1. Public Health and Pediatrics Module 1 Choking, Smoking, Teen Driving November, 2010 Deborah Moss, MD MPH Dianna Ploof, EdD

2. Case 1:Case 2:Case 3: Choking CaseSmoking Case Teen Driving Case SSS EEE PPP AAA You have completed Case 1. Now try applying the SEPA approach for Case 2 or Case 3 in this jeopardy-style format. Click on the topic of your choice to get started.

3. Case 1: Choking On a July afternoon in 2006 while watching TV together, Patrick Hale’s 23-month-old daughter, Allison, turned purple and was unable to breathe. An autopsy found that she had inhaled pieces of popcorn into her vocal cords, her bronchial tubes and a lung. SS E P AEPA

4. Have you had any similar cases in your clinical experience? Discuss S E P AEPA

5. What is the epidemiology of choking in the pediatric population? Fatal Choking Rates Non-Fatal Choking Rates Contributors to increased risk in younger children

6. Fatal Choking Rates 449 deaths from aspirated non-food foreign bodies (coins and toys) among children < 14 yo*; 65% of these in <3 yo Leading causes of choking: 1. Latex balloons (29% of all choking deaths) 2. Round toys, small balls and marbles 3. Food (hot dogs, popcorn, peanuts, hard candy, etc) 17 % of food-related choking events are due to hot dogs. *(1972-1992, US Consumer Product Safety Commission)

7. Non-Fatal Choking Rates Non-fatal choking rates by age: (CDC) Infants: 140.4 per 100 000 population < 14 years: 29.9 per 100 000 population (NOTE: same as SIDS rate) Of 17, 537 children <14 year treated for non- fatal choking: 77.1% occurred among children aged < 3 years 59.5% of those treated for choking were food-related 31% were due to a non-food item (13% from coins, 19% from candy or gum)

8. Determinants of Health Contributors to increased choking risk Younger children: Put things in their mouths Lack molars to grind food (erupt after 1.5 years) Have weak, non-forceful coughs Have smaller airway diameters Also, airway mucous and secretions can seal around the foreign body, making it difficult to dislodge even with the Heimlich S E P APA

9. What are public health/preventive health approaches to this issue? Primary Prevention Secondary Prevention Tertiary Prevention S E P AA

10. Primary prevention = prevent the choking from happening (making the walk along the cliff safe) Product safety screening, product labels, and product re-design (hot dog cutter) are results of identifying choking hazard characteristics (size and shape*) US Consumer Product Safety Commission (CPSC) Child Protection Act Fact Sheet: Choking Hazards List http://www.cpsc.gov/cpscpub/pubs/282.html http://www.cpsc.gov/cpscpub/pubs/282.html *Small parts test fixture: Cylinder: 1.25” diameter; 1 - 2.25” depth (CPSC Jan 2001)

11. Primary prevention = prevent the choking from happening (making the walk along the cliff safe) Epidemiology informs problem: who is at risk? Public health campaigns, community and individual education are result of identifying the population at risk

12. Secondary prevention = early detection of choking hazard (address contributors to cliff being unsafe) Surveillance of choking events lead to product recall by the U.S. Consumer Product safety commission (started 1972)

13. Tertiary prevention = reducing the impact of the choking event (ambulance in the valley) Develop treatment/response approaches to choking victims Example: offer Community CPR training S E P AA

14. What are actions you could take to reduce morbidity and mortality related to choking in children? Become informed Actions in the clinic Actions beyond the clinic

15. How can you become more informed about this issue? (Discuss, then click the light bulb) Action

16. How can you become informed? Websites: US Consumer Product Safety Commission; Centers for Disease Control Colleagues: (your ideas) Associations: AAP Other ways: (your ideas) Action

17. Actions in the clinical encounter What are actions you might take while in the clinic to protect your patient(s) from the risks of choking? (Discuss, then click the light bulb) Action

18. Actions in the clinic? Adhere to best practices : Talk to parents about choking hazards (anticipatory guidance is clinical advocacy) Give the choking hand-out with first aid instructions (12 month age-specific packet) Other ideas? Action

19. Actions beyond the clinic What are actions you could take beyond the clinical setting to protect your patient(s) from the risks of choking? (Discuss, then click the light bulb) Action

20. Actions beyond the clinic? Promote CPR training for parents, caregivers and others Work with your AAP chapter or a specific committee: e.g., join the AAP committee on injury, violence and poison prevention - participate in the advocacy effort calling for the FDA to require warning labels on foods proven to be choking hazards. End of Case 1 Action

21. Case 2: Smoking You are seeing Justin Smith who is brought by his mother for his 2 month well child check. He was born full term without complications, has been generally healthy, and is Mrs. Smith’s 4 th child. SS E P AEPA In reviewing the vital signs on the chart, you notice that the smoking status vital sign box is marked “yes”.

22. Have you had any similar cases in your clinical experience? Discuss S E P AEPA

23. What is the epidemiology of maternal smoking? of child exposure to second hand smoke (SHS)?

24. 15.1% of women smoke during pregnancy (Allen et al, 2004); up to 30-40% in some low income populations 19.8% of adults in US report current smoking: 20.9% in PA (2007 MMWR) 59.6% of non-smoking children ages 3-11 had serum cotinine levels consistent with second hand smoke exposure (Pirkle, 2006) S E P APA Epidemiology :

25. What are the public health implications related to this infant’s exposure to mother’s smoking?

26. Exposure to maternal smoking is associated with: Prenatal risks: preterm delivery, low birth weight, pregnancy complications 2-3 times the risk of SIDS 4 times the rate of hospitalizations for exposed infants Increased rates of lower respiratory tract illnesses and of asthma exacerbations

27. Exposure to maternal smoking or SHS is associated with: Increased incidence (new cases) of asthma Increased rate of middle ear infections More respiratory symptoms Dental caries Increased risk of meningitis Greater risk for injury and death due to fires

28. Exposure to maternal smoking is associated with: Increased health care costs. SHS exposure from parental smoking is responsible for * : 22,000 national annual excess hospitalizations for RSV/bronchiolitis 1.8 million national annual excess outpatient visits for asthma 8000-26,000 new asthma cases per year $4.6 billion excess annual health care costs * Aligne: Arch Pediatr Adolesc Med, Volume 151(7). July 1997, 648-653

29. Additional long-term health risks related to parental smoking include: Increased risk of teen smoking initiation Impaired cardiovascular health Impaired lung function Adult periodontal disease S E P AA

30. What actions could you take to protect children from the harms of second hand smoke? Become informed Actions in the clinic Actions beyond the clinic

31. How can you become more informed about this issue? Discuss, then click the light bulb Action

32. How can you become informed? Google it! Learn about advocacy resources: e.g., the AAP Advocacy Guide (excellent resource!) http://www.aap.org/moc/advocacyguide/chapter2- main.cfm (See “Resource Section”) Join a list-serve Bill Godshall: bg-announce@ smoke screen.org (See “Resource Section”) Read newspapers Other ideas? Action

33. Actions in the clinic What are actions in the clinic you might take to protect a patient(s) from second- hand smoke exposure? (Discuss, then click the light bulb) Action

34. Actions in the clinic? Adhere to evidence-based practice guidelines* : a. Ask every parent if they smoke cigarettes b. Advise every parent to protect their children: advise smokers to quit (physicians’ advice doubles quit rate) advise non-smokers to keep home and child’s environment smoke-free c. Assist every parent (See “Resources Section for information, sample Rx and links to brochures) *Fiore MC et al. 2000 Action

35. Actions beyond the clinic What actions outside the clinic could you take to protect children from second-hand smoke exposure? Action

36. Actions beyond the clinic? Join existing campaigns: e.g., campaign to regulate smoking in movies http://smokefreemovies.ucsf.edu/ (See “Resources Section”) Support local efforts: e.g., support our CHP/UPMC smoke-free campus policy Advocate for legislation that benefits child health: e.g., advocate for more comprehensive smoking bans locally and statewide. Call, write letters to legislators. Testify at hearings on this issue. Action

37. Actions beyond the clinic? Identify your legislator : http://www.pasen.gov/cfdocs/legis/home/find.cfm Meet with your legislator so you can be a resource: One call can make a difference. Example*: …one pediatrician took 5 minutes between patient appoint- ments to call her state representative about a bill she cared about. Later that day, the representative spoke on the floor of the state house on behalf of the bill, and specifically stated: "My pediatrician supports this bill, and if it's good enough for her, it's certainly good enough for the state”. * extracted from the AAP advocacy website End of Case 2 Action

38. Case 3: Teen Driving You are seeing a 16 year old boy for a driver’s license physical. You notice during the encounter that he checks his phone frequently and even sends a few texts while you’re talking. SS E P AEPA

39. Have you had any similar cases in your clinical experience? Discuss S E P AEPA

40. What is the epidemiology of driving while distracted?

41. Driver Distraction For all ages, driver distraction is the leading contributor to automobile accidents (80%) (NHTSA). includes cell phone use and texting Inexperienced drivers < 20 yo have the highest proportion of distraction-related fatal crashes 87% of motor vehicle accident (MVA) deaths involving teens are related to distraction (Allstate Foundation study) 16-year-olds have almost 10 times the crash risk of older drivers (30-59 yo); and 3 times the risk compared with older teen drivers (David Hemenway, While we were sleeping, p. 12)

42. Driver Distraction The AAA Foundation for Traffic Safety analyzed data on fatal motor vehicle crashes from 1998 through 2007: In 2008, nearly 6,000 people died in crashes involving a distracted driver and more than 500,000 people were injured. (CDC) S E P APA

43. What are public health approaches to this issue?

44. Policies and legislation that prevent accidents (placing a the fence along the cliff). E.g.: Graduated driver’s license programs – where enacted, these laws have reduced the crash risk by 30% Bans on texting while driving Public education campaigns about not driving while distracted (placing a warning sign near the cliff) S E P AA

45. What are actions you can take to protect teens from the risks of driving while distracted? Become informed Actions in the clinic Actions beyond the clinic

46. How can you become more informed about this issue? Where/How can you find out more about this topic/issue ? (Discuss, then click the light bulb) Action

47. How can you become more informed about this issue? Generate your own ideas Action

48. Actions in the clinical encounter? What are actions you might take in the clinic for injury prevention regarding teen driving and texting? (Discuss, then click the light bulb) Action

49. Actions in the clinic? Address these issues with your patients/ parents During the driver’s license physical examination, emphasize the risks of driver distraction. Advise the driver to be to turn the cell phone off and place it well out of reach before starting the car. Action

50. Actions beyond the clinic? What are actions you might take for injury prevention / health promotion regarding safe driving advocacy activities outside of the clinic setting? (Discuss, then click the light bulb) Action

51. Actions beyond the clinic? Join the CHP letter-writing campaign advocating for comprehensive texting bans in PA (to get to link, go to www.chp.edu and click on “protect teen drivers” at top right-hand corner)www.chp.edu See a Sample Letter in the “Resources Section” of the module. End of case Action

52. You have finished applying the SEPA approach. Please close this PowerPoint program to return to the remaining on-line materials.