Recovering from the devastation caused by the hurricanes that hit Puerto Rico in 2017 was a main priority during 2019 but it quickly changed when facing the emergent 2020 challenges. On January 7, 2020 Puerto Rico had a mayor 6.4 earthquake in the southwest region causing structural damages and displacing families from their homes. There was a switch from a recovery phase to a relief and support phase, interrupted by the changes required upon the worldwide menace of the COVID-19 Pandemia. Protective measures to prevent and control infection caused disruption in the daily routines of life for everyone, requiring adaptation to deliver services and continue to achieve our goals.
Earthquake crisis
Due to PR’s geographical localization in a highly seismic area, recurring earthquakes began in December 2019 and continued at a lower magnitude and frequency throughout 2020. In the south region, epicenter of earthquakes, homes were destroyed forcing families to live in shelters. The MCAHD promptly responded identifying the needs of families with children in government and community shelters and referral for services in the community. The MCAHD Pediatric Consultant also had multiple visits in collaboration with MCAH stakeholders, visiting families in shelters and providing orientation on management and preventive measures for contagious disease for those living in overcrowded conditions.
The 2019-2020 challenges added additional stress to the PR population with a negative impact on mental health. The displaced families suffered emotional trauma, but the general population was also affected with the uncertainty and fear of a stronger quake affecting the whole island. The effect of the quake on displaced children was emotional instability due to improvised dwellings, interruption in their schedules, loss of contact with playmates due to the need to relocate, the interruption in school semester, and emotional devastated parents and caretakers among other causes. The recovery from this event was complicated with a slow recovery from the damage caused by the 2017 hurricanes.
MCAH collaborated with stakeholders in initiatives that were implemented with the purpose to mitigate the emotional distress and promote the health and wellbeing of the affected pediatric population. On February 14, 2020, an activity was delivered outside a structurally damaged Head Start (HS) facility with the participation of more than 30 families and over 40 HS and Early Head Start staff of the surrounding towns of Guánica (epicenter of earthquakes). Most of the HS and EHS of the south region were non-operational due to damage to structures by the earthquakes. This activity was done in collaboration with the PR AAP Chapter, United Way of Puerto Rico, ASSMCA (PR Mental Health Services Agency, Adolescent and Children Division), Puerto Rico Family Department mobile library and VOCES (mobile immunization clinic). Participants received basic hygiene kits, mosquito repellents, and sunscreen. Educational material on the correct use of mosquito repellents and sunscreen protection in children, safe sleep practices, and oral care in dislocated families was provided. Vaccination against the flu was also provided.
The coloring book “Trinka y Juan, cuando la tierra se movió” (Trinka and Sam, when the earth moved), as an instrument to help families mitigate the stress caused by the earthquakes in their children was distributed. Gratitude for the support was expressed by all the participants. Similar activities were also done in Ponce and Yauco, providing support.
The MCAH staff also suffered additional stress as the rest of the population, and work was interrupted when seismic movements was felt all over the island. From December to February most of the population lived in a constant state of alertness and readiness to protect life in case of a mayor earthquake.
COVID-19
The earthquake challenge was further complicated with the emergence of COVID-19. The pediatric consultant organized and moderated a virtual meeting on March 4, were a compilation of information and recommendations from CDC, AAP and the PR DOH were presented to pediatric leaders from all over the island followed by a discussion and proposals on how to contribute to the preparedness and management of COVID-19 in the community. From this collaboration, materials for patient education and protocols for office staff in Spanish were developed and shared. Primary care doctors are the first line of contact for most patients and adequate protection of staff and physicians is vital importance. Strategies to implement telephone triage were also developed by this group anticipating the arrival of COVID-19 to the island.
On March 16, 2020, in response to the identification of COVID-19 cases in the Island, the PR government declared a state of emergency and ordered a shutdown of non-essential business, schools, and workplaces to deter the spread of infection. Working from home to comply with the governor’s order, the pediatric consultant continued in communication and collaboration with pediatric organization identifying the gaps for the identification and management of this new challenge and as a member of a Pediatrician Task Force to develop a toolkit with guidelines for the diagnosis and management of COVID-19 in the pediatric population (March 2020).
