COVID-19

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. 

The COVID-19 crisis posed challenges to families whose lives were adversely affected. A challenge faced by many families with children is related to school closures and distance learning as only 54% of households in PR have access to the internet and 62% have a computer at home.  Another challenge for many working parents, especially those with low-income, is that they were unable to work from home as they have jobs that require their presence in the workplace.  A third challenge relates to food insecurity due to income loses that forced more families to enroll in the Nutritional Assistance Program (NAP).

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 2020-2021 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. 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 2020-2021 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 incidence of positive PCR testing in children younger than 10 years was 28 cases per 1,000 children (Data from PRDOH COVID-19 vigilance, July 2020 to June 2021).

Promoting preventive health visits

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. 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.

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.

In 2021, 38.5% 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. This percent was similar as compared to the 2020 report of 39%, but less than the reported in the 2019 report of 58%. This continues to reflect the impact of the COVID-19 on outpatient clinical services. Most parents postponed their children medical visit due to the concern of get infected with the COVID-19.

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.

 

 

 

 

 

 

 

 

 

  Percent of New Patient Preventive Visits by Age Range

  Based on Billing Data Classified by ICD-10 Code and Insurance Type,

  2020-2021

 

 Percent of Established Patient Preventive Visits by Age Range

 Based on Billing Data Classified by ICD-10 Code and Insurance Type

 2020-2021

* Percent of visits calculated using the number of billing services divided by the number of insured participants eligible services with a private health insurance

** Percent of visits calculated using the number of billing services divided by the number of insured participants eligible services with a government health insurance

***Average percent of visits using the number of billing services divided by the number of insured participants eligible for services with a private health insurance and government health insurance.

 

 

 

 

 

 

Licensed Physicians registered in the PR Medical

Licensing and Disciplinary Board from July 2020 to June 2021

 

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 PRHIA reported that for 2020-2021 there were 704 Pediatricians (including subspecialists), 397 Family Physicians, and 2,519 General Physicians 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 157,770.

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

During 2020-2021, 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 to 11 y/o and 72.8% in the MCH-Jurisdictional Survey for 2019, stated that their child was in excellent or good health. Data for the PR Behavioral Risk Factor Surveillance System for 2017 showed that 86% of parents reported their child had a preventive service visit in the last year.

MCAH staff strives to increase the 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 2,916 families reached during 2020-2021.

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 11.0% of children between the ages of 2 to 5y/o participants in the PR WIC program (2020-2021). 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. Obesity is a risk factor for many of the common chronic diseases related to mortality and morbidity.

During 2020-2021 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 2020-2021 due to the COVID-19 pandemic, there were few courses delivered. Only 6 courses consisting of 4 sessions on Responsible Parenting 0 to 5 y/o were provided throughout the Island by HEs and CHWs. Of a total of 18 participants registered, 15 completed all 4 sessions, 89% females and 11% males. The following tables summarize the comparison and outcome of the average pre and post test scores, by session.

 

 

 Average Pre and Post-Test Scoring in Sessions of the

 “Responsible Parenting Course 0 to 5 y/o”, 2020-2021

 

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 HEs and CHWs, Responsible Parenting 6 to 11 y/o, had 51 participants, 96% females and 4% males. A total of 23 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).

 Average Pre and Post-Test Scoring in Sessions of the

 “Responsible Parenting Course 6 to 11 y/o”, 2020-2021

 

   Other Parenting Orientation Provided by the HE and CHW, 2020-2021

 

Additional orientations related to nutrition and physical activity were delivered to 298 participants by the CHWs and HEs in educational activities in the community during 2020-2021. 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. 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.

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 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 was in the process of recovery. In December 2020, the PR Immunization Program launched a new electronic system for immunization data, known as the PR Electronic Immunization System (PREIS). This system replaced the PRIR and was primarily used to collect the COVID-19 immunization data but also to continue the recovery process of the data collected previously in the PRIR.

The following graph shows the estimated vaccine coverage of children 0 to 24 months of age for the years 2018 to 2020. This data was presented in a virtual meeting of the Immunization Program, held on April 26, 2022. Data for 2018 represents those recovered in the PREIS and 2019, 2020 shows the results of the PR National Immunization Survey.

