Pediatric Primary Health Care: The Central Role of Pediatricians in Maintaining Children's Health in Evolving Health Care Models.

Pediatric primary health care (PPHC) is of principal importance to the health and development of all children, helping them reach their true potential. Pediatricians, as the clinicians most intensively trained and experienced in child health, are the natural leaders of PPHC within the context of the medical home. Given the rapidly evolving models of pediatric health care delivery, including the explosion of telehealth in the wake of the COVID-19 pandemic, pediatricians, together with their representative national organizations such as the American Academy of Pediatrics (AAP), are the most capable clinicians to guide policy innovations on both the local and national stage.

Does Obesity Influence Body Mass Index Changes in Nulliparous Adolescent Users of Long-Acting Reversible Contraceptives?

OBJECTIVES: To compare body mass index (BMI) changes in adolescents using long-acting reversible contraceptives (LARCs), specifically, the etonogestrel subdermal implant (ENG-implant), levonorgestrel intrauterine device (LNG-IUD), and copper IUD (Cu-IUD), by initial BMI category from the time of LARC insertion to within 6-18 months after insertion. DESIGN: This was a single-center retrospective cohort study. SETTING AND PARTICIPANTS: We reviewed electronic health records from our large health system to identify and follow a cohort of 196 adolescents aged 14-19 years with LARCs inserted from 2010 to 2016. We excluded adolescents with conditions or medications affecting weight, including childbirth. MAIN OUTCOME MEASURE: BMI change from LARC insertion to first BMI documented after 6-18 months RESULTS: Mean age was 17.2 ± 0.2 years; 59% of the cohort was Hispanic and 29% Black. Mean BMI was 26.4 ± 7.1 kg/m2. Of the total cohort of adolescents, 51% were underweight/normal, 24% overweight, and 25% obese. Mean time to first BMI documented after LARC insertion was 10.1 ± 3.2 months. Mean BMI change for the total cohort was +0.73 ± 1.8 kg/m2, indicating weight gain. Mean BMI change for the ENG-implant + LNG-IUD users (n = 127) was larger than for Cu-IUD users (n = 69) (+0.92 ± 1.9 kg/m2 vs +0.37 ± 1.6 kg/m2, respectively, P < .05). Two-way analysis of variance showed that both initial BMI category (P = .001) and type of LARC (P = .011) had an independent significant main effect on BMI change. A significant interaction effect (P = .017) showed that obese adolescents had a larger increase in BMI when they were using a progestin-releasing LARC, either ENG-implant or LNG-IUD, as compared to a Cu-IUD (P < .05). CONCLUSION: Adolescents using progestin-releasing LARCs had a larger increase in BMI within 6-18 months after device insertion than those using Cu-IUDs. The disproportionate increase in BMI with progestin-releasing LARCs was primarily contributed by obese users.

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.

The Reproductive Health Care of Transgender Young People: A Guide for Primary Care Providers.

Primary care providers should have a general understanding of the medical care available to transgender youth throughout childhood and adolescence. Providers and parents should create an affirming environment for young people at every developmental stage, while ensuring thorough and thoughtful evaluations prior to any medical intervention. Transgender teens have unique reproductive health care needs. Transgender boys may seek suppression of menses, and they will need to pay particular attention to pregnancy prevention if they decide to undergo masculinizing hormonal treatment. Transgender girls who undergo feminizing hormonal treatment will also see profound changes to their reproductive and sexual function. Providers should feel comfortable getting detailed sexual histories to properly counsel on and test for sexually transmitted infections. Finally, the effects of medical and surgical transition on a young person's potential for future fertility is a profoundly important concept for both the teen and their parents to understand. [Pediatr Ann. 2019;48(2):e64-e70.].

The Female Athlete Triad: A Comparison of Knowledge and Risk in Adolescent and Young Adult Figure Skaters, Dancers, and Runners.