Due to the emerging concerns of how to implement protective protocols in the day care and HS and EHS settings the Pediatric Consultant in collaboration with the PR AAP Chapter developed and delivered a virtual meeting on March 16 on the spread of COVID-19 and infection control measures in public settings promoting the adoption of personal protective behaviors. The virtual conference had a total of 170 participants: day care and HS/EHS staff and community leaders. The content was based on the most recent recommendations by the CDC, AAP, and the PR DOH. During the continued shutdown multiple webinars were coordinated and delivered by the Pediatric consultant with the collaboration of Pediatric colleagues and other stakeholders. These webinars had participants from all over the island; families and staff of HS, EHS and day care centers. Pre and post-test were administered with the purpose to evaluate participant’s beliefs and knowledge, and topics for future educational webinars.
A chat with the participation of pediatricians from all over the island was created with the purpose to serve as a forum to share updated information on the diagnosis and management of Pediatric COVID-19, implementation of changes in practices to continue pediatric preventive services during the crisis while protecting their staff and themselves.
Another chat with the participation of multiple MCAH stakeholders was created with a similar purpose, to share updated information on COVID-19 and initiatives to support the MCAH population. Among participants in this chat are representatives of United Way of PR, ACOG, Breastfeeding support groups, psychologist, pediatricians, MCAH advocates, Voces (vaccine advocate NPO), PR AAP leaders, presidents of all the Pediatric Organization on the Island and the pediatric representative of the PR COVID-19 Task Force.
Webinars relevant to best practices in pediatric care during the COVID-19 crisis have also been coordinated by the pediatric consultant, with participation of pediatricians from all over the island, United States and Latin America.
With the COVID-19 crisis many aspects of family life faced emerging challenges related to the prevention and infection control measures imposed. Children remained at home with closed schools and day cares, receiving virtual education under the direct supervision of their parents. Some parents were also working virtually while taking care of their children. Poverty stricken families had even further economic challenges without opportunities to find work, as most businesses remained closed until partial opening in late June 2021. Restoration of homes damaged by the earthquake were also stalled. Families faced increased stress with an emotional burden as they found themselves isolated in their homes.
Dr. Chandra Ghosh Ippen, Associate Director and Dissemination Director at the Child Trauma Research Program at the University of California, San Francisco, and author of the Trinka and Juan series collaborated as a presenter in the May 19, 2020 webinar teaching participants how to use the new publication, Trinka and Juan against the virus, Trinka y Juan luchando contra el gran virus, to help families and children deal with the stress caused by the COVID-19 crisis.
Multiple short video clips were produced by the pediatric consultant with the collaboration of colleagues and published in the PR AAP Chapter you tube channel, social media and chats with messages targeted to parents, promoting continued preventive pediatric care, immunization, and breastfeeding during the crisis and protective measures to prevent contagion and transmission of COVID-19. All the webinars and videos are published in the PR AAP YouTube channel, accessible to the public, and have been shared through social media.
(www.youtube.com/channel/UCy8fBS9CNsgjXdIHW5TJRdw)
During 2019-2020 the MCAH staff continued their efforts to provide support and guidance to families of the available resources in their community and how to access them with the purpose to sustain and improve the health and wellbeing of their families. One to one, small groups and larger community educational initiatives were delivered by the MCAHD staff until the shutdown was ordered and interventions were modified to deliver services by telephone. Social media venues were also used for the same purpose. Many community services were also interrupted until alternate methods to deliver were established, such as WIC, Demographic registration of newborns, SNAP program etc.
During the COVID-19 crisis the HVP implemented changes and continued to provide support for participants, establishing a protocol for weekly or biweekly telephone evaluations and orientations, including how to access services and information virtually.
The caveat to all these efforts was the limited access to telephones and internet in portions of the population and staff, who became more isolated during the pandemia. All the initiatives and efforts were aimed at informing and educating families and the public about the unique needs of the pediatric population, foster lifestyle changes to benefit them, and promote COVID-19 infection control and prevention measures.
The MCAHD continued to advocate for high quality health care access and the establishment of pediatric best practices in the delivery of health care services, but with the emergent COVID-19 pandemia services were interrupted with the shutdown. Prior to the arrival of the COVID-19 crisis collaboration with diverse partners, including families, community-based organizations, private sector, and other government agencies, was continued by the MCAHD staff with the purpose to share the vision for leveraging resources, integrating, and improving systems of care, promoting quality health services, and developing supportive policies. The Pediatric Consultant as the elected president of the PR Chapter of the AAP (2019-2021), strengthened the collaboration with this organization that pursues similar goals.
During 2019-2020 the MCAHD continued to develop and implement varied strategies to achieve the national and state performance goals relevant to the Child Domain and contributing in the recovery phase, preparedness for future events, and the prevention and control of COVID-19 infection.
Control measures imposed on the population by the government demonstrated to be effective in controlling the spread of COVID-19 in Puerto Rico, and the prevalence of positive PCR testing in children younger than 10 years was less than 0.1% (Data from billing and PRDOH COVID-19 vigilance, June 2019 to July 2020) .
Promoting preventive health visits
The impact of the storms increased the fiscal challenges the pediatric health care workforce has been confronting the recent years. Since 2015 many 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. After the hurricane disaster, the National Health Service Corps (NHSC) loan repayment assistance was offered to qualified health care providers willing to work on the island as a strategy to motivate physicians to remain in Puerto Rico. With the pandemia modifications to deliver services in a safe manner decreasing the risk of contagion, increased the cost of delivering care because of the need to adopt personal protective equipment. The financial burden required to deliver services and the risk of contracting COVID-19 convinced many aging pediatricians to retire, limiting even more the availability of pediatricians on the Island. Since March 2020, there has been the death of 7 pediatricians related to COVID-19 infection.
During the COVID-19 crisis the in person preventive services were initially stalled, and priority was provided for urgent care via telemedicine, which was authorized for all physicians with a PR medical license, due to the lockdown. Visit to emergency rooms, hospitals and primary care physicians decreased markedly due to fear of contagion. Families with newborns and infants were recommended to continue the in-person visits to their pediatricians, calling ahead and following the office protocols, established to protect both staff and families.
Despite these effort in 2020, 38% of children between the ages of 0 to 9 years old with the GHP were reported having at least one preventive screening in the data provided in the CMS-416 report a decrease compared to 2019 report of 58%. This reflects the impact of the shutdown and stay home order due to COVID-19 on outpatient clinical services.
As the crisis became prolonged, physicians and dentist adopted the COVID-19 prevention and control measures, physical barriers, social distancing between patients and staff, PPE for staff, and disinfecting protocols in their offices. They also modified the protocols to receive in person visits, providing a lower risk experience for the families and the staff. Annual preventive visits require a physical exam which cannot be replaced by a telemedicine visit, therefore the MCAHD staff continued to promote that families contact their medical and dental home for their children’s preventive visits, reassuring them of the safety measures adopted for the control and prevention of infection.
The PR Health Insurance Administration (PRHIA) underwent an administrative change expanding participants’ choice of election of primary care physicians and hospitals, which was previously constrained to specific regions. The PR HIA reported that for 2019-2020 there were 560 Pediatricians (including subspecialist), 215 Family Physicians, 1,626 General Physicians and 301 Internal medicine specialists contracted and available to provide services to the pediatric population from 0 to 21 y/o insured with the GHP (Government Health Plan). The total pediatric population between the ages of 1 to 9 years old enrolled in GHP and eligible for EPSDT as of June 2020 was 309,047.
The Puerto Rico Preventive Pediatric Health Care Service Guidelines (PR PPHCSG) steer primary health care providers to deliver high-quality preventive health care that 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 who receive medical services by other private insurance companies. These guidelines are revised and updated by the MCAHD staff with the collaboration of a group of experts on pediatric health care and epidemiology. The latest version was revised, updated, and published as public policy by the PR DOH in October 2018.
During 2019-2020, 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 by including this topic in their providers CME activities.
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).
MCAH staff strives to increase the prevalence of preventive visits, 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 2,785 families reached during 2019-2020.
Promoting physical activity and preventing risk for obesity
Obesity continues to be a concern due to its high prevalence in the population with 20.2% overweight or obese youth, between 10 to 17 years old, as reported in the 2019 JS and 22.4% of children between the ages of 2 to 5y/o participants in the PR WIC program (2019-2020). During the pandemia, the methodology used in the WIC Program to calculate BMI and identify overweight or obese children depended on telephone interviews with parents providing the estimated weight and height numbers, therefore these numbers may not reflect a correct estimate. The shutdown further limited involvement in sports or physically active recreation and may be a factor increasing the risk of childhood obesity. Obesity is a risk factor for many of the common chronic diseases related to mortality and morbidity.
During 2019-2020 the MCAH staff continued initiatives to encourage increased physical activity and healthier nutritional choices to decrease the risk of obesity. Participants of the HVP and the Parenting courses continued receiving updated information and recommendations by the AAP encouraging daily physical activity, outdoor play, 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 as provided by Law 256 of 2015 requiring food outlets to offer consumers the option to exchange soda for bottled or filtered water in combo meals at no extra charge.
Brochures 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.
During 2019-2020 and before the shutdown 61 courses consisting of 4 sessions on Responsible Parenting 0 to 5 y/o were provided throughout the Island by HE and CHW. A total of 376 (92%) of 410 participants completed all 4 sessions, 78% females and 22% males. The following tables summarize the comparison and outcome of the average pre and post test scores, by session.
An achievement of the courses is a statistically significant improvement in knowledge in each session, (a similar finding in last year’s evaluation).
Another parenting course delivered by HE and CHW prior to the shutdown, Responsible Parenting 6 to 11 y/o, had 921 participants, 86% females and 14% males. A total of 255 courses on this topic were delivered. This course also presented a significant improvement when comparing the average pre and post test session scores (a similar finding in last year’s evaluation).
Additional orientations related to nutrition and physical activity were delivered to 947 participants by the CHWs and HEs in educational activities in the community during 2019-2020. 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.
As previously stated, 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 Obesity Prevention Plan (PRNOPP) with other PRDOH Programs, government agencies and the Pan American Health Organization. During 2019-2020 the group reevaluated objectives and strategies, implementing modifications to achieve the prevention of obesity in the pediatric population. The PRNOPP is a Public Policy implementation plan of the PR Government promoted 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.
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 committee 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.
Infant feeding recommendations from 0 to 24 months of age was approved and adopted as public policy by the Secretary of Health in 2018 after a review of literature, data pertaining to infant feeding practices in PR and a compilation of recommendations from a group of early childhood feeding stakeholders experts. In the ninth edition of the Dietary Guidelines for Americans 2020 – 2025 a chapter was dedicated on Infant and toddler nutrition recommendations that coincide with the recommendations included in the PR DOH adopted policy of feeding in the first 24 months.
www.dietaryguidelines.gov/sites/default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf
Promoting On-schedule Immunizations
In an article published by Santoli JM, et al. (Santoli JM, Lindley MC, DeSilva MB, et al. Effects of the COVID-19 Pandemic on Routine Pediatric Vaccine Ordering and Administration — United States, 2020. MMWR Morb Mortal Wkly Rep 2020; 69:591–593. DOI: http://dx.doi.org/10.15585/mmwr.mm6919e2external icon MMWR. 69(19):591-3) “CDC reported a steep decline in immunization rates during the COVID-19 pandemia, as observed in the Vaccines for Children Program (VFC) provider order data from CDC’s Vaccine Tracking System and Vaccine Safety Datalink (VSD) vaccine administration data. The identified declines in routine pediatric vaccine ordering and doses administered might indicate that U.S. children and their communities face increased risks for outbreaks of vaccine-preventable diseases. To the extent that this is the case, reminding parents of the vital need to protect their children against serious vaccine-preventable diseases, even as the COVID-19 pandemic continues, is critical. As social distancing requirements are relaxed, children who are not protected by vaccines will be more vulnerable to diseases such as measles. In response, continued coordinated efforts between health care providers and public health officials at the local, state, and federal levels will be necessary to achieve rapid catch-up vaccination.”
In December 2019, PR law 169 was approved making it mandatory for all immunizations administered to be reported to the PR Immunization Registry (PRIR) by providers and insurance companies. Puerto Rico laws grant immunization exemptions to children for medical reasons, children with a justified medical condition for which immunization is contraindicated as certified by a doctor, and religious exemptions for children from families who belong to religions with a dogma that objects to immunizations requiring evidence by a sworn statement of their religious affiliation. These exemptions may be declared null by the Secretary of Health in case an epidemic is declared. The PRIR ceased function in early 2020 due to technical problems which required the system to be replaced. The immunization data that was collected in the PRIR is in the process of recovery for what immunization data for 2019-2020 is not yet available to evaluate trends or prevalence.
In Puerto Rico with the shutdown, in person medical office visits were converted to telemedicine health services and progressively have returned to in-person visits with the adoption of protocols to help in the control and prevention of COVID-19 infection, but parents continued to avoid the well child visit due to fear of exposure to COVID-19. PR immunization services were also impacted, as reflected in a decrease in orders for vaccines during March to June 2020, despite the modification in service protocols of the immunization centers to ensure a safe and controlled environment. Parents refused to continue vaccination schedules due to fear of COVID-19 contagion and the perception that vaccinations are not necessary because students remained at home, with virtual learning and low risk of exposure.
