2019-20 TOW #4: Early adolescence well care

We move into the land of adolescents and the fun and challenge that can bring in well visits for ages 11-14 years. Perhaps invoking memories of our own experience at that age helps us be more empathetic to what early adolescents and their parents are experiencing as the tidal wave of hormonal changes hit the body! Let’s review some key approaches and resources for this age group.

Materials for this week:

Take-home points

  1. What are the priorities for well child visits in early adolescence (ages 11-14)? We will be addressing patient and parent concerns first, though may have a harder time eliciting them from patients at this age. That’s why it’s important to allow time 1:1 with the adolescent and to set the tone by explicitly reviewing confidentiality, discussing their strengths and then HEADSSS questions. Some adolescent docs have adopted “SSHADESS” as an alternative to HEADSSS as it reviews strengths and school first before other more challenging topics. As long as we ask more personal/intimate questions later in the interview, either approach can work.
  2. What are the Bright Futures priority areas for these ages? 1) Physical growth and development (puberty, body image, healthy eating, activity), 2) social and academic competence (connections with family and peers, relationships, school performance), 3) emotional well-being (coping, mood regulation, mental health, sexuality), 4) risk reduction (tobacco, alcohol, other drugs, pregnancy, STIs), and 5) violence and injury prevention (seatbelts, helmets, firearms, personal violence).
  3. What are the most evidence-based aspects of our care? Vaccines for adolescents are again a bigger evidence-based aspect of our care at this age. In addition, using strengths-based interviewing and a motivational interviewing approach has been shown to be effective. MI has been applied successfully in adolescent care to address cigarette smoking, alcohol and marijuana use, chronic disease management, and adoption of safety behaviors.
  4. What are the recommended screenings? In addition to measuring weight, height, BMI, and BP, we should screen for vision once in early adolescence. The AAP recommends universal lipid screening for kids in this age group, which has been one of the more controversial recommendations; many opt for a risk-based screening. All other screenings would be considered selective: vision, anemia, TB, STIs, pregnancy, alcohol and drug use.
  5. How do we establish rapport with our patients at this age? What are some clinical pearls? As with children, we try to enter the kids’ world by asking about things they are enjoying, new activities, or their favorite subject. Particularly at this age we want to hear about patients’ strengths (see Dr. Ginsberg’s article above) – we can ask them to describe themselves, or ask how their family or friends describe them. Since parents and young teens are often not having great opportunities to converse, drawing this out during the visits by asking parents what they appreciate about their kids can lead to some amazingly reflective and positive dialogue.

2018-19 TOW #50: Social media

Social media is now at essentially ubiquitous levels of use among adults and adolescents. The new interns just discussed how to use it safely now that they are practicing doctors. Let’s review for youth as well.

Materials for this week:

Take-home points:

  1. How do we define social media? Social media can be defined as any online applications that allow for the creation and exchange of user-generated content. The collaborative approach is what separates “Web 1.0” functionality (i.e., static Internet pages) from “Web 2.0” where there is continuous modification and participation by users.
  2. How often are internet and social media used in children and adolescents? Even back in 2015, the Pew Internet and American Life Project found that 92% of teens went online daily. Nearly one quarter used the internet “almost constantly” via smartphones, with 73% of teens owning a mobile device and 91% using it to go online. We know the numbers have only increased! What I was surprised to learn is that even 50″% of 5 year olds and 70% of 8 year olds went online daily. By 4 years of age, nearly 75% of children had their own mobile device in a study of low-income urban minority children. A separate study found that by age 10, more than half of children had accessed an online social network site. We have truly entered a new digital age.
  3. What are some of the positives of social media use? (this is like an MI-style pro-con discussion!) There are 2 main categories: social connectedness and learning. Social media facilitates staying connected with friends and family, making new friends, and also creating social inclusion through community engagement. On the learning front, there are data that it helps with motivation to learn, and can be associated with higher test scores, especially for older youth. It also allows teens to access health information easily and anonymously. Additionally, it allows for self-expression, developing an individual identity, creativity, and exposure to ideas.
  4. What are some of the negatives? We now know there are quite a few: all of those positives seem to have their negative corollary. Risks of social media include cyberbullying, sexting, dissociating one’s online and offline life, and permanence of the digital footprint. Additional negative aspects include exposure to age-inappropriate and/or sexually explicit content, addiction to the Internet, and what’s been termed “Facebook depression”. By extension, these can negatively impact grades, relationships with family and friends, and physical and mental health (including sleep deprivation). Online exposure to alcohol and tobacco use, and sex is associated with earlier initiation of these high-risk behaviors.
  5. How can parents help youth navigate the Internet and social media? Parents should have open and honest discussions about Internet and social media use. Parents should evaluate sites their child wishes to participate in, discuss safe and appropriate usage, and routinely supervise and monitor usage. Though 94% of parents report ever talking with their teen about appropriate content to view and share online, only 40% do it frequently. At our house, our daughters need to use their devices in family areas (not in the bedroom). Even so, my daughter was trying to get on a Harry Potter website that required her to be 18 this weekend! It does take constant vigilance to be aware and support youth. The data are rapidly emerging on risks of depression with a lot of use. Adults need to model and encourage moderation. Avoid phone use during meals and before bed as a start. I like saying “the phone / device has it’s own bedtime and sleeping place.”

2018-19 TOW #46: Adolescent immuniztions

There’s a lot going on in adolescence, including trying to complete additional recommended vaccines, the most challenging being HPV and flu. We will review some of the barriers and recommendations to address this.

Materials for this week:

Key take-home points:

  1. What types of clinical settings do adolescents use? Most teenagers have a medical home in the US, and >90% of adolescent vaccinations are received in a pediatric, family medicine or community health clinic. A few receive vaccines in school clinics, internal medicine and OB-GYN settings.
  2. What are the recommended vaccines for pre-teens and adolescents? Starting at age 11, we recommend a 2-dose meningococcal series (1 dose at 11-12, 2nd at age 16), single dose of Tdap, 2-dose HPV vaccine series (separated by minimum of 5 months; it’s 3 doses if started at age 15 or older), and an annual influenza vaccine.
  3. What are adolescent immunization rates in the US? The 2016 National Immunization Survey showed that adolescents aged 13-15 years met the Healthy People 2020 goal of 80% coverage for Tdap (88% coverage) and first dose of meningococcal vaccine (82% coverage), but did not meet the HPV vaccine benchmark (50% of females, 38% of males). Flu vaccine rates are especially low for teens (49% of 13- to 17-year-olds).
  4. What are common barriers to adolescent immunizations? Provider/clinic factors include not offering vaccines at acute visits, and not having follow-up visits; family factors include not coming for annual wellness visits. There has been particular parental concern about the HPV vaccine safety and need for it at a younger age. The HPV vaccine is only effective against HPV strains before exposure to the strains. Even before teens start having sex, they may be at risk for HPV related disease. HPV DNA has been detected in cervicovaginal swabs from girls who report never having had vaginal intercourse, so the virus is also transmitted through other forms of sexual contact. Data suggest better immunogenicity to the vaccine when given at a younger age, and teens are motivated that it is only 2 doses if done before age 15.
  5. What are ways we can help increase vaccination rates? A strong provider recommendation is one of the most important factors that positively affects vaccination, as has been shown in several studies for the HPV vaccine. Other strategies are to review immunization records at visit, offer immunizations at each visit, and schedule follow-up visits for the next vaccines due. System-level approaches include family-oriented ones like text reminders to families, web-based education and social marketing, as well as clinician-focused ones like automatic EMR reminders and incentives.

2018-19 TOW #45: Substance use

As pediatricians in primary care, our roles include universal screening, brief intervention, and referral to treatment (SBIRT) for adolescent substance use. After Washington state legalized adult use of marijuana in 2012, we entered a new era of adolescent substance use. One patient I saw under age 13 described in detail why marijuana was a “natural drug” that had medicinal properties to justify why she used it. The societal messages are confusing and often erroneous for teens, so it’s important for us to help provide accurate information and support.

