Academic Careers in Advocacy: Aligning Institutional Values Through Use of an Advocacy Portfolio.

Academic children's hospitals must embrace advocacy as a central component of their missions to discover new knowledge and improve the health of the communities and patients they serve. To do so, they must ensure faculty have both the tools and the opportunities to develop and articulate the work of advocacy as an academic endeavor. This can be accomplished by integrating the work of advocacy at the community and policy-change levels into the traditional value systems of academic medicine, especially the promotions process, to establish its legitimacy. Academic pediatric institutions can support this transformation through robust training and professional development programs and establishing opportunities, resources, and leadership positions in advocacy. The adoption of an advocacy portfolio can be used to align these activities and accomplishments to institutional values and promotion. This alignment is crucial to supporting the advocacy work of pediatricians at a time in which community engagement and systems and policy change must be added to professional activities to ensure optimal outcomes for all children.

The Catch to Confidentiality: The Use of Electronic Health Records in Adolescent Health Care.

PURPOSE: This study aims to understand pediatric health-care providers' expectations and the practices they employ to protect confidentiality in electronic health records (EHRs) and subsequently how EHRs affect the documentation and dissemination of information in the course of health-care delivery to adolescent minors. METHODS: Twenty-six pediatric health-care providers participated in in-depth interviews about their experiences using EHRs to understand a broad spectrum of expectations and practices guiding the documentation and dissemination of information in the EHR. A thematic analysis of interviews was conducted to draw findings and conclusions. RESULTS: Two themes and several subthemes emerged centering on how EHRs affected confidentiality expectations and practices. Participants expressed confidentiality concerns due to the EHR's longevity as a legacy record, its multidimensional uses, and increased access by users (theme 1). These concerns affected practices for protecting adolescent confidentiality within the EHR (theme 2). Practices included selectively omitting or concealing information and utilizing sets of personal and collective codes designed to alert providers or teams of providers to confidential information within a patient's record. CONCLUSIONS: EHRs create new and unresolved challenges for pediatric health care as they alter expectations of confidentiality and the documentation and dissemination of information within the record. This is particularly relevant in the course of care to adolescent minors as EHRs may compromise the tenuous balance providers maintain between protecting confidentiality and effective documentation within the record.

Reducing injury risk from body checking in boys' youth ice hockey.

Ice hockey is an increasingly popular sport that allows intentional collision in the form of body checking for males but not for females. There is a two- to threefold increased risk of all injury, severe injury, and concussion related to body checking at all levels of boys' youth ice hockey. The American Academy of Pediatrics reinforces the importance of stringent enforcement of rules to protect player safety as well as educational interventions to decrease unsafe tactics. To promote ice hockey as a lifelong recreational pursuit for boys, the American Academy of Pediatrics recommends the expansion of nonchecking programs and the restriction of body checking to elite levels of boys' youth ice hockey, starting no earlier than 15 years of age.

Menstrual irregularity and musculoskeletal injury in female high school athletes.

CONTEXT: The female athlete triad describes the interrelatedness of energy availability, menstrual function, and bone density. Although associations between triad components and musculoskeletal injury (INJ) have been reported in collegiate athletes, limited information exists about menstrual irregularity (MI) and INJ in the high school population. OBJECTIVE: To determine the prevalence of and relationship between MI and INJ in high school athletes. DESIGN: Cross-sectional study. SETTING: High schools. PATIENTS OR OTHER PARTICIPANTS: The sample consisted of 249 female athletes from 3 high schools who competed in 33 interscholastic, school-sponsored sport teams, dance teams, and cheerleading or pom-pon squad during the 2006-2007 school year. Each athlete remained on the roster throughout the season. MAIN OUTCOME MEASURE(S): Participants completed a survey regarding injury type, number of days of sport participation missed, and menstrual history in the past year. RESULTS: The prevalences of M I and INJ were 19.7% and 63.1 %, respectively. Athletes who reported MI sustained a higher percentage of severe injuries (missing ≥ 22 days of practice or competition) than did athletes who reported normal menses. Although the trend was not significant, athletes with MI were almost 3 times more likely to sustain an injury resulting in 7 or more days of time lost from sport (odds ratio = 2.7, 95% confidence interval = 0.8, 8.8) than those who sustained an injury resulting in 7 or fewer days of time lost. CONCLUSIONS: The incidences of MI and INJ in this high school population during the study period were high. Athletes who reported MI sustained a higher percentage of severe injuries than did athletes who reported normal menses. Education programs to increase knowledge and improve management of MI and its potential effects on injury in female high school athletes are warranted.

National Athletic Trainers' Association position statement: prevention of pediatric overuse injuries.

OBJECTIVE: To provide certified athletic trainers, physicians, and other health care professionals with recommendations on best practices for the prevention of overuse sports injuries in pediatric athletes (aged 6-18 years). BACKGROUND: Participation in sports by the pediatric population has grown tremendously over the years. Although the health benefits of participation in competitive and recreational athletic events are numerous, one adverse consequence is sport-related injury. Overuse or repetitive trauma injuries represent approximately 50% of all pediatric sport-related injuries. It is speculated that more than half of these injuries may be preventable with simple approaches. RECOMMENDATIONS: Recommendations are provided based on current evidence regarding pediatric injury surveillance, identification of risk factors for injury, preparticipation physical examinations, proper supervision and education (coaching and medical), sport alterations, training and conditioning programs, and delayed specialization.

Associations between disordered eating, menstrual dysfunction, and musculoskeletal injury among high school athletes.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To determine the prevalence of, and association between, disordered eating (DE), menstrual dysfunction (MD), and musculoskeletal injury (MI) among high school female athletes. BACKGROUND: Female athlete triad (Triad) syndrome is the interrelatedness of DE, MD, and low bone mass. Few studies have examined 2 or more Triad components simultaneously, or their relationship to injury, among female high school athletes. METHODS: The subject sample consisted of 311 female high school athletes competing on 33 interscholastic high school teams during the 2006-2007 school year. Athletes completed the Eating Disorder Examination Questionnaire (EDE-Q) and Healthy Wisconsin High School Female Athletes Survey (HWHSFAS). Athletes were classified by sport type as aesthetic (AES), endurance (END), or team/anaerobic (T/A). RESULTS: Of those surveyed, 35.4% reported DE, 18.8% reported MD, and 65.6% reported sustaining a sports-related musculoskeletal injury during the current sports season. Athletes reporting DE were twice as likely to be injured compared to those reporting normal eating behaviors (odds ratio [OR], 2.3; 95% confidence interval [CI]: 1.4, 4.0). Multivariate logistic regression analyses revealed that athletes who reported a history of DE (OR, 2.1; 95% CI: 1.1, 3.9) or prior injury (OR, 5.1; 95% CI: 2.9, 8.9) were more likely to be injured during the sports season. CONCLUSION: A high prevalence of DE and MD exists among high school female athletes. Additionally, athletes with DE were over 2 times more likely to sustain a sports-related injury during a sports season. Screening and intervention programs designed to identify and decrease the prevalence of DE should be implemented with high school females. LEVEL OF EVIDENCE: Prognosis, level 2b.

Family history predicts stress fracture in active female adolescents.

OBJECTIVE: Increased physical activity and menstrual irregularity have been associated with increased risk for stress fracture among adult women active in athletics. The purposes of this study were to determine whether menstrual irregularity is also a risk factor for stress fracture in active female adolescents and to estimate the quantity of exercise associated with an increased risk for this injury. PATIENTS AND METHODS: A case-control study was conducted of 13- to 22-year-old females diagnosed with their first stress fracture, each matched prospectively on age and self-reported ethnicity with 2 controls. Patients with chronic illnesses or use of medications known to affect bone mineral density were excluded, including use of hormonal preparations that could alter menstrual cycles. The primary outcome, stress fracture in any extremity or the spine, was confirmed radiographically. Girls with stress fracture had bone mineral density measured at the lumbar spine by dual-energy x-ray absorptiometry. RESULTS: The mean +/- SD age of the 168 participants was 15.9 +/- 2.1 years; 91.7% were postmenarchal, with a mean age at menarche of 13.1 +/- 1.1 years. The prevalence of menstrual irregularity was similar among cases and controls. There was no significant difference in the mean hours per week of total physical activity between girls in this sample with stress fracture (8.2 hours/week) and those without (7.4 hours/week). In multivariate models, case subjects had nearly 3 times the odds of having a family member with osteoporosis or osteopenia. In secondary analyses, participants with stress fracture had a low mean spinal bone mineral density for their age. CONCLUSIONS: Among highly active female adolescents, only family history was independently associated with stress fracture. The magnitude of this association suggests that further investigations of inheritable skeletal factors are warranted in this population, along with evaluation of bone mineral density in girls with stress fracture.

Effects of nutrition, puberty, and gender on bone ultrasound measurements in adolescents and young adults.

PURPOSE: Quantitative ultrasound (QUS) evaluation of bone is attractive for evaluating skeletal status in adolescents, but its use is limited in the United States due to sparse pediatric reference data. This study evaluated associations between radial and tibial speed of sound (SOS) measurements via QUS and demographic, anthropometric and nutritional variables. METHODS: We enrolled 151 healthy participants, aged 11-26 years, during routine visits to an urban adolescent clinic. SOS measurements were obtained using the Omnisense 7000P (Sunlight Medical Ltd., Tel-Aviv, Israel) and correlated with weight, height, gender, race, sexual maturity rating (SMR), and reported nutritional intake. RESULTS: The sample was 53% female; aged 17+/- 2.8 years (mean +/- SD); and 48% African-American, 21% Hispanic, and 21% Caucasian. Seventy percent of males and 91% of females had achieved SMR 5; 96% of females were postmenarchal. Males met the recommended daily allowance for calcium intake, on average; the females did not. Both the girls and boys reported consumption of inadequate vitamin D. Intake of neither calcium nor vitamin D was correlated with SOS. Radial and tibial SOS were significantly higher in those with SMR 5 (p < .001) and were moderately correlated with age in both genders (r = .42-.64, p < .001). In multivariate analyses, age was associated with SOS at both sites (p < .0001). CONCLUSIONS: This study provides QUS measurements of the peripheral skeleton among healthy adolescents. QUS measurements followed similar age and pubertal distributions to dual-energy X-ray absorptiometry (DXA) bone density measurements; other variables did not follow expected trends. Further research is needed to clarify what skeletal properties are assessed by this technique. This study adds to accumulating evidence that many adolescents do not consume adequate vitamin D or calcium.

Adolescent bone health.

Pediatric and adolescent care professionals have increasingly recognized the importance of understanding the skeletal health of their patients. Peak bone mass, the "bone bank" on which an individual will draw for their entire adult life, is likely achieved by late adolescence, with the critical window for accumulation occurring much earlier. This review outlines the known conditions that are associated with impaired bone mineral accrual and clinical settings in which the evaluation of "at-risk" adolescents should be considered. We describe the methods available to the health care professional for evaluating bone density, along with the limitations of each technology. Potential therapeutic options for patients identified to have a low bone mineral density are discussed. Finally, current recommendations regarding physical activity and nutrition, beneficial interventions for all adolescents, are presented.

Exposure to the mass media, body shape concerns, and use of supplements to improve weight and shape among male and female adolescents.

OBJECTIVE: To assess the prevalence and correlates of products used to improve weight and shape among male and female adolescents. METHODS: A cross-sectional study was conducted of 6212 girls and 4237 boys who were 12 to 18 years of age and enrolled in the ongoing Growing Up Today Study. The outcome measure was at least weekly use of any of the following products to improve appearance, muscle mass, or strength: protein powder or shakes, creatine, amino acids/hydroxy methylbutyrate (HMB), dehydroepiandrosterone, growth hormone, or anabolic/injectable steroids. RESULTS: Approximately 4.7% of the boys and 1.6% of the girls used protein powder or shakes, creatine, amino acids/HMB, dehydroepiandrosterone, growth hormone, or anabolic/injectable steroids at least weekly to improve appearance or strength. In multivariate models, boys and girls who thought a lot about wanting more defined muscles (boys: odds ratio [OR]: 1.6; 95% confidence interval [CI]: 1.1-2.2; girls: OR: 2.3; 95% CI: 1.2-3.2) or were trying to gain weight (boys: OR: 3.0; 95% CI: 2.0-4.6; girls: OR: 4.3; 95% CI: 1.6-11.4) were more likely than their peers to use these products. In addition, boys who read men's, fashion, or health/fitness magazines (OR: 2.3; 95% CI: 1.1-4.9) and girls who were trying to look like women in the media (OR: 2.9; 95% CI: 1.4-4.0) were significantly more likely than their peers to use products to improve appearance or strength, but hours per week watching television, watching sports on television, and participation in team sports were not independently associated with using products to improve appearance or muscle mass. CONCLUSIONS: Girls and boys who frequently thought about wanting toned or well-defined muscles were at increased risk for using potentially unhealthful products to enhance their physique. These results suggest that just as girls may resort to unhealthful means to achieve a low body weight, girls and boys may also resort to unhealthful means to achieve other desired physiques.

Correlates of stress fractures among preadolescent and adolescent girls.

OBJECTIVE: Although stress fractures are a source of significant morbidity in active populations, particularly among young female athletes, the causes of stress fractures have not been explored among females <17 years of age or in the general population. The purpose of this study was to examine correlates of stress fractures in a large, population-based, national, cohort study of preadolescent and adolescent girls. METHODS: A cross-sectional analysis of data from 5461 girls, 11 to 17 years of age, in the Growing Up Today Study, an ongoing longitudinal study of the children of registered female nurses participating in Nurses' Health Study II, was performed. Mothers self-reported information regarding their children's histories of stress fractures on their 1998 annual questionnaire. Growing Up Today Study participants self-reported their weight and height, menarcheal status, physical activity, dietary intake, and disordered eating habits on annual surveys. RESULTS: In 1998, the mean age of the participants was 13.9 years. Approximately 2.7% of the girls had a history of stress fracture, 3% engaged in disordered eating (using fasting, diet pills, laxatives, or vomiting to control weight), and 16% participated in > or =16 hours per week of moderate to vigorous activity. Age at menarche, z score of BMI in 1998, calcium intake, vitamin D intake, and daily dairy intake were all unrelated to stress fractures after controlling for age. Independent of age and BMI, girls who participated in > or =16 hours per week of activity in 1998 had 1.88 greater odds of a history of stress fracture than did girls who participated in <4 hours per week (95% confidence interval [CI]: 1.18-3.30). Girls who participated in > or =16 hours per week of activity were also more likely than their peers to engage in disordered eating (4.6% vs 2.8%); however, disordered eating did not have an independent association with stress fractures (odds ratio [OR]: 1.33; 95% CI: 0.61-2.89). Independent of age and BMI, each hour per week of high-impact activity significantly increased the risk of stress fracture (OR: 1.05; 95% CI: 1.02-1.09). Among the high-impact physical activities, only running (OR: 1.13; 95% CI: 1.05-1.22) and cheerleading/gymnastics (OR: 1.10; 95% CI: 1.01-1.21) were independently associated with greater odds of stress fracture. CONCLUSIONS: These findings suggest that, although activity can be beneficial for bone health, there is a threshold over which the risk of stress fracture increases significantly among adolescent girls. High-impact activities, particularly running, cheerleading, and gymnastics, appear to be higher risk than other activities. Prospective studies are needed to explore the directionality of these relationships, as well as the role of menstrual history. In the meantime, clinicians should remain vigilant in identifying and treating disordered eating and menstrual irregularities among their highly active, young, female patients.