2017-2018 was a challenging year as a consequence of the devastation caused by the hurricanes that hit Puerto Rico causing disruption of the electrical grid and damage to the infrastructure. A study funded by Save the Children, Angel Ramos Foundation, Instituto de Desarrollo de la Juventud (Youth Development Institute), and Massachusetts United Fund on The Impact of Hurricane Maria on Puerto Rico Children raises an alert of the need to address emotional wellbeing and mental health post the stress caused by the disaster. The study consisted of a survey of 705 households with children younger than 18 y/o carried out from July to September 2018 by Estudios Técnicos, Inc. It was complemented by a study by the University of Puerto Rico, in which they visited five municipalities from October to November of 2018 and collected qualitative information from around 60 people in each municipality (www.juventudpr.org/en/about-us/library/?libroId=20511). The populations identified as most vulnerable and impacted by the aftermath of hurricane Maria were the lowest income families, children under the care of grandparents, and children with special medical care needs. It also identified that the degree of preparation for the event was less efficient in low income families, most municipalities had no plan for children in a disaster, and children living in poverty were more likely to experience a worsening economic situation in their homes, with 3 of every 10 children economically worse than previously.

 

Children younger than 5 y/o were out of day care an average of 92 days, and 7% of children in day care presented behavioral changes associated to hurricane stress. A majority of children between the ages of 5 to 17 (79%) are in the public education system. After the storm they were out of school an average of 78 days, and when returning they had modified hours due to lack of basic utilities. Forty-four percent (44%) of parents or caretakers observed behavioral changes after the storm. The impact caused by the interruptions in academic routines for minors, especially for special education students or students with other disabilities, affected their behavior and sense of appreciation and commitment to school; 23% of these children displayed changes in behavior at school, while 12% had problems focusing at school. These preliminary results reflect the issues faced by families with children lacking the resources to handle stress, tension or trauma situations; they were severely affected by the hurricane and the long period of difficulties it left in its wake, which in turn greatly affected their already complicated economic situation.

After the disaster and in the initial recovery phase a priority in the MCAHD, as advocates for the pediatric population, was to identify emerging needs and propose strategies to address them. Immediately after the storms the MCAH staff assumed multiple responsibilities to support the recovery response and protect the wellbeing of the vulnerable pediatric population. Recovery plan teams had to be reminded that children are not small adults; therefore their needs must be considered when implementing mass rescue and recovery strategies.

The MCAH Pediatric Consultant contributed in the response team created as a collaboration between the MCAHD, the PR AAP Chapter, the Pediatric Hospital Foundation, and the Pediatric Department of the PR School of Medicine, helping identify the urgent needs of the pediatric population, actively supporting recovery organizations on the island and in the mainland, and collaborating in the development of strategies to mitigate the effects of the storm. Among the prompt responses created by this team were visits to official and community-created shelters to assess needs and offer support (medications, first aid supplies, tap water, etc.); identification of needed medical supplies and creation of a list of needs to guide donations from the mainland; organization of the distribution of medication and other basic supplies by priorities in the temporary distribution center created in the Pediatric Hospital; visits to shelters to offer medical services and distribute medication and facilitate communication; networking with other pediatric organizations to develop mitigation plans and provide health care services. A guide on the Identification and Management of Common Health Conditions in Children After a Disaster as an instrument to guide community leaders was developed and distributed throughout the island. The guide provided community leaders with basic information on common health conditions that may emerge in overcrowded situations such as in shelters, or in the recovery phase after a disaster, and recommendations on how to manage them. Training sessions on information provided by the guide were also offered in multiple workshops throughout the island to community leaders in collaboration with United Way of PR and the PR AAP Chapter.

The Pediatric Consultant also represented the DOH in the Children Task Force (CTF) created in the recovery phase to promote collaboration in the identification of emerging needs and the development of strategies to address them. The CTF was composed of representatives of local and federal government agencies, community leaders, and not-for-profit organizations and held weekly meetings. The MCAHD Pediatric Consultant contributed to organizations that arrived on the island by providing information on the status and needs of the pediatric population, resources available, links to local agencies and organizations, and information on cultural characteristics of the population to help maximize their recovery efforts.

The HVP nurse in Culebra, an outlying island municipality, demonstrated her leadership role by becoming the main liaison for the mitigation and recovery efforts directed to families, due to her knowledge and established relationship with the community. Most of the HVPs played a similar role in their communities. The leadership role and the knowledge of the MCAH population by the MCAHD staff proved to be instrumental in the recovery and mitigation efforts, providing support to the MCHA population after the storm. In the recovery phase, MCAHD staff continued their efforts to provide services needed to have an impact on families, communities and the health care system, in order to sustain and improve the health and wellbeing of Puerto Rico’s children, youth, and their families. As the recovery phase progressed the MCAHD reinstituted all its initiatives and efforts aimed at informing and educating families and the public about the unique needs of the pediatric population and foster changes to benefit this population. The MCAHD continued conducting ongoing assessment of the emerging health needs to drive priorities for achieving high quality health care access and to continue to establish the medical home model and ensure continuity of care.