Materials for this week:

Take-home points for substance use problems:

  1. What’s the epidemiology of youth substance use? Among US teens, average first use of alcohol is 13.1 years, ~50% have tried alcohol by 8th grade, and almost 80% have tried it by high school graduation. >50% have tried other drugs by the end of high school, most often marijuana, and ~20% have used prescription drugs non-medically (a BIG increase).
  2. What are the risk factors for substance abuse? Parents with substance abuse, history of abuse, depression or learning disabilities (especially ADHD), family conflict, friend use, and  living in a rural area. Data have shown that those who drink prior to age 15 years are 4 times more likely to develop alcohol use disorder than those who start at age 21. Protective factors include a stable, supportive home environment with clear parental expectation and rules, friends not involved with substances, and personal, academic and social success.
  3. What are the associated problems with substance use? There are many including school drop-out, violence, motor vehicle accidents, pregnancy, and permanent decrease in IQ with prolonged use. Youth getting Ds and Fs in school are 3x more likely to be using alcohol than those getting As.
  4. How should we screen? Use the HEADSSS assessment to screen all youth. It’s helpful to frame this as a “we care about you, teenage years can be hard, and we want to help.” It is also recommended to ask parents and teens together what they have talked about and their attitudes. If concerned, follow-up with the CRAFFT assessment: 2 or more positive responses are predictive of problem use.
  5. Where can we refer? Options to address problem use include mental health counseling and specific substance use treatment. Local resources: Adolescent medicine at SCH, and community programs such asRyther Center for Children and Youth and Therapeutic Health Services

2018-19 TOW #35: Menstrual disorders

As we help with the process of puberty, addressing the challenges that arise with menarche and menstrual disorders in adolescents is a common issue we see in primary care. This is a great topic for seniors who have done their adolescent rotation to facilitate.

Materials for this week:

Take-home points for this week:

  1. How is the menstrual cycle different for adolescents than fully mature females? In adolescents the hypothalamic-pituitary-ovarian (HPO) axis feedback loops are not yet mature. For the first 1-2 years after menarche, steroid hormones do not yet regularly have coordinated negative and positive feedback loops to cause ovulation, so menstrual cycles may be anovulatory or infrequent /irregular (oligoovulation). In the first year after menstruation, ~50% of cycles are anovulatory. One of the most difficult aspects of these cycles for teens is that they can cause prolonged and/or unpredictable bleeding.
  2. What’s considered a “normal” cycle for a teen? AAP and ACOG define normal menstrual cycles for adolescents as having an interval of 21–45 days with the duration of flow lasting <=7 days, and average product use of 3-6 pads/tampons per day. We should be concerned when there’s heavier bleeding (soaking through products after 1-2 hours), cycles >90 days apart for even one cycle, or a change from regular to very irregular.
  3. What defines “abnormal uterine bleeding (AUB)”? Bleeding that’s heavy or prolonged or occurs outside normal menstrual cycles. Ovulatory AUB, or heavy menstrual bleeding, occuring as part of the usual cycle, is most commonly caused by uterine problems (i.e., endometrial polyps, leiomyomas, malignancy) or bleeding disorders. Ovulatory dysfunction is AUB that presents as irregular, heavy, or frequent episodes of bleeding without a clear pattern. While this is usually from anovulatory cycles, it’s considered a diagnosis of exclusion; other causes to consider would be endocrine disorders, pregnancy and infection.
  4. When working up AUB, what are key parts of the history and physical? In addition to regular elements of H&P, we should obtain 1) Menstrual history: timing of menarche, usual frequency, duration, and volume of bleeding, presence of menstrual cramps, when/how did menstrual bleeding change, and any medical problems or lifestyle changes or other events that coincided with the change; 2) confidential HEADSSS review of substance use, sexuality, sexual activity, exposure to STIs, contraception, and any history of sexual abuse; 3) related ROS including symptoms of PCOS, thyroid disease, bleeding disorders, pelvic infection, anemia, psychosocial disorders like eating disorders/female athlete triad; and 4) physical exam including external genitalia; consider a full pelvic exam in sexually active females.
  5. What tests would you obtain? Depending on the presentation, appropriate lab testing could include a urine pregnancy test or quantitative hCG level, CBC, TSH, and iron studies. If there’s heavy bleeding, check coagulation studies including von Willebrand panel and possibly platelet function. An androgen panel would be useful if a patient is hirsute or has significant acne. An ultrasound would be done to help evaluate pelvic anatomy, uterine abnormalities and endometrial thickness – usually it could be done transabdominally, but transvaginal can provide better anatomy if patient is sexually active and more detail is needed.

2018-19 TOW #33: Adolescent Contraception

This week we will review contraception, with a big thank you to adolescent specialists Taraneh Shafii MD MPH and Emily Ruedinger MD MPH for sharing their terrific expertise in this topic.

Materials for next week:

Take-home points:

  1. Epidemiology: Whereas rates of teen sexual activity between ages of 15-19 have been relatively stable, the rates of teen pregnancy, birth, and abortion have all been declining thanks to more appropriate condom and birth control use. About 47% of 9-12 graders report having had sex in national surveys, with 59% having used a condom before last sex, 19% having used birth control pills, and 5% using other forms. Even with decreasing rates, rates of teen pregnancy in the US are about twice rates in Europe, with the CDC reporting 1 in 4 adolescent girls will become pregnant by age 20.
  2. What’s the most common birth control among adolescents? Condoms are the most commonly used form by teens, with 90% reporting using at least once. Condoms have a failure rate up to 25%. Next most common are combined oral contraceptive pills (COCs); the failure rate is 8-9% for typical use and up to 25% for teens. Other combined hormonal forms including the transdermal patch and vaginal ring, which may be more effective among teens as they don’t require daily dosing. Injectable progestin-only hormonal method (Depo-provera) lasts for 12 weeks and is more effective, but is associated with weight gain and some bone density loss with longer term use.
  3. What’s the most effective birth control? Remember, IDEAL is DUAL USE: CONDOMS + another form. The long-acting reversible contraceptives (LARCs) including implantable (e.g., Nexplanon) and intrauterine devices (IUDs) are most effective pregnancy prevention (less than 1% failure rate), and are now recommended as first-line for adolescents. Nexplanon is inserted into the subcutaneous tissue of the upper arm and lasts 3 years; the main side effect is irregular menstrual bleeding, and 15% of individuals amenorrheic at one year. IUDs last longest, but require a pelvic exam to insert. The hormonal IUDs (Mirena-up to 7 years, Kyleena- up to 5 years, Liletta -up to 7, Skyla – up to 3 years) are better for decreasing bleeding overall. The copper IUD (ParaGard) has no hormones, lasts up to 12 years, can be inserted as emergency contraception, yet is associated with more bleeding and cramping.
  4. What myths about IUDs do we need to dispel? 1) IUDs do not increase a woman’s risk of pelvic inflammatory disease (PID), as long as she’s not infected at time of insertion. 2) If exposed to gonorrhea or chlamydia post-insertion, treatment can occur without IUD removal. 3) IUDs can be used in females who have not yet conceived and do not increase the risk of infertility; fertility returns to baseline within 1-2 months post-removal.
  5. What needs to happen in a visit to start COCs?
  • Brief medical and sexual hx, including date of last unprotected sex and current meds.
  • Blood pressure and weight. Pelvic exams are no longer needed
  • Negative pregnancy test
  • Provide affirmation and education, as well as condoms and advance emergency contraception

2018-19 TOW #31: Promoting wellness & self-care

As we head into the Valentine’s week, we will discuss some ways to teach how to love and care for ourselves and how to promote wellness among our patients. While teens may be notorious narcissists, they need to be given support in how to actually care for themselves.

Materials/Resources for this week:

Take-home points for promoting wellness and self-care among our patients:

  1. Rising concerns about teen stress and mental health: As rates of depression and anxiety have risen for kids and teens, pediatricians are called upon to become more comfortable discussing these conditions, and what we can do to prevent and treat them. Many teens may take some time to warm up to the idea of seeing a therapist or another provider, so we will be their first stop, and sometimes the only one.
  2. Priorities for wellness promotion: Most importantly, we can focus on basics: sleep, nutrition, and physical activity. Increasingly tools like mindfulnessrelaxation skills (e.g. breathing techniques, stretching), biofeedback, mindful eating, and positive psychology practices like offering gratitude have shown success among youth.
  3. Wellness skills can be learned and practiced: long before the frontal lobe is fully developed, youth can learn and practice self-care and wellness. These skills are not necessarily innate, so we get better with practice: think of them like exercises for the mind. I often remind patients that even professional athletes get a lot of help to manage stress and build skills to perform at the top levels.
  4. Offer resources for parents to support their children/teens: Parents offer guidance, resources, and role modeling and may need help themselves in navigating challenges. We can support parents’ self care and offer resources, like those here.
  5. Walk the talk: “Doctor, heal thyself” is a well known expression in medicine. As we become familiar with self-care approaches and resources, we can use this to help patients. Teens appreciate knowing that the adults around them are human and have to keep learning too. We can be deliberate about acknowledging the need for and benefit of self-care/wellness amidst the daily stressors of life.