Spread of misinformation and myths through social media were intensified by anti-vaxxers during the COVID-19 pandemia and in response to the mass COVID-19 Vaccination. This messages further influenced many parents to postpone immunization of their children. Prior to the pandemia a report by the CDC (National Center for Immunization and Respiratory Diseases, NIS, ChildVax View Interactive, 2014-2016) described 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 the COVID-19 pandemia shutdown and stay home orders, many parents postponed vaccination further, increasing the gap of children vaccinated following the recommended schedule. The MCAH staff continued to emphasize the importance of vaccinating their children in compliance with the recommended schedule providing protection against preventable infectious conditions which could further complicate clinical management during the pandemia.
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. Upon discharge from the HVP 95.6% of children had up-to-date immunization coverage (data for 2019-2020).
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 registration in school since 2017. PR law 25 of 1983 requires all children registered for school or day care to have evidence of up to date completed immunization against diseases which may interfere with their maximum development of their physical and intellectual capacity. The required immunization by age is dictated by the DOH and are actualized every year based on recommendations of the CDC and Advisory Committee on Immunization Practices (ACIP). Despite schools remaining closed in 2020, families are required to present evidence upon registration for the 21-22 school year. The requirement has helped maintain high immunization rates in school aged children in the previous years.
Influenza vaccination is not mandatory for school and day care registration in Puerto Rico, and its prevalence has been much lower, a 7% prevalence of influenza immunization for 2018-2019 for population registered in the 6 months to 17 years old age range (total registered in this age range was 735, 260). MCAHD will continue to promote yearly flu vaccine and to collaborate with the PR Immunization program in the yearly influenza campaigns with other collaborators such as PR AAP Chapter and VOCES (PR Immunization coalition).
Preventing Unintentional Injuries
The MCAHD has continued collaborating with the PR AAP Chapter. Pediatric Emergency Program and United Way of PR in promoting the prevention of unintentional injury, emphasizing areas of major concern: use of adequate protective equipment for bicycles, skateboards and skates, precautions when using electric power generators during hurricane season, precautions to avoid burns when using gas burners to cook and candles, and safe toy selection.
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 Puerto Rico Poison Control Call Center reported they received 1330 calls for children between the ages of 0 to 9 y/o and 177 in infants less than 1 y/o during 2019-2020. These findings support the need to continue to orient parents and caretakers in adopting the preventive measures at home.
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 2019-20, two fatalities and 313 non-fatal injuries related to incorrect use of car seats or seat belts were reported in minors of 10 years old.
Besides the parenting courses the CHW and HE delivered orientations on parenting skills and injury prevention specific for different age ranges. The HVNs also deliver age specific orientation on unintentional injury prevention in their home visits.
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 2019-2020, emphasis continued to be the 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
Stress and other social determinants have an impact on wellbeing of children. In response to the challenges faced in 2019-2020 many efforts were continued to mitigate the effects of the stress. As previously stated, these initiatives were coordinated with the collaboration of stakeholders. During 2019-20, PRHIA data reported 18,031 (5,4%) children between the ages of 0 to 9 years old received treatment due to mental and behavioral disorders, with diagnosis that included, major depressive disorder, recurrent post-traumatic syndrome, anxiety disorders, attention deficit, among others.
The early identification of developmental delay provides the opportunity for a timely diagnosis and early 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. The use of developmental screening tools by primary care physicians may increase 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.
Analysis of billing data revealed that <2% of the insured population between the ages of 0 to 48 months were billed with CPT code 096110 in 2019-2020, indicated for billing autism screening with MCHAT or developmental screening using ASQ. These numbers may not represent the actual number of screenings, because developmental screening CPT codes may not have been included in the billing statements due to multiple reasons. Yet with the decreased prevalence of preventive visits, there is an expected decrease in developmental screening which are difficult to perform optimally through telemedicine.
Participants in the parenting courses receive information on the expected development milestones of children and availability of screening test to evaluate development attainment. 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 contributes to early identification of developmental delays and referral for further evaluation and early intervention if required by periodically screening all infants and pediatric participants using the Ages and Stages Questionnaires (ASQ-3) and the Ages and Stages Social Emotional Questionnaire (ASQ:SE-2) in the home setting.
During 2019-2020, a total of 1,110 (<12 months old) and 1,235 toddlers (12 to 24 months old) participated in the HVP, each completing ASQ-3 or ASQ: SE-2 screenings as indicated in the HVP screening schedule. The test administered to these children are not billed and do not appear in the GHP data. One hundred and fifty-one (151), which represents a 7.1% of participants tested had positive screening results or were identified with some concern requiring a referral. The following table specifies to what services they were referred to and how many were completed.
