Family planning in adolescents.

PURPOSE OF REVIEW: As politics continue to shape contraception and abortion care, providers have a responsibility to address the specific needs of the adolescent patient. Here we review the current literature on contraception and abortion in adolescents. RECENT FINDINGS: Shared decision-making among patients, parents, and providers is the cornerstone of successful adolescent family planning. Providers should be aware of local state regulations related to consent in minors. When provided directive and noncoercive contraception counseling at no cost, adolescents are motivated and effective decision-makers in their care. Long-acting reversible contraceptives should be offered as the first-line method of contraception in adolescents. SUMMARY: Family planning in adolescents presents unique challenges to obstetrician-gynecologists. Improved access to contraception and abortion services is significantly lowering unintended pregnancies rates in adolescents, but more data assessing the effectiveness of interventions in marginalized communities are needed.

[Treatment for children and adolescents with pain in Spain: data from a survey on current specialized programs]. / El tratamiento del dolor en población infantojuvenil en España: Datos de una encuesta sobre los programas especializados existentes.

OBJECTIVE: The treatment of children and adolescents with pain has improved considerably in the last 30 years. In Spain, progress is also evident, and specialized units or programs have emerged as part of the care provided for this population. However, there are no studies on the characteristics or activities of these specialized units or programs. This lack of information prevents an adequate evaluation of the current procedures, and hinders an adequate administration and management of these resources. The objective of this work was to study the characteristics of these units and programs for the treatment of children and adolescents with pain in Spain. METHODS: A total of 10 specialized units or specific treatment programs for pediatric pain in Spain were identified, and the person responsible was contacted. Through a self-administered online survey, information was collected on the organization of the program, the involvement in relevant fields such as research, training of professionals and the raising of awareness and visibility of the problem, the specialties involved, the type of treatments offered, the evaluation of results and the services provided. RESULTS: Of the ten units or programs contacted, eight answered the survey (80%). Pain programs for children and adolescents proved to be primarily pharmacological, also for chronic pain. They reported to promote awareness about the problem (88%), to contribute to the training of specialists (88%) and to a lesser extent to research and knowledge generation (75%). CONCLUSIONS: This survey provides valuable information on the current characteristics of specialized programs and units for the treatment of children and adolescents with pain in Spain, and can be used to propose actions that improve its current management and administration.

OBJETIVO: El tratamiento de la población infantojuvenil con dolor ha mejorado considerablemente en los últimos 30 años. En España, el progreso también es evidente, y han surgido unidades o programas especializados como parte de la atención a esta población, aunque no existen estudios sobre las características o la actividad de estas unidades o programas especializados. Esta falta de información impide una evaluación adecuada de los procedimientos vigentes y dificulta una adecuada administración y gestión de estos recursos. El objetivo de este trabajo fue conocer las características de estas unidades y programas para el tratamiento de la población infantojuvenil con dolor en España. METODOS: Se identificaron un total de 10 unidades especializadas o programas de tratamiento específicos del dolor infantil en España y se contactó con la persona responsable. A través de una encuesta autoadministrada online se recogió información sobre la organización del programa, su implicación en ámbitos relevantes como la investigación, la formación de los profesionales, la sensibilización y visibilidad del problema en la sociedad y entre los profesionales, las especialidades implicadas, el tipo de tratamientos que se ofrecen, la evaluación de resultados y los servicios prestados. Se han utilizado medias y porcentajes para describir los resultados. RESULTADOS: De las diez unidades o programas contactados, ocho contestaron a la encuesta (80%). Los programas de tratamiento del dolor infantojuvenil demostraron ser fundamentalmente farmacológicos, también en los casos de dolor crónico. Informaban de que se preocupaban por impulsar la sensibilización de los especialistas y la sociedad sobre el problema (88%), de contribuir también a la formación de especialistas (88%) y, en menor medida, de investigar y generar conocimiento (75%). CONCLUSIONES: Esta encuesta proporciona información valiosa sobre las características actuales de los programas y unidades especializadas para el tratamiento de la población infantojuvenil con dolor en España. Puede servir para proponer acciones que mejoren la gestión y administración actual.

The future of paediatric and adolescent gynaecology in Europe.

Paediatric and Adolescent Gynaecology (PAG) is a subspecialty under the umbrella of Obstetrics and Gynaecology but linked to other branches of medicine including Paediatrics, Surgery, Endocrinology and Urology. Therefore future developments in clinical care and education requires a multidisciplinary approach combining aspects of all the above medical specialties, and also with inputs from Public Health, Genetics, Radiology and Psychology. A multidisciplinary collaboration among different specialists is as important as the establishment and adoption of standards in education, training and management. PAG in Europe has evolved from its first steps and it is still growing with the aim of providing increasing protection of the gynaecological and reproductive health of female children and adolescents. In fact, without proper advice and care, inappropriate management of gynaecological issues in childhood and adolescence can be expected to have significant repercussions throughout later years, and into adulthood. The aim of this third paper in this mini-symposium is to explore how PAG should develop in Europe in the near future.

Workforce Trends and Analysis of Selected Pediatric Subspecialties in the United States.

OBJECTIVE: To update pediatric subspecialty workforce data to support evidence-based legislation and public policy decisions by replicating the American Academy of Pediatrics' 1998 Future of Pediatric Education (FOPE II) workforce survey. METHODS: A descriptive and comparative analysis of survey responses from 9950 US pediatric subspecialists who completed an electronic survey. RESULTS: Pediatric subspecialists are working fewer hours and spending less of their time in direct patient care than they did in 1998 but the mean hours worked differs significantly according to subspecialty. Most subspecialists continue to be board-certified, white, non-Hispanic men, although the percentage who are women and from minority groups has increased. The proportion of subspecialists practicing in an academic medical center has increased since 1998. Thirty percent of pediatric subspecialists reported appointment wait times of >2 weeks and pediatric subspecialists in developmental pediatrics, endocrinology, and neurology identified much longer wait times than other subspecialists. CONCLUSION: The demographic and practice characteristics of pediatric subspecialists have changed since the FOPE II survey and access to subspecialty care in a family's community remains a challenge. However, pediatric subspecialties are not monolithic and solutions to workforce shortages will need to take into account these differences to improve access to subspecialty care.

Not Missing the Future: A Call to Action for Investigating the Role of Regenerative Medicine Therapies in Pediatric/Adolescent Sports Injuries.

In August 2016, a group including sport medicine clinicians, researchers, and a bioethicist met in Vail, Colorado to discuss regenerative medicine and its potential role in youth sports injuries. There was consensus that a call to action is urgently needed to understand the current evidence base, the risks and rewards, and future directions of research and clinical practice for regenerative medicine therapies in youth sports. We present here a summary of our meeting, which was supported by the National Youth Sports Health and Safety Institute (NYSHSI), a partnership between the American College of Sports Medicine (ACSM) and Sanford Health. The group's goal is to educate practitioners and the public, and to pioneer a means of accumulating meaningful clinical data on regenerative medicine therapies in pediatric and adolescent athletes.

[HBSC Study as an Instrument for Health Reporting among Children and Adolescents - Potential and Limitations]. / HBSC-Studie als Instrument der Gesundheitsberichterstattung im Kindes- und Jugendalter - Potenziale und Grenzen.

Prevention and health promotion have to target children and adolescents. Health reporting significantly contributes to assess the needs in terms of intervention planning in children and adolescents and to plan interventions of the highest priority. In Germany, reporting on children and adolescent's health takes place at federal, federal state and regional levels. Health reporting is based on surveys or monitoring, official statistics or on other data provided by institutions and stakeholders in the health system. The nationally representative Health Behaviour in School-Aged Children (HBSC) survey under the auspices of the WHO - which has been conducted every 4 years since 1982, is a further database in Germany that is representative for the 11-15-year olds girls and boys from general educational schools. In this paper, the HBSC survey will be located within the canon of the German health reporting system. A special emphasis is to describe the potential and limitations of HBSC study for health reporting and to highlight the additional value for health reporting in Germany.

Accreditation of Adolescent Medicine as a pediatric sub-specialty: the Canadian experience and lessons learned.

The Royal College of Physicians and Surgeons of Canada (Royal College) has an extensive process for recognizing new specialties and subspecialties. Among other requirements, the process requests that the applicants demonstrate that sufficient scientific breadth and depth exists within the proposed field, that a unique field of clinical practice exists, and that there is a societal need for individuals with this distinct area of specialization. In 2004, a group of adolescent medicine specialists from across Canada started the application process for the field to become an accredited pediatric subspecialty. A 3-year process was undertaken to demonstrate the need for accreditation of this new and emerging discipline. In 2007, Adolescent Medicine became the 63rd discipline and a sub-specialty of Pediatrics. This paper provides an overview of the process that led to the accreditation of Adolescent Medicine by the Royal College and offers insights into the lessons learned from this Canadian experience.

Adolescent and young adult medicine in Australia and New Zealand: towards specialist accreditation.

In Australia and New Zealand, a critical mass of academic and clinical leadership in Adolescent Medicine has helped advance models of clinical services, drive investments in teaching and training, and strengthen research capacity over the past 30 years. There is growing recognition of the importance of influencing the training of adult physicians as well as paediatricians. The Royal Australasian College of Physicians (RACP) is responsible for overseeing all aspects of specialist physician training across the two countries. Following advocacy from adolescent physicians, the RACP is advancing a three-tier strategy to build greater specialist capacity and sustain leadership in adolescent and young adult medicine (AYAM). The first tier of the strategy supports universal training in adolescent and young adult health and medicine for all basic trainees in paediatric and adult medicine through an online training resource. The second and third tiers support advanced training in AYAM for specialist practice, based on an advanced training curriculum that has been approved by the RACP. The second tier is dual training; advanced trainees can undertake 2 years training in AYAM and 2 years training in another area of specialist practice. The third tier consists of 3 years of advanced training in AYAM. The RACP is currently seeking formal recognition from the Australian Government to have AYAM accredited, a process that will be subsequently undertaken in New Zealand. The RACP is expectant that the accreditation of specialist AYAM physicians will promote sustained academic and clinical leadership in AYAM to the benefit of future generations of young Australasians.

Training international medical graduate clinical fellows: the challenges and opportunities for adolescent medicine programs.

Adolescent medicine achieved accreditation status first in the United States in 1994 and then in Canada in 2008 and even if it is not an accredited subspecialty in most other Western nations, it has still become firmly established as a distinct discipline. This has not necessarily been the case in some developing countries, where even the recognition of adolescence as a unique stage of human development is not always acknowledged. The program at SickKids in Toronto has prided itself in treating its international medical graduates (IMG) clinical fellows the same as their Canadian subspecialty residents by integrating them seamlessly into the training program. Although this approach has been laudable to a great extent, it may have fallen short in formally acknowledging and addressing the challenges that the IMG trainees have had to overcome. Moving forward, faculty must be trained and supports instituted that are geared specifically towards these challenges. This must be done on a formal basis to ensure both the success of the trainees as well as the overall enrichment of the fellowship training programs.

Opportunities and challenges in adolescent health training abroad: trainees' experience and perspective.

As the global adolescent population increases and as there is enhanced recognition internationally of the unique nature of the adolescent period, the need for specialized training in adolescent medicine for international physicians becomes more apparent. There are challenges in securing placement in an adolescent medicine fellowship program, as well as, on acceptance, challenges with acculturation to a new setting, socially, academically and clinically. During fellowship, international medical graduates (IMGs) are exposed to new opportunities such as learning best-practices and being mentored by experienced advocates and clinicians in the field of adolescent health and medicine. This paper considers recommendations for improving adolescent medicine fellowship programs with a focus on IMGs.

The role of Society for Adolescent Health and Medicine in training of health professionals.

The Society for Adolescent Health and Medicine (SAHM) was created by health professionals committed to identifying and better addressing the health needs of adolescents and young adults, and this work has continued for nearly 50 years. The society initially focused primarily on clinical education, but has evolved to include educational activities providing clinical, research, policy, advocacy, and professional development content. Strategies have included high-quality annual meetings designed to meet the educational needs of its multi-disciplinary membership, publishing an internationally recognized journal, and developing strategic collaborations to advocate for legitimacy of the field and reform in health profession education. Historically, SAHM has been most successful at increasing specialized training in the United States among physicians, and primarily pediatricians, likely driven by the nuances of the development of adolescent medicine in this country. Successes are often linked to strategic collaborations with other professional organizations, and have been facilitated by federally funded initiatives to improve adolescent and young adult health. Recent efforts to improve professional training are focused on the use of technology, and SAHM is also currently exploring strategies to directly reach adolescents, young adults, and their parents. As the society becomes increasingly multidisciplinary and international, members have extraordinary opportunities to learn from each other, build upon lessons learned, and collaborate. Descriptions of the history of SAHM's training-focused efforts, selected highlights, and current priorities will be used to illustrate this long-standing commitment to the training of health professionals.

Adolescent health in the Caribbean region: insights from the Jamaican experience.

Adolescent health in Jamaica and the wider English-speaking Caribbean has over the past three decades advanced in achieving improved healthcare services for adolescents. The path taken to achieve success thus far is reviewed - including a historical perspective on the services offered, revision of the relevant policy and legislation frameworks, improved service delivery through education and training of relevant stakeholders and providers, improved youth participation, and sustained involvement of advocates.

Adolescent health in Asia: insights from Thailand.

BACKGROUND: Adolescence in an age of opportunity in Thailand. The main health issues of this age group are related to pregnancy, injuries and poisoning, all which should be preventable. OBJECTIVE AND METHODS: This article presents the experiences of Thai physicians, who received adolescent medicine fellowship training in North America and brought their experience, knowledge, skills, and adolescent health care principles and practice back to Thailand. The anticipations and the facts faced in everyday practice, training, research, and collaboration in a place with their own culture and societal norms are described. RESULTS: Currently, there are six adolescent medicine specialists who work with experienced specialist in the subcommittee of adolescent health under the Royal College of Pediatricians of Thailand. There has been collaboration with both the public sector and health care sector, government and non-government organizations with regards to health care service and promotion. Many hospitals especially residency training institutes have increased the cut-off age of patients to be seen by pediatricians to 15 or 18 years of age. Since 2011, adolescent medicine was made one of the mandatory rotations in all pediatric resident training programs. CONCLUSION: There is still more work to be done - issues around policies for confidentiality and a lower age of consent, collaboration between other specialties to enable a large-scale youth-friendly one-stop services, and multicenter research opportunities are still awaiting.

Selected highlights of the VIII International Symposium of Clinicians for Endocrinopathies in Thalassemia and Adolescent Medicine (ICET-A) on Growth, Puberty and Endocrine Complications in Thalassaemia. Auditorium of the Sultan Qaboos University (SQU) Muscat (Sultanate of Oman), 20th of December 2014.

The VIII ICET-A International Symposium was held in Muscat (Sultanate of Oman) on the 20th of December, 2014. The symposium included four sessions on a wide range of topics covering growth disorders and endocrine complications in thalassaemia. Despite the fact that endocrine complications are very common in multi-transfused thalassaemia patients a recent survey conducted by the International Network of Clinicians for Endocrinopathies in Thalassemia and Adolescent Medicine (ICET-A) in 2014 in Acitrezza (Catania, Italy) showed that the major difficulties reported by hematologists or pediatricians experienced in thalassaemias or thalassaemia syndromes in following endocrine complications included: Lack of familiarity with medical treatment of endocrine complications, interpretation of endocrine tests, lack of collaboration and on-time consultation between thalassaemic centres supervised by haematologists and endocrinologists. Endocrine monitoring of growth, pubertal development, reproductive ability and endocrine function in general are essential to achieve a good quality of life as well as controlling the pain which results from the defects of bone structure, all of which increase with the age of patients. Such comprehensive care is best provided by coordinated, multidisciplinary teams working in expert centres. The multidisciplinary team must include an endocrinologist, preferably someone experienced in the management of hormonal deficiencies caused early in life by transfusion-induced iron overload.

Psychometric properties of the German version of the Diabetes Eating Problem Survey-Revised: additional benefit of disease-specific screening in adolescents with Type 1 diabetes.

AIM: To examine the psychometric properties of the German version of the abbreviated 16-item Diabetes Eating Problem Survey-Revised in a sample of young people with Type 1 diabetes. METHODS: A total of 246 young people, aged 11-19 years, with Type 1 diabetes from six pediatric diabetes centres in Germany were assessed using the Diabetes Eating Problem Survey-Revised. In addition, they underwent screening with two generic tools as well as the WHO five-question well-being index. A clinician's report was also obtained. RESULTS: The Diabetes Eating Problem Survey-Revised was found to have good internal consistency (Cronbach's α = 0.84). The Diabetes Eating Problem Survey-Revised scores significantly correlated with those provided by the non-specific screening tools (r = 0.37, P ≤ 0.000 and r = 0.50, P ≤ 0.000 for boys and r = 0.62, P ≤ 0.000 and r = 0.79, P ≤ 0.000 for girls), indicating convergent validity. The mean (sd) total of the scores was 12.0 (9.6). Criterion validity was confirmed against HbA1c value, BMI standard deviation score and expert (clinician) report. Of the boys included in the study, 11 scored higher than the threshold score on the Diabetes Eating Problem Survey-Revised, of whom only three (27%) were classified as 'suspected to have a disordered eating behaviour' by their clinicians. CONCLUSIONS: The Diabetes Eating Problem Survey-Revised delivered more specific information than generic screening instruments and identified more young people with eating disorders than did clinician report, especially regarding the detection of boys at risk. The results of this study support the utility of the German version of the Diabetes Eating Problem Survey-Revised to identify eating disorders in young people with Type 1 diabetes at an early stage. (German Clinical Trials Registry no.: DRKS00004699).

The perinatal origins of major reproductive disorders in the adolescent: Research avenues.

The fetal endometrium becomes responsive to steroid hormones around the fourth month of pregnancy starting with an oestrogenic phase, which is followed late in pregnancy by a secretory phase. Based on post-mortem studies, the endometrium at birth is secretory in only one-third of neonates and proliferative in the remaining cases. Decidual or menstrual changes are rare in fetal endometrium despite high circulating steroid hormone levels, which drop rapidly after birth. Hence, acquisition of progesterone responsiveness appears to be dependent on endometrial maturation and relative immaturity may persist in a majority of girls until the menarche and early adolescence. Two major reproductive disorders have been linked with either advanced or delayed endometrial maturation. First, early-onset endometriosis may be caused by menstruation-like bleeding in the neonate, leading to tubal reflux and ectopic implantation of endometrial stem/progenitor cells. Second, persistence of partial progesterone resistance in adolescent girls may compromise deep placentation and account for the increased risk of major obstetrical syndromes, including preeclampsia, fetal growth retardation and preterm birth. The concept of neonatal origins of common reproductive disorders poses important research challenges but also subsumes potential new preventative strategies.

Complications and comorbidities of T2DM in adolescents: findings from the TODAY clinical trial.

With the rise in childhood obesity, type 2 diabetes mellitus (T2DM) has been recognized to occur in adolescents with increasing frequency. Although much is known about T2DM in adults, few studies have examined the treatment and complications of T2DM in youth. The Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY) study was designed to evaluate the efficacy of various treatments and provided a unique opportunity to study the disease progression and appearance of complications in a pediatric cohort with recent onset of the disease. In the TODAY study, hypertension was present in 11.6% of the population at baseline and increased to 33.8% by the end of the study. Prevalence of high-risk LDL-cholesterol rose from 4.5% at baseline to 10.7% at the end of the study. Microalbuminuria was found in 6.3% of the cohort at baseline and increased to 16.6%. Retinopathy was not assessed upon entry into TODAY, but was present in 13.9% of the TODAY cohort at the end of the study. Experience to date indicates that these complications and comorbidities are similar to those seen in adults, but occur on an accelerated timeline. The early manifestation of diabetes complications in youth-onset T2DM suggests that this group will be burdened with the tangible consequences of cardiovascular disease, nephropathy, and retinopathy in the third and fourth decades of life. It is hoped that through an early, aggressive approach to treatment and prevention, we may be able to curb the onset and progression of these potentially devastating outcomes.