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 #32: Primary Care of Premature Infant

We love our babies in pediatrics, and we have the privilege to care for increasing numbers of babies that survive very premature birth thanks to the expertise of our amazing neonatologists and the many breakthroughs they have had in care in recent decades. Once babies graduate from the NICU, we can offer ongoing specialized care, reviewed here.

Materials for this week:

Take-home points

  1. How do we support families after graduation from the NICU? We can help families transition by assessing their social support and emotional health, sharing what to expect, and offering more frequent visits. We should explain how we use corrected age (subtract number of weeks of prematurity from their chronological age) to assess growth and development so they know what to expect.
  2. How long do we adjust growth parameters based on gestational age? Until infants reach a chronological age of 2 years, we should adjust height, weight, and head circumference for prematurity. Blood pressures should be assessed initially for all NICU grads, and followed regularly for babies with extra complications, such as BPD.
  3. To support adequate growth, how do we typically fortify feedings for premies? Babies under 2 kg or <28 weeks at birth typically receive a transitional formula of 22-24kcal/oz at discharge from the NICU. As infants demonstrate consistently good growth, and self-regulation of intake, they can be switched to term formula – often between 4-9 months, though may be longer for some. Premature formula provides extra calcium and phosphorus to prevent osteopenia of prematurity. Some recommend extra vit D (up to 1000 IU) for premies (compared to 400 IU for term infants). To prevent anemia, a MVI with iron should be provided for breastfed infants until 1 year to ensure the recommended 2mg/kg/day of elemental iron. Preterm babies typically start solids at 4-6 months adjusted age when showing appropriate cues.
  4. How should the vaccine schedule be adjusted? We give vaccines on the chronological age schedule. The only routine vaccine not given to premies in the hospital is the rotavirus vaccine as it is a live virus vaccine that can be shed. All family members should have Tdap and flu vaccines to “cocoon” infants and protect them from illnesses.
  5. What is the recommended neurodevelopmental follow-up? All high-risk neonates should be referred to early intervention or the state birth to three program. Premature infants should be monitored for development using standardized screening such as the ASQ. All infants who were in the NICU for 5 or more days should have formal audiologic screening done by 24-30 months, even if they passed the initial screen. Given the higher incidence of vision problems including ROP, amblyopia, strabismus and cataracts, vision should be evaluated by an ophthalmologist, typically around 8-10 months.

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 #30: Race and Medicine

Happy February! As we celebrate Black History Month in February, we are covering a critical topic affecting all children: bias and racism.* A big thank you to the input of many people on this topic and the efforts happening at SCH/UW, including our amazing residents and faculty in D-Comm, INCLUDE curriculum team, and the Center for Diversity and Health Equity (CDHE). Given the national dialogue and health disparities, it’s more important than ever that we use our roles as physicians to address bias and racism. While we honor the significant work that has come before us, we acknowledge there’s much more work yet to do. I’m grateful our children in Seattle Public Schools are also getting specific education this week with a national Black Lives Matter at school week.

*Note: This is a really big topic – try to review at least one article. In clinic, I suggest you watch Dr. Jones’ or Dr. Roberts’ TED talks and discuss how you have observed racism affecting health and personal ways we can try to make a difference.

Materials for this week:

Take-home points for this week – structured as a charge to each of us, as outlined from the article by Hardeman et al. in the NEJM

  1. Learn about, understand and accept racism – in ourselves and in our institutions. As Hardeman et al, describe “Most physicians are not explicitly racist and are committed to treating all patients equally. However, they operate in an inherently racist system. Structural racism is insidious, and a large and growing body of literature documents disparate outcomes for different races despite the best efforts of individual health care professionals. If we aim to curtail systematic violence and premature death, clinicians and researchers will have to take an active role in addressing the root cause.” Those who have had white privilege must be able to understand and recognize what that means to see the effects of racism in our society. Watch Dr. Camara Jones’ TED talk on the gardener story and effect of differential preference over time.
  2. Understand how racism has shaped our narrative and the rhetoric we have used in medicine to erroneously relate race to biologic differences. Medical schools are now recognizing the need to address the curriculum to better deconstruct race as a social rather than biologic construct, and we need more change (see Rebekah’s article above and R3 Paul Homer’s RCP this year). We must continue to educate ourselves about our societal and institutional structural racism and approaches to address this through writers such as Ta-Nehesi Coates, local writer Ijeoma Oluo, and UW-trained sociologist Robin DiAngelo. PBS’ Black Culture Connection features writers, community influencers, and movies/documentaries.
  3. Define and name racism – develop consistent definitions and use accurate vocabulary – Dr. Jones describes race as “the societal box into which others put you based on your physical features.” Racism is a “system that encompasses economic, political, social and cultural structures, actions and beliefs that institutionalize and perpetuate an unequal distribution of privileges, resources and power between White people and people of Color.” (Hilliard, 1992). We should shift our focus in medicine and health research from identifying race to identifying racism and its effects on health. We also need to name and discuss the concepts of race and racism with our children, especially white children. Great article about this in the Washington Post by a child development professor who also is in a mixed-race family. Most children by the ages of 5-6 have developed some sense of racial identity. We have found children’s books to be a great way to broach the conversations at our house. There’s also Teaching children about race – Modules 13 and 14 from the UW I-LABS (includes many fantastic video training resources about child development).
  4. Provide clinical care and conduct research that contributes to equity – As physicians we have opportunities to be change-makers and it starts with therapeutic alliances with patients and becoming aware of the resources available to us as pediatricians. Our residents are now shaping our own INCLUDE curriculum with talks from local experts like Roberto Montenegro MD PhD and Tumaini Coker MD MPH. As part of INCLUDE, this spring interns will receive a day-long Equity, Diversity and Inclusion training from the CDHE.
  5. Be aware of and join local efforts. UW President Ana Marie Cauce launched a Race and Equity Initiative in 2015 for the UW community to acknowledge and confront bias and racism at all levels. The Department of Pediatrics continues active efforts to address diversity and equity, thanks to the leadership and vision of many, including our residency’s Diversity Committee and CDHE. There are so many ways to continue to inform ourselves, and here are a few more: