Transforming Pediatric Education in Response to Dobbs v. Jackson: Empowering Adolescents to Manage Their Reproductive Choices.

The June 2022 landmark decision from the US Supreme Court in Dobbs v. Jackson Women's Health Organization removed the federal constitutional protection for abortions, leading to an immediate, profound impact on reproductive rights for people of all ages and, thus, on the practice of the medical providers who serve them. The Dobbs ruling forced a swift and drastic change in the availability of comprehensive reproductive care available to pregnant teens. Further, it led to confusion, fear, and moral distress regarding how pediatricians could legally provide counseling on reproductive choices. Pediatricians were left scrambling to understand the rapidly evolving laws in each state, while also attempting to interpret these new statutes for our trainees. Pediatric educators need to understand the impact of the Dobbs ruling on the education of pediatric trainees. The repercussions for the entirety of pediatric graduate medical education are widespread. Recruitment and retention of both trainees and faculty are jeopardized. Curricula and patient care opportunities for reproductive health training have been limited. Additionally, the ethical and legal implications of our work have been called into question, thus affecting the moral standing and professional identity development of pediatric trainees. As pediatric health educators, it is imperative that we take a lead role in teaching and mentoring our trainees to provide comprehensive reproductive health care to all patients, with an emphasis on the principles of reproductive justice. This will entail additional training in advocacy skills essential to ensure a just, equitable future for all our pediatric and adolescent patients.

Conscientious Objection to Providing Gender Health Care in Pediatric Training: Balancing the Vulnerability of Transgender Youth and the Vulnerability of Pediatric Residents.

Within pediatric graduate medical education, the care of transgender youth presents opportunities for deepening learners' understanding of equity, access, the role of the physician as an advocate, and health disparities caused by stigma and minority stress. However, when a pediatric resident objects to providing health care to this uniquely vulnerable population owing to their personal beliefs and values, how should pediatrician-educators respond? Important reasons to respect healthcare professionals' conscience have been described in the scholarly literature; however, equally important concerns have also been raised about the extent to which conscientious objection should be permitted in a pluralistic society, particularly given power differentials that favor healthcare professionals and grants them a monopoly over certain services. In the context of medical education, however, residents are in a unique position: they are simultaneously learners and employees, and although privileged relative to their patients, they are also vulnerable in relation to the hierarchy of healthcare and of institutions. We must find a compassionate balance between nurturing the evolving conscience of students and trainees and protecting the health and well-being of our most vulnerable patients. Educators have an obligation to foster empathy, mitigate bias, and mentor their learners, regardless of beliefs, but in some cases, they may recognize that there are limits: patients' welfare ultimately takes precedence and trainees should be guided toward alternative career paths. We explore the limits of conscientious objection in medical training and propose a framework for pediatrician-educators to support learners and patients in challenging circumstances.

So your patient is a gamer: an exploration of benefits and harms.

PURPOSE OF REVIEW: The appropriate amount and type of screen time for children remains a persistent topic of discussion between parents and pediatricians. During the COVID-19 pandemic, screen time has considerably increased. The need to quarantine and utilize remote learning prompted our review of the basis for current screen time recommendations and more recent research. RECENT FINDINGS: The broad stroke of recent research points to an association of increased video game screen time with sedentary lifestyle and its related harms. However, there also are specific instances where video games have been found to be therapeutically useful for certain populations. SUMMARY: In light of these findings, it is prudent for the pediatrician to explore more of the 'why' of video game use as opposed to purely the 'how much'. Given the future beneficial therapeutic uses of some video games, clinicians should keep their eyes on this space for its continued development.

COVID-19 Trial Enrollment for Those Who Cannot Consent: Ethical Challenges Posed by a Pandemic.

The current coronavirus disease 2019 (COVID-19) pandemic has triggered an intense global research effort to inform the life-saving work of frontline clinicians who need reliable information as soon as possible. Yet research done in pressured circumstances can lead to ethical dilemmas, especially for vulnerable research subjects. We present the case of a child with neurocognitive impairment who is diagnosed with COVID-19 infection after presenting with fever and a seizure. The child lives in a group home and is in the custody of the state; her parents lost parental rights many years ago. Some members of the health care team want to enroll her in a randomized clinical trial evaluating an experimental treatment of COVID-19. For minor patients to enroll in this clinical trial, the institutional review board requires assent of patients and consent of guardians. An ethics consult is called to help identify relevant concerns in enrollment. In the accompanying case discussion, we address historical perspectives on research involving people with disabilities; proper management of research participation for people with disabilities including consent by proxy, therapeutic misconception, and other threats to the ethical validity of clinical trials; and the potentially conflicting obligations of researchers and clinicians.

Reducing Outpatient Infant Blood Draws with Transcutaneous Measurement of Bilirubin.

