National Center for Education in Maternal and Child Health

alert

October 15, 1999

1. President Discusses Federal CHIP Outreach Issues, AAP Recommends Universal Children's Health Insurance Plan

2. Article Reviews Hazards of Placing Children to Sleep in Adult Beds

3. Study Finds Domestic Violence Screening by Pediatricians Effective

4. Child Health USA 1999 Available on the Internet

5. Review Provides Clarification for Treatment of Depression in Pregnancy

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See End of This Edition for Reader-Survey Results
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1. PRESIDENT DISCUSSES FEDERAL CHIP OUTREACH ISSUES, AAP RECOMMENDS UNIVERSAL CHILDREN'S HEALTH INSURANCE PLAN

At the American Academy of Pediatrics (AAP) annual meeting this week, President Clinton announced federal steps to increase enrollment of uninsured children, and the AAP presented its own plan to provide universal health insurance coverage for children.

The Federal Interagency Task Force on Children's Health Insurance Outreach recently reported its activities to the President, with a main focus of the federal efforts concerning school involvement in the outreach effort. President Clinton signed an executive memorandum instructing the Secretaries of Health and Human Services (HHS), Education, and Agriculture to report back in six months on ways in which the federal government can "institutionalize school-based outreach and enrollment." The Secretaries of HHS and Education also sent guidance to state agencies this week describing the financial, administrative and technical assistance that the Children's Health Insurance Program (CHIP) offers for school-based outreach. And, more than 1,500 schools have responded to the Secretary of Education's request last year for schools to incorporate CHIP outreach materials into their back-to-school activities.

Other federal activities include: 1) Requiring that every new AmeriCorps and VISTA volunteers working with children and in health care settings receive outreach information so that they can link uninsured children to programs; 2) Informing grandparents, who are often caregivers to children, about CHIP/Medicaid via Medicare materials; and 3) Providing outreach information to more than 8,000 Voluntary Income Tax Assistance volunteers who help families complete their taxes.

In addition, the AAP unveiled a national children's health insurance program that would replace Medicaid and CHIP. The program would allow children and adolescents up to age 21 to be automatically eligible for the program, without means testing. Plan aspects include:

• Families may enroll their children in a private insurance plan, or they will be automatically enrolled in the program;
• All programs, private or public, must meet AAP standards; and
• All children will have access to primary care pediatricians, pediatric medical subspecialists and pediatric surgical specialists; and assurances would be developed to ensure program quality.

AAP's plan would attempt to utilize the existing contributions to child health insurance from federal, state and private sources, and would develop incentives to minimize reduction in employer-based contributions. The AAP states that enactment of their proposal would increase spending on child health by $44 billion a year, mainly to ensure the private plans meet quality standards.

Report to the President by the Interagency Task Force on Children'sHealth Insurance Outreach. October, 1999. The report can be downloaded from three WordPerfect files at <http://www.hrsa.gov/childhealth/Report.htm>.

A press release, "The American Academy of Pediatrics' Proposal to Insure America's Children." is available at <http://www.aap.org/advocacy/washing/web101199.htm>.

A press release, "The Clinton-Gore Administration Takes New Steps to Increase Enrollment of Uninsured Children." is available at <http://www.whitehouse.gov/library/ThisWeek.cgi?type=p&date=2&briefing=0>

"Memorandum for the Secretary of Health and Human Services, the Secretary of Education, the Secretary of Agriculture." is available at <http://www.whitehouse.gov/library/ThisWeek.cgi?type=p&date=2&briefing=8>

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2. ARTICLE REVIEWS HAZARDS OF PLACING CHILDREN TO SLEEP IN ADULT BEDS

Placing children younger than two years to sleep in adult beds exposes them to potentially fatal hazards that are generally not recognized by the parent or caregiver, concludes an article in the Archives of Pediatrics and Adolescent Medicine. The study reviewed data collected by the US Consumer Product Safety Commission from 1990-1997, and found 515 deaths of children younger than two who were placed to sleep in adult beds. Of the 515 deaths, 121 were reported due to overlying of the child by a parent, other adult, or sibling, and 394 were caused by entrapment in the bed structure, causing suffocation or strangulation. Most deaths occurred among infants younger than 12 months. Specifically, the hazards include overlying by someone sharing the bed, entrapment or wedging of the child between the mattress and another object, head entrapment in bed railings, and suffocation in waterbeds.

The authors note that "one of the most troubling aspects of these deaths is that they are largely preventable." Also, mothers should be informed of the hazard of overlying when the infant remains in bed with the mother after breastfeeding. The authors provide the following recommendations for health care providers to educate parents:

• Children younger than two years should sleep in cribs meeting federal safety standards and the industry voluntary standard;
• Children younger than two years, or disabled children whose movements are restricted, should not be put to sleep in adult beds (including waterbeds) that present a risk of entrapment between the bed mattress and a wall, headboard, footboard, side railings, or adjoining furniture; and
• Children younger than two years, or disabled children whose movements are restricted, should not be put to sleep in adult beds with railings (headboard, footboard, or side railings) that present a risk of strangulation by head entrapment.

Nakamura, Suad et al. "Reviews of Hazards Associated With Children Placed in Adult Beds." Archives of Pediatrics & Adolescent Medicine. 1999; 153: 1019-1023.

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3. STUDY FINDS DOMESTIC VIOLENCE SCREENING BY PEDIATRICIANS EFFECTIVE

A small pilot study published in this month's Pediatrics examined the efficacy of screening for domestic violence (DV) in the pediatric office setting. During a three month period in Kentucky, researchers screened 154 women who went to the pediatrician for well-child visits without their partners. Screening consisted of six questions recommended by the American Medical Association regarding domestic violence in women's relationships with their partners, their partner's violence towards their children, and their partner's and children's violence towards pets. A positive response to any of the questions prompted a referral to an in-house social worker who then linked women to other services. Episodes of abuse were also reported to the Kentucky Domestic Violence Team and to the state child protective agency.

Study results include:

• A total of 47 women (31%) disclosed a history of injury by a partner some time in their lives, and 25 women (16%) reported abuse within the past two years. Of this number 10 women were abused in their most recent pregnancy;
• Of the 25 recent episodes of DV disclosed, seven had previously not been reported to the police or state domestic violence team;
• Of the five episodes of child abuse disclosed, two were not previously reported, thus legal action to protect the women or children had not been taken; and
• There was no significant difference in the incidence of DV according to insurance status -- 37% of women with Medicaid versus 20% of women with private insurance reported abuse. It should be noted however, that this difference would be significant in a larger sample size.

The study shows the efficacy of screening for DV in a pediatric practice. Although pediatricians may face time and resource limitations, the authors state that "there is a subgroup of women, those with young children who have recently separated from their partners, who may particularly benefit from DV screening." Further research is needed on the longer term outcomes of the screening and referrals.

Siegel, Robert M., et al. "Screening for Domestic Violence in the Community Pediatric Setting." Pediatrics. 1999; 104(4): 874-877.

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4. CHILD HEALTH USA 1999 AVAILABLE ON THE INTERNET

The tenth edition of "Child Health USA," the Maternal and Child Health Bureau's compilation of national and state-level MCH data, is now available to be downloaded from the Internet at <http://www.mchirc.net/CH-USA.htm>. Child Health USA 1999 amasses secondary data on health status and service needs of children. The report is based on 54 health status indicators and includes information on infants, children, and adolescents, health service utilization, state-specific and local data, as well as information on the nation's progress towards meeting the Healthy People 2000 objectives.

Child Health USA 1999 highlights improvements in US health status, such as the increases in access and use of prenatal care, and in the rates of breastfeeding and childhood immunization. The report also describes regional and racial disparities in health status. For instance, while the national infant mortality rate is 7.2 per 1,000 live births, it is 4.3 in New Hampshire (the state with the lowest rate), and 13.2 in the District of Columbia (the highest rate). Furthermore, the infant mortality rate for African American infants is twice that of whites, and maternal mortality is over three times as high for African American than for white women. Child Health USA 1999 also outlines the nation's progress towards the goal of healthy children and families, yet emphasizes the need for continued progress.

