JUNE • 2019
June Brings Summer Joys

Graduations, transitions, vacations, and so much more
Global health, dental caries management, and toolkits to explore
With CME Committee and Advocacy updates
And not to forget, the new immunization medical exemptions requirements in the states.
President's Column
John I. Takayma, MD, MPH, FAAP

While the weather continues to remain spring-like, news of graduations from high schools and colleges, along with discussions about vacation plans during patient encounters, remind us that summer is almost upon us. It’s a transition of sorts for our chapter as well, as we celebrate the start of new tenures, with Kyle Yasuda starting the year as President of the Academy, followed by the election of Yasuko Fukuda as District IX (our district) Chair, and now the start for Raelene Walker as our Chapter President. Many congratulations!

I want to take this opportunity to thank the Executive Committee, Zoey Goore (Immediate Past President), Raelene Walker (Vice President), Janice Kim (Communications Director), Nivedita More (Treasurer) and Isra Uz-Zaman (Executive Director) and board members and chapter committees for a productive and memorable two years; and welcome Raelene as our incoming Chapter President! Zoey reminded me at the start of this tenure of the importance of thinking about the “health” of the children and their pediatricians, as well as that of the chapter itself. We can all take pride that our chapter has now reached the financial and organizational level where we can consistently invest in the future. Summer is a great time for transition! Thank you and best wishes!
Continuing Medical Education Committee Report
Mika Hiramatsu, MD, FAAP

A sold-out crowd got a crash course in mental health at the chapter Pediatric Mental Health Day, May 4, at O’Connor Hospital in San Jose. Many of the over 100 attendees were South Bay residents who said they appreciated the event closer to home. With a last-minute change of program, we were able to offer the morning session to all those on the waitlist, and it was videotaped for future viewing by folks unable to attend. A couple of the comments received so far include: “Thank you for doing this, it was superb!” And “Hats off to the committee -- the conference was beyond my expectations but really met what I needed as primary care to add the psychopharmacological management of these patients.”
Psychiatrist Dr. Madeleine Lansky , Developmental and Behavioral pediatrician Dr. David Ansel , and LCSW and school counselor Nell Branco gave presentations on psychiatric evaluation, psychopharmacology and mental health resources. They were joined by therapist Grace Kodama for a Q & A panel. The afternoon featured small group discussions on Trauma Informed Care and the Medically Complex Child/Anxiety, facilitated by members of our chapter’s new Mental Health Access Committee: Drs. Yvonne Brouard, Diane Dooley, Joan Jeung, Anika Sanda, Carmela Sosa, and John Takayama , as well as Dr. Lansky.
Many thanks to our hard-working CME committee members:  Nelson Branco, Yasmin Carim, Jacqueline Chak, Katie Ellgass, Yasuko Fukuda, Dane Gehringer, Janice Kim, Jeff Ribordy and John Takayama. This was the first CME event for our new chapter executive director, Isra Uz-Zaman, who did a terrific job managing all the details to make our event a success. Handouts from the event will soon be available on our new chapter website. Save the date for our 4th annual all-audience-response Pediatric Puzzles at UCSF Mission Bay on December 7th!
Save the Date: 4th Annual Pediatric Puzzles
December 7, 2019
Advocacy Update
John I. Takayama, MD, MPH, FAAP
Chapter President

Last weekend was AAP Legislative Day, when AAP members from all over California assembled in Sacramento to participate in legislative advocacy training and fanned out to meet with state legislators to confirm their support for AAP sponsored legislation. Kris Calvin , Executive Director of AAP California (District IX), kicked off the event with some tips on communication; she reminded us that when legislators ask us about something that we don’t know the answer to, we respond with “I don’t know the answer to that, but we’ll get back to you.” This can be a segue to building relationships, our ultimate goals as child advocates.

