Francine Pearce, MD

Anaphylaxis is a relatively common occurrence for many adolescents. As primary care doctors, we normally see the patient after the acute phase, and then are required to do the detective work to figure out the causes of the episode. The cause may be obvious, but many times we have to hope for another occurrence with similar circumstances to identify it. Surprisingly, the cause may not be what you think. Factors that contribute to an anaphylaxis response may be related to activity, timing of food ingestion, an environmental factor, or medication.

Let’s look at just one type, exercise-induced anaphylaxis. It’s divided into two categories: food dependent and nonfood dependent. Both are described as an induction of itching, urticaria, and fatigue, with progression to angioedema and hypotension, associated with exercise (J. Allergy Clin. Immunol. 1980;66:106-11).

Food-dependent exercise-induced anaphylaxis occurs when exercise is started 30 minutes after ingesting food. This may be difficult to identify because patients react to the food only if they exercise, so food is usually eliminated as a cause. Wheat and wheat flour are common culprits for this type of reaction because of the omega-5 gliadin, which is the protein in gluten (J. Allergy Clin. Immunol. 1991;87:34-40). In one study, larger amounts of the suspected agent were given; hives and angioedema did start to occur in 20% of patients challenged, which suggested that there was likely a baseline allergy to the food, and exercise itself might be a cofactor in augmentation of the allergic reaction.

In nonfood-dependent exercise-induced anaphylaxis, symptoms of itching, urticaria, and fatigue can occur 5-30 minutes after the start of exercise. Although bronchospasm is rare, it can occur along with angioedema, nausea, vomiting, and hypotension, and can even be fatal if exercise continues. If exercise is stopped, it usually resolves. However, many people try to push through it, which only worsens the symptoms.

Cofactors associated with nonfood-dependent exercise-induced anaphylaxis are ingestion of alcohol and an NSAID several hours beforehand. These agents also might be overlooked if well tolerated independently (Br. J. Dermatol. 2001;145:336-9).

Timing of the episode also plays a role. Premenstrual syndrome can be a factor in augmentation of anaphylaxis, so it also should be considered. Knowing the date of the last menstrual cycle and identifying if the anaphylaxis is episodic will identify premenstrual syndrome as a cause.

The work-up should include standard allergy testing and determination of tryptase levels. Skin testing is essential to identify offending agents, and is rarely negative. If a food is suspected and skin testing is negative, repeat the skin testing in 6 months. In one study, wheat extract was found to be positive in only 29% of persons suspected of having a wheat allergy, but when the paste of wheat flour was tested, 80% were identified. The ImmunoCAP Test also was found to have a sensitivity of 80%, so it is a valuable test to try along with the skin prick.

Tryptase levels should be evaluated because in nonfood-dependent exercise-induced anaphylaxis, these levels are slightly elevated at the time of the anaphylaxis, but return to normal. A patient with mastocytosis, a group of disorders characterized by pathologic mast cells infiltrating the skin, will consistently have elevated tryptase levels. Seasonal allergies associated with pollen, and asthma bronchospasm also should be considered as causes.

Although these exercise-induced anaphylaxis episodes can occur at any age, they are most frequent in the adolescent age group, probably because that’s the time most of this population are involved in organized sports. Upon presentation, a careful detailed history will help to identify the cause of anaphylaxis and result in quicker resolution.

Treatment includes avoidance of the offending agent if identified and an antihistamine, and if symptoms do occur, ceasing exercise immediately to avoid a full-blown anaphylactic reaction.

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected].

Anaphylaxis is a relatively common occurrence for many adolescents. As primary care doctors, we normally see the patient after the acute phase, and then are required to do the detective work to figure out the causes of the episode. The cause may be obvious, but many times we have to hope for another occurrence with similar circumstances to identify it. Surprisingly, the cause may not be what you think. Factors that contribute to an anaphylaxis response may be related to activity, timing of food ingestion, an environmental factor, or medication.

Let’s look at just one type, exercise-induced anaphylaxis. It’s divided into two categories: food dependent and nonfood dependent. Both are described as an induction of itching, urticaria, and fatigue, with progression to angioedema and hypotension, associated with exercise (J. Allergy Clin. Immunol. 1980;66:106-11).

Food-dependent exercise-induced anaphylaxis occurs when exercise is started 30 minutes after ingesting food. This may be difficult to identify because patients react to the food only if they exercise, so food is usually eliminated as a cause. Wheat and wheat flour are common culprits for this type of reaction because of the omega-5 gliadin, which is the protein in gluten (J. Allergy Clin. Immunol. 1991;87:34-40). In one study, larger amounts of the suspected agent were given; hives and angioedema did start to occur in 20% of patients challenged, which suggested that there was likely a baseline allergy to the food, and exercise itself might be a cofactor in augmentation of the allergic reaction.

In nonfood-dependent exercise-induced anaphylaxis, symptoms of itching, urticaria, and fatigue can occur 5-30 minutes after the start of exercise. Although bronchospasm is rare, it can occur along with angioedema, nausea, vomiting, and hypotension, and can even be fatal if exercise continues. If exercise is stopped, it usually resolves. However, many people try to push through it, which only worsens the symptoms.

Cofactors associated with nonfood-dependent exercise-induced anaphylaxis are ingestion of alcohol and an NSAID several hours beforehand. These agents also might be overlooked if well tolerated independently (Br. J. Dermatol. 2001;145:336-9).

Timing of the episode also plays a role. Premenstrual syndrome can be a factor in augmentation of anaphylaxis, so it also should be considered. Knowing the date of the last menstrual cycle and identifying if the anaphylaxis is episodic will identify premenstrual syndrome as a cause.

The work-up should include standard allergy testing and determination of tryptase levels. Skin testing is essential to identify offending agents, and is rarely negative. If a food is suspected and skin testing is negative, repeat the skin testing in 6 months. In one study, wheat extract was found to be positive in only 29% of persons suspected of having a wheat allergy, but when the paste of wheat flour was tested, 80% were identified. The ImmunoCAP Test also was found to have a sensitivity of 80%, so it is a valuable test to try along with the skin prick.

Tryptase levels should be evaluated because in nonfood-dependent exercise-induced anaphylaxis, these levels are slightly elevated at the time of the anaphylaxis, but return to normal. A patient with mastocytosis, a group of disorders characterized by pathologic mast cells infiltrating the skin, will consistently have elevated tryptase levels. Seasonal allergies associated with pollen, and asthma bronchospasm also should be considered as causes.

Although these exercise-induced anaphylaxis episodes can occur at any age, they are most frequent in the adolescent age group, probably because that’s the time most of this population are involved in organized sports. Upon presentation, a careful detailed history will help to identify the cause of anaphylaxis and result in quicker resolution.

Treatment includes avoidance of the offending agent if identified and an antihistamine, and if symptoms do occur, ceasing exercise immediately to avoid a full-blown anaphylactic reaction.

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected].

Anaphylaxis is a relatively common occurrence for many adolescents. As primary care doctors, we normally see the patient after the acute phase, and then are required to do the detective work to figure out the causes of the episode. The cause may be obvious, but many times we have to hope for another occurrence with similar circumstances to identify it. Surprisingly, the cause may not be what you think. Factors that contribute to an anaphylaxis response may be related to activity, timing of food ingestion, an environmental factor, or medication.

Let’s look at just one type, exercise-induced anaphylaxis. It’s divided into two categories: food dependent and nonfood dependent. Both are described as an induction of itching, urticaria, and fatigue, with progression to angioedema and hypotension, associated with exercise (J. Allergy Clin. Immunol. 1980;66:106-11).

Food-dependent exercise-induced anaphylaxis occurs when exercise is started 30 minutes after ingesting food. This may be difficult to identify because patients react to the food only if they exercise, so food is usually eliminated as a cause. Wheat and wheat flour are common culprits for this type of reaction because of the omega-5 gliadin, which is the protein in gluten (J. Allergy Clin. Immunol. 1991;87:34-40). In one study, larger amounts of the suspected agent were given; hives and angioedema did start to occur in 20% of patients challenged, which suggested that there was likely a baseline allergy to the food, and exercise itself might be a cofactor in augmentation of the allergic reaction.

In nonfood-dependent exercise-induced anaphylaxis, symptoms of itching, urticaria, and fatigue can occur 5-30 minutes after the start of exercise. Although bronchospasm is rare, it can occur along with angioedema, nausea, vomiting, and hypotension, and can even be fatal if exercise continues. If exercise is stopped, it usually resolves. However, many people try to push through it, which only worsens the symptoms.

Cofactors associated with nonfood-dependent exercise-induced anaphylaxis are ingestion of alcohol and an NSAID several hours beforehand. These agents also might be overlooked if well tolerated independently (Br. J. Dermatol. 2001;145:336-9).

Timing of the episode also plays a role. Premenstrual syndrome can be a factor in augmentation of anaphylaxis, so it also should be considered. Knowing the date of the last menstrual cycle and identifying if the anaphylaxis is episodic will identify premenstrual syndrome as a cause.

The work-up should include standard allergy testing and determination of tryptase levels. Skin testing is essential to identify offending agents, and is rarely negative. If a food is suspected and skin testing is negative, repeat the skin testing in 6 months. In one study, wheat extract was found to be positive in only 29% of persons suspected of having a wheat allergy, but when the paste of wheat flour was tested, 80% were identified. The ImmunoCAP Test also was found to have a sensitivity of 80%, so it is a valuable test to try along with the skin prick.

Tryptase levels should be evaluated because in nonfood-dependent exercise-induced anaphylaxis, these levels are slightly elevated at the time of the anaphylaxis, but return to normal. A patient with mastocytosis, a group of disorders characterized by pathologic mast cells infiltrating the skin, will consistently have elevated tryptase levels. Seasonal allergies associated with pollen, and asthma bronchospasm also should be considered as causes.

Although these exercise-induced anaphylaxis episodes can occur at any age, they are most frequent in the adolescent age group, probably because that’s the time most of this population are involved in organized sports. Upon presentation, a careful detailed history will help to identify the cause of anaphylaxis and result in quicker resolution.

Treatment includes avoidance of the offending agent if identified and an antihistamine, and if symptoms do occur, ceasing exercise immediately to avoid a full-blown anaphylactic reaction.

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected].

The relationship between parents and pediatricians is unique. More than any other field of medicine, there is a level of trust that develops because of the consistent and ongoing interaction for several years. But as the child grows older and enters the adolescent years, the relationship shifts from catering to the desires of the parent to the needs of the child.

When a strong relationship is established, the transition of trust is usually easy, and parents are very comfortable and welcoming of an independent relationship between the physician and the child. But there are many issues that come up in adolescence that may be very difficult for a child to discuss with the parent despite having a good relationship, putting the physician directly in the middle.

The issue of minor consent is complex, and because it differs from state to state, it becomes even more complex. Of course, the best approach is to have a conversation with the parent to determine their views on various issues and ask for consent to address them should their child present to you for treatment, but new patients present, and time to establish a relationship is not always possible. The American Academy of Pediatrics statement on treatment of adolescents requires that every attempt is made to encourage inclusion of the parent in any decision making.

Understanding the laws that govern the state in which you practice is imperative. The state policies and laws can be found at www.Guttmacher.org. Although there has not been a physician held liable for nonnegligent care given to a minor who gave consent, it is important for parents to understand what their child can consent to or against. It also is important for the physician to be explicitly clear as to what their limitations are by law.

A minor status is defined by age under 18 years of age. An emancipated minor is someone who attained legal adulthood because of marriage, military service, or living separately from parents and managing one’s financial affairs (Understanding Legal Aspects of Care, in “Adolescent Health Care: A Practical Guide,” 5th ed [Philadelphia Lippincott Williams & Wilkins, 2008]). These laws are very clear and do not usually cause much confusion. Where the situation becomes very grey is in the case of the mature minor. This category is recognized in some states as an exception to the rules requiring parental consent for medical care (Int. J. Gynaecol. Obstet. 1998;63:295-300). The mature minor is defined as being at least 14 years old, having the ability to understand risk and benefits, and having the ability to provide informed consent. But this requires a subjective assessment of the adolescent, which could be argued by the parent.

Minors can consent to contraceptive services in most states. In 1977, the Supreme Court ruled that the right to privacy protects a minor’s access to nonprescriptive contraception, and although prescribed contraception is not included, it is generally considered to be included (Med. Clin. North Am, 1990; 74:1097-112). It is important to note that a pharmacist under the Pharmacist Conscience Clause, in some states, can refuse to fill the prescription without parental consent at their discretion (Arch. Pediatr. Adolesc. Med. 2003;157:361-5). Although this not a common issue, it may present a larger issue if the patient requested confidentiality.

Diagnosis and treatment of sexually transmitted disease also can be done with the consent of a minor, but the age of the patient, usually greater than 14 years, is required in most states. A careful assessment must be done for abuse regardless of whether the minor admitted to consensual sex or not. The laws regarding statutory rape are clearly defined state to state and may present a larger problem if disputed by the parent.

Elective abortion is always a topic of debate. States require at least one parent to consent when a minor is seeking an abortion, but a minor also can seek a judicial bypass, which is a request from a minor to not have parental consent for an abortion if they believe that notification will bring harm to the minor. Conversely, an adolescent also can refuse to consent to an abortion that the parent requests.

Immunizations also can be given with the consent of the minor, but extra precaution should be given to documentation of clear explanation of risk and benefits. Despite there being no federal law requiring parental consent, some states do require it, and it is prudent to obtain it.

Parents don’t often realize the limitations of their ability to prevent or demand treatment. So although the abortion itself falls outside the scope of care of a pediatrician, educating parents on the laws can help them navigate the situation better. Parents also may request drug, sexually transmitted infection, or pregnancy testing without the knowledge of the minor. Whether it is done is left to the discretion of the physician but the AAP advises that this only be done as a rare exception (Pediatrics 2007;119:627-30).

