Primary and Preventive Services for Children

 

The role of Title V, through Local Health Departments (LHDs), has been to provide safety net services and assure all children have access to well child, nutrition, and immunization services. Direct preventive well child health services identify growth and development issues according to the standards recommended by the American Academy of Pediatrics (AAP).

 

Assuring well child exams and immunizations has been a hallmark activity for MCH Title V and has been part of identified needs consistently since the early 1990’s on the 5-year needs assessments. During the 2020 needs assessment, this remained a priority with much discussion about early childhood development and mental health and addressing mental/behavioral health of adolescents.

 

Funding from the Title V Block Grant has supported a university-based training program for public health registered nurses (RNs) to develop skills in pediatric assessment, which certifies them to perform preventive pediatric well-child examinations and provide remedial/acute services to students in the schools.

 

Since its inception in 2003, this program provided 23-module web-based well child training to 1,015 nurses have. LHD well child protocols, as provided by DPH, follow AAP Bright Futures recommendations. This training allows the RN to provide an exam with expanded training and knowledge to recognize abnormal findings with referral to mid-level or higher licensed providers. To assure ongoing practice fidelity and knowledge, the MCH Title V program contracts with the universities for annual professional development, continuing education for nurses that review current topics related to pediatric preventive services, as well as school health. In 2019, both the UK and UL provided a full day of face-to-face training with over 100 nurses in attendance. These trainings and those from 2018 were developed into webinars offering nursing contact hours available online through Training Finder Real Time Affiliate Integrated Network (TRAIN).

 

The School Health Program promotes access to preventive health services for school-aged children and adolescents and improves access to health information at critical times for influencing health behaviors. Depending on the local arrangement with LHDs, nursing services may include preventive health services, education, emergency care, referrals, and management of acute and chronic conditions in a school setting. School nurses serve children aged pre-school through adolescence (up to age 21). MCH encourages children and adolescents to have a medical home and, where possible, for schools to augment this service. The MCH school health and well child nurse consultant sent monthly injury prevention information to all school nurses across KY, along with opportunities for nursing contact hours webinars, and provided additional education regarding case management of chronic conditions such as asthma, diabetes, and seizures to nurses in attendance at the 2019 Kentucky School Nurse Association annual conference with about 300 school nurses in attendance.

 

The KDE employs a 1.0 FTE nurse consultant who provides technical assistance to the public schools on health issues. In a collaborative approach to school health services, KDPH funds one-half of the salary for this position. The MCH nurse and KDE nurse collaborated with the Diabetes Prevention and Control Program to develop modules released in July 2020 for school nurses. These modules provide education on pathophysiology of diabetes in children, current best practice treatment, pharmacology updates, and considerations for management in the school system.

 

The MCH School Health Program collaborated with the KY Immunization Branch to create protocols to address infectious disease control in shared band instruments in school. This protocol was distributed to all school districts. Additionally, MCH collaborated with KDE and the KY Immunization branch to develop a reporting mechanism for identification of flu like illness in school. This resulted in a weekly report queried from KY Infinite Campus of aggregate counts that helped to inform the Immunization Branch for targeted flu clinic promotions. The Immunization Branch worked with local pharmacies to provide flu shots to communities and to promote the need for flu vaccines.

 

The number of direct pediatric preventive services provided at the LHDs is decreasing as LHDs move to population health measures and have discontinued provision of school nursing services. However, the opportunity to assure a trained and skilled workforce of school nurse continues to be a need as most schools in KY do not have a school nurse, and those newly entering the workforce do not have pediatric experience.

 

The LHD continues to be a source for linking children to care in a medical home with community partners. While still supporting basic safety net services, the Title V program is focusing more on population-based activities such as prevention of child injury, increasing physical activity, promoting a nutritious diet, and decreasing exposure to tobacco smoke.

 

Challenges will need to be addressed as LHDs move from a primary provider of direct services to population health services. There is ongoing opportunity for well child exams and immunization during WIC visits, childhood lead poisoning prevention case management, and school health visits. For rural areas in KY with access to pediatric care, this service by a LHD will continue to fill a gap.

 

Immunizations:

Annually, The KY Immunization Program promotes vaccine administration during well child exams and by local providers when deficits are noted. They work closely with KDE to assure children are up-to-date prior to entry in child care or school. Statewide, compliance rates for vaccine administration were above 90% for all kindergarten vaccines. Per the KY Annual School Immunization Survey Report for School 2018-2019 (Division of Epidemiology and Health Planning, 2020):

• The KY Immunization Program strives to meet the Healthy People 2020 objectives of 95% or greater for each of the following vaccines: four or more DTaP, three or more polio, three or more HepB, two MMR, two varicella, and 85% or greater for HepA in kindergarteners. During the 2018-2019 survey, 48 (40.8%) of KY’s 62 counties met this standard. 85.1% reported >90% of kindergarten certificates on file were current.
• For 7th grade students, 41 counties (39.1%) met the Healthy People 2020 objectives for each antigen, (80%or greater with Tdap/Td booster and MenACWY, 85% or greater for HepA, 90% or greater for varicella, and 95% or greater for HepB and MMR).

 

The KY Immunization Registry (KYIR) section has, through many outreach efforts, increased school nurse usage of KYIR over the past year. School nurses are given read only access to the Immunization Registry so they are able to view student immunization records and print immunization certificates as needed.

