TOW #46: Adolescent immunizations

There's a lot going on in adolescence, including trying to complete additional recommended vaccines. There's been a bigger emphasis on completing newer immunization series recommended for adolescents, the most controversial being HPV. We will review some of the barriers and recommendations to address this.

Materials for this week:

Key take-home points:

  1. What types of practice settings do adolescents use? Most teenagers do 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 adolescent immunization rates in the US? The 2014 National Immunization Survey results showed that vaccination rates among adolescents ages 13-17 are improving, but are still consistently lower than among young children. Coverage rates in 2014 were: Tdap -88% coverage, quadrivalent meningococcal conjugate vaccine or MCV4-79%, and HPV vaccine Girls:>1 dose [60%], 3 doses [40%]; Boys: >1 dose [42%], 3 doses [22%].
  3. What are the recommended vaccines for pre-teens and adolescents? Starting at age 11, we recommend a 2-dose meningococcal series, single dose of Tdap, 2-dose HPV vaccine series (2 doses if started before age 15; 3 doses if started at 15+ yo), and an annual influenza vaccine.
  4. What are common barriers to adolescent immunizations? Provider/clinic factors include not offering vaccines at acute visits, and not having follow-up visits; and 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 intercourse, they may be at risk for HPV related disease. In fact, HPV DNA has been detected in cervicovaginal swabs from girls who report never having had sexual intercourse, so the virus is also transmitted through other forms of sexual contact. Some data suggest better immunogenicity to the vaccine when given at a younger age.
  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 every visit, offer immunizations at each visit, and schedule follow-up visits for the next vaccine due.

TOW #45: Newborn circumcision

Newborn male circumcision is a topic that remains controversial in pediatrics, and overall the AAP has maintained a neutral stance on it. The most recent reports from the AAP were issued in 2012 with our own Dr. Doug Diekema as one of the authors on the policy statement. In reviewing the evidence, they declared that, overall, male circumcision has adequate benefits compared to risks to "justify access to the procedure for families who choose it." In Washington State, families who choose circumcision must pay for the procedure out of pocket. At the UW Northgate Clinic, one of the sites recommended from the UW nursery, it costs about $300. We are often called upon to discuss the procedure and evaluate complications, so let's review.

Materials for this week:

Key take-home points:

  1. What are the main benefits of circumcision and what are the main risks? Benefits include decreased risk of UTI before age 2, and decreased risk of heterosexual transmission of STIs including HIV, HPV, HSV-2, and bacterial vaginosis in female partners. It may reduce the risk of penile cancer, which is rare overall. Complication rate is about 0.2% and mostly minor, including bleeding (0.1%), infection (0.06%) and penile injury (0.04%). There are also known later complications, such as adhesions, phimosis, inclusion cysts, and poor cosmetic outcome. Contraindications include known bleeding disorders, penis malformations including chordee, hypospadias, epispadias, and buried penis.
  2. What are the 3 most common circumcision procedures? There are many types of approaches/devices, but the Gomco, Plastibell and Mogen (or Mogan) are the most commonly used (see videos above for all 3). Gomco and Mogen use scalpel dissection to cut the tissue and have a higher risk of bleeding. Plastibell technique uses a tying off of tissue with the Plastibell ring (minus handle), residual foreskin, and suture remaining on the glans and falling off in 5-7 days. All procedures should have appropriate analgesia, ideally with a dorsal penile or subcutaneous ring block, less helpful is topical lidocaine/prilocaine. Adjunctive oral sucrose can be used but should not be the sole analgesia.
  3. What key anticipatory guidance should we provide regarding circumcision care? After circumcision, the glans can appear red and raw from lysing foreskin adhesions, and can be somewhat worrisome to parents. Swelling peaks 24-48 hours after the procedure and there may be fibrinous exudate as the glans heals. Parents should clean with warm water and mild soap if fecal material gets on the penis. Fortunately, infection is rare; observe for increasing redness, swelling, pain or purulent discharge. For circumcisions done with sharp dissection (Gomco or Mogen), parents should apply petroleum jelly on a gauze pad over the penis tip with each diaper change for 1-2 weeks until the skin is epithelialized. Plastibell circumcisions do not require vaseline but observe for slippage of the bell or difficulty urinating.
  4. When is referral indicated for management of circumcision problems? What about for later circumcision? Most often referral to urology after circumcision is for addressing redundant foreskin, meatal stenosis, and adhesions or skin bridges. Later medical circumcision might be considered for recurrent UTI, phimosis or paraphimosis, or high risk of UTI (high grade vesicoureteral reflux, bladder neck obstruction hydronephrosis, posterior urethral valves). 
  5. What advice do we give about care for the uncircumcised penis? The only care needed is washing the external surface with soap and water and not retracting the foreskin, which can cause pain, bleeding and lead to paraphimosis, when it becomes stuck in the retracted position. Only 4% of uncircumcised infants have completely retractible foreskin initially. Most babies have physiologic phimosis (inability to retract the foreskin), which usually resolves by age 3 in about 90% of boys, and by teenage years in almost all boys. 

