North Pacific Pediatric Society (NPPS): Scientific Conference

BELLEVUE, WASH. – Dr. Claudia M. Gold spent 17 years in general and behavioral pediatrics being frustrated time and again by a familiar cycle: A parent would ask for help with a child’s problematic behavior, Dr. Gold’s "bag of behavioral tricks" wouldn’t help, the parent would begin to speak in increasingly negative terms about the child, and Dr. Gold would feel increasingly negative about the parent.

At a loss, she would recommend that the parent take the child to a therapist, the parent usually would not, and eventually the child would end up with a psychiatric diagnosis and on medication. Those years paralleled an explosion in diagnoses of pediatric bipolar disorder in the United States and the use of atypical antipsychotics in children with explosive behavior.

Sherry Boschert/IMNG Medical Media

Then Dr. Gold took classes to learn more about infant mental health and attachment theory. She incorporated an emphasis on reflective relationships in her work, which "transformed my practice. Suddenly children were getting better. Amazing things were happening," said Dr. Gold, director of the Early Childhood Social Emotional Health Program at Newton-Wellesley Hospital, Newton, Mass.

The key to this change was implementing principles of reflective functioning, also known as "mentalization," which Dr. Gold calls "holding the child in mind." She and other speakers at a conference sponsored by the North Pacific Pediatric Society said that applying these principles to the pediatrician-parent relationship, and helping parents use them in the parent-child relationship, makes all the difference.

"Behavior problems" are problems of self-regulation of intense emotion, and self-regulation develops through coregulation in relationships with primary caregivers, Dr. Gold explained.

She starts by helping the parent reflect on the meaning of the child’s behavior, the child’s wants and needs, instead of just focusing on the behavior itself. "Even for a moment, reflect on the child’s experience. The child feels that, and calms down or begins to calm down. Parents begin to feel better," she said.

Dr. Gold outlined four essential components of reflective functioning in her book, "Keeping Your Child in Mind: Overcoming Defiance, Tantrums, and Other Everyday Behavior Problems by Seeing the World Through Your Child’s Eyes" (Boston: Da Capo Press, 2011):

1. Curiosity about the meaning of behavior. This means considering the thoughts and feelings driving a child’s behavior.

2. Empathy. This means reframing "difficult" behavior as "stressed" behavior.

3. Containing and regulating the child’s experience. This step can involve setting limits.

4. Self-regulation. This step involves the parent or pediatrician managing their own feelings.

When the pediatrician uses these same principles to reflect on the parent’s experience, that supports the parent’s efforts to reflect on the child’s experience, Paula D. Zeanah, Ph.D., said in a separate presentation.

Just as infants and young children in distress rely on the parental relationship, the pediatrician is "functioning as that go-to figure when the parent is in distress," said Dr. Zeanah, professor of clinical psychiatry at Tulane University and interim chief of pediatrics at Tulane Hospital for Children, both in New Orleans.

And just as a child’s behavior can trigger emotions and frustrations in the parent, the parent’s actions do the same for pediatricians. "We don’t spend enough time reflecting on how parents make us feel," she said.

Studies have shown that patients often provide clues to aspects of their inner lives that primary clinicians usually don’t recognize or acknowledge, missing opportunities for empathy and personal connection that are key to building the physician-patient relationship.

Dr. Zeanah recommended "really basic stuff that seems to make a difference," such as active listening, fewer interruptions, sitting so you’re face-to-face and making eye contact, and tailoring short-term and long-term goals according to the child’s and family’s needs.

Ask open-ended questions: "Is this what you expected?" of parenting. About social support: "Who helps you with the baby?" About mood: "Being a new parent can be exhausting. How are you doing?" About work: "How much time off do you have from work for the new baby?" About behavior: "What upsets you most about your baby?"

Notice parent-infant interactions and support parents by acknowledging the relationship. Especially during times of distress, say something supportive like, "Your baby turns to you when he’s upset."

Dr. Nancy Thordarson, codirector of the meeting, used to follow a typical pediatrician’s impulse to show parents how to calm a child and be a better parent. Things have really shifted for the better in her practice since she started pointing out the relationship to parents with comments like, "I notice he turns to you for comfort when he’s stressed. He looks to you for support. Your relationship is helping him grow his brain."

Sometimes those simple sentences move a parent to tears, said Dr. Thordarson, a pediatrician in Marysville, Wash.

She teaches parents to first calm themselves, then calm the child. "Notice your feelings, take a breath," then try some specific suggestion for the particular behavior, she said. "Once they get that, you often don’t need to show them, ‘This is how you do it.’ "

Dr. Thordarson and other meeting organizers said interest is growing in promoting first relationships and reflective functioning. "We’re really hoping this will catch fire," she said.

Dr. Gold added that the 2013 meeting of the American Academy of Pediatrics will feature an emphasis on infant mental health.

The speakers reported having no financial disclosures.

BELLEVUE, WASH. – Dr. Claudia M. Gold spent 17 years in general and behavioral pediatrics being frustrated time and again by a familiar cycle: A parent would ask for help with a child’s problematic behavior, Dr. Gold’s "bag of behavioral tricks" wouldn’t help, the parent would begin to speak in increasingly negative terms about the child, and Dr. Gold would feel increasingly negative about the parent.

At a loss, she would recommend that the parent take the child to a therapist, the parent usually would not, and eventually the child would end up with a psychiatric diagnosis and on medication. Those years paralleled an explosion in diagnoses of pediatric bipolar disorder in the United States and the use of atypical antipsychotics in children with explosive behavior.

Sherry Boschert/IMNG Medical Media

Then Dr. Gold took classes to learn more about infant mental health and attachment theory. She incorporated an emphasis on reflective relationships in her work, which "transformed my practice. Suddenly children were getting better. Amazing things were happening," said Dr. Gold, director of the Early Childhood Social Emotional Health Program at Newton-Wellesley Hospital, Newton, Mass.

The key to this change was implementing principles of reflective functioning, also known as "mentalization," which Dr. Gold calls "holding the child in mind." She and other speakers at a conference sponsored by the North Pacific Pediatric Society said that applying these principles to the pediatrician-parent relationship, and helping parents use them in the parent-child relationship, makes all the difference.

"Behavior problems" are problems of self-regulation of intense emotion, and self-regulation develops through coregulation in relationships with primary caregivers, Dr. Gold explained.

She starts by helping the parent reflect on the meaning of the child’s behavior, the child’s wants and needs, instead of just focusing on the behavior itself. "Even for a moment, reflect on the child’s experience. The child feels that, and calms down or begins to calm down. Parents begin to feel better," she said.

Dr. Gold outlined four essential components of reflective functioning in her book, "Keeping Your Child in Mind: Overcoming Defiance, Tantrums, and Other Everyday Behavior Problems by Seeing the World Through Your Child’s Eyes" (Boston: Da Capo Press, 2011):

1. Curiosity about the meaning of behavior. This means considering the thoughts and feelings driving a child’s behavior.

2. Empathy. This means reframing "difficult" behavior as "stressed" behavior.

3. Containing and regulating the child’s experience. This step can involve setting limits.

4. Self-regulation. This step involves the parent or pediatrician managing their own feelings.

When the pediatrician uses these same principles to reflect on the parent’s experience, that supports the parent’s efforts to reflect on the child’s experience, Paula D. Zeanah, Ph.D., said in a separate presentation.

Just as infants and young children in distress rely on the parental relationship, the pediatrician is "functioning as that go-to figure when the parent is in distress," said Dr. Zeanah, professor of clinical psychiatry at Tulane University and interim chief of pediatrics at Tulane Hospital for Children, both in New Orleans.

And just as a child’s behavior can trigger emotions and frustrations in the parent, the parent’s actions do the same for pediatricians. "We don’t spend enough time reflecting on how parents make us feel," she said.