Now a larger consideration for physicians is financial liability. Parents are not obligated to pay for treatment and procedures for which they did not consent. The financial responsibility falls on the minor who requested it. Obviously, this could be costly for the facility, and therefore a decision has to be made to either disrupt continuity of care and refer to an outside facility or absorb the cost. This can be a challenging decision. Disclosing to the minor that payment sent through the insurance might unintentionally breach the confidentiality of the treatment is also an important consideration if the minor’s desire is to keep the parent uninformed.

The issue of consent to treatment when it comes to minors is multifaceted. Maintaining the trust of the parent and gaining the trust of the adolescent is tricky when the lines of communication between them are limited. Establishing early a relationship of trust with the parent to advise and treat the child appropriately in the event he or she does present with complex issues will settle many of the issues. More importantly, as pediatricians our goal is to establish a relationship with the adolescent so that he or she knows where to go to get good sound advice and treatment to ensure good health and prevent avoidable consequences.

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected]. Scan this QR code to view similar columns or go to pediatricnews.com.

The relationship between parents and pediatricians is unique. More than any other field of medicine, there is a level of trust that develops because of the consistent and ongoing interaction for several years. But as the child grows older and enters the adolescent years, the relationship shifts from catering to the desires of the parent to the needs of the child.

When a strong relationship is established, the transition of trust is usually easy, and parents are very comfortable and welcoming of an independent relationship between the physician and the child. But there are many issues that come up in adolescence that may be very difficult for a child to discuss with the parent despite having a good relationship, putting the physician directly in the middle.

The issue of minor consent is complex, and because it differs from state to state, it becomes even more complex. Of course, the best approach is to have a conversation with the parent to determine their views on various issues and ask for consent to address them should their child present to you for treatment, but new patients present, and time to establish a relationship is not always possible. The American Academy of Pediatrics statement on treatment of adolescents requires that every attempt is made to encourage inclusion of the parent in any decision making.

Understanding the laws that govern the state in which you practice is imperative. The state policies and laws can be found at www.Guttmacher.org. Although there has not been a physician held liable for nonnegligent care given to a minor who gave consent, it is important for parents to understand what their child can consent to or against. It also is important for the physician to be explicitly clear as to what their limitations are by law.

A minor status is defined by age under 18 years of age. An emancipated minor is someone who attained legal adulthood because of marriage, military service, or living separately from parents and managing one’s financial affairs (Understanding Legal Aspects of Care, in “Adolescent Health Care: A Practical Guide,” 5th ed [Philadelphia Lippincott Williams & Wilkins, 2008]). These laws are very clear and do not usually cause much confusion. Where the situation becomes very grey is in the case of the mature minor. This category is recognized in some states as an exception to the rules requiring parental consent for medical care (Int. J. Gynaecol. Obstet. 1998;63:295-300). The mature minor is defined as being at least 14 years old, having the ability to understand risk and benefits, and having the ability to provide informed consent. But this requires a subjective assessment of the adolescent, which could be argued by the parent.

Minors can consent to contraceptive services in most states. In 1977, the Supreme Court ruled that the right to privacy protects a minor’s access to nonprescriptive contraception, and although prescribed contraception is not included, it is generally considered to be included (Med. Clin. North Am, 1990; 74:1097-112). It is important to note that a pharmacist under the Pharmacist Conscience Clause, in some states, can refuse to fill the prescription without parental consent at their discretion (Arch. Pediatr. Adolesc. Med. 2003;157:361-5). Although this not a common issue, it may present a larger issue if the patient requested confidentiality.

Diagnosis and treatment of sexually transmitted disease also can be done with the consent of a minor, but the age of the patient, usually greater than 14 years, is required in most states. A careful assessment must be done for abuse regardless of whether the minor admitted to consensual sex or not. The laws regarding statutory rape are clearly defined state to state and may present a larger problem if disputed by the parent.

Elective abortion is always a topic of debate. States require at least one parent to consent when a minor is seeking an abortion, but a minor also can seek a judicial bypass, which is a request from a minor to not have parental consent for an abortion if they believe that notification will bring harm to the minor. Conversely, an adolescent also can refuse to consent to an abortion that the parent requests.

Immunizations also can be given with the consent of the minor, but extra precaution should be given to documentation of clear explanation of risk and benefits. Despite there being no federal law requiring parental consent, some states do require it, and it is prudent to obtain it.

Parents don’t often realize the limitations of their ability to prevent or demand treatment. So although the abortion itself falls outside the scope of care of a pediatrician, educating parents on the laws can help them navigate the situation better. Parents also may request drug, sexually transmitted infection, or pregnancy testing without the knowledge of the minor. Whether it is done is left to the discretion of the physician but the AAP advises that this only be done as a rare exception (Pediatrics 2007;119:627-30).

Now a larger consideration for physicians is financial liability. Parents are not obligated to pay for treatment and procedures for which they did not consent. The financial responsibility falls on the minor who requested it. Obviously, this could be costly for the facility, and therefore a decision has to be made to either disrupt continuity of care and refer to an outside facility or absorb the cost. This can be a challenging decision. Disclosing to the minor that payment sent through the insurance might unintentionally breach the confidentiality of the treatment is also an important consideration if the minor’s desire is to keep the parent uninformed.

The issue of consent to treatment when it comes to minors is multifaceted. Maintaining the trust of the parent and gaining the trust of the adolescent is tricky when the lines of communication between them are limited. Establishing early a relationship of trust with the parent to advise and treat the child appropriately in the event he or she does present with complex issues will settle many of the issues. More importantly, as pediatricians our goal is to establish a relationship with the adolescent so that he or she knows where to go to get good sound advice and treatment to ensure good health and prevent avoidable consequences.

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected]. Scan this QR code to view similar columns or go to pediatricnews.com.

The relationship between parents and pediatricians is unique. More than any other field of medicine, there is a level of trust that develops because of the consistent and ongoing interaction for several years. But as the child grows older and enters the adolescent years, the relationship shifts from catering to the desires of the parent to the needs of the child.

When a strong relationship is established, the transition of trust is usually easy, and parents are very comfortable and welcoming of an independent relationship between the physician and the child. But there are many issues that come up in adolescence that may be very difficult for a child to discuss with the parent despite having a good relationship, putting the physician directly in the middle.

The issue of minor consent is complex, and because it differs from state to state, it becomes even more complex. Of course, the best approach is to have a conversation with the parent to determine their views on various issues and ask for consent to address them should their child present to you for treatment, but new patients present, and time to establish a relationship is not always possible. The American Academy of Pediatrics statement on treatment of adolescents requires that every attempt is made to encourage inclusion of the parent in any decision making.

Understanding the laws that govern the state in which you practice is imperative. The state policies and laws can be found at www.Guttmacher.org. Although there has not been a physician held liable for nonnegligent care given to a minor who gave consent, it is important for parents to understand what their child can consent to or against. It also is important for the physician to be explicitly clear as to what their limitations are by law.

A minor status is defined by age under 18 years of age. An emancipated minor is someone who attained legal adulthood because of marriage, military service, or living separately from parents and managing one’s financial affairs (Understanding Legal Aspects of Care, in “Adolescent Health Care: A Practical Guide,” 5th ed [Philadelphia Lippincott Williams & Wilkins, 2008]). These laws are very clear and do not usually cause much confusion. Where the situation becomes very grey is in the case of the mature minor. This category is recognized in some states as an exception to the rules requiring parental consent for medical care (Int. J. Gynaecol. Obstet. 1998;63:295-300). The mature minor is defined as being at least 14 years old, having the ability to understand risk and benefits, and having the ability to provide informed consent. But this requires a subjective assessment of the adolescent, which could be argued by the parent.

Minors can consent to contraceptive services in most states. In 1977, the Supreme Court ruled that the right to privacy protects a minor’s access to nonprescriptive contraception, and although prescribed contraception is not included, it is generally considered to be included (Med. Clin. North Am, 1990; 74:1097-112). It is important to note that a pharmacist under the Pharmacist Conscience Clause, in some states, can refuse to fill the prescription without parental consent at their discretion (Arch. Pediatr. Adolesc. Med. 2003;157:361-5). Although this not a common issue, it may present a larger issue if the patient requested confidentiality.

Diagnosis and treatment of sexually transmitted disease also can be done with the consent of a minor, but the age of the patient, usually greater than 14 years, is required in most states. A careful assessment must be done for abuse regardless of whether the minor admitted to consensual sex or not. The laws regarding statutory rape are clearly defined state to state and may present a larger problem if disputed by the parent.

Elective abortion is always a topic of debate. States require at least one parent to consent when a minor is seeking an abortion, but a minor also can seek a judicial bypass, which is a request from a minor to not have parental consent for an abortion if they believe that notification will bring harm to the minor. Conversely, an adolescent also can refuse to consent to an abortion that the parent requests.

Immunizations also can be given with the consent of the minor, but extra precaution should be given to documentation of clear explanation of risk and benefits. Despite there being no federal law requiring parental consent, some states do require it, and it is prudent to obtain it.

Parents don’t often realize the limitations of their ability to prevent or demand treatment. So although the abortion itself falls outside the scope of care of a pediatrician, educating parents on the laws can help them navigate the situation better. Parents also may request drug, sexually transmitted infection, or pregnancy testing without the knowledge of the minor. Whether it is done is left to the discretion of the physician but the AAP advises that this only be done as a rare exception (Pediatrics 2007;119:627-30).

Now a larger consideration for physicians is financial liability. Parents are not obligated to pay for treatment and procedures for which they did not consent. The financial responsibility falls on the minor who requested it. Obviously, this could be costly for the facility, and therefore a decision has to be made to either disrupt continuity of care and refer to an outside facility or absorb the cost. This can be a challenging decision. Disclosing to the minor that payment sent through the insurance might unintentionally breach the confidentiality of the treatment is also an important consideration if the minor’s desire is to keep the parent uninformed.

The issue of consent to treatment when it comes to minors is multifaceted. Maintaining the trust of the parent and gaining the trust of the adolescent is tricky when the lines of communication between them are limited. Establishing early a relationship of trust with the parent to advise and treat the child appropriately in the event he or she does present with complex issues will settle many of the issues. More importantly, as pediatricians our goal is to establish a relationship with the adolescent so that he or she knows where to go to get good sound advice and treatment to ensure good health and prevent avoidable consequences.

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected]. Scan this QR code to view similar columns or go to pediatricnews.com.

Times are changing! To compete in to today’s times, doctors are faced with the challenge of seeing 30-plus patients per day, keeping the wait times down, adhering to the meaningful use guidelines – all while participating in the endless maintenance of certification activities. But like it or not, medicine has changed, and you have to keep up or you likely are going to be left behind.

Pediatricians and family physicians more than other specialties are inundated with phone calls and lengthy conversations on constipation and congestion. Most of us just take the call with a smile, and chalk it up to part of the job. But what if you could provide a service that allowed you to get paid for those lengthy conversations, offered the convenience of a consultation without the patient having to come in the office – without the risk of your giving faulty advice because you haven’t actually evaluated the patient. Well, that’s what telemedicine has to offer. For a nominal monthly fee, your patients can subscribe to your “virtual” office. Whether you schedule during your office hours or set aside time before or after clinic, you now can capture a whole new clientele.

For teens, access to their doctors through their electronic devices would provide the convenience they need. Even if the issue cannot be treated without a visit, it allows for early evaluation. Acne, skin rashes, emotional issues, menstrual issues, hair issues, weight issues – all of these can be addressed via telemedicine.

The American Academy of Pediatrics’ Section on Telehealth Care (SOTC) helps guide you on how to bill for telemedicine services. It provides newsletters, educational series, and liability information. Much of the concern with telemedicine is the inconsistency of reimbursement for the service, but things are changing, and more and more of these services are being recognized for their value in meeting the needs of the patient.

There are different products on the market to assist you in setting up your virtual office. Understanding the differences in services is important. Services such as Doctor on Demand have a team of doctors available for fee-for-consult, at approximately $40. Other services, such as myowndoctor.com, set up a virtual office for you, which allows more of a concierge type service for a nominal monthly fee – approximately the amount of a copay – to allow patients access to the telemedicine service with their own physicians. This a great option that can create a cash revenue for you and broader access to patients.

There are several services provided by insurance companies – MDLIVE (Cigna), LiveHealth Online (WellPoint), and Online Care Anywhere (BC/BS Minnesota) – where providers are reimbursed at $45-$49 per visit. What is important to know when choosing a company is to be sure that the software is HIPAA (Health Insurance Portability and Accountability Act) compliant. Currently there are more than 15 companies on the market, and many more to come.

Staying up with the times is going to be key in surviving the current changes in health care. Teens in particular are a difficult group to access, but telemedicine provides that access and the comfort in continuity of care with their own physicians.

Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures. E-mail her at [email protected].

Times are changing! To compete in to today’s times, doctors are faced with the challenge of seeing 30-plus patients per day, keeping the wait times down, adhering to the meaningful use guidelines – all while participating in the endless maintenance of certification activities. But like it or not, medicine has changed, and you have to keep up or you likely are going to be left behind.

Pediatricians and family physicians more than other specialties are inundated with phone calls and lengthy conversations on constipation and congestion. Most of us just take the call with a smile, and chalk it up to part of the job. But what if you could provide a service that allowed you to get paid for those lengthy conversations, offered the convenience of a consultation without the patient having to come in the office – without the risk of your giving faulty advice because you haven’t actually evaluated the patient. Well, that’s what telemedicine has to offer. For a nominal monthly fee, your patients can subscribe to your “virtual” office. Whether you schedule during your office hours or set aside time before or after clinic, you now can capture a whole new clientele.

For teens, access to their doctors through their electronic devices would provide the convenience they need. Even if the issue cannot be treated without a visit, it allows for early evaluation. Acne, skin rashes, emotional issues, menstrual issues, hair issues, weight issues – all of these can be addressed via telemedicine.

The American Academy of Pediatrics’ Section on Telehealth Care (SOTC) helps guide you on how to bill for telemedicine services. It provides newsletters, educational series, and liability information. Much of the concern with telemedicine is the inconsistency of reimbursement for the service, but things are changing, and more and more of these services are being recognized for their value in meeting the needs of the patient.

