Pediatricians as Child Health Advocates: The Role of Advocacy Education.

In this article, we discuss the role of formal advocacy education with high-effort advocacy activities among pediatricians. We discuss the historical role of advocacy in the field of pediatrics and the changing role of advocacy education in pediatric training programs. We describe our survey of pediatricians in New York, in which we asked about a history of formal child health advocacy education, current high- and low-effort advocacy activities, perceived barriers to advocacy work, and child health advocacy issues of interest. Our findings demonstrate an association between a history of formal child health advocacy education and recent participation in high-effort advocacy activities on behalf of children's health. We also found that practicing pediatricians were more likely to participate in high-effort advocacy work than individuals still in pediatric residency training. Our findings imply that education in child health advocacy should be considered an important part of pediatric training. Advocacy education should not only be included in residency and fellowship training programs but also made available as part of continuing medical education for pediatricians. Time for professional advocacy work should be allotted and encouraged.

Fertility Desires of Adolescent Females: Decreased Desire for Children in Those Identifying as Transgender/Gender Diverse and in Depressed Adolescents.

STUDY OBJECTIVE: We aimed to describe fertility desires in healthy adolescent females and to explore associations of fertility desire with conditions and therapies potentially compromising fertility. DESIGN: This was a cross-sectional, anonymous survey. SETTING AND PARTICIPANTS: A total of 323 female adolescents aged 13-19 years were recruited from clinic waiting areas at a children's hospital. We oversampled on days when clinics serving adolescents with potential fertility compromise were scheduled. MAIN OUTCOME MEASURES: We measured fertility desire by agreement with the statement "I want to have children someday." To measure compromised fertility we asked "In the past year, has a doctor, nurse or other medical professional ever talked to you about the possibility that you may have decreased fertility and may not be able to have your own biological child someday?" To measure depression severity, we used a validated scale, the PHQ-9, scores were dichotomized into no/mild and moderate/severe depression. RESULTS: Mean age was 16.06 ± 1.87 years. Of the 323 participants, 57% identified as Hispanic, 24% as Black, 93.5% as cisgender, 6.5% as transgender/gender diverse, 70% as heterosexual, and 30% as sexual minority. A total of 35% had moderate/severe depression, and 12% had compromised fertility. Overall, 89% wanted children. Fewer transgender/gender diverse than cisgender participants wanted children (67% vs 93%, P < .001), as did fewer with moderate/severe versus no/mild depression (83% vs 93%, P < .05), whereas those with compromised fertility versus those without and heterosexual versus sexual minority participants had similar fertility desires. Transgender/gender diverse identity (odds ratio, 0.33; 95% confidence interval, 0.11-0.97; P < .05) and moderate/severe depression (odds ratio, 0.45; 95% confidence interval, 0.22-0.93; P < .05) were independently associated with lower fertility desire. CONCLUSIONS: We found a high overall proportion of female adolescents desiring future children, and only 2 independent predictors of decreased fertility desire, namely, transgender/gender diverse identity and moderate/severe depression.

Prepubertal and Adolescent Vulvovaginitis: What to Do When a Girl Reports Vaginal Discharge.

Vaginitis presents with vaginal discharge, odor, pruritis, and/or discomfort and affects up to 75% of girls and women over the course of their lifetimes, with most women experiencing their first episode during adolescence. Given the prevalence of this disorder, this article aims to provide an overview of vaginitis for the general pediatrician. We start with prepubertal etiologies of vaginitis, then discuss pubertal and normal physiologic discharge, and then focus on the most common etiologies of adolescent vulvovaginitis. The three most common microbial etiologies of vaginitis (bacterial vaginosis, vulvovaginal candidiasis, and trichomonas) are addressed, as well as their diagnosis and treatment in adolescents. [Pediatr Ann. 2020;49(4):e170-e175.].

Painful Periods in the Adolescent Girl.

Up to two-thirds of adolescent girls report painful periods but few seek medical care for their dysmenorrhea. Dysmenorrhea is associated with multiple physical and psychological symptoms, and the delayed evaluation and treatment of dysmenorrhea contributes to a poor quality of life and can result in lifelong health problems, including chronic pelvic pain and infertility. It is recommended that an assessment of patients' menstrual cycles be performed regularly, as identification of abnormally painful menstrual cycles may reveal potential health problems, including pelvic diseases such as endometriosis and adenomyosis. Visits to primary care providers offer an opportunity to assess and educate adolescents and their families on normal menstrual physiology. The purpose of this article is to review the evaluation and management of dysmenorrhea. [Pediatr Ann. 2020;49(4):e176-e182.].

Fertility Counseling for Adolescents.

Fertility awareness, or general knowledge about one's fertility, is low in adolescents and in adult women as well. Misconceptions about reproduction contribute to high rates of unplanned pregnancy in the United States, as well as delayed childbearing and infertility. Alhough primary care providers caring for adolescents have historically focused on contraception and reduction of sexually transmitted infections during their sexual and reproductive health conversations with adolescents and young adult women, fertility awareness counseling would help these women optimize their future fertility and make informed reproductive choices throughout their life. This is particularly true for adolescents with chronic medical conditions, certain gynecologic conditions, or a history of therapies that could potentially affect fertility, for whom preemptive conversations about fertility are needed, but often overlooked. [Pediatr Ann. 2019;48(2):e86-e91.].

The Impact of a Clinical Asthma Pathway on Resident Education.

Clinical pathways for asthma management decrease hospital cost and length of stay; however little is known about the educational impact of pathways on residents. Pediatric residents at a children's hospital (N = 114) were invited to complete a 22-item computerized, anonymous survey 6 months before and 6 months after asthma pathway implementation. The survey assessed pathway use and residents (1) pathway knowledge, (2) attitudes and experiences with managing asthma, and (3) perceived educational benefits. Mean pathway knowledge score increased from the case before to the case after implementation [1.5 ± 1.0 versus 2.6 ± 1.3, p < 0.001], as did high preparedness to manage asthma [61% versus 91%, p < 0.001] and electronic order set use [28% versus 80%, p < 0.001]. The top three educational benefits of the pathway endorsed by residents were application of evidence-based medicine (57%), ability to assess exacerbations (52%), and skill at communicating respiratory status (47%). After implementation, residents' knowledge and preparedness to manage asthma improved as well as many endorsed educational benefits.

Acceptance of Routine HIV Testing by Hospitalized Adolescents and Young Adults.

BACKGROUND AND OBJECTIVES: Youth carry a disproportionate burden of new HIV infections. With our study, we aimed to characterize HIV testing experiences among adolescents and young adults admitted to a children's hospital that is located in a high HIV-prevalent community and implemented routine HIV testing for all patients ≥13 years of age. METHODS: A total of 120 patients aged 13 to 24 years old who were admitted to our hospital and had a documented offer of routine HIV testing on admission were invited to complete a self-administered survey that asked about sex, race and/or ethnicity, HIV risk behaviors, and attitudes toward routine HIV testing in the hospital. Date of birth, admission diagnosis, and verification of HIV testing and results were collected by chart review. RESULTS: Study participants (N = 99) were 17.4 ± 2.3 years old, 52% female, 47% Hispanic, and 29% African American. Additional characteristics include the following: 65% had previous sexual activity, 11% had a history of sexually transmitted infections, and 12% were worried about their risk for HIV. Forty-seven percent of participants accepted HIV testing, with older patients (P < .01) and those reporting previous sexual activity (P < .01) and a previous HIV test (P < .01) being more likely to accept testing. A total of 96% of participants agreed that the hospital is a good place to offer HIV testing. CONCLUSIONS: Our findings support offering routine HIV testing to youth admitted to children's hospital. Given the high incidence of new and undiagnosed HIV infections among youth, additional venues for HIV testing are essential.

Resident Education Curriculum in Pediatric and Adolescent Gynecology: The Short Curriculum 2.0.

The degree of exposure to pediatric and adolescent gynecology (PAG) varies across residency programs in obstetrics and gynecology and pediatrics. Nevertheless, these programs are responsible for training residents and providing opportunities within their programs to fulfill PAG learning objectives. To that end, the North American Society for Pediatric and Adolescent Gynecology has taken a leadership role in PAG resident education by creating and systematically updating the Short Curriculum. This curriculum outlines specific learning objectives that are central to PAG education and lists essential resources for learners' reference. This updated curriculum replaces the previous 2014 publication with added content, resources, and updated references. Additionally, attention to the needs of learners in pediatrics and adolescent medicine is given greater emphasis in this revised North American Society for Pediatric and Adolescent Gynecology Short Curriculum 2.0.