2018-19 TOW #16: Precocious Puberty

Time for more talk of puberty – this week we will discuss what happens if there are signs it’s happening too early.

Materials for this week:

Take-home points:

  1. How do we define precocious puberty? Development of pubertal changes occuring 2.5 standard deviations below mean age. Traditionally, that’s been <8 years for girls and <9 years for boys based on data from Europe in the 60’s. More recent cross-sectional data in the US has shown thelarche is occuring up to 2 years earlier in African American girls and 1 year earlier among white girls. However, the timing of menarche has only been about 4 months earlier than in prior studies. There’s less clear evidence of earlier puberty onset for boys. Many endocrinologists still use the <8 year cut-off, but it’s somewhat controversial.
  2. What are factors associated with precocious puberty? These include female sex, family history of early puberty, low birthweight or overweight/obesity in infancy or early childhood, exposure to endocrine disrupting hormones, and international adoption. The link with obesity is especially strong – probably due to effects of multiple hormones including leptin, insulin and estrogen.
  3. What are the types of precocious puberty? Most cases in girls are due to central early activation of the hypothalamic-pituitary axis (also known as gonadotropin dependent or complete precocious puberty). These can be from CNS tumors but are most often idiopathic. Much less common for girls is the peripheral form – sex steroids from ectopic or exogenous sources (also called gonadotropin independent or incomplete precocious puberty). Sources of excess estrogen production include follicular cysts, ovarian tumors and adrenal tumors, severe hypothyroidism. It can also be McCune-Albright syndrome, a rare genetic mutation leading to uncontrolled estrogen that includes café au lait spots, osseous lesions, and multiple endocrinopathies. Boys are more likely to have the peripheral form, especially from congenital adrenal hyperplasia (CAH).
  4. What should evaluation include? Physical exam to assess height, weight, and Sexual Maturation (Tanner) stage, findings of potential endocrinopathy (café au lait spots, acanthosis, signs of hypothyroidism). Females should be examined for estrogenization of the labia and vaginal tissue. A radiographic bone age should be obtained. Consider pelvic ultrasound to view ovaries if peripheral form is suspected. Labs should be obtained in consultation with an endocrinologist and may include early morning plasma estradiol, LH/FSH, and thyroid function. If there is adrenarche, add plasma DHEA, DHEAS, and 17-hydroxyprogesterone. GnRH stimulation test is the gold standard for central precocious puberty. When there is central precocity, especially before age 6, MRI would be used to assess for CNS lesions.
  5. What are adverse outcomes? Biggest are decreased adult height and psychosocial impact such as early sexual activity and drug and alcohol use. When appropriate, we may treat with a GnRH analog like leuprolide to slow central precocious puberty – this is considered generally safe and effective to delay puberty progression and improve adult height.

2018-19 TOW #15: Puberty – Normal and Delayed

It’s time to talk puberty! We will review normal/delayed this week followed by precocious puberty next week. The puberty topic is getting a little more airtime at my house with a 9.5 year old at home. We are gearing up for the highly acclaimed puberty classes, offered through SCH for 10-12 year olds.

Here are the materials for this week:

Normal and delayed puberty take-home points:

  1. What is puberty and what triggers it? Puberty is the process of normal sexual maturation culminating in full reproductive capability. Pubertal changes are due to increased secretion of sex steroids (gonadarche) triggered by the release GnRH from the hypothalamus and release of LH and FSH from the anterior pituitary. The genetic trigger for puberty is still not well understood. NOTE – Terminology is changing now: what used to be “Tanner Staging” is now more often being referred to in the literature as “Sexual Maturation Rating (SMR)” – see article for updates.
  2. When does puberty start for girls and what is the sequence? For females, average puberty onset is 11 years, but normal range is considered from 8-14 years. The average duration of pubertal development is 3 years (range of 2-6 years). Thelarche, the onset of breast development, is usually the first visible evidence of puberty in girls. The growth of pubic hair usually follows within the next 6 months, along with a growth spurt. Menarche usually occurs 2 years after the onset of pubertal breast growth and coincides with SMR (aka Tanner) Stage IV. After menarche, girls grow 4-6 cm on average (varies a lot), and finish growing within two years. Generally, early menarche is correlated with shorter adult height.
  3. When does puberty start for males and what is the sequence? For males, average puberty onset is 12 years (normal range 8-14). Increased LH, FSH, and testosterone cause testicular maturation and enlargement. Increased testicle size is the first visible evidence of gonadarche, though often not recognized until the growth of penile length and pubic hair, typically within 6 months. As the testicles mature, other physical features virilize including increased muscle mass and voice deepening. Facial hair growth usually happens 3 years after pubic hair onset. Pubertal growth spurt is later in males, and puberty lasts longer (typically 5 years).
  4. How do we identify delayed puberty? Delayed puberty is more common in boys than girls. Delay is considered as no pubertal changes by 13 in girls and 14 in boys. Work-up for both sexes includes reviewing weight gain and linear growth, obtaining a bone age, and looking for other evidence of endocrinopathy such as panhypopituitarism or hypothyroidism. Laboratory studies include serum LH and FSH levels, growth hormone secretion, thyroid function and, in males, a morning testosterone level. Typically, these patients should be referred to endocrinology.
  5. What are the causes of delayed puberty? Delayed puberty is divided into causes based on serum LH/FSH levels: 1) normal/low (constitutional delay and hypogonadotropic hypogonadism (e.g., CNS tumors, endocrinopathies) and 2) elevated (hypergonadotropic hypogonadism or gonadal failure)-most common cause among these is Klinefelter Syndrome in boys and Turner Syndrome in girls.

2018-19 TOW #11: Bullying

With return to school and National Bullying Prevention Month coming up, this is an opportune time to discuss bullying. Bullying has received increasing attention and concern for children’s health in recent years. The effects of bullying can be devastating, and our role in identifying, discussing, and addressing bullying is really important. Our esteemed and internationally known child health and injury prevention expert at Harborview, Dr. Fred Rivara MD MPH, chaired a panel for the Institute of Medicine to report on bullying and how to prevent it.

Materials for this week:

Take-home points:

  1. How do we define bullying, and what are the forms? Bullying is an intentional, aggressive and repeated behavior that involves an imbalance of power or strength. The power difference can be in size, age, political, economic, or social advantage. Bullying includes physical, verbal, social (trying to hurt a person’s reputation within a group or organization), cyberbullying, and cyber harassment (bullying by an adult online).
  2. How frequent is bullying? Estimates are that ~20-30% of youth in the US report being bullied, and 1 in 3 youth is affected either as a victim or perpetrator or both. Cyberbullying is estimated for 7-15% of youth. While “bully” conjures up certain images, most kids who are bullying are typically developing boys and girls who are learning to navigate their social world.
  3. What are the effects of bullying? All forms of bullying can lead to physical illness, low self-esteem, anxiety and depression, including becoming suicidal. Some victims may also become bullies themselves.
  4. What are risk factors and how do we identify it? Risk factors for aggressive behavior include depression, school problems, living in violent communities, and having parents who are absent, abusive, or disengaged. Risk factors for being a victim include developmental or physical differences, such as intellectual disability or obesity and LGBT status. Red flags include somatic complaints, decreased motivation/school performance, avoiding school, frequently losing items or asking for money, unexplained injuries, and threatening to hurt self or others.
  5. What can we do to help prevent bullying? Ask questions to help screen. “Do you ever see kids picking on other kids?” “Do kids ever pick on you?” “Do you ever pick on kids? (And tell the truth; you’re not in trouble.)” The motto often shared is “Telling is not tattling. It is getting someone help” (not just to get someone in trouble). When we identify bullying, we should take concerns seriously. We should talk to children and their parents and provide counseling about the importance of getting help from an adult. We should contact school personnel directly if we are concerned they are not adequately addressing it. We should also refer the child to a therapist or counselor for help.