There are different products on the market to assist you in setting up your virtual office. Understanding the differences in services is important. Services such as Doctor on Demand have a team of doctors available for fee-for-consult, at approximately $40. Other services, such as myowndoctor.com, set up a virtual office for you, which allows more of a concierge type service for a nominal monthly fee – approximately the amount of a copay – to allow patients access to the telemedicine service with their own physicians. This a great option that can create a cash revenue for you and broader access to patients.

There are several services provided by insurance companies – MDLIVE (Cigna), LiveHealth Online (WellPoint), and Online Care Anywhere (BC/BS Minnesota) – where providers are reimbursed at $45-$49 per visit. What is important to know when choosing a company is to be sure that the software is HIPAA (Health Insurance Portability and Accountability Act) compliant. Currently there are more than 15 companies on the market, and many more to come.

Staying up with the times is going to be key in surviving the current changes in health care. Teens in particular are a difficult group to access, but telemedicine provides that access and the comfort in continuity of care with their own physicians.

Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures. E-mail her at [email protected].

Times are changing! To compete in to today’s times, doctors are faced with the challenge of seeing 30-plus patients per day, keeping the wait times down, adhering to the meaningful use guidelines – all while participating in the endless maintenance of certification activities. But like it or not, medicine has changed, and you have to keep up or you likely are going to be left behind.

Pediatricians and family physicians more than other specialties are inundated with phone calls and lengthy conversations on constipation and congestion. Most of us just take the call with a smile, and chalk it up to part of the job. But what if you could provide a service that allowed you to get paid for those lengthy conversations, offered the convenience of a consultation without the patient having to come in the office – without the risk of your giving faulty advice because you haven’t actually evaluated the patient. Well, that’s what telemedicine has to offer. For a nominal monthly fee, your patients can subscribe to your “virtual” office. Whether you schedule during your office hours or set aside time before or after clinic, you now can capture a whole new clientele.

For teens, access to their doctors through their electronic devices would provide the convenience they need. Even if the issue cannot be treated without a visit, it allows for early evaluation. Acne, skin rashes, emotional issues, menstrual issues, hair issues, weight issues – all of these can be addressed via telemedicine.

The American Academy of Pediatrics’ Section on Telehealth Care (SOTC) helps guide you on how to bill for telemedicine services. It provides newsletters, educational series, and liability information. Much of the concern with telemedicine is the inconsistency of reimbursement for the service, but things are changing, and more and more of these services are being recognized for their value in meeting the needs of the patient.

There are different products on the market to assist you in setting up your virtual office. Understanding the differences in services is important. Services such as Doctor on Demand have a team of doctors available for fee-for-consult, at approximately $40. Other services, such as myowndoctor.com, set up a virtual office for you, which allows more of a concierge type service for a nominal monthly fee – approximately the amount of a copay – to allow patients access to the telemedicine service with their own physicians. This a great option that can create a cash revenue for you and broader access to patients.

There are several services provided by insurance companies – MDLIVE (Cigna), LiveHealth Online (WellPoint), and Online Care Anywhere (BC/BS Minnesota) – where providers are reimbursed at $45-$49 per visit. What is important to know when choosing a company is to be sure that the software is HIPAA (Health Insurance Portability and Accountability Act) compliant. Currently there are more than 15 companies on the market, and many more to come.

Staying up with the times is going to be key in surviving the current changes in health care. Teens in particular are a difficult group to access, but telemedicine provides that access and the comfort in continuity of care with their own physicians.

Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures. E-mail her at [email protected].

With the recent legalization of marijuana in many states, marijuana and its uses are a hot topic in most social circles. As physicians, we see the full spectrum, from its healing properties to its destructive ones. The goal of this article is not to persuade you into changing positions on its legalization, but rather to stress the importance of remaining neutral and educating families on the facts and potential pros and cons as they relate to the health of their children.

On Jan. 26, 2015,* the American Academy of Pediatrics released its policy statement on marijuana and its use (Pediatrics 2014 [doi:10.1542/peds.2014-4146]). The AAP does not support the legalization of marijuana because of the harm that it poses to children and adolescents, nor does it support legalization of medical marijuana outside the regulatory process of the Food and Drug Administration. It does recognize that marijuana may be an option for children with life-threatening or debilitating illnesses. The AAP does support the decriminalization of marijuana use or possession and advocates for less-harsh criminal penalties. Many of the recommendations were made because of the current research on marijuana and its use.

According to 2014’s Monitoring the Future survey of drug use and attitudes among American 8th, 10th, and 12th graders, marijuana is the most common illegal drug used by adolescents. Among 8th graders, 6.5% reported use; among 10th graders, 16.6% reported use; and 21.2 % of 12th graders reported use. A total of 81% of 12th grade students stated it was easy to get. Marijuana use at all three grade levels was higher than cigarette use (National Institute on Drug Abuse. Drug Facts, 2014). Another study found that early initiation of marijuana use was 6.5 times more likely to result in addiction than if it was initiated after the age of 21 years (Adolescent substance use: America’s #1 public health problem. CASA Columbia, 2011).

One thing we can agree upon is that an adolescent using any substance to mask or lessen the pain of a situation is in trouble. Whether adolescents are overeating or denying themselves food, or using drugs to get high, or behaving promiscuously to get attention, overindulgence is never good. So when we evaluate the effects of marijuana use among teens, we have to separate out the underlying emotional issues from the effects related to the drug. Adolescents are at particular risk for overuse because most lack the experience or maturity to stop when things get out of hand. And they are at risk when using anything that will give them a “high.” Substances like glue, gasoline, and cold medicine can bring them that high, and marijuana is no different – except that it is illegal.

©iStock/ThinkStockPhotos.com

Alcohol, cigarettes, and prescription medications are also vehicles to that desired high. Each has greater addictive properties than marijuana does. According to the Monitoring the Future study, most high school seniors do not think occasional use of marijuana is harmful, with only 36% saying regular use puts you at greater risk, compared with 39.5% in 2013 and 52% in 2009. The perception that marijuana is harmful has definitely declined.

Cannabis smoke contains three times the amount of tar found in tobacco smoke and 50% more carcinogens (N. Engl. J. Med. 1988;318:347). It also can irritate the airways, causing exacerbations of asthma, cystic fibrosis, sputum production, and pharyngitis (Arch. Intern. Med. 2007;167:221). Long-term studies showed that extended use was associated with increased obstructive lung diseases.

There is substantial evidence that indicates that cannabis use can cause psychosis. One review noted evidence that genetic factors may influence the risk of psychosis in adults who used cannabis as adolescents (Biol. Psychiatry 2005;57:1117). Cannabis is believed to release dopamine in the body, which may lead to the psychosis. Another study found that the onset of psychotic illness occurred more than 2 years earlier in patients who were heavy cannabis users (Arch. Gen. Psychiatry 2011;68:555).

Another important finding is that marijuana can suppress testosterone secretion in men, which may result in decreased libido, impotence, and gynecomastia (N. Engl. J. Med. 1974;290:872). Many teens believe cannabis is safe because it’s a plant, and consequently, may not relate these symptoms to its use.

The research on cannabis smoke and its relationship to cancer are limited by inadequate sample sizes and confounding factors not taken into account, but there does seem to be a relationship between cannabis smoke and lung cancer and bladder cancer (J. Psychoactive Drugs 1994;26:285; Urology 2006;67:100). However, head and neck cancers have not shown a relationship to marijuana use (Cancer Epidemiol. Biomarkers Prev. 2009;18:1544-51). Cardiovascular effects have been related to the increased sympathetic activity and decreased parasympathetic activity that can result in bradycardia and hypotension with high doses. This may be of particular concern in older people with coronary artery disease (J. Clin. Pharmacol. 2002;42:58S).

The medicinal properties of marijuana are an important consideration. Marijuana has been shown to be particularly effective in controlling some forms of seizure, pain, nausea from chemotherapy, muscle spasms caused by multiple sclerosis, and Crohn’s disease. The FDA has approved tetrahydrocannabinol, or THC, a key ingredient in marijuana, to treat nausea and improve appetite. In states that have legalized cannabis, qualifying patients can get prescriptions from their physicians to use at authorized dispensaries. For some patients, the effects can be life changing; for others, it can help with pain management and the discomfort associated with certain illnesses.

Beyond the scope of medicine is the economics of the legalization of marijuana. States that have already legalized it have seen revenues in the billions. Marijuana cash crops are estimated at $14 billion in revenue. Jon Gettman’s 2007 study, “Lost Taxes and Other Costs of Marijuana,” states that the prohibition of marijuana costs the government $113 billion, while it costs taxpayers $31.1 billion each year. The study projects that legalization of cannabis may save the criminal justice system $10.7 billion and an additional $6.2 billion for taxpayers. That sort of money does talk: Regardless of current opposition to the legalization of marijuana, it is probably just a matter of time before marijuana is legalized in every state.

The scope of marijuana issues is broad and, for many, controversial. The drug can serve as a healer, create health challenges, lead to drug addiction, or even become a significant revenue source to a state’s coffers. As providers, we need to be able to provide our patients with research-based information and resources, and dispel myths, so that they can make informed decisions for themselves that are in the best interests of their children.

Dr. Pearce is a pediatrician in Frankfort, Ill. She had no relevant financial disclosures. E-mail her at [email protected].

*Correction, 1/29/2015: An earlier version of this story had the incorrect date of publication of the AAP's policy statement.

With the recent legalization of marijuana in many states, marijuana and its uses are a hot topic in most social circles. As physicians, we see the full spectrum, from its healing properties to its destructive ones. The goal of this article is not to persuade you into changing positions on its legalization, but rather to stress the importance of remaining neutral and educating families on the facts and potential pros and cons as they relate to the health of their children.

On Jan. 26, 2015,* the American Academy of Pediatrics released its policy statement on marijuana and its use (Pediatrics 2014 [doi:10.1542/peds.2014-4146]). The AAP does not support the legalization of marijuana because of the harm that it poses to children and adolescents, nor does it support legalization of medical marijuana outside the regulatory process of the Food and Drug Administration. It does recognize that marijuana may be an option for children with life-threatening or debilitating illnesses. The AAP does support the decriminalization of marijuana use or possession and advocates for less-harsh criminal penalties. Many of the recommendations were made because of the current research on marijuana and its use.

According to 2014’s Monitoring the Future survey of drug use and attitudes among American 8th, 10th, and 12th graders, marijuana is the most common illegal drug used by adolescents. Among 8th graders, 6.5% reported use; among 10th graders, 16.6% reported use; and 21.2 % of 12th graders reported use. A total of 81% of 12th grade students stated it was easy to get. Marijuana use at all three grade levels was higher than cigarette use (National Institute on Drug Abuse. Drug Facts, 2014). Another study found that early initiation of marijuana use was 6.5 times more likely to result in addiction than if it was initiated after the age of 21 years (Adolescent substance use: America’s #1 public health problem. CASA Columbia, 2011).

One thing we can agree upon is that an adolescent using any substance to mask or lessen the pain of a situation is in trouble. Whether adolescents are overeating or denying themselves food, or using drugs to get high, or behaving promiscuously to get attention, overindulgence is never good. So when we evaluate the effects of marijuana use among teens, we have to separate out the underlying emotional issues from the effects related to the drug. Adolescents are at particular risk for overuse because most lack the experience or maturity to stop when things get out of hand. And they are at risk when using anything that will give them a “high.” Substances like glue, gasoline, and cold medicine can bring them that high, and marijuana is no different – except that it is illegal.

©iStock/ThinkStockPhotos.com

Alcohol, cigarettes, and prescription medications are also vehicles to that desired high. Each has greater addictive properties than marijuana does. According to the Monitoring the Future study, most high school seniors do not think occasional use of marijuana is harmful, with only 36% saying regular use puts you at greater risk, compared with 39.5% in 2013 and 52% in 2009. The perception that marijuana is harmful has definitely declined.

Cannabis smoke contains three times the amount of tar found in tobacco smoke and 50% more carcinogens (N. Engl. J. Med. 1988;318:347). It also can irritate the airways, causing exacerbations of asthma, cystic fibrosis, sputum production, and pharyngitis (Arch. Intern. Med. 2007;167:221). Long-term studies showed that extended use was associated with increased obstructive lung diseases.

There is substantial evidence that indicates that cannabis use can cause psychosis. One review noted evidence that genetic factors may influence the risk of psychosis in adults who used cannabis as adolescents (Biol. Psychiatry 2005;57:1117). Cannabis is believed to release dopamine in the body, which may lead to the psychosis. Another study found that the onset of psychotic illness occurred more than 2 years earlier in patients who were heavy cannabis users (Arch. Gen. Psychiatry 2011;68:555).

Another important finding is that marijuana can suppress testosterone secretion in men, which may result in decreased libido, impotence, and gynecomastia (N. Engl. J. Med. 1974;290:872). Many teens believe cannabis is safe because it’s a plant, and consequently, may not relate these symptoms to its use.

The research on cannabis smoke and its relationship to cancer are limited by inadequate sample sizes and confounding factors not taken into account, but there does seem to be a relationship between cannabis smoke and lung cancer and bladder cancer (J. Psychoactive Drugs 1994;26:285; Urology 2006;67:100). However, head and neck cancers have not shown a relationship to marijuana use (Cancer Epidemiol. Biomarkers Prev. 2009;18:1544-51). Cardiovascular effects have been related to the increased sympathetic activity and decreased parasympathetic activity that can result in bradycardia and hypotension with high doses. This may be of particular concern in older people with coronary artery disease (J. Clin. Pharmacol. 2002;42:58S).

The medicinal properties of marijuana are an important consideration. Marijuana has been shown to be particularly effective in controlling some forms of seizure, pain, nausea from chemotherapy, muscle spasms caused by multiple sclerosis, and Crohn’s disease. The FDA has approved tetrahydrocannabinol, or THC, a key ingredient in marijuana, to treat nausea and improve appetite. In states that have legalized cannabis, qualifying patients can get prescriptions from their physicians to use at authorized dispensaries. For some patients, the effects can be life changing; for others, it can help with pain management and the discomfort associated with certain illnesses.

