Prevention of Youth Access: How Michigan Ranks
By SHARON SWINDELL, MD, MPH
The MIAAP continues to advocate for laws and policy to reduce youth access to tobacco products, including e-cigarettes. This is a work in progress, requiring persistence in an environment where the influence of tobacco companies remains powerful. Prevention in youth is centered around the knowledge that smoking initiation is a pediatric issue—90 percent of adult daily smokers started before the age of 19.
In December 2019, federal law was enacted to raise the age of tobacco sales to 21, inclusive of all tobacco products including e-cigarettes. Although this law applies to Michigan sales, the effectiveness of youth access prevention depends largely on state measures that do not yet exist.
Jared Burkhart, our MIAAP CEO, has co-chaired the Keep MI Kids Tobacco Free
. A key aim of the alliance is to strengthen Michigan’s tobacco control laws. A legislative package addressing tobacco control, though not ideal and ultimately not passed in the MI 2019-2020 legislative session, was strengthened considerably by the advocacy work of Jared and other alliance members. Unfortunately, the case for primary prevention in youth has been overshadowed by the voice of tobacco retailers, bolstered by the tobacco industry, and the claim that vaping is an effective smoking cessation tool.
In summary, it is federal law, and thus applies to Michigan, that the minimum age for tobacco sales is 21 years. For this law to have its intended effect of preventing youth access--and ultimately youth tobacco and nicotine addiction and the prevention of adult smokers with the accompanying health effects and costs-- Michigan needs to enact state laws.
Strong tobacco 21 and youth prevention policy includes:
- Definition of products inclusive of e-cigarettes as tobacco products (consistent with the AAP, CDC, FDA). Current state law defines e-cigarettes, alternative nicotine products, vapor products, and other emerging tobacco products separately from tobacco products.
- Consistent taxation on tobacco products. A different definition of e-cigarette products has allowed for language to include different taxation (lower) level. Youth are more sensitive to price changes—higher priced products are a deterrent. Given the high potential for nicotine addiction with e-cigarettes, the association with higher rates of future combustible cigarette use, and the unknown long-term effects on health, e-cigarettes should be in the same tax classification as combustible cigarettes.
- Creation of a Tobacco Retail License with license fees that are high enough to cover a state-level enforcement plan.
- Penalties for violations directed toward retailers/licensees, not youth. Elimination of Purchase, Use and Possession (PUP) penalties, which have not been shown to be effective in youth deterrence.
Inclusion of vape-products in state-level smoke-free laws (currently in Michigan, the use of these products is restricted by state law in childcare centers only).
- Restriction of advertising targeting youth.
- Restriction of flavors, including menthol.
As the MI 2021-2022 legislative session progresses, staff and members of the MIAAP will continue to look for opportunities to advocate on behalf of tobacco and nicotine access, use, and addiction in Michigan youth. We welcome your input and involvement.
Podcast Among Latest MIAAP Member Offerings
By PAUL NATINSKY
MIAAP is excited and pleased to announce its new podcast—to access, visit miaap.org/podcast
Dubbed the “MIAAP Peds Health Podcast,” the first two episodes feature sound advice on how to manage screen time for kids (featuring Dr. Jenny Radesky) and suggestions on how to provide care for children during a pandemic (with Drs. Layla Mohammed, Neal Weinberg and Gwen Reyes).
“(MIAAP CEO) Jared (Burkhart) and I helped create the podcast; I usually recruit speakers and write up the questions to ask them beforehand. Jared and I both co-host the podcast,” said Dr. Amrit Misra.
The idea sprung to life a year or two ago at a MIAAP meeting during a discussion on how to best provide information on key pediatric health topics that would help both physicians and families. A podcast seemed like an accessible format for both groups.
It’s too early to evaluate the new venture’s success, but the possibilities seem endless.
“We are really excited about the future of the podcast,” said Misra. “There’s so many interesting things to cover, so I’m sure that we won’t run out of ideas.”
Misra encourages members to share their ideas and suggestions for both topics and guests. To date, Misra says, “Our guests come from the topics. Once we choose a topic, we ask other people for ideas for questions and people to talk to about the topic, and invite then accordingly.”
Advocacy Day at the End of May
Topic: Children's Mental Health
Please join us for our 15th annual Pediatric Legislative Advocacy Day on Thursday, May 27, 2021 on the Zoom virtual platform.
During this half-day session, you will learn to advocate effectively for child health and for the practice of pediatrics.
- Where legislators get information about child health.
- How to find time to advocate for children.
- How you can find others who share your views.
- What you can expect when meeting with a state legislator.
- All attendees must register.
- Registrants will receive more information and virtual links via email.
- Pre-event training and advocacy sessions will take place on a virtual platform.
- Additional information and platform links will be emailed to all registrants.
For more information, please call the MIAAP office at: (517) 484-3013.
The Evaluation and Management of Pediatric Somatic Symptom and Related Disorders in Primary Care
By NASUH MALAS, MD, MPH
MC3 Child and Adolescent Psychiatrist
Note: This article was adapted from a longer article written by Dr. Malas and others and originally published in Psychiatric Times.
Somatic Symptom and Related Disorders (SSRDs) are a set of psychiatric conditions
characterized by physical symptoms that are:
● Inconsistent with physical disease
● Significantly influenced by psychological distress
● Pervasive and impairing
Although commonly seen in primary care pediatrics, patients, families and providers express frustration associated with SSRDs due to a lack of a standardized framework to provide care to this population. Without this framework, there can be an over focus on disability and impairment leading to low-yield diagnostic testing and interventions that do not address the biopsychosocial and rehabilitative needs of the patient.
Evaluation & Collaboration
SSRD evaluation is built on:
● Concurrent mental health and physical health evaluation
● Unified and consistent evidence-based language use
● Communication with the family regarding the multifactorial nature of SSRD presentation
Care of youth with SSRDs requires close interprofessional team engagement between:
● Social work
● Primary care
● School personnel
● Pediatric subspecialty services
Mental health professionals should be engaged at the earliest suspicion of an SSRD to normalize psychiatric involvement in the comprehensive care of this population. Mental health professionals can aid with:
● Language use
● Framing conversations with the patient and family
● Provision of evidence-based interventions
● Addressing psychiatric comorbidities, such as mood or anxiety disorders
Discussion of symptom development and diagnostic conceptualization should be paired with management strategies, highlighting the multifactorial contributors to symptom development. Pairing the varied biopsychosocial factors contributing to the presentation in the management plan allows for a coherent, systematic approach to rehabilitative care, psychotherapeutic management, and judicious use of targeted psychopharmacology. This can be accomplished through interprofessional communication of a conceptual framework for symptom development with the family, highlighting mind-body interactions.
Management of youth with an SSRD is an iterative process that begins with:
● Setting clear goals
● Clarifying familial expectations, verbalizing care team expectations and ensuring some level of alignment in the overall care expectations
● Provision of early and regular education to the patient and family is critical to the initial framing of the diagnoses and associated management
Cognitive behavioral therapy (CBT) has a strong evidence base in addressing psychological factors underpinning pediatric SSRD. The focus is on improving functioning in small, achievable steps, while shifting the focus away from impairment. CBT psychotherapy can occur in tandem with delivery of rehabilitative services. This can occur concurrently with judicious treatment of psychiatric comorbidities when they exist.
The primary care provider should focus on coordination of communications, resources and care delivery, while providing proactive, regularly scheduled visits or calls with the patient and family. The focus of these calls and visits is to coordinate services, address questions, monitor progress, provide reassurance, and promote functioning. When done consistently, the tendency for youth and their families to seek care in crisis and pursue care in a disjointed fashion can diminish over time.
MIAAP is happy to present this monthly column with insights from the MC3 Program’s child and adolescent psychiatrists. MC3 offers no-cost psychiatry support to primary care providers in Michigan who are managing patients with behavioral health problems. To learn more or become an MC3 enrolled provider, visit mc3.depressioncenter.org.
