Francine Pearce, MD

In an era where everything around us has moved toward an "I need it now and I need it fast" attitude, the face of medicine also has changed. The days of patients wanting to wait to see their physician have faded, and now there is a demand for a quick fix so they can keep their already hectic lives moving.

Retail clinics also have thrown a curve ball to practicing physicians because now patients can get their fast medicine right along with their fast food, all at the corner strip mall.

The Internet also has changed how office visits run. Now physicians spend a lot of time explaining diagnoses that patients have found during their exhaustive research of their symptoms, or dispelling erroneous information that has been found on the Internet. This adds to time per patient, as well as distrust. Patients are now smarter, busier, and more likely to have chronic illnesses, so how does medicine keep up with the times?

As physicians, we must remember that our expertise as medical doctors is to rule in and rule out serious diseases. The "bread and butter" of any medical practice is likely easy to identify and treat, but where the expertise comes in is how to distinguish minor acute illness from life-threatening or potentially chronic illness. Many disease states are efficiently diagnosed only because the patient presents with further complaints that put the entire picture together. How is that achieved when patients fast-track through "minute clinics"?

Experience is also golden. If you have practiced long enough, you have had your share of surprises and know that "oh, it’s nothing" is the diagnosis only after all the "somethings " have been ruled out. For example, in adolescent medicine I commonly get the complaints of abdominal pain and anxiety. So when a patient presents with ongoing complaints of abdominal pain with no other clinical signs of disease, there is a temptation to assume it is just the anxiety. But experience teaches you that viral hepatitis, appendicitis, or urological disorders could be the underlying problem.

Another lesson that is taught by experience is how children express themselves. I recently saw an adolescent who had a minor trauma where he was struck in the chest with a basketball. He subsequently complained of chest pain, but kept saying, "I feel like I’m going to die." His mother was insistent that this was just his already diagnosed anxiety, and that he would settle down. But stating he "felt like he was going to die" was such an unusual complaint for a child that I was prompted to do an EKG, which revealed a viral myocarditis. Although this may have been identified in an express clinic, knowing the patient helped in expediting the diagnosis.

As physicians, we must educate and ensure that our patients feel they are getting the best care by sticking with someone who knows them. We have to accept that patients have options, so if we are going to keep their business, we have to work more efficiently, form relationships, and provide good care. Many practices have moved toward a concierge service, where a fee is charged for immediate appointments or telephone access. Utilization of a nurse practitioner can allow you to run your office more efficiently to manage the more acute illnesses, shorten the wait times, and maximize patient visits.

Retail clinics are here to stay. If we are going to keep private practices afloat, we have to make the visit worth the wait!

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

In an era where everything around us has moved toward an "I need it now and I need it fast" attitude, the face of medicine also has changed. The days of patients wanting to wait to see their physician have faded, and now there is a demand for a quick fix so they can keep their already hectic lives moving.

Retail clinics also have thrown a curve ball to practicing physicians because now patients can get their fast medicine right along with their fast food, all at the corner strip mall.

The Internet also has changed how office visits run. Now physicians spend a lot of time explaining diagnoses that patients have found during their exhaustive research of their symptoms, or dispelling erroneous information that has been found on the Internet. This adds to time per patient, as well as distrust. Patients are now smarter, busier, and more likely to have chronic illnesses, so how does medicine keep up with the times?

As physicians, we must remember that our expertise as medical doctors is to rule in and rule out serious diseases. The "bread and butter" of any medical practice is likely easy to identify and treat, but where the expertise comes in is how to distinguish minor acute illness from life-threatening or potentially chronic illness. Many disease states are efficiently diagnosed only because the patient presents with further complaints that put the entire picture together. How is that achieved when patients fast-track through "minute clinics"?

Experience is also golden. If you have practiced long enough, you have had your share of surprises and know that "oh, it’s nothing" is the diagnosis only after all the "somethings " have been ruled out. For example, in adolescent medicine I commonly get the complaints of abdominal pain and anxiety. So when a patient presents with ongoing complaints of abdominal pain with no other clinical signs of disease, there is a temptation to assume it is just the anxiety. But experience teaches you that viral hepatitis, appendicitis, or urological disorders could be the underlying problem.

Another lesson that is taught by experience is how children express themselves. I recently saw an adolescent who had a minor trauma where he was struck in the chest with a basketball. He subsequently complained of chest pain, but kept saying, "I feel like I’m going to die." His mother was insistent that this was just his already diagnosed anxiety, and that he would settle down. But stating he "felt like he was going to die" was such an unusual complaint for a child that I was prompted to do an EKG, which revealed a viral myocarditis. Although this may have been identified in an express clinic, knowing the patient helped in expediting the diagnosis.

As physicians, we must educate and ensure that our patients feel they are getting the best care by sticking with someone who knows them. We have to accept that patients have options, so if we are going to keep their business, we have to work more efficiently, form relationships, and provide good care. Many practices have moved toward a concierge service, where a fee is charged for immediate appointments or telephone access. Utilization of a nurse practitioner can allow you to run your office more efficiently to manage the more acute illnesses, shorten the wait times, and maximize patient visits.

Retail clinics are here to stay. If we are going to keep private practices afloat, we have to make the visit worth the wait!

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

In an era where everything around us has moved toward an "I need it now and I need it fast" attitude, the face of medicine also has changed. The days of patients wanting to wait to see their physician have faded, and now there is a demand for a quick fix so they can keep their already hectic lives moving.

Retail clinics also have thrown a curve ball to practicing physicians because now patients can get their fast medicine right along with their fast food, all at the corner strip mall.

The Internet also has changed how office visits run. Now physicians spend a lot of time explaining diagnoses that patients have found during their exhaustive research of their symptoms, or dispelling erroneous information that has been found on the Internet. This adds to time per patient, as well as distrust. Patients are now smarter, busier, and more likely to have chronic illnesses, so how does medicine keep up with the times?

As physicians, we must remember that our expertise as medical doctors is to rule in and rule out serious diseases. The "bread and butter" of any medical practice is likely easy to identify and treat, but where the expertise comes in is how to distinguish minor acute illness from life-threatening or potentially chronic illness. Many disease states are efficiently diagnosed only because the patient presents with further complaints that put the entire picture together. How is that achieved when patients fast-track through "minute clinics"?

Experience is also golden. If you have practiced long enough, you have had your share of surprises and know that "oh, it’s nothing" is the diagnosis only after all the "somethings " have been ruled out. For example, in adolescent medicine I commonly get the complaints of abdominal pain and anxiety. So when a patient presents with ongoing complaints of abdominal pain with no other clinical signs of disease, there is a temptation to assume it is just the anxiety. But experience teaches you that viral hepatitis, appendicitis, or urological disorders could be the underlying problem.

Another lesson that is taught by experience is how children express themselves. I recently saw an adolescent who had a minor trauma where he was struck in the chest with a basketball. He subsequently complained of chest pain, but kept saying, "I feel like I’m going to die." His mother was insistent that this was just his already diagnosed anxiety, and that he would settle down. But stating he "felt like he was going to die" was such an unusual complaint for a child that I was prompted to do an EKG, which revealed a viral myocarditis. Although this may have been identified in an express clinic, knowing the patient helped in expediting the diagnosis.

As physicians, we must educate and ensure that our patients feel they are getting the best care by sticking with someone who knows them. We have to accept that patients have options, so if we are going to keep their business, we have to work more efficiently, form relationships, and provide good care. Many practices have moved toward a concierge service, where a fee is charged for immediate appointments or telephone access. Utilization of a nurse practitioner can allow you to run your office more efficiently to manage the more acute illnesses, shorten the wait times, and maximize patient visits.

Retail clinics are here to stay. If we are going to keep private practices afloat, we have to make the visit worth the wait!

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

Bullying affects approximately 20% of children, according to a 2012 survey of 20,000 students in grades 3-12 (Bullying in U.S. Schools 2012 Status Report, published by the Hazelden Foundation 2013).

As pediatricians, we have all faced the grieving parent distraught by the ill treatment of their child. Many of us have probably felt helpless because it’s not a medical issue – or is it? I think we can all agree that it doesn’t start as a medical issue, but for sure it can end as one.

Anxiety, depression, cutting, abdominal pain, headaches, and weight loss can all be the end result of the stress of bullying. Some children are able to be honest about how they are feeling, but many internalize it and parents are sometimes the last to know. Approximately 160,000 students stay home from school everyday because of bullying, according to the National Association of School Psychologists.

Many school systems have adopted antibullying programs in which children are educated on the effects of bullying, how to treat their peers, and what to do if they are bullied. But some recent research shows that these programs may not be successful, and bullying rates are actually higher at schools that have implemented these programs, according to the Canadian Journal of School Psychology (2011;26:283-300).

One of the main differences with bullying now is that social media may play a significant role in the extent of the bullying. Facebook, Instagram, and Snapchat are vehicles that are used by the bully and that can make the extent of the damage much worse. Twenty years ago, a rumor had to spread by word of mouth; now, with just a touch of a button, hundreds of students can see and know of the ill-intended work of a bully.

"Bullycide" is a newly coined term that suggests a child committed suicide because she was bullied. The rate of these occurrences is rising largely because of the attention placed on bullying, but the media also serves as an information trail, which allows us to connect the dots more clearly.

Intervention that we can do as professionals is to identify things that may put a student at risk and try to intervene early. Severe acne, obesity, and social anxiety are all things that can be treated to improve a child’s self-esteem and make them less of a target. Parents are not always in tune to this because their love is unconditional, and they may not recognize the role these play. Using the well-child visit to uncover these issues and offer treatment for things that may not have been brought up.

When approached by parents who are seeking help, directing them to the stopbullyingnow.gov provides a great source of information that can help parents navigate dealing with the school and helping the child deal with stress. The CyberBully Hotline is a program that schools can implement that allows parents and student to anonymously report cyberbullying. This has been shown to be extremely effective in reducing the number of fights that occur.

Parents should be educated that any threat of suicide should be taken seriously, and an immediate intervention should be taken. 800-273-TALK is the suicide hotline that parents can use if they are concerned that their child is at risk. Emergency departments are equipped with social workers who can assess if hospitalization is necessary or if a child should be followed as an outpatient.

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

Bullying affects approximately 20% of children, according to a 2012 survey of 20,000 students in grades 3-12 (Bullying in U.S. Schools 2012 Status Report, published by the Hazelden Foundation 2013).

As pediatricians, we have all faced the grieving parent distraught by the ill treatment of their child. Many of us have probably felt helpless because it’s not a medical issue – or is it? I think we can all agree that it doesn’t start as a medical issue, but for sure it can end as one.

Anxiety, depression, cutting, abdominal pain, headaches, and weight loss can all be the end result of the stress of bullying. Some children are able to be honest about how they are feeling, but many internalize it and parents are sometimes the last to know. Approximately 160,000 students stay home from school everyday because of bullying, according to the National Association of School Psychologists.

Many school systems have adopted antibullying programs in which children are educated on the effects of bullying, how to treat their peers, and what to do if they are bullied. But some recent research shows that these programs may not be successful, and bullying rates are actually higher at schools that have implemented these programs, according to the Canadian Journal of School Psychology (2011;26:283-300).

One of the main differences with bullying now is that social media may play a significant role in the extent of the bullying. Facebook, Instagram, and Snapchat are vehicles that are used by the bully and that can make the extent of the damage much worse. Twenty years ago, a rumor had to spread by word of mouth; now, with just a touch of a button, hundreds of students can see and know of the ill-intended work of a bully.