Beyond the scope of medicine is the economics of the legalization of marijuana. States that have already legalized it have seen revenues in the billions. Marijuana cash crops are estimated at $14 billion in revenue. Jon Gettman’s 2007 study, “Lost Taxes and Other Costs of Marijuana,” states that the prohibition of marijuana costs the government $113 billion, while it costs taxpayers $31.1 billion each year. The study projects that legalization of cannabis may save the criminal justice system $10.7 billion and an additional $6.2 billion for taxpayers. That sort of money does talk: Regardless of current opposition to the legalization of marijuana, it is probably just a matter of time before marijuana is legalized in every state.

The scope of marijuana issues is broad and, for many, controversial. The drug can serve as a healer, create health challenges, lead to drug addiction, or even become a significant revenue source to a state’s coffers. As providers, we need to be able to provide our patients with research-based information and resources, and dispel myths, so that they can make informed decisions for themselves that are in the best interests of their children.

Dr. Pearce is a pediatrician in Frankfort, Ill. She had no relevant financial disclosures. E-mail her at [email protected].

*Correction, 1/29/2015: An earlier version of this story had the incorrect date of publication of the AAP's policy statement.

With the recent legalization of marijuana in many states, marijuana and its uses are a hot topic in most social circles. As physicians, we see the full spectrum, from its healing properties to its destructive ones. The goal of this article is not to persuade you into changing positions on its legalization, but rather to stress the importance of remaining neutral and educating families on the facts and potential pros and cons as they relate to the health of their children.

On Jan. 26, 2015,* the American Academy of Pediatrics released its policy statement on marijuana and its use (Pediatrics 2014 [doi:10.1542/peds.2014-4146]). The AAP does not support the legalization of marijuana because of the harm that it poses to children and adolescents, nor does it support legalization of medical marijuana outside the regulatory process of the Food and Drug Administration. It does recognize that marijuana may be an option for children with life-threatening or debilitating illnesses. The AAP does support the decriminalization of marijuana use or possession and advocates for less-harsh criminal penalties. Many of the recommendations were made because of the current research on marijuana and its use.

According to 2014’s Monitoring the Future survey of drug use and attitudes among American 8th, 10th, and 12th graders, marijuana is the most common illegal drug used by adolescents. Among 8th graders, 6.5% reported use; among 10th graders, 16.6% reported use; and 21.2 % of 12th graders reported use. A total of 81% of 12th grade students stated it was easy to get. Marijuana use at all three grade levels was higher than cigarette use (National Institute on Drug Abuse. Drug Facts, 2014). Another study found that early initiation of marijuana use was 6.5 times more likely to result in addiction than if it was initiated after the age of 21 years (Adolescent substance use: America’s #1 public health problem. CASA Columbia, 2011).

One thing we can agree upon is that an adolescent using any substance to mask or lessen the pain of a situation is in trouble. Whether adolescents are overeating or denying themselves food, or using drugs to get high, or behaving promiscuously to get attention, overindulgence is never good. So when we evaluate the effects of marijuana use among teens, we have to separate out the underlying emotional issues from the effects related to the drug. Adolescents are at particular risk for overuse because most lack the experience or maturity to stop when things get out of hand. And they are at risk when using anything that will give them a “high.” Substances like glue, gasoline, and cold medicine can bring them that high, and marijuana is no different – except that it is illegal.

©iStock/ThinkStockPhotos.com

Alcohol, cigarettes, and prescription medications are also vehicles to that desired high. Each has greater addictive properties than marijuana does. According to the Monitoring the Future study, most high school seniors do not think occasional use of marijuana is harmful, with only 36% saying regular use puts you at greater risk, compared with 39.5% in 2013 and 52% in 2009. The perception that marijuana is harmful has definitely declined.

Cannabis smoke contains three times the amount of tar found in tobacco smoke and 50% more carcinogens (N. Engl. J. Med. 1988;318:347). It also can irritate the airways, causing exacerbations of asthma, cystic fibrosis, sputum production, and pharyngitis (Arch. Intern. Med. 2007;167:221). Long-term studies showed that extended use was associated with increased obstructive lung diseases.

There is substantial evidence that indicates that cannabis use can cause psychosis. One review noted evidence that genetic factors may influence the risk of psychosis in adults who used cannabis as adolescents (Biol. Psychiatry 2005;57:1117). Cannabis is believed to release dopamine in the body, which may lead to the psychosis. Another study found that the onset of psychotic illness occurred more than 2 years earlier in patients who were heavy cannabis users (Arch. Gen. Psychiatry 2011;68:555).

Another important finding is that marijuana can suppress testosterone secretion in men, which may result in decreased libido, impotence, and gynecomastia (N. Engl. J. Med. 1974;290:872). Many teens believe cannabis is safe because it’s a plant, and consequently, may not relate these symptoms to its use.

The research on cannabis smoke and its relationship to cancer are limited by inadequate sample sizes and confounding factors not taken into account, but there does seem to be a relationship between cannabis smoke and lung cancer and bladder cancer (J. Psychoactive Drugs 1994;26:285; Urology 2006;67:100). However, head and neck cancers have not shown a relationship to marijuana use (Cancer Epidemiol. Biomarkers Prev. 2009;18:1544-51). Cardiovascular effects have been related to the increased sympathetic activity and decreased parasympathetic activity that can result in bradycardia and hypotension with high doses. This may be of particular concern in older people with coronary artery disease (J. Clin. Pharmacol. 2002;42:58S).

The medicinal properties of marijuana are an important consideration. Marijuana has been shown to be particularly effective in controlling some forms of seizure, pain, nausea from chemotherapy, muscle spasms caused by multiple sclerosis, and Crohn’s disease. The FDA has approved tetrahydrocannabinol, or THC, a key ingredient in marijuana, to treat nausea and improve appetite. In states that have legalized cannabis, qualifying patients can get prescriptions from their physicians to use at authorized dispensaries. For some patients, the effects can be life changing; for others, it can help with pain management and the discomfort associated with certain illnesses.

Beyond the scope of medicine is the economics of the legalization of marijuana. States that have already legalized it have seen revenues in the billions. Marijuana cash crops are estimated at $14 billion in revenue. Jon Gettman’s 2007 study, “Lost Taxes and Other Costs of Marijuana,” states that the prohibition of marijuana costs the government $113 billion, while it costs taxpayers $31.1 billion each year. The study projects that legalization of cannabis may save the criminal justice system $10.7 billion and an additional $6.2 billion for taxpayers. That sort of money does talk: Regardless of current opposition to the legalization of marijuana, it is probably just a matter of time before marijuana is legalized in every state.

The scope of marijuana issues is broad and, for many, controversial. The drug can serve as a healer, create health challenges, lead to drug addiction, or even become a significant revenue source to a state’s coffers. As providers, we need to be able to provide our patients with research-based information and resources, and dispel myths, so that they can make informed decisions for themselves that are in the best interests of their children.

Dr. Pearce is a pediatrician in Frankfort, Ill. She had no relevant financial disclosures. E-mail her at [email protected].

*Correction, 1/29/2015: An earlier version of this story had the incorrect date of publication of the AAP's policy statement.

Most physicians can recall the impressive x-ray of the rickets rosary or the flared radial head seen in medical school. On almost every exam, there was an a reference to the infant who was solely breastfed which led to seizures and abnormal finding on physical exam, but in practice, most of us would be hard pressed to recall an infant that presented with any of those symptoms.

With recent guideline changes to require that all infants be supplemented with vitamin D from birth, extreme presentations of vitamin D deficiency such as rickets are rare, but has vitamin D deficiency really gone away?

It is hard to pin down the prevalence of vitamin D deficiency in adolescents; it depends on the cut-off you use. In one study of 307 healthy Boston adolescents presenting for primary care, 24% were vitamin D deficient (serum 25[OH]D level, ≤15 ng/mL); of these 4.6% were severely vitamin D deficient (25[OH]D level, ≤8 ng/mL) (Arch. Pediatr. Adolesc. Med. 2004;158:531-7). Broader studies have demonstrated the prevalence of vitamin D deficiency to be 7% for adolescent males aged 14-18 years and 10% for females that age (National Center for Health Statistics Data Brief No. 59, March 2011). This makes sense given that the natural sources of vitamin D are oily fishes such as salmon and sardines, cod liver oil, liver, egg yolk, and organ meat, none of which are big favorites in the adolescent population.

Other factors that contribute to the rise in D deficiency are the promotion of sunscreen use to block UV rays which are essential for cutaneous synthesis. Skin cancer prevention and the promotion of the use of sunscreen and a direct correlation of lower vitamin D levels have been identified(Am. J. Clin. Nutr. 2008;88:1519-27).

Obesity plays a unique role, in that it causes sequestration of the vitamin D into the fat cells. With the dramatic rise in adolescent obesity plus poor nutritional intake, vitamin D deficiency is the natural result.

Clinically it is easy for vitamin D deficiency to go unnoticed. Bones have mineralized, so the typical changes seen in the infant do not occur in the adolescent. But what is apparent is the generalized fatigue, muscle or bone pain, and increased upper respiratory infections. Adolescents with low vitamin D levels also are at increased risk for hypertension, elevated blood sugars, and metabolic syndrome.

Screening for vitamin D deficiency is imperative for the adolescent age group who have been identified to have risk factors because the deficiency can compound other illnesses, prevents appropriate bone mineralization, and decreases the patient’s generalized sense of well-being. Serum 25(OH)D has a long half-life and is a better predictor of serum levels (Am. J. Clin. Nutr. 2008;88:582S-6S).

Supplementation of Vitamin D should be in the form of D₃, which has been shown to be more efficient in raising the serum level (Am. J. Clin. Nutr. 2012;95:1357-64), and dose will vary depending on the severity. Complimenting it with a calcium supplement also will improve bone mineralization and absorption.

Vitamin D deficiency is not a thing of the past. A simple nutritional review with every encounter allows for the educational opportunity for healthy eating and appropriate supplementation. The patient with recurrent upper respiratory infections should be encouraged to maintain a daily intake of at least 600 IU, but in patients with increased risk factors an actual blood test should be done to determine the amount that should be prescribed.

Dr. Pearce is a pediatrician in Frankfort, Ill. She had no relevant financial disclosures. E-mail her at [email protected]. Scan this QR code or go to pediatricnews.com to view similar articles.

Most physicians can recall the impressive x-ray of the rickets rosary or the flared radial head seen in medical school. On almost every exam, there was an a reference to the infant who was solely breastfed which led to seizures and abnormal finding on physical exam, but in practice, most of us would be hard pressed to recall an infant that presented with any of those symptoms.

With recent guideline changes to require that all infants be supplemented with vitamin D from birth, extreme presentations of vitamin D deficiency such as rickets are rare, but has vitamin D deficiency really gone away?

It is hard to pin down the prevalence of vitamin D deficiency in adolescents; it depends on the cut-off you use. In one study of 307 healthy Boston adolescents presenting for primary care, 24% were vitamin D deficient (serum 25[OH]D level, ≤15 ng/mL); of these 4.6% were severely vitamin D deficient (25[OH]D level, ≤8 ng/mL) (Arch. Pediatr. Adolesc. Med. 2004;158:531-7). Broader studies have demonstrated the prevalence of vitamin D deficiency to be 7% for adolescent males aged 14-18 years and 10% for females that age (National Center for Health Statistics Data Brief No. 59, March 2011). This makes sense given that the natural sources of vitamin D are oily fishes such as salmon and sardines, cod liver oil, liver, egg yolk, and organ meat, none of which are big favorites in the adolescent population.

Other factors that contribute to the rise in D deficiency are the promotion of sunscreen use to block UV rays which are essential for cutaneous synthesis. Skin cancer prevention and the promotion of the use of sunscreen and a direct correlation of lower vitamin D levels have been identified(Am. J. Clin. Nutr. 2008;88:1519-27).

Obesity plays a unique role, in that it causes sequestration of the vitamin D into the fat cells. With the dramatic rise in adolescent obesity plus poor nutritional intake, vitamin D deficiency is the natural result.

Clinically it is easy for vitamin D deficiency to go unnoticed. Bones have mineralized, so the typical changes seen in the infant do not occur in the adolescent. But what is apparent is the generalized fatigue, muscle or bone pain, and increased upper respiratory infections. Adolescents with low vitamin D levels also are at increased risk for hypertension, elevated blood sugars, and metabolic syndrome.

Screening for vitamin D deficiency is imperative for the adolescent age group who have been identified to have risk factors because the deficiency can compound other illnesses, prevents appropriate bone mineralization, and decreases the patient’s generalized sense of well-being. Serum 25(OH)D has a long half-life and is a better predictor of serum levels (Am. J. Clin. Nutr. 2008;88:582S-6S).

Supplementation of Vitamin D should be in the form of D₃, which has been shown to be more efficient in raising the serum level (Am. J. Clin. Nutr. 2012;95:1357-64), and dose will vary depending on the severity. Complimenting it with a calcium supplement also will improve bone mineralization and absorption.

Vitamin D deficiency is not a thing of the past. A simple nutritional review with every encounter allows for the educational opportunity for healthy eating and appropriate supplementation. The patient with recurrent upper respiratory infections should be encouraged to maintain a daily intake of at least 600 IU, but in patients with increased risk factors an actual blood test should be done to determine the amount that should be prescribed.

Dr. Pearce is a pediatrician in Frankfort, Ill. She had no relevant financial disclosures. E-mail her at [email protected]. Scan this QR code or go to pediatricnews.com to view similar articles.

Most physicians can recall the impressive x-ray of the rickets rosary or the flared radial head seen in medical school. On almost every exam, there was an a reference to the infant who was solely breastfed which led to seizures and abnormal finding on physical exam, but in practice, most of us would be hard pressed to recall an infant that presented with any of those symptoms.

With recent guideline changes to require that all infants be supplemented with vitamin D from birth, extreme presentations of vitamin D deficiency such as rickets are rare, but has vitamin D deficiency really gone away?