 

Early in 2019, KY had the first cases of measles in KY since 2010. While KY does not have active transmission of disease, we are proactive. Community providers and other partners receive national measles updated information as provided by the KY Immunizations Program. These updates and guidance reflect CDC recommendations. KY promotes vaccination above all. Materials include recognition of measles and actions to take for prevention of the spread of the illness, as well as care measures. KY Immunization Program created talking points regarding vaccination and measles education.

 

KY actively recruits new Vaccines for Children (VFC) providers. This active and strong program aided KY’s public health response during the Hepatitis A outbreak. In addition, KY has a nurse vaccination team that travels to local communities statewide to administer Hepatitis A vaccinations.

 

As described, the KY Immunization Program has many standardized processes to assure high rates continue as reported. The challenges for immunizations will be maintaining this level when faced with public health outbreaks. The response to Hepatitis A, in in 2018, positively reflects upon the strength of KY to respond and maintain immunization rates at a high level. MCH epidemiologists provided staff support for investigation and surveillance during the Hepatitis A outbreak.

 

As KY prepares for Covid-19 vaccination, the Immunization Branch is actively researching community partners and evaluating logistical plans to meet the need for administration and follow-up once a vaccine is available.

 

Injury Prevention

 

Injury is the leading cause of death among KY children over the age of one and was a priority for children in our statewide needs assessment. This need continued to be identified in the 2020 needs assessment as one of the highest priorities. In particular, child maltreatment was the highest priority. Child passenger safety and teen driving were also concerns raised by the participating groups.

 

The NPM selected for this domain is NPM #7: Rate of hospitalization for non-fatal injury per 100,000 children ages 0-9 and adolescents ages 10-19.

 

Per federally available data, state inpatient hospital data shows a decline in the rate of hospitalizations both nationally and in KY. In 2008, the rate per 100,000 children was 159.4. This rate has declined to 117.7 in 2017, and is lower than the US rate of 128.6. While this improvement is promising, it is too soon to draw a conclusion about this data, as the 2015 indicator was 108.4. In looking at the data by age, infants under the age of 1 year are at the highest rate of injury (243.7/100,000), which is over 3.5 times higher than the rate for a school age child of 5-9 years of age (90.9/100,000). This is not surprising as KY child death data also finds infants at highest risk of death.

 

Injury Prevention and Intervention

 

To reduce this rate, LHDs collaborate with the child fatality and injury prevention team and Safe Kids KY to promote best practice injury prevention messaging and activities. One activity has been to develop TRAIN webinars with nursing contact hours for promotion to schools, child cares, and other community partners. During fall 2018 and spring 2019, 6 pediatric courses specific to child injury, child abuse, and SUID have had 2,773 individuals complete the courses.

 

With the improved CFR processes, LHDs and coroners are able to understand many details related to child fatalities specific to their communities. This has led to community prevention plans that included safety prevention campaigns for safe pedestrian walkways for children to bus stops, safe sleep campaigns, gun safety and storage campaigns, and smoke alarm programs in which smoke alarms are purchased via local grants and installed by the local fire department. Many rural LHDs and MCH contract with the KY Injury Prevention Research Center (KIPRC) at the University of KY, the bona fide agent for injury prevention for the KDPH. KIPRC applies for and coordinates the CDC Injury and Violence Prevention Cooperative Agreement for KY.

 

Title V funds the Pediatric Injury Prevention Program at KIPRC, which includes a pediatrician with expertise in injury prevention and child death reviews. This pediatrician provides technical assistance and training to child-serving agencies including LHDs, health professionals, local CFR teams, and community partners across the state on injury prevention activities and resources. In addition, she serves as the state Safe Kids Coordinator, facilitating the training and sustainability of a rural child passenger safety workforce.

 

MCH partners on prevention activities with KIPRC’s KY Violence and Injury Prevention Program (KVIPP) and the statewide injury coalition, the KY Safety and Prevention Alignment Network (KSPAN). KSPAN is a network of public and private organizations and individuals that are dedicated to promoting safety and preventing injuries throughout the Commonwealth of KY. KSPAN is specifically working to improve the state's capacity to conduct injury prevention and control activities across a wide range of injury causes and types and risk factors to increase the reach, efficiency, and effectiveness of existing prevention efforts through greater coordination and alignment of resources. KSPAN published the KY Strategic Plan for Violence and Injury Prevention 2017-2021 which has several injury and violence prevention focus areas, nine which align with the KY Violence and Injury Prevention Plan). Emphasis areas include, but are not limited to:

• Motor Vehicle, Child Passenger, and Teen Driver Safety
• Pedestrian and Bicycle Safety
• Prevention of Drug Overdose
• Fall Prevention for Older Adults
• Residential Fire Safety and Prevention
• Prevention of Child Maltreatment – Abusive Head Trauma
• Sexual Violence Prevention of Sexual Assault
• Prevention of Suicide
• Child Home Safety
• Occupational Safety and Health (Total Worker Health and Safety)

 

This partnership has deep impact in the community with an ability and scope as a recognized leader to advocate and educate for injury prevention. In addition, MCH works with KSPAN to promote and support the Safe Communities America accreditation of KY Safe Community coalitions. This enhances the MCH capacity to disseminate best practice injury prevention programming.

 

Child Passenger Safety:

During the 2015 MCH Title V Needs Assessment, improper use of car seats and/or lack of a car seat was a top issue causing child injuries and deaths. In 2020, this was part of the discussion topics, and it was grouped under the primary focus of reducing child injury or child death as an action item.

 

In the 2015 legislative session, KY improved its booster seat bill to meet national recommendations, increasing the height requirement to 57 inches and the age requirement to 8 years.

 

MCH Title V Block Grant funding was made available for local health departments to support training for a staff member to become a certified car seat installer and educator for the caregivers on correct fit and installation of car seats. This person is able to provide community education regarding the correct age and size appropriate child safety seat and child passenger safety, including “Look Before Locking.”

 

The CPS work completed for KY MCH injury prevention program is reliant upon small grants identified by the KIPRC contractor. This program is challenged by turnover of CPS technicians in the community, re-education of local program staff, and limited resources for purchasing child seats.

 

CPS certification is tracked by the KY Office of Highway Safety (KOHS) Child Passenger Safety Program. For 2019, the KOHS CPS coordinator reported

• 17 national certification courses taught certifying 222 new technicians

• 2,050 car seats were checked

 

Potentially, more car seats were checked; however, many agencies fail to report these to the KOHS. Many fitting stations continue to have needs for donations of car seats as many families come with no car seat or resource for a car seat.

 

Child Safety CoIIN

 

In 2019, MCH did not have the workforce capacity to continue participation in the Child Safety CoIIN. Recognizing that more children and adolescents ages 1-19 die from injuries and violence than from all diseases combined and that injuries are a leading cause of emergency department visits, hospitalizations, and disabilities, KY continued ongoing work with KIPRC/KOHP on promoting and supporting the work initiated by the CoINN team for CPS. In 2020, MCH rejoined the CoINN with a targeted focus on child/adolescent suicide.

 

Primary Prevention Home – Visiting

 

HANDS is KY’s statewide home visiting program for overburdened parents. The supportive phrase often used and imbedded in this program is “every parent needs a second pair of HANDS”. KY HANDS is one of the oldest home visitation programs in the nation. Goals of the program include healthy pregnancies and births and for children to live in healthy/safe homes. Home visitors emphasize child safety checklists for appropriate ages, healthy child growth and child development, child abuse prevention, and family self-sufficiency. Family self-sufficiency includes goal setting, resource development, positive parenting, and even anger management so that families are less likely to use harsh discipline or have violence in the home. Every HANDS home visitor must complete:

• 1.5 hours of Cabinet-approved Pediatric Abusive Head Trauma training before they are allowed to bill for visits
• Continuing education hours in the areas of:
  • Child abuse and neglect
  • Problem solving and crisis intervention
  • Domestic violence
  • Temperament and discipline

 

KY has a mandatory reporting law and all home visitors report any suspicions to CPS. HANDS home visits include using the Ages & Stages-3 and the Ages & Stages-SE2 questionnaires to identify children who are at risk of a developmental delay. These developmental screens act as a conversation starter between the home visitor and the parent about activities and behaviors that are developmentally appropriate in all children, and they prepare the parent for when their child transitions into new developmental stages.

 

HANDS is a core function of public health with PH Transformation Program. MCH began a revision of the HANDS process manual to streamline reporting forms and procedures. MCH is conducting a program assessment to assure fidelity to program curriculum while restructuring to improve efficiencies. LHD and state staff are collaborating on this project.

 

Child Abuse Surveillance

 

KY continues to strive to reduce circumstances of Pediatric Abusive Head Trauma (PAHT). MCH has been deeply committed to continuing education and promotion of best practice to reduce PAHT. MCH will continue to work on projects with KSPAN, the Division of Pediatric Forensic Medicine at the University of Louisville, Prevent Child Abuse KY, the KY AAP, and LHDs on developing materials for specific groups of providers.

 

KY House Bill 285, passed in 2010, requires training for foster parents, health care workers, child protection officials, day care employees, and others who work with children, so they can recognize and help prevent PAHT. The web-based training modules have been available for nurses and other community providers since 2011. Since that time, 4,013 nurses have received the training. In 2019, the TRAIN courses were completed by 2,220 nurses. Because of frequent questions received from KBN and local university professors for enrollment, MCH learned that during Covid-19 college closures many KY colleges required this course for nursing students as part of their curriculum. Evaluation comments received have noted some have repeated the course after providing care for a child diagnosed with PAHT to assure personal understanding and knowledge remained current.

 

Under the guidance of Dr. Melissa Curry, with the Division of Pediatric Forensic Medicine at the University of Louisville, and in collaboration with Prevent Child Abuse of KY, KY Violence and Injury Prevention Program (KVIPP), KSPAN, KY AAP, MCH, and the Northern KY District HD developed a high school curriculum to educate high school students about AHT and a safe sleep environment, Keeping Infants Safe. This curriculum enhances KY House Bill 285, as the law encourages KY high schools to include a segment during a student’s final year of study concentrating on prevention of PAHT. The curriculum has a pre-test to determine the knowledge base of the student, and a post-test, for administration later in the school year, to determine retention of materials. The curriculum includes lecture and interactive materials/visuals. This pilot program held a train the trainer course for three independent high schools in Northern KY. Preliminary results showed from pre-test to post-test, 74% of students improved their overall PAHT/ Safe Sleep knowledge after completing the curriculum. The average test score across all items improved by 12% from pre- to post-test. Other notable findings from pre- and post-tests reveal:

• 85% increase in the knowledge of child abuse prevention (e.g., recognize child abuse, understand state reporting practices, and recognize normal bruising patterns)
• 19% increase in awareness of risk factors for PAHT
• 16% increase in knowing how to select a safe caregiver
• 10% increase in knowing how to solve problems non-violently and manage stress (e.g., soothe a crying baby)
• 6% increase in knowledge regarding the identification of PAHT and its associated injuries
• 5% increase of how to promote safe sleep practices for infants (e.g., identify and mitigate risk factors for unsafe sleep)

 

In 2019, KVIPP and the North Kentucky District HD presented the curriculum that was delivered to high school students at the HOSA Future Health Professionals and to 110 students at the state meeting of Health Occupations Students of America. The Northern KY District HD had to redirect efforts due to funding, allowing KVIPP to take the lead in early 2019. KVIPP sustained the project, presenting the curriculum to teachers at the Annual KY Career and Technical Educators Conference. KVIPP created online assessment tools to evaluate pre-/post knowledge, attitudes, and behaviors before and after curriculum delivery later in the year. KVIPP launched the 2019-2020 Fall Pilot of the High School Curriculum across the state, and MOU agreements with educators from over 10 high schools across the state have been secured and train-the-trainers have been conducted. One LHD, Lake Cumberland Health District, secured MOUs and delivered curriculum to some schools within their service area. Moreover, this curriculum was adapted for use with drug treatment centers to at-risk and expecting mothers by KVIPP and delivered to four classes at two drug treatment centers.

 

The cost for this joint collaboration was minimal. Title V funding was used for training supplies and education materials placed in a lending program at the LHD for use by area high schools.

 

LHDs often provide PAHT training alongside safe sleep education for families and the community. In 2019, PAHT education has been provided to over 49,584 Kentuckians. In the 2018, there were 15,249 Kentuckians that received PAHT training by 681 community partners. Area birthing hospitals also provide PAHT training to new mothers after birth of their baby prior to discharge. The strength of MCH to reduce PAHT lies in the collaboration and communication between state departments and community partners to maintain this as a primary mission for reduction.

 

In the 2015 needs assessment process, both consumers and stakeholders were particularly concerned about injury related to child abuse. While DCBS functions as a lead agency to reduce and prevent child abuse, Title V actively participates in the Child Fatality and Near Fatality External Review Panel and targets reduction of child abuse through education, surveillance, and child death reviews. Title V and DCBS actively collaborate on cases and educational efforts.

 

The Child Fatality and Near Fatality External Review Panel was created and established by KY Revised Statute 620.055 for the purpose of conducting comprehensive reviews of child fatalities and near fatalities suspected to be the result of abuse or neglect. The Panel is a twenty-member multidisciplinary team of professionals, including representatives from the medical, social services, mental health, legal, and law enforcement communities, as well as others who work with and on behalf of KY's children. The MCH Title V Director and the MCH CFR Nurse Coordinator attend the Child Fatality/Near Fatality External Panel Review meetings. The MCH CFR Coordinator reviews cases that are to be discussed by the External Panel for a final determination of the cause of death or injury, systems issues, preventable problems, and recommendations for prevention. Local cases in which suspected abuse/neglect could be part of the final determination are referred to the External Panel through the MCH CFR Coordinator.

 

MCH actively collaborates with the Department of Child Protective Services (DCBS) to provide safe sleep education, materials, and information learned from child death reviews. DCBS is essential with HEART, participation on local and state review panels, and it participates as a presenter at MCH annual and regional meetings.

 

In 2019, the Child Abuse and Neglect Annual Report of Child Fatalities and Near Fatalities, published by the CHFS Department of Community Based Services, DCBS saw an 18% increase in fatality and near fatality reports. There was an increase in substantiated near fatalities in SFY19. However, it is unknown, based on limited data for SFY20, if this was an aberration specific to SFY19 or if it will be part of a continuing trend. Of significant note, 77% of substantiated fatalities and 64% of substantiated near fatalities over a 5 year period had prior agency involvement.

 

The majority of fatality and near fatality cases had prior agency involvement. The majority of cases (47.72%) were less than 1 year of age. Male children represented 60.79% of cases. Nearly 86% of all victims are 4 years of age or younger. Natural parents were found to be the perpetrator of maltreatment at a rate of 65%. Neglect (53%) and assault (47%) were the types of maltreatment. PAHT and battered children were found in 89.68% of physical abuse cases.

 

 

Child Fatality Review

 

The Title V MCH Program has striven to improve the quality and timeliness of data in our Public Health Child Fatality Review Program to better inform our injury prevention strategies. MCH is the lead for this program, which was established in 1996 by statute. The program supports and encourages reviews of child deaths by local multidisciplinary teams to assist the coroner in determining an accurate manner and cause for each child death. The MCH Child Fatality and Injury Prevention Program currently receives notifications of any child death occurring in KY from multiple data sources. KY utilizes an electronic death registration system as one source of data for child death reports. An annual report of child death data prepared by MCH is required by legislation to be submitted to the Governor, the Legislative Research Commission, and the Chief Justice of the KY Supreme Court by November 1 each year.

 

MCH provides Title V funds to 120 LHDs to support local CFR review teams and to implement evidence informed strategies in alignment with state priorities. Title V funding allocations for LHDs supports local CFR team meetings, implementation of injury prevention/community interventions, and reimbursement for training costs to certify Child Passenger Safety (CPS) technicians if no CPS technicians are available to that community.

 

Beginning in February 2018, MCH began evaluating and improving program structure for the CFR program. During this evaluation, the CFR nurse found:

• Coroner turnover and LHD CFR coordinator turnover greatly impacted the timeframe of review, knowledge of review, and reporting requirement knowledge
• 78 counties reported the death on forms to the state MCH program, but did not conduct formal child death reviews
• 5 counties and 1 district had strong, quality child death reviews
• KRS governing child death review has permissive language for child death review, as called by the coroner, and most coroners were not actively participating or leading a review team

 

During the assessment, the nurse consultant began collaborating with KIPRIC, DBHDID suicide coordinator, KY Chief Medical Examiner, and KDPH to conduct intensive training with local coroners at the KY New Coroner Training, Coroners Convention, and LHDs at sites across the state. During 2018, the CFR program worked closely with over 60 counties to build strong review teams and provide education. In 2019, this count rose to 100 counties having review teams organized.

 

In 2019, an additional CFR nurse consultant was added to help with facilitating local reviews, training coroners and other team members, and developing a data surveillance system to capture the outcomes of the CFR teams. In 2016, 37.7% of child deaths had a local review completed. With the increase in teams and state support, 96.8% of CFR cases were reviewed by local teams in 2018. In addition, MCH identified more cases for referral to the Child Fatality and Near Fatality External Review Panel for suspected child abuse or neglect. Following data reflect the number of cases referred to the External Panel by CFR program: 9 cases in 2016; 13 cases in 2017; 16 cases in 2018, and 41 cases in 2019.

 

Publication of the annual Child Fatality Report occurs 2 years after date of death, as data from the Office of Vital Statistics is preliminary. For 2017, there were 601 child deaths in KY. The KY mortality rate of 59.4 deaths per 100,000 children exceeded the US rate of 49.8 deaths per 100,000 children. Child deaths occurred in two groups: infants (less than one year of age) and children (1-17 years of age). Infant deaths comprised 62% of all child deaths. Eighty-six percent (86%) of infant deaths are non-injury related, and 60% of child deaths are due to injuries.

 

The five leading causes of infant mortality in 2017 were prematurity related conditions, SUID, birth defects, perinatal conditions, and homicide. There were 370 infant deaths (6.8 deaths per 1,000 live births) in 2017. The rate is approximately 15% higher than the US rate (6.4 deaths per 1,000 live births).

 

Infant mortality rate in black infants (10.7 deaths per 1,000 live births) is almost twice as high as the infant mortality rate in white infants (6.4 deaths per 1,000 live births). Prematurity-related conditions were the leading cause of infant mortality in KY, increasing by 6% since 2016. Nationally, prematurity is the second leading cause of infant mortality. The number of sudden unexpected infant deaths in KY decreased from 101 in 2016 to 82 in 2017. Ninety-five percent (95%) of these deaths had at least one unsafe sleep factor noted from case investigation, re-enactment, and record review. Birth defects contributed to approximately 20% of infant deaths (1.5 deaths per 1,000 live births). Nationally, birth defects are the leading cause of infant mortality.

 

The five leading causes of child mortality in 2017 were motor vehicle collisions, homicide, suicide, cancer, and birth defects. There were 231 deaths among KY children 1-17 years of age. (24.2 deaths per 100,000 children) in 2017. The rate is approximately 18% higher than the US rate (20.5 deaths per 100,000 children).

 

Black children are 1.7 times more likely to die than white children. The mortality rate among black children in KY was 37 deaths per 100,000 children compared to 21 deaths per 100,000 white children. Child deaths due to motor vehicle collisions have declined by 39% since 2005. However, collisions remain the leading cause of injury-related death and are highest among children 15-17 years of age, which is consistent with the nation. The number of childhood homicides in KY increased from 20 in 2016 to 34 in 2017. Approximately 50% of these homicides occurred by a firearm. Suicides contributed to approximately 10% of child deaths, with over 50% occurring by use of a firearm.

 

Prior to 2017, primarily counties with large populations conducted the reviews to discuss case details without a broad interest in trends, gaps, and prevention efforts. The focus of the CFR Program has been developing relationships with CFR Coordinators and Coroners to educate about the program and obtain their voluntary cooperation and leadership to develop local teams to review the cases. The CFR Program is at the point of working with the teams to obtain quality reviews to develop targeted prevention efforts in an attempt to thwart another child from death due to preventable injury.

 

Other data points of consideration are for child deaths are:

 

Homicide:

• Child homicide deaths are the highest rate since 2012.
• Child homicides increased from 20 deaths in 2016 to 34 deaths in 2017.

• Firearms along with child abuse and neglect were the primary mechanisms for child homicide.
• Homicide by firearm is highest among children 15-17 years of age.
• Homicide by child abuse and neglect is highest among children less than 5 years of age.

• Black children are more likely to die from homicide (9.2 deaths per 100,000) compared to white children (2.4 deaths per 100,000).

 

Suicide:

• Child suicides nearly doubled from 2014 to 2015 and continues to remain high with 24 suicides in 2017.
• Over half of child suicides involved the use of a firearm.
• Suicide by firearm is more prevalent among children 10-14 years of age (67%) compared to children 15-17 years of age (60%).
• Sixty percent (60%) of suicides among children 15-17 years of age are firearm-related and the remaining 40% are related to hanging/strangulation.
• White children die at a greater rate due to suicide (2.5 deaths per 100,000) compared to black children (1.8 deaths per 100,000).

 

Drowning:

• An average of 12 children die annually from unintentional drowning.
• 58% of the 2017 drowning deaths occur among children under 5 years of age.
• Tub drownings are highest among infants.
• Pool drownings are highest among children 1-4 years of age.
• Natural water drownings (e.g., rivers, lakes, creeks) increase with age of children.

 

Poisoning:

• Poisoning deaths are low with only two child deaths in 2017.

• Poisonings are not isolated to young children.

• In 2017, all childhood poisoning deaths occurred in children 15-17 years of age.
• Poisoning deaths were related to drug/alcohol overdose.

 

Fire:

• There were three child deaths related to fire in 2017.
• All of these fire-related deaths occurred among children under 5-9 years of age.

 

This program has built internally many strength-based processes in communications and community resources with local coroners, school systems, LHDs, and providers. Besides building promotion activities to reduce child near fatalities and fatalities, LHDs work as collaborative partners with many agencies or organizations to effect change on the local level. The following are two examples of great outcomes from local CFR team in-depth reviews of child fatalities. With the State CFR guidance, a local CFR team identified an area of concern on a roadway where motor vehicle collision occurred, the area of concern referred to KY Department of Highway Safety (KDHS). Upon further review of the previous three-year average, there were 18 MVCs per year in the area of concern. KDHS assessed area of concern brought forth by the CFR Program. KDHS implemented measures (application of traction surface) to make area safer. No accidents reported in area of concern since the resurfacing project in 2018. Another local CFR team lost two kids in a house fire in June and in September had a Community Safety Day (with collaboration of multiple agencies) and installed smoke detectors in many homes. As with any prevention efforts, it is unknown exactly how many lives saved (adults and children) from prevention efforts of our local teams that function with very little budget.

 

Early Childhood Obesity Prevention

 

Obesity and overweight remain a significant public health problem in KY. Due to the health risks associated with long term overweight and obesity and the impact on child development, obesity data remain concerning. Obesity reduction goals focus on education of healthy nutrition and activity beginning in early childhood to build healthy behaviors and promote these behaviors throughout the lifespan. Activities include training for caregivers in environments in which children spend large portions of their day and consume many of their daily meals.

 

Since 2012, MCH has promoted the 5-2-1-0 public awareness:

• Five: Eat five or more servings of fruits and vegetables daily
• Two: Limit screen time to no more than two hours daily
• One: Be physically active at least one hour daily
• Zero: Do not drink sweetened beverages

 

Designed for parents, early childhood professionals, and healthcare professionals, the campaign specifies a memorable method for caregivers to talk about key evidence-based behaviors and encourage parents to adopt obesity prevention strategies for children. The KDPH, KY Chapter of the AAP, and Foundation for a Healthy KY helped to establish the campaign. To support community agencies and technical assistance providers in sharing information about the behaviors, MCH developed a toolkit. The 5-2-1-0 campaign will continue through the next year.

 

Childcare health consultants (CCHCs) provided information and education for the campaign and other measures for obesity prevention through face-to-face visits, consultation, newsletters, and outreach to local childcare centers across the state.

 

In FY2019, the Healthy People, Active Communities Package was selected by 27 LHDs. Work in this package continues to be innovative and relies heavily upon community engagement to promote engagement of adoption of healthy behaviors for nutrition and activity. LHDs participated in local health coalitions, performed walkability studies of their communities for planning purposes of walking paths, and implemented media campaigns and other physical activity plans.

 

In KY, young children are cared for in many settings including Head Start, Public Preschool, and regulated childcare. Each setting has different strategies and goals to address the child’s needs and support the family such as:

• School readiness
• Wrap-around services with more intentional health screenings
• Support parent employment or ability to attend school

 

Additionally, the various childcare settings have different state agencies governing them and different regulations may apply to the various settings. Any effort to improve the health environments of young children in care in KY requires intentional collaboration between agencies and solidifying strategies that align with the goals for these agencies.

 

Currently, KY has licensed childcare centers that mirror the minimum nutrition practices set by the Child and Adult Care Food Program (CACFP) and limit screen time for children based on national benchmarks. Although these guidelines ensure basic needs are met, KY’s children deserve more.

 

While research links optimal nutrition and physical activity with brain development and long-term health outcomes, these behaviors are not a consistent value among early care professionals, agencies, or technical assistance providers. KY has made progress increasing awareness of the impact and importance of health behaviors in young children through the 5-2-1-0 campaign, social media/blogs, and the Nemours Early Care and Education Learning Collaboratives.

 

The obesity program at the state level continues to support web trainings about:

• 5-2-1-0 Toolkit
• Staff Wellness in ECE
• Getting Kids Moving: Physical Activity in ECE
• Engaging Families Using the KY Strengthening Families Protective Factors: Focus on Healthy Behaviors
• Creating a Supportive Environment for Breastfeeding in Childcare
• Nurturing Healthy Eaters in Early Childhood Education

 

The strengths of this program are based upon the ability to engage early childhood caregivers to promote healthy behaviors at the youngest ages. Turnover at the program level make awareness and education on the importance of child health a continuing challenge.

 

KY Strengthening Families Initiative

 

In a more socio-ecologic, preventive approach to injury prevention, specifically child maltreatment prevention, MCH Title V is leading the KY Strengthening Families (KYSF) initiative in collaboration with the Governor’s Office of Early Childhood. KY’s initial focus is children prenatal through five years and their families and follows a collective impact model, similar to the CDC “Safe, Stable, and Nurturing Environments” work. KY is an affiliate of the national Strengthening Families Network, which is a research-based framework of protective factors for child maltreatment prevention. KY’s initiative is somewhat unique, in that KY developed a cross-sector, cross-agency, public-private framework so that families will be supported in strength-based environments no matter what systems or child-serving agencies they access within their community. It is an intentional approach to systems change and common messaging among all child-serving agencies to respond to the science of toxic stress and early brain development. MCH is raising awareness of ACEs and toxic stress and is laying the groundwork for why Strengthening Families and building protective factors are critical to children’s health and well-being.

 

In April 2017, the KYSF Initiative hosted a KYSF Summit for agency and community teams to create action plans for implementing the initiative. In September 2017, the Early Childhood Advisory Council (ECAC) approved the KYSF Leadership Team to serve as the ECAC Family Engagement Subcommittee. In January 2018, the KYSF Leadership Team developed a two-year strategic plan that included the integration and development of the Youth Thrive initiative, which compliments the KYSF Protective Factor Framework with having Youth Protective Factors for youth 9 to 26 years old.

 

KYSF workforce had many transitions. As of midyear 2020, this program has one opening. In the past year, this team (with the new parent/family representative) has begun planning for the parent advisory council and supported training for HEART engagement and evaluation plans.

 

 

 

 

Help Me Grow Developmental Screening

 

Although KY did not choose the NPM for developmental screening, MCH worked with the KY Chapter of the AAP to implement “Help Me Grow,” an evidence-based, national program model for promoting developmental screening. The KY Help Me Grow model has been implemented in a limited capacity in KY secondary to lack of MCH funding and workforce resources. Help Me Grow KY (HMGKY) continues to work with four pediatric practices, two childcare centers, and one local health department.

 

Metro United Way’s Ages and Stages Program has become an affiliate of HMGKY and assistance has been provided to the pediatric expansion program.

 

Tobacco Use

 

Broad goals for tobacco cessation and prevention are to prevent initiation of tobacco use among youth and young adults, promote tobacco use cessation among youth and adults, eliminate exposure to secondhand smoke, and identify and eliminate tobacco-related disparities. Efforts are targeted to NPM 14.2) Percent of children, ages 0 through 17, who live in households where someone smokes. Specific strategies to achieve these goals include:

• Increasing the use of smoking cessation therapy
• Supporting tobacco-free schools, campuses, and communities

 

The Tobacco Prevention and Cessation Program was part of a CHFS reorganization moving it to the Division of Prevention and Quality Improvement in December 2018. Ongoing collaboration and efforts continue regardless of reorganization as both divisions mutually work toward reduction of tobacco use.

 

A statewide 100% Tobacco Free School (TFS) bill proposed during the 2017 and again in 2018, but legislative session failed. In 2019, the bill was signed into law. This new law will prohibit the use of tobacco products by students, school personnel and visitors in schools, school vehicles, properties, and activities beginning in school year 2020-21. Several cities have strengthened their already existent partial smoke-free laws in 2018.

 

In 2019, eight LHDs chose the MCH Evidence Informed Strategy, 100% TFS for their community. Local health departments provide assistance to local Boards of Education in passing and implementing 100% TFS. The package supports collaboration with appropriate student groups and distribution of survey results and information about policies to key stakeholders. When policies are adopted, this package can also be used to assist with implementation of the policy. To date LHDs have provided education to 4,156 community stakeholders.

 

Adverse Childhood Experiences

 

Recent data released for KY has shown KY children and families have higher ACEs scores than seen nationally. Per the ACEs study, the higher the ACEs score is, the greater the risk for poor health outcomes later in life. Some ACEs information shown here is from the 2018 National Survey of Children’s Health as it relates to children in KY.

 

 

Children in KY (15.3%) as young as 0-5 years report two or more adverse family experiences. This percentage increases with age to 31.9% of children 12-17 reporting adverse family experiences. These rates for KY are under in-depth review as suicide rates for children as young as 10 years of life are rising, and more children have been placed in outside home care secondary to NAS, abuse, and neglect. Comparatively, over 80 percent of children have reports of living in homes demonstrating positive resilience responses, to all or most of the time, to all four items on the survey.

 

 

The ACES and epigenetics helps explain the multigenerational issues related to poor outcomes and why the KYSF leadership team is promoting the “two generations” approach. Audiences have been eager to receive this information and have included Kids Are Worth It, Early Childhood Institute, Behavioral health staff, Administrative Office of the Courts statewide meeting, Family Youth Resource Service Centers, the Early Childhood Advisory Council, the State Interagency Advisory Council (SIAC) for Children with Emotional Disorders, HANDS, Community Early Childhood Councils, and many smaller organizations.

 

Building resilience is the primary work process for improving ACEs outcomes. This need must become part of the strengthening families framework promoted in all work within MCH programs. A major challenge to improving outcomes for children in KY is the emerging issue of the number of children experiencing ACEs and the need to address them at the earliest age identified. These potentially traumatic events can have a lasting impact on the physical and mental health of an individual.

 

Inherent, in the KYSF cross-agency approach for integrating protective factors into systems, are a number of challenges as each agency has its own constraints and specific purposes. Evaluation of this cross-agency, multi-layered effort is also challenging, as measures and measurement are quite different across agencies and depend on whether agency outcomes, front-line staff changes in behavior, or outcomes for families are measured.

 

Childhood Lead Poisoning Prevention Program:

During 2019, the KY Childhood Lead Poisoning Prevention Program undertook a needs assessment that identified barriers encountered by local health departments when dealing with lead poisoning cases. The main issue identified was a lack of adequate training and guidance for health department staff about childhood lead poisoning causes and appropriate interventions. Each of KY’s 120 counties are responsible for handling case management of any child under 6 years of age who has a confirmed blood lead level greater than or equal to 5μg/dL. This comes out to around 150 local health department environmentalists and nurses across the state that require a comprehensive understanding of childhood lead exposures. To address this barrier, the KY Childhood Lead Poisoning Program is working toward conducting a series of trainings across the state. These trainings will cover every aspect of lead from what it is and where it comes from to how they can help families control and mitigate known exposures. In addition, all materials, including educational materials, are in the process of being reformatted based on local health department feedback obtained through this needs assessment.

 

In years past, the only known high-risk regions for childhood lead poisoning included Jefferson County and Northern KY Health Department District. As part of the needs assessment, additional high-risk regions were identified based on the number of active childhood lead poisoning cases in a given region. This expansion includes Green River District, Christian County, Madison County, and Lake Cumberland District. Additional childhood lead poisoning prevention funds were allocated for these newly identified high-risk regions. Community-specific outreach campaigns will be coordinated in the coming year in an effort to spread lead poisoning prevention awareness to KY’s high-risk populations.

 

Oral Health:

The final NPM KY has selected for this domain is NPM # 13: Percent of children, ages one through 17, who had a preventive dental visit in the past year. While this NPM was moved to the child domain, work completed by the KY Oral Health Program (KOHP) promotes improved health outcomes across the lifespan.

 

Community Fluoridation Program:

The Community Fluoridation Program works with municipal and private water systems to assure compliance with KY’s statewide law that requires fluoridation at optimal levels to reduce decay rates in the state. KY has the highest rate of municipal system customers having optimally fluoridated water than any other state in the country.

 

Fluoride Varnish Program:

Fluoride varnish and the application of dental sealants are preventive health strategies used to improve outcomes for children residing in areas of the state lacking access to pediatric dentists and Medicaid providers. To improve access to care, LHD public health registered hygiene programs or LHD contracted dentists screen, place sealants, or treat patients in these areas. This program assures linkage to a dental home in the community for any higher-level dental needs. The target audience for this outreach is children that do not have a payment source for sealants and are under 300% FPL.

 

Ongoing training in dental development and disease prevention is provided to public health nurses throughout the state annually to assure competence with assessment and treatment. The cost of fluoride varnish and treatment is a reimbursable service through Medicaid. Since inception of the program, fluoride varnish has been recognized as a primary oral health preventive service. KOHP provides fluoride varnish education for interested primary care providers, or pediatricians, and encourages them to perform an oral health screening with application of fluoride varnish during well child exams if the child is not seen/followed by an oral health provider.

 

The MCH fluoride varnish package had 19 LHDs opt to provide outreach activities, train RNs to establish school based varnish clinics, and perform quality assurance for fluoride varnish and education activities. In FY19, this package has reached 10,476 community members.

 

KRS 156.160 requires all children entering public school to have a dental assessment. The training provided by KOHP ensures nurses are prepared to complete this screening. In collaboration with KOHP, KDE adopted the Smiles for Life Curriculum for training school district nurses to complete prior to performing these dental assessments. Despite a requirement for screening, about 50% of children entering school report a dental assessment.

 

Public Health Dental Hygiene Program:

To improve access to care in rural and underserved areas of KY, KRS 313.040 established a special licensure category for public health registered dental hygienists (RDH) expanding the scope of preventive dental work performed by the RDH without requiring the presence of a dentist on site. This expanded scope allows the public health RDH to provide preventive dental services to healthy children who may be at high risk for dental disease. KY has nine public health RDH teams serving underserved areas providing a comprehensive range of primary preventive services with a clinical focus on the placement of sealants on erupting molars and linkage to a permanent oral health home. Since program inception in 2014, these programs have an 83% success rate of provision of comprehensive dental treatment to these high-risk patients.

 

The success of the public health RDH teams is published the annual report of the Centers for Medicare and Medicaid outlining clinical experience of Medicaid children relative to dental services (CMS 416 Report). Based on the FY2017 data, KY RDH programs provide preventive care for 4.2% of all of the preventive dental care in the state, serving 29 of 120 counties. Secondary to changes in records management, data from 2017-2018 is limited. Preliminary data from 2019 appears decreased. This may be because LHDs elected to stop participation in the program or because they are transitioning services to a population health model.