Improving Resident Knowledge in Pediatric and Adolescent Gynecology: An Evaluation of the North American Society for Pediatric and Adolescent Gynecology Short Curriculum.

STUDY OBJECTIVE: Resident education in pediatric and adolescent gynecology (PAG) is challenging. It encompasses patients from neonates to young adults with different disorders involving multiple subspecialties. Residents have inadequate exposure to PAG topics and report lack of knowledge in this area. The objective of this study was to determine if the North American Society for Pediatric and Adolescent Gynecology (NASPAG) Short Curriculum improves self-reported knowledge in PAG among obstetrics and gynecology (ObGyn), family medicine, and pediatric residents. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Participants were 47 US ObGyn, family medicine, and pediatric residency training programs across a 4-month study window, from September to December 2016. The NASPAG Short Curriculum was distributed to them with a request to complete a retrospective pre- and post-test survey. Primary outcome measure was improvement in self-perceived knowledge after exposure to the curriculum. RESULTS: Forty-eight programs responded to the study comprising a total of 1130 residents. One program was excluded because of logistical barriers to the distribution of study incentive. In total, 1080 residents were invited and 103 chose to participate (10% response rate); 68 residents completed all survey questions to be included in the final analysis. After completing the curriculum, self-reported knowledge improved in all 10 learning objectives, across all 3 specialties (47% [32/68] to 82% [56/68]; P < .01). Pre-test knowledge correlated with previous clinical exposure to PAG patients, but did not correlate with year of residency training, type of residency, or previous PAG lectures. CONCLUSION: Significant deficiencies exist regarding self-reported knowledge of core PAG topics among ObGyn, family medicine, and pediatric residents. Use of the NASPAG Short Curriculum improves self-reported knowledge in PAG trainees across all 3 specialties.

Creation and Dissemination of a Multispecialty Graduate Medical Education Curriculum in Pediatric and Adolescent Gynecology: The North American Society for Pediatric and Adolescent Gynecology Resident Education Committee Experiences.

STUDY OBJECTIVE: The goal was to develop a multispecialty committee to address deficiencies in pediatric and adolescent gynecology (PAG) resident education through curricular development under the auspices of the North American Society for Pediatric and Adolescent Gynecology. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: A multispecialty North American committee was organized to develop short as well as long curricula in PAG through a combination of conference calls and face-to-face meetings. Content was guided by objectives of national accrediting organizations. The curricula used print as well as interactive electronic resources. RESULTS: After publication of the short and long curricula, a dissemination strategy was developed to present the information at national meetings. A curricular study was performed after introduction of the curriculum to evaluate its efficacy. Long-term plans for further curricular components and expansion of educational tools are ongoing. CONCLUSION: We gathered a diverse multispecialty group of doctors to collaborate on a unified educational goal. This committee developed and disseminated resident PAG curricula using a variety of learning tools. This curricular development and implementation can occur with a minimal financial burden.

Reproductive Coercion in High School-Aged Girls: Associations with Reproductive Health Risk and Intimate Partner Violence.

STUDY OBJECTIVE: To determine the prevalence of reproductive coercion, a form of intimate partner violence (IPV) including contraceptive sabotage and pregnancy pressure, among urban high school-aged girls and to examine its associations with reproductive health risks. DESIGN AND SETTING: A self-administered survey completed by high school-aged girls living in high-poverty neighborhoods while awaiting medical care in a pediatric emergency room, inpatient service, school-based, and hospital-based clinic. PARTICIPANTS: One hundred forty-nine sexually active girls aged 14-17 years. INTERVENTIONS AND MAIN OUTCOME MEASURES: To determine the prevalence of reproductive coercion and to examine associations with unprotected sex, sexually transmitted infections, physical IPV, and risk factors for abusive relationships. RESULTS: Twenty-nine of 149 (19%) of girls reported reproductive coercion, most frequently that a romantic or sexual partner had ever: "told them not to use any birth control" (n = 23; 79%); "took off a condom during sex so they would get pregnant" (n = 12; 43%); and "said he would leave them if they didn't get pregnant" (n = 6; 21%). Girls reporting reproductive coercion were nearly 3 times more likely than those not coerced to have had chlamydia (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.01-7.19) and nearly 5 times more likely to report IPV (OR, 4.8; 95% CI, 2.0-11.8). In addition, girls reporting coercion were less likely to have high recognition of abusive behaviors (OR, 0.10; 95% CI, 0.01-0.8) and less likely to have high comfort communicating with their sexual partners (OR, 0.32; 95% CI, 0.1-0.7) than girls not reporting coercion. CONCLUSION: Reproductive coercion is experienced by 1 in 5 high school-aged girls in a high-poverty community and is associated with chlamydia infection and IPV. Awareness of the high prevalence and health risks of coercion might allow for intervention.

Fertility Awareness Counseling for Adolescent Girls; Guiding Conception: The Right Time, Right Weight, and Right Way.

STUDY OBJECTIVE: To provide a detailed summary of fertility awareness counseling pearls for healthy teens and those with fertility-relevant comorbidities, and to assist providers in offering such counseling to adolescents and young adult women. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Comprehensive literature review of English-language studies relating to fertility in pediatric and adolescent female patients (ages 13-21 years), and evidence-based dialogue guide. RESULTS: The literature indicates that although adolescents are interested in discussing sexuality and reproduction, this is commonly overlooked during the standard office medical visit. As a result, adolescents often turn to less reliable sources and hold a variety of reproductive misconceptions and a sense of lack of control over future fertility. We found no studies that examined the routine provision of fertility awareness counseling with healthy adolescents. There are a multitude of specific gynecologic and medical conditions that have ramifications for fertility. We detail these comprehensively, and provide a dialogue guide to assist with fertility awareness counseling for the female adolescent, containing specific information and indications for referral. CONCLUSION: Providers caring for adolescent girls have the opportunity to enhance fertility awareness as part of a larger reproductive health conversation that adolescents desire, and from which they might benefit. Identifying potential future fertility issues, understanding age-related fertility decline, and aiding in health optimization before future conception might empower the adolescent to make informed reproductive decisions. We provide an algorithm to use with adolescents to discuss the "right time, right weight, right way" to pursue childbearing.

Polycystic Ovary Syndrome: An Under-recognized Cause of Abnormal Uterine Bleeding in Adolescents Admitted to a Children's Hospital.

STUDY OBJECTIVE: To evaluate whether ovulatory dysfunction due to polycystic ovary syndrome (PCOS) is a common underlying etiology of abnormal uterine bleeding (AUB) in adolescents who require hospitalization and to explore etiology, treatment, and complications of AUB with severe anemia in adolescents. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We identified female patients aged 8-20 years admitted to a children's hospital for treatment of AUB from January 2000 to December 2014. Our hospital protocol advises hormonal testing for PCOS and other disorders before treatment for AUB. We reviewed medical records and recorded laboratory evaluations, treatments, and final underlying diagnoses as well as recurrences of AUB and readmissions in the subsequent year. RESULTS: Of the 125 subjects, the mean age was 16.5 ± 2.9 years; mean hemoglobin level was 7.0 ± 1.8 g/dL; 54% were overweight/obese; and 41% sexually active. PCOS accounted for 33% of admissions; hypothalamic pituitary ovarian axis immaturity 31%; endometritis 13%; bleeding disorders 10%. Girls with PCOS were more likely to be overweight/obese (74% vs 46%; P < .01) and girls with hypothalamic pituitary ovarian axis immaturity had lower hemoglobin levels (6.4 g/dL vs 7.4 g/dL; P < .05), than girls with all other etiologies of AUB. Treating physicians failed to diagnose endometritis as the etiology for AUB in 4 of 8 girls with positive tests for sexually transmitted infection and no other etiology. CONCLUSION: PCOS was the most common underlying etiology in adolescents hospitalized with AUB. Screening for hyperandrogenemia is important for early diagnosis of PCOS to allow ongoing management and prevention of comorbidities. Endometritis was frequently underestimated as an etiology for AUB.

Challenges to Adolescent Confidentiality in a Children's Hospital.

OBJECTIVES: Protecting confidentiality for hospitalized adolescents can be challenging and may interfere with optimal adolescent-friendly care. The goal of this study was to explore physician trainees' experience with adolescent confidentiality at an academic children's hospital. METHODS: A total of 175 trainees were invited to complete an online survey about knowledge, attitudes, and experiences with confidential adolescent concerns in the inpatient setting. A total of 133 (76%) responded: 78% female; 65% pediatric or family medicine residents; and 35% medical students. RESULTS: In the past year, 56 (42%) of 133 trainees cared for a hospitalized adolescent whose confidentiality had been breached. Barriers to ensuring confidentiality included: patient/family not knowledgeable about minor consent law (50%); trainees not knowledgeable about minor consent law (47%); and hospital discharge summary requiring parental signature (47%). On patient- and family-centered rounds (PFCR), respondents reported that minor adolescents (aged <18 years) compared with young adults (aged ≥18 years) were more likely to have social history discussed away from the bedside (91% vs 84%; P < .001) and less likely to have confidential time with the medical team (28% vs 47%; P < .001). Barriers to participation in PFCR included the following: patient was sleeping (61%), patient declined to participate (51%), and confidentiality concerns (32%). CONCLUSIONS: Breaches in confidentiality for hospitalized adolescents are a common trainee experience. On PFCR, adolescents are less likely to have confidential time with the medical team than young adults. In trainees' experience, hospital systems such as PFCR and discharge procedures pose inherent challenges to confidentiality for minor adolescent patients, as do lack of knowledge of minor consent laws by both clinicians and families.

Treatment of Vitamin D Deficiency in Predominantly Hispanic and Black Adolescents: A Randomized Clinical Trial.

OBJECTIVES: To compare 3 different treatment regimens for vitamin D deficiency in minority adolescents and to explore factors that impact treatment efficacy. STUDY DESIGN: We conducted an 8-week, prospective, open-label, randomized clinical trial in an urban, academic, children's hospital. A total of 183 vitamin D-deficient adolescents, mean 25-hydroxyvitamin D or 25(OH)D 13.7 ± 3.9 ng/mL; mean age 16.6 ± 2.2 years, were randomized into 3 vitamin D3 (cholecalciferol) treatment arms: 50,000 IU/wk; 5000 IU/d; and 1000 IU/d. Serum 25(OH)D and vitamin D binding protein (VDBP) levels were measured pre-and posttreatment; 122 (67%) participants completed posttreatment measures. Complete-case and multiple-imputation, intention-to-treat analyses were performed. RESULTS: Mean change in 25(OH)D level posttreatment was significantly different among the 3 arms, 24.9 ± 15.1 vs 21.0 ± 15.2 vs 6.2 ± 6.5 ng/mL, for 50,000 IU, 5000 IU, and 1000 IU doses, respectively, P < .001. Both high-dose treatments were effective in increasing the 25(OH)D level out of deficiency range (≥ 20 ng/mL) in more than 80% of participants, and 60% remained deficient after low-dose treatment. Only 72%, 56%, and 2% achieved vitamin D sufficiency (>30 ng/mL) with 50,000 IU, 5000 IU, and 1000 IU doses, respectively, P < .001. Obese participants had substantially less mean change in 25(OH)D level after treatment than normal-weight participants, 13.7 ± 10.7 vs 21.9 ± 16.9 ng/mL, P < .001. Mean baseline VDBP level was almost twice as high in Hispanic compared with black participants (P < .001) and did not alter treatment response or change with treatment. CONCLUSIONS: Adult-sized adolescents require 8 weeks of high-dose cholecalciferol, at least 5000 IU/d, to correct deficiency. Obese adolescents have poorer response to treatment and may need higher doses than nonobese youth. Hispanic and black adolescents have different VDBP levels but similar treatment responses. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01784029.

Resident education curriculum in pediatric and adolescent gynecology: the short curriculum.

The degree of exposure to Pediatric and Adolescent Gynecology (PAG) varies across academic programs in Obstetrics and Gynecology, Pediatrics, and Adolescent Medicine. Nevertheless, these programs are responsible to train residents and provide opportunities within their training programs to fulfill PAG learning objectives. To that end, North American Society for Pediatric and Adolescent Gynecology has taken a leadership role in PAG resident education by disseminating the Short Curriculum with specific learning objectives and list of essential resources where key concepts in PAG can be covered.