"Bullycide" is a newly coined term that suggests a child committed suicide because she was bullied. The rate of these occurrences is rising largely because of the attention placed on bullying, but the media also serves as an information trail, which allows us to connect the dots more clearly.

Intervention that we can do as professionals is to identify things that may put a student at risk and try to intervene early. Severe acne, obesity, and social anxiety are all things that can be treated to improve a child’s self-esteem and make them less of a target. Parents are not always in tune to this because their love is unconditional, and they may not recognize the role these play. Using the well-child visit to uncover these issues and offer treatment for things that may not have been brought up.

When approached by parents who are seeking help, directing them to the stopbullyingnow.gov provides a great source of information that can help parents navigate dealing with the school and helping the child deal with stress. The CyberBully Hotline is a program that schools can implement that allows parents and student to anonymously report cyberbullying. This has been shown to be extremely effective in reducing the number of fights that occur.

Parents should be educated that any threat of suicide should be taken seriously, and an immediate intervention should be taken. 800-273-TALK is the suicide hotline that parents can use if they are concerned that their child is at risk. Emergency departments are equipped with social workers who can assess if hospitalization is necessary or if a child should be followed as an outpatient.

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

Bullying affects approximately 20% of children, according to a 2012 survey of 20,000 students in grades 3-12 (Bullying in U.S. Schools 2012 Status Report, published by the Hazelden Foundation 2013).

As pediatricians, we have all faced the grieving parent distraught by the ill treatment of their child. Many of us have probably felt helpless because it’s not a medical issue – or is it? I think we can all agree that it doesn’t start as a medical issue, but for sure it can end as one.

Anxiety, depression, cutting, abdominal pain, headaches, and weight loss can all be the end result of the stress of bullying. Some children are able to be honest about how they are feeling, but many internalize it and parents are sometimes the last to know. Approximately 160,000 students stay home from school everyday because of bullying, according to the National Association of School Psychologists.

Many school systems have adopted antibullying programs in which children are educated on the effects of bullying, how to treat their peers, and what to do if they are bullied. But some recent research shows that these programs may not be successful, and bullying rates are actually higher at schools that have implemented these programs, according to the Canadian Journal of School Psychology (2011;26:283-300).

One of the main differences with bullying now is that social media may play a significant role in the extent of the bullying. Facebook, Instagram, and Snapchat are vehicles that are used by the bully and that can make the extent of the damage much worse. Twenty years ago, a rumor had to spread by word of mouth; now, with just a touch of a button, hundreds of students can see and know of the ill-intended work of a bully.

"Bullycide" is a newly coined term that suggests a child committed suicide because she was bullied. The rate of these occurrences is rising largely because of the attention placed on bullying, but the media also serves as an information trail, which allows us to connect the dots more clearly.

Intervention that we can do as professionals is to identify things that may put a student at risk and try to intervene early. Severe acne, obesity, and social anxiety are all things that can be treated to improve a child’s self-esteem and make them less of a target. Parents are not always in tune to this because their love is unconditional, and they may not recognize the role these play. Using the well-child visit to uncover these issues and offer treatment for things that may not have been brought up.

When approached by parents who are seeking help, directing them to the stopbullyingnow.gov provides a great source of information that can help parents navigate dealing with the school and helping the child deal with stress. The CyberBully Hotline is a program that schools can implement that allows parents and student to anonymously report cyberbullying. This has been shown to be extremely effective in reducing the number of fights that occur.

Parents should be educated that any threat of suicide should be taken seriously, and an immediate intervention should be taken. 800-273-TALK is the suicide hotline that parents can use if they are concerned that their child is at risk. Emergency departments are equipped with social workers who can assess if hospitalization is necessary or if a child should be followed as an outpatient.

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

It is important to recognize that as pediatricians we have the unique opportunity to see to the lives of a very vulnerable group of people known as teenagers.

We can all relate to the discomfort of the stone-faced teenager with one-word answers and one foot out the door. There is usually a parent present who is answering all of the questions, and if you are lucky, the patient may put the cell phone down long enough to get an eye exam in, but, we must realize that the 15 minutes of captive audience could be the most important 15 minutes of the teen’s life.

Before we start our exam, we should have a plan in place for what topics we should be addressing. Every thorough physical should include a screen on drugs and alcohol, depression, sexual activity, and violence. In a busy practice, it seems impossible to address these issues in a time-conservative manner, but if we plan ahead, we can be thorough, casual, and informative.

First, you must analyze your own style. If having these discussions is uncomfortable for you, then attempting them without a plan will be disastrous. Many pediatricians just choose to avoid the entire discussion and hope that the parent is parenting and will address the major issues. But fewer than half of all parents talk to their children about the issues that they are faced with daily, and a great majority are ill-informed, or driven by their own beliefs.

First, pediatricians must make a list of hot topics to be discussed. Review the most current data and how they are affecting the teens in your area. Next, whether your talking style is comfortable or not, having a questionnaire that introduces each topic is always helpful (Am. J. Psychiatry 1995;152:1601-7

Lastly, have teenagers come in by themselves. Parents cannot help themselves and will always speak for their children, and most teens will not ask questions that they don’t think their parent will approve of or that relate to private family issues. So, you must set the stage for a comfortable talking environment. By having the questionnaire available, you can use it as a guide to see what issues are affecting the patient.

Knowing current information is also imperative to a good wellness exam. Know what the latest drugs are being used by the teens in the area, and know the street names of drugs (drugabuse.gov/drugs-abuse). Where do the local teens hang out? Major issues happening at the local high schools can help guide your conversations and build trust as patients begin to see you as an active and involved leader in the community.

Depression affects 8% of teens every year. Therefore, there is a guarantee that at least a handful will present in your office every year. Asking the right questions is key to getting helpful answers. Be direct, ask, "Have you ever, or are you now having suicidal ideation?" Over 90% of children and adolescents who commit suicide have a mental disorder (J. Clin. Psychiatry 1999;60 (Suppl. 2):70-4). There is a Web site supported by the American Academy of Pediatrics that has questionnaires to assist in identifying symptoms of depression (brightfutures.aap.org). Knowing the family history of psychiatric disorders can be very helpful in guiding the physician of what questions to ask. Many teens are fearful that they may be having symptoms of a psychiatric disorder, but are too afraid to ask, given the stigma that goes along with it.

Address issues of self-image. If patients are overweight, give tips on healthy eating and exercise. Develop a nutritional plan and track a patient’s progress by having her follow up. Allow her to discuss what make her feel sad or uncomfortable. How is she interacting with her peers, does she fit in or is she often alone?

A wellness exam is not complete without addressing sex and sexuality. No matter how you slice it, talking about sex with a complete stranger will never be easy. Using the questionnaire to bring up the topic helps. Start with generalizations about the risks of unprotected sex and general statistics of sexually transmitted infections in teenagers. Next, a general statement about abstinence is important so that teens realize it is an option. Review the common birth control methods and their risks. Encourage him to have at least one adult that he can trust to discuss delicate issues with and to return to your office if other issues arise.

Teenagers also are under the belief that they are invincible and that bad things only happen to other people. Discuss the leading cause of death in teenagers so they understand the reality of risk taking. Talk about date rape and physical abuse amongst teen couples. In a study done in California, 35% of teens questioned had experienced some form of violence with-in their relationships (Social Work 1986;31:465-8)

Knowing the laws that govern what advice can be given and what information can remain confidential is imperative. A great resource in understanding the basic laws that protect the physician and the patient’s rights is guttmacher.org/statecenter/spibs/spib_OMCL.pdf. Most states provide an online version of their laws governing teens and medical practice.

Establishing a rapport with your teenage patients can be very rewarding. Many teenagers are in search of a listening ear and need guidance in this new and critical era of their life. With a little planning and practice, you will provide with ease the information to help them make good decisions. It is important that we are equipped and ready because you may just save a life!

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected]. Go to pediatricnews.com to view similar columns.

It is important to recognize that as pediatricians we have the unique opportunity to see to the lives of a very vulnerable group of people known as teenagers.

We can all relate to the discomfort of the stone-faced teenager with one-word answers and one foot out the door. There is usually a parent present who is answering all of the questions, and if you are lucky, the patient may put the cell phone down long enough to get an eye exam in, but, we must realize that the 15 minutes of captive audience could be the most important 15 minutes of the teen’s life.

Before we start our exam, we should have a plan in place for what topics we should be addressing. Every thorough physical should include a screen on drugs and alcohol, depression, sexual activity, and violence. In a busy practice, it seems impossible to address these issues in a time-conservative manner, but if we plan ahead, we can be thorough, casual, and informative.

First, you must analyze your own style. If having these discussions is uncomfortable for you, then attempting them without a plan will be disastrous. Many pediatricians just choose to avoid the entire discussion and hope that the parent is parenting and will address the major issues. But fewer than half of all parents talk to their children about the issues that they are faced with daily, and a great majority are ill-informed, or driven by their own beliefs.

First, pediatricians must make a list of hot topics to be discussed. Review the most current data and how they are affecting the teens in your area. Next, whether your talking style is comfortable or not, having a questionnaire that introduces each topic is always helpful (Am. J. Psychiatry 1995;152:1601-7

Lastly, have teenagers come in by themselves. Parents cannot help themselves and will always speak for their children, and most teens will not ask questions that they don’t think their parent will approve of or that relate to private family issues. So, you must set the stage for a comfortable talking environment. By having the questionnaire available, you can use it as a guide to see what issues are affecting the patient.

Knowing current information is also imperative to a good wellness exam. Know what the latest drugs are being used by the teens in the area, and know the street names of drugs (drugabuse.gov/drugs-abuse). Where do the local teens hang out? Major issues happening at the local high schools can help guide your conversations and build trust as patients begin to see you as an active and involved leader in the community.

Depression affects 8% of teens every year. Therefore, there is a guarantee that at least a handful will present in your office every year. Asking the right questions is key to getting helpful answers. Be direct, ask, "Have you ever, or are you now having suicidal ideation?" Over 90% of children and adolescents who commit suicide have a mental disorder (J. Clin. Psychiatry 1999;60 (Suppl. 2):70-4). There is a Web site supported by the American Academy of Pediatrics that has questionnaires to assist in identifying symptoms of depression (brightfutures.aap.org). Knowing the family history of psychiatric disorders can be very helpful in guiding the physician of what questions to ask. Many teens are fearful that they may be having symptoms of a psychiatric disorder, but are too afraid to ask, given the stigma that goes along with it.

Address issues of self-image. If patients are overweight, give tips on healthy eating and exercise. Develop a nutritional plan and track a patient’s progress by having her follow up. Allow her to discuss what make her feel sad or uncomfortable. How is she interacting with her peers, does she fit in or is she often alone?

A wellness exam is not complete without addressing sex and sexuality. No matter how you slice it, talking about sex with a complete stranger will never be easy. Using the questionnaire to bring up the topic helps. Start with generalizations about the risks of unprotected sex and general statistics of sexually transmitted infections in teenagers. Next, a general statement about abstinence is important so that teens realize it is an option. Review the common birth control methods and their risks. Encourage him to have at least one adult that he can trust to discuss delicate issues with and to return to your office if other issues arise.

Teenagers also are under the belief that they are invincible and that bad things only happen to other people. Discuss the leading cause of death in teenagers so they understand the reality of risk taking. Talk about date rape and physical abuse amongst teen couples. In a study done in California, 35% of teens questioned had experienced some form of violence with-in their relationships (Social Work 1986;31:465-8)

Knowing the laws that govern what advice can be given and what information can remain confidential is imperative. A great resource in understanding the basic laws that protect the physician and the patient’s rights is guttmacher.org/statecenter/spibs/spib_OMCL.pdf. Most states provide an online version of their laws governing teens and medical practice.