It is hard to pin down the prevalence of vitamin D deficiency in adolescents; it depends on the cut-off you use. In one study of 307 healthy Boston adolescents presenting for primary care, 24% were vitamin D deficient (serum 25[OH]D level, ≤15 ng/mL); of these 4.6% were severely vitamin D deficient (25[OH]D level, ≤8 ng/mL) (Arch. Pediatr. Adolesc. Med. 2004;158:531-7). Broader studies have demonstrated the prevalence of vitamin D deficiency to be 7% for adolescent males aged 14-18 years and 10% for females that age (National Center for Health Statistics Data Brief No. 59, March 2011). This makes sense given that the natural sources of vitamin D are oily fishes such as salmon and sardines, cod liver oil, liver, egg yolk, and organ meat, none of which are big favorites in the adolescent population.

Other factors that contribute to the rise in D deficiency are the promotion of sunscreen use to block UV rays which are essential for cutaneous synthesis. Skin cancer prevention and the promotion of the use of sunscreen and a direct correlation of lower vitamin D levels have been identified(Am. J. Clin. Nutr. 2008;88:1519-27).

Obesity plays a unique role, in that it causes sequestration of the vitamin D into the fat cells. With the dramatic rise in adolescent obesity plus poor nutritional intake, vitamin D deficiency is the natural result.

Clinically it is easy for vitamin D deficiency to go unnoticed. Bones have mineralized, so the typical changes seen in the infant do not occur in the adolescent. But what is apparent is the generalized fatigue, muscle or bone pain, and increased upper respiratory infections. Adolescents with low vitamin D levels also are at increased risk for hypertension, elevated blood sugars, and metabolic syndrome.

Screening for vitamin D deficiency is imperative for the adolescent age group who have been identified to have risk factors because the deficiency can compound other illnesses, prevents appropriate bone mineralization, and decreases the patient’s generalized sense of well-being. Serum 25(OH)D has a long half-life and is a better predictor of serum levels (Am. J. Clin. Nutr. 2008;88:582S-6S).

Supplementation of Vitamin D should be in the form of D₃, which has been shown to be more efficient in raising the serum level (Am. J. Clin. Nutr. 2012;95:1357-64), and dose will vary depending on the severity. Complimenting it with a calcium supplement also will improve bone mineralization and absorption.

Vitamin D deficiency is not a thing of the past. A simple nutritional review with every encounter allows for the educational opportunity for healthy eating and appropriate supplementation. The patient with recurrent upper respiratory infections should be encouraged to maintain a daily intake of at least 600 IU, but in patients with increased risk factors an actual blood test should be done to determine the amount that should be prescribed.

Dr. Pearce is a pediatrician in Frankfort, Ill. She had no relevant financial disclosures. E-mail her at [email protected]. Scan this QR code or go to pediatricnews.com to view similar articles.

Acne vulgaris is a diagnosis common to all primary care physicians, and the No. 1 concern for most adolescents. Referral wait times to a dermatologist can be anywhere from 3 to 6 months; if you’re lucky, dermatologists have a physician assistant or nurse practitioner who can see patients sooner. But the majority of acne cases – even complex ones – can successfully be treated by a primary care physician. Not only would you be improving patient satisfaction because the patient can be treated immediately, you also would increase your revenue.

Acne care is a billion dollar industry. Prescription medications are a $2 billion industry, and nonprescription medications are three to four times that (Semin. Cutan. Med. Surg. 2008;27:170). Yet, the average primary care physician will start treatment, then refer to the dermatologist.

The scope of acne care is not that broad; this should decrease your anxiety about being more aggressive with the treatment. Acne begins when there is follicular hyperproliferation, which leads to the obstruction of the follicle. This is followed by an increase in the sebum, by inflammation, and then by colonization with bacteria. Topical retinoids (tretinoin, adapalene, and tazarotene) normalize the follicular hyperproliferation and decrease inflammation. Antibiotics kill the bacteria. So, with implementation of topical retinoids, antibiotics, and a good home regimen, the vast majority of acne cases can be successfully treated without a referral.

When a patient presents with either concerns about acne or obvious full-blown acne, an assessment of the condition should be done. Realizing that there is gender gap in the treatment of acne is crucial. Males are much less likely to admit that they are bothered by their acne or adhere to treatment because they think it’s “girly” to use products on the face or follow a cleansing regimen. But, it is well documented that acne is associated with lower self-esteem, being bullied, depression, and anxiety. The patient assessment should identify acne type (comedonal, inflammatory, nodular), severity, scarring, menstrual history in girls, and the psychological impact on the patient.

Also review past treatments and what worked, what didn’t work, and why. Most patients upon presentation have used the over-the-counter preparations, which usually consist of benzoyl peroxide and salicylic acid.

Managing patients’ expectations is another key component to successful treatment. Most of the topical treatments have undesirable side effects like drying and reddening and hyperpigmentation of the skin. Informing them that irritations will lessen and will improve over time can aid in adherence to the regimen.

If a patient has dry skin, cream formulations will be less irritating; more oily skin will respond better to gels that tend to be more drying. The percentage of benzoyl peroxide also contributes to the discomfort. One study showed that the 2.5% was as effective as the 10% formulation, but resulted in less irritation (Br. J. Dermatol .2014;170:557). Salicylic acid is a good alternative if benzoyl peroxide is not tolerated.

Antibiotics are an essential part of acne treatment. Topicals such as erythromycin, clindamycin, and dapsone reduce Propionibacterium acnes, which also reduces inflammation. Oral antibiotics have similar efficacy, but are associated with more rapid clinical improvement. Another consideration in using oral antibiotics is the side effects. Photosensitivity and gastrointestinal upset are significant issues that arise with their use. Doxycycline monohydrate tends to have fewer GI side effects and is preferred over doxycycline hyclate. Minocycline has fewer GI effects and less photosensitivity, but tends to be more expensive and is associated with vertigo and serum sickness (Arch. Dermatol. 1982;118:989-92). Prolonged use of either topical or oral antibiotics increases the risk of resistant strains of P. acnes. Other antibiotics are available for use, such as trimethoprim-sulfamethoxazole, clindamycin, and erythromycin, but all have either significant side effects associated with them or higher levels of resistance.

Combination therapy is superior to monotherapy. Whether combining benzoyl peroxide with a topical retinoid, antibiotic, or both, improved outcomes have been shown. Studies also confirm that use of benzoyl peroxide with antibiotics lowers the risk of P. acne’s resistance (Dermatol. Clin. 2009;27:25-31).

Now, how do you make acne care work for your business model? It’s easier than you may think. Other highly effective, inexpensive, and efficient treatments can be implemented with little investment.

Establishing and marketing an acne program and dedicating a few hours a week to an acne clinic can add significant revenue to your practice. Educate the patient on cleansing and diet; information can be found at www.acne.com. Beyond using the traditional acne treatments, consider adding peels and a light-based therapy to the regimen. Salicylic acid peels are easy to apply and give great results. Treatments are done monthly for five to six treatments at a cost of $140-$250 per treatment. The application process takes 15-20 minutes.

Light therapy is also easy to implement. With the purchase of a lamp that costs less than $1,000, you can offer this treatment. Patients can come twice a week for 15-minute sessions for a total of eight sessions. The average cost for these treatments is $50-$75 per treatment. Combinations of peels and light therapy have great results with minimal risk and prevent families from having to wait the 3-6 months it takes to get to see the dermatologist.

Lastly, consider cosmeceuticals. There is no great mystery as to what is in the acne medications. You can create your own line using a compounding pharmacy such as MasterPharm or University Compounding Pharmacy . Or use a cosmeceuticals company that will provide you quality products at wholesale prices. Many of them don’t require you to stock the product. SkinMedica and SkinCeuticals ( are popular ones, but there are several more. As opposed to your patient going to the local pharmacy and guessing at which product is best, you can provide a full line of products that will give the best results.

Without compromising care, you can provide complete skin care to your patients and increase your revenue and your patient’s satisfaction.

Dr. Pearce is a pediatrician in Frankfort, Ill. Dr. Pearce had no relevant financial disclosures. E-mail her at [email protected].

Acne vulgaris is a diagnosis common to all primary care physicians, and the No. 1 concern for most adolescents. Referral wait times to a dermatologist can be anywhere from 3 to 6 months; if you’re lucky, dermatologists have a physician assistant or nurse practitioner who can see patients sooner. But the majority of acne cases – even complex ones – can successfully be treated by a primary care physician. Not only would you be improving patient satisfaction because the patient can be treated immediately, you also would increase your revenue.

Acne care is a billion dollar industry. Prescription medications are a $2 billion industry, and nonprescription medications are three to four times that (Semin. Cutan. Med. Surg. 2008;27:170). Yet, the average primary care physician will start treatment, then refer to the dermatologist.

The scope of acne care is not that broad; this should decrease your anxiety about being more aggressive with the treatment. Acne begins when there is follicular hyperproliferation, which leads to the obstruction of the follicle. This is followed by an increase in the sebum, by inflammation, and then by colonization with bacteria. Topical retinoids (tretinoin, adapalene, and tazarotene) normalize the follicular hyperproliferation and decrease inflammation. Antibiotics kill the bacteria. So, with implementation of topical retinoids, antibiotics, and a good home regimen, the vast majority of acne cases can be successfully treated without a referral.

When a patient presents with either concerns about acne or obvious full-blown acne, an assessment of the condition should be done. Realizing that there is gender gap in the treatment of acne is crucial. Males are much less likely to admit that they are bothered by their acne or adhere to treatment because they think it’s “girly” to use products on the face or follow a cleansing regimen. But, it is well documented that acne is associated with lower self-esteem, being bullied, depression, and anxiety. The patient assessment should identify acne type (comedonal, inflammatory, nodular), severity, scarring, menstrual history in girls, and the psychological impact on the patient.

Also review past treatments and what worked, what didn’t work, and why. Most patients upon presentation have used the over-the-counter preparations, which usually consist of benzoyl peroxide and salicylic acid.

Managing patients’ expectations is another key component to successful treatment. Most of the topical treatments have undesirable side effects like drying and reddening and hyperpigmentation of the skin. Informing them that irritations will lessen and will improve over time can aid in adherence to the regimen.

If a patient has dry skin, cream formulations will be less irritating; more oily skin will respond better to gels that tend to be more drying. The percentage of benzoyl peroxide also contributes to the discomfort. One study showed that the 2.5% was as effective as the 10% formulation, but resulted in less irritation (Br. J. Dermatol .2014;170:557). Salicylic acid is a good alternative if benzoyl peroxide is not tolerated.

Antibiotics are an essential part of acne treatment. Topicals such as erythromycin, clindamycin, and dapsone reduce Propionibacterium acnes, which also reduces inflammation. Oral antibiotics have similar efficacy, but are associated with more rapid clinical improvement. Another consideration in using oral antibiotics is the side effects. Photosensitivity and gastrointestinal upset are significant issues that arise with their use. Doxycycline monohydrate tends to have fewer GI side effects and is preferred over doxycycline hyclate. Minocycline has fewer GI effects and less photosensitivity, but tends to be more expensive and is associated with vertigo and serum sickness (Arch. Dermatol. 1982;118:989-92). Prolonged use of either topical or oral antibiotics increases the risk of resistant strains of P. acnes. Other antibiotics are available for use, such as trimethoprim-sulfamethoxazole, clindamycin, and erythromycin, but all have either significant side effects associated with them or higher levels of resistance.

Combination therapy is superior to monotherapy. Whether combining benzoyl peroxide with a topical retinoid, antibiotic, or both, improved outcomes have been shown. Studies also confirm that use of benzoyl peroxide with antibiotics lowers the risk of P. acne’s resistance (Dermatol. Clin. 2009;27:25-31).

Now, how do you make acne care work for your business model? It’s easier than you may think. Other highly effective, inexpensive, and efficient treatments can be implemented with little investment.

Establishing and marketing an acne program and dedicating a few hours a week to an acne clinic can add significant revenue to your practice. Educate the patient on cleansing and diet; information can be found at www.acne.com. Beyond using the traditional acne treatments, consider adding peels and a light-based therapy to the regimen. Salicylic acid peels are easy to apply and give great results. Treatments are done monthly for five to six treatments at a cost of $140-$250 per treatment. The application process takes 15-20 minutes.

Light therapy is also easy to implement. With the purchase of a lamp that costs less than $1,000, you can offer this treatment. Patients can come twice a week for 15-minute sessions for a total of eight sessions. The average cost for these treatments is $50-$75 per treatment. Combinations of peels and light therapy have great results with minimal risk and prevent families from having to wait the 3-6 months it takes to get to see the dermatologist.

Lastly, consider cosmeceuticals. There is no great mystery as to what is in the acne medications. You can create your own line using a compounding pharmacy such as MasterPharm or University Compounding Pharmacy . Or use a cosmeceuticals company that will provide you quality products at wholesale prices. Many of them don’t require you to stock the product. SkinMedica and SkinCeuticals ( are popular ones, but there are several more. As opposed to your patient going to the local pharmacy and guessing at which product is best, you can provide a full line of products that will give the best results.

Without compromising care, you can provide complete skin care to your patients and increase your revenue and your patient’s satisfaction.

Dr. Pearce is a pediatrician in Frankfort, Ill. Dr. Pearce had no relevant financial disclosures. E-mail her at [email protected].

Acne vulgaris is a diagnosis common to all primary care physicians, and the No. 1 concern for most adolescents. Referral wait times to a dermatologist can be anywhere from 3 to 6 months; if you’re lucky, dermatologists have a physician assistant or nurse practitioner who can see patients sooner. But the majority of acne cases – even complex ones – can successfully be treated by a primary care physician. Not only would you be improving patient satisfaction because the patient can be treated immediately, you also would increase your revenue.

Acne care is a billion dollar industry. Prescription medications are a $2 billion industry, and nonprescription medications are three to four times that (Semin. Cutan. Med. Surg. 2008;27:170). Yet, the average primary care physician will start treatment, then refer to the dermatologist.

