May/June 2018 - Early Childhood Development by Advocates for Better Health

“Your patients will thank you for referring them to Dr. Crutchfield.”

A FAC E O F A M I N N E SOTA DE R M ATOL O GIST Recognized by physicians and nurses as one of the nation’s leading dermatologists, Charles E. Crutchfield III MD has received a significant list of honors including the Karis Humanitarian Award from the Mayo Clinic, 100 Most Influential Health Care Leaders in the State of Minnesota (Minnesota Medicine), and the First a Physician Award from the Minnesota Medical Association, for positively impacting both organized medicine and improving the lives of people in our community. He has a private practice in Eagan and is the team dermatologist for the Minnesota Twins, Wild, Vikings and Timberwolves. Dr. Crutchfield is a physician, teacher, author, inventor, entrepreneur, and philanthropist. He has several medical patents, has written a children’s book on sun protection, and writes a weekly newspaper health column. Dr. Crutchfield regularly gives back to the Twin Cities community including sponsoring academic scholarships, camps for children, sponsoring programs for children with dyslexia, mentoring under-represented students from the University of Minnesota, and establishing a Dermatology lectureship at the University of Minnesota. As a professor, he teaches students at both Carleton College and the University of Minnesota Medical School. He lives in Mendota Heights with his wife Laurie, three beautiful children and two hairless cats.

AES

THET I C

L OF APPROVA L SEA

CRUTCHFIELD DER MATOLOGY Experience counts. Quality matters. Mayo Clinic Medical School Graduate | University of Minnesota Dermatology Trained Top Doctor Minneapolis St. Paul Magazine | Best Doctors for Women Minnesota Monthly Magazine Team Dermatologist for the Minnesota Twins, Vikings, Timberwolves and Wild 1185 Town Centre Drive, Suite 101, Eagan | 651.209.3600 | www.CrutchfieldDermatology.com

CONTENTS V O L U M E 2 0 , N O . 3 M AY / J U N E 2 0 1 8

IN THIS ISSUE

Nurturing Our Youngest Members of Society By Thomas E. Kottke, MD

PRESIDENT’S MESSAGE

Now is the Time to Talk…and Act By Thomas E. Kottke, MD

5 7 11 Page 7

TCMS IN ACTION By Nancy K. Bauer, Interim CEO FIRST 1,000 DAYS

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Colleague Interview: A Conversation with Sylvia Sekhon, MD

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Early Childhood Development, A High-Return Investment in Minnesota and Beyond By Arthur Rolnick and Rob Grunewald

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A Community Response: African American Babies Coalition and Projects By Sameerah Bilal-Roby

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SPONSORED CONTENT:

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Nutrition in the First 1,000 Days to Support Childhood Development By Sarah J. Schwarzenberg, MD and Michael K. Georgieff, MD

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Forget What You Learned: There are Four Trimesters in Pregnancy By Lisa L. Saul, MD, MBA

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CF Newborn Screening Creating a Lifelong Chronic Care Team By Carlye Tomczyk, APRN, CNP

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SPONSORED CONTENT: Preparing Pediatricians to Promote Healthy

The Case for Addressing Early Brain Development Making Talking, Reading and Singing a Standard of Care By Andrea D. Singh, MD, Nathan T. Chomilo, MD, and Charles W. Lais, MD

Development in the First 1,000 Days of Life By Emily Borman-Shoap, MD

Page 32

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Environmental Health —Reducing Asthma Risk in MN Kids By Gail Brottman, MD In Memoriam

Senior Physicians Hold Winter Meeting Disposal of Opioid and Other Medications Physicians Serving Physicians Can Help

Page 29

Medical Student Match Day! 2018 Charles Bolles Bolles-Rogers Award Radon Education

TCMS Reducing Gun Violence Policy TCMS Public Health Committee is Now Physician Advocacy Network TCMS Research Published in BMC Medicine

Career Opportunities

LUMINARY OF TWIN CITIES MEDICINE

James H. Moller, MD

Page 5 MetroDoctors

The Journal of the Twin Cities Medical Society

Providing children with opportunities for learning words and sounds throughout early childhood are key markers for life-long success. Articles begin on page 7.

May/June 2018

Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Physician Co-editor Peter J. Dehnel, MD Physician Co-editor Thomas E. Kottke, MD Physician Co-editor Robert R. Neal, Jr., MD Physician Co-editor Marvin S. Segal, MD Physician Co-editor Richard R. Sturgeon, MD Physician Co-editor Charles G. Terzian, MD Medical Student Co-editor Mac Garrett Medical Student Co-editor James Pathoulas Managing Editor Nancy K. Bauer TCMS INTERIM CEO Nancy K. Bauer Production Manager Sheila A. Hatcher Advertising Representative Erica Nelson Cover Design by Annie Krapek MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of TCMS.

May/June Index to Advertisers TCMS Officers

President: Thomas E. Kottke, MD President-elect: Ryan Greiner, MD Secretary: Andrea Hillerud, MD Treasurer: Nicholas J. Meyer, MD Past President: Matthew A. Hunt, MD TCMS Executive Staff

Nancy K. Bauer, Interim CEO, and Managing Editor, MetroDoctors (612) 623-2893; nbauer@metrodoctors.com Karen Peterson, Executive Director, Honoring Choices Minnesota (612) 362-3704; kpeterson@metrodoctors.com Lynn Betzold, Program Coordinator, Honoring Choices Minnesota (612) 362-3703; lbetzold@metrodoctors.com Trish Greene, Administrative Specialist, Honoring Choices Minnesota (612) 362-3739; tgreene@metrodoctors.com Grace Higgins, Senior Project Coordinator, Physician Advocacy Network (612) 362-3706; ghiggins@metrodoctors.com Annie Krapek, Assistant Project Coordinator, Physician Advocacy Network (612) 362-3715; akrapek@metrodoctors.com Linda Singh, Executive Director, The Convenings (612) 362-3724; lsingh@theconvenings.org Katie Snow, Administrative Coordinator, The Convenings (612) 362-3739; ksnow@theconvenings.org

ChooseYourFish.org .........................................15 Crutchfield Dermatology..................................... Inside Front Cover Fairview Health Services .................................31 Gislasen & Hunter, LLP ................................... 9 HealthPartners...................................................... 6 Lakeview Clinic .................................................31 University of Minnesota Health ........................ Inside Back Cover Schuster Clinic ...................................................14 St. Cloud VA Medical Center .......................30 Tillges Certified Orthotic Prosthetic, Inc. ...... Outside Back Cover U.S. Army ............................................................10

SAVE THE DATE

Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com. For advertising rates and space reservations, contact: Erica Nelson 4084 Jana Ave. NE St. Michael, MN 55376 phone: (763) 497-1778 fax: (763) 497-8810 e-mail: erica@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Nancy Bauer at (612) 623-2893.

May/June 2018

MAY 15 Following its successful health equity forum fo in January, the MMA will host a forum on LGBTQ health. Tuesday, May 15 | University of Minnesota Campus Club Reception: 5 to 6 pm | Program: 6 to 8 pm

To register: visit www.mnmed.org/LGBTQForum

MetroDoctors

The Journal of the Twin Cities Medical Society

IN THIS ISSUE...

Nurturing Our Youngest Members of Society

henever the topic of early childhood development comes up, I am quick to tell people that my sole training in pediatrics was completing a 3rd year medical student rotation at Community-University Health Care Center (CUHCC) and observing my four children as they grew into adulthood. My interest and passion for early childhood development was kindled just a few years ago when Mary Brainerd, then CEO of HealthPartners, tapped me to help develop an evaluation of HealthPartners’ Children’s Health Initiative. What I’ve learned by working with child development experts is that safety, security and nurturing in the first 1,000 days can have an indelible impact on a child’s entire life. Will their first experiences lead to a productive, fulfilling life, or condemn them to the margins of society? This question is answered, in part, by the economists, neonatologists, academic pediatricians, community pediatricians, community activists, and the obstetrician who have contributed to this issue. In our Colleague Interview, Dr. Sylvia Sekhon provides her passionate perspective on the benefits of promoting early childhood development, and then we turn to an economic analysis of high quality early childhood programs. Arthur Rolnick and Rob Grunewald calculate an annual return on investment in the range of 7 percent to 20 percent. In a case study from the Rondo neighborhood of St. Paul, Sameerah Bilal-Roby describes how the African American Babies Coalition translates the science of child development into a community program. The African American Babies Coalition is a model for other communities to emulate. Doctors Andrea Singh, Nathan Chomilo and Charlie Lais describe the process they used to implement Reach Out and Read in every one of the 53 HealthPartners’ primary care clinics, and they encourage other healthcare organizations to do the same. As described by Drs. Sarah Schwarzenberg and Michael Georgieff, each stage of brain development depends on the prior stage, and if optimal development does not occur,

By Thomas E. Kottke, MD Member, MetroDoctors Editorial Board

MetroDoctors

The Journal of the Twin Cities Medical Society

an opportunity is missed for life. They provide us with a list of eight actions that promote early brain development by optimizing nutrition. I expect that you’ve read of ACEs (adverse childhood experience), and death of a parent is one of the most significant. Every year there are children in Minnesota who lose their mothers, but they don’t lose them to the 19th century causes. Dr. Lisa Saul tells us why they die. Because of programs that have been developed at the University of Minnesota to care for children with cystic fibrosis, median life expectancy has increased from just a few years to nearly 40. The new treatments can be expected to promote both quality of life and life expectancy even further. As with many other new drugs, the cost of these agents is in the range of $1,000/day. This is more than five times the median U.S. family income. Society will soon need to make some difficult ethical decisions. Pediatrics is now an ambulatory practice for most physicians who treat children, and Dr. Emily Borman-Shoap, Director of the University of Minnesota Pediatric Residency Program, tells us how she’s preparing physicians-in-training for 21st century practice. One University of Minnesota Professor who has trained countless pediatricians over the decades is our Luminary, Dr. James Moller. I have admired him since I was a medical student, and I still quote his insights about medical decision-making. Editing this issue of MetroDoctors has deepened my appreciation that there is no substitute for positive human interaction in the first 1,000 days; I hope that this issue of MetroDoctors has convinced you of that fact. Electronics have no role in the development of a child of this age. I also hope that this issue of MetroDoctors will move you to support the programs that are so important for infant development and well-being.