Establishing a rapport with your teenage patients can be very rewarding. Many teenagers are in search of a listening ear and need guidance in this new and critical era of their life. With a little planning and practice, you will provide with ease the information to help them make good decisions. It is important that we are equipped and ready because you may just save a life!

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected]. Go to pediatricnews.com to view similar columns.

It is important to recognize that as pediatricians we have the unique opportunity to see to the lives of a very vulnerable group of people known as teenagers.

We can all relate to the discomfort of the stone-faced teenager with one-word answers and one foot out the door. There is usually a parent present who is answering all of the questions, and if you are lucky, the patient may put the cell phone down long enough to get an eye exam in, but, we must realize that the 15 minutes of captive audience could be the most important 15 minutes of the teen’s life.

Before we start our exam, we should have a plan in place for what topics we should be addressing. Every thorough physical should include a screen on drugs and alcohol, depression, sexual activity, and violence. In a busy practice, it seems impossible to address these issues in a time-conservative manner, but if we plan ahead, we can be thorough, casual, and informative.

First, you must analyze your own style. If having these discussions is uncomfortable for you, then attempting them without a plan will be disastrous. Many pediatricians just choose to avoid the entire discussion and hope that the parent is parenting and will address the major issues. But fewer than half of all parents talk to their children about the issues that they are faced with daily, and a great majority are ill-informed, or driven by their own beliefs.

First, pediatricians must make a list of hot topics to be discussed. Review the most current data and how they are affecting the teens in your area. Next, whether your talking style is comfortable or not, having a questionnaire that introduces each topic is always helpful (Am. J. Psychiatry 1995;152:1601-7

Lastly, have teenagers come in by themselves. Parents cannot help themselves and will always speak for their children, and most teens will not ask questions that they don’t think their parent will approve of or that relate to private family issues. So, you must set the stage for a comfortable talking environment. By having the questionnaire available, you can use it as a guide to see what issues are affecting the patient.

Knowing current information is also imperative to a good wellness exam. Know what the latest drugs are being used by the teens in the area, and know the street names of drugs (drugabuse.gov/drugs-abuse). Where do the local teens hang out? Major issues happening at the local high schools can help guide your conversations and build trust as patients begin to see you as an active and involved leader in the community.

Depression affects 8% of teens every year. Therefore, there is a guarantee that at least a handful will present in your office every year. Asking the right questions is key to getting helpful answers. Be direct, ask, "Have you ever, or are you now having suicidal ideation?" Over 90% of children and adolescents who commit suicide have a mental disorder (J. Clin. Psychiatry 1999;60 (Suppl. 2):70-4). There is a Web site supported by the American Academy of Pediatrics that has questionnaires to assist in identifying symptoms of depression (brightfutures.aap.org). Knowing the family history of psychiatric disorders can be very helpful in guiding the physician of what questions to ask. Many teens are fearful that they may be having symptoms of a psychiatric disorder, but are too afraid to ask, given the stigma that goes along with it.

Address issues of self-image. If patients are overweight, give tips on healthy eating and exercise. Develop a nutritional plan and track a patient’s progress by having her follow up. Allow her to discuss what make her feel sad or uncomfortable. How is she interacting with her peers, does she fit in or is she often alone?

A wellness exam is not complete without addressing sex and sexuality. No matter how you slice it, talking about sex with a complete stranger will never be easy. Using the questionnaire to bring up the topic helps. Start with generalizations about the risks of unprotected sex and general statistics of sexually transmitted infections in teenagers. Next, a general statement about abstinence is important so that teens realize it is an option. Review the common birth control methods and their risks. Encourage him to have at least one adult that he can trust to discuss delicate issues with and to return to your office if other issues arise.

Teenagers also are under the belief that they are invincible and that bad things only happen to other people. Discuss the leading cause of death in teenagers so they understand the reality of risk taking. Talk about date rape and physical abuse amongst teen couples. In a study done in California, 35% of teens questioned had experienced some form of violence with-in their relationships (Social Work 1986;31:465-8)

Knowing the laws that govern what advice can be given and what information can remain confidential is imperative. A great resource in understanding the basic laws that protect the physician and the patient’s rights is guttmacher.org/statecenter/spibs/spib_OMCL.pdf. Most states provide an online version of their laws governing teens and medical practice.

Establishing a rapport with your teenage patients can be very rewarding. Many teenagers are in search of a listening ear and need guidance in this new and critical era of their life. With a little planning and practice, you will provide with ease the information to help them make good decisions. It is important that we are equipped and ready because you may just save a life!

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected]. Go to pediatricnews.com to view similar columns.

Imagine a place where thousand of teens were homeless, many sleeping on park benches, hungry, and vulnerable. No, this is not a far-away land or third-world country; it’s here in the United States: 1.6 million children will be homeless for some period right here in America, according to the Substance Abuse and Mental Health Services Administration Office of Applied Studies

It’s hard to believe that in one of the richest nations that we would actually have teens walking the streets with no place to go. You might think that these are the wayward teen or the nonconformist, or oppositional defiant teens. But, statistics show that most teens run away to escape abuse they experience at home. Almost 20%-40% of homeless youths identify themselves as LGBT (lesbian, gay, bisexual, or transgender), according to a 2006 report by the National Coalition for the Homeless. Regardless of the reason, the number of homeless children is growing, and the hardship that teens face on the street is even greater than that faced by adults.

Finding shelter as a teen is particularly challenging because many shelters have only a few "youth" beds allotted. There is already a shortage of shelters so the availability is even less for teens. Teens also are particularly vulnerable to sexual predators and human traffickers. Many start by trading sex for food, which puts them at risk of HIV, physical abuse, and likely drug abuse.

Although many of us assume that this is a problem relegated to the inner city, the reality is that these children come from all areas, all cities, and all states. The majority of homeless teens are white (57%), black or African American comprises (27%), then American Indian and Alaskan (3%), according to the SAMHSA Office of Applied Studies (2004). As medical professionals, our critical role is to identify the at-risk teens.

Once we recognize that a teen is in dispute with his or her family because of sexual orientation, drug use, or as a victim of sexual abuse, we have taken the first step to identify a patient at risk.

The second step is to know what resources are available to assist teens that are homeless. The National Runaway Safeline – by phone, at 1-800-RUNAWAY (1-800-786-2929) or at their website, 1800runaway.org – is the national hotline designed to help keep America’s runaway, homeless, and at-risk youth safe and off the streets and to provides access to local shelters.

Homelessness is a growing crisis that affects our youth. If we understand that many of these teens are escaping abuse, it may help to explain why they end up in these situations and to define the support that they need. Remember that shelters are always in need of donations and volunteers.

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

Imagine a place where thousand of teens were homeless, many sleeping on park benches, hungry, and vulnerable. No, this is not a far-away land or third-world country; it’s here in the United States: 1.6 million children will be homeless for some period right here in America, according to the Substance Abuse and Mental Health Services Administration Office of Applied Studies

It’s hard to believe that in one of the richest nations that we would actually have teens walking the streets with no place to go. You might think that these are the wayward teen or the nonconformist, or oppositional defiant teens. But, statistics show that most teens run away to escape abuse they experience at home. Almost 20%-40% of homeless youths identify themselves as LGBT (lesbian, gay, bisexual, or transgender), according to a 2006 report by the National Coalition for the Homeless. Regardless of the reason, the number of homeless children is growing, and the hardship that teens face on the street is even greater than that faced by adults.

Finding shelter as a teen is particularly challenging because many shelters have only a few "youth" beds allotted. There is already a shortage of shelters so the availability is even less for teens. Teens also are particularly vulnerable to sexual predators and human traffickers. Many start by trading sex for food, which puts them at risk of HIV, physical abuse, and likely drug abuse.

Although many of us assume that this is a problem relegated to the inner city, the reality is that these children come from all areas, all cities, and all states. The majority of homeless teens are white (57%), black or African American comprises (27%), then American Indian and Alaskan (3%), according to the SAMHSA Office of Applied Studies (2004). As medical professionals, our critical role is to identify the at-risk teens.

Once we recognize that a teen is in dispute with his or her family because of sexual orientation, drug use, or as a victim of sexual abuse, we have taken the first step to identify a patient at risk.

The second step is to know what resources are available to assist teens that are homeless. The National Runaway Safeline – by phone, at 1-800-RUNAWAY (1-800-786-2929) or at their website, 1800runaway.org – is the national hotline designed to help keep America’s runaway, homeless, and at-risk youth safe and off the streets and to provides access to local shelters.

Homelessness is a growing crisis that affects our youth. If we understand that many of these teens are escaping abuse, it may help to explain why they end up in these situations and to define the support that they need. Remember that shelters are always in need of donations and volunteers.

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

Imagine a place where thousand of teens were homeless, many sleeping on park benches, hungry, and vulnerable. No, this is not a far-away land or third-world country; it’s here in the United States: 1.6 million children will be homeless for some period right here in America, according to the Substance Abuse and Mental Health Services Administration Office of Applied Studies

It’s hard to believe that in one of the richest nations that we would actually have teens walking the streets with no place to go. You might think that these are the wayward teen or the nonconformist, or oppositional defiant teens. But, statistics show that most teens run away to escape abuse they experience at home. Almost 20%-40% of homeless youths identify themselves as LGBT (lesbian, gay, bisexual, or transgender), according to a 2006 report by the National Coalition for the Homeless. Regardless of the reason, the number of homeless children is growing, and the hardship that teens face on the street is even greater than that faced by adults.

Finding shelter as a teen is particularly challenging because many shelters have only a few "youth" beds allotted. There is already a shortage of shelters so the availability is even less for teens. Teens also are particularly vulnerable to sexual predators and human traffickers. Many start by trading sex for food, which puts them at risk of HIV, physical abuse, and likely drug abuse.

Although many of us assume that this is a problem relegated to the inner city, the reality is that these children come from all areas, all cities, and all states. The majority of homeless teens are white (57%), black or African American comprises (27%), then American Indian and Alaskan (3%), according to the SAMHSA Office of Applied Studies (2004). As medical professionals, our critical role is to identify the at-risk teens.

Once we recognize that a teen is in dispute with his or her family because of sexual orientation, drug use, or as a victim of sexual abuse, we have taken the first step to identify a patient at risk.

The second step is to know what resources are available to assist teens that are homeless. The National Runaway Safeline – by phone, at 1-800-RUNAWAY (1-800-786-2929) or at their website, 1800runaway.org – is the national hotline designed to help keep America’s runaway, homeless, and at-risk youth safe and off the streets and to provides access to local shelters.

Homelessness is a growing crisis that affects our youth. If we understand that many of these teens are escaping abuse, it may help to explain why they end up in these situations and to define the support that they need. Remember that shelters are always in need of donations and volunteers.

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

As providers we are often questioned about healthy habits, working out, and diets, but in the pediatric population, what works for adults may be very harmful to the growing body. Many of the food products that are advertised as "healthy" are nowhere close to healthy.

With childhood obesity on the rise, many parents and teens are looking for ways to lose weight or maintain a healthy lifestyle to avoid obesity. But, many resort to restricted diets that lack important nutrients for proper growth.