Collaboration with diverse partners, including families, community based organizations, private sector and other government agencies, was a key to advancing a shared vision for leveraging resources, integrating and improving systems of care, promoting quality public health services and developing supportive policies. The Pediatric Consultant was elected vice-president of the PR Chapter of the AAP in June 2017, strengthening the collaboration with this organization that pursues similar goals. The Pediatric Consultants work in the MCAHD was spotlighted in an article published in AAP News, April 10 2019, How public health work can extend pediatricians’ reach, (www.aappublications.org/news/2019/04/10/chapters041019).

The MCAHD continued to develop and implement varied strategies to achieve the national and state performance goals relevant to the Child Domain and contribute in the recovery phase and preparedness for future events.

 

Promoting preventive health visits

After the hurricane, many pediatricians closed their offices due to structural damage or flooding; others decreased their office hours due to the extended period without electrical power, which required the use of electric power generators. The cost of diesel to maintain the generators increased their overhead while their incomes decreased due to a reduced flow of patients to their offices. Many families postponed preventive health care visits, due to higher priorities to other challenges after the storm; lack of basic needs such as water and electricity, decreased income, and loss of a safe roof over their heads. Other families had poor access to transportation or lived in isolated communities due to damage to roads and bridges.

The impact of the storms increased the fiscal challenges the pediatric health care workforce has been confronting the recent years. Since 2015 a number of pediatricians have closed their offices in response to the economic difficulties created by the migration of the population (young families with children) to the mainland and difficulties in the reimbursement from health insurance companies. Many have moved away from the Island or have joined an emergency room or intensive care unit as employees to ensure a sustained income. As reported by the PR Health Insurance Administration (PRHIA), for 2017-2018 there were 1,917 Pediatricians (including pediatric subspecialist), 2,593 Family Physicians, and 14,661 General Physicians contracted for services in the GHP (Government Health Plan). The GHP served a population of 424,939 in the pediatric age range under EPSDT (0 to 21 years old).

The DHHS Assistant Secretary for Preparedness and Response (ASPR) provided support to the PR AAP Chapter and the National AAP, with the collaboration of MCAHD, in evaluating the needs of pediatricians and health care services for the pediatric population in PR after the hurricane.  A series of regional meetings were coordinated to provide pediatricians information on opportunities to overcome their losses and how to recover their practices, in order to motivate them to remain in Puerto Rico. Orientations were provided on how to process insurance claims for damages and loss of income, how to apply for loans to help in the recovery process and incentives, and the National Health Service Corps (NHSC) loan repayment assistance to support qualified health care providers willing to work on the island. Generators were distributed by FEMA and Small Business Administration loans were offered to primary care pediatricians. Pediatric health services slowly recovered, with some areas lagging behind due to the overwhelming damage to infrastructure. Some areas remained without electric power for 7 months, and the recovery of the infrastructure remains slow.

The Puerto Rico Preventive Pediatric Health Care Service Guidelines (PR PPHCSG) steer primary health care providers to deliver high-quality preventive health care that will have an impact on child health and well-being. The PR PPHCSG improve the provision of primary health care services of infants, children, and adolescents by promoting the use of universal and selective screenings by age, complete history-taking and physical exam, and the delivery of anticipatory guidance. The guidelines recommend the evaluation of nutritional habits, physical activity, BMI, oral health, development status, signs of depression and risky behavior, and the use of specific validated screening instruments to help in an early identification and timely intervention. They emphasize the role of anticipatory guidance for effective prevention by providing the opportunity to share strategies to improve healthy lifestyles and to educate parents on changes and needs of children in each stage.

The guidelines encourage providers to identify risk factors as early as possible for prompt evaluation and intervention that will allow children to achieve their full potential. Common conditions which may be identified by following a scheduled itinerary for preventive care services include obesity and children at risk for obesity, developmental delays and risk for dental caries. Provider compliance with the PR PPHCSG fulfills the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) requirements for the Medicaid-served population, established as a public policy by the PR DOH. EPSDT also serves as a guideline for preventive medical services for the rest of the pediatric population. During 2017-2018, the contracted health insurance companies continued to reinforce the use of PR PPHCSG as EPSDT guidelines in pediatric preventive health care services provided to the GHP population.

