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MNAAP Newsletter

Advocating for Prenatal to Three Investments and Interventions

By Mark Nupen, MD

As a retired pediatrician but lifelong child advocate, I had the privilege of recently attending the bipartisan “Prenatal to Three Policy Forum” hosted by Elders for Infants and Representatives Deb Kiel and Dave Pinto.

These quarterly forums, which have been gaining traction among policy makers and pediatric advocates, are designed to help attendees “learn about what key organizations and coalitions are working on to improve state policy for early childhood, from prenatal through age 3.”
I highly recommend pediatricians attend, if possible, because prevention works best when it’s done early.

Literacy, for example, is an extremely important social determinant of health. Although language development is critical in the first three years, half of all new mothers receiving Medicaid do not have books in their house. Research suggests as many as 70 percent of prison inmates are mostly illiterate. Low literacy is also a key factor in high school dropouts and teen pregnancies.

If I were still in practice, parental literacy would be one of my new “vital signs.”

In my opinion, prenatal to age 3 is the perfect span of time for focused interventions. It is the prime age for child abuse and family dysfunction, which is why it is the prime age for building parenting skills and literacy.

During the forum, legislators spoke about the importance of keeping in contact with your own representatives and senators because it is likely they have little knowledge about these issues and need your help.

Following the forum, I connected with Clara Sharp, a doula from North Minneapolis who works with at-risk moms. I also connected with Laura Lacroix-Dalluhn who works with the Minnesota Coalition for Targeted Home Visiting, which includes pregnant moms in prison.

We cannot do this work alone, nor can we rely on a few legislators. We all need to contribute to our legislators’ skills and knowledge.

Using the EMR to Streamline Care for Children in Foster Care

By Amelia Burgess, MD

A nine-year-old boy comes in to your clinic with a foster parent. It is his second placement, after his 6-week “shelter” placement. He has an undescended testis, vision impairment, caries, and asthma. His school record has been spotty – he has moved several times since kindergarten, and has missed many days each school year. His permanency plan is not yet clear. His father lives in another state, he has a relative two counties over, and his younger siblings live in yet another county in a pre-adoptive home. He does not have a primary care physician.
You know that you need to “hook him in,” and quickly, to the services he needs. But you also know that he may move to a new home before you get his records, and before his evaluations and treatment are complete. Children in foster care often get the same evaluations several times, but never get a treatment plan.

Since January 1, 2015, we have all been practicing with electronic health records. Electronic tools embedded in these systems can be used to:
Access outside health records. Allina, CentraCare, Essentia, Fairview, HealthEast, HealthPartners, Hennepin County Medical Center, North Memorial, and Park Nicollet are all connected through Care Everywhere. This means that, with appropriate consent, we can access medical records from other institutions immediately, and that our records will be accessible to others.

Create checklists for common orders and considerations. If your electronic health record allows you to, you can create an order set based on the American Academy of Pediatrics recommendations for the comprehensive evaluation of children placed in foster care. If you can’t create an order set, you can create a note template that triggers you to plan for the necessary evaluations. A prototype may be found at the Healthy Foster Care America website. (

Write efficient, thorough reports and letters. Medical, surgical, birth, medication and social histories can usually be pulled in to any document. Epic has a problem list function that allows you to describe the problem and update it at each visit, and pull the problem and the current plan. I have a standard template for foster care reports that can be used to create a health report for use by caseworkers, judges, and family members.

Foster parents, adoptive parents, caseworkers, and judges are very grateful to get a comprehensive health summary to help make decisions for children. Using tools within our electronic health records can help us advocate for children by providing accurate historical information along with our best pediatric recommendations.