The scope of acne care is not that broad; this should decrease your anxiety about being more aggressive with the treatment. Acne begins when there is follicular hyperproliferation, which leads to the obstruction of the follicle. This is followed by an increase in the sebum, by inflammation, and then by colonization with bacteria. Topical retinoids (tretinoin, adapalene, and tazarotene) normalize the follicular hyperproliferation and decrease inflammation. Antibiotics kill the bacteria. So, with implementation of topical retinoids, antibiotics, and a good home regimen, the vast majority of acne cases can be successfully treated without a referral.

When a patient presents with either concerns about acne or obvious full-blown acne, an assessment of the condition should be done. Realizing that there is gender gap in the treatment of acne is crucial. Males are much less likely to admit that they are bothered by their acne or adhere to treatment because they think it’s “girly” to use products on the face or follow a cleansing regimen. But, it is well documented that acne is associated with lower self-esteem, being bullied, depression, and anxiety. The patient assessment should identify acne type (comedonal, inflammatory, nodular), severity, scarring, menstrual history in girls, and the psychological impact on the patient.

Also review past treatments and what worked, what didn’t work, and why. Most patients upon presentation have used the over-the-counter preparations, which usually consist of benzoyl peroxide and salicylic acid.

Managing patients’ expectations is another key component to successful treatment. Most of the topical treatments have undesirable side effects like drying and reddening and hyperpigmentation of the skin. Informing them that irritations will lessen and will improve over time can aid in adherence to the regimen.

If a patient has dry skin, cream formulations will be less irritating; more oily skin will respond better to gels that tend to be more drying. The percentage of benzoyl peroxide also contributes to the discomfort. One study showed that the 2.5% was as effective as the 10% formulation, but resulted in less irritation (Br. J. Dermatol .2014;170:557). Salicylic acid is a good alternative if benzoyl peroxide is not tolerated.

Antibiotics are an essential part of acne treatment. Topicals such as erythromycin, clindamycin, and dapsone reduce Propionibacterium acnes, which also reduces inflammation. Oral antibiotics have similar efficacy, but are associated with more rapid clinical improvement. Another consideration in using oral antibiotics is the side effects. Photosensitivity and gastrointestinal upset are significant issues that arise with their use. Doxycycline monohydrate tends to have fewer GI side effects and is preferred over doxycycline hyclate. Minocycline has fewer GI effects and less photosensitivity, but tends to be more expensive and is associated with vertigo and serum sickness (Arch. Dermatol. 1982;118:989-92). Prolonged use of either topical or oral antibiotics increases the risk of resistant strains of P. acnes. Other antibiotics are available for use, such as trimethoprim-sulfamethoxazole, clindamycin, and erythromycin, but all have either significant side effects associated with them or higher levels of resistance.

Combination therapy is superior to monotherapy. Whether combining benzoyl peroxide with a topical retinoid, antibiotic, or both, improved outcomes have been shown. Studies also confirm that use of benzoyl peroxide with antibiotics lowers the risk of P. acne’s resistance (Dermatol. Clin. 2009;27:25-31).

Now, how do you make acne care work for your business model? It’s easier than you may think. Other highly effective, inexpensive, and efficient treatments can be implemented with little investment.

Establishing and marketing an acne program and dedicating a few hours a week to an acne clinic can add significant revenue to your practice. Educate the patient on cleansing and diet; information can be found at www.acne.com. Beyond using the traditional acne treatments, consider adding peels and a light-based therapy to the regimen. Salicylic acid peels are easy to apply and give great results. Treatments are done monthly for five to six treatments at a cost of $140-$250 per treatment. The application process takes 15-20 minutes.

Light therapy is also easy to implement. With the purchase of a lamp that costs less than $1,000, you can offer this treatment. Patients can come twice a week for 15-minute sessions for a total of eight sessions. The average cost for these treatments is $50-$75 per treatment. Combinations of peels and light therapy have great results with minimal risk and prevent families from having to wait the 3-6 months it takes to get to see the dermatologist.

Lastly, consider cosmeceuticals. There is no great mystery as to what is in the acne medications. You can create your own line using a compounding pharmacy such as MasterPharm or University Compounding Pharmacy . Or use a cosmeceuticals company that will provide you quality products at wholesale prices. Many of them don’t require you to stock the product. SkinMedica and SkinCeuticals ( are popular ones, but there are several more. As opposed to your patient going to the local pharmacy and guessing at which product is best, you can provide a full line of products that will give the best results.

Without compromising care, you can provide complete skin care to your patients and increase your revenue and your patient’s satisfaction.

Dr. Pearce is a pediatrician in Frankfort, Ill. Dr. Pearce had no relevant financial disclosures. E-mail her at [email protected].

During an adolescent visit, we all can agree that getting answers to even the simplest of questions can be a day’s work. Despite the reason for the visit, it always is important to ask a few basic questions in hopes that it might unveil a less obvious condition, or one that potentially could cause harm later. Asking the right questions is as important as getting the right answer to make a correct diagnosis. Questions that are too general usually yield zero information for diagnostic purposes. Adolescents are concrete thinkers; therefore, if we don’t ask the question in several different ways, we are likely not to get the right answers, or any at all.

Two questions that I feel must be asked at every female-patient visit are, “When was your last period?” and “How often does your period come?” Answers to these two questions can assist in diagnosing several medical conditions that otherwise might have gone unnoticed.

Amenorrhea, or absence of menses, is established if a female has never had a period by age 15 years (primary) or has gone 6 months or greater without one (secondary). Primary amenorrhea is generally caused by genetic or anatomic abnormalities, and commonly is identified at an earlier age. But if the presentation of the genetic disorder is not classic, such as in Turner’s syndrome, it may go unnoticed and the first clue may be amenorrhea.

Pregnancy is an obvious consideration with amenorrhea. But the picture is a little less clear when light or irregular periods are present. Postmenarche menstrual cycles are commonly irregular and not without risk of pregnancy if the adolescent becomes sexually active. Also, a patient with an ectopic pregnancy tends to have oligomenorrhea before the amenorrhea. Therefore, regardless of age, if the periods are abnormal, a pregnancy test should be done.

Early polycystic ovarian syndrome (PCOS) also can present as irregular/ infrequent periods. Many of the common signs such as hirsutism or acne may be minor and not convincing. In an age where obesity is so common, a clear picture is less likely, so PCOS may not be considered. PCOS is the No. 1 cause of infertility in women, and if suspected should be worked up.

Anovulation or dysfunctional ovaries, as seen in PCOS, may not be obvious early on. As stated, oligomenorrhea is very common in the first few years following menarche, but persistent oligomenorrhea is not normal. General guidelines state that oligomenorrhea post menarche is likely to be a sign of anovulation if 1 year post menarche, less than four menstrual cycles; 2 years post menarche, less than six menstrual cycles; 3-5 years post menarche, less than eight menstrual cycles; and greater than 5 years post menarche, less than nine menstrual cycles. Heavy bleeding occurring less than every 21 days is also a sign.

Thyroid dysfunction is a common consideration when the menstrual cycle is abnormal, and we normally attribute heavy periods to hypothyroidism and amenorrhea or irregular periods to hyperthyroidism. The truth is thyroid dysfunction – regardless of whether the hormone is high or low – can present in either fashion. Other endocrine disorders – such as adrenal hyperplasia, prolactinomas, or metabolic syndromes – also disrupt the menstrual cycle, but initial presentations can be vague and only the prudent investigator will identify the disorder.

If the patient appears underweight, careful evaluation for anorexia should be done. Irregular periods present with caloric deprivation. Questions should be asked about body image to determine if this is a concern.

Once it is established that there is a menstrual dysfunction, a careful physical exam should follow. Screening labs and a pelvic ultrasound will help identify the dysfunction, but a referral to an endocrinologist still should follow if the results are equivocal or unclear.

As demonstrated, those two simple questions have the potential to unveil so many disorders that likely would go unnoticed for months to years. Every encounter is an opportunity to obtain information regardless of the chief complaint. Posing questions in several different ways lessens the likelihood that the question will be misunderstood and compensates for varied levels of intellect.

Remember, you have to ask the right question to get the right answer!

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected].

During an adolescent visit, we all can agree that getting answers to even the simplest of questions can be a day’s work. Despite the reason for the visit, it always is important to ask a few basic questions in hopes that it might unveil a less obvious condition, or one that potentially could cause harm later. Asking the right questions is as important as getting the right answer to make a correct diagnosis. Questions that are too general usually yield zero information for diagnostic purposes. Adolescents are concrete thinkers; therefore, if we don’t ask the question in several different ways, we are likely not to get the right answers, or any at all.

Two questions that I feel must be asked at every female-patient visit are, “When was your last period?” and “How often does your period come?” Answers to these two questions can assist in diagnosing several medical conditions that otherwise might have gone unnoticed.

Amenorrhea, or absence of menses, is established if a female has never had a period by age 15 years (primary) or has gone 6 months or greater without one (secondary). Primary amenorrhea is generally caused by genetic or anatomic abnormalities, and commonly is identified at an earlier age. But if the presentation of the genetic disorder is not classic, such as in Turner’s syndrome, it may go unnoticed and the first clue may be amenorrhea.

Pregnancy is an obvious consideration with amenorrhea. But the picture is a little less clear when light or irregular periods are present. Postmenarche menstrual cycles are commonly irregular and not without risk of pregnancy if the adolescent becomes sexually active. Also, a patient with an ectopic pregnancy tends to have oligomenorrhea before the amenorrhea. Therefore, regardless of age, if the periods are abnormal, a pregnancy test should be done.

Early polycystic ovarian syndrome (PCOS) also can present as irregular/ infrequent periods. Many of the common signs such as hirsutism or acne may be minor and not convincing. In an age where obesity is so common, a clear picture is less likely, so PCOS may not be considered. PCOS is the No. 1 cause of infertility in women, and if suspected should be worked up.

Anovulation or dysfunctional ovaries, as seen in PCOS, may not be obvious early on. As stated, oligomenorrhea is very common in the first few years following menarche, but persistent oligomenorrhea is not normal. General guidelines state that oligomenorrhea post menarche is likely to be a sign of anovulation if 1 year post menarche, less than four menstrual cycles; 2 years post menarche, less than six menstrual cycles; 3-5 years post menarche, less than eight menstrual cycles; and greater than 5 years post menarche, less than nine menstrual cycles. Heavy bleeding occurring less than every 21 days is also a sign.

Thyroid dysfunction is a common consideration when the menstrual cycle is abnormal, and we normally attribute heavy periods to hypothyroidism and amenorrhea or irregular periods to hyperthyroidism. The truth is thyroid dysfunction – regardless of whether the hormone is high or low – can present in either fashion. Other endocrine disorders – such as adrenal hyperplasia, prolactinomas, or metabolic syndromes – also disrupt the menstrual cycle, but initial presentations can be vague and only the prudent investigator will identify the disorder.

If the patient appears underweight, careful evaluation for anorexia should be done. Irregular periods present with caloric deprivation. Questions should be asked about body image to determine if this is a concern.

Once it is established that there is a menstrual dysfunction, a careful physical exam should follow. Screening labs and a pelvic ultrasound will help identify the dysfunction, but a referral to an endocrinologist still should follow if the results are equivocal or unclear.

As demonstrated, those two simple questions have the potential to unveil so many disorders that likely would go unnoticed for months to years. Every encounter is an opportunity to obtain information regardless of the chief complaint. Posing questions in several different ways lessens the likelihood that the question will be misunderstood and compensates for varied levels of intellect.

Remember, you have to ask the right question to get the right answer!

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected].

During an adolescent visit, we all can agree that getting answers to even the simplest of questions can be a day’s work. Despite the reason for the visit, it always is important to ask a few basic questions in hopes that it might unveil a less obvious condition, or one that potentially could cause harm later. Asking the right questions is as important as getting the right answer to make a correct diagnosis. Questions that are too general usually yield zero information for diagnostic purposes. Adolescents are concrete thinkers; therefore, if we don’t ask the question in several different ways, we are likely not to get the right answers, or any at all.

Two questions that I feel must be asked at every female-patient visit are, “When was your last period?” and “How often does your period come?” Answers to these two questions can assist in diagnosing several medical conditions that otherwise might have gone unnoticed.

Amenorrhea, or absence of menses, is established if a female has never had a period by age 15 years (primary) or has gone 6 months or greater without one (secondary). Primary amenorrhea is generally caused by genetic or anatomic abnormalities, and commonly is identified at an earlier age. But if the presentation of the genetic disorder is not classic, such as in Turner’s syndrome, it may go unnoticed and the first clue may be amenorrhea.

Pregnancy is an obvious consideration with amenorrhea. But the picture is a little less clear when light or irregular periods are present. Postmenarche menstrual cycles are commonly irregular and not without risk of pregnancy if the adolescent becomes sexually active. Also, a patient with an ectopic pregnancy tends to have oligomenorrhea before the amenorrhea. Therefore, regardless of age, if the periods are abnormal, a pregnancy test should be done.

Early polycystic ovarian syndrome (PCOS) also can present as irregular/ infrequent periods. Many of the common signs such as hirsutism or acne may be minor and not convincing. In an age where obesity is so common, a clear picture is less likely, so PCOS may not be considered. PCOS is the No. 1 cause of infertility in women, and if suspected should be worked up.

Anovulation or dysfunctional ovaries, as seen in PCOS, may not be obvious early on. As stated, oligomenorrhea is very common in the first few years following menarche, but persistent oligomenorrhea is not normal. General guidelines state that oligomenorrhea post menarche is likely to be a sign of anovulation if 1 year post menarche, less than four menstrual cycles; 2 years post menarche, less than six menstrual cycles; 3-5 years post menarche, less than eight menstrual cycles; and greater than 5 years post menarche, less than nine menstrual cycles. Heavy bleeding occurring less than every 21 days is also a sign.

Thyroid dysfunction is a common consideration when the menstrual cycle is abnormal, and we normally attribute heavy periods to hypothyroidism and amenorrhea or irregular periods to hyperthyroidism. The truth is thyroid dysfunction – regardless of whether the hormone is high or low – can present in either fashion. Other endocrine disorders – such as adrenal hyperplasia, prolactinomas, or metabolic syndromes – also disrupt the menstrual cycle, but initial presentations can be vague and only the prudent investigator will identify the disorder.