Nearly all mothers (99%) participating in the Estudio de Salud Materno Infantil de PR (ESMIPR, PR Maternal Infant Health Study) follow-up surveys at 6 and 12 months in 2017 reported their children had a primary care physician and had visited them for preventive visits. In similar findings, in the preliminary data of the PRAMS-ZPER survey of 2017, 99.1% of mothers responded in the affirmative when asked if their baby had “any health care visits with a doctor, nurse, or other health care worker since you left the hospital when your baby was born.”

During 2017-2018, 28 % of the insured population in the <1y/o age range and 11% in the 1 to 11 y/o age range had at least one preventive visit billed, according to the Insurance Commissioner’s Office (ICO) data. A disparity is observed when comparing preventive visits billed between PI (private insurance) and GHP in the <1 y/o age range (24% versus 76%) and in the 1 to 11 y/o age range (31% versus 69%), as reported by the ICO (with at least one billed preventive visit). Pediatricians have shared their difficulty in preventive visit being recognized and paid by private insurance in > 2 y/o, which will require documentation and investigation prior to establishing improvement efforts. Another observation is that as children grow older there is a tendency for fewer children to have at least one preventive visit. This different pattern of outpatient visit utilization between the privately insured and the GHP insured brings up the concern of its possible impact on the quality of care and the cost of care between both sectors. Disparities are summarized in the following table.

 

In 2017, 71% of parents with children between the ages of 1 and 11 y/o stated that their child was in excellent or good health and 86% reported their child had a preventive service visit in the last year PR Behavioral Risk Factor Surveillance System, (BRFSS). This difference may reflect a lack of proper use of codes for billing preventive visits by providers, or a misconception of parents of what is a preventive visit versus an urgent visit to an outpatient clinic. MCAH staff strives to increase this %, therefore we continue to advocate the dissemination and implementation of PR PPHCSG. Participants of various initiatives received information promoting the recommended Preventive Pediatric Visit schedules by age. The Parenting course and the Prenatal course promote compliance with pediatric preventive visits and provide orientation on the purpose of these visits. The HVNs provided information regarding the pediatric preventive visits to the 3,633 families reached during 2017-2018.

The uninsured population between 1 to 11 years of age for 2017-2018 is 8,048 (2.2%).

 

Promoting physical activity and preventing risk for obesity

Nutritional choices were limited for a period following the storm. Many people depended on donations and food boxes distributed to the population during the recovery phase. Children had the opportunity to play outdoors and use their outdoor recreational toys, for there was no electricity, limited internet services and television, and many schools remained closed for a prolonged period. In many communities and shelters children could be observed playing and riding bikes, increasing outdoor physical activities. When the MCAH staff reinstituted the interventions, they continued to encourage increased physical activity and healthier nutritional choices in an effort to decrease the risk of obesity.

During 2017-2018, participants of the HVP and the Parenting courses continued receiving information of the updated AAP recommendations encouraging daily physical activity and limiting exposure to television or other passive digital media for infants, toddlers and children. Parents also received orientation on the obesity risk for their children when they consume high-calorie snacks with low nutritional value. The AAP’s recommendation to limit juice intake to less than 4 ounces a day in toddlers, 6 to 8 ounces a day in children, and no juice before 1 year old was reinforced. The Parenting course, directed at parents of children from birth to 5 years, includes messages encouraging physical activity and making healthier nutritional choices for their families.

The MCAH staff continued to promote healthy nutritional habits and compliance with the culturally and linguistically adapted My Plate recommendations during home visits and in community based activities. The staff also continued to encourage the exchange of water instead of high-calorie sweetened beverages in purchased meals. Law 256 of 2015 requires food outlets to offer consumers the option to exchange soda for bottled or filtered water in combo meals at no extra charge. Brochures developed with culturally appropriate simple language reinforce the messages delivered during orientations to families in the community, in the Parenting courses, the Prenatal courses, and in the HVP. The following tables summarize the number of participants in the Responsible Parenting Courses during 2017-2018.

 

Additional orientations related to nutrition and physical activity was delivered to 1436 participants by the CHWs and HEs in educational activities in the community during 2017-2018.

Short and simple physical activity breaks (Pausas Activas) are offered in all courses promoting active lifestyles and the adoption of physical activities in daily routines.

The PR PPHCSG emphasizes calculating BMI and its percentile, history of physical activity and nutritional habits of children during their preventive visits, reminding primary care providers of the importance of including nutritional and physical activity advice when delivering anticipatory guidance, therefore promoting the prevention of obesity in the pediatric population.