Sample visit summary:

This is an after visit summary for the use of parents (birth, foster, and adoptive) and caseworkers.
Please fax to ***.
Reason for visit: @dx@
Accompanied by: ***
Other concerns (home, school, community):***
Next appointment: *** with ***
Children in foster care should be seen for well-child care every month for the first 6 months, every 3 months thereafter until 2 years old, and every 6 months after age 2.
It has been my pleasure to meet with @fname@. Please call with any questions. You can reach our department assistant [name] at [phone number]. Our care coordinator can be reached at [phone number].
*** Triggers typed input
@dx@ pulls in the visit diagnoses
@probl@ pulls in the existing problem list. I keep entries for educational, developmental, oral, and mental health so that I will be reminded to address them at each visit.
@cmed@ pulls in current medications.
@alg@ pulls in allergies.
@probvisitnotes@ pulls in plans related to problems addressed at the visit


Member Profile: Janna Gewirtz-O’Brien, MD, FAAP

gewirtz-obrien-janna-15933253What do you like best about being a pediatrician at Mayo?
I went into pediatrics to help children and adolescents of all backgrounds thrive. I love watching my patients grow and develop at every visit. I am incredibly grateful for my wonderful interdisciplinary team at Mayo. There is a true appreciation of the biologic, psychological and social determinants of health. The whole team works together to provide endless support for my patients and their families.

What’s one pediatric issue you are particularly passionate about and why?
I am particularly passionate about mental health and substance abuse among adolescents. Mental illness touches the lives of many of my patients. In 2013, 15 percent of 9th graders in the state of Minnesota reported seriously considering suicide and there is good evidence to support that the number of suicides in the state of Minnesota is on the rise. When I meet a teenager who is struggling with mental illness, I am full of hope that we can help them feel better, return to function and thrive. There is so much that we as pediatricians can do in our offices, in our communities and in our state to promote positive mental health.

You’re a board member of MNAAP. What benefits have you gained from your involvement?
I have met a dynamic group of pediatricians who share my passion for advocacy. The members of the Minnesota AAP leadership team work tirelessly on behalf of Minnesota’s children and families. They have helped engage me in legislative advocacy. Pediatricians’ Day at the Capital is just one of many opportunities to speak to legislators on behalf of children. I have also enjoyed being involved in work groups targeting mental health, poverty and health disparities.

Which other organizations or initiatives are you currently involved with?
I work as a volunteer physician at the Rochester Alternative Learning Center Health Clinic and serve on the board of Rochester Students’ Health Services, the organization that runs this clinic. Seeing students at the Rochester Alternative Learning Center has helped to drive my passion for working with adolescents.

What’s one thing most people are surprised to learn about you?
I am a passionate Rochesterian! Prior to moving to Rochester, Minnesota, I lived in Rochester, New York, where I attended college and medical school at the University of Rochester. I still sport my Rochester Yellowjacket gear around town in Minnesota. It is a constant source of confusion for family and friends. Go Yellowjackets!

What do you enjoy doing in your free time?
These days, my favorite activities include chasing my 1-year-old daughter around the park and watching her explore the world. My husband and I love finding new adventures for her around Minnesota.

Anything else you want to add?
I would encourage Minnesota pediatricians to take advantage of all that the Minnesota AAP has to offer. Whether it is a webinar on children’s mental health, an opportunity in legislative advocacy or involvement with a grant to combat food insecurity within your practice, the AAP has a lot to offer. We are always looking for ways to better support pediatricians, our patients and their families. The Minnesota AAP is a place for your voice to be heard on behalf of all children.


Prevention of Peanut Allergy

Nancy-Ott-181x182By Nancy Ott, MD

Peanut allergy has increased significantly over the last several decades. Peanut is often severe and not outgrown. It is difficult to avoid because it is common to find peanut in baked goods, candy, ethnic food and even hidden in soups and flavorings. Peanut is the food most often responsible for a severe allergy reaction or anaphylaxis and triggers most of the 150 food allergy deaths each year.

Good news for prevention of food allergy came along in 2015 when researchers from the U.K. published a landmark study about peanut allergy prevention titled “Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy” in the New England Journal of Medicine. Prior to the study, the researchers of the LEAP (Learning Early About Peanut) Study Team took note of a previous study suggesting infants in Israel had less peanut allergy than their counterparts in the U.K. The babies in Israel ate Bamba, a corn puff product made with peanut; the U.K. babies didn’t.

In the LEAP study, 640 infants age 4 to 11 months who came to an allergy clinic in the U.K. with severe eczema, egg allergy or both were randomized to avoid peanut or consume the equivalent of a teaspoon of peanut protein (2 grams) three times a week. Infants were stratified into two study cohorts based on either a negative peanut skin test wheal or a 1-4 mm wheal. Children with a wheal 5 mm or greater were excluded and assumed allergic. Infants randomized to consume peanut underwent a peanut challenge.

When the study participants turned 5 years of age, the peanut consumers stopped peanut for a month. A peanut challenge was then performed for consumers and non-consumers. The consumption group infants had significantly lower peanut allergy at 5 years of age. The skin test negative group had a relative risk reduction of peanut allergy prevalence of 86% (p < 0.001) and the skin test positive group had relative risk reduction of 70% (p=.004).

Over the next year, a second study was done, “Effect of Avoidance on Peanut Allergy after Early Peanut Consumption” and was referred to as the LEAP-on Study. The peanut consumers and avoiders all avoided peanut for a full year. A peanut challenge was then repeated in all and the peanut consumers had maintained tolerance.

This has led to the Addendum Guidelines for the Prevention of Peanut Allergy in the United States: Report of the NIAID, which the AAP also endorses.

Addendum Guideline 1 is for infants with severe eczema, egg allergy or both. Allergy testing is strongly advised prior to peanut introduction. A board-certified allergist that evaluates and treats infants can perform skin testing and advise avoidance, supervised feeding in an office or graded office food challenge in a hospital setting. (Refer to guidelines on next page.)

Addendum Guideline 2 recommends for infants eating solid food with mild to moderate eczema, introduce age-appropriate peanut-containing food around 6 month of age at home.

Addendum Guideline 3 recommends for an infant with no eczema or food allergy, introduce -age-appropriate peanut-containing food in accordance of family preference and cultural practices.

By following these guidelines, an estimated 70 to 80 percent of peanut allergy could be prevented. This would cause a significant decrease in the morbidity and mortality of a medical condition that affects 1 to 2 percent of children in the U.S. Watch for further studies looking at cow milk and egg allergy prevention.

As Benjamin Franklin said, “An ounce of prevention is worth a pound of cure.”


Reflections on Caring for Refugees in Lesbos, Greece

boys at fireBy Chuck Oberg, MD

As President Trump’s proposed U.S. refugee travel ban continues to work its way through the courts, I make a plea for benevolence and tolerance rather than that of fear.

I recently returned home from working in the refugee camps in Lesbos, Greece. I was volunteering with the Boat Refugee Foundation, a Netherlands based NGO.

I spent the majority of my time in the notorious Moria Refugee Camp. The camp is beyond description and is a surreal mix of an interment camp and shanty, squatter community encampment. Based in an old army compound, it is defined by the steel gates, high fencing and barb wire from the outside and an amorphous sea of tarps and tents on the inside. The weather had turned brutally cold. Over a foot of snow was followed by freezing rain. The cold and dampness penetrated to the bone. Food queues, inadequate unsanitary toilet facilities and ubiquitous garbage were the norm.

There are over 4,500 refugees. They had traveled from Syria, Iraq, Iran, Afghanistan and Pakistan from the Middle East. They came from across the African Continent with families from the Democratic Republic of the Congo (DRC), Ghana, Uganda, Somalia, Eretria and Sudan. In addition, I treated families from as far east as Bangladesh and west from Haiti and the Dominican Republic.

Almost all had experienced trauma. Some beaten, shot, tortured, and raped and all had experienced the stress of living in unlivable conditions. The complaints were a blur of physical, mental, and spiritual aliments.

Yet there was a palpable hope that one day things would be better with aspirations of a better future. Daily they expressed their gratitude that someone would listen as they shared the story of their journey, affirmed their worth, acknowledged their struggle and celebrated their humanity. You could see it in their eyes and their smiles that each was seeking a better life for themselves and their children.

I saw no terrorist. I just saw families, children, men and women–all vulnerable and suffering. So let us remember that our kindness will make us safer than any ban.

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