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MNAAP Newsletter

Disaster Preparedness: Planning for the Unimaginable

PaulaKocken2By Paula Kocken, MD, FAAP

It seems that there are disasters happening every day and everywhere. Some occur very far away from us and others seem to be at our doorsteps. The AAP, recognizing the increase in disasters, has encouraged each state chapter to ask for pediatricians knowledgeable and interested in disaster preparedness to champion the efforts in their state to improve preparedness.  Dr. Kiragu asked if I could accept the challenge of improving the awareness of information and programs about disaster preparedness and move forward Minnesota’s pediatricians in their ability to respond to disasters.

I was very pleased to be asked to help Minnesota and the AAP in this complex and challenging topic. I have been working with disaster preparedness for over the past 15 years through many venues.  Beyond being a pediatric emergency medicine physician based at Children’s of Minnesota, I took additional training in the hospital response to disasters with the U.S. army.  As the medical director of Minnesota’s Emergency Medical Services for Children (EMSC), I have been working on “all hazards” readiness for pediatric disaster preparedness for EMS providers and emergency departments. I also participate with the MN Department of Health Advisory Committee for emergencies.

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No Hit Zone at the U of M Masonic Children’s Hospital

 

By Rebecca E. Foell, MSW, LICSW, and Nancy S. Harper, MD, FAAP

In 2016, The University of Minnesota Masonic Children’s Hospital launched the first No Hit Zone in the state of Minnesota. A No Hit Zone is an environment in which no adult shall hit a child, no adult shall hit another adult, no child shall hit an adult, and no child shall hit another child. The purpose of the No Hit Zone is to create a safe and healthy environment for patients, families, visitors, and staff as well as to provide support, education, and resources surrounding effective discipline.

Definition and Prevalence
The United Nations Convention on the Rights of the Child in 2006 defined corporal punishment or physical punishment to include hitting with a hand or object as well as shaking, throwing, scratching, biting, kicking, and burning of children with a call for countries to enact legislation prohibiting violence against children as a form of discipline.

To date, 52 countries have banned physical punishment of children starting with Sweden in 1979. The United States has not yet banned corporal punishment. In fact, 19 states in America still allow corporal punishment in schools, but there appears to be a general shift in the use of corporal punishment in the United States. According to one study, the percentage of mothers reporting that they would hit or spank their kindergarten-age child in response to a child’s misbehavior declined by 20 to 26 percentage points across all income levels between 1988 and 2011. Likewise, the percentage of mothers reporting that they spanked their child in the past week declined by 26 to 40 percentage points. These declines emerged at all income levels.

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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.”

 

Newborn Screening: New Disorders and the Changing Landscape

SheldonBerkowitzBy Sheldon Berkowitz, MD, FAAP, MNAAP Board of Directors; Maggie Dreon, MS, CGC, Amy Gaviglio, MS, CGC, Sondra Rosendahl, MS, CGC, Minnesota Department of Health Newborn Screening Program

Minnesota has a long history of being a leader in newborn screening, often being one of the first states to tackle a new initiative or add a new disorder. Over the past year, Minnesota’s Newborn Screening program has been working to bring three disorders to Minnesota’s panel: mucopolysaccharidosis type I (MPS I), Pompe disease, and X-linked adrenoleukodystophy (X-ALD).

Adding a new condition always brings with it new challenges, and these three disorders present several novel issues not previously encountered in newborn screening. Because these conditions have variable severity, age of onset, and treatment efficacy, the role of the primary care provider (PCP) in follow-up of positive screens will be increasingly vital and ongoing.

Take X-ALD, for example. There are three types of X-ALD and screening cannot clearly distinguish among them: childhood cerebral, adrenomyeloneuropathy, and Addison’s disease only. Furthermore, diagnostic testing is often unable to determine type until symptoms present. In X-ALD, treatment isn’t usually initiated until the onset of symptoms, which can take years to develop. Even individuals with the childhood cerebral type (the most severe and earliest onset type), may not show symptoms prior to four years of age. This means that PCPs will need to work with specialists to monitor their patients for symptom onset for longer than they have had to do for newborn screening conditions in the past. This later age of onset puts families—and PCPs—in a “sit and wait” situation. The risk is that families will become complacent with waiting, will stop following up, and then miss the key features of the disorder that show onset has occurred. Once onset occurs, the impact of the disease is irreversible, making the goal of catching symptoms early essential and the relationship between the family and PCP critical.

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Pediatricians as Public Health Sentinels

Moline, Heidi (1)

By Heidi Moline, MD, MPH, pediatric resident, University of Minnesota

Microcephaly. Elevated lead levels. Acute respiratory distress. The past few years have reminded us that pediatricians are at the front line of public health emergencies in our communities and across the globe.

We find ourselves entrenched in outbreaks during their infancy, without case definitions, laboratory guidelines, or media coverage — only patients with curious symptoms.

Zika

In early 2015, Brazil experienced a recognized surge of both Zika virus and Dengue virus cases across the country. Several months later, pediatric neurologists Drs. Vanessa van der Linden Mota and Ana van der Linden noted an increase in the number of infants with microcephaly in their Northeastern Brazil clinics.

While in a normal month the might see one microcephalic infant, they were now seeing up to 5-7 per day. The Ministry of Health was notified, and by October, their province which usually has 10 cases of microcephaly per year, had registered 141 cases. Previously known only to cause rash and mild illness, with the aid of observant pediatricians, Zika virus was soon linked to microcephaly and other congenital malformations.

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