May/June 2018

President’s Message

Now is the Time to Talk…and Act THOMAS E. KOTTKE, MD

I WAS PLANNING TO PUBLISH MY THOUGHTS about the ethical obligation of physicians

to assure that women have access to sexual health services, but the school shooting in Parkland, Florida and the daily gun violence reported in the newspaper compels me to write about the actions that we must take if we are to protect our children from the epidemic of gun violence. Gun violence in my life is a mirror of the American experience. When I was in high school, a life-long friend committed suicide with his father’s pistol. When I was in college, the gallery in the state capitol laughed at a man as he testified that his wife was murdered while dining in a Dinkytown restaurant. As with the school shootings, it was a random act of violence. When my oldest daughter was in elementary school, one of her classmates went to the morgue one day instead of class because he had been shot in the head by a toddler who had found a pistol under a pillow. A few years later, a family friend, a retired anesthesiologist, shot himself with his shotgun while sitting in his recliner at home. In 2012, a 4-year-old shot and killed his younger brother across the street from my clinic in the Riverside neighborhood of Minneapolis. These are my stories, but they are also the statistics of Minnesota. Nearly 80% of Minnesotans who die of gun shot wounds — young to middle aged men — die by their own hand. Most have no history of mental illness. In the U.S. in 2015, toddlers shot 58 people. Every day, on average, two dozen children are shot in the United States. In 2018, there have been more school shootings in the U.S. that have resulted in death or injury than there have been weeks in the year. Gun rights advocates and the gun lobby consistently and persistently steers the conversation away from reducing the number of guns out in the public. They would have us believe that the public is too emotional to hold a rational discussion after a mass shooting; that reducing the number of guns owned by the public is not possible; that more guns make us safer. We just need to accept firearm violence as a fact of life. They argue that any action that will not be totally effective is without value. They would have us believe that hardening targets or focusing on the mentally ill can solve the problem. They prevent the public from knowing the facts by promoting laws that prohibit analysis at the state level and electing members of Congress who intimidate researchers at the CDC. Looking at all of the shooters, there are only two things they have in common: they have one or more guns and they intend to kill indiscriminately. The experience of other countries and other states demonstrates that firearm violence can be curbed without impinging on their citizens’ sense of freedom or legitimate desire to hunt. Steps that might be taken to reduce (albeit, not eliminate) the terror of gun violence include: • Prohibiting civilians from possessing semi-automatic military-style assault weapons. • Closing the Minnesota loophole that allows a private seller to sell a gun without performing a background check. Half of this transaction, the purchase, is illegal if the purchaser is prohibited from purchasing a firearm for any reason. • Amending Minnesota law to allow the Minnesota Department of Health to collect data for public health and epidemiologic investigation so that the public can better understand how to reduce the burden of gun violence. • Supporting those most at risk from the physical and psychological trauma of gun violence — in particular, youth in communities of color. Focus on investing, not arresting. A public health and public safety approach has markedly reduced the death rate per mile driven in cars. The same strategy could be used to reduce the burden of epidemic gun violence, but we need to talk about reducing the number and killing power of guns that are available to the public. The time to talk is now. The time to act is now. We must continue to talk and continue to act until the epidemic is under control. See TCMS policy on Reducing Gun Violence, page 29. 4

May/June 2018

MetroDoctors

The Journal of the Twin Cities Medical Society

TCMS IN ACTION NANCY K. BAUER, INTERIM CEO

Physicians Serving Physicians

On March 1, 2018, TCMS assumed full management responsibility for Physicians Serving Physicians (PSP), a physician-centric resource for physicians suffering from alcohol and/or chemical addition. Coinciding with the retirement of long-time executive director Diane Naas (pictured), Jeffrey Morgan, MD has agreed to serve as the Interim Medical Director. If you, or a colleague are in need of confidential services, please reach out to PSP. Call (612) 362-3747; psp@metrodoctors.com; psp-mn.com; or contact Dr. Morgan at (612) 267-8912. Reducing Gun Violence Policy

At the March meeting of the TCMS Board, a Reducing Gun Violence Policy was approved. See page 29 for specific policy information. MMA Day at the Capitol

TCMS Board member Chris Reif, MD and several other TCMS members participated in the annual Day at the Capitol sponsored by MMA on March 14, 2018.

Volunteers of America to assist in developing and implementing ACP in the African American communities and is finalizing a relationship with a partner organization to reach Native American communities. Training was provided to a group of physicians and APRNs from Regions Hospital in Serious Illness Conversations (Ariadne Labs model). And, HCM Staff helped lead an ACP skills development seminar for 1st and 2nd year residents and led an ACP orientation module for 4th year medical students starting an ICU rotation (occurs monthly during school year). Public Health Advisory Committee Restructure

The Board approved a recommendation to restructure the TCMS Public Health Advisory Committee under the umbrella of the Physician Advocacy Network, allowing more physicians to engage in initiatives specific to their interest. See page 29 for more information. PAN Update

Physician Advocacy Network (PAN) Medical Director Pete Dehnel, MD spoke about the health risks of vaping at an MDH press conference on the release of 2017 Minnesota Youth Tobacco Survey data. TCMS Board Member Caleb Schultz, MD also spoke at a press conference at the State Capitol on the introduction of a bipartisan Tobacco 21 bill in the Minnesota House.

Honoring Choices Minnesota

Honoring Choices will be partnering with Stratis Health to provide health information technology and outcome evaluation for advance care plan (ACP) services being provided throughout the state. In addition, HCM has engaged MetroDoctors

The Journal of the Twin Cities Medical Society

PAN intern Hlee Yang spoke to a group of students participating in United Family Medicine residents’ monthly educational program in St. Paul about Tobacco 21 and her advocacy work with TCMS. PAN staff Grace Higgins, Annie Krapek, and Hlee Yang also joined Minnesotans for a Smoke-Free Generation’s Day at the Capitol on March 22, delivering postcards to legislators from 150 physicians from across the state in support of increasing the tobacco sales age to 21 and funding tobacco cessation services beyond the sunset of QUITPLAN Services® in 2020. The Convenings

Welcome to two new Convenings staff: Linda Singh, Executive Director, has spent most of her career in public broadcasting and non-profit management, most recently as Managing Director of External Partnerships for American Public Media/Minnesota Public Radio. And, I am pleased to announce that Katie Snow has rejoined our staff assisting Linda parttime as the Administrative Coordinator for The Convenings. Senior Physicians Association

William Walsh, MD was the guest speaker at the February 20, 2018 meeting of the Senior Physicians Association. His presentation, “Housing as Medicine,” was informative and engaging. The spring meeting will be held on May 15, 2018. See article on page 27. May/June 2018

A prescription for healthy kids: 65,000 books Each year, one in three children in the U.S. starts kindergarten without the skills needed to read. At HealthPartners, we know that nurturing childrenâ&#x20AC;&#x2122;s health and well-being isnâ&#x20AC;&#x2122;t limited to the exam room. Our 25,000 team members are devoted to supporting kids in our communities. Through Reach Out and Read, care teams at our clinics handed out over 65,000 books to our youngest patients last year. Nathan Chomilo, MD Charles Lais, MD Andrea Singh, MD

First 1,000 Days

Colleague Interview: A Conversation with Sylvia Sekhon, MD

ylvia Sekhon, MD graduated from the University of Minnesota Medical School where she also completed a Pediatric Residency. She pursued a fellowship at the Yale School of Medicine in the Child Study Center in child development. Following a return to Minneapolis, Dr. Sekhon spent two years at Minneapolis Children’s Hospital and Clinics/Behavioral Pediatrics Clinic and then joined Group Health (now HealthPartners) as a general and developmental pediatrician practicing at the Como Clinic until retirement, although continuing to work part time at HealthPartners Urgent Care and the Como Clinic. Dr. Sekhon serves on the board of Reach Out and Read, teaches second year residents in Pediatrics and Internal Medicine/Pediatrics in the Developmental/Behavioral Pediatrics rotation; and serves on the board of Help Me Grow with the Department of Education.

What changes in understanding and therapeutic approach have occurred during your career in child development? Have there been objective measures of their effectiveness? The concept of an infant being a “blank slate” who responds to environmental effects is gone. And, the Nature vs Nurture concept is replaced with both being important. Epigenetics research in animals and clinical research has shown that genes respond to stressors and this can be transmitted over generations (the Dutch hunger study). No longer do I hear from young parents that “a crying baby strengthens its lungs.” Research in child development has developed the theory of attachment and its importance for a healthy life. We now use standardized developmental measures at well child visits to screen for delays and start intervention early.

What are your thoughts about the age-old question re: the relative contribution of heredity vs. environment in the development of a child up to age 5? Both are important. See above.

Beyond the time of early intervention in treatment aspects for young child developmental issues, what recommendations do you have for continuing “care” into later childhood and adolescence? A child’s fundamental physical and mental health depends on the first five years. This gives them resilience and coping strategies MetroDoctors

The Journal of the Twin Cities Medical Society

for later life challenges. But good physical and emotional health continues over the whole trajectory of life even into old age. It is possible for “catch up” or healing to take place after the first year of life (thinking of attachment) but it requires trained professionals to implement this. If a child has good attachment and gets a new, competent caretaker (think adoption) the feelings of trust can transfer to the new caretaker.

Please discuss the impact of the family on early childhood development. The family is the crucible for emotional, physical and cognitive growth. This is why we now talk about a Two Generation solution to poverty, depression, homelessness and food insecurity. The Jeremiah Program in St. Paul is a good example. The Jeremiah Program works with both mothers and their children to provide support, childcare, advancing education and access to health care. The Two Generation approach is most successful. With the opioid epidemic, we are seeing many grandparents with custody of grandchildren. Both need assistance just like the Two Generation approach. Recently while working at urgent care in St. Paul (for HealthPartners) a mother brought in her 15-month-old son for fever. He was cooperative with me, the frightening stranger; however, she helped him cope with my touch and equipment. I complimented her on how well he did. She said she has a daycare scholarship for him and the staff has taught her how to work with him. Once a month she attends a

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May/June 2018

First 1,000 Days Colleague Interview (Continued from page 7)

parenting class to help parents anticipate the next developmental steps and how to deal with them.

Is there any difference in child development in single or multiple language families? New research on children with more than one language shows that they have more flexibility in problem solving and other positive cognitive strengths. Learn a second language before age 3 and it will be there for life. Cognitive strengths are best developed with a loving, calm emotional foundation. Feelings preceded thoughts and are the first memories. I recently met a grandmother from Malta who told me that it is customary for parents to read to the baby in the last months of pregnancy. Certainly the baby can hear human voices before birth. It is the tone and rhythm of the human voice that helps an infant settle and focus. If a baby is calm, it can focus and learn. A baby is like a sponge, gathering information from touch, smells, sights and sounds. Their brain makes a network of predictable, pleasurable experiences that are the foundation for more learning. If an infant does not have a good beginning with their parents, it is possible to remediate this, but it takes skilled professionals to do the work.

Nutrition during pregnancy. It is very important to have a healthy, balanced diet with multivitamins as the baby “takes” from the mother’s nutritional intake. Also avoiding any harmful substances: smoking, alcohol, marijuana, other drugs and medications. Currently there is very limited research on the effect on the fetal/newborn brain available; however, more is in progress.

To what extent does childhood nutrition (including intrauterine) affect cognitive development? Pregnant women need good quality food, not processed, fast food and multivitamins. They need to avoid alcohol, marijuana, smoking, pollutants like mercury in fish, and medications for which we have no good research on fetal development. They also don’t thrive with a lot of stress and it does impact the genes of the fetus. The genes can be switched on or off through methylation, this is called epigenetics. One example is the Dutch Hunger study that followed babies whose mothers suffered starvation during World War II in Holland. Later in life, these adults had more health problems at a younger age. An infant benefits most from breastmilk. There are 2,000 different compounds in breast milk to help the infant; more research needs to be done on what these compounds do for the infant. A healthy diet establishes life-long good nutrition, and prevents obesity, diabetes and cardiac problems in adults. 8

May/June 2018

How do twin studies inform our knowledge of nature vs. nurture in early childhood development? Any specific environmental factors from these studies? Outside the immediate family interventions; are they of value? Identical twin studies will continue to be helpful as we learn more about epigenetics. In my practice, I have cared for identical twins where one had better attachment and nurturing than the other. Some mothers can only care for one baby. This is where extended family is very important for nurturing in the first 3 years of life.

What current resources are underutilized to promote early childhood development? Early Childhood Family Education classes are offered through our school systems in this state. I think all first-time parents should attend with classes offered in the evening and on the weekend as well as during the day so no one is left out. These classes stop in the summer when schools are on vacation. Early Childhood Family Education started as a pilot 42 years ago within our public school systems. By l982 it had spread to all school systems in the state. Its goal is to strengthen families by enhancing the parent child relationship. It is open to all families on a sliding fee scale but no one is turned away because of money. The teachers are trained, licensed early childhood educators. Parents and children starting with babies through age 5 spend two hours a week together. One hour the parent plays with the child to build skills and their relationship. The second hour the children have supervised play with the teachers while the parents meet with another teacher to talk about their children. There are now language specific groups to meet cultural needs. Last summer I met an Ethiopian father in the clinic who had his 3-year-old and toddler in ECFE and loved going with them to class. Another program that strengthens development and family relationships is Reach Out and Read. This is a clinic-based literacy program that gives age appropriate books to babies starting at 6 months through age 5. Babies love books about baby faces. Parents are their children’s first teachers about language while helping a child become comfortable with books. Children who experience talking, reading, singing and playing daily from birth to age 3 hear 30 million words by age three. Children without this experience only hear a few thousand words and are already behind by age 3. This program reaches over 90% of children in the U.S. because of Medicaid coverage for children. For our new Americans, a language-based program with teachers skilled in the language and culture would engage new parents about other ways to care for their babies. This would give parents connection to resources in the community that they can access. Recently I saw a mother and baby for a 6 month well child visit. I gave the baby her book and talked with the mother about talking, singing and reading. This was an educated, middle class mother who was rather reserved. She said she didn’t talk that much to her baby. We talked about the positive effect language had on MetroDoctors

The Journal of the Twin Cities Medical Society

her daughter’s emotional and cognitive development. Then she made a connection: in her baby’s child care group, her daughter preferred the Somali teacher because she did lots of talking with her daughter.