The MCAH continued collaborating in the implementation of the Puerto Rico National Plan for the Prevention of Obesity with other PRDOH Programs, government agencies and the Pan American Health Organization. During 2017-18 the group reevaluated objectives and strategies, implementing modifications so as to achieve the prevention of obesity in the pediatric population. The Puerto Rico National Obesity Prevention Plan has been a Public Policy of the PR Government since 2016 which includes promoting BF, following the My Plate recommendations, increasing access to areas that promote physical activity and proposing policies and laws that support the prevention of obesity.

An increasing trend in the percent of children ages 2 to 5 receiving WIC services who have a BMI at or above 85th percentile has been observed in PR, from 16.3% in 2015, to 17.7% in 2017and 18.6% in 2018.

The data related to behaviors that increase the risk of obesity points toward the need to continue educational interventions. New research reviews have focused on the need to implement strategies to prevent obesity at early ages, beginning with the promotion of exclusive breastfeeding and the delay in the introduction of solids until 6 months of age. The development of recommendations for introduction of solid food in infants requires knowledge and understanding of the cultural values and rituals, food resources and nutritional knowledge of the population. Considering the previous factors and the latest recommendations of the AAP and the World Health Organization (WHO) on infant nutrition, a committee of specialists in infant nutrition, convened and coordinated by the MCAHD, developed recommendations for best practices in the introduction of solid food for infants adapted to the Puerto Rican culture and in compliance with WIC guidelines. These recommendations also included orientation on implementing perceptive feeding. Perceptive infant feeding is a parental skill to observe hunger and satiety signals prior to feeding baby, versus feeding a previously determined volume on a set schedule. Members of the task force included the MCAH Pediatric consultant (coordinator of the group), a nutritionist from the PR WIC program, infant nutrition specialist Dr. Rafael Escamilla from the School of Public Health at Yale University, representative of the World Health Organization (WHO) and the Pan American Health Organization (PAHO) in Puerto Rico Dr. Raul Castellano, nutritionist Sofía Pérez from PAHO, neonatologist Dr. Maribel Campos, and nutritionist Dr. Cristina Palacios from the Human Development Department of the University of Puerto Rico Graduate School of Public Health.

A review of literature and data pertaining to infant feeding practices in PR was studied and discussed prior to developing the recommendations. The preliminary recommendations were presented and discussed in a workshop in May 2017. During this workshop a group of stakeholders, among them pediatricians, nutritionists, nurses, experts in breastfeeding and infant nutrition, and WIC staff shared their feedback on the recommendations and proposed further modifications. A final version of infant feeding recommendations from 0 to 24 months of age and perceptive feeding has been approved and adopted as public policy by the Secretary of Health in 2018.

Promoting On-schedule Immunizations

After the storms, another challenge that had an impact on child well-being was access to immunizations. There was loss of vaccines due to the prolonged lack of electricity to maintain the recommended temperatures, and the closure of vaccination centers in the areas of the Island with the worst infrastructure damages. Additional challenges for immunization were getting all preventive immunizations in needed numbers to PR, limitations of vaccines available and distribution, limitation for the storage of vaccines that require refrigeration due to lack of electricity, vaccination access for remote communities and family priorities for basic needs above preventive services like immunizations. Influenza vaccination season was also interrupted by the storm. To mitigate this situation the DOH developed a flu immunization campaign. The MCAH staff joined the campaign in November and December 2017, when vaccines began to be replaced and redistributed throughout the Island to centers which had the capacity to store them at the appropriate temperatures. As reported to the PR Secretary of Health by the CDC Senior Liaison Coordinator, in December 15 2017, a total of 61 mass flu vaccination clinics had been established throughout the Island, and 93 VFC sites were functional providing and ordering vaccines.  Thirty-six(36) VFC sites had an assessment of which, 7 sites (not for profit) were referred to FEMA as potential recipients of generators and 6 sites (for profit) were referred to Americares as potential grant recipients to purchase generator.  The other 23 sites assessed were referred to PRDOH VFC Coordinator to follow up on issues related to data logger temperature reading, pending vaccine orders and pending on assessment of vaccine viability.  Total amount of estimated wasted vaccine of VFC was 49,000 doses which represent $2,300,000.

In  January 2018, there were105 providers for VFC sites ordering vaccines versus 224 providers previous to the storm, as reported by the PR AAP Chapter Presidents Dr. Yasmin Pedrogo in the conference Coming Out of the Dark: Lessons from Long-Term Recovery in Puerto Rico, February 2018.

Distributors of vaccinations from the mainland hesitated to send vaccines requiring refrigeration, such as the varicella vaccine, to PR until the electricity was fully reestablished in the island. The intervention and collaboration of the PR AAP Chapter and AAP headquarters leadership was required to overcome this hurdle. PR had sustained very good prevalence of immunizations; however, 51 days after the storm most of the infants between 2 and 4 months were not vaccinated. The HVP nurses, in their interactions with vulnerable families, identified barriers to immunization, helped them identify resources in their community to overcome them, or referred them as necessary to complete their children’s immunization on schedule. Ninety six percent (96%) of children had up-to-date immunization coverage on discharge from HVP (data for 2017-2018).

Spread of misinformation and myths through social media also continued to influence many parents to resist immunizing their children. A recent study by the CDC (National Center for Immunization and Respiratory Diseases, NIS, ChildVax View Interactive, 2014-2016) revealed a decrease in the on-schedule vaccination of infants before 24 months of age, with a catch up by 24 months. This reflects the trend among parents to postpone vaccination until children reach school or day care, where vaccination is mandatory. This trend is not unique to PR and is observed in other states such as Florida and California. During 2017-2018 the PR MCAH staff (HVNs, HEs and CHWs) continued to promote on-schedule immunization, with emphasis on the protective effect of immunizations in the vulnerable period between birth and 2 years old, in the Responsible Parenting Courses, Prenatal Course and in the HVP. The following table present vaccine coverage in Puerto Rico as reported in multiple data sources.

 

In 2017 the Secretary of Health implemented a public policy to make Human Papilloma Virus (HPV) immunization mandatory for all 11-year-olds of both sexes, as a requirement for the 2018-2019 school years.

 

Preventing Unintentional Injuries

As previously stated, children had the opportunity to play outdoors and use their outdoor recreational toys, for there was no electricity, limited internet services and television, and many schools remained closed for a prolonged period. In many communities and shelters children could be observed playing and riding bikes, increasing their outdoor physical activities. The accumulated rubble in the communities after the storm represented additional danger for these children. Many were displaced from their homes to shelters or sheltered in relatives’ homes, in overcrowded situations.

The concern for the safety of these children prompted the development of a train-the-trainer educational intervention on the Prevention of Unintentional Injury in the recovery phase for community leaders. This educational intervention was developed and delivered by the collaborative efforts of the MCAH Pediatric Consultant with PR AAP Chapter colleagues and the United Way of PR. Six educational activities were offered in 5 regions of the island. In post training evaluation by the participants, 97% expressed satisfaction with the activity, 90% stated they were prepared to provide orientation to others in the community, and 89% perceived the information provided was beneficial for the recovery and mitigation phase of the disaster. The MCAH consultant also collaborated with the recovery and mitigation support orientation on Identification and Management of Common Health Conditions After a Disaster and Prevention of Unintentional Injury provided by the Early Head Start and Head Start Region 2 to all staff of this agency in Puerto Rico and the Virgin Islands in November 2017. The MCAH Pediatric Consultant collaborated with members of the PR AAP Chapter and United Way of PR in the development of a multimedia campaign on the prevention of unintentional injury during the recovery phase, emphasizing four areas of major concern in the recovery phase: use of adequate protective equipment for bicycles, skateboards and skates, precautions when using electric power generators, gas burners to cook, and candles for illumination.

MCAH also collaborated with United Way and PR AAP Chapter in the development of a multimedia campaign educating families on consuming water from a safe source after a disaster.

 

Another significant collaboration with the PR AAP is in their efforts to help improve preparedness plans relevant to the health and wellbeing of children.

PR Pediatric Mortality Rate for 2017 was 11.4 per 100,000 children ages 1 to 11 years, a decrease compared to the Pediatric Mortality Rate in 2016 of 13.8 per 100,000. The unintentional injury death rate was 2.8 per 100,000 (1-11 y/o). It continues to be the first cause of death in this population. The following tables report the specific causes for 2017.

 

 

The Prenatal and Parenting courses continued to promote injury prevention providing orientation and recommendations on safety strategies, including safe toy selection, the Poison Control phone number and support they provide, and the proper use of car seats, among others.  The MCAH personnel continued disseminating the latest NHSTA and AAP car seat guidelines and recommendations for adequate protective car seat selection and use according to the age and weight of the child. MCAH staff also continued to promote compliance with local laws that require children be restrained while riding in a car, and the use of approved safety helmets correctly when riding a bicycle, motorcycle or other open motorized vehicles. In 2017, five (5) fatalities related to incorrect use of car seats or seat belts were reported: 3 in the 0 to 8 y/o range and 2 in the 9 to 17 y/o range.

Besides the parenting courses the CHW and HE delivered orientations on parenting skills and injury prevention specific for different age ranges.

 

 

The MCAH staff continued to collaborate with the Emergency Medical Services for Children (EMSC) Advisory Council’s efforts towards improving the emergency response infrastructure in Puerto Rico and establishing a well-coordinated, well equipped and up to date Emergency Response System that complies with the latest recommendations of the National Pediatric Readiness Project (NPRP). In 2017-2018, emphasis has been given to pre-hospital management of pediatric emergencies, the use of the Broselow System to deliver pediatric emergency care, and improved patient transfer for critical care. MCAH staff also collaborated in the revision and update of the PRDOH hospital regulations and requirements, incorporating the AAP guidelines as a mandate for all hospitals that provide pediatric emergency care.

 

Promoting developmental screening, early developmental stimulation and emotional wellbeing

Day care centers are an important resource for families with young children, providing significant support to families. Their services were also adversely affected by the storms. A survey to determine the status of day care centers on the Island was carried out by the Educational Research Center of the University of Puerto Rico under the oversight of Dr. Annette López from November 2017 to February 2018. This survey shed light on the status and recovery efforts of day care centers after the storms. There was response from 197 day care centers, in 59 of the 78 municipalities, including the island municipality of Vieques. No responses were received from day care facilities in municipalities with poor access to communication. The following table summarizes the most relevant findings.

Most of the centers expressed they had used all their savings to make short term repairs and to sustain operations and that they are not prepared for another such event, nor are they ready to help their enrolled families prepare. In response to the needs identified in the community, MCAH collaborated with the PR Chapter of the AAP and United Way of PR by developing and offering a series of trainings in April 2018. A mitigation strategy to provide families with the tools to help their children overcome the trauma of the storm was established using the coloring Book Trinka y Juan en un día de mucho viento y lluvia (“Trinka and Juan in a Windy and Rainy Day”). The book is authored by Chandra Ghosh, sponsored by SAMHSA and HHS, and in collaboration with the National Child Traumatic Stress Network. Through train-the-trainer sessions, day care staff learned to use the book to teach parents how to better understand their children’s and their own reactions to the stress caused by the storm and how to mitigate its effects on their emotional wellbeing. This tool and the training have continued to be shared through different forums by the MCAH staff.

 

 

 

Stress and other social determinants have an impact on wellbeing of children. The early identification of developmental delay is necessary for a timely diagnosis and intervention. The earlier a needed intervention is instituted, the better the outcome, with an optimum developmental progression attained. Most cases of developmental delay are not identified until the children start school, due to a lack of appropriate developmental screening. During 2017, PRHIA data reflected 2.9% of children between ages of 0 to 4 y/o had a developmental screening billed. This may not reflect the actual number of screenings, because physicians may not include it in their billing statements due to the lack of recognition and payment by insurance companies. The use of developmental screening tools by primary care physicians may increases early detection of atypical patterns of development. MCAH staff continued to advocate for the use of developmental screening tools by primary care physicians as recommended in the PR PPHCSG and the inclusion of this topic in their continued medical education activities. The Physician Regulatory and Licensing Board has sustained the requirement of at least 6 CME hours in the topic of autism spectrum disorder for pediatricians, prompting multiple educational sessions on this topic.  This has provided additional opportunities to promote awareness of the Early Intervention Program and the use of autism and developmental screening instruments as recommended in the PR PPHCSG.  In the parenting courses they receive information on the development patterns of children.  Parents and caregivers benefit from education on the typical and atypical patterns of development to help them identify children at risk and share knowledge of resources in the community to evaluate and refer as needed.

The HVP infants and pediatric participants are screened periodically using the Ages and Stages Questionnaires (ASQ-3) and the Ages and Stages Social Emotional Questionnaire (ASQ:SE-2) in the home setting in an effort to identify delays, teach parents how to stimulate maximum development, and refer for further evaluation and early intervention if needed. During 2017-2018, 1,128 infants (<12 months old) and 1,586 children (12 to 24 months old) participated in the HVP. A total of 1,409 ASQ-3 or ASQ: SE-2 screenings were performed, of which 103 (7.3%) were positive or were identified with some concern requiring a referral. The following table specifies referrals required and disposition.

 

 

Evidence supports the importance of brain stimulation in early childhood to attain optimum brain development, which can lead to higher education, better jobs, and better quality of life. Sixty nine percent (69%) of mothers participating in the ESMIPR in the follow up survey at 6 and 12 months reported reading books to their babies. HVNs teach parenting skills in their interventions, including strategies parents can use in their day-to-day interactions to stimulate development. The educational materials of Crianza Justo a Tiempo (Spanish version of Just in Time Parenting) from eXtensions were adopted after authorization by Anne Mims Adrian, PhD, eXtension Director of Programs at Auburn University (www.articles.extension.org/pages/70394/crianza-justo-a-tiempo) as an additional tool to prepare the HVNs to teach parenting skills. A guide for HVNs that specifies topics and screenings for each home visit was developed (Guía de temas educativos e intervenciones postparto). Culturally adapted brochures at a basic reading level on socio-emotional development, parenting skills and other topics were developed to help strengthen the interventions. Incentives related to the topics are used to reinforce the information.

The Parenting courses also presented information to participants on typical patterns of development as well as signs of delays, so they can identify any deviations early and reach out for help. The course also promoted the use of nurturing and positive parenting skills to stimulate optimum child development.

Quality child care has an impact on the wellbeing of young children. The MCAH staff evaluated and submitted recommendations in the development of the regulation aimed at improving child care services,  including supportive settings for breastfeeding mothers, adequate physical activity for age, optimal nutritional selection, activities that stimulate development, and safety, among others, in response to Law 173 of August 2016. The MCAH advocated for the establishment of this law and offered its recommendations in public hearings. The law established the Department of the Family as the entity responsible for developing and establishing the regulations, licensing day care centers, and developing guidelines.

MCAH staff continued to collaborate as member of the Normative Policy Council for Head Start and Early Head Start of the Child Care Program of the Department of the Family of Puerto Rico. This provided the opportunity to offer resources developed by MCAH, such as the Parenting and Prenatal courses, among others, to the population they serve, and to collaborate in the development of their policies.

 

Promoting oral care

The main strategies used by the MCAHD to address oral health were to provide information and education on the importance of preventing early childhood caries, identify children at higher risk for early childhood caries for referral to the dentist, educate on nutritional habits and behaviors that decrease the risks for dental caries, promote visits to the dentist at early ages, educate on the protective effect of sealants in young children and promote their use, and advocate for GHP coverage for visits and preventive procedures.

In the WIC Program, 2.2% of children (1 to 5 y/o) were identified with oral health issues (2017-2018 data). During 2017-2018, data provided by the ICO revealed that 14% of the insured population between the ages of 1 and 11 y/o had caries requiring dental procedures, and 64% had a preventive dental visit. The PRHIA reported that 6.6% of patients aged 5 to14 received protective sealant on at least one permanent molar. In the 2017 BRFSS survey, 68%of parents with children between the ages of 1 and 11 y/o reported their child had a preventive dental visit in the past year.

 

 

The College of Dental Surgeons of Puerto Rico and the School of Dental Medicine of the University of Puerto Rico, in a press conference in August 2018, informed the positive impact the implementation of the PR Government Health Plan had in preventing dental decay in the pediatric population, with an increase in the use of sealants from 16.4% to 37.4% in 12 y/o children. A study by Elias-Boneta et al. reported a decrease in caries prevalence among 12 years old to 69% in 2011 from 81% in1997, and a higher percentage of the filled component of the mean Decayed, Missing, and Filled Surfaces (DMFS) (67% as opposed to 50% in 1997), which is interpreted as evidence of greater access of the pediatric population to dental services with the GHP. (Elias-Boneta et al. (2016). Persistent oral health disparity in 12-year-old Hispanics: a cross-sectional study. BMC Oral Health 16(1), DOI: 10.1186/s12903-016-0162-7)

Poor oral health can have adverse effects on school performance and quality of life. Positive oral health enables children and adolescents to speak, eat and socialize without experiencing pain, discomfort or embarrassment, improving their learning and school attendance. Reaching and educating children and adolescents helps them to gain knowledge about oral health, develop positive attitudes toward oral hygiene, healthy eating habits, and regular dental visits.

A mother with history of dental caries and inadequate oral care increases the risk of development of caries in their offspring by transmitting Streptococcus mutans to them, even before their teeth erupt. Pregnant women and caretakers of infants need to be educated about the transmission of Streptococcus mutans and its relation to an increased risk of developing dental caries in infants, as well as the role of proper hygiene in decreasing the transmission. The fact that during 2017-2018, data provided by ICO reported that 10% of insured pregnant women had caries requiring dental procedures signals the existing need to educate pregnant women and caretakers of infants. Oral health education and promotion of preventive measures were delivered to participants through the Prenatal and Parenting courses. Additional 377 oral health educational activities were provided in the community by HEs during 2017-2018.

MCAH staff promoted messages directed at increasing the number of parents and children that adopt healthy oral habits. They continued to increase awareness among parents with elementary school children that dental sealants are covered by the GHP and encouraging them to request this service. The HVNs and CHWs distributed educational materials concerning the importance of protective sealants to reinforce their orientations. Promoting dental sealants, particularly among low income parents, is important since they are the group less likely to have a dental sealant application and are at a higher risk for dental decay, as reported in the medical literature.

The PR PPHCSG includes recommendations for preventive dental visits twice a year since early infancy and throughout childhood and adolescence. They also emphasize the need of caries risk assessment in early infancy, with first teething, for an effective preventive intervention and referral to a dental home. Data provided by PRHIA and ICO shows that during 2016 and 2017 only 0.05% of patients between the ages 0 and 5 y/o had fluoride varnish preventive treatment performed by a pediatric dentist. In Puerto Rico, the use of fluoride varnish by primary care practitioners is currently not practiced. Most pediatric dentists do not apply it because not all insurance companies reimburse it, and it is an off-label use without Federal Drug Administration (FDA) approval. Some do apply it and do not bill the insurance company.

The MCAH Program has maintained communication with the Pediatric Dentist Society of Puerto Rico (PDSPR) to build an optimal oral health workforce that ensures access and availability of services in PR and enhance the public awareness of evidence-based preventive strategies for improving oral health. The MCAHD continued to advocate for the inclusion of oral health care in early childhood and pregnancy in professional training and CME activities.

In regard to availability of dental services, according to the Puerto Rico Office for the Regulation and Certification of Health Professionals / Medical Licensing and Discipline Board, the number of professionals certified as active pediatric dentists in 2016 was 81, representing a ratio of 22.6 pediatric dentist/100,000 children in the 0 to 8 year age range. The concentration of pediatric dentists in the larger metropolitan areas limits access due to limited transportation.

There continues to be reluctance of general dentists to provide services to children between 0 and 8 years old, because of their lack of skills to manage this population, and a lack of equipment to monitor sedated children when required, a safety measure for optimum delivery of services. This reflects the crisis that PR is facing with the migration of professionals to the mainland due to economic deterioration on the Island. A report published online by the Kaiser Family Foundation, Health Care in Puerto Rico and the U.S. Virgin Islands: A Six-Month Check-Up after the Storms (www.files.kff.org/attachment/Issue-Brief-Health-Care-in-Puerto-Rico-and-the-US-Virgin-Islands-A-Six-Month-Check-Up-After-the-Storms ; April 2018, S Artiga, C Hall, R Rudowitz, and B Lyons) raises concern of decreased workforce in the dental and medical profession due to young professionals and health care providers continuing to migrate away from the islands after the storm. This has prompted the need to advocate and increase awareness of the inclusion of pediatric oral health care in the training of general dental health care providers and in the CME activities for dentists in the School of Dental Medicine at the University of Puerto Rico and in the College of Dental Surgeons. Collaboration has continued with the director of the Oral Health Promotion Program to identify strategies to increase and promote referrals for dental home from the first tooth (6 to 12 months of age) and the early identification of infants at high risk of dental caries for referral to dentist.

During 2016-17 an Early Childhood Caries (ECC) risk screening for infants at 6 and 12 months was established in the HVP following a Quality Improvement Strategy implemented in one region. In 2017-2018 this QI strategy was progressively implemented in all MCAH regions. HVNs received training on oral care of pregnant women and children, use of the screening instrument to identify infants at high risk for caries, and appropriate referrals as needed. They also received training on strategies to share with parents on how to decrease the risk of dental decay in their infants. The MCAH Pediatric Consultant adapted the Caries-risk Assessment Form for 0-3 Year Olds published by the American Academy of Pediatric Dentistry (AAPD) to the HVP population and added a management plan and referral section.

 

The global aim is to promote oral hygiene and preventive oral care dental visits in early infancy to decrease the incidence of early childhood caries. The preventive management plan incorporated promotion of oral hygiene, healthy habits and nutrition to prevent caries in infants and toddlers. It emphasized the avoidance of sugary foods for children, since it is customary in PR to put sugar in children’s milk and/or give sodas to infants and children, and the weaning of milk bottles when putting children to bed. Early identification of at-risk infants provides the opportunity for early referral to a dental home and to teach the families preventive measures. During 2017-2018, 65% of participants in the HVP stated they had a dental care provider during pregnancy and 23% of infants and 67% of toddlers were reported to have a dental home for oral care. During 2017-2018 HVNs screened 1,338 participants between the ages of 6 and 24 months old. Two thirds (64%) were found to be at high risk for early childhood caries (ECC) (63% of infants < 12 months and 65% of children 12 to 24 months old). Of these, 75% were referred to a dentist because they already had a first erupted tooth or they did not have a dental home; however, only 18% completed the referral.

The modified infant caries risk assessment was also adopted by the PR MIECHV program, Familias Saludables.

A Pediatric Dentist Directory that includes hours, services offered and medical insurance plan accepted by dentists (pediatric and general) that offer services to infants and children was completed, but will require updating by region and identification of gaps in services provided by these providers to the early childhood population. The purpose of improving the directory is to ease the referral process for this population and improve dental care access.

The Public Policy implemented that requires children to have an oral evaluation certificate prior to school registration is an effort to promote preventive dental visits. HS and EHS also promote oral health since infancy, and reported that in 2017 32,600 children in PR had continuous access to dental care in Head Start.