INTRODUCTION: Newborn jaundice is a common outpatient problem. Transcutaneous bilirubin (TcB) measurements correlate well with total serum bilirubin (SB) measurements below 15 mg/dl and are efficient and noninvasive. Some concern exists that TcB measurement may subsequently lead to an increase in the number of SB measurements performed in the outpatient setting. We aimed to implement the use of a TcB device in an outpatient clinic. By doing so, we sought to increase the number of newborns screened solely by TcB as opposed to SB, by 30%, within 12 months. METHODS: We conducted plan-do-study-act cycles with targeted interventions to promote the use of TcB in an outpatient clinic for eligible newborns older than 35 weeks gestational age, aged 1-20 days, and without a history of transfusion, phototherapy, extensive bruising, or risk of hemolysis. We used statistical process control methods to measure proportions of newborns evaluated with TcB (run chart) and patients-between SB measurements (G-chart) over time in the outpatient clinic. RESULTS: We collected preintervention data for 18-months and intervention data for 12 months. For newborns attending the outpatient clinic, the proportion of TcB measurements increased after implementation of the use of TcB measurement. There was an increase in patients-between SB measurements. At project inception, SB was drawn for every 8 eligible patients. By the end of the project, there were 98 eligible newborns between instances of SB testing. CONCLUSION: Implementation of a quality-improvement initiative to measure TcB in the outpatient clinic was feasible and reduced the number of SB tests.

Adolescent suicide: what can pediatricians do?

PURPOSE OF REVIEW: Suicide is a major public health concern and the second leading cause of death for adolescents. Faced with an already-high prevalence and increasing rates over the past decade, pediatricians feel inadequately prepared to manage a suicidal patient. This article will review the changing rates of suicide, discuss recent literature on risk factors, identify methods to screen for suicidal thoughts and suggest an approach to counseling a suicidal patient. Finally, there will be a brief discussion on safety planning and public health measures to help reduce suicide rates. RECENT FINDINGS: Rates of attempted suicide and death by suicide have been increasing for more than a decade. Risk assessment of potential suicidality remains very challenging, as the risk factors are multifactorial. However, some common risk factors persist including sexual minority identification and family or personal history of mental health issues. Although keeping these and other risk factors in mind, regular screening of adolescents for depression and self-harm is important. Finally, the best safety plans and treatment methods appear to be team-based. SUMMARY: It remains the responsibility of pediatricians to stay aware of risk factors, regularly screen adolescents and prioritize collaborative safety planning for suicidal patients.

When Specialty Care Is Unavailable to Rural Families.

We present the case of a 2-year-old boy with epidermolysis bullosa and supraglottic stenosis whose parents refuse an elective tracheostomy because of the significant care the tracheostomy would require. The patient's family lives in a rural area with few health care resources and his parents are already handling hours of daily skin care for his epidermolysis bullosa. In an attempt to convince the parents to pursue the intervention, the medical team recommends that the family move to an area with additional resources to assist in the child's care. The parents refuse to move, citing the many benefits their home environment provides for their son. The medical team calls an ethics consultation, questioning whether this decision constitutes medical neglect. This case raises important questions about medical decision-making in pediatrics. First, is a parent's refusal of a recommended medical intervention because it would require moving their family to a new environment a reasonable decision? Second, how broadly can parents define their child's best interest? Should only physical interests be included when making medical decisions? Is there a limit to what can be considered a relevant interest? Third, can parents only consider the interests of the individual child, or can they consider the interests of other members of the family? Finally, what is the threshold for overruling a parental decision? Is it whenever the parent's definition of a patient's best interest is different from the medical team's, or do other criteria have to be met?

Effective, recommended, underutilized: a review of the literature on barriers to adolescent usage of long-acting reversible contraceptive methods.

PURPOSE OF REVIEW: Teenage pregnancy rates in the United States remain at epidemic proportions. To help stem the tide of adolescent pregnancy, both the American Academy of Pediatrics and American College of Obstetricians and Gynecologists have released policy statements that long-acting reversible contraceptives (LARC) be considered the first-line option for contraception in adolescents. Despite the recommendations and efficacy, LARCs are utilized by less than 5% of American teens. The purpose of this review is to elucidate the barriers to adolescent access to LARC, which are broken down into provider, patient, and cultural barriers. RECENT FINDINGS: Recent literature suggests that shortcomings in physician training in LARC method counseling and placement begin as early as medical school and are further augmented by the clinical cost and logistical difficulty of device placement. Patients experience barriers due to cost, confidential access, and perceptions or misconceptions about contraceptive options. Cultural barriers are derived from the absence of expectation for adolescents to pursue safe and effective contraceptive options, as well as the historical complications from intrauterine devices (IUDs) and implants. SUMMARY: These barriers have led to poor utilization of the most effective methods in preventing adolescent pregnancy. It is essential that pediatricians be up-to-date on the most current recommendations surrounding LARC to help negate barriers and provide the best care to adolescent patients.

When Residents Let Conscience Be Their Guide: Professional Development and Educational Opportunity.