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 85.4% of children had up-to-date immunization coverage (data for 2020-2021).

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 updated every year based on recommendations of the CDC and the Advisory Committee on Immunization Practices (ACIP). Despite schools remaining closed in 2020, families were 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 centers registration in Puerto Rico, and its prevalence has been much lower, a 5% prevalence of influenza immunization for 2020-2021 for population registered in the 6 months to 17 years old age range (an estimate of the data that has been recovered). MCAHD 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. 

PR Pediatric Mortality Rate for 2020 was 10.3 per 100,000 children ages 1 to 11 years and 10.0 for the ages from 1 to 14y/o. Lower in comparison with 2019 (11.9) and the US Pediatric Mortality Rate of 16 per 100,00 children ages 1 to 14 in 2019 (Data Provided by National KIDS COUNT). The unintentional injury death rate was 1.6 per 100,000 (1-11 y/o) in 2020, and it continues to be the first cause of death in this population.

 

Mortality Rate in Children by Age Group, Puerto Rico, 2018 - 2020  

         NVSS Data, 2018, 2019 and 2020

 

 

 

 

 

 

 

 

Death Rates by Unintentional Injuries, Puerto Rico, 2019 - 2020

           NVSS Data, 2019 and 2020

 

Causes of Death in Children between 1 t

o 14 y/o, Puerto Rico, 2019 and 2020 

     NVSS Data, 2019 and 2020

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 1,094 calls for children between the ages of 0 to 9 y/o and 187 in infants less than 1 y/o during 2020-2021. These findings support the need to continue to orient parents and caretakers in adopting the preventive measures at home.

 

 

 

 

 

 

 

 

 Puerto Rico Poisson Control Call Center Report 2020-2021

    Distribution of Substance Exposure by Age Group

 

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 2020-2021, one fatality and 313 non-fatal injuries related to incorrect use of car seats or seat belts were reported in minors of 10 years old.

Non-fatal injuries to passengers in motor vehicle crashes, 2020-2021

    Data for the Administration for Car Accidents Compensation (ACAC 2020-21)

Besides the parenting courses the CHWs and HEs 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). 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. These initiatives were coordinated with the collaboration of stakeholders. During 2020-2021, Health Insurance Commissioner Office (HICO) data reported 11,957 (5.0%) 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 2020-2021, 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 2020-2021, a total of 734 (<12 months old) and 1,535 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. Eighty-four (84), which represents a 3.7% 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.

 

 

 

 

 

 

 HPV Pediatric Participants Screening Results of ASQ-3 and ASQ:SE-2 during  

  2020-2021     

 

The total number of screened represents multiple screening of children following the HPV schedule:

 HPV Referrals for Services due to Positive ASQ Screenings not Completed

                       2020-2021

 

    Referral age for HPV participants with a High-Result on ASQ

                and ASQ-SE Screening in 2020-2021

 

8 were identified prior to their 13-month birthday allowing for a very early referral.

 

 

  Distribution of ASQ and ASQ-SE with a high-risk results in

              HVP Participants Screening, 2020-22021

 

Of 84 screenings with a high-risk result, 72.6% 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.

 

 

 

 

Data relevant to Oral Health Care in Pediatric Population of Puerto Rico

 

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 2020-2021 PR Health Insurance Commissioner Office (HICO) reported that 26.5% of pregnant women had a preventive dental visit signals the existing need to educate pregnant women and caretakers of infants. During 2020-2021 the CHW delivered orientation on prenatal oral care to 315 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 2020-21 the HE’s delivered oral care education in activities reaching 37 participants, among them 33 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 5.2% (6 to 14 y/o age range) and the PR HICO reported 6.4% of billing for sealants (5 to 14 y/o range) during 2020-2021.

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 2020-2021 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 81.  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 2017 storms, 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.

 

 

 

 

 

HVP Infant Caries Risk Screening Results and Outcomes (2020-2021)

 

Of the 1,251 screenings for high early childhood caries risk done in 2020-2021 to participants of the HVP between the ages of 6 to 12 months old, 72% had a high-risk result. Of the cases referred for a dental home appointment 63% were in process that was delayed due to the pandemic restrictions and 26% 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.