Adolescents also are notorious for skipping meals, snacking, and late night eating. Teens in particular resort to starvation to lose weight quickly. This is usually ineffective because most will binge on unhealthy food when they become hungry, negating the effects of the decreased intake (J. Pediatr. Nurs. 2005;20:258-67). In terms of skipping breakfast in particular, a study of schools that participated in a breakfast program showed that there was an increase in math grades and physical performance in children who ate breakfast. Generally, teens who consistently ate breakfast had better nutrition than those who did not.

The use of diet aids and stimulants is another quick weight loss trick that has detrimental side effects. Hydroxycut, diuretics, and amphetamines are just a few of the many substances used. Hydroxycut use has been linked to elevated liver enzymes, jaundice, and seizures. The Food and Drug Administration has urged consumers to stop using this product. Improper use of diuretics can cause electrolyte imbalances, and improper use of some stimulants has been indicated as a cause of sudden death.

Fad diets come out weekly and usually include low-carbohydrate/low-fat or meatless diets. Vegetarian diets also are becoming more popular. The problem with any diet in the adolescent age group is that their bodies are growing, and they actually have a higher demand for certain nutrients, in particular iron, zinc, and calcium.

A typical adolescent diet is low in iron, calcium, folic acid, fiber, and zinc. Low iron intake has been shown to impair cognitive function and physical performance. Low calcium intake increases the risk of fractures and osteoporosis later in life.

Vegetarian diets, depending on how restricted they are, can leave children with significant deficiencies. Children with rapid growth have increased iron needs. Iron from meat sources are more readily absorbed than from plant sources, and iron absorption from plant sources is greatly affected by dietary components. Therefore, there is less absorption of iron if consumed with legumes, nuts, and soy protein. Supplementing the diet with consumption of vitamin C during a meal significantly increases the absorption of iron (Hum. Nutr. Appl. Nutr. 1986;40:97-113). Careful consideration of what food is eliminated in a diet and ensuring its replacement by food substitution or vitamin supplements can prevent deficiencies.

Exercise and weight training are another avenue for weight loss but unfortunately are not used as often because they require discipline and time. But exercising and weight lifting aren’t without risk either. The growing adolescent has open growth plates. Therefore, with intense resistance exercises, there is a risk of injuring the growth plate, which could negatively impact the growth of the affected bone. Encouraging teens to train with supervision and to get accurate instructions are crucial to avoiding injury.

The use of protein shakes is popular among male teens, who are often looking to bulk up. Whey protein is commonly used and is safe when taken in proper amounts and with good hydration. The average teen needs approximately 50 g of protein per day. Excessive protein has been thought to cause kidney disease, but the research does not support this claim. Although lowering protein intake can be beneficial for a person with kidney disease, that does not extrapolate to excessive protein leading to kidney disease. But adequate hydration should be encouraged.

It is always prudent to monitor for eating disorders and the use of illicit drugs to improve physique. In adolescents who seem to be overly competitive or overly obsessed with their appearance, addressing concerns directly, informing parents of your observations, and making the appropriate referrals can prevent significant injury and health consequences.

Here are some general recommendations to help you guide your patients:

• Visit choosemyplate.gov, a comprehensive site that reviews dietary guidelines and individualizes the guidelines based on age, sex, and activity level.

• Educate families on reading food labels so they can make good choices.

• Warn against following restricted diets that could lead to nutritional deficiencies resulting in illness.

• Educate about the danger of weight loss drugs and their risks.

• Advise families that strength training can be effective but only when well designed and supervised to avoid injury.

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

As providers we are often questioned about healthy habits, working out, and diets, but in the pediatric population, what works for adults may be very harmful to the growing body. Many of the food products that are advertised as "healthy" are nowhere close to healthy.

With childhood obesity on the rise, many parents and teens are looking for ways to lose weight or maintain a healthy lifestyle to avoid obesity. But, many resort to restricted diets that lack important nutrients for proper growth.

Adolescents also are notorious for skipping meals, snacking, and late night eating. Teens in particular resort to starvation to lose weight quickly. This is usually ineffective because most will binge on unhealthy food when they become hungry, negating the effects of the decreased intake (J. Pediatr. Nurs. 2005;20:258-67). In terms of skipping breakfast in particular, a study of schools that participated in a breakfast program showed that there was an increase in math grades and physical performance in children who ate breakfast. Generally, teens who consistently ate breakfast had better nutrition than those who did not.

The use of diet aids and stimulants is another quick weight loss trick that has detrimental side effects. Hydroxycut, diuretics, and amphetamines are just a few of the many substances used. Hydroxycut use has been linked to elevated liver enzymes, jaundice, and seizures. The Food and Drug Administration has urged consumers to stop using this product. Improper use of diuretics can cause electrolyte imbalances, and improper use of some stimulants has been indicated as a cause of sudden death.

Fad diets come out weekly and usually include low-carbohydrate/low-fat or meatless diets. Vegetarian diets also are becoming more popular. The problem with any diet in the adolescent age group is that their bodies are growing, and they actually have a higher demand for certain nutrients, in particular iron, zinc, and calcium.

A typical adolescent diet is low in iron, calcium, folic acid, fiber, and zinc. Low iron intake has been shown to impair cognitive function and physical performance. Low calcium intake increases the risk of fractures and osteoporosis later in life.

Vegetarian diets, depending on how restricted they are, can leave children with significant deficiencies. Children with rapid growth have increased iron needs. Iron from meat sources are more readily absorbed than from plant sources, and iron absorption from plant sources is greatly affected by dietary components. Therefore, there is less absorption of iron if consumed with legumes, nuts, and soy protein. Supplementing the diet with consumption of vitamin C during a meal significantly increases the absorption of iron (Hum. Nutr. Appl. Nutr. 1986;40:97-113). Careful consideration of what food is eliminated in a diet and ensuring its replacement by food substitution or vitamin supplements can prevent deficiencies.

Exercise and weight training are another avenue for weight loss but unfortunately are not used as often because they require discipline and time. But exercising and weight lifting aren’t without risk either. The growing adolescent has open growth plates. Therefore, with intense resistance exercises, there is a risk of injuring the growth plate, which could negatively impact the growth of the affected bone. Encouraging teens to train with supervision and to get accurate instructions are crucial to avoiding injury.

The use of protein shakes is popular among male teens, who are often looking to bulk up. Whey protein is commonly used and is safe when taken in proper amounts and with good hydration. The average teen needs approximately 50 g of protein per day. Excessive protein has been thought to cause kidney disease, but the research does not support this claim. Although lowering protein intake can be beneficial for a person with kidney disease, that does not extrapolate to excessive protein leading to kidney disease. But adequate hydration should be encouraged.

It is always prudent to monitor for eating disorders and the use of illicit drugs to improve physique. In adolescents who seem to be overly competitive or overly obsessed with their appearance, addressing concerns directly, informing parents of your observations, and making the appropriate referrals can prevent significant injury and health consequences.

Here are some general recommendations to help you guide your patients:

• Visit choosemyplate.gov, a comprehensive site that reviews dietary guidelines and individualizes the guidelines based on age, sex, and activity level.

• Educate families on reading food labels so they can make good choices.

• Warn against following restricted diets that could lead to nutritional deficiencies resulting in illness.

• Educate about the danger of weight loss drugs and their risks.

• Advise families that strength training can be effective but only when well designed and supervised to avoid injury.

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

As providers we are often questioned about healthy habits, working out, and diets, but in the pediatric population, what works for adults may be very harmful to the growing body. Many of the food products that are advertised as "healthy" are nowhere close to healthy.

With childhood obesity on the rise, many parents and teens are looking for ways to lose weight or maintain a healthy lifestyle to avoid obesity. But, many resort to restricted diets that lack important nutrients for proper growth.

Adolescents also are notorious for skipping meals, snacking, and late night eating. Teens in particular resort to starvation to lose weight quickly. This is usually ineffective because most will binge on unhealthy food when they become hungry, negating the effects of the decreased intake (J. Pediatr. Nurs. 2005;20:258-67). In terms of skipping breakfast in particular, a study of schools that participated in a breakfast program showed that there was an increase in math grades and physical performance in children who ate breakfast. Generally, teens who consistently ate breakfast had better nutrition than those who did not.

The use of diet aids and stimulants is another quick weight loss trick that has detrimental side effects. Hydroxycut, diuretics, and amphetamines are just a few of the many substances used. Hydroxycut use has been linked to elevated liver enzymes, jaundice, and seizures. The Food and Drug Administration has urged consumers to stop using this product. Improper use of diuretics can cause electrolyte imbalances, and improper use of some stimulants has been indicated as a cause of sudden death.

Fad diets come out weekly and usually include low-carbohydrate/low-fat or meatless diets. Vegetarian diets also are becoming more popular. The problem with any diet in the adolescent age group is that their bodies are growing, and they actually have a higher demand for certain nutrients, in particular iron, zinc, and calcium.

A typical adolescent diet is low in iron, calcium, folic acid, fiber, and zinc. Low iron intake has been shown to impair cognitive function and physical performance. Low calcium intake increases the risk of fractures and osteoporosis later in life.

Vegetarian diets, depending on how restricted they are, can leave children with significant deficiencies. Children with rapid growth have increased iron needs. Iron from meat sources are more readily absorbed than from plant sources, and iron absorption from plant sources is greatly affected by dietary components. Therefore, there is less absorption of iron if consumed with legumes, nuts, and soy protein. Supplementing the diet with consumption of vitamin C during a meal significantly increases the absorption of iron (Hum. Nutr. Appl. Nutr. 1986;40:97-113). Careful consideration of what food is eliminated in a diet and ensuring its replacement by food substitution or vitamin supplements can prevent deficiencies.

Exercise and weight training are another avenue for weight loss but unfortunately are not used as often because they require discipline and time. But exercising and weight lifting aren’t without risk either. The growing adolescent has open growth plates. Therefore, with intense resistance exercises, there is a risk of injuring the growth plate, which could negatively impact the growth of the affected bone. Encouraging teens to train with supervision and to get accurate instructions are crucial to avoiding injury.

The use of protein shakes is popular among male teens, who are often looking to bulk up. Whey protein is commonly used and is safe when taken in proper amounts and with good hydration. The average teen needs approximately 50 g of protein per day. Excessive protein has been thought to cause kidney disease, but the research does not support this claim. Although lowering protein intake can be beneficial for a person with kidney disease, that does not extrapolate to excessive protein leading to kidney disease. But adequate hydration should be encouraged.

It is always prudent to monitor for eating disorders and the use of illicit drugs to improve physique. In adolescents who seem to be overly competitive or overly obsessed with their appearance, addressing concerns directly, informing parents of your observations, and making the appropriate referrals can prevent significant injury and health consequences.

Here are some general recommendations to help you guide your patients:

• Visit choosemyplate.gov, a comprehensive site that reviews dietary guidelines and individualizes the guidelines based on age, sex, and activity level.

• Educate families on reading food labels so they can make good choices.

• Warn against following restricted diets that could lead to nutritional deficiencies resulting in illness.

• Educate about the danger of weight loss drugs and their risks.

• Advise families that strength training can be effective but only when well designed and supervised to avoid injury.

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

In the adolescent years, it’s all about "YOLO" (You only live once!), which is the premise for many of the behaviors that primary care doctors see during this time. Many teens come into the office covered in piercings and tattoos. My favorite is the boyfriend’s name tattooed across an arm, a leg, or even the buttocks. You can’t help but think to yourself, "You are going to regret that one, for sure!"