If the patient appears underweight, careful evaluation for anorexia should be done. Irregular periods present with caloric deprivation. Questions should be asked about body image to determine if this is a concern.

Once it is established that there is a menstrual dysfunction, a careful physical exam should follow. Screening labs and a pelvic ultrasound will help identify the dysfunction, but a referral to an endocrinologist still should follow if the results are equivocal or unclear.

As demonstrated, those two simple questions have the potential to unveil so many disorders that likely would go unnoticed for months to years. Every encounter is an opportunity to obtain information regardless of the chief complaint. Posing questions in several different ways lessens the likelihood that the question will be misunderstood and compensates for varied levels of intellect.

Remember, you have to ask the right question to get the right answer!

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected].

In a casual conversation I was having with a marriage counselor, he mentioned that a growing number of young couples are struggling with impotence. The main cause is watching too much pornography.

Now, it is no surprise that adolescents would watch pornography. Since the dawn of time young men have been seeking arousal from pornographic images. With the advent of the Internet, the availability and variety of images is endless. Teens are able to access pornography on their phones, tablets, computers, and cable. It’s next to impossible for parents to block all access because every adolescent has one form of technology or another; if he doesn’t have access at home, it surely can be seen at a friend’s house.

The physiologic effect of pornography is an excessive release of dopamine that binds to dopamine receptors and causes a maximal state of arousal. These receptors over time become less and less sensitive, so when these young men engage in intercourse, the stimulation is much less, and they are unable to have an erection. Many men do not make the connection between the pornography and their erectile dysfunction, so they may go years without seeking help.

There is a growing trend among younger men to use Viagra and Cialis, according to statistics (Int. J. Impot. Res. 2004;16:313-8). Most are using them for sexual enhancement, but others are seeking them for performance anxiety which may be related to their dysfunction associated with pornography. The problem is, pornography-induced erectile dysfunction is not an issue of blood flow, so these drugs are not helpful in most cases. Since the issue is the sensitivity of the dopamine receptors, the only treatment is to reduce or stop watching pornography, thus allowing the dopamine receptors to become more sensitive.

Now, as a physician, this clearly is an awkward topic to bring up during a routine health physical. But if left unsaid, this behavior could clearly lead to years of dysfunction. What I have found to be a simple solution to the “not so popular topics” is to present a handout with a topic simply stated and easy to read. This allows you to give patients the information without the embarrassment. The purpose is just to identify what is normal and what is not so normal so a patient knows to seek help if the problem occurs. Quick fixes also should be listed if known, especially if the quick fix is just to stop the behavior.

Other topics – such as bacterial vaginosis, the morning after pill, acne, and gynecomastia – can be addressed similarly because teens don’t know what they don’t know, so they may not even consider asking. Many women don’t realize that bacterial vaginosis requires a prescription medication and so may remain symptomatic for long periods of time.

Education is key. As pediatricians, arming our patients with knowledge allows them to at least ask the appropriate questions, which hopefully will get them the right answer.

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected].

In a casual conversation I was having with a marriage counselor, he mentioned that a growing number of young couples are struggling with impotence. The main cause is watching too much pornography.

Now, it is no surprise that adolescents would watch pornography. Since the dawn of time young men have been seeking arousal from pornographic images. With the advent of the Internet, the availability and variety of images is endless. Teens are able to access pornography on their phones, tablets, computers, and cable. It’s next to impossible for parents to block all access because every adolescent has one form of technology or another; if he doesn’t have access at home, it surely can be seen at a friend’s house.

The physiologic effect of pornography is an excessive release of dopamine that binds to dopamine receptors and causes a maximal state of arousal. These receptors over time become less and less sensitive, so when these young men engage in intercourse, the stimulation is much less, and they are unable to have an erection. Many men do not make the connection between the pornography and their erectile dysfunction, so they may go years without seeking help.

There is a growing trend among younger men to use Viagra and Cialis, according to statistics (Int. J. Impot. Res. 2004;16:313-8). Most are using them for sexual enhancement, but others are seeking them for performance anxiety which may be related to their dysfunction associated with pornography. The problem is, pornography-induced erectile dysfunction is not an issue of blood flow, so these drugs are not helpful in most cases. Since the issue is the sensitivity of the dopamine receptors, the only treatment is to reduce or stop watching pornography, thus allowing the dopamine receptors to become more sensitive.

Now, as a physician, this clearly is an awkward topic to bring up during a routine health physical. But if left unsaid, this behavior could clearly lead to years of dysfunction. What I have found to be a simple solution to the “not so popular topics” is to present a handout with a topic simply stated and easy to read. This allows you to give patients the information without the embarrassment. The purpose is just to identify what is normal and what is not so normal so a patient knows to seek help if the problem occurs. Quick fixes also should be listed if known, especially if the quick fix is just to stop the behavior.

Other topics – such as bacterial vaginosis, the morning after pill, acne, and gynecomastia – can be addressed similarly because teens don’t know what they don’t know, so they may not even consider asking. Many women don’t realize that bacterial vaginosis requires a prescription medication and so may remain symptomatic for long periods of time.

Education is key. As pediatricians, arming our patients with knowledge allows them to at least ask the appropriate questions, which hopefully will get them the right answer.

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected].

In a casual conversation I was having with a marriage counselor, he mentioned that a growing number of young couples are struggling with impotence. The main cause is watching too much pornography.

Now, it is no surprise that adolescents would watch pornography. Since the dawn of time young men have been seeking arousal from pornographic images. With the advent of the Internet, the availability and variety of images is endless. Teens are able to access pornography on their phones, tablets, computers, and cable. It’s next to impossible for parents to block all access because every adolescent has one form of technology or another; if he doesn’t have access at home, it surely can be seen at a friend’s house.

The physiologic effect of pornography is an excessive release of dopamine that binds to dopamine receptors and causes a maximal state of arousal. These receptors over time become less and less sensitive, so when these young men engage in intercourse, the stimulation is much less, and they are unable to have an erection. Many men do not make the connection between the pornography and their erectile dysfunction, so they may go years without seeking help.

There is a growing trend among younger men to use Viagra and Cialis, according to statistics (Int. J. Impot. Res. 2004;16:313-8). Most are using them for sexual enhancement, but others are seeking them for performance anxiety which may be related to their dysfunction associated with pornography. The problem is, pornography-induced erectile dysfunction is not an issue of blood flow, so these drugs are not helpful in most cases. Since the issue is the sensitivity of the dopamine receptors, the only treatment is to reduce or stop watching pornography, thus allowing the dopamine receptors to become more sensitive.

Now, as a physician, this clearly is an awkward topic to bring up during a routine health physical. But if left unsaid, this behavior could clearly lead to years of dysfunction. What I have found to be a simple solution to the “not so popular topics” is to present a handout with a topic simply stated and easy to read. This allows you to give patients the information without the embarrassment. The purpose is just to identify what is normal and what is not so normal so a patient knows to seek help if the problem occurs. Quick fixes also should be listed if known, especially if the quick fix is just to stop the behavior.

Other topics – such as bacterial vaginosis, the morning after pill, acne, and gynecomastia – can be addressed similarly because teens don’t know what they don’t know, so they may not even consider asking. Many women don’t realize that bacterial vaginosis requires a prescription medication and so may remain symptomatic for long periods of time.

Education is key. As pediatricians, arming our patients with knowledge allows them to at least ask the appropriate questions, which hopefully will get them the right answer.

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected].

Likely, one of the most important roles of a pediatrician is to maximize health in childhood and positively impact health in adulthood. Bone density is one of the few things that can be maximized in adolescence. By maximizing bone density, we can directly slow and reduce the osteopenia that occurs later in life and the osteoporosis that 10 million Americans struggle with annually.

The physiology of calcium absorption changes throughout life. In early adolescence, the absorption is greater than the elimination. Between 30 and 50 years of age, absorption and elimination are about equal, but as we enter into the sixth decade of life, there is significant bone loss. Studies have shown that bone density is maximized by age 30 years, and little change is made later in life despite supplementation (Eur. J. Clin. Nutr. 1993;47:617-22). The greatest amount of bone loss occurs after the age of 65 years, and fractures after this age are predominantly at cortical sites.

Consumption of the appropriate amounts of calcium can be difficult given the inadequacies of most adolescents’ diet. The recommended daily intake is 1,200-1,500 mg of elemental calcium. But, absorption of calcium is quite variable and is dependent on other factors to be in place for it to be maximized.

The two most common form of calcium are calcium carbonate and calcium citrate malate. Calcium carbonate requires a higher pH of the stomach, and therefore needs to be taken with food. Calcium carbonate is more cost effective but is also associated with more side effects such as gas and bloating. Calcium citrate malate is found in many juices that are fortified with calcium, can be taken with or without food, is better absorbed with chronic conditions, and is thought to be protective against stone formation (J. Am. Coll. Nutr. 1996;15:313-6; Adv. Food. Nutr. Res. 2008;54:219-346).

Common sources of calcium include milk, yogurt, cheese, Chinese cabbage, kale, broccoli, and spinach. Appropriate levels of vitamin D are important to maximize the absorption of calcium, and recent studies have shown that 40% of adolescents are deficient in vitamin D (Arch. Pediatr. Adolesc. Med. 2004;158:531-7; Arch. Pediatr. Adolesc. Med. 2008;162:513-9). Many other adolescents are lactose intolerant or have a milk protein allergy, which also limit the calcium sources. Soymilk has similar levels of calcium, compared with whole milk. Almond-coconut milk has double the amount of calcium, compared with whole milk, so it is a great substitute for those who are lactose intolerant.

Oxalic acids are found in food such as spinach, collard greens, and sweet potatoes, all of which are rich in calcium, but the oxalic acid reduces the absorption of the calcium. Consumption of large amounts of tea and coffee also can reduce calcium absorption, so despite consuming appropriate amounts of calcium, limited amounts become bioavailable.

If using calcium supplements, ingesting less than or equal to 500 mg is better than taking 1,000 mg at once because it is better absorbed (Adv. Food Nutr. Res. 2008;54:219-346). Orange juice, apple juice, and cereals are fortified with calcium so these also are great sources that usually are accepted by adolescents.

Calcium is a critical dietary supplement that is needed for strong bones, metabolic functions, nerve transmission, and vascular contraction and vasodilation. Long-term deficiency will result in disease, and fragility of the bones. Early supplementation and calcium rich diets can ensure maximum bone development, but if parents are not educated on the appropriate delivery, this opportunity could be missed.

An excellent resource is the National Institutes of Health, Office of Dietary Supplements website. This site gives a wealth of information for sources and consumption of calcium. Another excellent resource for parents to use to guide them to make healthier choices is the U.S. Department of Agriculture site, www.choosemyplate.gov. Parents are looking for quick simple ways to maximize their children’s diet and ensure they are getting everything they need to be healthy adults. Becoming familiar with the basics will allow you to give informed advice that will significantly affect their children’s future.

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected].

Likely, one of the most important roles of a pediatrician is to maximize health in childhood and positively impact health in adulthood. Bone density is one of the few things that can be maximized in adolescence. By maximizing bone density, we can directly slow and reduce the osteopenia that occurs later in life and the osteoporosis that 10 million Americans struggle with annually.

The physiology of calcium absorption changes throughout life. In early adolescence, the absorption is greater than the elimination. Between 30 and 50 years of age, absorption and elimination are about equal, but as we enter into the sixth decade of life, there is significant bone loss. Studies have shown that bone density is maximized by age 30 years, and little change is made later in life despite supplementation (Eur. J. Clin. Nutr. 1993;47:617-22). The greatest amount of bone loss occurs after the age of 65 years, and fractures after this age are predominantly at cortical sites.

Consumption of the appropriate amounts of calcium can be difficult given the inadequacies of most adolescents’ diet. The recommended daily intake is 1,200-1,500 mg of elemental calcium. But, absorption of calcium is quite variable and is dependent on other factors to be in place for it to be maximized.

The two most common form of calcium are calcium carbonate and calcium citrate malate. Calcium carbonate requires a higher pH of the stomach, and therefore needs to be taken with food. Calcium carbonate is more cost effective but is also associated with more side effects such as gas and bloating. Calcium citrate malate is found in many juices that are fortified with calcium, can be taken with or without food, is better absorbed with chronic conditions, and is thought to be protective against stone formation (J. Am. Coll. Nutr. 1996;15:313-6; Adv. Food. Nutr. Res. 2008;54:219-346).

Common sources of calcium include milk, yogurt, cheese, Chinese cabbage, kale, broccoli, and spinach. Appropriate levels of vitamin D are important to maximize the absorption of calcium, and recent studies have shown that 40% of adolescents are deficient in vitamin D (Arch. Pediatr. Adolesc. Med. 2004;158:531-7; Arch. Pediatr. Adolesc. Med. 2008;162:513-9). Many other adolescents are lactose intolerant or have a milk protein allergy, which also limit the calcium sources. Soymilk has similar levels of calcium, compared with whole milk. Almond-coconut milk has double the amount of calcium, compared with whole milk, so it is a great substitute for those who are lactose intolerant.

Oxalic acids are found in food such as spinach, collard greens, and sweet potatoes, all of which are rich in calcium, but the oxalic acid reduces the absorption of the calcium. Consumption of large amounts of tea and coffee also can reduce calcium absorption, so despite consuming appropriate amounts of calcium, limited amounts become bioavailable.

If using calcium supplements, ingesting less than or equal to 500 mg is better than taking 1,000 mg at once because it is better absorbed (Adv. Food Nutr. Res. 2008;54:219-346). Orange juice, apple juice, and cereals are fortified with calcium so these also are great sources that usually are accepted by adolescents.

Calcium is a critical dietary supplement that is needed for strong bones, metabolic functions, nerve transmission, and vascular contraction and vasodilation. Long-term deficiency will result in disease, and fragility of the bones. Early supplementation and calcium rich diets can ensure maximum bone development, but if parents are not educated on the appropriate delivery, this opportunity could be missed.