The total number of screened represents multiple screening of children following the HPV schedule.
32 were identified prior to their 13-month birthday allowing for a very early referral.
Of 151 screenings with a high-risk result, 52% were in the social emotional screening test, not commonly used in primary pediatric medical care.
HVNs besides screening for developmental delays, teach parenting skills in their interventions, including strategies parents can use in their day-to-day interactions to stimulate development. 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. 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. The HVN also use the CDC Learn the Signs, Act Early in Spanish materials with their participants. 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 presents 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.
Day care centers are an important resource for families with young children, providing significant support, therefore promoting quality childcare improves the impact on the wellbeing of young children. The MCAH staff continued supporting the implementation of regulations for day care centers, which include providing supportive settings for breastfeeding mothers, adequate physical activity for child age, optimal nutritional selection, activities that stimulate development, and safety, among others, by providing orientation and education to directors and staff of the centers. 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 promote 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, and educate on the protective effect of sealants in young children and promote their use.
Multiple strategies have contributed to the improvement in oral health in the pediatric population in the last 20 years; the implementation of the PR Government Health Plan with dental care coverage, an increase in the use of sealants, and the requirement established by law 63 of 2017 that mandates children have an oral evaluation and periodic dental cleanings along with a compulsory Oral Health Certificate (OHC) upon school enrollment, for students entering grades Kindergarten, 2nd, 4th, 6th, 8th, and 10th. This ensures the student have a dentist evaluation in the last 6 months prior to enrollment. Schools are required to complete an annual report for the Health Promotion Division of the DOH. Reports are analyzed and results are evaluated by members of the Oral Health Coalition for evaluation and proposal of strategies to continue to promote oral health. The MCAH staff continued as collaborator in the Oral Health Coalition. Despite these improvements dental decay continues to be highly prevalent in the PR pediatric population.
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 in the 2019- 2020 PR Health Insurance Commissioner Office (HICO) reported that 26.9% of pregnant women had a preventive dental visit signals the existing need to educate pregnant women and caretakers of infants. During 2019-20 the CHW delivered orientation on prenatal oral care to 1,233 persons.
Oral health education and promotion of preventive measures were delivered to participants through the Prenatal and Parenting courses. 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. During 2019-20 the HE’s delivered oral care education in multiple activities reaching 571 participants, among them 279 children between the ages of 3 to 9 y/o.
The HEs 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 CMS 416 GHP report stated 6% (6 to 14 y/o age range) and the PR HICO reported 5.8% of billing for sealants (5 to 14 y/o range) during 2019-2020.
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. The HS and EHS also promote oral health since infancy and have adopted the Caries risk assessment.
Billing data provided by PRHIA shows that during 2019-2020 less than 1% 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 collaboration with the Pediatric Dentist Society of Puerto Rico (PDSPR) promoting access and availability of services in PR and enhancing the public awareness of evidence-based preventive strategies to improve 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 is 80. 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.
The concern raised by 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) on the 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 has increased with the additional challenges presented by the pandemia. 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. Since 2017 an Early Childhood Caries (ECC) risk screening for infants at 6 and 12 months was established in the HVP. HVNs are trained 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. In the HVP interventions they share strategies on how to decrease the risk of dental decay in their infants. Infants less than 12 months, identified at high risk but without teeth yet, are not referred to the dentist until reaching 12 months. All participants receive orientation on how to reduce the risk for caries by the HVNs.
Of the 918 screenings for high early childhood caries risk done in 2019-2020 to participants of the HVP between the ages of 6 to 12 months old, 74% had a high-risk result. Of the cases referred for a dental home appointment 49% were in process that was delayed due to the March 2020 shutdown and 34% had completed and received services in a dental home. All infants are referred for a dental home when they are 12 months old, but infants identified at high risk are urgently referred besides providing all parents with an orientation on how to decrease the risk and the importance of caring for their baby’s teeth. The modified infant caries risk assessment was also adopted by the PR MIECHV program, Familias Saludables. A Pediatric Dentist Directory that includes office hours 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. During the COVID-19 pandemia dental services have been interrupted and less accessible due to the adjustment in the offices to decrease the risk of infection, which includes decreasing the number of patients that may receive services in a day due to protocols of disinfection that take time to complete between patients.
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