Residency is a time of professional identity formation. During this time, residents may first be exposed to conflicts between professional duties and personal beliefs which may lead to a request for a conscience-based exemption. Faculty, whether the supervising attending or the program director, have an important role in the professional and ethical development of residents by acknowledging and supporting residents as they encounter these potential conflicts. In this paper, we highlight three areas of unique issues that arise within the context of residency training programs when a resident makes a request to be excused from clinical duties based on personal conscience: namely, the maintenance of educational standards, the burdens that may be placed on colleagues, and the responsibility for faculty to foster the professional development of ethically sensitive pediatricians.

High-altitude illness in the pediatric population: a review of the literature on prevention and treatment.

PURPOSE OF REVIEW: Increasing numbers of children are now traveling to high-altitude destinations, and pediatricians often see these children prior to and immediately following their travels. Thus, pediatricians have the opportunity to provide guidance for the prevention of altitude illness and must treat high-altitude illness (HAI) in some circumstances. This review will examine guidelines for prevention and management of HAI in the pediatric population. RECENT FINDINGS: Recent research has examined children's short-term cardiorespiratory adaptation to high altitude, incidence of acute mountain sickness, hypoxic ventilator response, and maximal exercise capacity. Overall, studies indicate that children and adults are largely similar in these variables. Furthermore, studies suggest that heritability seems to be a component of response to altitude and development of altitude illness - a finding that may have implications for family vacation planning. SUMMARY: Increasing numbers of children are visiting high altitude destinations. Whereas most of these child travelers will only experience mild to moderate symptoms of HAI, a small percentage, particularly those with predisposing health conditions, may experience severe disease. Pediatricians should encourage preventive measures with an emphasis on gradual ascent and vigilance for onset of symptoms that should prompt immediate transport to medical care.

Addressing substance misuse in adolescents: a review of the literature on the screening, brief intervention, and referral to treatment model.

PURPOSE OF REVIEW: Adolescent substance use is a major public health concern in the United States. Pediatricians are in a unique position via the medical home to address this issue. Screening, brief intervention, and referral to treatment (SBIRT) is a comprehensive approach that aims to prevent, identify, and reduce substance use. SBIRT has been heavily studied in adults, but research with adolescents is still ongoing. This review examines the SBIRT model and highlights recent applicable research. RECENT FINDINGS: This research indicates that alcohol and drug use has a negative impact on the developing brain. In 2011, the American Academy of Pediatrics (AAP) released a policy statement recommending the use of SBIRT. An adolescent SBIRT algorithm can be used clinically. Recent studies focus on individual components of SBIRT; however, there have been no studies that examine all three components together in adolescents. Nevertheless, research indicates that SBIRT is an important tool to assess and intervene regarding adolescent substance use. SUMMARY: SBIRT is recommended by the AAP as a way to address adolescent substance use. Pediatricians should be screening adolescents for substance use at every well exam, and acute care visits when possible, with a validated tool. Although more research is needed, SBIRT is an effective method to address adolescent substance use.

Recent advances in the understanding and management of long QT syndrome.

PURPOSE OF REVIEW: The sudden death of a previously healthy young individual is a dreadful occurrence. Identifying those at risk of such a dire outcome, and appropriately managing and counseling them, has been an ongoing challenge, but rapid advances are being made. This review will focus on the long QT syndrome (LQTS), the most common of the potentially lethal inheritable arrhythmias, with specific focus on the genetics relevant to clinical presentation, therapy and response. RECENT FINDINGS: The past 2 decades have seen tremendous progress in the field of inheritable arrhythmias. Emphasis is given to risk stratification, screening of family members, and the counseling of young athletes, as well as new developments in screening and treatment. SUMMARY: For the primary care provider, long QT syndrome should be considered during the evaluation of syncope, near-syncope and seizures, especially in the setting of exercise or with a family history of sudden unexplained death in a first-degree relative. The corrected QT interval (QTc) should be assessed as a routine when obtaining electrocardiograms. If there are concerns on the basis of electrocardiogram findings, medical history or family history, referral to a cardiologist is indicated. Providers need to be cognizant of the challenges of therapy and lifestyle changes for patients and families with long QT syndrome.

Adolescent STIs for primary care providers.

PURPOSE OF REVIEW: Sexually transmitted infections (STIs) remain a significant source of morbidity among adolescents, who bear a disproportionate burden of disease. Many infections are asymptomatic, but pose significant risk for long-term sequelae in this at-risk population. RECENT FINDINGS: Recommendations published within the last 5 years from the Centers for Disease Control, United States Preventive Services Task Force, and American Academy of Pediatrics are available to aid providers in appropriate screening, treatment, and prevention of common STIs. However, recent data indicate that many adolescents at risk for STIs are not being appropriately screened. In this review, we summarize screening and treatment recommendations for chlamydia and gonorrhea; prevention and screening recommendations for human papilloma virus (HPV); and appropriate testing for HIV and syphilis. SUMMARY: Primary care providers are in a unique position to address STIs with adolescents. Improved adherence to screening, treatment, and vaccination recommendations by primary care providers is imperative to reduce prevalence, complications, and transmission of STIs in the adolescent population.