Although tattooing and piercing are practiced in many cultures, extensive body art and multiple piercings are practices that are often done by adolescents who also engage in other risky behaviors. ("Tattooing in adults and adolescents," UpToDate, Aug. 29, 2013). One study showed that this population is much more likely to engage in sexual activity, binge drinking, marijuana smoking, and fighting significantly more than were non–tattooed adolescents.

As a primary care doctor, you’re less likely to be asked for advice about getting a tattoo or piercing than you are to be asked to fix the mishaps of these practices, but it is still important to be up to date on the potential risks. Adolescents are at an even a greater risk than are adults for complications because, in most states, children under age 18 years are required to have parental consent to get a tattoo or piercing. Therefore, this age group is more likely to seek out illegal or unlicensed businesses. Where there is a greater risk of substandard protocols and hygiene, the risk of infection increases. Many of the infections come from nonsterile cleaning fluid and water used in the tattooing or piercing procedure. Improper education of the client on aftercare is another contributing factor.

Local infections are the No. 1 complication of tattoos and piercings. Staphylococcus aureus and methicillin-resistant S. aureus (MRSA) are the most common causes of infection, but several other infectious agents have also been identified. It is not uncommon to have outbreaks of a particular infection occur because a certain provider is not using appropriate hygiene or is a carrier of one of the blood-borne illnesses.

Some caution tattoo seekers about blood-borne infections such as HIV, hepatitis C, and hepatitis B. But the number of such infections is currently relatively low. In fact, the research does not show a clear causal relationship between tattoos and piercings. Instead, it shows that, because adolescents who get tattoos are risk takers and are more likely to be intravenous drug users, they are also more likely to become infected with these diseases (Pediatrics 2002;109:1021-7).

A major complication that should not be overlooked is infective endocarditis. Although rare, if a teen presents 1-2 months after a body piercing or tattoo and has unexplained fevers, weakness, arthritis, and malaise, a work-up should be done with infective endocarditis in mind.

The role of the primary care doctor in this situation is to educate patients on appropriate practices so that they will be less inclined to have an inexperienced and unlicensed person perform body art procedures on them. Patients should expect the skin to be cleaned initially with alcohol and iodine, and sterile water and gloves to be used in the procedure. A clear understanding of the potential health risks and life-long complications should also help to deter them unsafe practices.

In the event of a local infection, it may actually be better to leave the piercing in because it allows for drainage. Antibiotic coverage that includes MRSA will also speed recovery.

Tattoos and piercing can be safe when done properly. Being proactive and sharing the appropriate information can help an adolescent make a better decision so that not only do they get to live it up, they can live a healthy long life as well

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

In the adolescent years, it’s all about "YOLO" (You only live once!), which is the premise for many of the behaviors that primary care doctors see during this time. Many teens come into the office covered in piercings and tattoos. My favorite is the boyfriend’s name tattooed across an arm, a leg, or even the buttocks. You can’t help but think to yourself, "You are going to regret that one, for sure!"

Although tattooing and piercing are practiced in many cultures, extensive body art and multiple piercings are practices that are often done by adolescents who also engage in other risky behaviors. ("Tattooing in adults and adolescents," UpToDate, Aug. 29, 2013). One study showed that this population is much more likely to engage in sexual activity, binge drinking, marijuana smoking, and fighting significantly more than were non–tattooed adolescents.

As a primary care doctor, you’re less likely to be asked for advice about getting a tattoo or piercing than you are to be asked to fix the mishaps of these practices, but it is still important to be up to date on the potential risks. Adolescents are at an even a greater risk than are adults for complications because, in most states, children under age 18 years are required to have parental consent to get a tattoo or piercing. Therefore, this age group is more likely to seek out illegal or unlicensed businesses. Where there is a greater risk of substandard protocols and hygiene, the risk of infection increases. Many of the infections come from nonsterile cleaning fluid and water used in the tattooing or piercing procedure. Improper education of the client on aftercare is another contributing factor.

Local infections are the No. 1 complication of tattoos and piercings. Staphylococcus aureus and methicillin-resistant S. aureus (MRSA) are the most common causes of infection, but several other infectious agents have also been identified. It is not uncommon to have outbreaks of a particular infection occur because a certain provider is not using appropriate hygiene or is a carrier of one of the blood-borne illnesses.

Some caution tattoo seekers about blood-borne infections such as HIV, hepatitis C, and hepatitis B. But the number of such infections is currently relatively low. In fact, the research does not show a clear causal relationship between tattoos and piercings. Instead, it shows that, because adolescents who get tattoos are risk takers and are more likely to be intravenous drug users, they are also more likely to become infected with these diseases (Pediatrics 2002;109:1021-7).

A major complication that should not be overlooked is infective endocarditis. Although rare, if a teen presents 1-2 months after a body piercing or tattoo and has unexplained fevers, weakness, arthritis, and malaise, a work-up should be done with infective endocarditis in mind.

The role of the primary care doctor in this situation is to educate patients on appropriate practices so that they will be less inclined to have an inexperienced and unlicensed person perform body art procedures on them. Patients should expect the skin to be cleaned initially with alcohol and iodine, and sterile water and gloves to be used in the procedure. A clear understanding of the potential health risks and life-long complications should also help to deter them unsafe practices.

In the event of a local infection, it may actually be better to leave the piercing in because it allows for drainage. Antibiotic coverage that includes MRSA will also speed recovery.

Tattoos and piercing can be safe when done properly. Being proactive and sharing the appropriate information can help an adolescent make a better decision so that not only do they get to live it up, they can live a healthy long life as well

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

In the adolescent years, it’s all about "YOLO" (You only live once!), which is the premise for many of the behaviors that primary care doctors see during this time. Many teens come into the office covered in piercings and tattoos. My favorite is the boyfriend’s name tattooed across an arm, a leg, or even the buttocks. You can’t help but think to yourself, "You are going to regret that one, for sure!"

Although tattooing and piercing are practiced in many cultures, extensive body art and multiple piercings are practices that are often done by adolescents who also engage in other risky behaviors. ("Tattooing in adults and adolescents," UpToDate, Aug. 29, 2013). One study showed that this population is much more likely to engage in sexual activity, binge drinking, marijuana smoking, and fighting significantly more than were non–tattooed adolescents.

As a primary care doctor, you’re less likely to be asked for advice about getting a tattoo or piercing than you are to be asked to fix the mishaps of these practices, but it is still important to be up to date on the potential risks. Adolescents are at an even a greater risk than are adults for complications because, in most states, children under age 18 years are required to have parental consent to get a tattoo or piercing. Therefore, this age group is more likely to seek out illegal or unlicensed businesses. Where there is a greater risk of substandard protocols and hygiene, the risk of infection increases. Many of the infections come from nonsterile cleaning fluid and water used in the tattooing or piercing procedure. Improper education of the client on aftercare is another contributing factor.

Local infections are the No. 1 complication of tattoos and piercings. Staphylococcus aureus and methicillin-resistant S. aureus (MRSA) are the most common causes of infection, but several other infectious agents have also been identified. It is not uncommon to have outbreaks of a particular infection occur because a certain provider is not using appropriate hygiene or is a carrier of one of the blood-borne illnesses.

Some caution tattoo seekers about blood-borne infections such as HIV, hepatitis C, and hepatitis B. But the number of such infections is currently relatively low. In fact, the research does not show a clear causal relationship between tattoos and piercings. Instead, it shows that, because adolescents who get tattoos are risk takers and are more likely to be intravenous drug users, they are also more likely to become infected with these diseases (Pediatrics 2002;109:1021-7).

A major complication that should not be overlooked is infective endocarditis. Although rare, if a teen presents 1-2 months after a body piercing or tattoo and has unexplained fevers, weakness, arthritis, and malaise, a work-up should be done with infective endocarditis in mind.

The role of the primary care doctor in this situation is to educate patients on appropriate practices so that they will be less inclined to have an inexperienced and unlicensed person perform body art procedures on them. Patients should expect the skin to be cleaned initially with alcohol and iodine, and sterile water and gloves to be used in the procedure. A clear understanding of the potential health risks and life-long complications should also help to deter them unsafe practices.

In the event of a local infection, it may actually be better to leave the piercing in because it allows for drainage. Antibiotic coverage that includes MRSA will also speed recovery.

Tattoos and piercing can be safe when done properly. Being proactive and sharing the appropriate information can help an adolescent make a better decision so that not only do they get to live it up, they can live a healthy long life as well

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

Cutting, otherwise known as nonsuicidal self-injury (NSSI), is a frightening and complex disorder that is prevalent among adolescents, but poorly understood. Typically, pediatricians see distraught parents who, unaware that their children were even depressed, have discovered that they engage in self-harming activities. Quick answers are needed, and with most psychology services being overwhelmed, an immediate evaluation is unlikely. Therefore, it is important to have a clear understanding and resources available to help defuse the situation.

For most, it is hard to understand why young people would want to inflict bodily harm on themselves. The questions that always arise are, was this a suicide attempt? Or, was it a cry for help? Well, the answer to both is quite surprisingly "no," at least in the majority of cases.

Cutting, or NSSI, is an unhealthy reaction to anxiety, pain, frustration, or stress. It is an impulsive behavior that is not necessarily associated with intent to die.

A 2007 study showed that 46% of 633 9th and 10th graders admitted to a least one episode of cutting, burning, scratching, or hitting themselves in response to emotional stress (Psychol. Med. 2007;37:1183-92).

The prevalence of NSSI among adolescents is reported to be 14%-15% and declines to 4% by adulthood (J. Youth Adolesc. 2002;31:67-77). There is no significant gender difference, but the method of self-harm for females tends to be cutting, whereas males are more likely to hit or burn themselves.

So why do people want to inflect pain on themselves? Well, there is a physiologic basis for the most common reason, which is termed affect regulation. Although not completely understood, it is believed that by eliciting pain, endorphins are released, and there is an immediate relief of anxiety, pain, or stress. Most "cutters" report infrequent episodes, but some do become addicted to the sensation, and the episodes increase.

Another reason for cutting is self-punishment. Young people who suffer from low self-esteem, or self-degradation, may use self-harm to express anger toward themselves.

A surprising finding was that interpersonal influence was one of the least common reasons given for self-harm. It is not a common method for a "cry for help" or attention as is a suicide attempt. People who cut are looking for an immediate relief from the emotional stress they are feeling. In fact, many are very secretive about this behavior, and it usually goes unnoticed for several months to years.

Although NSSI can occur independently of any psychological dysfunction, it has been found to have a comorbidity with borderline personality disorder (BPD), anxiety, and depression. All of these disorders are associated with negative emotional stress. Sexual abuse and self-harm are associated because they have the same psychological risk factors but not a cause and effect relationship with NSSI (J. Clin. Psychol. 2007;63:1045-56).

One of the biggest risk factors for suicide is the frequency of the cutting. Addiction to the behavior resulting in daily or weekly episodes does significantly increase the risk of a suicide attempt. Therefore, anyone who presents with a history of cutting should have a Suicide Risk Assessment completed.

First-line treatment for nonsuicidal self-harm is psychotherapy, for example, cognitive-behavioral therapy. Pharmacotherapy of comorbid conditions such as depression and anxiety can be helpful in reducing symptoms, and therefore reducing episodes.

Understanding the psychology behind self-harm will be very helpful in educating and calming families through this difficult situation. Being able to direct the patient to the appropriate resources will expedite evaluation and treatment. Such resources include www.selfinjury.com, www.helpguide.org/mental/self_injury.htm, and www.selfinjury.bctr.cornell.edu.

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

Cutting, otherwise known as nonsuicidal self-injury (NSSI), is a frightening and complex disorder that is prevalent among adolescents, but poorly understood. Typically, pediatricians see distraught parents who, unaware that their children were even depressed, have discovered that they engage in self-harming activities. Quick answers are needed, and with most psychology services being overwhelmed, an immediate evaluation is unlikely. Therefore, it is important to have a clear understanding and resources available to help defuse the situation.

For most, it is hard to understand why young people would want to inflict bodily harm on themselves. The questions that always arise are, was this a suicide attempt? Or, was it a cry for help? Well, the answer to both is quite surprisingly "no," at least in the majority of cases.

Cutting, or NSSI, is an unhealthy reaction to anxiety, pain, frustration, or stress. It is an impulsive behavior that is not necessarily associated with intent to die.

A 2007 study showed that 46% of 633 9th and 10th graders admitted to a least one episode of cutting, burning, scratching, or hitting themselves in response to emotional stress (Psychol. Med. 2007;37:1183-92).

The prevalence of NSSI among adolescents is reported to be 14%-15% and declines to 4% by adulthood (J. Youth Adolesc. 2002;31:67-77). There is no significant gender difference, but the method of self-harm for females tends to be cutting, whereas males are more likely to hit or burn themselves.

So why do people want to inflect pain on themselves? Well, there is a physiologic basis for the most common reason, which is termed affect regulation. Although not completely understood, it is believed that by eliciting pain, endorphins are released, and there is an immediate relief of anxiety, pain, or stress. Most "cutters" report infrequent episodes, but some do become addicted to the sensation, and the episodes increase.

Another reason for cutting is self-punishment. Young people who suffer from low self-esteem, or self-degradation, may use self-harm to express anger toward themselves.

A surprising finding was that interpersonal influence was one of the least common reasons given for self-harm. It is not a common method for a "cry for help" or attention as is a suicide attempt. People who cut are looking for an immediate relief from the emotional stress they are feeling. In fact, many are very secretive about this behavior, and it usually goes unnoticed for several months to years.

Although NSSI can occur independently of any psychological dysfunction, it has been found to have a comorbidity with borderline personality disorder (BPD), anxiety, and depression. All of these disorders are associated with negative emotional stress. Sexual abuse and self-harm are associated because they have the same psychological risk factors but not a cause and effect relationship with NSSI (J. Clin. Psychol. 2007;63:1045-56).

One of the biggest risk factors for suicide is the frequency of the cutting. Addiction to the behavior resulting in daily or weekly episodes does significantly increase the risk of a suicide attempt. Therefore, anyone who presents with a history of cutting should have a Suicide Risk Assessment completed.

First-line treatment for nonsuicidal self-harm is psychotherapy, for example, cognitive-behavioral therapy. Pharmacotherapy of comorbid conditions such as depression and anxiety can be helpful in reducing symptoms, and therefore reducing episodes.

Understanding the psychology behind self-harm will be very helpful in educating and calming families through this difficult situation. Being able to direct the patient to the appropriate resources will expedite evaluation and treatment. Such resources include www.selfinjury.com, www.helpguide.org/mental/self_injury.htm, and www.selfinjury.bctr.cornell.edu.

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

Cutting, otherwise known as nonsuicidal self-injury (NSSI), is a frightening and complex disorder that is prevalent among adolescents, but poorly understood. Typically, pediatricians see distraught parents who, unaware that their children were even depressed, have discovered that they engage in self-harming activities. Quick answers are needed, and with most psychology services being overwhelmed, an immediate evaluation is unlikely. Therefore, it is important to have a clear understanding and resources available to help defuse the situation.

For most, it is hard to understand why young people would want to inflict bodily harm on themselves. The questions that always arise are, was this a suicide attempt? Or, was it a cry for help? Well, the answer to both is quite surprisingly "no," at least in the majority of cases.

Cutting, or NSSI, is an unhealthy reaction to anxiety, pain, frustration, or stress. It is an impulsive behavior that is not necessarily associated with intent to die.

A 2007 study showed that 46% of 633 9th and 10th graders admitted to a least one episode of cutting, burning, scratching, or hitting themselves in response to emotional stress (Psychol. Med. 2007;37:1183-92).

The prevalence of NSSI among adolescents is reported to be 14%-15% and declines to 4% by adulthood (J. Youth Adolesc. 2002;31:67-77). There is no significant gender difference, but the method of self-harm for females tends to be cutting, whereas males are more likely to hit or burn themselves.

So why do people want to inflect pain on themselves? Well, there is a physiologic basis for the most common reason, which is termed affect regulation. Although not completely understood, it is believed that by eliciting pain, endorphins are released, and there is an immediate relief of anxiety, pain, or stress. Most "cutters" report infrequent episodes, but some do become addicted to the sensation, and the episodes increase.

Another reason for cutting is self-punishment. Young people who suffer from low self-esteem, or self-degradation, may use self-harm to express anger toward themselves.

A surprising finding was that interpersonal influence was one of the least common reasons given for self-harm. It is not a common method for a "cry for help" or attention as is a suicide attempt. People who cut are looking for an immediate relief from the emotional stress they are feeling. In fact, many are very secretive about this behavior, and it usually goes unnoticed for several months to years.

Although NSSI can occur independently of any psychological dysfunction, it has been found to have a comorbidity with borderline personality disorder (BPD), anxiety, and depression. All of these disorders are associated with negative emotional stress. Sexual abuse and self-harm are associated because they have the same psychological risk factors but not a cause and effect relationship with NSSI (J. Clin. Psychol. 2007;63:1045-56).

One of the biggest risk factors for suicide is the frequency of the cutting. Addiction to the behavior resulting in daily or weekly episodes does significantly increase the risk of a suicide attempt. Therefore, anyone who presents with a history of cutting should have a Suicide Risk Assessment completed.

First-line treatment for nonsuicidal self-harm is psychotherapy, for example, cognitive-behavioral therapy. Pharmacotherapy of comorbid conditions such as depression and anxiety can be helpful in reducing symptoms, and therefore reducing episodes.

Understanding the psychology behind self-harm will be very helpful in educating and calming families through this difficult situation. Being able to direct the patient to the appropriate resources will expedite evaluation and treatment. Such resources include www.selfinjury.com, www.helpguide.org/mental/self_injury.htm, and www.selfinjury.bctr.cornell.edu.

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

Let’s face it, most of us when we entered into pediatrics envisioned bouncing babies, adorable toddlers, and snotty-nosed children drawing us pictures that adorned the walls of our office. Never did we imagine sitting in a room across from a stone-faced teenage girl to talk about birth control.

But, reality quickly sets in, and staying up to date with the latest recommendation on birth control is imperative or you need to make the proper referral. Knowing the laws of your state about birth control, which govern your ability to administer contraception without parental consent, is vital. The Guttmacher website gives you a concise list for each state. Parental involvement is always encouraged, but may be the obstacle that prevents the patient from having the discussion.

Abstinence is the only foolproof way to avoid pregnancy, yet many of us forget to discuss it during our conversation. With statistics like 40% of teens report to having engaged in some level of sexual activity by age 15, it is not far-fetched to believe that there are teens who just assume all of their peers are having sex (Hatcher, R.A., et al. Contraceptive Technology, 20th revised ed. New York: Ardent Media, 2011). It is important that teens know that the majority of teens are not having sex, and saying "No" is an option. But teens will need support and help in developing the skills to incorporate abstinence into their relationships.

Discussing the health risk of sexually transmitted infections (STIs) and the possibility of infertility has a strong impact. Being clear on the risks of contracting human papillomavirus with the subsequent risk of cervical cancer associated with having multiple sexual partners, as well as the risk of contracting an incurable disease such as HIV, can be very persuasive.

Discussing condoms, how they protect against sexually transmitted diseases, and the value of dual protection is also important.

With pregnancy rates lower than 1% with perfect and typical use, long-acting reversible contraceptive (LARC) methods "are the best reversible methods for preventing unintended pregnancy, rapid repeat pregnancy, and abortion in young women," according to the American College of Obstetricians and Gynecologists committee opinion No. 539, written by the Committee on Adolescent Health Care Long-Acting Reversible Contraception Working Group (Obstet. Gynecol. 2012;120:983-8). Complications of these methods – intrauterine devices (IUDs) and the contraceptive implant – are rare and are similar in adolescents and older women, yet LARCs are underused in the younger age group.

An IUD is a LARC that eliminates the need for the teen to remember to take an oral contraceptive. Mirena is one such IUD that has little to no side effects, and is easily placed and removed. It can be used to control dysmenorrhea and abnormal uterine bleeding/heavy menstrual bleeding as well.

Skyla is the newest intrauterine system on the market. Compared with Mirena, which has been available since 2000, the new system uses less levonorgestrel (14 vs. 20 mcg), has a smaller frame and inserter tube that have been shown to be less painful on insertion in nulliparous women, is associated with more abnormal bleeding, and is approved for 3 years (vs. 5 years) of use.

In the past, IUDs were discouraged because there was a fear that there was an increased risk of infection and pelvic inflammatory disease (PID) with their use. However, more recent research shows that there is only a slightly increased risk of PID at the time of insertion, and there is no increased risk of STIs or infertility associated with using IUDs. They have become increasingly popular for adolescents, and should be given as an option.

The contraceptive implant (Nexplanon), which is approved for 3 years of use, is another form of LARC.

The use of oral contraceptives is a common option, although challenging for the already-preoccupied teen. The birth control pill has a failure rate of 0.3% when used correctly, but that increases to 8% when used in its typical fashion, according to the U.S. Medical Eligibility Criteria for Contraceptive Use (MMWR 2010;59:1-88). Many parents express concerns regarding the safety of OCs because of all the media advertisements for lawsuits. The reality is they are safe. The risk of deep vein thrombosis is low in women younger than 35 years who are nonsmokers, without hypertension, and who are not obese. Starting with an ultralow dose of estrogen minimizes side effects. If a patient begins to have breakthrough bleeding, switching to a triphasic pill helps reduce those episodes.

The Minipill (a progestin-only contraceptive) and Depo-Provera (a progestogen-only injection) are options for women who cannot tolerate estrogen, but the downsides are that their use can increase acne and appetite (which can lead to weight gain). Depo-Provera use also has been shown to lead to significant bone density loss if used greater than 2 years. These contraceptives are all reasonable options for a teen who demonstrates a high level of responsibility.

A talk on contraception would not be complete without including information about emergency contraception. It is important to let teens know that if there is a risk of pregnancy, taking emergency contraception within 3-5 days can prevent them from becoming pregnant. In June 2013, the Food and Drug Administration removed the requirement for minors to have a script to receive Plan B. My Way and Next Choice still require a prescription. Other options such as ella (ulipristal acetate, available by prescription) are hormone free, have fewer side effects, and have been shown to be more effective than hormones in preventing pregnancy.

In 2012, the American Academy of Pediatrics released a policy statement on emergency contraception, which stated: "All adolescents, males and females, ... should be counseled on emergency contraception as part of routine anticipatory guidance in the context of a discussion on sexual safety and family planning regardless of current intentions of sexual behavior" (Pediatrics 2012;130:1174-82).

All of the oral emergency contraception methods are significantly less effective in obese women, and obese women are four times more likely to get pregnant despite using these methods. The copper IUD has been shown to be the most effective form of emergency contraception regardless of weight and offers continuous protection. But, it should be noted that using the copper IUD for this purpose is an off-label use in the United States.

Knowledge is power, and sharing this little bit of information can be life changing for a teen who is considering being sexually active.

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

Let’s face it, most of us when we entered into pediatrics envisioned bouncing babies, adorable toddlers, and snotty-nosed children drawing us pictures that adorned the walls of our office. Never did we imagine sitting in a room across from a stone-faced teenage girl to talk about birth control.

But, reality quickly sets in, and staying up to date with the latest recommendation on birth control is imperative or you need to make the proper referral. Knowing the laws of your state about birth control, which govern your ability to administer contraception without parental consent, is vital. The Guttmacher website gives you a concise list for each state. Parental involvement is always encouraged, but may be the obstacle that prevents the patient from having the discussion.

Abstinence is the only foolproof way to avoid pregnancy, yet many of us forget to discuss it during our conversation. With statistics like 40% of teens report to having engaged in some level of sexual activity by age 15, it is not far-fetched to believe that there are teens who just assume all of their peers are having sex (Hatcher, R.A., et al. Contraceptive Technology, 20th revised ed. New York: Ardent Media, 2011). It is important that teens know that the majority of teens are not having sex, and saying "No" is an option. But teens will need support and help in developing the skills to incorporate abstinence into their relationships.

Discussing the health risk of sexually transmitted infections (STIs) and the possibility of infertility has a strong impact. Being clear on the risks of contracting human papillomavirus with the subsequent risk of cervical cancer associated with having multiple sexual partners, as well as the risk of contracting an incurable disease such as HIV, can be very persuasive.

Discussing condoms, how they protect against sexually transmitted diseases, and the value of dual protection is also important.

With pregnancy rates lower than 1% with perfect and typical use, long-acting reversible contraceptive (LARC) methods "are the best reversible methods for preventing unintended pregnancy, rapid repeat pregnancy, and abortion in young women," according to the American College of Obstetricians and Gynecologists committee opinion No. 539, written by the Committee on Adolescent Health Care Long-Acting Reversible Contraception Working Group (Obstet. Gynecol. 2012;120:983-8). Complications of these methods – intrauterine devices (IUDs) and the contraceptive implant – are rare and are similar in adolescents and older women, yet LARCs are underused in the younger age group.

An IUD is a LARC that eliminates the need for the teen to remember to take an oral contraceptive. Mirena is one such IUD that has little to no side effects, and is easily placed and removed. It can be used to control dysmenorrhea and abnormal uterine bleeding/heavy menstrual bleeding as well.

Skyla is the newest intrauterine system on the market. Compared with Mirena, which has been available since 2000, the new system uses less levonorgestrel (14 vs. 20 mcg), has a smaller frame and inserter tube that have been shown to be less painful on insertion in nulliparous women, is associated with more abnormal bleeding, and is approved for 3 years (vs. 5 years) of use.

In the past, IUDs were discouraged because there was a fear that there was an increased risk of infection and pelvic inflammatory disease (PID) with their use. However, more recent research shows that there is only a slightly increased risk of PID at the time of insertion, and there is no increased risk of STIs or infertility associated with using IUDs. They have become increasingly popular for adolescents, and should be given as an option.

The contraceptive implant (Nexplanon), which is approved for 3 years of use, is another form of LARC.

The use of oral contraceptives is a common option, although challenging for the already-preoccupied teen. The birth control pill has a failure rate of 0.3% when used correctly, but that increases to 8% when used in its typical fashion, according to the U.S. Medical Eligibility Criteria for Contraceptive Use (MMWR 2010;59:1-88). Many parents express concerns regarding the safety of OCs because of all the media advertisements for lawsuits. The reality is they are safe. The risk of deep vein thrombosis is low in women younger than 35 years who are nonsmokers, without hypertension, and who are not obese. Starting with an ultralow dose of estrogen minimizes side effects. If a patient begins to have breakthrough bleeding, switching to a triphasic pill helps reduce those episodes.

The Minipill (a progestin-only contraceptive) and Depo-Provera (a progestogen-only injection) are options for women who cannot tolerate estrogen, but the downsides are that their use can increase acne and appetite (which can lead to weight gain). Depo-Provera use also has been shown to lead to significant bone density loss if used greater than 2 years. These contraceptives are all reasonable options for a teen who demonstrates a high level of responsibility.

A talk on contraception would not be complete without including information about emergency contraception. It is important to let teens know that if there is a risk of pregnancy, taking emergency contraception within 3-5 days can prevent them from becoming pregnant. In June 2013, the Food and Drug Administration removed the requirement for minors to have a script to receive Plan B. My Way and Next Choice still require a prescription. Other options such as ella (ulipristal acetate, available by prescription) are hormone free, have fewer side effects, and have been shown to be more effective than hormones in preventing pregnancy.

In 2012, the American Academy of Pediatrics released a policy statement on emergency contraception, which stated: "All adolescents, males and females, ... should be counseled on emergency contraception as part of routine anticipatory guidance in the context of a discussion on sexual safety and family planning regardless of current intentions of sexual behavior" (Pediatrics 2012;130:1174-82).

All of the oral emergency contraception methods are significantly less effective in obese women, and obese women are four times more likely to get pregnant despite using these methods. The copper IUD has been shown to be the most effective form of emergency contraception regardless of weight and offers continuous protection. But, it should be noted that using the copper IUD for this purpose is an off-label use in the United States.

Knowledge is power, and sharing this little bit of information can be life changing for a teen who is considering being sexually active.

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

Let’s face it, most of us when we entered into pediatrics envisioned bouncing babies, adorable toddlers, and snotty-nosed children drawing us pictures that adorned the walls of our office. Never did we imagine sitting in a room across from a stone-faced teenage girl to talk about birth control.

But, reality quickly sets in, and staying up to date with the latest recommendation on birth control is imperative or you need to make the proper referral. Knowing the laws of your state about birth control, which govern your ability to administer contraception without parental consent, is vital. The Guttmacher website gives you a concise list for each state. Parental involvement is always encouraged, but may be the obstacle that prevents the patient from having the discussion.

Abstinence is the only foolproof way to avoid pregnancy, yet many of us forget to discuss it during our conversation. With statistics like 40% of teens report to having engaged in some level of sexual activity by age 15, it is not far-fetched to believe that there are teens who just assume all of their peers are having sex (Hatcher, R.A., et al. Contraceptive Technology, 20th revised ed. New York: Ardent Media, 2011). It is important that teens know that the majority of teens are not having sex, and saying "No" is an option. But teens will need support and help in developing the skills to incorporate abstinence into their relationships.

Discussing the health risk of sexually transmitted infections (STIs) and the possibility of infertility has a strong impact. Being clear on the risks of contracting human papillomavirus with the subsequent risk of cervical cancer associated with having multiple sexual partners, as well as the risk of contracting an incurable disease such as HIV, can be very persuasive.

Discussing condoms, how they protect against sexually transmitted diseases, and the value of dual protection is also important.

With pregnancy rates lower than 1% with perfect and typical use, long-acting reversible contraceptive (LARC) methods "are the best reversible methods for preventing unintended pregnancy, rapid repeat pregnancy, and abortion in young women," according to the American College of Obstetricians and Gynecologists committee opinion No. 539, written by the Committee on Adolescent Health Care Long-Acting Reversible Contraception Working Group (Obstet. Gynecol. 2012;120:983-8). Complications of these methods – intrauterine devices (IUDs) and the contraceptive implant – are rare and are similar in adolescents and older women, yet LARCs are underused in the younger age group.

An IUD is a LARC that eliminates the need for the teen to remember to take an oral contraceptive. Mirena is one such IUD that has little to no side effects, and is easily placed and removed. It can be used to control dysmenorrhea and abnormal uterine bleeding/heavy menstrual bleeding as well.

Skyla is the newest intrauterine system on the market. Compared with Mirena, which has been available since 2000, the new system uses less levonorgestrel (14 vs. 20 mcg), has a smaller frame and inserter tube that have been shown to be less painful on insertion in nulliparous women, is associated with more abnormal bleeding, and is approved for 3 years (vs. 5 years) of use.

In the past, IUDs were discouraged because there was a fear that there was an increased risk of infection and pelvic inflammatory disease (PID) with their use. However, more recent research shows that there is only a slightly increased risk of PID at the time of insertion, and there is no increased risk of STIs or infertility associated with using IUDs. They have become increasingly popular for adolescents, and should be given as an option.

The contraceptive implant (Nexplanon), which is approved for 3 years of use, is another form of LARC.

The use of oral contraceptives is a common option, although challenging for the already-preoccupied teen. The birth control pill has a failure rate of 0.3% when used correctly, but that increases to 8% when used in its typical fashion, according to the U.S. Medical Eligibility Criteria for Contraceptive Use (MMWR 2010;59:1-88). Many parents express concerns regarding the safety of OCs because of all the media advertisements for lawsuits. The reality is they are safe. The risk of deep vein thrombosis is low in women younger than 35 years who are nonsmokers, without hypertension, and who are not obese. Starting with an ultralow dose of estrogen minimizes side effects. If a patient begins to have breakthrough bleeding, switching to a triphasic pill helps reduce those episodes.

The Minipill (a progestin-only contraceptive) and Depo-Provera (a progestogen-only injection) are options for women who cannot tolerate estrogen, but the downsides are that their use can increase acne and appetite (which can lead to weight gain). Depo-Provera use also has been shown to lead to significant bone density loss if used greater than 2 years. These contraceptives are all reasonable options for a teen who demonstrates a high level of responsibility.

A talk on contraception would not be complete without including information about emergency contraception. It is important to let teens know that if there is a risk of pregnancy, taking emergency contraception within 3-5 days can prevent them from becoming pregnant. In June 2013, the Food and Drug Administration removed the requirement for minors to have a script to receive Plan B. My Way and Next Choice still require a prescription. Other options such as ella (ulipristal acetate, available by prescription) are hormone free, have fewer side effects, and have been shown to be more effective than hormones in preventing pregnancy.

In 2012, the American Academy of Pediatrics released a policy statement on emergency contraception, which stated: "All adolescents, males and females, ... should be counseled on emergency contraception as part of routine anticipatory guidance in the context of a discussion on sexual safety and family planning regardless of current intentions of sexual behavior" (Pediatrics 2012;130:1174-82).

All of the oral emergency contraception methods are significantly less effective in obese women, and obese women are four times more likely to get pregnant despite using these methods. The copper IUD has been shown to be the most effective form of emergency contraception regardless of weight and offers continuous protection. But, it should be noted that using the copper IUD for this purpose is an off-label use in the United States.

Knowledge is power, and sharing this little bit of information can be life changing for a teen who is considering being sexually active.

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

In the dawn of the vaccines Gardasil and Cervarix, pediatricians, family physicians, and ob.gyns. are faced with the daunting task of educating parents about the sexually transmitted infection human papillomavirus.

We can all relate to the moment the words leave our mouths, and the parents are already refusing it because they are sure their children will never engage in such activities. Or they have been inundated with negative media reports that there are many side effects, and that the body will clear the human papillomavirus (HPV) infection on its own. It is understandable that there would be some hesitation to consent to a three-dose vaccine for a virus that is passed sexually for a child who most recently was more interested in dolls than the opposite sex. As well, many pediatricians are on the fence as to how important it is to give this vaccine to the 10- to 16-year-olds, so they shy away from detailed explanations, and the vaccine is declined.

Well, half of all oropharyngeal cancers are caused by HPV (Oral Oncol. 2011;47:1048-54), and the incidence of oropharyngeal cancers caused by HPV has increased from 16% in 1984-1989 to 72% in .2000-2004 (J. Clin. Oncol. 2011;29:4294-301).

Another CDC report on results of the 2006-2010 National Survey of Family Growth indicated that although the rates of vaginal intercourse were declining among teens, the rates of oral sex were escalating. In the survey of more than 6,000 teens aged 15-19 years, 41% of females admitted to performing oral sex, as did 35% of males. That number increased to more than 80% in both men and women when 20- to 26-year-olds were surveyed. (Natl. Health Stat. Report 2012;56:1-16).

The reason put forth for the increase in oral sex was that teens deemed it a "safer" way to have sex, and some even felt that it is not a form of sex and that they maintain their virginity as long as they don’t engage in vaginal intercourse. Many studies even point out that teens deem oral sex as a casual interaction and term it the new "goodnight kiss."

With this reality, as pediatricians and family physicians, we need to get very comfortable with this vaccine and be aggressive about educating families about the risk not only of cervical cancer, but vaginal, vulvar, and penile cancers, and most importantly the oral cancers. The time from infection to presentation of a tumor is usually about 10 years.

Although there are more than 100 strains of HPV and our bodies can clear most of them in 1-2 years, HPV 16/18 has been shown to be oncogenic and much harder to treat in the oropharyngeal area when compared with the cervical area. It also has been noted that the survival rate is better and there is less metastasis with HPV-associated cancers than non–HPV-associated cancers.

Current studies support that the HPV vaccines are decreasing the incidence of HPV infections (J. Inf. Dis. 2013;208:385-93). Awareness and education are key to eradication of this virus, and prevention starts in our offices.

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

In the dawn of the vaccines Gardasil and Cervarix, pediatricians, family physicians, and ob.gyns. are faced with the daunting task of educating parents about the sexually transmitted infection human papillomavirus.

We can all relate to the moment the words leave our mouths, and the parents are already refusing it because they are sure their children will never engage in such activities. Or they have been inundated with negative media reports that there are many side effects, and that the body will clear the human papillomavirus (HPV) infection on its own. It is understandable that there would be some hesitation to consent to a three-dose vaccine for a virus that is passed sexually for a child who most recently was more interested in dolls than the opposite sex. As well, many pediatricians are on the fence as to how important it is to give this vaccine to the 10- to 16-year-olds, so they shy away from detailed explanations, and the vaccine is declined.

Well, half of all oropharyngeal cancers are caused by HPV (Oral Oncol. 2011;47:1048-54), and the incidence of oropharyngeal cancers caused by HPV has increased from 16% in 1984-1989 to 72% in .2000-2004 (J. Clin. Oncol. 2011;29:4294-301).

Another CDC report on results of the 2006-2010 National Survey of Family Growth indicated that although the rates of vaginal intercourse were declining among teens, the rates of oral sex were escalating. In the survey of more than 6,000 teens aged 15-19 years, 41% of females admitted to performing oral sex, as did 35% of males. That number increased to more than 80% in both men and women when 20- to 26-year-olds were surveyed. (Natl. Health Stat. Report 2012;56:1-16).

The reason put forth for the increase in oral sex was that teens deemed it a "safer" way to have sex, and some even felt that it is not a form of sex and that they maintain their virginity as long as they don’t engage in vaginal intercourse. Many studies even point out that teens deem oral sex as a casual interaction and term it the new "goodnight kiss."

With this reality, as pediatricians and family physicians, we need to get very comfortable with this vaccine and be aggressive about educating families about the risk not only of cervical cancer, but vaginal, vulvar, and penile cancers, and most importantly the oral cancers. The time from infection to presentation of a tumor is usually about 10 years.

Although there are more than 100 strains of HPV and our bodies can clear most of them in 1-2 years, HPV 16/18 has been shown to be oncogenic and much harder to treat in the oropharyngeal area when compared with the cervical area. It also has been noted that the survival rate is better and there is less metastasis with HPV-associated cancers than non–HPV-associated cancers.

Current studies support that the HPV vaccines are decreasing the incidence of HPV infections (J. Inf. Dis. 2013;208:385-93). Awareness and education are key to eradication of this virus, and prevention starts in our offices.

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

In the dawn of the vaccines Gardasil and Cervarix, pediatricians, family physicians, and ob.gyns. are faced with the daunting task of educating parents about the sexually transmitted infection human papillomavirus.

We can all relate to the moment the words leave our mouths, and the parents are already refusing it because they are sure their children will never engage in such activities. Or they have been inundated with negative media reports that there are many side effects, and that the body will clear the human papillomavirus (HPV) infection on its own. It is understandable that there would be some hesitation to consent to a three-dose vaccine for a virus that is passed sexually for a child who most recently was more interested in dolls than the opposite sex. As well, many pediatricians are on the fence as to how important it is to give this vaccine to the 10- to 16-year-olds, so they shy away from detailed explanations, and the vaccine is declined.

Well, half of all oropharyngeal cancers are caused by HPV (Oral Oncol. 2011;47:1048-54), and the incidence of oropharyngeal cancers caused by HPV has increased from 16% in 1984-1989 to 72% in .2000-2004 (J. Clin. Oncol. 2011;29:4294-301).

Another CDC report on results of the 2006-2010 National Survey of Family Growth indicated that although the rates of vaginal intercourse were declining among teens, the rates of oral sex were escalating. In the survey of more than 6,000 teens aged 15-19 years, 41% of females admitted to performing oral sex, as did 35% of males. That number increased to more than 80% in both men and women when 20- to 26-year-olds were surveyed. (Natl. Health Stat. Report 2012;56:1-16).

The reason put forth for the increase in oral sex was that teens deemed it a "safer" way to have sex, and some even felt that it is not a form of sex and that they maintain their virginity as long as they don’t engage in vaginal intercourse. Many studies even point out that teens deem oral sex as a casual interaction and term it the new "goodnight kiss."

With this reality, as pediatricians and family physicians, we need to get very comfortable with this vaccine and be aggressive about educating families about the risk not only of cervical cancer, but vaginal, vulvar, and penile cancers, and most importantly the oral cancers. The time from infection to presentation of a tumor is usually about 10 years.

Although there are more than 100 strains of HPV and our bodies can clear most of them in 1-2 years, HPV 16/18 has been shown to be oncogenic and much harder to treat in the oropharyngeal area when compared with the cervical area. It also has been noted that the survival rate is better and there is less metastasis with HPV-associated cancers than non–HPV-associated cancers.

Current studies support that the HPV vaccines are decreasing the incidence of HPV infections (J. Inf. Dis. 2013;208:385-93). Awareness and education are key to eradication of this virus, and prevention starts in our offices.

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

One thing that is consistent for all teenage boys is that no one is talking about what going on "down there!" As young men approach adolescence, the thought of a conversation regarding their testicles is almost ludicrous. Certainly they will not talk to their parents, and the doctor also is likely to get the silent treatment when questioning if they have any concerns regarding their "private parts." One study, however, showed that testicular cancer is on the rise, particularly in the industrialized nations (J. Urol. 2003;170:5-11).

Testicular cancer is rare, accounting for only 1% of all male cancers, but it is the most common cancer for males aged 15-35 years (CA Cancer J. Clin. 2013;63:11-30). Every year there are about 8,300 men diagnosed with testicular cancer, approximately 350 of whom will die (CA Cancer J. Clin. 2011;61:212-36).

Risk factors for testicular cancer are history of undescended testes, family history, and history of contralateral testicular cancer. A screening test has not been found to be beneficial, given the low incidence and high cure rate.

Testicular cancer is very treatable when caught early, with nearly a 90% cure rate with radical orchiectomy and continued surveillance with radiation and or single-agent chemotherapy. When it is not caught early and metastasis has occurred that number decreases to 70% (Eur. J. Cancer 2006;42:820-6).

Testicular cancer is painless, presenting as a lump on the testicle. The testicle may enlarge, feel heavy, or become hard, so it’s not hard to imagine how this can easily be overlooked without regular self-exams.

With this cancer being on the rise, it is imperative that pediatricians educate young men about their risk and teach them how to do self-examinations. Also, using sports physicals and annual wellness exams to do an inspection will aid in early diagnosis, so that even subtle changes can be identified.

We have become very comfortable in educating women that monthly breast exams are important. Testicular exams also are important, and education is the first step in preventing advanced testicular disease.

One thing that is consistent for all teenage boys is that no one is talking about what going on "down there!" As young men approach adolescence, the thought of a conversation regarding their testicles is almost ludicrous. Certainly they will not talk to their parents, and the doctor also is likely to get the silent treatment when questioning if they have any concerns regarding their "private parts." One study, however, showed that testicular cancer is on the rise, particularly in the industrialized nations (J. Urol. 2003;170:5-11).

Testicular cancer is rare, accounting for only 1% of all male cancers, but it is the most common cancer for males aged 15-35 years (CA Cancer J. Clin. 2013;63:11-30). Every year there are about 8,300 men diagnosed with testicular cancer, approximately 350 of whom will die (CA Cancer J. Clin. 2011;61:212-36).

Risk factors for testicular cancer are history of undescended testes, family history, and history of contralateral testicular cancer. A screening test has not been found to be beneficial, given the low incidence and high cure rate.

Testicular cancer is very treatable when caught early, with nearly a 90% cure rate with radical orchiectomy and continued surveillance with radiation and or single-agent chemotherapy. When it is not caught early and metastasis has occurred that number decreases to 70% (Eur. J. Cancer 2006;42:820-6).

Testicular cancer is painless, presenting as a lump on the testicle. The testicle may enlarge, feel heavy, or become hard, so it’s not hard to imagine how this can easily be overlooked without regular self-exams.

With this cancer being on the rise, it is imperative that pediatricians educate young men about their risk and teach them how to do self-examinations. Also, using sports physicals and annual wellness exams to do an inspection will aid in early diagnosis, so that even subtle changes can be identified.

We have become very comfortable in educating women that monthly breast exams are important. Testicular exams also are important, and education is the first step in preventing advanced testicular disease.

One thing that is consistent for all teenage boys is that no one is talking about what going on "down there!" As young men approach adolescence, the thought of a conversation regarding their testicles is almost ludicrous. Certainly they will not talk to their parents, and the doctor also is likely to get the silent treatment when questioning if they have any concerns regarding their "private parts." One study, however, showed that testicular cancer is on the rise, particularly in the industrialized nations (J. Urol. 2003;170:5-11).

Testicular cancer is rare, accounting for only 1% of all male cancers, but it is the most common cancer for males aged 15-35 years (CA Cancer J. Clin. 2013;63:11-30). Every year there are about 8,300 men diagnosed with testicular cancer, approximately 350 of whom will die (CA Cancer J. Clin. 2011;61:212-36).

Risk factors for testicular cancer are history of undescended testes, family history, and history of contralateral testicular cancer. A screening test has not been found to be beneficial, given the low incidence and high cure rate.

Testicular cancer is very treatable when caught early, with nearly a 90% cure rate with radical orchiectomy and continued surveillance with radiation and or single-agent chemotherapy. When it is not caught early and metastasis has occurred that number decreases to 70% (Eur. J. Cancer 2006;42:820-6).

Testicular cancer is painless, presenting as a lump on the testicle. The testicle may enlarge, feel heavy, or become hard, so it’s not hard to imagine how this can easily be overlooked without regular self-exams.

With this cancer being on the rise, it is imperative that pediatricians educate young men about their risk and teach them how to do self-examinations. Also, using sports physicals and annual wellness exams to do an inspection will aid in early diagnosis, so that even subtle changes can be identified.

We have become very comfortable in educating women that monthly breast exams are important. Testicular exams also are important, and education is the first step in preventing advanced testicular disease.