What should individual physicians and organized medicine be doing to promote early childhood development? Our profession sees adults who have multiple health problems that often stem from pregnancy and the first three years of life. We should see a healthy beginning as a professional and societal responsibility for all families. We could prevent school failure, incarceration, drug use, abuse, and mental and physical health problems later in life. As a profession we have a responsibility to our youngest patients who can’t vote or advocate for what they need to flourish. Government programs like Medicaid, SNAP, WIC, subsidized housing and child care all provide children and families a chance to succeed and move ahead. State programs like Early Childhood Family Education need expanded hours to reach working parents who could come on a Saturday or in the evening. Parents also want classes in the summers when schools are not in session. Reach Out and Read is a non-profit that is funded though donations and private foundations. For families who can’t afford a simple

MetroDoctors

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board book, the gift of these books by a physician sends a strong message that a baby can learn to love books. For every dollar that is spent on a child from birth to age five, $16.00 is saved in remedial programs later in life. This is a tremendous economic value that needs our support.

What do you do when a parent hands their infant a smart phone to keep them occupied? If there is time to address it, I suggest that the parent is more important than a gadget. They can give kisses and praise and make the child feel loved. A toy doesn’t give a child that feeling. Practical advice: use moments when you change a diaper, feed or bathe a child to talk and sing. Set aside special time before nap or bedtime to read, talk and sing. Riding in a car is a good time to talk.

What makes you so passionate about early childhood development? A combination of a family foundation that valued those early years, a healthy educational environment and some early childhood experts who influenced me on the importance of the earliest years as a pediatrician.

May/June 2018

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Early Childhood Development, A High-Return Investment in Minnesota and Beyond

igh-quality early childhood development (ECD) programs targeted to vulnerable children can pay high returns to society. Research shows that program participants earn higher wages, pay more in taxes, and live healthier lives. In addition, society also benefits as there is a reduction in remedial education and crime. Indeed, research shows that such ECD investments can yield as much as a 20 percent annual rate of return. Minnesota is one of a handful of states leading the way on investing in its most vulnerable children. However, there are still too many children who do not have access to high-quality ECD programs. Minnesota needs to capture more of these benefits through expanding ECD investments and promoting cross-sector partnerships and referrals in which physicians can play a key role. First Few Years Have a Long-Term Impact

The science of ECD shows that the first few years of life set the foundation for developing the attributes and skills needed to succeed in school and work. As stated by James Heckman, Nobel laureate economist at the University of Chicago, skills learned later in life build on those learned as a young child; thus, “skills beget skills.”1 Neuroscience and developmental psychology research describes the type of early experiences that help children thrive, including stable and nurturing relationships with caregivers, language-rich environments, and encouragement to explore By Arthur Rolnick and Rob Grunewald MetroDoctors

Arthur Rolnick

Rob Grunewald

through movement and senses. With supportive early experiences, children are more likely to start kindergarten prepared to succeed. Research also describes experiences that hinder healthy development. Adverse experiences and chronic exposure to “toxic stress” can lead to a brain wired for negligence or threat, impairing learning, memory, or the ability to self-regulate. Economically-struggling families living in low-income areas are more likely to endure exposure to such negative experiences. The achievement gap between children from more advantaged environments and those in disadvantaged situations starts well before children enter kindergarten and widens somewhat during their time in school.2 That is, the experiences children have before they enter school likely have stronger impact on the achievement gap than experiences during their school-age years. Early adversity not only affects success in school, but it is also associated with

mental and physical health issues later in life. According to the Minnesota Adverse Childhood Experiences study, adults who suffered multiple types of adverse experiences in childhood were more likely to suffer from asthma; depression or anxiety; drinking; smoking; or being in poor health.3 For better or worse, early experiences have life-long implications for education, health, and success in the workforce.

The Journal of the Twin Cities Medical Society

Early Investments in Young Children Can Yield a High Return

In response to the science of ECD, public investments in young children are designed to provide resources to children and families that promote development. Such investments include maternal and child home visiting for families with pregnant women and young children, family health

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First 1,000 Days Early Childhood Development (Continued from page 11)

and nutrition programs, early learning programs, and early childhood mental health services. Four key longitudinal evaluations demonstrate that early interventions can have a positive impact on young children from disadvantaged environments that

associated with chronic health conditions such as heart disease and diabetes. Minnesota’s Investments in Young Children

In recent years, Minnesota has made increases in investments in education and health programs for young children and their families. For example, from fiscal year 2013 to fiscal year 2019, annual

Research shows that parents who are part of a Reach Out and Read program are more likely to read with their children and their children make stronger gains in language skills. lasts well into adulthood. Analyses of the Perry Preschool Program in Michigan,4 the Abecedarian Project in North Carolina,5 the Chicago Child-Parent Centers6 and the Elmira (N.Y.) Prenatal/Early Infancy Project7 have demonstrated inflation-adjusted average annual rates of return from 7 percent to about 20 percent. And while children and families benefit from these investments, the majority of benefits accrue to the rest of society, including cost reductions related to health care, education, and crime. The Perry Preschool Program and Chicago Child-Parent Centers provided preschool at ages 3 and 4, Abecedarian provided full-day care and education for children a few months old through age 4 and the Elmira Prenatal/Early Infancy Project of the Nurse Family Partnership model provided home visits by a nurse to high-risk mothers during pregnancy until the child turned age 2. Early investments have demonstrated impact on short- and long-term health outcomes. Research on the Nurse Family Partnership model shows improvements in prenatal health and fewer childhood injuries. Meanwhile, biometric measures of participants in the Abecedarian study demonstrate that the early childhood program led to reductions in risk factors 12

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that parents who are part of a Reach Out and Read program are more likely to read with their children and their children make stronger gains in language skills. Despite all the progress we have made here in Minnesota our work has only begun as tens of thousands of young children still do not have access to high-quality ECD programs. No business would underfund an investment yielding a double-digit return. And because it costs Minnesota and our economy so much not to invest, today is the time to fully fund ECD, not tomorrow. Arthur Rolnick is a senior fellow at the Humphrey School of Public Affairs at the University of Minnesota and former research director at the Federal Reserve Bank of Minneapolis.

funding for Early Learning Scholarships increased from $4 million to over $70 million. Low-income families with children age 3 and 4 and higher-risk families with younger children can use scholarships to enroll a child in a high-quality early learning program of their choice. In addition, last year the Minnesota legislature allocated an increase of $6 million per year in fiscal years 2018 and 2019, and $16.5 million per year the following two years for family home visiting. In these programs a nurse, parent educator, or social worker provides information and resources on health, nutrition, and parenting issues to vulnerable families with pregnant women or young children. Minnesota physicians have also played a unique role in ECD by supporting maternal and child health, conducting wellchild visits, screening for developmental delays, among other responsibilities. Recognizing the myriad of influences affecting child development, many of which are outside the medical model, pediatricians have been tapped to support ECD beyond care in the treatment room. One example is the Reach Out and Read program where pediatricians incorporate books, instruction, and encouragement for families to read aloud with each other. Research shows

Rob Grunewald is an economist in the Community Development Department at the Federal Reserve Bank of Minneapolis. The views expressed here do not necessarily represent the views of the Federal Reserve Bank of Minneapolis or the Federal Reserve System. (Endnotes) 1. James J. Heckman. “Schools, Skills, and Synapses.” Economic Inquiry, 46(3), pp. 289-324, 2008. 2. Bruce Bradbury, Miles Corak, Jane Waldfogel, and Elizabeth Washbrook. Too Many Children Left Behind: The U.S. Achievement Gap in Comparative Perspective. Russell Sage Foundation, 2015. 3. Minnesota Department of Health. Adverse Childhood Experiences in Minnesota. Findings & Recommendations. Based on the 2011 Minnesota Behavioral Risk Factor Surveillance System, February 2013. 4. James J. Heckman, Seong Hyeok Moon, Rodrigo Pinto, Peter Savelyev, and Adam Yavitz. “The Rate of Return to the HighScope Perry Preschool Program.” Journal of Public Economics, 94(1-2), pp. 114–28, 2010. 5. Jorge Luis García, James J. Heckman, Duncan Ermini Leaf, and María José Prados. “The Life-Cycle Benefits of an Influential Early Childhood Program.” Human Capital and Economic Opportunity Working Paper Series. The University of Chicago, 2016. 6. Arthur J. Reynolds, Judy Temple, Barry White, Suh-Ruu Ou, and Dylan L. Robertson. “Age 26 Cost-Benefit Analysis of the Child-Parent Center Early Education Program.” Child Development, 82(1), pp. 379–404, 2011. 7. Lynn A. Karoly, Peter W. Greenwood, Susan S. Everingham, Jill Houbé, M. Rebecca Kilburn, C. Peter Rydell, Matthew Sanders, and James Chiesa. Investing in Our Children: What We Know and Don’t Know About the Costs and Benefits of Early Childhood Interventions. Santa Monica, Calif.: RAND Corporation, 1998.

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A Community Response: African American Babies Coalition and Projects When it comes to love and affection, you can’t spoil babies. Hold infants when they need to be held. Respond to their cries. Infants who are responded to are less demanding as toddlers. Toxic stress, like fearful environments, can affect a child’s brain development. Children can’t listen or learn well when they feel scared, hurt, or angry. Instead of teaching children how to behave responsibly, physical punishment is more likely to increase problem behaviors including resistance, power struggles, anger, and rebellion. The statements above are all based on the latest brain development research, but you won’t find them published in a medical journal or a doctoral thesis, even though they have a significant impact on medical outcomes. These messages appear in community trainings and short videos aired on public television as a way to share the latest brain development science with the people who need it most — parents. These messages and many more are the work of the African American Babies Coalition and Projects (AABC), a collaborative of parents, caregivers, researchers, doctors and childhood development professionals working to ensure that African American babies, from pre-birth through school age, receive the nurturing they need to build strong brains to succeed for a lifetime. African American babies are among the most vulnerable in our community because they start life at increased risk for By Sameerah Bilal-Roby

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social determinants that impede healthy development. Among Black children in Minnesota: • 44% live in poor families1 • 29% receive inadequate or no prenatal care2 • 10% are born at low-birth weight3 These statistics also reveal a great deal about the African American parents of these young children. They too are experiencing the physical and emotional stress of poverty, lack of access to health care, and the ongoing impacts of day-to-day racism, historical trauma, and Adverse Childhood Experiences (ACEs). Putting Research to Work

In response to these disparities, a group of African American citizens formed a campaign in 2008 to impact the community in a way which was helpful and non-judgmental. At the first meeting the group named itself the “African American Babies Coalition” to incite positive feelings and a focus on children. As the work of the Coalition grew, “Projects” was added to the name. The Amherst H. Wilder Foundation partners with the Coalition to provide infrastructure support, to assist with research on outcomes, and to help spread the learnings from this program to other community and care-related systems. Since the beginning, AABC has included parents, grandparents, community neighbors, educators, childcare providers, nonprofit and civic leaders, researchers, and public health professionals from across Minnesota, who all share a common goal: ensuring African American children are ready for kindergarten and lifelong success. Brain development research and

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science has exploded in the past decade. An abundance of information is readily available to healthcare professionals, but little has been done to put it in the hands of families who are shaping babies’ brains every day. AABC works to put this research into action through a three-stage community-owned model: 1. Listen: Conduct community-based participatory research to uncover the African American cultural knowledge and patterns that show up in the caregiving of children ages 0-3 and understand how they contribute to, and inhibit, healthy child development. 2. Share: Increase community awareness and engagement in the African American community through accessible, culturally relevant messaging on parenting practices that are grounded in brain development research. 3. Train: Provide training — which draws on early childhood development, Adverse Childhood Experiences and resilience research and is adapted to be culturally appropriate for the (Continued on page 14)

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First 1,000 Days A Community Response (Continued from page 13)

African American community — to key networks: parents, grandparents, and community members; para-professionals, and systems and providers that interact with and impact parents and caregivers. This process coupled with the latest

neurological research from Harvard University on babies and infants has led to the development of several community-owned products including: informational posters, public service announcements airing on local public television, Mommy-and-Me bags; a bundle of educational toys and parental tools to encourage healthy play between parents and their children; and youth summits to teach the next generation

of parents about the importance of healthy brain development in order to break the generational cycle of ACEs. Brains are Built

A cornerstone of the Coalition’s work is the “Brains are Built” public service announcement campaign. Through a series of short videos, posters and other materials, the campaign translates brain science and child development research concepts into honest, real, on the ground language, ideas and parenting tools. African American parents share what the research means to them in their own words: “It’s important to understand how to discipline children where it’s not physical.” “Give your child as much love and attention as you possibly can, and they’ll be better for it.” “When they put on the temper tantrums, if you make a big deal out of it, they’re just going to put on a bigger show. I just try to talk calm with them.”

THE SCHUSTER CLINIC FOR FOR ENDOCRINE FO E DO EN OCR OC CRIN INE NE AND AN ND METABOLIC META META ME TABO TABO OLI LIC DISORDERS LIC D SO DI SORDERS S −and− −an and d−

THE TH T H HE E THYROID TH HYRO OIID CENTER CE C ENT N ER E

www.schusterclinic.com

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The authenticity of these messages cannot be overstated. It’s one thing to read a research report about the impact of ACEs in a child’s development. It’s quite another to hear a family share their personal experiences with parenting in a way that is relatable to your own life. It’s the difference between knowing and understanding. The Brains are Built campaign was recognized with a 2017 Upper Midwest Emmy Award in the public service announcement category. Through this grassroots effort to prompt new conversations and new ways of engaging communities in messaging around early brain development, the AABC aims to achieve the following positive outcomes in the communities most affected by early childhood disparities: • 80% of parent/grandparent participants will report increased knowledge and understanding of brain development and how trauma and toxic stress impairs healthy development. • 60% of professional/provider participants will report increased knowledge of how trauma impacts the parents and families they serve, and how they MetroDoctors

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can support parents in a culturally informed manner. Beginning Before Birth

Recognizing that healthy child development begins before birth, AABC is collaborating with health clinics in the Twin Cities to provide integrated perinatal care to African American women at risk for low birth weight and infant mortality. The Integrated Care High Risk Pregnancy Initiative (ICHRP) will engage the African American community and convene collaborative partners using a model similar to AABC to support better birth outcomes. Acknowledging the role historical trauma has played in the prevalence of high-risk pregnancies among African American women, this collaborative will work across disciplines to develop integrated care interventions as well as capacity building and training opportunities. Such services will help African American families meet basic needs and achieve goals related to healthy pregnancies and self-reliance. By involving counties, cities, faith communities and families to improve birth outcomes together, project experts expect to see improvements in healthy pregnancy outcomes, decreased crisis care and increased community involvement in health systems.

in more natural, respectful manners. The project team looks forward to sharing outcomes to demonstrate the effectiveness of healthcare models that are developed with, not for, communities. Sameerah Bilal-Roby is Program Manager for the Integrated Care High Risk Pregnancies Initiative (ICHRP) and Director of the African American Babies Coalition (AABC) Projects, which include the Brains Are Built Campaign, Copartner with Me and My Baby Brain Building Bags and co-producer with Twin City Public Television “Brains Are Built” PSAs. Her focus is early childhood brain development and toxic stress, infant mortality and low birth weight, equity and disparities in training and health — specifically in the African American community. Sameerah was educated at Metropolitan State University in Early Childhood Education and Adult Education, she is a Master ACE, seasoned trainer

Looking Ahead

AABC has been at the forefront of system-wide racial and health equity work in Minnesota. The Coalition recently established and facilitated an Interest Group for a Minnesota chapter of the Black Child Development Institute. For more than 40 years, the National Black Child Development Institute has engaged leaders, policymakers, professionals, and parents around critical issues that directly impact Black children and their families. The work of the Minnesota Black Child Development Institute will be to serve as an agent of systems change by connecting communities, sharing information, building coalitions of stakeholders, and coordinating the advocacy efforts of initiatives already at work in Minnesota. Through all of these efforts, AABC expects to influence systems to serve families MetroDoctors

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highlighting trauma and toxic stress awareness, travel team member of CityMatCH and Co-chair of BECC (Birth Equity Community Council), and a certified MN Council Professional Development trainer. She sits on many community action committees such as SHIP, CVAS, AALF Health and Wellness, Mill City Kids, and recently appointed to the Minnesota Department of Health HEAL leadership council. Her leadership experiences heighten a natural energy to respond to mounting developments that negatively impact a family’s health and well-being. She is passionate about influencing grass-roots people to speak at important tables and act as catalysts for systemic change. She was honored to be presented with the Friend of the Family Award from the Minnesota Family Council on Relationships (MCFR). Data Sources: 1. http://www.nccp.org/profiles/MN_profile_7. html 2. www.marchofdimes.org/peristats 3. CDC, National Vital Statistics System, 201

ChooseYourFish.org for the first 1000 days of life and beyond “Eating fish during pregnancy and the first 1000 days of life improves brain and eye development. For accurate and actionable information, I refer my patients to ChooseYourFish.org” Abbey L. Mello, MD

Obstetrics and Gynecology HealthPartners Medical Group

May/June 2018

Sponsored Content

The Case for Addressing Early Brain Development Making Talking, Reading and Singing a Standard of Care Contributed by Andrea D. Singh, MD, Nathan T. Chomilo, MD, and Charles W. Lais, MD

Andrea D. Singh, MD

Clinicians who care for children have long understood that the nurturing of children’s health and well-being is not confined to the four walls of an exam room. Children’s health requires attention to not only physical exam results and vital signs but to the myriad factors that influence social, emotional, intellectual and physical development. Early health and well-being is strongly linked with health and well-being later in life, and this link transcends racial, ethnic, gender and geographic boundaries. With this in mind, in 2015, HealthPartners created the Children’s Health Initiative to comprehensively improve the health and well-being of children, mothers and families. The case to address these issues is compelling. Each year, more than one in three American children start kindergarten without the skills they need to read.1,2 Reading proficiency by the third grade is the most important predictor of high school graduation. A deficiency in this 16

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Nathan T. Chomilo, MD

Charles W. Lais, MD

area is an important predictor of chronic health issues in adulthood.3 In Minnesota, we continue to see racial disparities in literacy. Eighty-four percent of African-American, 86% of American Indian and 82% of Hispanic children score below proficiency in reading in the fourth grade, compared with 67% of Asian, 65% of biracial and 53% of white children.4 These gaps are exacerbated by poverty. In Minnesota, one in seven children younger than 5 lives below the federal poverty level.5 The Importance of Talking, Singing and Reading Early in Life

The first 90 days of brain development after birth are critical to future language development and word acquisition. Children exposed to more talking, singing and reading early in life typically develop larger receptive vocabularies by kindergarten. In children without this exposure, research

has identified learning gaps starting at 18 months. According to George Halvorson in his book, Three Key Years, “We can predict with a very high level of accuracy by age 3 which children are going to be unable to read — and we know that children who are reading-impaired by the third grade are 40% more likely to get pregnant in their teen years, 60% more likely to drop out of school and more than 70% more likely to end up in jail.”6 To keep the child at the center of everything it does, HealthPartners has deliberately incorporated programs that promote talking, singing and reading into its everyday work with families. Integrating these initiatives into our standard work helps ensure that all families can access these resources at critical stages in their children’s lives. We specifically encourage our immigrant populations to use their native languages while talking, singing and reading, because it is the words — not

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a particular language or cadence — that matter. Parents Rely on Health Professionals for EarlyChildhood Information

One of the prevailing axioms on early brain development is that babies are sponges who soak up everything around them. However, they really are active participants in their development, and parents play a critical role in shaping their opportunities and lessons. So where do parents get advice on how to guide their children through their first few years? Despite the allure of seemingly infinite online information, most parents still look to a select few trusted resources, among them their child’s physician. According to a 2015 ZERO to THREE survey,7 when parents of young children were asked where they get child-rearing advice, medical professionals were second only to “the way my parents raised me.” In fact, medical professionals were ahead of notable and expected sources such as “the child’s other parent” and “my mom.” The survey also found that 34% of parents did not know that talking to their child in the first year helped build future language skills, and 45% believed that their child had to reach age 2 before reading aloud would benefit them. Reach Out and Read Encourages a Love of Reading

Pediatricians developed the Reach Out and Read program8 more than 25 years ago to not only give books to children and families, but also to enhance early parent-child interactions and stimulate a love of reading. More than a dozen research studies on this model have shown that Reach Out and Read is associated with markedly more positive attitudes toward reading aloud, more frequent reading aloud by parents, improved parent-child interactions, an improved home literacy environment and significant increases in expressive and receptive language in young children — particularly in at-risk and low socioeconomic status families.2 Reach Out and Read was rolled out to Minnesota in 1997; however, clinics across the state have been challenged to incorporate this program into their daily

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practices. HealthPartners has focused on making this program work for its clinics and patients as a foundational block of its Children’s Health Initiative. With the help of Reach Out and Read Minnesota, HealthPartners successfully incorporated this program into all of its clinics in record time. Now, HealthPartners is setting an example for innovation within the Reach Out and Read model by training obstetricians to talk with parents about talking, singing and reading with their babies from Day 1. Parents in our care system get a book at their 32-week obstetric visit in addition to the books children receive at wellchild visits from 6 months to 5 years, as prescribed by the Reach Out and Read charter. All health care team members in all specialties give parents the same messages about the importance of early brain development. In addition, HealthPartners has launched a dental initiative that involves giving books about brushing teeth at 9-month well-child visits to reinforce the importance of dental care. Pairing early literacy with other anticipatory guidance not only helps drive home the message for parents, it helps save precious minutes during well-child visits. A High Return on Investment

By 2017, all 53 HealthPartners clinics were participating in Reach Out and Read. More than 65,000 books costing, on average, about $2.25 were distributed. The investment in providing these books to our youngest patients has a high financial rate of return to society in terms of total cost of care and long-term chronic disease burden. New parents typically also enjoy receiving a book and learning how to nurture their child’s development. Sadly, as effective as this intervention is, it is not funded directly through a standard medical practice. If promoting early brain development were a billable medical intervention, this program would be considered one of a health care organization’s most cost-effective and best investments. As clinicians, we are very proud of HealthPartners for focusing on the health and well-being of children in a comprehensive way by supporting the Children’s Health Initiative. We would like to encourage all healthcare organizations to promote

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early brain development in the care of families. Exposure to talking, reading and singing matters — but so does collaboration in this effort across specialties and the overarching recognition that we owe this to our youngest patients. Andrea D. Singh, MD is a pediatrician at the Park Nicollet Clinic in Lakeville and Chairperson of Pediatrics across Park Nicollet Health Systems. She has been with Park Nicollet since 2005 and is a co-Chair of the HealthPartners Children’s Health Initiative. Nathan T. Chomilo, MD is a pediatrician at the Park Nicollet Brookdale Clinic and an internal medicine hospitalist at Methodist Hospital. He is also the Medical Director of Reach Out and Read Minnesota and a member of Governor Mark Dayton’s Early Learning Council. Charles W. Lais, MD is an OB/GYN at the HealthPartners St. Paul Clinic and Regions Hospital. He is the Medical Director for Obstetrics and Gynecology across HealthPartners, and is a co-Chair of the HealthPartners Children’s Health Initiative. References 1. Data Resource Center for Child and Adolescent Health. The National Survey of Children’s Health 2011–2012. http://childhealthdata.org/ learn/NSCH. 2. American Academy of Pediatrics. Policy statement: Literacy Promotion: An Essential Component of Primary Care Pediatric Practice. http://pediatrics.aappublications.org/content/ pediatrics/early/2014/06/19/peds.2014-1384. full.pdf. 3. Center for Public Education. Learning to Read: Reading to Learn: At a Glance. http:// www.centerforpubliceducation.org/research/ learning-read-reading-learn-glance-2015. 4. Kids Count Data Center. Fourth Graders Who Scored Below Proficient Reading Level by Race. http://datacenter.kidscount. org/data/tables/5126-fourth-graders-whoscored-below-proficient-reading-level-byrace?loc=25&loct=2#detailed/2/any/fal se/573,36,867,38,18/10,168,9,12,185,107/11557. 5. Minnesota Department of Health. 2017 Minnesota Statewide Health Assessment. http:// www.health.state.mn.us/healthymnpartnership/docs/2017MNStatewideHealthAssessment.pdf. 6. Halvorson, George C. Three Key Years. Institute for InterGroup Understanding, 2016. https:// www.intergroupinstitute.org/books/threekey-years. 7. ZERO to THREE. National Parent Survey Report, 2016. https://www.zerotothree.org/ resources/1425-national-parent-survey-report. 8. Reach Out and Read. http://www.reachoutandread.org.

May/June 2018

First 1,000 Days

Nutrition in the First 1,000 Days to Support Childhood Development

e all recognize good nutrition as an essential factor in achieving good health. We also recognize that nutrition is even more important in young children, who are undergoing growth and development. However, until recently we did not appreciate the critical importance of specific nutrients in achieving optimal brain development in very young children. The human brain is recognizable as a separate structure by 18 days after conception. Thereafter the brain grows and changes throughout life. No period is more crucial for brain development than the period of time from conception until the age of two, the first 1,000 days of life. During this time the brain is not only growing but also undergoing a complex series of cellular and structural changes that proceed in a specified sequence. For the child to achieve optimal neurodevelopment, each of these changes must proceed at the specified time. The brain develops through scaffolding. This means that changes in one part of the brain are necessary building blocks for subsequent changes. Many of these scaffolding processes are time-limited; once a particular developmental sequence fails to occur it may not be possible to retrieve the function lost. Optimal brain development during the first thousand days of life requires that all necessary biologic factors be present at the defined developmental time point and that no inhibitory factors be present. Many factors are critical to optimal brain development, including a supportive environment, and attached primary provider, in the absence of toxic stress. Much By Sarah J. Schwarzenberg, MD and Michael K. Georgieff, MD

May/June 2018

Sarah J. Schwarzenberg, MD

Michael K. Georgieff, MD

of brain development is dependent upon key nutrients being present during structural changes. These key nutrients include macronutrients including protein, specific fats, including long-chain polyunsaturated fatty acids, glucose, as well as key micronutrients, including zinc, copper, iodine, iron, selenium, the B complex vitamins, vitamins A and K, folate, and choline. Many of these nutrients can be shown to be necessary during a critical or sensitive period of development. Thus, nutrition is one of several factors that affect early brain development, and one of the few that healthcare providers have the capacity to directly influence through well described, well piloted, effective interventions. Failure to provide essential nutrients in the first 1,000 days of life may result in medical and psychological problems that can lead to deficits in education and behavioral management. This provides us with a unique opportunity to influence long-term outcomes through management of nutrition in early life. Recently, the American Academy of

Pediatrics published a policy statement to inform pediatric healthcare providers about the importance of nutrition in the first 1,000 days of life to brain development. The policy provides guidance for providers both on recommending appropriate nutrition in the first 1,000 days of life and guides them in advocating for healthcare policy to support this nutrition for children. Healthcare providers who care for pregnant women and children must be aware of optimal nutritional management during the first 1,000 days of life. This includes adequate gestational intake of protein and calories, appropriate gestational weight gain, and iron and folate sufficiency. Following birth, breastmilk provides the nutrition for optimal neurodevelopment for the first 6 months of life. Providers can educate women in the importance of breast-feeding and advocate for policies that make breast-feeding in the workplace easier. After the first 6 months of life, ensuring that infants and children have adequate intake of important nutrients either through food choices or

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through appropriate supplementation is critical. Guidelines are available through the American Academy of Pediatrics and through the American College of Obstetrics and Gynecology to guide providers in nutrition recommendations. Importantly, there are children who have access to appropriate nutrition but who cannot utilize that nutrition or have greater needs than average because of other healthcare factors. For example, infants of mothers with gestational diabetes and small for gestational age babies may have reduced iron stores despite the presence of adequate iron in their mother’s food during pregnancy. Infants who have had many diagnostic blood draws may require iron supplementation earlier than expected. It is important for pediatric providers to anticipate the nutritional needs of the individual child. Providers can help mitigate the effects of unavoidable early nutrient deficiency with early screening for developmental issues. Healthcare providers may be aware of programs that offer supplemental nutrition to pregnant women, breast-feeding women and young children. Of these programs, the Special Supplemental Nutrition Program for Women Infants and Children, or WIC, is the most important program providing nutrition in the first 1,000 days of life. Over 50% of children under the age of 1 in the United States are served by WIC. Many families also benefit from the Supplemental Nutrition Assistance Program (SNAP), as well as food pantries and soup kitchens. These programs, with demonstrated efficacy, are under assault in the form of attempted changes in eligibility or financing structure. Maintaining these programs and, in fact, expanding them to more children, is a key focus of advocacy for healthcare providers with an interest in child health. In summary, the first 1,000 days of life is a time of tremendous opportunity and risk for the developing brain. Our actions as healthcare providers during this critical period of brain development can lead to improved long-term quality of life for our patients and can reduce the cost of their future health care and education. Applying the tools that are available to MetroDoctors

guide families to optimal nutrition, referring them to appropriate supplemental nutrition programs, and being vigilant regarding supportive care for children who did not receive appropriate nutrition can give our patients their best start in life. As experts in the care of children, we can use our voices to support the programs that give our most vulnerable patients every opportunity to grow to their full potential. Specific recommendations from the AAP policy statement: 1. Support breastfeeding. 2. Advocate for inclusion of nutrients essential to neurodevelopment in nutrition programs targeted at children in the first 1,000 days. 3. Assist families in choosing complementary foods and diets containing nutrients essential to neurodevelopment in the first 1,000 days. 4. Encourage and assist families in enrolling in programs that provide supplementary nutrition, for example, WIC, after the first year of life. 5. Advocate for expansion of critical nutrition programs, such as WIC, and oppose changes that would limit access to these programs. 6. For children who have undergone early life events that are associated with nutrient deficiencies (for example, many venipuncture events in early life), focus on early repletion of lost nutrients and on testing to uncover neurodevelopmental risks early. 7. Partner with providers caring for pregnant women to draw attention to nutrients critical to optimal fetal neurodevelopment. 8. Consider advocacy work in organizations that work to reduce hunger at any level — local to global. Key references that can assist providers in providing optimal nutrition for neurodevelopment include: • Schwarzenberg SJ, Georgieff MK, and the Committee on Nutrition, Advocacy for improving nutrition in the first 1,000 days to support childhood development and adult health, Pediatrics 2018 Feb;141(2). pii: e20173716. doi: 10.1542/peds.2017-3716. Epub 2018 Jan 22.

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•

Rao R, Georgieff MK. The nutritionally deprived fetus and newborn infant. In: Miller S, editor. International Review of Child Neurology Series: Acquired Brain Injury in the Fetus & Newborn: Mac Keith Press 2012. p. 277-87. This provides a comprehensive review on brain-nutrient interaction. Guidelines for Perinatal Care, 8th edition, American Academy of Pediatrics and American College of Obstetrics and Gynecologists, 2017. Pediatric Nutrition, 7th edition, Kleinman RE and Greer FR, eds, American Academy of Pediatrics, Elk Grove Village, IL, 2014. Hagan JF, Shaw JS, Duncan PM eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th ed. American Academy of Pediatrics, 2017. Schanler RJ, Krebs NF, Mass SB, eds. Breastfeeding Handbook for Physicians. 2nd ed. American Academy of Pediatrics and The American College of Obstetrics and Gynecologists; 2013. Policy statement: breastfeeding and the use of human milk. Section on breastfeeding. Pediatrics. 2012;129(3). Available at: www.pediatrics.org/cgi/ content/full/129/3/e827. Baker RD, Greer FR, and the Committee on Nutrition. Clinical report: diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0–3 y of age). Pediatrics. 2010;126(5):1–11.

Sarah Jane Schwarzenberg, MD is Director, Pediatric Gastroenterology, Hepatology and Nutrition; and Medical Director, Pediatric Ambulatory Services at the University of Minnesota Masonic Children’s Hospital. She can be reached at (612) 624-1133; schwa005@umn.edu. Michael K. Georgieff, MD is the Martin Lenz Harrison Land Grant Professor of Pediatrics at the University of Minnesota. He is Executive Vice-Chair of Pediatrics, Head of the Division of Neonatology and Director of the Center for Neurobehavioral Development at the University. He can be reached at (612) 626-0644; georg001@umn.edu.

May/June 2018

First 1,000 Days

Forget What You Learned: There are Four Trimesters in Pregnancy

aternal mortality is defined as maternal death during pregnancy or within the first year following the birth of a child. The death may be directly related to complications of pregnancy, or in other cases associated with pregnancy and its physiologic impact. In contrast, maternal deaths may also be unrelated to pregnancy, but classified as a maternal death due to temporal relationship to pregnancy. Most people imagine maternal mortality as 19th-century-style deaths such as hemorrhage in childbirth or death from eclampsia, a hypertensive condition of pregnancy. Those types of deaths still occur, but the rate of occurrence has not changed significantly over the last decade. The state of Minnesota boasts a low maternal mortality rate — defined as the number of maternal deaths per 100,000 live births — when compared to the United States as a whole (21.6 per 100,000 and 26.4 per 100,000 respectively). The causes of maternal mortality in Minnesota in the last several years, however, demonstrate a disturbing trend. Data from 2005-2009 show significant disparities in maternal mortality by ethnicity, with American Indian and African American mortality rates significantly higher than the state average. Between 2012 and 2015, 40% of maternal deaths were pregnancy associated, rather than specifically pregnancy related. The American College of Obstetrics and Gynecology (ACOG) and the Centers for Disease Control define pregnancy-associated death as: The death of a woman while pregnant or within one year of termination of pregnancy, irrespective of cause, and a pregnancy-related death as: The death of a woman while pregnant or within one year of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by her pregnancy or its management, but not from accidental or incidental causes. There were fewer deaths related to obstetric causes and chronic medical conditions. The trends in maternal deaths follow the mortality trends of the population at large: opioid overdoses, and violent deaths due to motor vehicle accidents, firearms, homicides, and suicides. The birth of a child is life-changing whether one is a brand new or veteran parent. For most, the weeks and months following the birth are filled with frequent sounds of crying, nursing or preparing bottles, and inexplicable fatigue. A woman must By Lisa L. Saul, MD, MBA

May/June 2018

adapt to multiple physical, social, and psychological changes. She must recover from childbirth, adjust to changing hormones, learn to feed and care for her newborn and adjust to her new family dynamics. For many new mothers, this is also a time of profound loneliness and isolation. In generations past, new mothers were surrounded by family members who availed themselves to help care for a family welcoming a new baby. While this scenario still occurs in some families, our society is less nuclear than it once was. Adult children often move away from home for educational or career opportunities, and as a result, move away from their support systems. Consequently, they must rely upon themselves in the early weeks and months following delivery. The three months following the birth of a child has been termed the “fourth trimester” in many books, scholarly articles, and by professional nursing, midwifery, and obstetric societies. In addition to being a time of joy and excitement, the fourth trimester can present considerable challenges for women, including lack of

Maternal Mortality Rates by Race/Ethnicity 2005-2009 180.0 160.0 140.0 Overall

120.0

Caucasian

100.0

African American

80.0

American Indian

60.0

Asian

40.0

Hispanic

20.0 0.0

Maternal Mortality disparity data for 2005-2009, Minnesota Department of Health. Please note that the rate in the graph is per 100,000 live births. Please note that this data may change as we continue to improve our methodology for identifying cases we are updating historic files.

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sleep, fatigue, pain, breastfeeding difficulties, stress, depression, lack of sexual desire, and urinary incontinence. Dealing with preexisting medical conditions such as diabetes, hypertension, or drug dependence can compound the stress that women feel. In June 2016, The American College of Obstetrics and Gynecology (ACOG) released a Committee Opinion emphasizing the importance of optimizing post-partum care, with specific reference to the fourth trimester. Post-partum visits for uncomplicated deliveries are typically scheduled six weeks after delivery to allow the obstetric provider the opportunity to assess success of physical recovery, breastfeeding, and overall well-being. Nearly half of all women, however, do not attend the postpartum visit. The Committee Opinion reports that attendance rates are lower among populations with limited resources, which contributes to health disparities already prevalent in these populations. When women do attend postpartum visits, they report unmet needs: less than one half of women report that they received enough information at their postpartum visit about postpartum depression, birth spacing, healthy eating, the importance of exercise, or changes in their sexual response and emotions. Active engagement in patient-centered, maternal postpartum care has the potential to improve outcomes for women, infants, and families and support ongoing health and well-being. The document stresses the importance of a comprehensive, multidisciplinary approach to a timely postpartum office visit that provides the new mother with individualized assessment and recommendations for family, community, and health system support. Such an approach offers wraparound rather than episodic care. Anticipatory guidance starting in the prenatal period and continuing through the fourth trimester will allow for a more coordinated approach to the care of new mothers. Active engagement in patient-centered, maternal postpartum care has the potential to improve outcomes for women, infants, and families and support ongoing health and well-being. To that end, ACOG recommends the following: • To optimize postpartum care, anticipatory guidance should begin during pregnancy. During antenatal care, it is recommended that the patient and her obstetrician–gynecologist or other obstetric care provider formulate a postpartum care plan and identify the healthcare professionals who will comprise the postpartum care team for the woman and her infant. • Ideally, during the postpartum period, a single health care practice assumes responsibility for coordinating the woman’s care. At discharge from hospital maternity care, the woman should receive contact information for her postpartum care team and written instructions regarding the timing of follow-up postpartum care. • Early postpartum follow-up is recommended for women with hypertensive disorders of pregnancy. Early follow-up also may be beneficial for women at high risk of complications. • It is recommended that all women undergo a comprehensive postpartum visit within the first six weeks after birth. This MetroDoctors

The Journal of the Twin Cities Medical Society

visit should include a full assessment of physical, social, and psychological well-being. • Systems should be in place to ensure that women who desire long-acting reversible contraception or any other form of contraception can receive it during the comprehensive postpartum visit, if immediate postpartum placement was not done earlier. • Recommended anticipatory guidance at the postpartum visit includes infant feeding, expressing breast milk if returning to work or school, postpartum weight retention, sexuality, physical activity, and nutrition. • Any pregnancy complication should be discussed with respect to risks for future pregnancies, and recommendations should be made to optimize maternal health during the inter-conception period. • At the conclusion of the postpartum visit, the woman and her obstetrician–gynecologist or other obstetric care provider should determine who will assume primary responsibility for her ongoing care. If responsibility is transferred to another primary care provider, the obstetrician–gynecologist or other obstetric care provider is responsible for ensuring that there is communication with the primary care provider so that he or she can understand the implications of any pregnancy complications for the woman’s future health and maintain continuity of care. Many of the maternal deaths in Minnesota occur after the six-week post-partum visit, which may indicate the need for additional follow up with new mothers in the first year after giving birth. Therefore, to these recommendations, I would add a three to six month “wellness” visit. In this period, acute sleep deprivation has subsided to some degree, those returning to work have done so, and the needs of the infant have changed in comparison to the six-week visit. A visit timed at the three to sixmonth interval would offer a provider the opportunity to assess the patient and family dynamics, discuss family planning, diet and exercise, breast feeding, and to assess social factors such as safety in the home. This interaction may elucidate issues related to alcohol, tobacco, and drug use, depression, and abuse. This visit can provide support to a mother, and her family, improving the overall health of the family unit — and each child — in the first 1,000 days and beyond. This visit just might save a life. Lisa L. Saul, MD, MBA is the President of the Mother Baby Clinical Service Line for Allina Health, and a board-certified maternal-fetal medicine specialist with Minnesota Perinatal Physicians. She leads quality and safety initiatives for Allina’s 11 birth centers, and is responsible for women’s health programs and services for the perinatal, OB/Gyn, OB Hospitalist and certified nurse midwife provider groups. She is passionate about promoting and protecting the health and wellness of women, and closing disparity gaps where they exist. A native of California, Dr. Saul is a graduate of The University of California, San Diego School of Medicine. She can be reached at: lisa.saul@allina.com. May/June 2018

First 1,000 Days

CF Newborn Screening Creating a Lifelong Chronic Care Team

ystic fibrosis (CF) is an inherited chronic disease that progresses over time. The hallmarks of cystic fibrosis are malnutrition and chronic lung infections. It affects more than 30,000 individuals in the United States. At this time, there is no cure for the disease. The median life expectancy of those with CF is nearly 40 years.1 CF is caused by changes in the cystic fibrosis transmembrane conductance regulator, or CFTR, gene.1 The CFTR gene is responsible for making sure the chloride channels inside our cells function properly. If salt and water are not moved correctly through these channels, mucus in the body will become thick and sticky, somewhat like wet sand. This thick and sticky mucus causes many of the problems in CF that contribute to morbidity, such as chronic lung infections, and mortality. Individuals with CF are not able to easily clear these thick secretions from their lungs due to ineffective airway ciliary clearance. CF is a genetic condition inherited in an autosomal recessive pattern, meaning that for a person with CF, there is a mutation in both copies of their CFTR gene. In this situation, both parents must have one mutation in their CFTR gene and are said to be carriers of the disease. Prior to the advent of newborn screening, early detection of this disease was challenging. Many children did not survive to attend elementary school because

of poor growth and nutritional status and advanced lung disease. In 1982, the state of Colorado was the first to add CF to the state newborn screen.2 Many states followed, and by 2010 all 50 states have CF on the newborn screen.1 Early diagnosis and early treatment with pancreatic enzyme replacement therapy, fat-soluble vitamins and salt supplementation have improved growth rates in infants with CF.3 Over the years there have been several studies that have demonstrated a clear correlation between improved nutritional status and pulmonary function. Early interventions as a result of early detection by newborn screening have led to improved outcomes and increased life expectancy. CF Newborn Screening

By Carlye Tomczyk, APRN, CNP

May/June 2018

Minnesota added CF to the stateâ&#x20AC;&#x2122;s newborn screening panel in March of

2006. The way the CF newborn screen is performed differs from state to state. In all states, the newborn screen starts by looking for high levels of immunoreactive trypsinogen (IRT), which is a chemical produced by the pancreas. IRT levels are usually elevated in newborns with cystic fibrosis, but can also be elevated due to other factors, such as prematurity or a stressful birth.1 If the IRT level is elevated, the second step of the Minnesota screen, DNA analysis, is performed. This is the part of the test that differs from state to state. Some states will call out a CF newborn screen as positive with the appearance of an initial elevated IRT level and recommend a repeat IRT test be done at two weeks of age. If it is again elevated, referral to a Cystic Fibrosis Foundation (CFF)-accredited care center is recommended.1 In Minnesota, the DNA analysis looks for 43 specific CFTR genetic mutations or changes. The newborn screen in Minnesota is considered positive when the IRT level is elevated and at least one CFTR mutation is identified. At this point, it is still possible that a child may be a carrier of CF and not affected by the disease. Only when two disease-causing CFTR mutations are found is the diagnosis of CF confirmed prior to a sweat chloride test. Primary care providers in the community are notified of this positive newborn screening result. Often, there is no family history of CF, and this diagnosis comes as a shock. According to the CFF, every child with a positive newborn screen should

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have an evaluation at an accredited CFF care center. The Pediatric Cystic Fibrosis Center at the University of Minnesota is one of three pediatric CFF accredited care centers in the state. When an infant is referred to the CFF care center, a sweat test is performed and families have meetings with a genetic counselor and, if needed, other members of the CF team. Further genetic testing may also be performed at this point in time. Lifetime of Care â&#x20AC;&#x201D; New Hope

The Minnesota Cystic Fibrosis Center at the University of Minnesota was formed over 50 years ago. The care model created at the Center provides care starting at diagnosis and continuing throughout the patientâ&#x20AC;&#x2122;s lifetime. We have a dedicated multidisciplinary team of both pediatric

they eat. Patients with CF are seen in our clinic frequently in the first year of life and then quarterly throughout their lives. The Minnesota Cystic Fibrosis Center is active in research trials aimed at identifying the best approaches to treating symptoms of CF. In recent years, we have also enrolled patients in clinical trials focused on CFTR modulator therapy as a treatment addressing the dysfunctional chloride channel that causes the problems seen in individuals with CF. (When the chloride channel does not work properly, thick and sticky mucus causes problems in the lungs.) Drugs known as CFTR modulators are designed to allow the chloride channels to work more effectively, thereby decreasing the likelihood of this thick and

A disease that was once a devastating diagnosis that held the prognosis of a very short life expectancy can now be met with more hope due to the advancement of research and the efforts of dedicated researchers and care providers.

and adult physicians, nurse practitioners, dietitians, respiratory therapists, social workers, genetic counselors, pharmacists, and nurses. Each patient seen at our center receives care based on the most recent research and up-to-date evidence-based practice. CF is a very labor-intensive disease. Patients spend several hours each day performing airway clearance and simultaneous nebulized medication treatment aimed at clearing the thick and sticky mucus in their lungs. Continual weight gain requires a very high calorie diet and often the use of pancreatic enzyme replacement therapy, so patients take enzymes to help digest food every time

MetroDoctors

sticky mucus causing problems. In 2012, ivacaftor (Kalydeco) was the first drug to be approved by the U.S. Food and Drug Administration to treat these defective chloride channels. This medication was initially only for individuals with CF who have a certain CFTR mutation. For this reason, only about 4% of those with CF were able to take ivacaftor. Since that time, two more CFTR modulator drugs targeting other mutations have been approved with more coming down the drug-development pipeline. Most recently, in February 2018, the FDA approved tezacaftor/ivacaftor and ivacaftor (Symdeco). This drug is approved for use with a much larger group of patients

The Journal of the Twin Cities Medical Society

with CF, based on their CFTR genotype. These CFTR modulator therapies provide a lot of excitement and hope for those individuals with CF. The current wholesale price for these therapies can be high, with an annual cost ranging from $259,000 to $311,000, and insurance coverage is variable. Co-pay assistance programs, however, are available through the drug company Vertex. A disease that was once a devastating diagnosis that held the prognosis of a very short life expectancy can now be met with more hope due to the advancement of research and the efforts of dedicated researchers and care providers. Carlye Tomczyk received her advanced practice nursing education (APRN) from the University of Minnesota, Twin Cities. She has been an APRN with the Pediatric Pulmonary Team at the Minnesota Cystic Fibrosis Center since 2008. In 2018, she was appointed the Cystic Fibrosis Program Associate Director of Clinical Care. Ms. Tomczyk primarily cares for the pediatric CF population in the outpatient clinical setting and also collaborates in their inpatient care. Ms. Tomczyk leads the quality improvement efforts within the pediatric team. References 1. Cystic Fibrosis Foundation Website. https:// www.cff.org. 2. Grosse SD, Boyle CA, Botkin JR, et al. Newborn Screening for Cystic Fibrosis: Evaluations of Benefits and Risks and Recommendations for State Newborn Screening Programs. Atlanta, GA: Centers for Disease Control; October 15, 2004. https://www.cdc.gov/mmwr/preview/ mmwrhtml/rr5313a1.htm. 3. Yen EH, Quinton H, Borowitz D. Better nutritional status in early childhood is associated with improved clinical outcomes and survival in patients with cystic fibrosis. J Pediatrics. 2013;162(3):530-535.

May/June 2018

Sponsored Content

Preparing Pediatricians to Promote Healthy Development in the First 1,000 Days of Life Contributed by Emily Borman-Shoap, MD

Acknowledgements: Special thanks to Dr. Sonja Colianni, course director for Continuity Clinic and Primary Care Fundamentals rotation, and Dr. Tom Scott, course director for the Developmental Behavioral Pediatrics rotation, for their leadership and commitment to pediatric education. The first 1,000 days of life are a critical time in a child’s development. Increasing evidence points to the multiple factors that can affect a child’s healthy brain development and the critical window for impacting optimal development. This article will review current evidence on factors that impact early brain development and highlight some of the unique approaches the University of Minnesota Pediatric Residency training program is taking to prepare pediatricians to be champions for the healthy development of our youngest patients. The most active periods of myelination and synaptogenesis in the brain occur within the first three years of life.1 The American Academy of Pediatrics emphasized the importance of broadening and redefining the approach to promoting healthy child development in their 2012 policy statement and technical report in which pediatricians were called upon to consider child development through an “ecobiodevelopmental framework.”2,3 Explicitly examining the environment in which a child is raised (the ecology) and their genetic predisposition (the biology) with an emphasis on close monitoring of 24

May/June 2018

expected healthy development is critical to supporting early brain development. The ecology of a child’s development is multifactorial and includes their relationships, their physical living spaces, and their nutrition. Lack of adequate nutrition and exposure to toxic stresses can have profound long-term impacts not only on brain development but also on overall health. The impact of childhood events on adult health were brought to the forefront in the seminal Kaiser Permanente study on adverse childhood experiences (ACEs), which were identified, in part, as experiencing physical or sexual abuse or neglect or living with an adult who has alcohol or substance abuse problems. This study demonstrated a clear link between experiencing ACEs and longterm morbidity in adulthood, including ischemic heart disease, cancer, and chronic lung disease.4 Additional studies in animals

and humans have demonstrated that fundamental changes in brain biology occur in response to stressful life events. The mandate for pediatricians to play an active role in promoting healthy child development, particularly in the first 1,000 days, is clear. The foundational preparation for this work occurs during pediatric residency. At the University of Minnesota Pediatric Residency Program, we draw on exceptional faculty as well as robust community partnerships to prepare our residents for their careers in caring for young children. The American Academy of Pediatrics highlighted the role of the pediatric medical home in promoting healthy child development through the construct of the ecobiodevelopmental framework.3 Pediatric residents at the University of Minnesota are assigned to a primary continuity clinic site for all three years of their training. We are fortunate to partner with skilled continuity clinic preceptors in clinics across the Twin Cities metro, including Fairview, Children’s Minnesota, HealthPartners, Park Nicollet, Southdale Pediatrics, South Lake Pediatrics, Partners in Pediatrics, Central Pediatrics, and Mendakota Pediatrics. A unique component of our first-year curriculum is the Primary Care Fundamentals Rotation, an eight-week immersion experience in which residents are embedded within their continuity clinic and begin to lay a solid foundation of skills in general pediatrics. Residents stay at the

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same continuity clinic site all three years of their residency, and they truly get to know that clinic’s approach to preventive and acute care. Residents gain experience in well-child care (developmental screening, immunizations, anticipatory guidance). Emphasizing the importance of consistently utilizing high-quality developmental screening tools, the Minnesota Department of Health requires their use in screening for appropriate development in all domains (gross motor, fine motor, communication, personal-social, problem-solving) as well as the use of specific screening tools for autism in early childhood.5 Screening in early childhood also includes post-partum depression screening in parents and social-emotional/mental health screening in young children. Residents build skills in interpreting, discussing, and creating management plans when delays and impairments are identified through screening, and they are able to compare and contrast the approach that different clinics take to implementing screening tools. In addition to the hands-on clinical work in primary care, during the Primary Care Fundamentals rotation, residents attend small group seminars as well as make a number of visits with community groups who are critical in supporting healthy growth and development in a child’s first 1,000 days. These include WIC office visits and home visits with an early childhood education specialist in Hennepin County. Residents also complete a “windshield survey” in which they drive through a patient’s neighborhood and document what they can see through their windshield, including safe outdoor play areas, access to high-quality fresh food, schools, pharmacies, and other community supports. The experiential, community-based components of the Primary Care Fundamentals rotation complement the hands-on clinical work and give residents a holistic approach to assessing and promoting healthy development. Residents continue to expand their skills in their Developmental Behavioral Pediatrics rotation. In this rotation, MetroDoctors

residents gain experience with multidisciplinary teams, including learning from child psychologists, developmental-behavioral pediatricians, neonatologists, speech and language pathologists, and occupational therapists. Seminars and clinical experiences related to the young child focus on early brain development, attachment, temperament, parenting, developmental delays and autism spectrum disorders, as well as common pediatric complaints like tantrums, potty training, and sleep issues. Clinical experiences are complemented with extensive connections to community organizations dedicated to supporting young children and their families. These highlight the importance of our community partners in contributing to the key components of the ecobiodevelopment approach to healthy development. Residents spend time with the team at Simpson Housing Services, where they can begin to understand the special supports that can be offered to families experiencing homelessness. The team at Fraser gives residents insight into the comprehensive and interdisciplinary approach used to support children with autism. Partnership with PACER gives residents a window into a community organization that supports and advocates for children with disabilities. The community-connected approach to resident education gives our residents a foundation to build on throughout their careers. In addition to clinical rotations, pediatric residents participate in a structured didactic curriculum that is delivered in bi-weekly seminars in an academic halfday model. The topics are organized in a three-year repeating curriculum with each year centered on an age group: infants and young children, school age children, and adolescents. Grouping topics in this manner allows for interdisciplinary approaches to teaching and creates better connections across the content of each seminar. The format has allowed for new approaches to topics pertinent to the care of young children. Classes have included sessions on normal early infant development and parenting, an interactive session on lead

The Journal of the Twin Cities Medical Society

poisoning and accidental toxic ingestions in young children cohosted by the Minnesota Department of Health and the Poison Control team, as well as a multidisciplinary session on identifying and responding to signs of physical abuse in children. Throughout their residency, pediatric trainees at the University of Minnesota build skills in caring for children of all ages. The breadth and depth of our clinical training opportunities gives our graduates a solid foundation in providing high-quality care to children in the critical period of development, their first 1,000 days of life. Mirroring the exponential development of the prenatal period to early preschool years, our pediatric trainees enter residency with a training in medicine and graduate with nuanced and advanced skills in promoting a child’s healthy growth and development. Emily Borman-Shoap, MD is the Pediatric Residency Program Director at the University of Minnesota Medical School and an Assistant Professor in the Division of General Pediatrics and Adolescent Health. She completed her medical degree at Washington University in St. Louis prior to coming to the University of Minnesota for her pediatric residency training. After her residency training, she stayed on as Chief Resident and then joined the faculty in 2007. References 1. AAP Early Brain and Child Development. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/EBCD/Pages/default. aspx. Accessed February 27, 2018. 2. Shonkoff JP, Garner AS, Siegel BS, et al. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1):e232-e246. doi:10.1542/peds.2011-2663. 3. Garner AS, Shonkoff JP, Siegel BS, et al. Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health. Pediatrics. 2012;129(1):e224-e231. doi:10.1542/peds.20112662. 4. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14(4):245-258. http://www.ncbi.nlm.nih. gov/pubmed/9635069. Accessed February 27, 2018. 5. Department of Human Services M. Schedule of Age-Related Screening Standards Early and Periodic Screening, Diagnosis and Treatment (EPSDT). https://edocs.dhs.state.mn.us/lfserver/ Public/DHS-3379-ENG. Accessed February 27, 2018.

May/June 2018

First 1,000 Days

In Memoriam Environmental Health — Reducing Asthma Risk in MN Kids

sthma, the most common chronic childhood illness, currently affects ~6 million U.S. children.1 It is the leading cause of missed school days and a leading cause of ED visits and hospitalizations. An estimated 10.6% of Minnesota middle and high school students currently have asthma.2 Asthma attacks can be triggered by infections, allergens and airborne irritants (e.g. tobacco smoke, air pollutants). High levels of ozone and toxic micro-particulates (PM2.5) are the primary causes of poor air quality. Ozone, a pulmonary irritant and carcinogen, is generated from precursor compounds (e.g. auto and industrial emissions) that react in warm weather conditions. Exposure to air pollution increases the risk of having an asthma attack and disproportionately impacts children who live near heavily traveled roads and industrial areas with idling trucks and toxic emissions.2 The struggle to find affordable housing often results in low income families and families of color being forced to locate in areas of highest pollution. Childhood asthma hospitalization rates for children living in the Twin Cities metropolitan area are 67% higher than in Greater Minnesota. Rates of ED visits for asthma for Twin Cities children are nearly twice as high as for children living in Greater Minnesota. Additionally, a large multi-center study of asthma in Latinos and African Americans found that exposure to NO2

By Gail Brottman, MD

May/June 2018

(vehicle emissions) during infancy was associated with an increased risk of the development of childhood asthma.3 Despite new data showing that asthma attacks in children have decreased between 2001 and 2016, asthma still remains a significant source of childhood morbidity that is negatively impacted by poor air quality.2 Asthma incidence and prevalence rates can be reduced by reducing traffic and industrial related pollution. Electric vehicles, mass transit, no-idle policies and clean energy sources can improve the health of our children and lower costs of care. Minnesota physicians can be leaders in advocating for policies that make our children healthier. To quote the American Lung Association, we are “Fighting for Air” because “It’s a matter of life and breath.” Gail Brottman, MD, Director, Pediatric Pulmonary Medicine , Hennepin Health. References 1. MMWR Vital Signs: Asthma in Children. Vol 67 February 6, 2018. 2. Minnesota Department of Health, Minnesota Asthma Program. http://www.health.state. mn.us/asthma/ Accessed February 18,2018. 3. Nishimura, K et al. Early Life Air Pollution and Asthma risk in Minority Children. Am J Respir Crit Care Med Vol 188, Iss. 3, pp 309–318, Aug 1, 2013.

EDWARD H. KELLY, MD, passed away on March 26, 2018. An orthopedic surgeon in both Minneapolis and St. Paul, Dr. Kelly performed the first total knee surgery in Minnesota. He went on to specialize in foot, ankle and lower leg surgery in addition to serving as faculty at the VA Hospital. Dr. Kelly joined the medical society in 1987. EDWARD “TED” POKORNY, DO, passed away on March 28, 2018. Dr. Pokorny served his residency at St. Joseph’s Hospital in St. Paul; and was currently practicing as a hospitalist at St. John’s Hospital in Maplewood, MN. Dr. Pokorny has been a member of TCMS since 2013. STEPHAN A. SMITH, MD, passed away on February 18, 2018. Dr. Smith was the Medical Director, Neuromuscular Program, Gillette Children’s Specialty Clinic and a Neuropathologist at Hennepin County Medical Center. BERNARD J. SPENCER, MD, passed away on January 4, 2018. Initially trained as a general surgeon, Dr. Spencer completed a fellowship in Pediatric Surgery at Boston Children’s Hospital. He established Pediatric Surgical Associates with his colleagues Drs. O.S. Wyatt and Tague Chisholm, and was a founding member of Minneapolis Children’s Hospital. Dr. Spencer joined the medical society in 1985.

Visit TCMS at www.metrodoctors.com With just one click you will find information on the latest TCMS and Foundation news; current and past issues of MetroDoctors; and new career opportunities!

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The Journal of the Twin Cities Medical Society

Senior Physicians Hold Winter Meeting “Housing as Medicine” was the title of the presentation given by William Walsh, MD, a Facial Plastic and Reconstructive Surgeon at Hennepin Health, who also serves as the Deputy Chief Innovation Officer of Upstream Health Innovations at Hennepin Health. The innovation team is partnering with patients and communities to improve health where

people live, work, learn and play. He has a particular interest in housing and works to promote health equity for people experiencing homelessness — envisioning a future where he can write a prescription for housing for his patients just like any other medication or service. Registration is now open for the Spring Meeting of the Senior Physicians Association.

Tuesday, May 15, 2018 “A Sneak Peek of the Bell Museum” Denise Young, EdD, Executive Director, Bell Museum, College of Food, Agricultural and Natural Resource Sciences, University of Minnesota 11:30 a.m.–Social; 12 noon–Lunch; 12:20 p.m.–Program Broadway Ridge NE, 3001 Broadway Street NE, Minneapolis, MN Cost: $25–Invite a guest! Contact Nancy Bauer to register: (612) 623-2893; nbauer@metrodoctors.com.

NEED HELP? Guest Speaker William Walsh, Jr., MD and SPA President, Eugene Ollila, MD.

Dr. Walsh describes how financial barriers and lack of affordable housing affect a patient's recovery and long-term well-being.

Because you asked…

Disposal of Opioid and Other Medications With the ever-increasing abuse of opioids and unused medications, it is more important than ever that proper disposal of these medications be adhered to in order to avoid harm. The resources listed in the links below provide important information about safe disposal of medicines. In addition, most healthcare systems and local police precincts have medication take-back programs available. • www.fda.gov/Drugs/ResourcesForYou/Consumers/ MetroDoctors

• •

•

The Journal of the Twin Cities Medical Society

BuyingUsingMedicineSafely/ EnsuringSafeUseofMedicine/SafeDisposalofMedicines/default.htm https://www.deadiversion.usdoj. gov/drug_disposal/takeback/ https://apps.deadiversion.usdoj.gov/pubdispsearch/spring/ main?execution=e1s1 https://www.rethinkrecycling. com/residents/materials-name/ medicine-prescription-drugs

Feeling overwhelmed and turning to alcohol and/or drugs for relief?

Physicians Serving Physicians is an independent, physician-centric organization that was established in 1981 by a group of physicians in recovery to help other physicians and their families struggling with chemical dependency. The core of PSP’s mission is to provide active help and service to physicians (including residents), medical students and their family members affected by alcohol and drug addiction.

Physicians Serving Physicians can help! For confidential assistance: • Call: (612) 362-3747; email: psp@metrodoctors.com • Jeffrey Morgan, MD, Interim Medical Director, (612) 267-8912 • Psp-mn.com

May/June 2018

Medical Student Match Day! Congratulations to the Class of 2018. TCMS and MMA were proud to be invited to share the excitement of the Match Day residency announcements. A few of the students active with TCMS and MMA stopped by our table for a photo. Best of luck to all!

(From left) Gretchen Colbenson, Alex Feng, Erica sanders, and Risa Visinar.

TCMS Board Member Jennifer Janssen.

TCMS Board Member Daniel Bernstein.

Radon Education

2018 Charles Bolles Bolles-Rogers Award Nominations are now open for the 2018 Charles Bolles Bolles-Rogers Award. Candidates for this “Physician of Excellence” award are nominated by their colleagues at Twin City area hospitals and/or clinics for achievement or leadership in medicine, contributions to clinical care, teaching and/or research. This candidate is considered to be an outstanding physician by his or her peers. Download a nomination form at: www.metrodoctors.com; foundation tab; awards Email completed nomination to nbauer@metrodoctors.com or mail to TCMSF office, 1300 Godward Street NE, Suite 2000, Minneapolis, MN 55413, no later than July 31, 2018.

May/June 2018

The Minnesota Department of Health’s (MDH) Indoor Air Unit is looking to partner with healthcare providers to initiate a radon education program. Radon is a colorless and odorless radioactive gas. The greatest exposure is in the home where radon can concentrate. It becomes a health concern because people spend most of their time indoors and long-term exposure to radon gas increases the risk of developing lung cancer. Healthcare providers can play a critical role in radon awareness and testing. MDH will be interviewing healthcare providers this spring to gain insight on what makes a successful radon education program and how to best promote the program. If you are interested in participating in this key informational interview or in the education program, please contact Marc Katz at (651) 201-4604 or marc.katz@state.mn.us. This is a free program and all materials are free. The healthcare provider can decide what level of participation is appropriate. MetroDoctors

The Journal of the Twin Cities Medical Society

Twin Cities Medical Society Reducing Gun Violence Policy Policy approved March 19, 2018 Consistent with the Minnesota Medical Association, Twin Cities Medical Society considers gun violence a public health crisis and supports common-sense changes to gun laws. Each year, more than 30,000 Americans are victims of gun violence and firearm-related accidents. Every day, on average, two dozen children are shot in the United States. In 2018, there have been more school shootings in the U.S.

TCMS Physicians Drs. Thomas Kottke and Greg Lehman and UMN medical students stand with Senator Matt Klein (center) following DFL announcement of new legislation to reduce gun violence on March 26, 2018.

that have resulted in death or injury than there are weeks in the year. Specifically, TCMS supports: • Prohibiting civilians from possessing semi-automatic military-style assault weapons. (As defined by Minnesota Bureau of Criminal Apprehension, Minnesota Statutes, section 624.712, subdivision 8, current authoritative list of firearms included within the definition of “semiautomatic military-style assault weapon.) • Closing the Minnesota loophole that allows a private seller to sell a gun without performing a background check. • Amending Minnesota law to allow the Minnesota Department of Health to collect data for public health and epidemiologic investigation so that the public can better understand how to reduce the burden of gun violence. • Creating a “red flag law” in Minnesota that allows a judge to order the

TCMS Public Health Committee is Now Physician Advocacy Network At the March meeting of the Board of Directors a proposal was presented to restructure the TCMS Public Health Advocacy Committee. Matt Kruse, MD, Chair, submitted a recommendation, and the Board agreed, that specific-issue task forces be placed under the umbrella of the Physicians Advocacy Network (PAN). A cellular structure would be utilized for initiatives such as e-cigs, adolescent sexual health, obesity, gun violence, etc. The new format allows for:

MetroDoctors

•

Maximizing the impact of initiatives with current resources; • Prioritizing physician’s time and efforts dedicated to specific public health issues; and • Maintaining an appropriate degree of focus and scope. For more information on the Physician Advocacy Network and/or how you can get involved, please contact Grace Higgins, MPH, Senior Project Manager, PAN, at (612) 362-3706 or ghiggins@ metrodoctors.com.

The Journal of the Twin Cities Medical Society

temporary seizure of guns from a person/people deemed to be a threat to themselves or others. Examples of behaviors could include mental illness, escalating threats, substance abuse and domestic violence, among others. • Restricting the sales of any firearm to persons age 21 and over. • Supporting those most at risk from the physical and psychological trauma of gun violence — in particular, youth in communities of color. Focus on investing, not arresting. Approved, TCMS Board, March 19, 2018.

TCMS Research Published in BMC Medicine A recent article “What do medical students know about e-cigarettes? A cross-sectional survey from one U.S. medical school” was released in BMC Medicine by lead author University of Minnesota Family Medicine resident Dr. Katie Hinderaker in collaboration with former TCMS Physician Advocacy Network Project Manager Ellie Parker, Dr. David Power, Dr. Sharon Allen and Dr. Kolawole Okuyemi. Only 12% of participants agreed or strongly agreed that they felt confident in their ability to discuss e-cigarettes with patients and 95% believed that they had not received adequate education about e-cigarettes in medical school. Findings were based on a cross-sectional online survey of University of Minnesota medical students enrolled in Fall 2015.

May/June 2018

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The Journal of the Twin Cities Medical Society

May/June 2018

LUMINARY of Twin Cities Medicine By Marvin S. Segal, MD

JAMES H. MOLLER, MD “CHILDREN.” “HEART.” Those two words just seem to evoke thoughts and emotions that are very special in many ways. There’s something also very special about our Luminary who has devoted much of his life to both of them. Fresno, California was a quiet San Joaquin Valley town when Dr. James Moller was born there some 84 years ago. He has come a long way since then, both literally and figuratively. An early stop along the way to Minnesota was at Stanford University where he earned both his B.A. and M.D. degrees. 1959 signaled the beginning of his Minnesota connection that has continued to this day save for four years away in the U.S. Army and as a Research Trainee at the National Heart Institute. Jim remembers being quoted at age 5 or 6 — that when he grew up, he “wanted to be a baby doctor,” and his U of M pediatric residency certainly moved him toward fulfilling the foresight of that wish and apparent prophecy. The intricacies of congenital heart malformations and their complex potential treatment modalities drew him to a pediatric cardiology fellowship at the “U” and a research associate position in cardiovascular pathology with Dr. Jesse Edwards at St. Paul’s Miller Hospital. Once fully trained as a Pediatric Cardiologist, Dr. Moller embarked upon a distinguished decades-long career which included hands-on clinical patient care, research, teaching and administrative leadership positions. His faculty appointment in the departments of pediatrics and medicine spans 53 years with steady early advancement culminating in the current rank of Professor Emeritus. Dr. Moller was the Head of the Department of Pediatrics for seven years, was Chief of Staff of the University Hospital for five years and held the Dwan Chair in Pediatric Cardiology for 30 years. His international and national positions of prominence include a prestigious visiting professorship at the University of London and Presidency of the American Heart Association. Jim is a master clinician whose clinical skills oft times make the utilization of various imaging and technical measures less than necessary in the initial diagnosis and subsequent follow-up of patients. His teaching in the techniques of observation, palpation, percussion and auscultation — while applying a pathophysiological approach to understanding congenital heart disease — have been conveyed to countless students, residents and collegial mentees through the years and have resulted in many Distinguished and Outstanding teaching awards from our “U” and national 32

May/June 2018

bodies. Both a post-doctoral research fellowship and medical student fellowship have been named in his honor. Dr. Moller has published extensively — 18 books, many chapters and well over 200 journal articles in his chosen field ranging from cardiac arrhythmias, medical genetics, and adult congenital disease to the complex syndromes of Tetrology of Fallot and Transposition of the Great Vessels. There were numerous well-earned awards of recognition, though less well-known experiences of which he is very proud include his collaborative work with Nobel Prize nominees, Dr. C. Walton Lillihei and Robert Good plus meetings with Dr. Helen Tausig, the acknowledged “mother of pediatric cardiology.” Jim continues to regularly meet with students and about his myriad of past career experiences, firmly stating, “my most gratifying work has been working with and teaching young people.” In addition to his professional interests, family and community activities have been extensive — the good doctor somehow finding the time to help his wife raise two children to become professionals in their own right, advising for Tobacco-Free Kids and being chosen the Scoutmaster of the Year. He is humbly appreciative of the many opportunities afforded him during his successful tenure at the U of M. Dr. Moller expresses concern about the syndromes of “BurnOut” and depression currently in our medical profession, and advises his younger medical colleagues to “seek balance by embracing significant avocations away from medicine.” Yes, “CHILDREN” and “HEART,” meaningful words that summarize the special dedications of our Luminary who has given so much to our profession and our community. This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine. Please forward names of physicians you would like considered for this recognition to Nancy Bauer, Managing Editor, nbauer@metrodoctors.com.

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The Journal of the Twin Cities Medical Society

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