STUDY OBJECTIVE: The female athlete triad is often found in sports that value leanness and aesthetics and can lead to adverse health effects. We aimed to compare knowledge and risk of the triad among adolescent figure skaters, dancers, and runners. DESIGN, SETTING, PARTICIPANTS, AND MAIN OUTCOME MEASURES: We advertised our survey on social media platforms: sports-specific forums; Facebook; and Instagram. We received 928 responses. We included female figure skaters, dancers, and runners aged 25 years or younger (N = 712). We asked participants to name the triad components and dichotomized knowledge scores as high or low. We developed a 6-question triad risk scale and defined "at risk" if participants endorsed 3 or more questions. RESULTS: Of 712 participants: 60% were figure skaters; 28% dancers; 12% runners; 78% were adolescents (≤17 years of age); 22% young adults (18-25 years); 12% had heard of the triad. A higher proportion of runners than figure skaters and dancers had high knowledge of the triad (16% vs 6% vs 5%, P < .01). Overall 60% of athletes were "at risk" of the triad, 25% skipped a period for 3 or more months, and 34% had a history of stress fractures or shin splints. Young adults vs adolescents and dancers vs figure skaters and runners had nearly twice the odds of triad risk. CONCLUSION: Most athletes were at risk of the triad but few knew about it. Dancers were at higher risk compared with figure skaters and runners. Efforts should be made to raise awareness of the triad among athletes, parents, and coaches, with special attention paid to the dance community.

Adolescent gun violence prevention: what we know, and what we can do to keep young people safe.

PURPOSE OF REVIEW: This review will focus on recent research, initiatives, and legislation regarding the issue of gun violence as it pertains to adolescents. RECENT FINDINGS: Homicide and suicide continue to be major killers of adolescents in the United States. Gun homicide kills teens in the most urban areas of the United States at the same rate as suicide kills teens in the most rural areas of the United States. Research on assault-injured youth sheds light on risk factors for teen gun homicide, and has found high rates of illegal gun carrying and retaliatory attitudes among at-risk teens. Suicide research continues to show a strong correlation between gun ownership and accessibility, and risk of completed suicide. Stand Your Ground laws and campus carry laws present unique threats to different populations of American teens. SUMMARY: Given the enormous toll that gun violence takes on adolescent lives, pediatricians should ask about guns in the home and become involved in efforts to strengthen laws that would decrease gun violence.

Sense of Mission and Sexual Health Outcomes Among Young Adult Women.

STUDY OBJECTIVE: To examine the association between self-reported sense of mission and sexual health behaviors in a geographically diverse cohort of U.S. young adult females in the Growing Up Today Study (GUTS). DESIGN: We conducted a cross-sectional analysis of the 2007 wave of GUTS data from self-reported online or mailed surveys. Outcomes were early sex initiation and history of sexually transmitted infection (STI), which were analyzed as a binary outcome using logit link, and number of sex partners, which was analyzed as a continuous outcome. Models for number of sex partners and history of STIs were adjusted for age. PARTICIPANTS: There were 5,624 young women aged 20 to 25 years who participate in GUTS and who answered the question on "sense of mission." MAIN OUTCOME MEASURES: Age at sexual initiation, history of STIs, and number of lifetime partners. RESULTS: When asked whether they had a sense of mission in their life, 28.1% of women strongly agreed, 54.9% agreed, and 17% disagreed. Women with a low sense of mission had higher odds of reporting a history of STI (odds ratio 1.35, 95% confidence interval 1.08 to 1.70), and more lifetime sexual partners (ß = .83, P < .001). CONCLUSIONS: Having a high sense of mission is associated with lower sexual risk in young women. Interventions to increase sense of mission among young women may improve sexual health outcomes.

Teen pregnancy prevention on a LARC: an update on long-acting reversible contraception for the primary care provider.

PURPOSE OF REVIEW: This update will highlight recent research and recommendations on long-acting reversible contraception (LARC) in the teen population, in order to make primary care providers more comfortable counseling on these methods in the medical home. LARC methods, which include intrauterine devices (IUDs) and subdermal hormonal implants, are used by only a small minority of sexually active teens, despite their endorsement by professional organizations as effective and well tolerated birth control options in this population. RECENT FINDINGS: Recent studies show a lack of knowledge about LARC methods among young women, as well as persistent misconceptions among providers regarding who is eligible for LARC use. Existing trials of small numbers of adolescents generally show enthusiasm for its use among teens who are educated about LARC, high satisfaction rates among users of subdermal implants and IUDs, as well as varying pregnancy and continuation rates. SUMMARY: The existing research on LARC shows promise for these methods in the teen population. However, larger trials are needed to establish accurate data on satisfaction, continuation, and failure rates, as well as to explore other barriers to use. Medical home providers should stay informed of research on LARC in order to improve contraceptive counseling to young women.