The MCAH Program has identified improving preventive health in children as a top priority, for which it will continue to focus its efforts on promoting: preventive dental and pediatric visits, healthy lifestyles to reduce the risk for childhood obesity,  increased on-schedule immunization compliance,  decreased unintentional injury,  prevention of child abuse and neglect, increased early childhood developmental screening and early developmental stimulation, quality child care, child emotional wellbeing and prevention of COVID-19 infection. PR MCAH will also continue to collaborate in the development of recommendations to improve preparedness and recovery plans of the PRDOH and other emergency response agencies with emphasis in advocating for the needs of children.  

In the presence of the COVID-19 pandemia, MCAHD will continue to deliver some of its programs and initiatives with modifications to provide infection control and prevention, including virtual meetings, digital chats, telephone communications, and modification of courses and orientation into virtual formats. Other MCAHD programs have begun in person interactions in small groups adopting social distancing, face mask, hand washing and avoiding the inclusion of persons at risk of exposure or suspected with COVID-19. 

The MCAHD will continue attentive to updated recommendations and instructions provided by the PR DOH and the CDC relating to COVID-19 and any other emerging public health emergency, sharing this information with all the staff to protect the workforce and to initiate strategies to help guide the population for an effective public health response.  Most of the staff has received the COVID-19 vaccine, but will continue to use face mask, hand washing and surface disinfection to prevent the spread of infection for as long as the Department of Health and the CDC recommend it.

The PR MCAH staff will continue working in close collaboration with all MCAH stakeholders that share similar aims.  Most of the meetings for collaboration will continue via digital telecommunication and will be restituted after the threat of COVID-19 is under control.

COVID-19

During the shutdown ordered to prevent and control COVID- 19 spread schools and day care centers were closed. Children remained at home with virtual education under the direct supervision of their parents. The families faced changes in their routines with additional stress due to the social isolation imposed by the shutdown and quarantine.  Return to in person schools is beneficial for the emotional wellbeing and developmental process of children, but it requires school preparation and outweighing the benefits versus risk for COVID-19 infection and transmission. The guidelines for reopening schools developed in July 2020 with the contribution of the Pediatric Consultant, were reevaluated and shared with the incoming administration in January 2021.These guidelines were considered to evaluate school’s readiness to reopen along with the daily epidemiology data compilated of COVID-19 cases in PR. Despite relaxation of restrictions to business and incoming tourism since January 2021, schools have remained virtual until May 2021.   This decision considered the fact that in April 2021 Puerto Rico had a surge in positive COVID-19 cases and hospitalizations, with a concerning increase in pediatric patients hospitalized and requiring Pediatric intensive care.  Schools are preparing and adopting recommendations to be able to open in August 2021 and hoping vaccination for younger than 16 y/o is soon approved.

Day care centers have opened, implementing COVID-19 prevention protocols. In PR HS and EHS have also remained virtual, although they are in the process of adopting all the PRDOH COVID-19 infection and control prevention protocols to open once authorized.

Due that COVID-19 is a novel virus, much about its signs, symptoms, diagnosis, and treatment was initially unknown. Experience and collected data have helped define it better and treatments have evolved. The vaccine efforts, which in PR began in December have helped create a population at lower risk, elderly and first responders and in April 2021 vaccination was extended to all the population at higher risk due to chronic disease until 16 years old. The MCAH staff will continue to collaborate with stakeholders in the promotion of COVID-19 vaccine for the pediatric population when the vaccine is available.

We will also continue to collaborate with stakeholders in providing updated infection and prevention control guidelines in Spanish for the primary care offices and general population based on the recommendations of the CDC, AAP, and the PR DOH.  

Promoting Preventive Pediatric Health and Dental Visits

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.  Families with newborns were recommended to visit their pediatricians in person, following the office protocols established to protect both staff and families.  As physicians and dentists realized that the crisis was becoming extended, they made physical modifications in their offices and adopted modified protocols to provide in person visits, in a safe in-person experience for the families and the staff. Annual preventive visits require a physical exam which cannot be replaced by a telemedicine visit. MCAHD staff will continue to promote that families continue contacting 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.