TOW #44: Temperament in the pediatric visit

Temperament is a great topic to integrate discussion about parenting approaches, and recognizing child needs/preferences. For those of you who have had Promoting First Relationships (PFR), this would be a good time to review with your colleagues how approaches might help teach parents to recognize child needs, including temperament. Remember that PFR handouts are available for each of the well visits and all clinics have received these. I've found them really helpful in anticipatory guidance and addressing parents' behavior/development concerns.


Take-home Points

  1. What is the definition of temperament and its underlying theory? Temperament is a little challenging to explain conceptually, but can be generally thought of as that aspect of us that influences the way we self-regulate and react in different situations. Temperament is associated with both emotions and behavior. It emerges early in life, is largely influenced by genetics, and mostly stable over our lifetime. We know temperament can affect developmental pathways and be associated with future psychopathology, but it has been difficult to agree on a consistent definition and exactly how this influences children's behavior and future.
  2. How many different temperament types are there? There are generally thought to be about 10 main temperament traits that can be assessed in childhood (adaptabillity, approach, sensory sensitivity, reactivity, distractibility, persistence, mood, regularity and emotional sensitivity). There are 3 main temperament clusters in childhood, as characterized by researchers Chess and Thomas: "easy" children, "slow to warm up" and "difficult," based on combinations of traits including impulsivity/self-control, high/low positive emotionality, and high/low negative emotionality. Easy children are, well, easy. "Slow to warm up" kids tend to be more careful, to have low adaptability to new situations, and to have difficulty separating from parents. "Difficult" children may be more irritable or fearful, have low adaptability and short attention span, have disordered sleep-wake-eat cycles, and may respond more intensely. I really love the framing of "spirited" for characterizing the "slow to warm up" and "difficult" temperament clusters in a more positive way. The book "Raising Your Spirited Child" by Mary Sheedy is a classic and definitely recommended reading for those who are parenting a child that is especially temperamentally challenging.
  3. How does parenting interact with temperament? We have to be really careful about labels and be sure use them to help parents recognize that some children are just more prone to having certain behavior/difficult reactions. This is not because they want to make life hard, but may just be how they are wired. Having parented a "slow to warm up" child through toddler years, I can say that it really did help me to learn about temperaments and have that knowledge to be empathic through some of the especially challenging times. Allowing parents to know it's not their fault when their child is easily upset can really help. Also, we can be aware of when their may be a temperament mismatch between parents and children. This may be really important for parents to recognize when there is not as good of fit between them and their child.
  4. How can we use concepts of temperament to discuss parental concerns? It's helpful to use open-ended questions to explore concerns and give parents a chance to step back to understand their child's perspective, such as "What do you think may be going on with her/him when you see this behavior? How do you think s/he is feeling?" Also exploring how parents may be reacting/ feeling to help you understand their perspective / temperament. Simply pausing to explore these factors more before offering any advice may allow parents insight into their child's and their own reactions, and help us provide better guidance and reflections to parents.

TOW #43: Substance use/abuse

As pediatricians in primary care, we should be using universal screening, brief intervention, and referral to treatment (SBIRT) for adolescent substance use. Since our state legalized adult use of marijuana, we have entered a new era of adolescent substance use. For example, we recently saw a patient in clinic under age 13 (already using multiple substances) who described in detail why “marijuana was a ‘natural’ drug” that had medicinal properties.  These are real issues, for sure.

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.
  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 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 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 treatmen. Local resources: Adolescent medicine at SCH offers online materials and a Adolescent Substance Abuse Program (ASAP). Additional community programs include Ryther Center for Children and Youth and Therapeutic Health Services