplinary teams organized at the county level that review each child death, ages birth through 17 years, looking at circumstances, risk factors, and preventability. The state CFR team gathers this data and publishes the annual report. Over its lifetime, the CFRP has recorded a decline in child fatalities, but several causes
of death continue to have a major impact on Arizona children. Most pediatric deaths are due to natural causes, especially dur ing the first month of life; happily important decreases in morbidity due to prematurity are being seen. The greatest number of preventable deaths occurs beyond the neonatal age range. Sleep related deaths (29-365 days), drowning (1-4 years), motor vehicle collisions (5-14 years) and firearm deaths (15-17 years) are the leading causes of death among older age groups, and most of these are preventable. Of great concern is that for 11% of Arizona child fatalities, maltreatment, whether physical abuse or neglect, played a role in the child’s death. 1
THE ARIZONA CHAPTER OF THE AMERICAN ACADEMY OF
PEDIATRICS
RECENTLY ESTABLISHED THE
PREVENTION COMMITTEE
CHILD FATALITY
TO RESPOND TO THE FINDINGS OF THE
CFRP. The first issue the committee is focusing on is infant sleep safety. Nearly 10% of all child fatalities in Arizona are sudden deaths among sleeping infants, and 91% of these are considered preventable. Most of these infants have risk factors in their sleep environment that contribute to their deaths.1 While “Back to Sleep” is well known, many caregivers are less familiar with other factors that promote a safe sleep environment: having a firm sleep surface; room sharing but not bed sharing with parents; breast feeding; avoiding tobacco exposure during pregnancy and after; eliminating soft objects from the sleep environment; preventing overheating; considering pacifier use; and avoiding use of alcohol and illicit drugs while caring for infants.2 As pediatricians we are familiar with these recommendations, but we may not be aware of resources and organizations available in our communities such as Baby Boxes, Cribs 4 Kids, and educational materials available from the National Institute of Health (NIH), American Academy of Pediatrics (AAP) and Arizona Department of Health Services (AzDHS) that support the goal of safe infant sleep environments. The committee is developing a directory of these resources and a tool kit of educational materials to aid your efforts with families. We also hope to reach out to programs that deal with particularly vulnerable populations (e.g. substance treatment centers) with similar educational materials.
So what can you do to help with the goal of decreasing deaths among sleeping infants? Continue to provide clear anticipatory guidance and stress the importance of a safe sleep environment for each baby’s health. Become the local “champion”, willing to talk to the media or community groups about this important topic; the AzAAP can help with talking points and information, but local voices carry the most weight. Also, consider joining our committee. It is a small time commitment that we hope will have lasting impact.
References: 1Arizona Child Fatality Review Program. Twenty-third Annual Report. November 2016. Available at http://www.azdhs.gov/documents/prevention/womens-childrens-health/reports-fact-sheets/child-fatalityreview-annual-reports/cfr-annual-report-2016.pdf. Accessed April 7, 2017 2 AAP TASK FORCE ON SUDDEN INFANT DEATH SYNDROME.SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment. Pediatrics. 2016, 138 (5) e20162938; DOI: 10.1542/peds.2016-2938
PARTNERSHIP BETWEEN ASU AND AZAAP TO ASSESS CAREGIVER SLEEP EDUCATION BY AYESHA KHAWAJA, MS AND JESSICA PIRKLE CALLAN, MS In 1992, the AAP recommended infants should
understanding of the caregivers’ personal beliefs
bed at night, in order to avoid falling asleep in a
sleep in a supine position, to combat the
and/or culture in regards to infant sleep.
more dangerous location. The World Health
increasing rates of sudden infant death syndrome,
For many years, the bulk of pediatrician sleep
Organization guide for health professionals urges
and the number of deaths subsequently
education has focused on the ABC’s; that an infant
pediatricians to recognize that most parents will
plummeted. However, in 2015, 78 infants in
should sleep alone, on their back, and in a crib.
end up co-sleeping at some point, for a variety of
Arizona suffered from sleep related or sudden
While such a simplified message is easy to
reasons, and that it is crucial to inform them of
unexpected infant death, and 71 of these deaths
communicate and remember, the reality is that
ways to mitigate the dangers; ensure the parent is
were judged to be preventable. It is evident that
there are many more risk factors which are
sober, bed mattress is firm, avoid overdressing/
preventable infant sleep deaths still regularly
important, and oftentimes, situations require more
overheating, area should be free of pillows,
occur, and national rates have remained virtually
nuanced conversations. This project looked at the
blankets, etc. Furthermore, both organizations
unchanged since the 1990s. In order to address
Child Fatality Review database, which details the
advise pediatricians to share with caregivers the
and ameliorate this problem, our team, a
circumstances around every sleep-related infant
impact of other behaviors on sleep safety, such as
partnership between ASU and the AzAAP launched
fatality in Arizona between 2006 and 2015. Given
avoiding smoke exposure, not using soft or loose
a project with three goals:
the 425 deaths which occurred in adult beds, the
bedding, keeping stuffed animals and pillows out
data was filtered to exclude fatalities where there
of cribs, and promoting breastfeeding. Another
1) Survey Arizona pediatricians to assess the
was suspicion of drug or alcohol use, where the
significant finding was that room-sharing (having
current state of caregiver sleep education.
infant was placed in any position other than supine,
the infant sleep in the room, but on a separate
2) Identify and weigh risk factors which contribute
and where additional children were also sleeping in
sleep surface) can reduce the risk of SIDS by as
to unsafe sleep, by examining and analyzing the
the bed. Of the original 425 fatalities, only 90
much as 50%! Encouraging room-sharing can help
state’s Child Fatality Review database.
remained. In other words, 79% of the deaths could
many parents find the closeness with their baby,
be attributed to risk factors beyond sleeping in an
that they would have otherwise sought through
countries and organizations, and compare these
adult bed. This is reflective of a British Medical
bed-sharing.
with the AAP’s 2016 updated safe sleep policy.
Journal study which found that 90% of co-sleeping
3) Evaluate safe sleep campaigns from different
Our survey respondents indicated that they
deaths were attributable to preventable hazardous
Pediatricians create the best outcomes for their
situations, rather than co-sleeping itself.
patients by cultivating and maintaining a good relationship with the patients’ caregivers. Regular,
believed co-sleeping was the greatest risk infant’s faced, followed by lack of a safe sleep surface,
Tragically, the unqualified message to never share
realistic, and respectful dialogue with caregivers
caregiver substance abuse, and cigarette smoke
a bed with an infant, has resulted in many
about safe sleep influences the environment in
exposure. When it comes to providing adequate in
compliant parents falling asleep on sofas or rocking
which patients spend the majority of their time.
-office education, unsurprisingly, the most
chairs instead, while feeding their infants at night, a
Frank and non-judgmental discussions during each
commonly cited obstacle was lack of time. The
significantly more dangerous scenario. To this end,
caregiver interaction help reinforce the message.
next greatest hurdle was providers lacking
the most recent AAP guidelines recommend that pediatricians advise parents to feed infants in their
Pediatric Digest, Summer 2017 Page 7
AzAAP Health Initiative: Infant Safe Sleep SARA PARK, MD, FAAP | PHOENIX, AZ Dr. Park received her B.A. from the University of Chicago, and her M.D. from the University of Chicago, Pritzker School of Medicine. She completed her residency at the Phoenix Children’s Hospital & Maricopa Medical Center Pediatric Residency Program in 1995. She practiced pediatrics in the private
The Arizona Child Fatality Review Program produces an annual report on child deaths, which includes data on Sudden Unexpected Infant Deaths (SUID) and Sleep related deaths. While not all SUID cases are unsafe-sleep related, there are a considerable number that are due to suffocation and unsafe sleep environments.
practice as well as in the academic setting in Arizona. She taught clinical pediatrics to
THE 23RD ANNUAL REPORT
students from the University of Arizona as
IN
well as Residents at the Phoenix Children’s
2015
Hospital/Maricopa Medical Center Pediatric
include underserved and vulnerable populations and she implemented the
THERE WERE:
78 infant deaths categorized as SUID
deaths in Arizona
Pediatric Refugee Program at MIHS. Dr. Park is also a Clinical Assistant Professor at
ARIZONA
and accounted for 10% of all Child
Residency Program at Maricopa Integrated Health System (MIHS). Her special interests
IN
FOUND THAT
49% of infants died while co-sleeping
Chief Medical Officer, Comprehensive Medical
Suffocation was the cause of death for
and Dental Program, Department of Child Safety, Phoenix, AZ
52 infants
the University of Arizona, Department of
91% of SUID and Sleep related deaths were preventable
Child Health.
THE
and Dental Program (CMDP) in October of
CASES WERE:
2015.
MAJOR RISKS IDENTIFIED IN THESE
An infant placed to sleep
children in out-of-home care in Arizona, it is also part of the Department of Child Safety
on their stomach or side on an unsafe sleeping
(DCS). Her current position as Chief Medical
surface i.e. an adult
Officer at CMDP allows her to remain in the
mattress, couch, chair, soft
patient care realm with evaluation of
object, pillows, or loose
services provided to the members, but also
coverings in the sleep
affords her the opportunity to advocate for
environment
children on a system level. She has taken up this cause with enthusiasm, by taking the opportunity to address the care of children in
System, the Juvenile Justice System, the Division of Developmental Disabilities and the medical community. Her position at CMDP is right up her alley, as she has been able to continue her dedication to serving vulnerable populations, by working with and for the children in out-of-home care.
Pediatric Digest, Summer 2017 Page 8
very important effort. Educating families
in an overheated
judgmental, and culturally sensitive way is the challenge.
CURRENT AAP POLICY STATEMENT RECOMMENDATIONS
TO
RISK
OTHER SLEEP-
INCLUDE:
3.
Breastfeeding is recommended
4.
It is recommended that infants sleep in the parents’ room, close to the parents’ bed, but on a separate surface designed for infants, ideally for the first year of life, but at least for the first 6 months.
5.
preventable deaths.
THE
Use a firm sleep surface
child
to reduce or, dare I say, eradicate these
REDUCE
Back to sleep for every sleep.
Co-sleeping with an adult or other
line effort to educate our patients’ families
AND
2.
Had been exposed to cigarette smoke
As pediatricians, we are part of the front-
SIDS
1.
- either prenatally or postnatal
OF
RELATED INFANT DEATHS
environment
out-of-home care internally with DCS, and externally with the Behavioral Health
Our anticipatory guidance is part of this
on safe sleep in a compassionate, non-
Dr. Park joined the Comprehensive Medical
CMDP is the Medicaid Health Plan for
Sara Park, MD, FAAP,
74 unsafe sleep related deaths
Keep soft objects and loose bedding away from the infant’s sleep area to reduce the risk of SIDS, suffocation, entrapment, and strangulation.
6.
Consider offering a pacifier at nap time and bedtime.
7.
Avoid smoke exposure during pregnancy and after birth.
8.
Avoid alcohol and illicit drug use during pregnancy and after birth.
9.
Avoid overheating and head covering in infants.
10. Pregnant women should obtain regular prenatal care. 11. Infants should be immunized in accordance with recommendations of the AAP and Centers for Disease Control and Prevention. 12. Avoid the use of commercial devices that are inconsistent with safe sleep
RESOURCES
United States CONSUMER PRODUCT
recommendations.
The AAP Policy Statement-SIDS and Other
SAFETY COMMISSION has a 12-minute
Sleep- Related Infant Deaths: Updated
Safe Sleep Video, as well as free posters
monitors as a strategy to reduce the
2016 Recommendations for a Safe Infant
and safety guides that can be found at
risk of SIDS.
Sleeping Environment available at http://
https://www.cpsc.gov/safety-education/
pediatrics.aappublications.org/content/
safety-education-centers/cribs
13. Do not use home cardiorespiratory
14. Supervised, awake tummy time is recommended to facilitate development
early/2016/10/20/peds.2016-2938 The Centers for Disease Control and
and to minimize development of Association of Supportive Child Care’s Child
Prevention has Grief Resources and
Care Injury Prevention Program can
Prevention material that is available at
swaddling as a strategy to reduce the
provide Crib Safety/Safe Sleep training and
https://www.cdc.gov/sids/parents-
risk of SIDS.
distribution of safe cribs and is open to all
caregivers.htm
positional plagiocephaly. 15. There is no evidence to recommend
16. Health care professionals, staff in
parents in Maricopa County. Information
newborn nurseries and NICUs, and child
can be found at http://www.asccaz.org/
The National Institute of Health’s Safe to
care providers should endorse and
prevention.html
Sleep Campaign has free materials that can be ordered and can be found at
model the SIDS risk-reduction Cribs for Kids can help you locate a local
https://www.nichd.nih.gov/sts/materials/
partner who can help provide a family with
Pages/default.aspx (You can find
safe sleep guidelines in their messaging
a free crib or play pen. Information can be
materials specific to certain groups and
and advertising.
found at http://www.cribsforkids.org/find-a
communities here as well)
recommendations from birth. 17. Media and manufacturers should follow
18. Continue the “Safe to Sleep” campaign,
-chapter/ DCS Safe Sleep Campaign involves
focusing on ways to reduce the risk of all sleep-related infant deaths, including
Arizona Department of Health Services has
educating families and providing them with
SIDS, suffocation, and other
some resources and patient education
resources for cribs if needed. DCS has
unintentional deaths. Pediatricians and
material that is free, including a
also initiated their DCS Baby Box program
other primary care providers should
downloadable crib card and Safe Sleep
that requires families to take safe sleep
actively participate in this campaign.
poster in English and Spanish that can be
training and sign a commitment form
19. Continue research and surveillance on
found at http://www.azdhs.gov/
the risk factors, causes, and
prevention/womens-childrens-health/safe-
pathophysiologic mechanisms of SIDS
sleep/
and other sleep-related infant deaths, with the ultimate goal of eliminating
acknowledging that they have been trained on safe sleep practices and are committed to properly using them. Currently, this is a pilot program at DCS, available to families with substance exposed newborns. More Information can
these deaths altogether. Pediatric Digest, Summer 2017 Page 9
Quality of Care and Child Safety Resources **AZAAP ADDRESS
HAS COLLECTED A VARIETY OF RESOURCES TO HELP YOU CONNECT PATIENTS AND FAMILIES TO PROGRAMS AND SERVICES THAT
QUALITY
OF
CARE
AND
CHLD SAFETY (QCCS).
SAFE SLEEP RESOURCES:
receive a box are also required to sign a commitment form that states
AMERICAN ACADEMY
they have been trained on safe sleep practices and are committed to
OF
PEDIATRICS
The American Academy of Pediatrics’ recommendations on creating
properly using them. Email OfficeofPrevention@azdes.gov for more
a safe sleep environment include:
information.
Place the baby on his or her back on a firm sleep surface such as a crib or bassinet with a tight-fitting sheet.
ARIZONA DEPARTMENT
Avoid use of soft bedding, including crib bumpers, blankets,
The Arizona Department of Health Services (AzDHS) recommends
pillows and soft toys. The crib should be bare.
that the safest place for a baby to sleep is in the same room with a
Share a bedroom with parents, but not the same sleeping
parent or caregiver, on a separate sleep surface, such as a safety-
surface, preferably until the baby turns 1 but at least for the
approved crib, bassinet, or playpen, and advertises the ABC’s of Safe
first six months. Room-sharing decreases the risk of SIDS by
Sleep- Alone on my Back in a Crib. AzDHS is collaborating with state
as much as 50 percent.
partners in the safe sleep boxes for babies program.
Avoid baby's exposure to smoke, alcohol and illicit drugs.
http://www.azdhs.gov/prevention/womens-childrens-health/safe-
https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/
OF
HEALTH SERVICES
sleep/
american-academy-of-pediatrics-announces-new-safe-sleep-
CRIBS
recommendations-to-protect-against-sids.aspx
FOR
KIDS®
Cribs for Kids® collaborates with other organizations to spread
SAFE
TO
SLEEP
uniform safe-sleep messages with the intervention of a crib if needed.
Safe to Sleep has various information and materials for many
Since 1998, Cribs for Kids® has been providing safe sleep education
audiences, including parents, grandparents, and health care
with the intervention of a Graco® Pack ‘n Play® portable crib to
providers. For more information on safe sleep, visit the National
families who cannot otherwise afford a safe place for their babies to
Institute of Health Safe to Sleep campaign.
sleep.
http://www.nichd.nih.gov/sts/
http://www.cribsforkids.org/
MARCH
OF
DIMES
Put your baby to sleep on his back on a flat, firm surface, like
BULLYING AND SUICIDE PREVENTION RESOURCES:
a crib or bassinet.
AMERICAN ACADEMY
Don’t bed-share. Put your baby to sleep in his own crib or
Through funding from the Department of Justice, the American
bassinet.
Academy of Pediatrics has developed resources for pediatricians and
March of Dimes safe sleep recommendations include:
OF
PEDIATRICS—THE RESILIENCE PROJECT
March of Dimes is participating with the baby safe sleep boxes
medical home teams to more effectively identify and care for children
distribution in Arizona.
and adolescents who have been exposed to violence. The Resilience
http://www.marchofdimes.org/baby/safe-sleep-for-your-baby.aspx
Project website is designed to provide pediatricians and medical home teams with information and resources needed to modify practice
DEPARTMENT
OF
CHILDREN’S SERVICES
OF
ARIZONA
operations to more effectively identify, treat, and refer children and
The Department of Children’s Services’ (DCS) safe sleep campaign
youth who have been exposed to or victimized by violence. While
involves educating families about safe sleep practices and
exposure to violence is traumatic, children and youth can heal and
providing them with resources for cribs if needed. The DCS Safe
continue to thrive with the support of their medical home and the
Sleep Box program also helps to spread the word about safe sleep
community around them. Resources address areas such as bullying
practices by requiring parents of newborns to complete a safe
and cyberbullying, child abuse and neglect, teen dating and sexual
sleep training prior to receiving their safe sleep box. Parents who
violence.
Pediatric Digest, Summer 2017 Page 10
https://www.aap.org/en-us/advocacy-and-policy/aap-health-
outlines the Council’s efforts to foster and expand State and National
initiatives/resilience/Pages/About-the-Project.aspx
collaboration and innovative research. http://endsextrafficking.az.gov/
THE COLUMBIA LIGHTHOUSE PROJECT The Columbia Lighthouse Project (formerly the Center for Suicide
TRUSTAZ.ORG
Risk Assessment) aims to save lives worldwide by making the
Training and Resources United to Stop Trafficking (TRUST) helps
Columbia-Suicide Severity Rating Scale (C-SSRS) use universal.
spread awareness about the warning signs of sexual abuse in younger
They also help people integrate the C-SSRS into a broader suicide
children and teens and sexual exploitation and human trafficking.
prevention program.
http://trustaz.org/
http://cssrs.columbia.edu/about-the-project/about-the-lighthouse-
PEDIATRIC DISASTER AND EMERGENCY PREPAREDNESS RESOURCES:
project/
SUBSTANCE ABUSE
AND
MENTAL HEALTH SERVICES
PEDIATRICS PREPARED EMERGENCY CARE (PPEC)
ADMINISTRATION
Pediatric Prepared Emergency Care (PPEC), a voluntary hospital
The connection between bullying and suicide is often
certification program, is a partnership between hospitals, physicians,
oversimplified, when, in fact, it is very complex. Many issues
nurses, and emergency personnel, the AzAAP, and the Emergency
contribute to suicide risk, including depression, substance use,
Medical Services for Children program at the Arizona Department of
problems at home, and trauma history. A panel of experts
Health Services. Through certification, emergency departments show
published these and other findings in 2013 on the relationship
they have met specific criteria, developed by a broad group of
between these two public health problems in the Journal of
stakeholders, for personnel training, policies, quality improvement
Adolescent Health. A Community Action Toolkit provides
activities, equipment and facilities that support optimal care for ill or
suggestions for identifying and responding to bullying, and seeking
injured infants, children, and teens.
help.
www.azaap.org/Pediatric_Prepared_Emergency
https://www.samhsa.gov/suicide-prevention/bullying
HEALTH DION INITIATIVE
AT
ARIZONA STATE UNIVERSITY
AND
HUMAN SERVICES—CENTER
FOR
MENTAL HEALTH
SERVICES
The Dion Initiative for Child Well-Being and Bullying Prevention is
Responding to the disaster-related needs of children is unlike any
a resource and research program that promotes environments that
other type of work with children. It is distinct because it always
foster the health, well-being, and academic success of children.
involves helping children and their support systems cope with the
The Dion Initiative for Child Well-Being and Bullying Prevention is
emotional impact of a traumatic event. The U.S. Department of
committed to promoting environments that foster the health, well-
Health and Human Services - Substance Abuse and Mental Health
being, and academic success of children. To accomplish this, the
Services Administration (SAMHSA) - Center for Mental Health Services
Dion Initiative brings together renowned educators, dedicated
- offers a publication for caregivers with information about providing
direct service providers, and private-sector innovators to create a
disaster mental health services and consultation.
greater understanding of the obstacles our children face and to
http://store.samhsa.gov/shin/content/ADM86-1070R/ADM86-
develop and share evidenced-based and easily replicable programs
1070R.pdf
that overcome those obstacles. https://www.dioninitiative.org/
AMERICAN ACADEMY
OF
PEDIATRICS—DISASTER PREPAREDNESS
ADVISORY COUNCIL
HUMAN TRAFFICKING AND COMMERCIAL SEXUAL EXPLOTATION RESOURCES:
Pediatricians often serve as expert advisors to local, state and federal agencies in disaster and terrorism preparedness. AAP’s Disaster Preparedness Advisory Council has created a 3-5 year Strategic Plan
ARIZONA HUMAN TRAFFICKING COUNCIL
to address these topics. For further information:
The Arizona Human Trafficking Council 2016 Annual Report details
https://www.aap.org/en-us/advocacy-and-policy/aap-health-
the Council’s many achievements and activities. The report
initiatives/Children-and-Disasters/Pages/default.aspx or
highlights training accomplishments, outreach and awareness
http://bit.ly/1LfNyVk
activities and victim services improvements. The report also
Pediatric Digest, Summer 2017 Page 11
NEWBORN SCREENING RESOURCES:
http://www.thenationalalliance.org/
ARIZONA DEPARTMENT
ADOLESCENT SEXUAL & REPRODUCTIVE HEALTH EDUCATION
OF
HEALTH SERVICES
The Arizona Department of Health Services Office of Newborn
PROJECT
Screening is charged with the responsibility of ensuring that the
Physicians for Reproductive Health’s Adolescent Reproductive and
testing for congenital disorders, critical congenital heart defects,
Sexual Health Education Program (ARSHEP) has created a
and hearing loss are conducted in an effective and efficient
comprehensive, evidence-based curriculum for residency programs,
manner. The program provides education to the general public, the
providers, and other professionals who serve adolescents on critical
medical community, parents and professional groups.
reproductive and sexual health topics. The modules are available for
www.aznewborn.com/
download at the website listed below. ARSHEP also prepares a select group of physicians to give free educational sessions to other
HEALTHYCHILDREN.ORG
providers about the best practices for adolescent health education.
The American Academy of Pediatrics HealthyChildren.org website
https://prh.org/teen-reproductive-health/arshep-downloads/
provides pediatrician-recommended and trusted information for parents about the importance of newborn screening.
ADOLESCENT HEALTH WORKING GROUP
https://www.healthychildren.org/English/ages-stages/baby/Pages/
The Adolescent Health Working Group (AHWG) is a coalition of
Newborn-Screening-Tests.aspx
committed youth, adults, and representatives of public and private agencies whose mission is to significantly advance the health and well
EAR FOUNDATION
OF
ARIZONA
-being of youth and young adults. While some of the resources are
The Ear Foundation of Arizona works in the area of newborn
California specific, they have a vast variety helpful resources for
hearing screening and seeks mandatory hospital screening of all
patients, providers, and youth in the areas of adolescent consent and
infants born in Arizona's hospitals. The Ear Foundation of Arizona
confidentiality, sexual health, and trauma and resilience, among
provides programs for children such as the “HEAR for Kids” which
others.
provides loaner hearing aids, and “HEAR to Train” which provides
http://www.ahwg.net/index.html
training modules for those who wish to become hearing screeners. Otoacoustic Emissions (OAE) screening equipment and
HEALTH
audiometers are also available for loan at no cost to schools and
Leading the nation to ensure that America’s adolescents thrive and
non-profit programs.
become healthy, productive adults. The Office of Adolescent Health
https://www.earfoundationaz.com/programs
(OAH) is dedicated to improving the health and well-being of
AND
HUMAN SERVICES-OFFICE
OF
ADOLESCENT HEALTH
adolescents. OAH leads through promoting strength-based
CENTERS
FOR
DISEASE CONTROL
approaches, bolstering multi-sector engagement, and bringing in
According to the Centers for Disease Control, all babies are
youth voices to support healthy development and transitions to
screened, even if they look healthy, because some medical
productive adulthood. Authorized by the Public Health Service Act,
conditions cannot be seen by just looking at the baby. Finding
OAH supports research, services, prevention and health promotion
these conditions soon after birth can help prevent some serious
activities, training, education, partnership engagement, national
problems, such as brain damage, organ damage, and even death.
planning, and information dissemination activities.
https://www.cdc.gov/newbornscreening/
https://www.hhs.gov/ash/oah/
ADOLESCENT HEALTH RESOURCES:
POSSIBILITIES
NATIONAL ALLIANCE
Rapid Assessment for Adolescent Preventive Services (RAAPS) Public
TO
ADVANCE ADOLESCENT HEALTH
FOR
CHANGE
The National Alliance to Advance Adolescent Health is devoted to
Health, developed in partnership with the American Public Health
education, policy analysis, technical assistance, and advocacy in
Association, for enhancing the Rapid Assessment for Adolescent
support of long-term, systemic improvements in comprehensive
Preventive Services© (RAAPS), to further identify youth most at risk
health care and insurance coverage for adolescents. The website
for school drop-out, based on factors such as discrimination, abuse,
contains resources in areas relevant to adolescent health including
and access to tangible needs (food, water, electricity). The
healthcare transition, adolescent consent and confidentiality, and
assessment has a billable component for medical providers.
delivery systems recommendations and innovations for
http://www.possibilitiesforchange.com/raaps/
adolescents.
Pediatric Digest, Summer 2017 Page 12
Human Trafficking: Understanding a Pediatrician’s Role in Helping Child Victims MRS. CINDY MCCAIN| PHOENIX, AZ
H
uman trafficking is a heinous crime of exploitation of which many of the victims are children. Victims of trafficking are abused and manipulated to provide forced labor or
commercial sex for the financial benefit of their trafficker. The crime is widely misunderstood by the general public and the term human trafficking typically conjures images of children in far away countries being kidnapped and sold for sex and labor. The shocking reality is that human trafficking is happening in our own backyards, right here in the U.S. and Arizona and the
“These children need our help and pediatricians are a key line of defense in protecting, identifying and rescuing victims from human trafficking,”
Mrs. Cindy McCain, Co-Chair Arizona Human Trafficking Council, Phoenix, AZ
vast majority of child trafficking victims are American children, sold to American buyers for sex. Local studies have demonstrated the
significant weight loss (WHO, 2012). Distinct physical effects of
average age a youth is first sex trafficked in Arizona is just 14 years
trafficking may include some form of tattoo or branding, bruising,
old (Roe-Sepowitz, 2013). Another recent report on 1,416 traffickers
scars, burns, ligature marks or broken bones. Emotionally, victims
across the country revealed there are traffickers who specialize in
may demonstrate as depressed, suicidal, and hopeless, and may
targeting children because of their increased vulnerability and ability
suffer from PTSD, disassociation, disorientation, anxiety, panic attacks
to be controlled (Roe-Sepowitz, 2017).
and addiction.
As mandated reporters in all 50 states, healthcare providers, and
Human trafficking victims have experienced very complex physical,
especially pediatricians, play a crucial role in keeping children safe.
sexual and emotional trauma, and are often difficult to treat or
Healthcare providers are one of the few professional groups who
unwilling to immediately receive help. That is why it is important to
interact with victims while they are still under the control of their
remember that anyone under the age of 18 involved in forced labor or
abuser (Issac, Solak & Giardino, 2011). A trafficking survivor health
the commercial sex industry is automatically a victim of trafficking
survey by Global Centurion showed that 87.8% of sex trafficking
under federal law. There is no such thing as a child prostitute! These
victims were seen by a healthcare professional at least once during
children need our help and pediatricians are a key line of defense in
the time they were trafficked. Unfortunately, similarly to victims of
protecting, identifying and rescuing victims from human trafficking .
domestic violence, victims of trafficking tend to hide their situation and are hesitant to disclose their victimization in medical or clinical
RESOURCES
settings. They are often very isolated and disoriented, and believe
ASU Office of Sex Trafficking Intervention Research Healthcare
there is no one that can help them out of their situation. Victims are
Professional Training Brochure http://endsextrafficking.az.gov/sites/
controlled by trauma bonds and threats of physical and sexual
default/files/sextraffickingasuhealthcarebrochure.pdf
violence that keep them from speaking out about their abuse. Further, a child’s trafficker may be their parent or guardian whose
U.S. Department of Health and Human Services – Pediatric Brochure
presence in the room would be preventative to a disclosure.
http://humantraffickingmed.stanford.edu/documents/ pediatric_health_care_provider_brochure.pdf
Pediatricians must be trained to understand the red flags and ask the right questions in order to develop trust and potentially help a victim
National Human Trafficking Resource Center Healthcare Assessment
out of a trafficking situation. Victims commonly present with fatigue,
Tool https://traffickingresourcecenter.org/sites/default/files/
headaches, sexual and reproductive health problems, back pain and
Healthcare%20Assessment%20-%20FINAL%20-%202.16.16.pdf
Pediatric Digest, Summer 2017 Page 14
NEWBORN SCREENING IN ARIZONA: THE CASE FOR TREC SCREENING FOR SCID (SEVERE COMBINED IMMUNODEFICIENCY)
DIANA HU, MD, FAAP | TUBA CITY, AZ
2016 was the 100th anniversary of
the birth of Dr. Robert Guthrie, physician and PhD biochemist who
created the “Guthrie test”- the first rapid screening test for a newborn
metabolic disease- in 1957. Using a filter paper, a few drops of
newborn blood, and the principle of bacterial inhibition by normal vs. abnormal metabolites in the blood
The condition should be an
screening technology is developed
important health problem.
daily.
There should be a treatment for the condition.
In 2010, the TREC (T Cell Receptor
There should be a latent stage of
Excision Circle) assay as a screening
the disease.
test for T cell immunodeficiencies was
There should be a test or
added to the RUSP. Data from
examination for the condition.
universal screening in other states has
The test should be acceptable to
shown that previously delayed
the population.
diagnosis of cases of SCID and other t
of an affected baby, he developed the initial test for Phenylketonuria (PKU) in 3 days. He refined it for years afterwards, and he also developed simple mass screening tests for 4 other disorders tested in
cell immunodeficiencies like DiGeorge There also needs to be access to the
syndrome, Omenn syndrome, or
treatment, both financially and
“leaky” SCID are more prevalent than
physically, for those patients screened and verified to have the condition.
newborn screening. In addition, he led a revolution in how to implement newborn screening.
The conditions screened for in routine newborn screening are exactly those conditions. Since 2003, the
WHY
SCREEN NEWBORNS?
Recommended Uniform Screening Panel
As pediatricians, we know that many
(RUSP) has been updated by the
babies are born with physically
secretary of Department of Health and
undetectable diseases that will progress
Social Services (DHSS) as technology,
and change, and sometimes by the
science, resources and ethics converge
time the physical diagnosis or medical
to add new disorders and refine testing
condition becomes apparent, it can be
to screen for more treatable conditions.
too late to cure, treat, or prevent irreparable damage. The 1968 WHO
Fast forward to 2017. Technology has
principles on screening for medical
changed, and there are over 60 tests
conditions are simple and still hold true
that have been developed for newborn
Diana Hu, MD, FAAP
screening, 31 of which are in the RUSP.
MCH Consultant: NAIHS, Chief Clinical Consultant
today:
Tandem Mass Spectrometry has replaced old technology. New
in Pediatrics: NAIHS, Pediatrics: Tuba City Regional Health Care Corporation, Tuba City, AZ
Pediatric Digest, Summer 2017 15
previously thought- but most
ADVOCACY HIGHLIGHT
importantly, morbidity and mortality of
In January 2017, after many years of
affected children is changed by early
advocacy by the AzAAP, the March of
identification and treatment. Done in
Dimes, the Immune Deficiency
bulk, the test costs about $6 per baby
Foundation, the Jeffrey Modell
screened- potentially with millions of
Foundation, and other stakeholders,
dollars saved per baby with early
Governor Ducey acknowledged that our
treatment.
state needed to address this issue to protect these vulnerable children and to
Unfortunately, Arizona is one of only 3
protect pediatric providers from
states not using the TREC screening
inadvertently giving a live virus vaccine
assay for uniform newborn testing-
to an immunodeficient child at 6 weeks
despite knowing we may have a higher
of age! Let’s hope that the legislature
incidence per capita than other states.
and Governor’s office continue to
We have the highest population
recognize how public health, science,
percentage of Athabascan Native
and fiscal responsibility can all be
Americans in the lower 48 states- who
achieved as TREC screening is
have an incidence of SCID (4-10 times
implemented.
higher than the general population). We have a high population of Hispanic
NEW—ARIZONA PASSED A BILL REQUIRING SCID SCREENING FOR ALL NEWBORNS
newborns who have the second highest incidence of SCID. After several years of advocacy, we are pleased to announce that Governor Ducey signed legislation at the close of the 2017 Legislative Session to allow the Arizona Department of Health Services Public Health Laboratory to test for Severe Combined Immunodeficiency (SCID), a severe, life -threatening disorder that can be treated and cured if detected early in a newborn screen.
“This practical policy puts Arizona infants on the right track to a healthy start in life,” said Governor Ducey. “Empowering our state lab to test for this treatable genetic disorder will save and improve the lives of people across Arizona.” (azdhs.org news release May 24)
The department expects to have this screening capability added to its newborn screening panel in August 2017, and AzAAP is working with the Office of Newborn Screening to keep members informed about the screening implementation and process.
Recommendations for Child Fatality Prevention: Addressing an Increase in Deaths Due to Maltreatment Cases in Arizona MARY RIMSZA, MD, FAAP | TUCSON, AZ The Arizona Child Fatality Review Program (ACFRP) was created by statute in 1993 and identifying preventable deaths, especially those due to child abuse/neglect or accidents, has been a major focus of its work. The increase in the numbers of deaths due to maltreatment since the program's inception is staggering. While deaths due to other causes (e.g. motor vehicle crashes) have declined, child abuse/ neglect deaths have increased. In 1995, ACFRP identified 16 child abuse/neglect deaths. In 2015,
Mary Ellen Rimsza, MD, FAAP,
ACFRP identified 87 deaths due to abuse/neglect and the percentage of deaths that were due to abuse/
AzAAP Board of Directors Member, Chair, Arizona Child Fatality Review,
neglect has increased from 1.8% in 1995 to 11% in 2015.
Tucson, AZ Some of the increase in the percentage of deaths identified by the ACFRP over the past 20 years may be due to improvements in our review process. Since 1995, we have improved the training of local teams on the identification of maltreatment deaths and also added a "second level" review of suspected maltreatment deaths identified by local teams. Currently, a local, county-based ACFRP team, which includes a pediatrician, reviews the death of every child under 18 years old in their community who has died. By statute, these teams have access to the child’s autopsy report, hospital records, Department of Child Safety (DCS) records, and other documents that can provide us with insight into the cause and preventability of each child’s death. The second-level review is done by a team which includes 3 pediatricians with expertise in abuse/neglect as well as a DCS representative who is able to share with us their records on the family's current and past involvement with DCS. While these changes have improved our ability to identify abuse/neglect deaths, they have been in place for many years, so un fortunately the continuing increase in maltreatment deaths is not simply due to better identification of these deaths.
IN 2016,
THE
ACFRP
REVIEW OF THE
MALTREATMENT
DEATHS:
2015
USED THE KEY FINDINGS FROM
MALTREATMENT DEATHS TO MAKE
RECOMMENDATIONS FOR PREVENTION.
INVOLVEMENT WITH ANY CHILD PROTECTIVE SERVICES AGENCY,
OUR
KEY
FINDINGS IN REVIEWING THESE DEATHS WERE:
ARIZONA, 2015
100
87
90
60
no cps history
53
cps history
50 40
34
30
17
20 10
80% of the children who died due to abuse/neglect
were less than 5 years old
80 70
100% of these deaths were preventable
61% of the deaths were associated with substance
abuse/use
61% of the children (n=53) were from families who had
prior involvement with a child protection agency and 17 of
open cps at time of death
these 53 children were from families that had an open case
total maltreatment cases
at the time of the child’s death
African American and American Indian children were
more likely to die from abuse/neglect than other racial
0
groups
2015
Pediatric Digest, Summer 2017 Page 18
AS
A RESULT OF THESE FINDINGS, SOME OF THE
ACFRP
RECOMMENDATIONS WERE TO:
Increase funding for childcare assistance programs so that all low-income working families can have access to safe child care for their children and are not forced to use caregivers who may harm or neglect their child
The Arizona Legislature should ensure there is sufficient funding for DCS and community based services Expand public awareness campaigns about child abuse/neglect reporting laws and effective prevention programs Improve collaboration between home visiting programs, law enforcement and DCS Increase training for law enforcement agencies on the recognition of signs and symptoms of abuse/neglect Provide sufficient funding for timely behavioral health and substance abuse assessment and treatment services for parents and their children
In 1995, the leading cause of preventable death was motor vehicle crashes (MVCs). These MVC deaths have declined dramatically from 1995 when 114 children died (10.1/100,000 children) to 88 children (3.9/100,000 children) in 2012. Over the past 25 years, the ACFRP has made recommendations to reduce MVC deaths such as enactment of laws mandating the use of infant car seat, booster seat, and seat belt use; tougher DUI laws; and graduated drivers license legislation. These joint community-wide efforts have paid off for Arizona's children and our success in reducing child deaths due to MVC serves as a model for how community action and legislative efforts can reduce deaths and should provide encouragement for us on efforts to reduce deaths due to abuse as well.
PEDIATRIC HEALTHCARE PROVIDERS HAVE THE RIGHT TO KNOW THE OUTCOME OF DEPARTMENT OF CHILD SAFETY INVESTIGATIONS In an effort to assist our members in the ongoing care for their patients and families, we have created a one-page information sheet on how to follow-up on Department of Child Safety (DCS) reports. To the right is a summary of the legislation that gives pediatricians and other healthcare professionals the right to follow-up on their patients if they are the reporting source. To download the DCS One-Pager Information Sheet, visit http://www.azaap.org/resources/Documents/ DCS%20One-Pager%20Information% 20Sheet.pdf
Pediatric Digest, Summer 2017 Page 19
Focus on Pediatric Emergency Preparedness TONI GROSS, MD, MPH, FAAP | PHOENIX, AZ PEDIATRICIANS
AND OTHERS WHO
and services can be restored as quickly
CARE FOR CHILDREN SERVE AS A
as possible. Individual and family
VALUABLE ASSET FOR COMMUNITY
resources, as well as business resources,
RESILIENCY. Because disasters impact
are available at the https://
locally, it is important for each
www.ready.gov/publications
community to consider likely potential
website. The AAP has created a
emergency situations, and to mitigate,
Preparedness Checklist for Pediatric
prepare, respond, and recover when
Practices (http://www.azaap.org/
events overwhelm usual resources. The
resources/Documents/
communities of Arizona come from
PedPreparednessChecklist.pdf), as well as
various geographic, topographic, and
the Pediatric Preparedness Resource Kit
cultural settings; therefore, potential
(https://www.aap.org/en-us/advocacy-
disasters may differ from one community
and-policy/aap-health-initiatives/Children
preparedness. The Collaborative serves
to another. Practices are encouraged to
-and-Disasters/Pages/Pediatric-
as the managing partner of the Arizona
consider which scenarios are most likely
Preparedness-Resource-Kit.aspx).
Pediatric Disaster Coalition (http://
to cause a serious disruption to normal
Toni Gross, MD, MPH, FAAP, AzAAP Chapter Contact for Disaster Preparedness, Phoenix, AZ
apdcaz.org/) as well as the National The state has several coalitions that
Pediatric Disaster Coalition (http://
facilitate collaboration among healthcare
www.npdcoalition.org/) and supports
Nothing better prepares individuals and
and community organizations, as well as
training events and Significant Event
communities for a disaster like everyday
a Bureau of Public Health Emergency
Readiness Forums.
readiness. Consider a little league
Preparedness (http://azdhs.gov/
baseball or soccer team – preparation
preparedness/emergency-preparedness/
PEDIATRIC
with exercise, practice, and scrimmage
index.php) to detect and respond to
BE AWARE OF THE RESOURCES FOR
games will increase the likelihood of
public health emergencies. Four regional
PEDIATRIC EMERGENCIES AT THEIR
excellent performance when the time
healthcare coalitions exist in Arizona
LOCAL HOSPITALS.
comes for playing in an important
(http://azdhs.gov/preparedness/
HOME TO
tournament. The same is true for our
emergency-preparedness/
EMERGENCY CARE,
office, hospital, and community
index.php#healthcare-coalitions-home).
VERIFICATION PROGRAM AVAILABLE
resiliency. The better we perform every
Each coalition performs preparedness
TO EMERGENCY DEPARTMENTS ACROSS
day, the easier it will be for us to step up
activities, including hazard vulnerability
THE STATE.
our game when a disaster strikes.
assessments, training, and exercises.
INVOLVED IN MAKING SURE YOUR
Healthcare providers should at a very
The Coyote Crisis Collaborative (http://
COMMUNITY HAS THE HIGHEST LEVEL
minimum have a personal plan for
coyotecampaign.org/) is an entity that
OF BASELINE PEDIATRIC
themselves and their family, to ensure
supports other coalitions and
PREPAREDNESS IS TO SUPPORT LOCAL
that they can provide services during a
associations, performing gap analyses
HOSPITAL LEADERS TO IDENTIFY
disaster. Also important is to have a
and providing tools, training, resources,
PEDIATRIC CHAMPIONS WITHIN THEIR
business continuity plan, so that our
and information to facilitate continuous
WALLS AND TO DETERMINE IF
patients’ medical records are preserved
improvement in community disaster
MEMBERSHIP CAN BE OBTAINED.
operations.
Pediatric Digest, Summer 2017 Page 20
CARE PROVIDERS SHOULD
THE AZAAP
IS
PEDIATRIC-PREPARED
A
A VOLUNTARY
GREAT WAY TO GET
PPEC
The program offers many benefits to
pediatric emergencies not only benefits
with federal or other volunteer medical
member hospitals, including an in-person
the children of Arizona, but also supports
reserve corps, such as the Emergency
site visit and electronic resources to
the resiliency of EMS providers who want
System for Advance Registration of
improve the ability to handle pediatric
to be prepared for the difficult cases they
Volunteer Health Professionals (https://
emergencies. Another area for pediatric
often treat.
www.phe.gov/esarvhp/Pages/about.aspx)
care providers to contribute their
or a Community Emergency Response
expertise is local Emergency Medical
Finally, pediatric care providers can be at
Team (https://www.fema.gov/community
Services (EMS) systems. Ensuring that
the ready to provide care during times of
-emergency-response-teams).
our EMS providers are ready to care for
urgent need by registering ahead of time
Children Shouldn’t Be Penalized for Where They Live PEGGY STEMMLER, MD, MBA, FAAP AND TOMI ST. MARS, MSN, RN, CEN, FAEN | PHOENIX, AZ
I
magine that you’re camping with your family near Greer. Your young child jumps from a rock, lands awkwardly and screams. Minutes later, after splinting her clearly broken arm, you’re in the car heading to… where? Which emergency department will you choose to care for your child?
Most families will drive to the nearest ED, confident that the services include all equipment, staff training, policies and procedures that will meet the needs of their child. As a pediatric professional, you probably guide your patients to certain facilities and away from others. AzAAP’s Pediatric Prepared Emergency Care program provides a layer of assurance that has now been shown to save lives.1
There are well-documented differences in the quality of care and services for children in emergency departments across the country.2,3,4 Periodic surveys assessing the pediatric readiness of
Peggy Stemmler, MD, MBA, FAAP,
Tomi St. Mars, MSN, RN, CEN,
Chair, AzAAP Pediatric Prepared
FAEN, Vice Chair, AzAAP Pediatric
EDs across the US have shown that many EDs still have
Emergency Care (PPEC) Steering
Prepared Emergency Care (PPEC)
significant room for improvement. 5 In 2013, 77 Arizona EDs
Committee, Director, FrameShift
Steering Committee, Chief, Office of
participated in this national survey. The average score – 72 of 100 – bested the national average of 69, but there is still room
Group, Phoenix, AZ
Injury Prevention, Arizona Department of Health Services, Phoenix, AZ
for improvement.
AzAAP’s Pediatric-Prepared Emergency Care program was established in 2008 to improve outcomes for Arizona’s ill and injured children through a system of regionalized pediatric emergency care. Our goal – no child should be penalized by where they live and seek care.
Pediatric Digest, Summer 2017 Page 21
Recent data show that this certification matters. Injury-related mortality at certified facilities has dropped compared with peer non-certified sites.
FIGURES 1,2 FIGURE 1 Based on the model of the Arizona Perinatal Trust, Pediatric-Prepared Emergency Care is a partnership between AzAAP, the Emergency Medical Services for Children program at the Arizona Department of Health Services, and participating hospitals, physicians, nurses, and emergency personnel throughout the state. Through the voluntary verification process, emergency departments show they have met specific criteria, developed by a broad group of stakeholders, for personnel training, policies, quality improvement activities, equipment and facilities that support optimal care for ill or injured infants, children, and teens.
Site visits are conducted by volunteer emergency health care professionals, with programmatic support and oversight by a
FIGURE 2
multidisciplinary Steering Committee working under the auspices of the AzAAP.
Pediatric-Prepared Emergency Care opened for membership in August 2011. Currently 30 facilities have been certified under the threelevel system: Advanced Care, Prepared Plus Care, or Prepared Care. Many have undergone the verification process for several 3-year cycles. Understanding, aligning and balancing the needs for children and families to receive optimal care in their home communities with the realities of a state in which tertiary care is concentrated in a few urban communities, is an on-going challenge. Pediatric Prepared Emergency Care continues to build a system of care that meets the needs of our diverse state. FOR MORE INFORMATION, VISIT HTTP://AZAAP.ORG/
PEDIATRIC_PREPARED_EMERGENCY/
References: 1
Rice A, Dudek J, et al. The impact of a pediatric emergency department facility verification system on pediatric mortality rates in Arizona. JEM 2017: http://dx.doi.org/10.1016/j.jemermed.2017.02.011
2
Seidel JS, Hornbein M, Yoshiyama K, Kuznets D, Finklestein JZ, St Geme JW Jr. Emergency medical services and the pediatric patient: are the needs being met? Pediatrics 1984;73:769–72.
3
Institute of Medicine. Emergency medical services for children. Washington, DC: The National Academies Press; 1993.
4
Gausche-Hill M, Schmitz C, Lewis RJ. Pediatric preparedness of US emergency departments: a 2003 survey. Pediatrics 2007;120: 1229–37.
5
http://pedsready.org/ Accessed April 19, 2017
Pediatric Digest, Summer 2017 Page 22
SAFE SLEEP IS AS EASY AS A-B-C VANESSA BUSTILLOS, MEd | STATEWIDE PREVENTION COORDINATOR | DCS supervisors. Once a DCS staff member is trained in
receives a Baby
safe sleep, they can offer families baby boxes. Prior
Box will also
to receiving a baby box, parents must complete a
receive a
safe sleep training with a DCS staff member and
health care kit
sign a commitment form stating they have been
along with
trained on safe sleep practices and are committed
other donations
to properly using them. DCS has also partnered
from the
with provider agencies in the community to help
community.
According to the Arizona Child Fatality Review,
spread the Safe Sleep message among families in
The donated
unsafe sleep environments claimed the lives of 74
Arizona.
baby items include electrical outlet covers, pacifiers (which help reduce the risk of SIDS), hygiene
Arizona infants in 2015. Of those sleep-related deaths, over 90 percent of them were deemed
Baby Boxes are an affordable alternative to cribs
preventable. These numbers caught the attention
and have proven to help reduce infant mortality
of the Department of Child Safety’s (DCS) Office of
rates in Finland over the past 75 years. According
Each box also contains a parent information folder
Prevention.
to “Statistics Finland”, Baby Boxes decreased the
that includes brochures and flyers for important
infant mortality rate from 65 deaths per each
topics such as Early and Periodic Screening,
Part of the Department of Child Safety’s (DCS)
1,000 infants born in 1938 to 3 deaths per 1,000
Diagnostic and Treatment (EPSDT), developmental
Strategic Plan is to expand the Office of Prevention.
births in 2013. DCS became aware of Finland’s
charts, tips for soothing a fussy baby, and other
The office focuses their efforts on preventing child
baby box program and
abuse and neglect, as well as injury prevention.
decided it would be a
One of the prevention initiatives is the Safe Sleep
good fit for the families
baby boxes or cribs is not
Campaign. The Safe Sleep Campaign promotes the
served by the
enough, we must always pair it
ABC’s of Safe Sleep: baby sleeps safest ALONE, on
department. In addition
with Safe Sleep education.
their BACK, and in a CRIB.
to providing baby boxes,
items, and sleep sacks.
important parent information.
ACTUAL DCS BABY BOX
Simply giving resources like
DCS chose to add an
Safe Sleep education starts at
To help spread the word about safe sleep and
educational component to
the hospital when babies are
prevent infant deaths in Arizona, the Department
their program as well as a
born, but it should continue at
of Child Safety is also launching the “DCS Baby Box
system to collect data.
every pediatrician visit, every
Program” for parents involved with the
DCS hopes these boxes
Home Visitor visit, and any other
department. “Every child’s death is a tragedy,” said
will help Arizona families keep their infants
program that involves parents of newborns.
DCS Director Greg McKay. “But when a child’s
sleeping safely.
Although the DCS Baby Box program is new, we have already seen a trend among parents involved
death is preventable, it’s even more devastating. So DCS is doing everything it can to provide
DCS chose to distribute Baby Boxes for multiple
in the program; most of the parents admitted to co
Arizona’s children with a safe place to sleep and to
reasons. The boxes are an affordable alternative to
-sleeping prior to receiving a baby box. Requiring
eliminate preventable sleep-related deaths.” The
cribs which means more families can have access
the parents to be trained prior to receiving a baby
baby box is intended to be used as a portable crib
to them. They are also more portable than other
box will hopefully encourage these parents to
for infants, and all parents involved with DCS are
sleep alternatives and have proven to be helpful for
adhere to Safe Sleep practices. DCS hopes the
eligible for this program.
families who move often. The boxes also save
message of Safe Sleep does not end there and that
space for families who may be sharing their room
the community (especially health care providers)
The goal is to minimize the risk of an infant dying
or house with other family members. Most
will help keep the conversation going.
due to unsafe sleep conditions by educating
importantly, these boxes can be carried to different
parents on safe sleep practices such as the ABC’s
rooms in the house which could prevent parents
Safe Sleep education can start with a simple
of Safe Sleep. The Office of Prevention is working
from placing infants on sofas or other items of
question: “Where does your baby sleep?” Speaking
toward training all field DCS specialists and
furniture that are not safe. Each family that
to parents in a culturally sensitive way and
providing the facts can help to change their mind
-Avoid overheating by dressing the infant
dcs.az.gov/dcs-services/prevention/safe-sleep or
about how their baby should sleep. No matter what
appropriately for the environment and utilizing
email OfficeofPrevention@azdes.gov.
your role is in the community, you can help spread
sleep sacks (when available).
the word. Safe Sleep is as simple as ABC: baby
-Make sure the sleep space is always smoke free.
sleeps safest ALONE, on their BACK, and in a CRIB.
References Arizona Child Fatality Review (CFR) Program. “Twenty-third Annual Report”. 15 Nov. 2016. http://azdhs.gov/documents/
BABY BOX TIPS
prevention/womens-childrens-health/reports-fact-sheets/ child-fatality-review-annual-reports/cfr-annual-report-
SAFE SLEEP TIPS
-DCS will not provide the baby box lids to families.
2016.pdf 15 Nov. 2016.
-Place infants on their backs to sleep every time.
-Completely empty the baby box, except for the
Baby Box Co. “Tradition”. http://www.babyboxco.com/pages/
-Place your baby in a crib with a firm mattress and
mattress, prior to putting baby in the box.
a fitted crib sheet.
-Place the baby box on the floor next to the
Editor’s Note: Recently, concerns have been raised
-Room-share, but do not bed-share.
parent’s bed at night.
about Baby Boxes as noted in the New York Times
-Never place your baby on chairs, sofas, waterbeds
-Keep pets and other children away from the box.
or cushions to sleep.
-Avoid moving the box while baby is in it.
-Keep toys, blankets, bumpers, loose bedding, and
-Use the boxes for babies under 30 pounds.
Infant Deaths (SUID) in infants sleeping in a Baby
other objects out of the crib.
-For more information on DCS’s Safe Sleep
Box reported to either the Arizona or other state
Campaign or Baby Box Program, visit https://
tradition 1 Sept. 2016.
article, “Put Your Baby in a Box? Experts Advise Caution,” by Rachel Peachman on May 24, 2017. However, there have been no Sudden Unexpected
Child Fatality Review programs.
AzAAP Member Spotlight JEFFREY WEISS, MD, FAAP | PHOENIX, AZ WHAT IS YOUR BACKGROUND?
used that opportunity to
I grew up in Philadelphia and graduated from Jefferson Medical
step down as Chief,
College in 1971. (Jefferson has been renamed for some rich guy to
resign from all
Sidney Kimmel Medical College- I hate that, but I don’t like
committees, and start
advertising logos on my tee shirts either!). I did my PL1 and PL2
the weaning process
year at Columbus Children’s Hospital (now renamed Nationwide
towards retirement.
Children’s Hospital), then my residency was interrupted by a 2
Nowadays, I take 3
year stint in the U.S. Army (still named the U.S. Army). It was the
months off in the
Vietnam War era, but I was assigned to the Pediatric Clinic at Ft.
summer and work
Hamilton in Brooklyn, New York, so I didn’t see any combat. After
alternate weeks the
the Army, I returned to Jefferson to finish my residency and join
rest of the year…it’s a
Hospital, Professor of Clinical Pediatrics,
the faculty in the Pediatric Ambulatory Department. Eventually, I
great schedule!
University of Arizona School of Medicine,
became Residency Director, Associate Department Chairman, and
Jeffrey Weiss, MD, FAAP, Pediatric Hospitalist, Phoenix Children’s
Phoenix, AZ
published just enough papers to get promoted to Clinical Professor.
WHY DID YOU
Then, sort of out of the blue, in 1993, my wife and I decided we
CHOOSE YOUR GIVEN PRACTICE COMPARED TO
had had enough of the east coast weather, so we moved to
OTHERS?
Phoenix, where I was the Pediatric Clinic Director at Maricopa
Except for my choice to be a hospitalist in 2007, I’m not sure I
Medical Center for about 2 years. In 1995, I came to PCH where I
ever really chose a career path. Various opportunities arose and I
was Chief of General Pediatrics until 2007. The division had grown
was just in a position to take advantage of them. When the
so large by 2007 that we decided to split into an Ambulatory group
hospitalist movement was first starting in the late 1990’s, I
and a Hospitalist group. Everyone had to select which group to
developed and organized the KidsLink Hospitalist Service for PCH.
join, and I had been doing mostly outpatient stuff my whole life, so
It has been interesting to watch how hospitalist programs have
I decided to become a hospitalist to try something new. I also
developed nationally and the role they are playing in improving the
Pediatric Digest, Summer 2017 Page 24
quality and safety of hospital care for children. I think it was partly
back where community pediatricians gave patients a 4 item quiz
a desire to be involved in a rapidly developing new field that led
that was designed to teach about pool safety and drowning
me to be a hospitalist.
prevention. Follow-up phone calls showed that after that short intervention, parental knowledge about pool safety was improved
WHAT LED YOU TO YOUR INVOLVEMENT IN THE
and a few people actually did install a new pool fence.
INJURY PREVENTION COMMITTEE OF THE AAP?
Unfortunately, we never got funding to expand that project.
When St. Luke’s Hospital went from being a non-profit to a forprofit hospital, it was required to divest all charitable funds that
WHAT ADVICE WOULD YOU GIVE PRACTICING
were donated, so they set up a trust for community projects. My
PEDIATRICIANS IN REGARDS TO THE MOST USEFUL
whole career had been in patient care and medical education, but I
ANTICIPATORY GUIDANCE FOR INJURY
hadn’t done much advocacy work. In order to fill that gap, I
PREVENTION?
applied for a grant to develop an injury prevention center at PCH.
It hurts me to say this, but I think that there is very little solid
The center was able to get large grants from the National Highway
scientific data to help pediatricians decide which of the hundreds of
Safety Administration (to research methods to get parents to use
injury prevention related anticipatory guidance items
booster seats) and the Center for Disease Control (to investigate
recommended in AAP policy statements they should pack into a
some novel methods to get middle school kids to wear bicycle
short health maintenance visit. Telling parents to supervise their
helmets.) When a position on the AAP Committee on Injury,
child carefully does NOT generally work to prevent injuries. You
Violence, and Poison Prevention (COIVPP) was open, I was asked
have a better chance of keeping a kid from getting injured if you
to apply, and I jumped at the chance.
focus on teaching parents how to create a safe environment for their child. Interventions that have to be done only once seem to
WHAT WERE THE POLICY STATEMENTS THAT YOU
work best. Examples include: install a pool fence, get a safe crib,
WROTE AND WHAT WERE THE CHALLENGES?
buy a car with high crash protection, and install an age appropriate
During my six years on COIVPP, I had the opportunity to be the
car seat. Interventions that require repeated actions, such as
lead author for the Teen Driver, Pedestrian Injury, and Drowning
“keep poisons out of reach” don’t tend to work so well. Of course,
Prevention policy statements. One of the challenges in writing a
it makes sense to focus on trying to prevent high frequency
policy statement is that there is just such a huge amount of
injuries and deaths, such as those caused by teen drivers. I’d like
material that needs to be reviewed, most of which is not in the
to see pediatricians spend a few seconds referring parents to the
usual journals that pediatricians read. Some of the information is
AAP material on teen drivers at healthychildren.org and advising
quite technical and much of it relates to legal and legislative
parents about the best driving schools in their community.
issues. A common problem relates to the age to recommend that
is some evidence that kids who learn to drive from their parents
a child be allowed to do something (i.e., drive independently, walk
get into more crashes!)
(There
to school, take swim lessons). Since kids of the same age have wide range of physical and cognitive abilities, giving age dependent
WHAT DO YOU DO FOR FUN?
advice was always a challenge for me and the committee. Also,
What do I do for fun? Well, I enjoy going to Portland Oregon
just getting through the whole review process is a challenge. After
where my kids and grandkids all live. We just bought a small condo
the first draft is finally finished, the document goes to the other
up there where my wife of 46 years and I spend the summer. On
committee members for review and I think there were probably 5-
my weeks off, I have been volunteering at the Arizona Science
10 more drafts before it was done….then it goes out to the other
Center. On most days, there are many school groups coming on
committees for review, then another 2-3 drafts, then to the AAP
field trips. Most recently, I developed a tabletop activity that
Board and another final draft. My first policy statement on Teen
demonstrates how optical illusions work…I have been able to
Drivers took almost 2 years to get published!
incorporate some little magic tricks into that activity, so the kids, and I, have a lot of fun with that. I still try to golf at least once a
HOW HAVE AZAAP AND OTHER ORGANIZATIONS
week and we like to travel. In the past few years we’ve been on
HELPED YOU IN OVERCOMING CHALLENGES AND
safari to see the migration in Kenya, gorilla trekking in Uganda,
IMPROVING CARE?
climbing Machu Pichu and cruising the Amazon in Peru, and seeing
The AZAAP has always been supportive of my injury prevention
the Ganges River and the Taj Majal in India. When we travel, I like
work. The AZAAP helped organize a little pilot project a few years
to do a lot of photography. And, how could I forget, we love to go out to eat for fun! We do that a lot! Pediatric Digest, Summer 2017 Page 25
Opioid Epidemic and Neonatal Abstinence Syndrome RENE BARTOS, MD, MPH, FAAP | PHOENIX, AZ There is an opioid epidemic in the
more likely to initiate medical before
possibility of NAS when they were
United States. According to the CDC,
nonmedical use.
prescribed opioids or not checked for pregnancy before being prescribed
from 1999-2013 the amount of prescription opioids dispensed in the
The opioid epidemic has significant
opioids. In Arizona, the rate of NAS
U.S. nearly quadrupled
impact in
has increased by 245% from 2008 to
and almost 2 million
Arizona.
2014 and 27% since 2013 according to
Americans abused or
Painkiller
the Arizona Department of Health
were dependent on
addiction often
Services (ADHS). This epidemic affects
prescription opioids in
starts with
pregnant women at all socioeconomic
2014. 80 percent of
misuse or
status levels and has been driven by
heroin users started with
sharing of a
the increase in prescribed opioids. The
prescription drugs. From
legitimate
Arizona Statewide Task Force on
2000-2015, more than
prescription
Preventing Prenatal Exposure to Alcohol
half a million people died
following an
and Other Drugs has a strategic plan
from drug overdoses and
injury, surgery
and resources for addressing this
the majority of drug
or dental
important health issue. This group
overdose deaths
procedure.
recently convened a workgroup of
involved an opioid.
According to the
AHCCCS health plan staff to develop
Arizona
health plan best practice guidelines.
Governor’s Office
Several health plans have developed
of Youth, Faith
programs including care management
and Family, we
and resources for pregnant women and
need to rethink
infants as well as guidance and support
Rx abuse, and
for healthcare providers:
https://www.cdc.gov/ Rene Bartos, MD, MPH, FAAP,
drugoverdose/opioids/ index.html
Although most U.S.
AzAAP Board of Directors Member, Medical Director and VP, Systems of Care, Mercy Care Plan, Phoenix, AZ
studies of medical and nonmedical use of prescription opioids
rethink the way we use, store, discard
http://azprenatal.wixsite.com/taskforce
have focused on adults, it has become
and discuss prescription drugs. The
www.azhealth.gov/opioidprescribing/
increasingly recognized that children
office website provides Parent Talk Kits
and youth are affected by this
and information about what adults can
Pregnant women dependent on opioids
epidemic. Recent articles in
do to prevent opioid misuse. http://
and infants exposed to opioids should
PEDIATRICS point out that from 2000
substanceabuse.az.gov/substance-
be offered comprehensive services and
through 2015, 188,468 pediatric opioid
abuse/rethink-rx
support. A supportive approach is important. The American College of
exposures were reported to US poison control centers. The rate of prescription
Another way in which children are
Obstetricians and Gynecologists’
opioid-related suspected suicides
being affected by the opioid epidemic is
recommendation is medication assisted
among teenagers increased by 52.7%
the growing problem of infants
treatment (MAT) during pregnancy for
during the study period. Prescription
experiencing opioid withdrawal after
opioid-dependent women. Abrupt
opioid-related health care facility
birth-neonatal abstinence syndrome
cessation of opioids during pregnancy
admissions and serious medical
(NAS). Women who become pregnant
can be harmful. Opioid weaning during
outcomes were higher among
while using opioids, whether
pregnancy is not the standard of care
teenagers. The Monitoring the Future
prescription or street drugs, are at risk
and has been associated with high
study of adolescents showed that
for having an infant with NAS. Women
rates of relapse. Pregnant women with
adolescents reporting opioid use were
are not consistently informed of the
opioid dependence should be assessed
Pediatric Digest, Summer 2017 Page 26
https://www.cdc.gov/drugoverdose/
for co-morbid behavioral health conditions and referred for behavioral health services. Birthing facilities should implement and utilize an evidence-based screening and treatment protocol for substance exposure to include opioids, and train all staff in consistent use of this protocol. Conservative treatment for NAS should be tried first before starting pharmacological treatment. Breastfeeding is not contraindicated unless there is polydrug/street drug use. Parents/guardians should be
Patrick SW, Schumacher RE, Horbar JD,
prescribing/providers.html
et. al. Improving Care for Neonatal Abstinence Syndrome. Pediatrics 2016;
http://www.azdhs.gov/audiences/
137(5): e20153835
clinicians/index.php#clinical-
http://pediatrics.aappublications.org/
guidelines-and-references-rx-
content/early/2016/04/13/peds.2015-
guidelines
3835 Check the Arizona Controlled
ACOG Statement on Opioid Use During
Substances Prescription Monitoring
Pregnancy
Database (CSPMP) before
http://www.acog.org/About-ACOG/
prescribing opioids https://
News-Room/Statements/2016/ACOG-
pharmacypmp.az.gov/
Statement-on-Opioid-Use-DuringPregnancy
Consider the possibility of NAS in
provided with resources to help manage an infant with NAS prior to discharge from the hospital and both mother and infant should have support services and close follow up by a primary care physician.
REFERENCES/RESOURCES:
STEPS
infants who were exposed to opioids
YOU CAN TAKE:
during pregnancy
Talk to parents/guardians about proper storage and disposal of
Learn about and provide local
any prescription painkillers and
resources and service referrals for
about checking on what is sitting
opioid dependency and for help with
around in the medicine cabinet at
infants with NAS and substance
home
exposure
McCabe SE, West BT, Velize P, et.al. Trends in Medical and Nonmedical Use of Prescription Opioids Among US Adolescents. 1976-2015. Pediatrics 2017; 139 (4): e20162387 http://pediatrics.aappublications.org/ content/early/2017/03/16/peds.20162387
Talk to parents/guardians and
Get involved! Join the Arizona
youth about the importance of
Statewide Taskforce on Preventing
having open dialog about opioid
Prenatal Exposure to Alcohol and
use and educate women about
other Drugs, give a presentation on
the possibility of NAS if they are
this topic, advocate for appropriate
using opioids and become
social services and health care
pregnant
services to address the opioid
Allen JD, Casavant MJ, Spiller HA, et.al. Prescription Opioid Exposures Among Children and Adolescents in the United States: 2000-2015. Pediatrics 2017;139(4):e20163382 http://pediatrics.aappublications.org/ content/early/2017/03/16/peds.20163382
programs offered by health plans for
opioids and babies exposed to opioids and refer your patients to
additional support
Dr. Cody Conklin-Aguilera is Editor of Pediatric Digest and Secretary to the AzAAP Board of Directors. She is Chief Medical Officer at the Public Health Department of Yavapai
on Substance Use and Prevention. A Public Health Response to Opioid Use in
Obtain training on
Pregnancy. Pediatrics 2017; 139 (3):
addressing the opioid
e20164070
epidemic and prescribe
http://pediatrics.aappublications.org/
opioids according to
content/early/2017/02/16/peds.2016-
best practice guidelines
4070
QUESTIONS FOR THE EDITOR
pregnant women using
these programs for Patrick, SW, Schiff DM, AAP Committee
epidemic
Inquire about special
County and Pediatric Program Manager at the Yavapai County Community Health Center in Cottonwood. Questions and concerns pertaining to the newsmagazine can be directed to Leadership@azaap.org or 602-532-0137. Pediatric Digest, Summer 2017 Page 27
2600 N 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 602-532-0137 ext. 416.
www.AzAAP.org/Career_Center