Oral Health

Oral health contributes to overall health and wellbeing, yet caries remains the most prevalent chronic disease of childhood, with an impact on oral health throughout life. Therefore, promoting oral health from infancy contributes to the individual’s well-being and development in subsequent years and life stages (school years, adolescence, and adulthood). The MCAHD will continue collaborating with MCAH stakeholders to advocate for dental services be provided at very early ages, since eruption of first tooth and continued dental coverage in the PR GHP. The MCAHD will strengthen work in oral health with existing partners to better coordinate educational and oral care services and referrals.  A webinar on Evaluation and promotion of children's oral health in the primary care office was cosponsored by the PRAAP Chapter and the MCAHD with 248 participants. The use of the Infant Carries Risk assessment and early referral to a dental home to prevent early childhood caries was promoted.

The Pediatric Consultant is a collaborator with the PR Territorial Dental Officer from the Health Promotion Division and other oral care stakeholders in a group working on improving oral health outcomes. In 2017 Law 63 was approved, stating the requirement of an oral exam certificate for minors prior to being enrolled or admitted in private or public school to kinder garden, second, fourth, sixth, eight or tenth grade.  The group will continue to promote its implementation and monitor the response.

During 2018 the PR Pediatric Preventive Health Care Services Guidelines (PR PPHCG) were updated, adding the most recent Bright Future recommendations of Early Childhood Caries Risk Screening of infants at 6 and 9 months and early referral. During 2021 these guidelines will be revised and updated in a collaborative effort with pediatric care experts. The MCAH Program will continue disseminating the PR PPHCG, and preventive dental visits twice a year (after the eruption of the first tooth) for infants, children and adolescents. The Program will advocate for the adoption of fluoride varnish as a preventive strategy for infants and young children at high risk for caries. This is a cost-effective strategy recommended by the AAP Bright Futures, reaffirmed in 2017.

The MCAH pediatric consultant will also continue promoting and collaborating with EHS and HS in the implementation of the infant at high risk for caries screening tool and referral for the early establishment of a dental home. The MCAH regional staff will also continue to deliver educational activities, following all the protective protocols, in the community promoting prevention of ECC and the establishment of a dental home for all the pediatric population. 

The MCAH staff will continue to implement multiple strategies to promote good oral hygiene and regular preventive dental check-ups. The Program will continue to deliver orientation on dental decay and oral disease to families, children, adolescents, pregnant women and the general public in an effort to increase awareness of the risks to overall health and wellbeing and how preventive oral hygiene, healthy oral habits, and preventive dental visits contribute to a better overall health.

All educational activities will continue to be delivered through modified workshops, presentations, work groups, and one-on one education. The HVP will continue to administer the caries risk assessment to infants and refer participants to preventive dental visits.

The Positive Parenting Courses (for parents of children 0 to 5 years old and 6 to 11 years old) will also continue to include education on the risk for dental caries. Participating parents will receive strong advice to instill healthy oral habits in their children from early childhood, as well as information regarding GHP coverage for dental visits for their children, and how to request this service. More importantly, it will encourage the involvement of families in promoting healthy oral habits, establishing a dental home, and oral health literacy in communities.  The Metropolitan Region MCAH Regional Board will continue to focus their collaborative efforts on promoting strategies for oral health in infants, children, adolescents, pregnant women, and women in reproductive age.

The HVP, HCW and HE staff will continue to receive training to update knowledge on oral care in pregnant women, WRA, infants and children to increase their skill in delivering information and evaluating risks.

Preventive Health Visits

The promotion of the PR PPHCSG will continue to be advocated by the MCAHD at all levels: providers, providers training programs, providers associations, community, families, and parents. Disseminating the PPHCSG to the public empowers parents on what to expect in preventive visits. Promotion will include orientation of modifications adopted by primary care offices to ensure patient safety during the COVID-19 crisis and to boost the trust of the population in returning for preventive care.

The content of the guides also needs to be known by academia, health care professionals, and the insurance companies, so each can do their part to support their implementation and improve the quality of preventive services. The MCAH staff will continue to encourage including the use of the PR PPHCSG in the continuing medical education of providers, especially by pediatricians’ professional associations in PR.

In their interventions, the HVNs, CHWs, PNs and HEs will continue to educate parents and promote scheduled preventive visits and screenings as recommended in the guides. The importance of preventive health care services for the wellbeing of children will continue to be emphasized in the Positive Parenting Courses (0 to 5 years old and 6 to 11 years old). 

The MCAH Program will continue to evaluate the use of clinical preventive services by the population to identify gaps and strategies to overcome them in collaboration with other stakeholders: agencies and professional organizations.

Promoting Physical Activity and Reducing the Risk for Childhood Obesity

MCAH staff will continue to encourage the inclusion of strategies that help improve nutritional habits and increase the time dedicated to physical activity of children according to ages, to reduce the risk of obesity. The MCAH staff will continue to educate participants regarding physical activity, breastfeeding, healthy eating, and compliance with the recommendations of My Plate (culturally and   linguistically adapted) during their home visits and in community based educational activities.

The Positive Parenting Course for ages 0 to 5 and 6 to 11 years old will continue to stress healthy nutritional choices and daily physical activity for children and their families. The Positive Parenting Courses include AAP recommendations for children ages 6 and older, to place consistent limits on the time spent using media, the types of media, and to make sure media use does not take the place of adequate sleep time, physical activity and other behaviors essential to health. Parents will also receive orientation on the obesogenic effect of consuming high calorie snacks with low nutritional value and 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. The MCAH staff will also continue to promote the exchange of water instead of high-calorie sweetened beverages in purchased meals as mandated by Law 256 of 2015. Brochures developed with culturally adapted simple language will reinforce the messages delivered during orientations to families in the community, in the Positive Parenting courses, the prenatal courses, and in the Home Visiting Program.

The Secretary of Health approved the final recommendations developed for Infant and Young Child Nutrition (0 to 24 months), and they have been adopted as public policy by the DOH. In 2021-22 these recommendations will continue to be disseminated among health care providers for use in anticipatory guidance to families with infants. These recommendations will also be used to stimulate families to adopt better eating habits, develop skills in perceiving infant satiety and hunger cues, and learn the proper introduction of solid foods in infancy. MCAHD will collaborate in the development of educational materials at an appropriate literary level and culturally sensitive for the population served and in the dissemination of the material.

Promoting On-Schedule Immunization

Basic hygiene habits that deter the spread of respiratory viral infections was reinforced by all MCAH staff in their interventions in the communities with the emergence of COVID-19 as a public health emergency. In addition, the PR MCAHD will continue to provide accurate and reliable information to families on contagious diseases and promoting immunization as recommended in the CDC itinerary through educational initiatives in the community. The staff is vigilant for the identification of any cases of measles, influenza, or corona virus in the population they serve, and informed on what actions to implement in order to protect themselves and the health of the most vulnerable and recommend strategies to deter further spread of the disease.

During 2021-2022 HVNs, HEs, PNs and CHWs will continue to promote immunization on schedule, with emphasis on updated schedules for children under 24 months of age. The HVN’s have continuous access to vulnerable families, allowing identification of barriers to immunization, such as those related to the vaccination system in the health care centers. This information will continue to be shared with the Puerto Rico Immunization Program (PRIP), enabling them to propose strategies to overcome them. The topic of immunization is also included in the Positive Parenting Course. VOCES is a nonprofit organization that offers education about immunizations to health care workers and the general population. The MCAH staff will continue to collaborate with them in their annual conference and providing advice for the development of strategies to promote immunization and educational interventions.

In May 2021, a Facebook live event was coordinated by the MCAH staff in collaboration with the PRAAP Chapter, the Puertorican Pediatric Society, and the Vaccination program of the DOH, on the topic of early childhood vaccination. Two videos promoting vaccination produced by the MCAHD staff were presented and a panel of pediatric experts on immunization answered common concerns and questions parents have relating to vaccines. The purpose was for parents to understand how vaccinating their children is a wise decision and how important it is for them to have correct information to make an informed decision.

Preventing Unintentional Injury

The HVNs will continue with one on one education and provide written materials to participants directed at reducing unintentional injuries. The HEs will continue to deliver a course on unintentional injury focused on promoting prevention of in-home injuries, firearm safety, car seat placement and use, safe sleep, protective play gear, safe toys, prevention of forgotten baby syndrome, and drowning prevention, among others.

The Prenatal Course and the Positive Parenting Course will continue to educate on the topics of unintentional injury prevention and safety, including preventing shaken baby syndrome, safe sleep, safe toys, and the proper use of car seats, among others. The MCAH personnel will continue providing and disseminating the latest NHSTA and AAP revised car seat guidelines and recommendations for adequate protective car seat selection and use according to the age and weight of the child through educational activities for parents and communities. In addition, staff will continue to promote compliance with local laws that require children be restrained while riding in a car and the use of safety approved helmets when riding a bicycle, motorcycle or any other moving vehicle. These efforts will be directed at decreasing the rate of deaths to children caused by motor vehicle crashes.

The MCAH staff will continue to collaborate with the Emergency Medical Services for Children (EMSC) Project in advocating for an improved emergency response infrastructure and a well-coordinated, well equipped and up-to date Emergency Response System in Puerto Rico that complies with the latest recommendations of the National Pediatric Readiness Project (NPRP). The PR DOH Hospital Operating Regulations Policy #9184 and requirements has incorporated the AAP guidelines for hospitals that provide pediatric emergency care (July 2020). The MCAH staff will continue to promote hospitals adopt the requirements improving emergency services to the pediatric population.

The MCAH staff, in collaboration with the Hospital Association and the EMSC Project, will continue to promote that hospitals adopt strategies to encourage pre-hospital management of pediatric emergencies and preparedness to manage mass casualties in case of a disaster, promote the use of the Broselow System to deliver pediatric care in emergency situations, the use of proper pediatric equipment in rescue and emergency interventions, improve patient transfer for critical care, and hospital preparedness to manage pediatric cases after a disaster or a mayor emergency.

Child Abuse and Neglect

Child abuse and neglect is a priority identified. The rate of child maltreatment in Puerto Rico is 7.4 /1000 for 2018 (birth to 17 y/o) a decrease compared to 8.8 in 2017 and lower than the national average of 9.2/1000(data source Child Maltreatment 2018 Report of the US Department of Human Health Services Administration for Children and families https://www.acf.hhs.gov/cb/resource/child-maltreatment-2018).

The HVP, the Positive Parenting Course, and the Interactive Intervention on Management of Crying Babies are strategies in the MCAHD aimed at teaching parents’ skills that contribute to decreasing child abuse and neglect. The Pediatric Consultant has been appointed to the PR Children’s Justice Act (CJA) Committee. In this capacity, she contributes to attain the goal to improve the system that provides the investigative, administrative, and judicial handling of cases of child abuse and neglect in a manner which reduces the additional trauma to the child victim and the victim's family, which also ensures procedural fairness to the accused, and in compliance with the recently enacted Federal Family First Act.

The HEs and MCAH staff will continue to deliver the interactive intervention on the management of crying babies to teach parents and caretakers skills to prevent Shaken Baby Syndrome (SBS). The SBS simulation doll will be used to help convey the message. The recommendations for Safe Sleep are included in this course, which will continue to be offered to caretakers and families in the community. The HEs will continue to collaborate with the Biopsychosocial Program (provides treatment and support to abused children) by delivering the Parenting course to assigned caretakers of abused children.

Promoting Developmental Screening and Early Developmental Stimulation

The HVP provides the opportunity to have an impact on the health and wellbeing of young children and their families. The HVN’s deliver relevant topics to educate and council families in the different stages from prenatal until child reaches 2 years, therefore contribute to the health and well-being of infants and young children. The HVP staff will continue to receive updated training on all topics pertaining to the Title V objectives chosen in Puerto Rico to strengthen their skills for working with families.

A parenting best practice is for parents and caregivers to learn the typical and atypical patterns of development so they can help identify at-risk children who can benefit from early intervention. To follow this recommendation, HVNs will continue administering the Ages and Stages Questionnaires (ASQ-2) and ASQ: Social Emotional (ASQ:SE-2) in the home setting in an effort to identify delays, teach parents how to stimulate maximum development,  and refer for further evaluation and early intervention, if needed. HVNs teach parents the importance of early stimulation and strategies to apply in their day-to-day interactions. The HVNs also have the Justo a Tiempo educational materials that specifies what to expect for each age and parenting recommendations to guide them in teaching parenting skills. HVNs and other MCAH staff will continue to offer educational activities and distribute educational materials on socio-emotional development, parenting skills, and related topics. The Positive Parenting course will continue to deliver and disseminate nurturing and positive parenting skills, including how to identify typical developmental milestones.

Adverse Childhood Experiences (ACE) studies have demonstrated the relationship between having been exposed to adverse events in childhood, such as physical or psychological abuse, neglect, witnessing violence, and the development of chronic health conditions in adulthood. In contrast, resilience has been proven to have a protective effect on ACE. The ACE questionnaire has been included in the revised Home Visiting Program Manual.

