Rajashree (Raji) Koppolu, RN, MSN, CPNP, MSL, spoke with Clinical Advisor to discuss some of the challenges facing pediatric nurse practitioners. In addition to being President of NAPNAP, Ms Koppolu is the manager of Advanced Practice at Lucile Packard Children’s Hospital Stanford in Palo Alto, California, where she works with the general surgery service, providing direct clinical care to complex pediatric surgery patients in both inpatient and ambulatory settings.

Q: What is the biggest challenge facing pediatric-focused advanced practice registered nurses (APRNs)?

A: One of the biggest challenges we face as a specialty is the rapidly changing health care environment and the increased numbers of uninsured patients.  Between 2017 and 2018, more than 400,000 children became uninsured, driven mainly by coverage losses in Medicaid and the Children’s Health Insurance Program (CHIP), which provides low-cost health coverage to children in families that do not qualify for Medicaid. Currently, more than 4 million US children are uninsured. 

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As health care providers, we know the importance of families having access to high-quality, affordable, accessible health care, whether that be preventive or tertiary-based care. 

To help deal with the new health care landscape, NAPNAP has made it a priority to understand insurance eligibility requirements and renewal processes, as well as what resources are available to families for outreach and enrollment. For example, we’ve been advocating for the reauthorization of programs such as CHIP. On the front lines, our members are helping families navigate the health insurance process and understand their benefits and eligibility requirements.

Another big challenge facing advanced practice professionals is understanding the social influencers of health, such as food and housing insecurity and exposure to violence, both domestic and in the community.  There are extensive data about the negative effects of adverse childhood experiences, especially when traumas occur during early development. These experiences affect the immediate and long-term health of children—both physical and mental.  We are encouraging members to identify and address these issues in their practices.

Q:  These social challenges are very different than the traditional ones clinicians typically cite, such as ensuring accurate diagnoses and effective treatments. How is NAPNAP addressing these new challenges?

A:  We are practicing in a time when there are many contextual factors that affect the health outcomes of children. As an association, NAPNAP recognizes this and is proactively trying to better understand these trends and find ways to support our members and help them in their practices.

Q: Do nurse practitioners have the time to ask about social and environmental factors during office visits or are they feeling too strapped for time?

A:  Many of us have high-volume practices, and we increasingly have a growing number of children with complex medical conditions. Over 30% of US children have a chronic health condition and nearly 20% have a special health care need. Given that, it can be a challenge to ask questions about these issues. But, if we think outside the box, we can become stakeholders in public health and policy. We need to understand these social and environmental factors and work together to have more influence over these issues in our daily clinical practices and as they relate to the broader society.

Q: What is the biggest public health issue facing pediatric nurse practitioners?

A:  NAPNAP has been involved in understanding the impact of gun violence in our communities, dealing with the medical-related effects of climate change, and offering members education and resources to work with families that are hesitant about providing vaccines to their children. 

Some other public health concerns are infectious disease outbreaks that we’ve seen around the country and the world, as well as the growing issue of antimicrobial resistance. The latter issue is particularly relevant to childhood illness. We have to be very thoughtful and mindful about the way we treat disease, becoming antibiotic stewards to prevent the overprescribing of antibiotics in situations in which they are not needed.

One issue that we have focused on this year has been the effects of electronic cigarette use and vaping among young children and adolescents. In the fall of 2019, NAPNAP  put out an official statement on vaping just as the Centers for Disease Control and Prevention was starting to report on the rise of EVALI [e-cigarette or vaping product-associated lung injury) cases.

Vaping has become socially normative in our culture, and a large population of children and youth use these products. But there is limited research and techniques to help patients quit or refrain from using e-cigarettes.

We need to educate our members about what, in addition to nicotine, is in these devices, how they work, and the clinical impact of EVALI in adolescents. The types of lung injuries seen with vaping are very different from other types of respiratory illness. As an organization, we’ve been active advocates for better regulation of these devices, specifically when it comes to targeting children. But we need more research and evidence-based recommendations on vaping cessation strategies, similar to our educational efforts related to smoking and smoking cessation.

Q: Can you speak a little bit more on the effects of climate change on childhood illness?

A:  Climate change can affect children in a number of ways. For example, when a natural disaster occurs (wildfires, tornados, hurricanes), children may experience food and water security issues, displacement, and trauma.  We also know that children are particularly vulnerable to ground level pollutants because they engage in a lot of crawling and hand-to-mouth activities. Children have a developing immune system, and childhood illness such as asthma and other conditions can be exacerbated by environmental changes. Our role is to support policies, advocate for research, and make sure that our members are well-versed in the latest information and regulations and laws that provide protection to children in order to provide anticipatory guidance to families.

Q:  Has it been difficult for NAPNAP to address the needs of nurse practitioners in the inpatient and outpatient sectors?

A: One of our core values as an association is diversity and inclusion.  We have more than 9000 members representing more than 18 special interest groups and 50 chapters. Although the majority of our members are working in primary care, rural health, school-based health, or community health practices, we have a growing number of members who work in subspecialty outpatient or inpatient critical care or acute care areas. 

When we look at our national clinical conferences, regional symposiums, and online teaching forums, we want to make sure that we are offering topics that are applicable to practitioners in inpatient settings as well as those who have an outpatient ambulatory care role. 

Because pediatric-focused APRNs do such a great job of caring for a diverse patient population, we want to ensure that we develop a pipeline of future practitioners who enter the workforce with a passion for caring for and working with children. So, I think part of that means we have a responsibility to promote the value of pediatric-focused APRNs in these clinical practices. We want to make sure that all the work we’re doing now is carried on by future providers.

Raji Koppolu, RN, MSN, CPNP, MSL, completed her bachelors degree in biology from Tufts University, her bachelors of science in nursing from the Johns Hopkins University School of Nursing, and her nursing master’s degree at the University of California, San Francisco in 2004. She also completed a Masters of Study in Law at the University of California Hastings College of the Law.