An excellent resource is the National Institutes of Health, Office of Dietary Supplements website. This site gives a wealth of information for sources and consumption of calcium. Another excellent resource for parents to use to guide them to make healthier choices is the U.S. Department of Agriculture site, www.choosemyplate.gov. Parents are looking for quick simple ways to maximize their children’s diet and ensure they are getting everything they need to be healthy adults. Becoming familiar with the basics will allow you to give informed advice that will significantly affect their children’s future.

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected].

Likely, one of the most important roles of a pediatrician is to maximize health in childhood and positively impact health in adulthood. Bone density is one of the few things that can be maximized in adolescence. By maximizing bone density, we can directly slow and reduce the osteopenia that occurs later in life and the osteoporosis that 10 million Americans struggle with annually.

The physiology of calcium absorption changes throughout life. In early adolescence, the absorption is greater than the elimination. Between 30 and 50 years of age, absorption and elimination are about equal, but as we enter into the sixth decade of life, there is significant bone loss. Studies have shown that bone density is maximized by age 30 years, and little change is made later in life despite supplementation (Eur. J. Clin. Nutr. 1993;47:617-22). The greatest amount of bone loss occurs after the age of 65 years, and fractures after this age are predominantly at cortical sites.

Consumption of the appropriate amounts of calcium can be difficult given the inadequacies of most adolescents’ diet. The recommended daily intake is 1,200-1,500 mg of elemental calcium. But, absorption of calcium is quite variable and is dependent on other factors to be in place for it to be maximized.

The two most common form of calcium are calcium carbonate and calcium citrate malate. Calcium carbonate requires a higher pH of the stomach, and therefore needs to be taken with food. Calcium carbonate is more cost effective but is also associated with more side effects such as gas and bloating. Calcium citrate malate is found in many juices that are fortified with calcium, can be taken with or without food, is better absorbed with chronic conditions, and is thought to be protective against stone formation (J. Am. Coll. Nutr. 1996;15:313-6; Adv. Food. Nutr. Res. 2008;54:219-346).

Common sources of calcium include milk, yogurt, cheese, Chinese cabbage, kale, broccoli, and spinach. Appropriate levels of vitamin D are important to maximize the absorption of calcium, and recent studies have shown that 40% of adolescents are deficient in vitamin D (Arch. Pediatr. Adolesc. Med. 2004;158:531-7; Arch. Pediatr. Adolesc. Med. 2008;162:513-9). Many other adolescents are lactose intolerant or have a milk protein allergy, which also limit the calcium sources. Soymilk has similar levels of calcium, compared with whole milk. Almond-coconut milk has double the amount of calcium, compared with whole milk, so it is a great substitute for those who are lactose intolerant.

Oxalic acids are found in food such as spinach, collard greens, and sweet potatoes, all of which are rich in calcium, but the oxalic acid reduces the absorption of the calcium. Consumption of large amounts of tea and coffee also can reduce calcium absorption, so despite consuming appropriate amounts of calcium, limited amounts become bioavailable.

If using calcium supplements, ingesting less than or equal to 500 mg is better than taking 1,000 mg at once because it is better absorbed (Adv. Food Nutr. Res. 2008;54:219-346). Orange juice, apple juice, and cereals are fortified with calcium so these also are great sources that usually are accepted by adolescents.

Calcium is a critical dietary supplement that is needed for strong bones, metabolic functions, nerve transmission, and vascular contraction and vasodilation. Long-term deficiency will result in disease, and fragility of the bones. Early supplementation and calcium rich diets can ensure maximum bone development, but if parents are not educated on the appropriate delivery, this opportunity could be missed.

An excellent resource is the National Institutes of Health, Office of Dietary Supplements website. This site gives a wealth of information for sources and consumption of calcium. Another excellent resource for parents to use to guide them to make healthier choices is the U.S. Department of Agriculture site, www.choosemyplate.gov. Parents are looking for quick simple ways to maximize their children’s diet and ensure they are getting everything they need to be healthy adults. Becoming familiar with the basics will allow you to give informed advice that will significantly affect their children’s future.

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected].

As pediatricians, we are constantly evaluating children of all ages. We make determinations of normal and abnormal all the time. But, sometimes determining normal can be a challenge because children come in all shapes, sizes, and complexions, so "normal" can appear in a variety of ways.

When it comes to the adolescent, this is an even greater challenge because the onset of puberty is so varied that children of the same age can look vastly different, and pubertal changes only widen the variety. Obesity also has impacted the appearance of normal because it makes children look older, pubertal changes more advanced, and a thorough exam more difficult. So when is it okay to say, "They will just grow out of it?" Well, the best answer is when all the serious illnesses have been considered and ruled out.

Gynecomastia is a common finding in the adolescent wellness exam; 50%-60% of adolescent males experience some degree of breast enlargement starting at the age of 10 years. This peaks at ages 13-14, then regresses over a period of 18 months (N. Engl. J. Med. 2007;357:1229-37). For approximately 25% of children, the breast tissue persists, which leads to significant anxiety and insecurities among adolescent males. Even when asked if they have concerns, few will admit to it because the thought of the evaluation is more than they can handle.

Gynecomastia is caused from the increased ratio of estrogen to androgen. Antiandrogens, drugs, and weight gain have all been implicated. But in the evaluation of increased breast tissue, normal as well as abnormal causes have to be considered.

Exogenous causes include herbal products, such as tea tree oil, or medications. The most common drugs are cimetidine, ranitidine, and omeprazole, as well spirolactone and ketoconazole. With the exception of spirolactone, these are all drugs that are used commonly for minor illness in children, but have been identified as a cause for gynecomastia. Discontinuation of these products usually resolves the issue within a few months (Pharmacotherapy 1993;13:37-45).

Obesity can cause a pseudogynecomastia as well as a true gynecomastia because aromatase enzyme increases with the increase in fat tissue, which converts testosterone to estradiol. Clinically, pseudogynecomastia can be distinguished from true gynecomastia by doing a breast exam. True gynecomastia is a concentric, rubbery firm mass greater than 0.5cm, and directly below the areola, where pseudogynecomastia has diffuse enlargement and no discernable glandular tissue.

Abnormal causes of gynecomastia are much less common, but do occur. A careful physical examination and a detailed review of systems can be very helpful in ruling in or out serious causes.

An imbalance of estrogen and testosterone can result from estrogen or testosterone going up or down. These changes can be caused by other hormonal stimulation. Human chorionic gonadotropin (HGC) is increased with germ cell tumors, which can be found in abdominal or testicular masses, resulting in secondary hypogonadism. Elevated estradiol is found with testicular tumors and adrenal tumors.

Hyperthyroidism can cause gynecomastia. Additional symptoms include palpitations, weight loss, and anxiety. Physical findings include a goiter, exophthalmoses, and tremors.

Klinefelter’s syndrome, a condition that occurs in men who have an extra X chromosome, includes gynecomastia and hypogonadism. There is a 20%-60% increased risk of breast cancer in these patients, who tend to have less facial and body hair, reduced muscle tone, and narrower shoulders and wider hips (N. Engl. J. Med. 2007;357:1229-37). Suspicion of breast cancer should increase if the mass is unilateral, nontender, and eccentric to the areola.

Although the vast majority of patients with gynecomastia will resolve spontaneously, careful evaluation and consideration of abnormal causes can lead to early diagnosis and treatment.

Experienced pediatricians know it’s never "nothing" unless all the possible "somethings" have been ruled out!

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected].

As pediatricians, we are constantly evaluating children of all ages. We make determinations of normal and abnormal all the time. But, sometimes determining normal can be a challenge because children come in all shapes, sizes, and complexions, so "normal" can appear in a variety of ways.

When it comes to the adolescent, this is an even greater challenge because the onset of puberty is so varied that children of the same age can look vastly different, and pubertal changes only widen the variety. Obesity also has impacted the appearance of normal because it makes children look older, pubertal changes more advanced, and a thorough exam more difficult. So when is it okay to say, "They will just grow out of it?" Well, the best answer is when all the serious illnesses have been considered and ruled out.

Gynecomastia is a common finding in the adolescent wellness exam; 50%-60% of adolescent males experience some degree of breast enlargement starting at the age of 10 years. This peaks at ages 13-14, then regresses over a period of 18 months (N. Engl. J. Med. 2007;357:1229-37). For approximately 25% of children, the breast tissue persists, which leads to significant anxiety and insecurities among adolescent males. Even when asked if they have concerns, few will admit to it because the thought of the evaluation is more than they can handle.

Gynecomastia is caused from the increased ratio of estrogen to androgen. Antiandrogens, drugs, and weight gain have all been implicated. But in the evaluation of increased breast tissue, normal as well as abnormal causes have to be considered.

Exogenous causes include herbal products, such as tea tree oil, or medications. The most common drugs are cimetidine, ranitidine, and omeprazole, as well spirolactone and ketoconazole. With the exception of spirolactone, these are all drugs that are used commonly for minor illness in children, but have been identified as a cause for gynecomastia. Discontinuation of these products usually resolves the issue within a few months (Pharmacotherapy 1993;13:37-45).

Obesity can cause a pseudogynecomastia as well as a true gynecomastia because aromatase enzyme increases with the increase in fat tissue, which converts testosterone to estradiol. Clinically, pseudogynecomastia can be distinguished from true gynecomastia by doing a breast exam. True gynecomastia is a concentric, rubbery firm mass greater than 0.5cm, and directly below the areola, where pseudogynecomastia has diffuse enlargement and no discernable glandular tissue.

Abnormal causes of gynecomastia are much less common, but do occur. A careful physical examination and a detailed review of systems can be very helpful in ruling in or out serious causes.

An imbalance of estrogen and testosterone can result from estrogen or testosterone going up or down. These changes can be caused by other hormonal stimulation. Human chorionic gonadotropin (HGC) is increased with germ cell tumors, which can be found in abdominal or testicular masses, resulting in secondary hypogonadism. Elevated estradiol is found with testicular tumors and adrenal tumors.

Hyperthyroidism can cause gynecomastia. Additional symptoms include palpitations, weight loss, and anxiety. Physical findings include a goiter, exophthalmoses, and tremors.

Klinefelter’s syndrome, a condition that occurs in men who have an extra X chromosome, includes gynecomastia and hypogonadism. There is a 20%-60% increased risk of breast cancer in these patients, who tend to have less facial and body hair, reduced muscle tone, and narrower shoulders and wider hips (N. Engl. J. Med. 2007;357:1229-37). Suspicion of breast cancer should increase if the mass is unilateral, nontender, and eccentric to the areola.

Although the vast majority of patients with gynecomastia will resolve spontaneously, careful evaluation and consideration of abnormal causes can lead to early diagnosis and treatment.

Experienced pediatricians know it’s never "nothing" unless all the possible "somethings" have been ruled out!

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected].

As pediatricians, we are constantly evaluating children of all ages. We make determinations of normal and abnormal all the time. But, sometimes determining normal can be a challenge because children come in all shapes, sizes, and complexions, so "normal" can appear in a variety of ways.

When it comes to the adolescent, this is an even greater challenge because the onset of puberty is so varied that children of the same age can look vastly different, and pubertal changes only widen the variety. Obesity also has impacted the appearance of normal because it makes children look older, pubertal changes more advanced, and a thorough exam more difficult. So when is it okay to say, "They will just grow out of it?" Well, the best answer is when all the serious illnesses have been considered and ruled out.

Gynecomastia is a common finding in the adolescent wellness exam; 50%-60% of adolescent males experience some degree of breast enlargement starting at the age of 10 years. This peaks at ages 13-14, then regresses over a period of 18 months (N. Engl. J. Med. 2007;357:1229-37). For approximately 25% of children, the breast tissue persists, which leads to significant anxiety and insecurities among adolescent males. Even when asked if they have concerns, few will admit to it because the thought of the evaluation is more than they can handle.

Gynecomastia is caused from the increased ratio of estrogen to androgen. Antiandrogens, drugs, and weight gain have all been implicated. But in the evaluation of increased breast tissue, normal as well as abnormal causes have to be considered.

Exogenous causes include herbal products, such as tea tree oil, or medications. The most common drugs are cimetidine, ranitidine, and omeprazole, as well spirolactone and ketoconazole. With the exception of spirolactone, these are all drugs that are used commonly for minor illness in children, but have been identified as a cause for gynecomastia. Discontinuation of these products usually resolves the issue within a few months (Pharmacotherapy 1993;13:37-45).

Obesity can cause a pseudogynecomastia as well as a true gynecomastia because aromatase enzyme increases with the increase in fat tissue, which converts testosterone to estradiol. Clinically, pseudogynecomastia can be distinguished from true gynecomastia by doing a breast exam. True gynecomastia is a concentric, rubbery firm mass greater than 0.5cm, and directly below the areola, where pseudogynecomastia has diffuse enlargement and no discernable glandular tissue.

Abnormal causes of gynecomastia are much less common, but do occur. A careful physical examination and a detailed review of systems can be very helpful in ruling in or out serious causes.

An imbalance of estrogen and testosterone can result from estrogen or testosterone going up or down. These changes can be caused by other hormonal stimulation. Human chorionic gonadotropin (HGC) is increased with germ cell tumors, which can be found in abdominal or testicular masses, resulting in secondary hypogonadism. Elevated estradiol is found with testicular tumors and adrenal tumors.

Hyperthyroidism can cause gynecomastia. Additional symptoms include palpitations, weight loss, and anxiety. Physical findings include a goiter, exophthalmoses, and tremors.

Klinefelter’s syndrome, a condition that occurs in men who have an extra X chromosome, includes gynecomastia and hypogonadism. There is a 20%-60% increased risk of breast cancer in these patients, who tend to have less facial and body hair, reduced muscle tone, and narrower shoulders and wider hips (N. Engl. J. Med. 2007;357:1229-37). Suspicion of breast cancer should increase if the mass is unilateral, nontender, and eccentric to the areola.

Although the vast majority of patients with gynecomastia will resolve spontaneously, careful evaluation and consideration of abnormal causes can lead to early diagnosis and treatment.

Experienced pediatricians know it’s never "nothing" unless all the possible "somethings" have been ruled out!

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected].