Health Issues in Indigenous Children: An Evidence-Based Approach for the General Pediatrician

Contents

Preface xvii

Anne B. Chang and Rosalyn Singleton

An Overall Approach to Health Care for Indigenous Peoples 1239

Malcolm King

Indigenous peoples across all the continents of the globe live with majorgaps in health status and health outcomes associated with well-describedsocial determinants of health, such as poverty and poor education. Indig-enous peoples face additional health determinant issues associated withurbanization, isolation from traditional territories, and loss of cultural con-tinuity. Indigenous children are particularly vulnerable as they grow up inisolation from their cultural and social roots and yet are also separatedfrom the mainstream environment of their society. Programs to addressthese difficult health issues should be viewed as complex clinical interven-tions with health researchers, social scientists, and clinicians workingtogether with Indigenous peoples to identify the most pressing needsand most appropriate and workable solutions that will result in effectivepolicies and practices.

Indigenous Newborn Care 1243

Susan M. Sayers

Infant mortality and morbidity disparities occur between non-Indigenousand Indigenous populations of Australia, Canada, New Zealand, and theUnited States. Neonatal mortality is due to high-risk births, which varyaccording to prevalence of the maternal risk factors of smoking, alcoholconsumption, infection, and disorders of nutritional status, whereaspostneonatal mortality is predominantly influenced by environmental fac-tors. Aside from changing socioeconomic conditions, a continuum ofmaternal and child health care is likely to be the most effective measurein reducing these health disparities.

Vaccine Preventable Diseases andVaccination Policy for Indigenous Populations 1263

Robert I. Menzies and Rosalyn J. Singleton

There are many similarities regarding the health status of Indigenouspeople in the 4 English-speaking developed countries of North Americaand the Pacific (United States, Canada, Australia, New Zealand), wherethey are all now minority populations. Although vaccines have contributedto the reduction or elimination of disease disparities for many infections,Indigenous people continue to have higher morbidity and mortality frommany chronic and infectious diseases compared with the general popula-tions in their countries. This review summarizes the available data on the

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epidemiology of vaccine-preventable diseases in Indigenous populationsin these 4 countries in the context of the vaccination strategies used andtheir impact, with the aim of identifying successful strategies with thepotential for wider implementation.

Undernutrition and Obesity in Indigenous Children: Epidemiology, Prevention,andTreatment 1285

Alan R. Ruben

Over the past 50 years there has been a shift in nutritional problemsamongst Indigenous children in developed countries from under-nutritionand growth faltering to overweight and obesity; the major exception issmall numbers of Indigenous children predominately living in remote areasof Northern Australia. Nutritional problems reflect social disadvantage andoccur with disproportionately high incidence in all disadvantaged sub-groups. There is limited evidence of benefit from any strategies to preventor treat undernutrition and obesity; there are a limited number of individualstudies with generalizable high grade evidence of benefit. Potential solu-tions require a whole of society approach.

Lower Respiratory Tract Infections 1303

Anne B. Chang, Christina C. Chang, K. O’Grady, and P.J. Torzillo

Acute lower respiratory infections (ALRI) are the major cause of morbidityand mortality in young children worldwide. ALRIs are important indica-tors of the health disparities that persist between Indigenous and non-In-digenous children in developed countries. Bronchiolitis and pneumoniaaccount for the majority of the ALRI burden. The epidemiology, diagno-sis, and management of these diseases in Indigenous children are dis-cussed. In comparison with non-Indigenous children in developingcountries they have higher rates of disease, more complications, andtheir management is influenced by several unique factors including theepidemiology of disease and, in some remote regions, constraints onhospital referral and access to highly trained staff. The prevention of re-peat infections and the early detection and management of chronic lungdisease is critical to the long-term respiratory and overall health of thesechildren.

Chronic Respiratory Symptoms and Diseases Among Indigenous Children 1323

Gregory J. Redding and Catherine A. Byrnes

Children from Indigenous populations experience more frequent, severe,and recurrent lower respiratory infections as infants and toddlers. The con-sequences of these infections are chronic lung disorders manifested byrecurrent wheezing and chronic productive cough. These symptoms areaggravated more frequently by active and passive tobacco smoke expo-sure among Indigenous groups. Therapies for these symptoms, althoughnot specific to children of Indigenous origins, are described as is theevidence for their use.

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Acute and Persistent Diarrhea 1343

Keith Grimwood and David A. Forbes

Socially disadvantaged Indigenous infants and children living in westernindustrialized countries experience high rates of infectious diarrhea, nomore so than Aboriginal children from remote and rural regions of NorthernAustralia. Diarrheal disease, poor nutrition, and intestinal enteropathy re-flect household crowding, inadequate water and poor sanitation and hy-giene. Acute episodes of watery diarrhea are often best managed byoral glucose-electrolyte solutions with continuation of breastfeeding andearly reintroduction of feeding. Selective use of lactose-free milk formula,short-term zinc supplementation and antibiotics may be necessary for illchildren with poor nutrition, persistent symptoms, or dysentery. Education,high standards of environmental hygiene, breastfeeding, and immuniza-tion with newly licensed rotavirus vaccines are all needed to reduce the un-acceptably high burden of diarrheal disease encountered in young childrenfrom Indigenous communities.

Glomerulonephritis and Managing the Risks of Chronic Renal Disease 1363

Gurmeet R. Singh

The rising global burden of chronic renal disease, the high cost of providingrenal replacement therapies, and renal disease also being a risk factor forcardiovascular disease is increasing focus on renal disease prevention.This article focuses on the aspects of renal disease (specifically poststrep-tococcal glomerulonephritis [PSGN] and chronic kidney disease [CKD]) inIndigenous populations in Australia, New Zealand, Canada, and the UnitedStates that diverge from those typically seen in the general population ofthose countries. The spectrum of renal and many other diseases seen inIndigenous people in developed countries is similar to that seen in devel-oping countries. Diseases like PSGN that have largely disappeared in de-veloped countries still occur frequently in Indigenous people. CKD duringthe childhood years is due to congenital anomalies of the kidney and uri-nary tract in up to 70% of cases and occurs later in polycystic kidney dis-ease and childhood-onset diabetes. Several risk factors for CKD inadulthood are already present in childhood.

Acute and Chronic Otitis Media 1383

Peter S. Morris and Amanda J. Leach

Otitis media (OM) is a common illness in young children. OM has histori-cally been associated with frequent and severe complications. Nowadaysit is usually a mild condition that often resolves without treatment. For mostchildren, progression to tympanic membrane perforation and chronic sup-purative OM is unusual (low-risk populations); this has led to reevaluationof many interventions that were used routinely in the past. Evidence froma large number of randomized controlled trials can help when discussingtreatment options with families. Indigenous children in the United States,Canada, Northern Europe, Australia, and New Zealand experience moreOM than other children. In some places, Indigenous children continue tosuffer from the most severe forms of the disease. Communities with

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more than 4% of the children affected by chronic tympanic membrane per-foration have a major public health problem (high-risk populations). Higherrates of invasive pneumococcal disease, pneumonia, and chronic suppu-rative lung disease (including bronchiectasis) are also seen. These childrenwill often benefit from effective treatment of persistent (or recurrent) bac-terial infection.

Acute Rheumatic Fever and Rheumatic Heart Disease in Indigenous Populations 1401

Andrew C. Steer and Jonathan R. Carapetis

Acute rheumatic fever and rheumatic heart disease are diseases of socio-economic disadvantage. These diseases are common in developing coun-tries and in Indigenous populations in industrialized countries. Clinicianswho work with Indigenous populations need to maintain a high index ofsuspicion for the potential diagnosis of acute rheumatic fever, particularlyin patients presenting with joint pain. Inexpensive medicines, such as as-pirin, are the mainstay of symptomatic treatment of rheumatic fever; how-ever, antiinflammatory treatment has no effect on the long-term rate ofprogression or severity of chronic valvular disease. The current focus ofglobal efforts at prevention of rheumatic heart disease is on secondaryprevention (regular administration of penicillin to prevent recurrent rheu-matic fever), although primary prevention (timely treatment of streptococ-cal pharyngitis to prevent rheumatic fever) is also important in populationsin which it is feasible.

Skin Disorders, Including Pyoderma, Scabies, andTinea Infections 1421

Ross M. Andrews, James McCarthy, Jonathan R. Carapetis, and Bart J. Currie

Pyoderma, scabies, and tinea are common childhood skin disorders toooften considered to be merely of nuisance value. More than 111 millionchildren are believed to have pyoderma, with many also co-infected withscabies, tinea, or both. These skin disorders cannot be differentiated byethnicity or socioeconomic status but, in high-prevalence areas, povertyand overcrowded living conditions are important underlying social deter-minants. Each is transmitted primarily through direct skin-to-skin con-tact. For many Indigenous children, these skin conditions are part ofeveryday life. Although rarely directly resulting in hospitalization ordeath, there is a high and largely unmet demand for effective manage-ment at the primary health-care level, particularly for pyoderma and sca-bies. Despite particularly high prevalence in some settings, treatment isnot sought for many children, and when sought, the clinical benefit fromsuch consultations is variable. The lack of standard, evidence-basedrecommendations is of much concern. The current evidence base forclinical diagnosis and treatment of these common childhood skin disor-ders is highlighted.

Clinical Management ofType 2 Diabetes in IndigenousYouth 1441

Elizabeth A.C. Sellers, Kelly Moore, and Heather J. Dean

Youth-onset type 2 diabetes is a serious public health problem for Indige-nous people throughout the world. This article reviews the epidemiology,

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disease burden, treatment, and challenges in achieving successful clinicalmanagement of this disorder in Indigenous youth. Screening criteria andthe complications and comorbidities of type 2 diabetes are also reviewed.

Behavioral andMental Health Challenges for IndigenousYouth: Research andClinical Perspectives for Primary Care 1461

Michael Storck, Timothy Beal, Jan Garver Bacon, and Polly Olsen

After first discussing historical, community and epidemiologic perspec-tives pertaining to mental health problems of Indigenous youth and fami-lies, this article reviews available research data on behavioral and mentalhealth interventions and the roles that Native and Indigenous research pro-grams are serving. Given the legacy of transgenerational trauma experi-enced by Indigenous peoples, community-based research andtreatment methods are essential for solving these problems. The primarycare provider stands in a unique position within the community to offera ‘‘coinvestigator spirit’’ to youth and families in the pursuit of improvingbehavioral health. Strategies are presented for using the research litera-ture, and collaborating with communities and families to help solve behav-ioral and mental health problems.

Oral Health of Indigenous Children and the Influence of Early Childhood Carieson Childhood Health andWell-being 1481

Robert J. Schroth, Rosamund L. Harrison, and Michael E.K. Moffatt

Dental caries in Indigenous children is a child health issue that is multifac-torial in origin and strongly influenced by the determinants of health. Theevidence suggests that extensive dental caries has an effect on healthand well-being of the young child. This article focuses on early childhoodcaries as an overall proxy for Indigenous childhood oral health becausedecay during early life sets the foundation for oral health throughout child-hood and adolescence. Strategies should begin with community engage-ment and always include primary care providers and other communityhealth workers.

Early Child Development and Developmental Delay in Indigenous Communities 1501

Matthew M. Cappiello and Sheila Gahagan

Developmental delay is common and often responds to early intervention.As with other health outcomes, the prevalence of developmental delaymay be socially determined. Children in many Indigenous communities ex-perience increased risk for developmental delay. This article highlightsspecial conditions in Indigenous communities related to child develop-ment. It addresses the challenges of screening and evaluation for develop-mental delay in the context of Indigenous cultures, and in settings whereresources are often inadequate. It is clear that careful research on child de-velopment in Indigenous settings is urgently needed. Intervention strate-gies tied to cultural traditions could enhance interest, acceptability, andultimately developmental outcomes in children at risk.

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Injuries and Injury Prevention Among Indigenous Children andYoung People 1519

Lawrence R. Berger, L.J. David Wallace, and Nancy M. Bill

Throughout the world, injuries and violence are a leading cause of mortalityand suffering among Indigenous communities. Among American Indianand Alaska Native children aged 1 to 19 years, 71% of deaths are from in-juries. Motor-vehicle accidents, attempted suicide, and interpersonal vio-lence are the most common causes of injuries in highly industrializedcountries. For Indigenous populations in middle- and low-income coun-tries, trauma caused by motor-vehicle accidents, agricultural injuries, in-terpersonal violence, child labor, and the ravages of war are priorities forintervention. To be effective, injury-prevention efforts should be basedon scientific evidence, be developmentally and culturally appropriate,and draw on the inherent strengths of Indigenous communities.

History, Law, and Policy as a Foundation for Health Care Delivery forAmericanIndian and Alaska Native Children 1539

Judith Thierry, George Brenneman, Everett Rhoades, and Lance Chilton

Most American Indian and Alaska Native Children (AIAN) receive healthcare that is based on the unique historical legacy of tribal treaty obligationsand a trust relationship of sovereign nation to sovereign nation. From co-lonial America to the early 21st century, the wellbeing of AIAN children hasbeen impacted as federal laws were crafted for the health, education andwellbeing of its AIAN citizens. Important public laws are addressed in thisarticle, highlighting the development of the Indian Health Service (IHS),a federal agency designed to provide comprehensive clinical and publichealth services to citizens of federally recognized tribes. The context dur-ing which various acts were made into law are described to note the timesduring which the policy making process took place. Policies internal andexternal to the IHS are summarized, widening the lens spanning the past200 years and into the future of these first nations’ youngest members.

History, Law, and Policy as a Foundation for Health Care Delivery forAustralianIndigenous Children 1561

Ngiare Brown

This article identifies significant historical and contemporary issues, pro-grams, and progress to better understand the current policy in Australia re-lating to Aboriginal child health and well-being. A legislative perspectivegives context to contemporary issues based on legally sanctioned histor-ical practices specifically designed to make Aboriginal peoples disappear,particularly through the control and assimilation of Indigenous children.

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