Importance of Re-Screening Same Sex Twins
Intellectual disability due to unrecognized and untreated primary congenital hypothyroidism (CH) is prevented easily by detecting elevated thyroid stimulating hormone (TSH) values on the newborn screen (NBS) and starting treatment with levothyroxine within the first two weeks of life. In Michigan, the state NBS Program mandates TSH screening at birth, followed by serum confirmatory test or a repeat TSH screen for all abnormal screens.
In monozygotic twins, there is a risk of missing a diagnosis of CH in one of the twins based on initial NBS as there is fetal blood mixing in multiple births (Perry et.al). The AAP and European Society for Pediatric Endocrinology both recommend a second screen for all monozygotic twins at two weeks of life so as reduce risk of missed diagnosis of CH. In Michigan, a recent analysis of NBS data since 2017 showed that only approximately 35% of same sex twins received a second TSH screen as recommended.
The Pediatric Endocrine Advisory Council (PEAC) of the State of Michigan strongly recommends a serum TSH or second newborn screen for all same sex twins at two weeks of life so as reduce risk of missed diagnosis of CH.
Update of Newborn Screening and Therapy for Congenital Hypothyroidism. American Academy of Pediatrics, Susan R. Rose, et. al., and the Section on Endocrinology and Committee on Genetics, American Thyroid Association, Rosalind S. Brown, et. al., and the Public Health Committee and Lawson Wilkins Pediatric Endocrine Society. Pediatrics June 2006, 117 (6) 2290-2303; DOI: https://doi.org/10.1542/peds.2006-0915.
Juliane Léger et.al., Clinical Practice Guideline. European Society for Paediatric Endocrinology Consensus Guidelines on Screening, Diagnosis, and Management of Congenital Hypothyroidism. J Clin Endocrinol Metab. 2014 Feb; 99(2): 363–384. doi: 10.1210/jc.2013-1891.
Rebecca Perry et.al., Discordance of monozygotic twins for thyroid dysgenesis: implications for screening and for molecular pathophysiology. J Clin Endocrinol Metab. 2002 Sep;87(9):4072-7. doi: 10.1210/jc.2001-011995.
Volume XXIX, Issue 4
In This Issue
Pediatric Mental Health
MIAAP Value: Now More Than Ever
For the first time since the 1980s, MIAAP is a finalist for the AAP Large Chapter of the Year Award, and I couldn’t be more proud for our Board of Directors and membership.
Earning the nomination means a chapter has pulled together competing elements much like the balance embodied in a fine meal or symphony.
MIAAP listened to its members. We expanded CME offerings and provided new, pandemic-friendly means to connect to CME opportunities and conferences covering timely issues such as Ethics, Human Trafficking, and Pain Management.
Our webinar series gives members the opportunity to earn free CME credits from their computers during a lunch break.
Our Spring Virtual Conference allowed physicians to participate from home, while earning CME credits. The last conference was the best-attended in MIAAP history.
Bolstering our CME work are numerous new opportunities for pediatricians to engage with workgroups on returning students to school, migrant health and immunization. We have restarted the Pediatric Council to help with payer issues and started an Ethics Council. And we are offering greatly expanded access to MOC credits.
At the same time, our advocacy efforts have not missed a beat. We have worked to put in place an administrative rule to ban flavors in e-cigarettes and stopped vape-device maker Juul from passing enabling legislation. We continue to work legislatively to strengthen car seat requirements and have successfully endeavored to have the state of Michigan fund immunization education. We are also working to make sure the state pays for more resources pediatricians can use to deal with the mental health crisis in our state.
As with our Spring Conference, our Annual Advocacy Day was virtual this year and enabled many members to press legislators on gun violence risks in Michigan communities. I invite you to be a a part of our 2021 advocacy day in May. (See related article to the left.)
The staff of the MIAAP are committed to serving the pediatricians of Michigan. We will continue to work hard to be an outstanding chapter for all of our members. Let’s make this a banner year!
The Michigan Chapter of the American Academy of Pediatrics is committed to improving the physical, mental and social health of Michigan’s infants, children, adolescents and young adults; partnering with pediatric providers, parents and communities; and supporting members by increasing their engagement, education and expertise.