California Surgeon General Nadine Burke Harris , MD, MPH, FAAP joined us with an inspirational account of how her career started with advocacy when Governor Gavin Newsom was Mayor of San Francisco; and a focused discussion of what lies ahead for California. Dr. Harris outlined her three priorities: (1) assuring a healthy start (including developmental screening and screening for ACEs (adverse childhood experiences); as well as support for parents), (2) considering the impact of toxic stress (including environmental sources) across the life course, and (3) achieving health equity. As an administrator, she reminded us, one of her roles is to identify untapped sources of governmental funding to help address key issues.

Two important bills currently under consideration are SB 276 (Pan) Public Health Review of Medical Exemptions and SB 394 (Skinner) Diversion for Primary Caregivers of Minor Children. SB 276 (Pan) assures a public health review of medical exemptions to make sure that children are exempted from immunizations for legitimate reasons. Leaders from Chapter 3 informed us that 1/3 of exemptions in San Diego were written by a single pediatrician. SB 394 (Skinner) provides a diversion option for primary caregivers of minor children. This means that parents charged with certain crimes may be eligible to enroll in a diversion program instead of serving prison time, so that their children are not impacted by their conviction and absence. Erin Haney , National Policy Director at the nonprofit Cut50, confirmed that this was not a “get out of jail free card” but rather an attempt to “hold primary caregivers accountable while simultaneously giving them the necessary tools and support to develop and maintain healthy families.”

As we navigated the narrow corridors of the Capitol and engaged legislative aides in crowded conference rooms, I could not help but feel that we are all part of a dynamic organization that works at the systems level to assure “the optimal physical, mental and social health and well-being for all infants, children, adolescents and young adults living in California,” our AAP mission.
AAP Legislative Day, State Capitol Building, Sacramento, May 20, 2019. Janice Kim, Isra Uz-Zaman, John Takayama, Diane Dooley, Yasuko Fukuda, Jacques Corriveau (AAPCA State Government Affairs Co-Chair).
Meet Our Second State Government Affairs Representative

Nora Pfaff , MD is currently finishing up her first year of pediatric hospital medicine fellowship at UCSF Benioff Children’s Hospital. She completed residency in general pediatrics at Children’s Hospital Los Angeles in 2018 after graduating from medical school at Case Western Reserve University in Cleveland, OH in 2015. Prior to this, she received her bachelor’s degree in Molecular and Cell Biology at UC Berkeley in 2011, where she was also involved with research in the School of Public Health.
Her work with advocacy and exposure to the AAP really began during residency as part of the IMPACT Advocacy Track at CHLA. There, she learned advocacy skills through workshops, trips to local legislators’ offices, and attending CMA Legislative Day in Sacramento. With the help of wonderful mentorship and a dedicated research team, Nora worked on advocating for adolescent vaccine uptake through an opportunistic care model of utilizing the hospital setting to screen for, document, and offer the HPV vaccine to admitted teenage patients—which had not previously been available on the inpatient side. This project uncovered the financial obstacles of vaccine funding leading to policy research and co-authoring an AAP resolution on Universal Access to Vaccines which was voted on as one of the top ten AAP resolutions in 2018.
In fellowship, Nora continues to explore and participate in research to inform policy and joined the AAP Chapter 1 Advocacy Committee where she is currently helping to organize the first Advocacy Training Day for Northern CA pediatricians, to be held in October. Outside of work and advocacy, Nora enjoys hiking, reading, and painting—and is excited to become a new mom very soon.
We are excited to announce the inaugural Advocating for Children Together Conference, a collaborative effort between pediatricians across the Bay Area sponsored by California’s Chapter 1 of the American Academy of Pediatrics (AAPCA1). Join us in learning from advocacy extraordinaires and coming together to better serve the children and families from the Bay to the borders and beyond!  
Overview: The day will include a series of “Ted Talk” style lectures that provide brief overviews of important areas for advocacy for pediatricians, including gun control, mental health, adverse childhood events, and climate change, and empower pediatricians to effectively message advocacy efforts, harness the power of social media, and collaborate with others for children’s health issues. In the afternoon, participants will break into smaller workshops led by local experts in politics, public health, and mass media to gain hands-on practice. The day will end with a reception during which conference participants continue to connect with fellow child advocates as well as utilize skills learned throughout the day to build relationships with and discuss child health issues with invited elected officials.   This conference will produce a community of pediatricians who are engaged and equipped to influence child health policy. It will also provide a networking opportunity for physicians to follow each other on various social media platforms, collaborate on op-eds, spark new research ideas that will influence policy decisions, and inspire each other to speak up and become change-makers.

Registration and more information will follow in a future newsletter.
San Francisco Member At Large Report
International Global Health: Is Disability Worse than Death?
Parental Perceptions of Pediatric Disability

Sohil Sud , MD, FAAP is the San Francisco Member At Large. As his report, Dr. Sud is forwarding this study by Colin Partridge , MD, MPH, Professor of Pediatrics, UCSF School of Medicine and Elizabeth Spiegel , MD, Chief Resident, UCSF Dept. of Pediatrics:

Advancements in technology, clinical management, and public health hold great potential to improve outcomes for infants born prematurely across the globe. A renewed focus on this issue through programs such as the UCSF Preterm Birth Initiative promise to accelerate such developments. However, as with many clinical advancements, such work carries the potential, particularly in the short term, of trading mortality for lifelong morbidity.

Accordingly, it is imperative that we learn more about family perceptions of pediatric disability. Understanding the value placed on the life of a child who might require additional support, especially in low-resource settings, will ultimately provide insight into the long-term care of that child. This may in turn inform policy conversations about resource allocation, healthcare priorities, and public health needs.

Our team is honing the tools to have this dialogue on a global scale. We published the first study of utilities that quantified perceptions of disabilities in a low-resource setting, India, showing significant differences between Canada and India. The results of this study showed the importance of developing culture and resource-specific utility scores for accurate prediction of the cost-utility of health care interventions. We have since completed similar investigations in Haiti, Peru, and Vietnam and discovered that major disability is valued as a fate worse than death in all three low-resource countries.

We now turn to California, where there are no studies among varying socio-demographic groups looking at the effect of race, ethnicity or socio-economic status on valuations of outcomes of prematurity. In this study, we hope to interview close to 400 mothers using validated time-trade off instruments to directly measure utilities, as in the previously described studies.

Data from this series of investigations will help characterize how different socio-cultural groups perceive morbidities of prematurity. They will provide a metric of local variations in valuations of outcomes of prematurity and inform physicians and policymakers of sub-group variations of perceived burdens. We look forward to sharing our findings with medical and public health communities in both local and global contexts.
Silver Diamine Fluoride for Dental Caries Management in Children
Kim Nichelini, D.M.D.
Board Certified Pediatric Dentist
Northern California Board Director and AAP Liason, California Society of Pediatric Dentistry

Despite our efforts to focus on education and prevention in our practices and communities, early childhood caries (ECC) remains highly prevalent in our infant, toddler and preschool populations. ECC can result in pain, lost school days, diminished ability to learn, hospitalizations, emergency room visits, and is the best predictor for caries in the secondary dentition. It is often expensive to treat and, due to behavioral issues and limited ability of this population to tolerate surgical removal of diseased tissue and restorations, may require advanced behavior guidance modalities such as sedation, general anesthesia or protective stabilization.

Silver Diamine Fluoride (SDF) is a colorless liquid consisting of silver, fluoride and ammonia solvent which became available for use in the United States in 2016. It is FDA approved as a dental desensitizer, but is increasingly being used off-label to treat and arrest cavitated carious lesions in primary teeth as part of a comprehensive caries management program. Unlike fluoride varnish, which is typically used to prevent cavitations of healthy enamel or white spot lesions, SDF is used to arrest cavitations that have already occurred. Case selection is critical and application is significantly more technique sensitive than fluoride varnish. SDF seems to work best when applied for a least a minute, under good isolation, to cavitated smooth surface lesions of primary teeth that have not neared or reached the dental pulp. It is most effective when applied to dry teeth multiple different times, tastes awful, and can burn gingiva and stain skin, clothes and counters. Some providers choose to place a topical fluoride varnish over the treated tooth immediately after SDF application to mask the metallic flavor. Within a few minutes of application, carious lesions and sometimes hypoplastic enamel and restoration margins stain dark black permanently until teeth are either restored or lost.