The HVN’s are trained on mental health and emotional wellbeing, on how to administer and interpret several related scales, including the ACE, the Cambridge Worry Scale, the Edinburgh Postnatal Depression Scale and other screening instruments. The HVNs acquired skills on Psychological First Aid tools to provide support to individuals and families after a traumatic event, will continued to be used as the population recovers from the recent earthquakes and the additional stress caused by the COVID-19 crisis. Additional training will reinforce the negative effects of ACEs on health, and offer strategies to promote resilience among participants and their families.

MCAH staff will continue to endorse the use of screening tests by primary care physicians and as recommended in the PR PPHCSG guidelines. The Survey of Wellbeing in Young Children is an alternative test for screening different aspects of child development and wellbeing that has been adopted by many states. This test is among those recommended by the AAP, does not require a license for use, and is available in Spanish. The SWYC has been added as alternative screening test in the PR PPHCSG update.

In 2021-22 the MCAHD will collaborate with the PRAAP Chapter and United Way of PR promoting the development of a reach out and read initiative in pediatric offices and day care centers. The goal is to identify funds that enable donations for baby books that cover topics such as oral health and safe sleep to parents with infants, at the earliest age possible, with the purpose to promote parent infant interaction and reading. Possible venues to donate the books could be in pediatric offices and day care centers.

Promoting Quality Child Care

Quality childcare also has an impact in the wellbeing of young children. The MCAH staff will continue to collaborate and advocate for the development of public policies and regulations that call for the improvement of child care services, such as: supportive settings for breastfeeding mothers, adequate physical activity according to age, optimal nutritional selection, activities that stimulate development, and safety, among others.  

During 2021-2022 the MCAH staff will continue to work in partnership with United Way, Association of Child Care Centers and Head Start/Early Head Start on strategies that empower community leaders and child care center staff to deal with the effects of natural disasters on the population. This includes preparedness for disasters, developing plans for an adequate response during a disaster, and mitigating the effects of trauma after a disaster strike. They will also continue to receive orientation on how to prepare their centers to reopen during the COVID-19 crisis adopting protective measure to decrease the risk of virus transmission.

During 2020-2021 the MCAH staff has taken part in another collaborative project to address early childhood wellbeing and development in the Puerto Rico Preschool Development Grant Birth through Five. This collaboration is led by the Administration for Integral Child Care Development (ACUDEN) of the Department of Family. The main goal is to update early childhood planning efforts in Puerto Rico and contribute to the strengthening and implementation of an integrated and coordinated system that will facilitate the access of children and families to high quality services for their development and the improvement of their quality of life. The project aims to develop a statewide strategic plan, informed by a needs assessment to guide systemic efforts. The work engages partners and stakeholders, including families, throughout the Project. It also aims to improve the quality of services for children with special needs and living in the most disadvantaged low-income communities in Puerto Rico.

The United Way of PR has instituted the Children Friendly Cities Award in 2019, 3 top municipalities in PR were selected after evaluating over 25 that participated. The competition is based on services and investments that the municipality directs to early childhood. The MCAHD supported the initiative by participating in the awards ceremony in 2019 and will participate in the evaluation process for 2021-2022.

Child Emotional Wellbeing

Due to the impact on emotional wellbeing on children and families by the earthquakes the MCAH program collaborated in the dissemination of the coloring book Trinka y Juan el día que la tierra se movió as an instrument to help families understand behavioral responses and strategies to mitigate it. The recently published coloring book Trinka y Juan luchando contra el gran virus will be adopted as a similar instrument to help families with young children deal with the uncertainty and stress of COVID-19.

MCAH staff and the HVN will continue to foster the development of resilience in the participant families, awareness of the effects of adverse childhood events and how to prevent them in their children. The HVN will also continue to administer the Ages and Stages Questionnaires: Social Emotional (ASQ:SE-2) at to participating children of the HVP at scheduled intervals, teach parents how to promote healthy emotional development, and refer children that require further interventions based on the results of the screenings.

Emergency Preparedness and Response

With each emerging disaster, the importance of advocating for children’s need has been identified as a priority. Therefore, the MCAH staff will continue to collaborate to develop an Emergency Preparedness and Response guide that considers the needs of children to incorporate in the state EPR plans.  

Education to childcare and HS/EHS staff will continue to be offered via virtual presentations during the quarantine on topics of safe sleep, ECC prevention, immunization myths, breastfeeding, child development, disaster preparedness, oral care, and unintentional injury prevention.