US Department of Health and Human Services, Health Resources and Services Administration. "Child Health USA 1999." (tenth ed). <http://www.mchirc.net/CH-USA.htm>

Paper copies can be ordered free of charge from: National Maternal and Child Health Clearinghouse, 2070 Chain Bridge Road, Suite 450, Vienna, VA 22182-2536. Phone: (703) 356-1964; Fax: (703) 821-2098; Email: <nmchc@circsol.com>; Web site: <http://www.nmchc.org>.

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5. REVIEW PROVIDES CLARIFICATION FOR TREATMENT OF DEPRESSION IN PREGNANCY

A review article in a recent Journal of the American Medical Association clarifies management information for physicians treating depression in pregnant women, also finding no significant association between antidepressant exposure and congenital malformations. The authors state that depression may affect one in seven pregnant women, however information on pharmacologic treatment during pregnancy is limited. Researchers analyzed results from four prospective studies (414 cases) comparing first trimester exposure to tricyclic antidepressants (fluoxetine, selective serotonin reuptake inhibitors) to non-exposed controls. The studies examined five domains of reproductive risk: intrauterine fetal death, morphologic/physical malformations, growth impairment, behavioral disorders, and neonatal toxicity.

Other study findings include:

• There is no evidence that exposure to tricyclic antidepressants during pregnancy increases the risk of intrauterine fetal death;
• Prenatal growth and birth weights were comparable between infants exposed to tricyclic antidepressants and non-exposed infants;
• No differences were found between the two groups in cognitive function, temperament, and general behavior of infants; and
• There were conflicting results regarding neonatal withdrawal syndrome.

The authors emphasize the need for increased research of depression in pregnancy, including studies of newer drugs, and the relationship between antidepressants and poor maternal weight gain.

Wisner, Katherine L., et al. "Pharmacologic Treatment of Depression During Pregnancy." Journal of the American Medical Association. 1999; 282(13): 1264-1269.

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MCH Alert Reader-Survey Results
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Thanks to all of our readers who participated in our reader survey this summer. At that time we had a readership of about 900, and 303 surveys were returned. Readership now is over 1,600 and growing!

Survey results:

• Of surveys returned, the majority of readers (92%) thought the overall length of the MCH Alert was "Just right," 6% thought it was "Too long," and 2% thought it was "Too short";
• Most thought the length of the summaries was "Just right" (93%), 5% said "Too long," and 2% said "Too short";
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• The top five subjects readers selected as most relevant are, in descending order: 1) CHIP/Medicaid 2) Prenatal care 3) Program evaluation 4) Managed care and 5) Adolescent health. The subject least selected was Environmental health.
• The top four choices respondents wrote-in under the "Other topics of interest" are 1) Infant/Early childhood health 2) Pregnancy outcomes 3) Breastfeeding and 4) Nutrition;
• The top five types of resources respondents preferred in descending order are: 1) Journal articles 2) Data/statistics 3) Federal initiatives 4) Grant announcements and 5) The Information Review. The least favorite was Job announcements.

In general we received an overwhelmingly positive response to the MCH Alert. Many commented that it is concise, yet comprehensive, and that the links to web sites are particularly useful. Some comments include:

• "I rely on the MCH Alert for up-to-date news in my field."
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Thanks again for your participation. Feel free to email us at the address below with additional comments.

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The Editors welcome your submissions, suggestions and questions. Please contact us at the address below.

EDITORS: Jessica Grumet, Lauren Raskin

FOUNDING EDITOR: Laura Kavanagh
MANAGING EDITOR: Leslie Gordon 

National Center for Education in Maternal and Child Health
2000 15th Street North, Suite 701
Arlington, VA 22201
(703) 524-7802
(703) 524-9335 FAX
Email: jgrumet@ncemch.org or lraskin@ncemch.org
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The MCH Alert is produced by the National Center for Education in Maternal and Child Health under its cooperative agreement (MCU-119301) with the Maternal and Child Health Bureau, Health Resources and Services Administration, US Department of Health and Human Services.

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