The American Academy of Pediatric Dentistry (AAPD) published a Clinical Practice Guideline in 2017, which, based on the results of randomized control trials and systematic reviews, found that approximately 68% of cavitated carious lesions in primary teeth would be expected to be arrested two years after SDF application(s). The quality of evidence presented was low, and there was considerable variation on effectiveness reported among studies utilized. Contraindications to use include silver allergy, open gingival lesions or pulp involvement. At this point, no toxicity or adverse events have been reported.

When using SDF, it is important to obtain informed consent and monitor caries arrest or growth over time with intraoral photos, radiographs and visual/tactile examinations. It is also imperative that SDF applications be part of a comprehensive caries management plan, developed in a dental home, which involves preventive strategies such as dietary modifications, oral hygiene regimens and topical fluoride products. Treated teeth may require future applications or restorations once behavior improves to allow for basic rather than advanced behavior guidance techniques to be utilized. It is advantageous, as a provider, to have a new low-cost and non-invasive tool to help manage the caries disease process in our very young and vulnerable patients and I look forward to the results of ongoing and future research about SDF.

Feel free to contact me with questions or comments at kimnichelini@gmail.com.
Developmental/Behavioral Screening and Referral Toolkit for Pediatricians
Eileen Yamada, MD, MPH, FAAP
California Department of Public Health, Maternal, Child and Adolescent Health Division

The American Academy of Pediatrics’ (AAP) Bright Futures Guidelines include recommendations for developmental surveillance and screening for young children. Although developmental surveillance is recommended at each encounter with the child, developmental screening using a standardized developmental questionnaire is recommended at 9 months, 18 months, and 30 months. In addition, screening for autism spectrum disorder is recommended at the 18 month and 2 year visits, social-emotional screening is recommended at regular intervals and maternal depression screening is recommended at the 1 month through 6 month visits. 

California’s State Screening Collaborative (CSSC), with joint funding from the California Department of Public Health and Department of Developmental Services, developed an online toolkit for healthcare providers. The toolkit contains information on developmental and behavioral screening, tools for screening, resources, and how to refer infants and toddlers who are identified as needing additional support or intervention. It is a valuable resource for pediatricians and other healthcare providers who conduct routine healthcare visits and who are the first line of defense for developmental and socio-emotional concerns. Children who are screened and provided intervention at the earliest possible point are more likely to be successful in school and later life. You can find this helpful online toolkit at: https://www.cascreenbto5.org. Additional national screening resources may be found at the AAP’s Screening Technical Assistance & Resource (STAR) Center at: http://www.aap.org/screening .
Upcoming Events for Your Benefit

New Immunization and Medical Exemption Requirements set to begin on July 1, 2019 (courtesy of AAPCA Chapter 2):
  1. Understanding California’s Child Care and School Immunization Requirements and Medical Exemptions
  2. Contraindications to Immunizations Required for Pre‐Kindergarten and Transitional Kindergarten/K‐12 School Entry 

October 5, 2019:  Advocating for Children Together Conference, Oakland

October 25-29, 2019:  AAP National Conference & Exhibition, New Orleans

November 21-24, 2019: AAP California 41 st Annual Las Vegas Seminars

December 7, 2019:   Pediatric Puzzles Interactive CME Conference, SF

Our mission is to promote the optimal health and development of children and
adolescents of Northern California in partnership with their families and communities, and to support the pediatricians who care for them.

President: John Takayama • Vice President: Raelene Walker
Secretary: Janice Kim • Treasurer : Nivedita More Past President: Zoey Goore
Executive Director: Isra Uz-Zaman