Studies have shown that patients often provide clues to aspects of their inner lives that primary clinicians usually don’t recognize or acknowledge, missing opportunities for empathy and personal connection that are key to building the physician-patient relationship.

Dr. Zeanah recommended "really basic stuff that seems to make a difference," such as active listening, fewer interruptions, sitting so you’re face-to-face and making eye contact, and tailoring short-term and long-term goals according to the child’s and family’s needs.

Ask open-ended questions: "Is this what you expected?" of parenting. About social support: "Who helps you with the baby?" About mood: "Being a new parent can be exhausting. How are you doing?" About work: "How much time off do you have from work for the new baby?" About behavior: "What upsets you most about your baby?"

Notice parent-infant interactions and support parents by acknowledging the relationship. Especially during times of distress, say something supportive like, "Your baby turns to you when he’s upset."

Dr. Nancy Thordarson, codirector of the meeting, used to follow a typical pediatrician’s impulse to show parents how to calm a child and be a better parent. Things have really shifted for the better in her practice since she started pointing out the relationship to parents with comments like, "I notice he turns to you for comfort when he’s stressed. He looks to you for support. Your relationship is helping him grow his brain."

Sometimes those simple sentences move a parent to tears, said Dr. Thordarson, a pediatrician in Marysville, Wash.

She teaches parents to first calm themselves, then calm the child. "Notice your feelings, take a breath," then try some specific suggestion for the particular behavior, she said. "Once they get that, you often don’t need to show them, ‘This is how you do it.’ "

Dr. Thordarson and other meeting organizers said interest is growing in promoting first relationships and reflective functioning. "We’re really hoping this will catch fire," she said.

Dr. Gold added that the 2013 meeting of the American Academy of Pediatrics will feature an emphasis on infant mental health.

The speakers reported having no financial disclosures.

BELLEVUE, WASH. – Dr. Claudia M. Gold spent 17 years in general and behavioral pediatrics being frustrated time and again by a familiar cycle: A parent would ask for help with a child’s problematic behavior, Dr. Gold’s "bag of behavioral tricks" wouldn’t help, the parent would begin to speak in increasingly negative terms about the child, and Dr. Gold would feel increasingly negative about the parent.

At a loss, she would recommend that the parent take the child to a therapist, the parent usually would not, and eventually the child would end up with a psychiatric diagnosis and on medication. Those years paralleled an explosion in diagnoses of pediatric bipolar disorder in the United States and the use of atypical antipsychotics in children with explosive behavior.

Sherry Boschert/IMNG Medical Media

Then Dr. Gold took classes to learn more about infant mental health and attachment theory. She incorporated an emphasis on reflective relationships in her work, which "transformed my practice. Suddenly children were getting better. Amazing things were happening," said Dr. Gold, director of the Early Childhood Social Emotional Health Program at Newton-Wellesley Hospital, Newton, Mass.

The key to this change was implementing principles of reflective functioning, also known as "mentalization," which Dr. Gold calls "holding the child in mind." She and other speakers at a conference sponsored by the North Pacific Pediatric Society said that applying these principles to the pediatrician-parent relationship, and helping parents use them in the parent-child relationship, makes all the difference.

"Behavior problems" are problems of self-regulation of intense emotion, and self-regulation develops through coregulation in relationships with primary caregivers, Dr. Gold explained.

She starts by helping the parent reflect on the meaning of the child’s behavior, the child’s wants and needs, instead of just focusing on the behavior itself. "Even for a moment, reflect on the child’s experience. The child feels that, and calms down or begins to calm down. Parents begin to feel better," she said.

Dr. Gold outlined four essential components of reflective functioning in her book, "Keeping Your Child in Mind: Overcoming Defiance, Tantrums, and Other Everyday Behavior Problems by Seeing the World Through Your Child’s Eyes" (Boston: Da Capo Press, 2011):

1. Curiosity about the meaning of behavior. This means considering the thoughts and feelings driving a child’s behavior.

2. Empathy. This means reframing "difficult" behavior as "stressed" behavior.

3. Containing and regulating the child’s experience. This step can involve setting limits.

4. Self-regulation. This step involves the parent or pediatrician managing their own feelings.

When the pediatrician uses these same principles to reflect on the parent’s experience, that supports the parent’s efforts to reflect on the child’s experience, Paula D. Zeanah, Ph.D., said in a separate presentation.

Just as infants and young children in distress rely on the parental relationship, the pediatrician is "functioning as that go-to figure when the parent is in distress," said Dr. Zeanah, professor of clinical psychiatry at Tulane University and interim chief of pediatrics at Tulane Hospital for Children, both in New Orleans.

And just as a child’s behavior can trigger emotions and frustrations in the parent, the parent’s actions do the same for pediatricians. "We don’t spend enough time reflecting on how parents make us feel," she said.

Studies have shown that patients often provide clues to aspects of their inner lives that primary clinicians usually don’t recognize or acknowledge, missing opportunities for empathy and personal connection that are key to building the physician-patient relationship.

Dr. Zeanah recommended "really basic stuff that seems to make a difference," such as active listening, fewer interruptions, sitting so you’re face-to-face and making eye contact, and tailoring short-term and long-term goals according to the child’s and family’s needs.

Ask open-ended questions: "Is this what you expected?" of parenting. About social support: "Who helps you with the baby?" About mood: "Being a new parent can be exhausting. How are you doing?" About work: "How much time off do you have from work for the new baby?" About behavior: "What upsets you most about your baby?"

Notice parent-infant interactions and support parents by acknowledging the relationship. Especially during times of distress, say something supportive like, "Your baby turns to you when he’s upset."

Dr. Nancy Thordarson, codirector of the meeting, used to follow a typical pediatrician’s impulse to show parents how to calm a child and be a better parent. Things have really shifted for the better in her practice since she started pointing out the relationship to parents with comments like, "I notice he turns to you for comfort when he’s stressed. He looks to you for support. Your relationship is helping him grow his brain."

Sometimes those simple sentences move a parent to tears, said Dr. Thordarson, a pediatrician in Marysville, Wash.

She teaches parents to first calm themselves, then calm the child. "Notice your feelings, take a breath," then try some specific suggestion for the particular behavior, she said. "Once they get that, you often don’t need to show them, ‘This is how you do it.’ "

Dr. Thordarson and other meeting organizers said interest is growing in promoting first relationships and reflective functioning. "We’re really hoping this will catch fire," she said.

Dr. Gold added that the 2013 meeting of the American Academy of Pediatrics will feature an emphasis on infant mental health.

The speakers reported having no financial disclosures.

BELLEVUE, WASH. – There’s no evidence that asking about an eating disorder will cause one, so busy clinicians should ask a few key questions to zero in quickly on adolescents who may have an eating disorder, one expert said.

General questions start with asking the teen what his or her maximum and minimum weights have been, and what their desired weight is, Dr. Cora C. Breuner said at the conference, which was sponsored by the North Pacific Pediatric Society.

Ask adolescents if they eat with their families (not counting eating fast food in a car). A family that doesn’t eat together at least three to five times per week is a red flag, said Dr. Breuner, professor of pediatrics and adolescent medicine at the University of Washington, Seattle.

Ask teenagers if there are any foods that they or their families consider "off limits," and whether any friends or family members have abnormal eating behaviors. Does the teen think he or she should be dieting?

Some useful questions come in pairs, Dr. Breuner said. Follow "How much do you exercise?" with "How do you feel if you can’t exercise?" If "Do you ever eat more than feels comfortable to you?" elicits a positive response, be sure to ask, "What do you do if you do that?"

Ask the adolescent to describe a typical day’s eating routine, and whether "energy drinks" are part of that. "Sadly, many don’t eat breakfast," she said.

To quickly identify physical symptoms of anorexia, ask the adolescent about amenorrhea, cold hands or feet, headaches, fainting or dizziness, and dry skin. Also query they about hair loss when brushing hair, or finding hair on the pillow in the morning.

Ask also about constipation. "Many kids don’t know what this means," Dr. Breuner said. Inquire if they have lost appetite and don’t get enough to eat.

To hone in on mental symptoms of eating disorders, ask about difficulty making decisions and about poor concentration – does it take longer to finish a test than it used to? A big symptom with teenagers is irritability: "Are you snapping at your friends?" Dr. Breuner suggests asking.

Inquire about depression and social withdrawal, which can be symptoms of eating disorders, as well as obsessiveness about food, guilt, or anxiety.

Some 50%-75% of adolescents with eating disorders have comorbid depression. With anorexia, more than 60% have comorbid anxiety, and more than 40% have comorbid obsessive-compulsive disorder (OCD).

"I think eating-disordered kids are anxious first, then find they’re less anxious if they don’t eat. We need to give them something else for the anxiety" or for the OCD, to replace the harmful don’t-eat strategy, she said.

Substance abuse also can be a red flag. Among patients with bulimia, 30%-37% also have substance abuse, studies suggest. Among the approximately half of patients with anorexia who will develop bulimia, 40% develop substance abuse, she said.

If the answers to these questions raise suspicion of an eating disorder, refer the patient for evaluation or look for clinical signs of eating disorders in your physical exam.

Physical signs of anorexia include hypothermia, acrocyanosis, resting bradycardia, hypotension, orthostatic blood pressure and pulse, and loss of muscle mass.

"A lot of times what I bill for is what I find on the physical exam" because coding the bill for an eating disorder slots the case into mental-health categories with lower reimbursements, Dr. Breuner said. "This is a medical problem, not just a mental problem."

Physical signs of binge eating include weight gain, bloating, fullness, lethargy, and salivary gland enlargement. Mental signs include guilt, depression, and anxiety.

Physical signs of vomiting or laxative abuse include weight loss, electrolyte disturbance, hypokalemia, hypochloremic metabolic alkalosis, dental enamel erosion, hypovolemia, or knuckle calluses. Mental signs include guilt, depression, anxiety, or confusion.

Dr. Breuner reported having no relevant financial disclosures.

BELLEVUE, WASH. – There’s no evidence that asking about an eating disorder will cause one, so busy clinicians should ask a few key questions to zero in quickly on adolescents who may have an eating disorder, one expert said.

General questions start with asking the teen what his or her maximum and minimum weights have been, and what their desired weight is, Dr. Cora C. Breuner said at the conference, which was sponsored by the North Pacific Pediatric Society.

Ask adolescents if they eat with their families (not counting eating fast food in a car). A family that doesn’t eat together at least three to five times per week is a red flag, said Dr. Breuner, professor of pediatrics and adolescent medicine at the University of Washington, Seattle.

Ask teenagers if there are any foods that they or their families consider "off limits," and whether any friends or family members have abnormal eating behaviors. Does the teen think he or she should be dieting?

Some useful questions come in pairs, Dr. Breuner said. Follow "How much do you exercise?" with "How do you feel if you can’t exercise?" If "Do you ever eat more than feels comfortable to you?" elicits a positive response, be sure to ask, "What do you do if you do that?"

Ask the adolescent to describe a typical day’s eating routine, and whether "energy drinks" are part of that. "Sadly, many don’t eat breakfast," she said.

To quickly identify physical symptoms of anorexia, ask the adolescent about amenorrhea, cold hands or feet, headaches, fainting or dizziness, and dry skin. Also query they about hair loss when brushing hair, or finding hair on the pillow in the morning.

Ask also about constipation. "Many kids don’t know what this means," Dr. Breuner said. Inquire if they have lost appetite and don’t get enough to eat.

To hone in on mental symptoms of eating disorders, ask about difficulty making decisions and about poor concentration – does it take longer to finish a test than it used to? A big symptom with teenagers is irritability: "Are you snapping at your friends?" Dr. Breuner suggests asking.

Inquire about depression and social withdrawal, which can be symptoms of eating disorders, as well as obsessiveness about food, guilt, or anxiety.

Some 50%-75% of adolescents with eating disorders have comorbid depression. With anorexia, more than 60% have comorbid anxiety, and more than 40% have comorbid obsessive-compulsive disorder (OCD).

"I think eating-disordered kids are anxious first, then find they’re less anxious if they don’t eat. We need to give them something else for the anxiety" or for the OCD, to replace the harmful don’t-eat strategy, she said.

Substance abuse also can be a red flag. Among patients with bulimia, 30%-37% also have substance abuse, studies suggest. Among the approximately half of patients with anorexia who will develop bulimia, 40% develop substance abuse, she said.

If the answers to these questions raise suspicion of an eating disorder, refer the patient for evaluation or look for clinical signs of eating disorders in your physical exam.

Physical signs of anorexia include hypothermia, acrocyanosis, resting bradycardia, hypotension, orthostatic blood pressure and pulse, and loss of muscle mass.

"A lot of times what I bill for is what I find on the physical exam" because coding the bill for an eating disorder slots the case into mental-health categories with lower reimbursements, Dr. Breuner said. "This is a medical problem, not just a mental problem."

Physical signs of binge eating include weight gain, bloating, fullness, lethargy, and salivary gland enlargement. Mental signs include guilt, depression, and anxiety.

Physical signs of vomiting or laxative abuse include weight loss, electrolyte disturbance, hypokalemia, hypochloremic metabolic alkalosis, dental enamel erosion, hypovolemia, or knuckle calluses. Mental signs include guilt, depression, anxiety, or confusion.

Dr. Breuner reported having no relevant financial disclosures.

BELLEVUE, WASH. – There’s no evidence that asking about an eating disorder will cause one, so busy clinicians should ask a few key questions to zero in quickly on adolescents who may have an eating disorder, one expert said.

General questions start with asking the teen what his or her maximum and minimum weights have been, and what their desired weight is, Dr. Cora C. Breuner said at the conference, which was sponsored by the North Pacific Pediatric Society.

Ask adolescents if they eat with their families (not counting eating fast food in a car). A family that doesn’t eat together at least three to five times per week is a red flag, said Dr. Breuner, professor of pediatrics and adolescent medicine at the University of Washington, Seattle.

Ask teenagers if there are any foods that they or their families consider "off limits," and whether any friends or family members have abnormal eating behaviors. Does the teen think he or she should be dieting?

Some useful questions come in pairs, Dr. Breuner said. Follow "How much do you exercise?" with "How do you feel if you can’t exercise?" If "Do you ever eat more than feels comfortable to you?" elicits a positive response, be sure to ask, "What do you do if you do that?"

Ask the adolescent to describe a typical day’s eating routine, and whether "energy drinks" are part of that. "Sadly, many don’t eat breakfast," she said.

To quickly identify physical symptoms of anorexia, ask the adolescent about amenorrhea, cold hands or feet, headaches, fainting or dizziness, and dry skin. Also query they about hair loss when brushing hair, or finding hair on the pillow in the morning.

Ask also about constipation. "Many kids don’t know what this means," Dr. Breuner said. Inquire if they have lost appetite and don’t get enough to eat.

To hone in on mental symptoms of eating disorders, ask about difficulty making decisions and about poor concentration – does it take longer to finish a test than it used to? A big symptom with teenagers is irritability: "Are you snapping at your friends?" Dr. Breuner suggests asking.

Inquire about depression and social withdrawal, which can be symptoms of eating disorders, as well as obsessiveness about food, guilt, or anxiety.

Some 50%-75% of adolescents with eating disorders have comorbid depression. With anorexia, more than 60% have comorbid anxiety, and more than 40% have comorbid obsessive-compulsive disorder (OCD).

"I think eating-disordered kids are anxious first, then find they’re less anxious if they don’t eat. We need to give them something else for the anxiety" or for the OCD, to replace the harmful don’t-eat strategy, she said.

Substance abuse also can be a red flag. Among patients with bulimia, 30%-37% also have substance abuse, studies suggest. Among the approximately half of patients with anorexia who will develop bulimia, 40% develop substance abuse, she said.

If the answers to these questions raise suspicion of an eating disorder, refer the patient for evaluation or look for clinical signs of eating disorders in your physical exam.

Physical signs of anorexia include hypothermia, acrocyanosis, resting bradycardia, hypotension, orthostatic blood pressure and pulse, and loss of muscle mass.

"A lot of times what I bill for is what I find on the physical exam" because coding the bill for an eating disorder slots the case into mental-health categories with lower reimbursements, Dr. Breuner said. "This is a medical problem, not just a mental problem."

Physical signs of binge eating include weight gain, bloating, fullness, lethargy, and salivary gland enlargement. Mental signs include guilt, depression, and anxiety.

Physical signs of vomiting or laxative abuse include weight loss, electrolyte disturbance, hypokalemia, hypochloremic metabolic alkalosis, dental enamel erosion, hypovolemia, or knuckle calluses. Mental signs include guilt, depression, anxiety, or confusion.

Dr. Breuner reported having no relevant financial disclosures.

BELLEVUE, WASH. – If a child has had abdominal pain for 4-6 weeks without constipation, it’s almost always functional abdominal pain.

That "somewhat bold thesis" explains nearly all childhood abdominal pain, Dr. Tyler Burpee said at the annual meeting of the North Pacific Pediatric Society.

Functional GI disorders, although frequently misdiagnosed, account for 2%-4% of general pediatric visits and more than half of consultations with pediatric gastroenterologists. These patients are suffering, and have lower quality-of-life scores compared with patients who have asthma or migraines, studies have shown.

When patients with functional GI disorders don’t meet criteria for functional dyspepsia, irritable bowel syndrome, or abdominal migraine, they fall into the catch-all diagnostic subcategory of functional abdominal pain, the most common type in children. Diagnostic criteria include continuous or episodic abdominal pain occurring at least weekly for at least 2 months with no evidence of an inflammatory, anatomical, metabolic, or neoplastic process that explains the symptoms.

When parents (and even some physicians) hear the diagnosis of functional abdominal pain, they commonly misinterpret it to mean, "It’s all in your head," said Dr. Burpee, a pediatric gastroenterologist at St. Luke’s Children’s Hospital, Boise, Idaho.

He explains to parents and the child that the transmission of pain from the gut to the brain is incredibly complex, with more nerves in the gut than in the brain or the spinal cord. Functional abdominal pain "means that there’s not something we can see, like an ulcer, but there’s something abnormal happening in the gut," he said.

There’s no cookie-cutter work-up for these patients because their symptoms and characteristics vary so widely, he said. Physicians often order an ultrasound of the abdomen or pelvis, but there’s no evidence that this is helpful in diagnosing functional abdominal pain. The predictive value of blood tests has not been well studied.

Esophagogastroduodenoscopy (EGD) should not be ordered unless the patient exhibits "alarm symptoms," Dr. Burpee said, which can include involuntary weight loss or growth failure, dysphagia, frequent vomiting, chronic and severe diarrhea, nocturnal symptoms (especially bowel movements), persistent right upper quadrant or right lower quadrant pain, or rectal bleeding without constipation. A recent study of 301 patients found that negative EGD results do not improve outcomes with functional GI disorders (Clin. Pediatr. 2011;50:396-401).

There are many useful treatments for functional abdominal pain in children, but antibiotics probably are not on that list. "I don’t think antibiotics are ready for prime time," he said.

Cognitive-behavioral therapy (CBT) and hypnotherapy have the most positive evidence behind them, but other helpful treatments may include peppermint oil, probiotics, the alteration of parenting techniques, and possibly tricyclic antidepressants, placebo pills, or biofeedback.

Parents who tried to distract their child’s attention from abdominal pain made the child feel better than did parents who offered solicitous attention ("Where is the pain? How much does it hurt?") in a prospective study of 223 children with and without functional abdominal pain. In fact, children’s symptom complaints nearly doubled under conditions of parent attention, and were reduced by half under conditions of parent distraction. However, parents in the study feared that the distraction strategy would do more harm than giving attention (Pain 2006;122:43-52).

A separate study of CBT randomized 200 children with functional abdominal pain and their parents to three sessions of either education (the control group) or CBT for training in relaxation, modifying responses to illness/wellness, and altering dysfunctional thoughts about symptoms. Decreases in pain and GI symptoms were significantly greater in the CBT group during 6 months of follow-up. Parents in the CBT group were significantly more likely to decrease their solicitous responses to the child’s symptoms (Am. J. Gastroenterol. 2010;105:946-56).

Hypnotherapy appeared to be astoundingly successful in a study that randomized 51 patients to standard medical therapy or six 50-minute sessions of gut-directed hypnotherapy over a 3-month period. Decreases in the frequency and intensity of abdominal pain were significantly greater in the hypnotherapy group. Rates of clinical remission (defined as at least an 80% decrease in pain intensity and frequency scores) were 25% in the control group and 85% with hypnotherapy – which is "incredible success" in functional abdominal pain, Dr. Burpee said.

The caveat is that the study used one very experienced hypnotherapist, but Seattle Children’s Hospital has begun treating functional abdominal pain and Dr. Burpee has worked with several individual hypnotherapists, both with "incredible success," he said. Hypnotherapy is safe, he added.

Another benign therapy showing promise is peppermint oil. A 2-week period of treatment decreased pain severity by 19% in patients who were randomized to placebo, and by 75% in patients randomized to take enteric-coated peppermint oil capsules (0.2 mL) three times per day, a study of 42 children with irritable bowel syndrome found (J. Pediatr. 2001;138:125-8). The study has limitations, but "it’s a good proof of concept" that also may apply to functional abdominal pain, Dr. Burpee said.

An 8-week period of probiotic therapy with Lactobacillus GG significantly reduced the frequency and severity of abdominal pain, with no significant effects from placebo, in a randomized study of 141 children with irritable bowel syndrome or functional abdominal pain. Benefits persisted for another 8 weeks of follow-up (Pediatrics 2010;126:e1445-52).

There is excellent evidence supporting biofeedback treatment for chronic headaches, and although there are no data for treating abdominal pain, biofeedback seems to work, Dr. Burpee said.

Both amitriptyline and placebo significantly relieved pain and produced a sense of improvement in a 4-week randomized study of 83 children with functional GI disorders. Results did not differ significantly between groups, however, which led the investigators to conclude that both the tricyclic antidepressant and placebo were effective (Gastroenterology 2009;137:1261-9).

"I think most of the things we do with fiber etc. are placebo," Dr. Burpee said. Amitriptyline might be a good choice in a child who has a lot of anxiety around functional abdominal pain, he suggested.

In the latest and probably largest study of antibiotics to treat functional abdominal pain, 1,260 patients were randomized to rifaximin (55 mg three times a day) or placebo for 2 weeks. The proportions of patients who reported relief from pain for at least 2 of the 4 weeks following the start of treatment were 40% with rifaximin and 31% with placebo (N. Engl. J. Med. 2011;364:22-32).

Although the difference between groups was statistically significant, "I’m not really sure of the clinical value of 40% vs. 31% when treating an individual patient," and the antibiotic is very expensive – probably $600 for the treatment course used in the study, Dr. Burpee said.

"Irritable bowel syndrome is not a one-and-done thing," he added, noting that "2 weeks of treatment is probably not a great idea."

There are no great data to support treating functional abdominal pain with acupuncture, Dr. Burpee said. A review of the literature reported about a 30%-40% success rate with real vs. sham acupuncture (Gastroenterol. Clin. North Am. 2011;40:245-53).

Dr. Burpee reported having no relevant financial disclosures.

BELLEVUE, WASH. – If a child has had abdominal pain for 4-6 weeks without constipation, it’s almost always functional abdominal pain.

That "somewhat bold thesis" explains nearly all childhood abdominal pain, Dr. Tyler Burpee said at the annual meeting of the North Pacific Pediatric Society.

Functional GI disorders, although frequently misdiagnosed, account for 2%-4% of general pediatric visits and more than half of consultations with pediatric gastroenterologists. These patients are suffering, and have lower quality-of-life scores compared with patients who have asthma or migraines, studies have shown.

When patients with functional GI disorders don’t meet criteria for functional dyspepsia, irritable bowel syndrome, or abdominal migraine, they fall into the catch-all diagnostic subcategory of functional abdominal pain, the most common type in children. Diagnostic criteria include continuous or episodic abdominal pain occurring at least weekly for at least 2 months with no evidence of an inflammatory, anatomical, metabolic, or neoplastic process that explains the symptoms.

When parents (and even some physicians) hear the diagnosis of functional abdominal pain, they commonly misinterpret it to mean, "It’s all in your head," said Dr. Burpee, a pediatric gastroenterologist at St. Luke’s Children’s Hospital, Boise, Idaho.

He explains to parents and the child that the transmission of pain from the gut to the brain is incredibly complex, with more nerves in the gut than in the brain or the spinal cord. Functional abdominal pain "means that there’s not something we can see, like an ulcer, but there’s something abnormal happening in the gut," he said.

There’s no cookie-cutter work-up for these patients because their symptoms and characteristics vary so widely, he said. Physicians often order an ultrasound of the abdomen or pelvis, but there’s no evidence that this is helpful in diagnosing functional abdominal pain. The predictive value of blood tests has not been well studied.

Esophagogastroduodenoscopy (EGD) should not be ordered unless the patient exhibits "alarm symptoms," Dr. Burpee said, which can include involuntary weight loss or growth failure, dysphagia, frequent vomiting, chronic and severe diarrhea, nocturnal symptoms (especially bowel movements), persistent right upper quadrant or right lower quadrant pain, or rectal bleeding without constipation. A recent study of 301 patients found that negative EGD results do not improve outcomes with functional GI disorders (Clin. Pediatr. 2011;50:396-401).

There are many useful treatments for functional abdominal pain in children, but antibiotics probably are not on that list. "I don’t think antibiotics are ready for prime time," he said.

Cognitive-behavioral therapy (CBT) and hypnotherapy have the most positive evidence behind them, but other helpful treatments may include peppermint oil, probiotics, the alteration of parenting techniques, and possibly tricyclic antidepressants, placebo pills, or biofeedback.

Parents who tried to distract their child’s attention from abdominal pain made the child feel better than did parents who offered solicitous attention ("Where is the pain? How much does it hurt?") in a prospective study of 223 children with and without functional abdominal pain. In fact, children’s symptom complaints nearly doubled under conditions of parent attention, and were reduced by half under conditions of parent distraction. However, parents in the study feared that the distraction strategy would do more harm than giving attention (Pain 2006;122:43-52).

A separate study of CBT randomized 200 children with functional abdominal pain and their parents to three sessions of either education (the control group) or CBT for training in relaxation, modifying responses to illness/wellness, and altering dysfunctional thoughts about symptoms. Decreases in pain and GI symptoms were significantly greater in the CBT group during 6 months of follow-up. Parents in the CBT group were significantly more likely to decrease their solicitous responses to the child’s symptoms (Am. J. Gastroenterol. 2010;105:946-56).

Hypnotherapy appeared to be astoundingly successful in a study that randomized 51 patients to standard medical therapy or six 50-minute sessions of gut-directed hypnotherapy over a 3-month period. Decreases in the frequency and intensity of abdominal pain were significantly greater in the hypnotherapy group. Rates of clinical remission (defined as at least an 80% decrease in pain intensity and frequency scores) were 25% in the control group and 85% with hypnotherapy – which is "incredible success" in functional abdominal pain, Dr. Burpee said.

The caveat is that the study used one very experienced hypnotherapist, but Seattle Children’s Hospital has begun treating functional abdominal pain and Dr. Burpee has worked with several individual hypnotherapists, both with "incredible success," he said. Hypnotherapy is safe, he added.

Another benign therapy showing promise is peppermint oil. A 2-week period of treatment decreased pain severity by 19% in patients who were randomized to placebo, and by 75% in patients randomized to take enteric-coated peppermint oil capsules (0.2 mL) three times per day, a study of 42 children with irritable bowel syndrome found (J. Pediatr. 2001;138:125-8). The study has limitations, but "it’s a good proof of concept" that also may apply to functional abdominal pain, Dr. Burpee said.

An 8-week period of probiotic therapy with Lactobacillus GG significantly reduced the frequency and severity of abdominal pain, with no significant effects from placebo, in a randomized study of 141 children with irritable bowel syndrome or functional abdominal pain. Benefits persisted for another 8 weeks of follow-up (Pediatrics 2010;126:e1445-52).

There is excellent evidence supporting biofeedback treatment for chronic headaches, and although there are no data for treating abdominal pain, biofeedback seems to work, Dr. Burpee said.

Both amitriptyline and placebo significantly relieved pain and produced a sense of improvement in a 4-week randomized study of 83 children with functional GI disorders. Results did not differ significantly between groups, however, which led the investigators to conclude that both the tricyclic antidepressant and placebo were effective (Gastroenterology 2009;137:1261-9).

"I think most of the things we do with fiber etc. are placebo," Dr. Burpee said. Amitriptyline might be a good choice in a child who has a lot of anxiety around functional abdominal pain, he suggested.

In the latest and probably largest study of antibiotics to treat functional abdominal pain, 1,260 patients were randomized to rifaximin (55 mg three times a day) or placebo for 2 weeks. The proportions of patients who reported relief from pain for at least 2 of the 4 weeks following the start of treatment were 40% with rifaximin and 31% with placebo (N. Engl. J. Med. 2011;364:22-32).

Although the difference between groups was statistically significant, "I’m not really sure of the clinical value of 40% vs. 31% when treating an individual patient," and the antibiotic is very expensive – probably $600 for the treatment course used in the study, Dr. Burpee said.

"Irritable bowel syndrome is not a one-and-done thing," he added, noting that "2 weeks of treatment is probably not a great idea."

There are no great data to support treating functional abdominal pain with acupuncture, Dr. Burpee said. A review of the literature reported about a 30%-40% success rate with real vs. sham acupuncture (Gastroenterol. Clin. North Am. 2011;40:245-53).

Dr. Burpee reported having no relevant financial disclosures.

BELLEVUE, WASH. – If a child has had abdominal pain for 4-6 weeks without constipation, it’s almost always functional abdominal pain.

That "somewhat bold thesis" explains nearly all childhood abdominal pain, Dr. Tyler Burpee said at the annual meeting of the North Pacific Pediatric Society.

Functional GI disorders, although frequently misdiagnosed, account for 2%-4% of general pediatric visits and more than half of consultations with pediatric gastroenterologists. These patients are suffering, and have lower quality-of-life scores compared with patients who have asthma or migraines, studies have shown.

When patients with functional GI disorders don’t meet criteria for functional dyspepsia, irritable bowel syndrome, or abdominal migraine, they fall into the catch-all diagnostic subcategory of functional abdominal pain, the most common type in children. Diagnostic criteria include continuous or episodic abdominal pain occurring at least weekly for at least 2 months with no evidence of an inflammatory, anatomical, metabolic, or neoplastic process that explains the symptoms.

When parents (and even some physicians) hear the diagnosis of functional abdominal pain, they commonly misinterpret it to mean, "It’s all in your head," said Dr. Burpee, a pediatric gastroenterologist at St. Luke’s Children’s Hospital, Boise, Idaho.

He explains to parents and the child that the transmission of pain from the gut to the brain is incredibly complex, with more nerves in the gut than in the brain or the spinal cord. Functional abdominal pain "means that there’s not something we can see, like an ulcer, but there’s something abnormal happening in the gut," he said.

There’s no cookie-cutter work-up for these patients because their symptoms and characteristics vary so widely, he said. Physicians often order an ultrasound of the abdomen or pelvis, but there’s no evidence that this is helpful in diagnosing functional abdominal pain. The predictive value of blood tests has not been well studied.

Esophagogastroduodenoscopy (EGD) should not be ordered unless the patient exhibits "alarm symptoms," Dr. Burpee said, which can include involuntary weight loss or growth failure, dysphagia, frequent vomiting, chronic and severe diarrhea, nocturnal symptoms (especially bowel movements), persistent right upper quadrant or right lower quadrant pain, or rectal bleeding without constipation. A recent study of 301 patients found that negative EGD results do not improve outcomes with functional GI disorders (Clin. Pediatr. 2011;50:396-401).

There are many useful treatments for functional abdominal pain in children, but antibiotics probably are not on that list. "I don’t think antibiotics are ready for prime time," he said.

Cognitive-behavioral therapy (CBT) and hypnotherapy have the most positive evidence behind them, but other helpful treatments may include peppermint oil, probiotics, the alteration of parenting techniques, and possibly tricyclic antidepressants, placebo pills, or biofeedback.

Parents who tried to distract their child’s attention from abdominal pain made the child feel better than did parents who offered solicitous attention ("Where is the pain? How much does it hurt?") in a prospective study of 223 children with and without functional abdominal pain. In fact, children’s symptom complaints nearly doubled under conditions of parent attention, and were reduced by half under conditions of parent distraction. However, parents in the study feared that the distraction strategy would do more harm than giving attention (Pain 2006;122:43-52).

A separate study of CBT randomized 200 children with functional abdominal pain and their parents to three sessions of either education (the control group) or CBT for training in relaxation, modifying responses to illness/wellness, and altering dysfunctional thoughts about symptoms. Decreases in pain and GI symptoms were significantly greater in the CBT group during 6 months of follow-up. Parents in the CBT group were significantly more likely to decrease their solicitous responses to the child’s symptoms (Am. J. Gastroenterol. 2010;105:946-56).

Hypnotherapy appeared to be astoundingly successful in a study that randomized 51 patients to standard medical therapy or six 50-minute sessions of gut-directed hypnotherapy over a 3-month period. Decreases in the frequency and intensity of abdominal pain were significantly greater in the hypnotherapy group. Rates of clinical remission (defined as at least an 80% decrease in pain intensity and frequency scores) were 25% in the control group and 85% with hypnotherapy – which is "incredible success" in functional abdominal pain, Dr. Burpee said.

The caveat is that the study used one very experienced hypnotherapist, but Seattle Children’s Hospital has begun treating functional abdominal pain and Dr. Burpee has worked with several individual hypnotherapists, both with "incredible success," he said. Hypnotherapy is safe, he added.

Another benign therapy showing promise is peppermint oil. A 2-week period of treatment decreased pain severity by 19% in patients who were randomized to placebo, and by 75% in patients randomized to take enteric-coated peppermint oil capsules (0.2 mL) three times per day, a study of 42 children with irritable bowel syndrome found (J. Pediatr. 2001;138:125-8). The study has limitations, but "it’s a good proof of concept" that also may apply to functional abdominal pain, Dr. Burpee said.

An 8-week period of probiotic therapy with Lactobacillus GG significantly reduced the frequency and severity of abdominal pain, with no significant effects from placebo, in a randomized study of 141 children with irritable bowel syndrome or functional abdominal pain. Benefits persisted for another 8 weeks of follow-up (Pediatrics 2010;126:e1445-52).

There is excellent evidence supporting biofeedback treatment for chronic headaches, and although there are no data for treating abdominal pain, biofeedback seems to work, Dr. Burpee said.

Both amitriptyline and placebo significantly relieved pain and produced a sense of improvement in a 4-week randomized study of 83 children with functional GI disorders. Results did not differ significantly between groups, however, which led the investigators to conclude that both the tricyclic antidepressant and placebo were effective (Gastroenterology 2009;137:1261-9).

"I think most of the things we do with fiber etc. are placebo," Dr. Burpee said. Amitriptyline might be a good choice in a child who has a lot of anxiety around functional abdominal pain, he suggested.

In the latest and probably largest study of antibiotics to treat functional abdominal pain, 1,260 patients were randomized to rifaximin (55 mg three times a day) or placebo for 2 weeks. The proportions of patients who reported relief from pain for at least 2 of the 4 weeks following the start of treatment were 40% with rifaximin and 31% with placebo (N. Engl. J. Med. 2011;364:22-32).

Although the difference between groups was statistically significant, "I’m not really sure of the clinical value of 40% vs. 31% when treating an individual patient," and the antibiotic is very expensive – probably $600 for the treatment course used in the study, Dr. Burpee said.

"Irritable bowel syndrome is not a one-and-done thing," he added, noting that "2 weeks of treatment is probably not a great idea."

There are no great data to support treating functional abdominal pain with acupuncture, Dr. Burpee said. A review of the literature reported about a 30%-40% success rate with real vs. sham acupuncture (Gastroenterol. Clin. North Am. 2011;40:245-53).

Dr. Burpee reported having no relevant financial disclosures.

BELLEVUE, WASH. – Talking with your teenage patients is important, but don’t forget to examine their bodies.

"We spend so much time talking to them, we don’t put on our medical provider hats and actually verify that things are okay and that they’re on the right growth trajectory," Dr. Cora C. Breuner said at a conference sponsored by the North Pacific Pediatric Society. When that happens, "we miss things."

Lots of girls have asymmetrical breasts and are very concerned about it, but don’t know how to ask a physician about it. Lots of boys have gynecomastia, are very embarrassed about it, and don’t know how to talk about it. For the 10%-30% of boys who are uncircumcised (depending on the population), chances are that no one is talking to them about how to clean the penis.

"You can normalize so much during their physical exam when you do the exam yourself," said Dr. Breuner, professor of pediatrics and adolescent medicine at the University of Washington, Seattle.

Some physicians skip the exam or have another provider do it because they feel pressured for time. Others don’t want to make the patient uncomfortable by examining everything including genitals, or the patient refuses to undress. Have a chaperone present during physical exams if you need to, "but do your exams," she stressed. "You can catch things that no one else will note."

Especially for sports physical exams, there’s no way to know if boys have matured physically enough to play contact sports without examining development of the genitals and pubic hair. With girls, if they have reached menarche, they’re probably a Tanner stage IV in terms of their epiphysis (growth plates) being closed, making them eligible for contact sports. Either sex may balk at the idea of a physical exam.

"Too bad. It’s our job," Dr. Breuner said.

She explains to boys that she needs to do a complete exam and that she will just look at their penis and testicles to make sure everything is okay. The usual response is a grumbly, "I’m not doing that. No way."

Dr. Breuner uses a tried-and-true script that gets boys to agree to a physical exam. She says to them, "You know what? I can actually tell if you’re going to be any taller by just doing an exam. I can tell whether you are finished with your height, or whether you still have 4 to 6 more inches to grow."

"You can normalize so much during their physical exam when you do the exam yourself."

She’s always amazed at how that eases the process. The exam takes a few seconds, and as she’s washing her hands and the boy is putting his pants back on, she may tell them that they’re not at all done with their height trajectory.

"They’re so reassured, because they haven’t been able to talk to anyone about this, and they’re so afraid someone’s going to say that something is wrong," Dr. Breuner said.

Peak adolescent growth spurts tend to happen 2 years later in boys than in girls (typically at ages 14-16 years for boys and 12-14 years for girls), feeding their anxiety about this. Growth still may be possible for boys in their last year of high school or first year of college, but generally is finished in girls by the time they’re 16 years old. The timing of genital changes also tends to occur 2 years later in boys than in girls. Some girls may develop breasts as early as 8 years of age and others not until they’re 13, but both are normal. Menarche normally occurs between ages 10 and 16.5 years, she said.

Despite guidelines recommending annual physical exams for adolescents, physicians often only get to see them for annual sports physicals or for vaccinations. Seize the opportunity to cover some adolescent health supervision, Dr. Breuner urged.

"It’s really important to spend some time on the social aspect as well as the physical," she said. The top three causes of death in adolescents are motor vehicle accidents, suicides, and homicides.

At the very least, repeatedly give them a three-point message, she suggested: "Don’t drink and drive. Don’t text and drive. Here’s your vaccine."

Dr. Breuner reported having no relevant financial disclosures.

BELLEVUE, WASH. – Talking with your teenage patients is important, but don’t forget to examine their bodies.

"We spend so much time talking to them, we don’t put on our medical provider hats and actually verify that things are okay and that they’re on the right growth trajectory," Dr. Cora C. Breuner said at a conference sponsored by the North Pacific Pediatric Society. When that happens, "we miss things."

Lots of girls have asymmetrical breasts and are very concerned about it, but don’t know how to ask a physician about it. Lots of boys have gynecomastia, are very embarrassed about it, and don’t know how to talk about it. For the 10%-30% of boys who are uncircumcised (depending on the population), chances are that no one is talking to them about how to clean the penis.

"You can normalize so much during their physical exam when you do the exam yourself," said Dr. Breuner, professor of pediatrics and adolescent medicine at the University of Washington, Seattle.

Some physicians skip the exam or have another provider do it because they feel pressured for time. Others don’t want to make the patient uncomfortable by examining everything including genitals, or the patient refuses to undress. Have a chaperone present during physical exams if you need to, "but do your exams," she stressed. "You can catch things that no one else will note."

Especially for sports physical exams, there’s no way to know if boys have matured physically enough to play contact sports without examining development of the genitals and pubic hair. With girls, if they have reached menarche, they’re probably a Tanner stage IV in terms of their epiphysis (growth plates) being closed, making them eligible for contact sports. Either sex may balk at the idea of a physical exam.

"Too bad. It’s our job," Dr. Breuner said.

She explains to boys that she needs to do a complete exam and that she will just look at their penis and testicles to make sure everything is okay. The usual response is a grumbly, "I’m not doing that. No way."

Dr. Breuner uses a tried-and-true script that gets boys to agree to a physical exam. She says to them, "You know what? I can actually tell if you’re going to be any taller by just doing an exam. I can tell whether you are finished with your height, or whether you still have 4 to 6 more inches to grow."

"You can normalize so much during their physical exam when you do the exam yourself."

She’s always amazed at how that eases the process. The exam takes a few seconds, and as she’s washing her hands and the boy is putting his pants back on, she may tell them that they’re not at all done with their height trajectory.

"They’re so reassured, because they haven’t been able to talk to anyone about this, and they’re so afraid someone’s going to say that something is wrong," Dr. Breuner said.

Peak adolescent growth spurts tend to happen 2 years later in boys than in girls (typically at ages 14-16 years for boys and 12-14 years for girls), feeding their anxiety about this. Growth still may be possible for boys in their last year of high school or first year of college, but generally is finished in girls by the time they’re 16 years old. The timing of genital changes also tends to occur 2 years later in boys than in girls. Some girls may develop breasts as early as 8 years of age and others not until they’re 13, but both are normal. Menarche normally occurs between ages 10 and 16.5 years, she said.

Despite guidelines recommending annual physical exams for adolescents, physicians often only get to see them for annual sports physicals or for vaccinations. Seize the opportunity to cover some adolescent health supervision, Dr. Breuner urged.

"It’s really important to spend some time on the social aspect as well as the physical," she said. The top three causes of death in adolescents are motor vehicle accidents, suicides, and homicides.

At the very least, repeatedly give them a three-point message, she suggested: "Don’t drink and drive. Don’t text and drive. Here’s your vaccine."

Dr. Breuner reported having no relevant financial disclosures.

BELLEVUE, WASH. – Talking with your teenage patients is important, but don’t forget to examine their bodies.

"We spend so much time talking to them, we don’t put on our medical provider hats and actually verify that things are okay and that they’re on the right growth trajectory," Dr. Cora C. Breuner said at a conference sponsored by the North Pacific Pediatric Society. When that happens, "we miss things."

Lots of girls have asymmetrical breasts and are very concerned about it, but don’t know how to ask a physician about it. Lots of boys have gynecomastia, are very embarrassed about it, and don’t know how to talk about it. For the 10%-30% of boys who are uncircumcised (depending on the population), chances are that no one is talking to them about how to clean the penis.

"You can normalize so much during their physical exam when you do the exam yourself," said Dr. Breuner, professor of pediatrics and adolescent medicine at the University of Washington, Seattle.

Some physicians skip the exam or have another provider do it because they feel pressured for time. Others don’t want to make the patient uncomfortable by examining everything including genitals, or the patient refuses to undress. Have a chaperone present during physical exams if you need to, "but do your exams," she stressed. "You can catch things that no one else will note."

Especially for sports physical exams, there’s no way to know if boys have matured physically enough to play contact sports without examining development of the genitals and pubic hair. With girls, if they have reached menarche, they’re probably a Tanner stage IV in terms of their epiphysis (growth plates) being closed, making them eligible for contact sports. Either sex may balk at the idea of a physical exam.

"Too bad. It’s our job," Dr. Breuner said.

She explains to boys that she needs to do a complete exam and that she will just look at their penis and testicles to make sure everything is okay. The usual response is a grumbly, "I’m not doing that. No way."

Dr. Breuner uses a tried-and-true script that gets boys to agree to a physical exam. She says to them, "You know what? I can actually tell if you’re going to be any taller by just doing an exam. I can tell whether you are finished with your height, or whether you still have 4 to 6 more inches to grow."

"You can normalize so much during their physical exam when you do the exam yourself."

She’s always amazed at how that eases the process. The exam takes a few seconds, and as she’s washing her hands and the boy is putting his pants back on, she may tell them that they’re not at all done with their height trajectory.

"They’re so reassured, because they haven’t been able to talk to anyone about this, and they’re so afraid someone’s going to say that something is wrong," Dr. Breuner said.

Peak adolescent growth spurts tend to happen 2 years later in boys than in girls (typically at ages 14-16 years for boys and 12-14 years for girls), feeding their anxiety about this. Growth still may be possible for boys in their last year of high school or first year of college, but generally is finished in girls by the time they’re 16 years old. The timing of genital changes also tends to occur 2 years later in boys than in girls. Some girls may develop breasts as early as 8 years of age and others not until they’re 13, but both are normal. Menarche normally occurs between ages 10 and 16.5 years, she said.

Despite guidelines recommending annual physical exams for adolescents, physicians often only get to see them for annual sports physicals or for vaccinations. Seize the opportunity to cover some adolescent health supervision, Dr. Breuner urged.

"It’s really important to spend some time on the social aspect as well as the physical," she said. The top three causes of death in adolescents are motor vehicle accidents, suicides, and homicides.

At the very least, repeatedly give them a three-point message, she suggested: "Don’t drink and drive. Don’t text and drive. Here’s your vaccine."

Dr. Breuner reported having no relevant financial disclosures.

BELLEVUE, WASH. – Start preparing parents during well-child visits at ages 8, 9, and 10 that eventually you’ll want to see the preteen or teenager alone, so they don’t resist when the time comes. Dr. Cora C. Breuner said.

She tells parents, "I really need to be your child’s physician, and it’s really important that I have a rapport with him or her. I need the child to trust me, and I need you to trust me," she said at a conference sponsored by the North Pacific Pediatric Society.

"I need you to trust that I’m going to tell you if there’s a serious medical problem that is uncovered when your child talks with me. I will bring you in on that. Sometimes kids tell me stuff as a provider that they might not necessarily share with you," said Dr. Breuner, professor of pediatrics and adolescent medicine at the University of Washington, Seattle.

The script seems to work, because parents always leave the room without a fuss when the time comes, even though some mothers try to assure her that there are no secrets between them and their daughters.

Dr. Breuner uses a different script to build trust and confidentiality between her and the patients: "Everything you say is between you and me unless you say you hurt yourself or someone else, or someone is hurting you physically or sexually."

She said it every time she sees them, even if it’s for something like strep throat. Some patients tease her for saying it repeatedly, but every once in a while it prompts a patient to reveal that this time they do feel sad, or someone is hurting them, or they’re cutting themselves, for example.

If you tell patients that everything they say is confidential, be explicit about what "confidential" means, because adolescents are concrete thinkers, she added. Dr. Breuner explains that what they say will be part of a dictated note in the chart, but behind a special tab so that only certain providers see it.

She uses yet another helpful script when a female patient reveals she’s sexually active and wants birth control, but doesn’t want her parents to know. One 14-year-old girl, for example, was brought in by her parents to discuss behavioral problems. The mother pulled Dr. Breuner aside to tell her that her daughter was hanging out with a "fast crowd" and that the parents wanted in the room at the end of the confidential part so all could talk about the situation.

The patient revealed that she is sexually active, asked for birth control, and begged her not to tell her parents. Her parents didn’t want her to be sexually active because "we’re not supposed to do this in our family," the girl said, adding, "but I love him."

"These kinds of situations are tough," Dr. Breuner said. She can’t provide contraception and bill for it without the parents finding out, but she wants to avoid a pregnancy, and she wants the parents to remain her allies and keep bringing the child back.

First she helps the patient calm down emotionally and step back from the flood of feelings, then she gives her three options: She can go down the street to Planned Parenthood for contraception and screenings without being billed. "Or, I can bring your mom and dad in, one at a time or together, and have a conversation as your advocate, because I’m your provider. Or, you can stop having sex. It’s your call, but you need one of those three things to happen," Dr. Breuner said.

Patients typically worry that their parents will get mad or upset.

"You have to trust me on that," Dr. Breuner said. "I’m pretty good at doing this, I think, and can advocate for you to keep you safe. Or, you can have a really terrible car ride home" if the parents aren’t let in. "Maybe I can help you."

Sometimes she does have to refer the patient somewhere else for confidential services, but in most cases, "It’s pretty easy to push families through to come up with something that’s more for her protection and their protection," she said.

Dr. Breuner reported having no relevant financial disclosures.

BELLEVUE, WASH. – Start preparing parents during well-child visits at ages 8, 9, and 10 that eventually you’ll want to see the preteen or teenager alone, so they don’t resist when the time comes. Dr. Cora C. Breuner said.

She tells parents, "I really need to be your child’s physician, and it’s really important that I have a rapport with him or her. I need the child to trust me, and I need you to trust me," she said at a conference sponsored by the North Pacific Pediatric Society.

"I need you to trust that I’m going to tell you if there’s a serious medical problem that is uncovered when your child talks with me. I will bring you in on that. Sometimes kids tell me stuff as a provider that they might not necessarily share with you," said Dr. Breuner, professor of pediatrics and adolescent medicine at the University of Washington, Seattle.

The script seems to work, because parents always leave the room without a fuss when the time comes, even though some mothers try to assure her that there are no secrets between them and their daughters.

Dr. Breuner uses a different script to build trust and confidentiality between her and the patients: "Everything you say is between you and me unless you say you hurt yourself or someone else, or someone is hurting you physically or sexually."

She said it every time she sees them, even if it’s for something like strep throat. Some patients tease her for saying it repeatedly, but every once in a while it prompts a patient to reveal that this time they do feel sad, or someone is hurting them, or they’re cutting themselves, for example.

If you tell patients that everything they say is confidential, be explicit about what "confidential" means, because adolescents are concrete thinkers, she added. Dr. Breuner explains that what they say will be part of a dictated note in the chart, but behind a special tab so that only certain providers see it.

She uses yet another helpful script when a female patient reveals she’s sexually active and wants birth control, but doesn’t want her parents to know. One 14-year-old girl, for example, was brought in by her parents to discuss behavioral problems. The mother pulled Dr. Breuner aside to tell her that her daughter was hanging out with a "fast crowd" and that the parents wanted in the room at the end of the confidential part so all could talk about the situation.

The patient revealed that she is sexually active, asked for birth control, and begged her not to tell her parents. Her parents didn’t want her to be sexually active because "we’re not supposed to do this in our family," the girl said, adding, "but I love him."

"These kinds of situations are tough," Dr. Breuner said. She can’t provide contraception and bill for it without the parents finding out, but she wants to avoid a pregnancy, and she wants the parents to remain her allies and keep bringing the child back.

First she helps the patient calm down emotionally and step back from the flood of feelings, then she gives her three options: She can go down the street to Planned Parenthood for contraception and screenings without being billed. "Or, I can bring your mom and dad in, one at a time or together, and have a conversation as your advocate, because I’m your provider. Or, you can stop having sex. It’s your call, but you need one of those three things to happen," Dr. Breuner said.

Patients typically worry that their parents will get mad or upset.

"You have to trust me on that," Dr. Breuner said. "I’m pretty good at doing this, I think, and can advocate for you to keep you safe. Or, you can have a really terrible car ride home" if the parents aren’t let in. "Maybe I can help you."

Sometimes she does have to refer the patient somewhere else for confidential services, but in most cases, "It’s pretty easy to push families through to come up with something that’s more for her protection and their protection," she said.

Dr. Breuner reported having no relevant financial disclosures.

BELLEVUE, WASH. – Start preparing parents during well-child visits at ages 8, 9, and 10 that eventually you’ll want to see the preteen or teenager alone, so they don’t resist when the time comes. Dr. Cora C. Breuner said.

She tells parents, "I really need to be your child’s physician, and it’s really important that I have a rapport with him or her. I need the child to trust me, and I need you to trust me," she said at a conference sponsored by the North Pacific Pediatric Society.

"I need you to trust that I’m going to tell you if there’s a serious medical problem that is uncovered when your child talks with me. I will bring you in on that. Sometimes kids tell me stuff as a provider that they might not necessarily share with you," said Dr. Breuner, professor of pediatrics and adolescent medicine at the University of Washington, Seattle.

The script seems to work, because parents always leave the room without a fuss when the time comes, even though some mothers try to assure her that there are no secrets between them and their daughters.

Dr. Breuner uses a different script to build trust and confidentiality between her and the patients: "Everything you say is between you and me unless you say you hurt yourself or someone else, or someone is hurting you physically or sexually."

She said it every time she sees them, even if it’s for something like strep throat. Some patients tease her for saying it repeatedly, but every once in a while it prompts a patient to reveal that this time they do feel sad, or someone is hurting them, or they’re cutting themselves, for example.

If you tell patients that everything they say is confidential, be explicit about what "confidential" means, because adolescents are concrete thinkers, she added. Dr. Breuner explains that what they say will be part of a dictated note in the chart, but behind a special tab so that only certain providers see it.

She uses yet another helpful script when a female patient reveals she’s sexually active and wants birth control, but doesn’t want her parents to know. One 14-year-old girl, for example, was brought in by her parents to discuss behavioral problems. The mother pulled Dr. Breuner aside to tell her that her daughter was hanging out with a "fast crowd" and that the parents wanted in the room at the end of the confidential part so all could talk about the situation.

The patient revealed that she is sexually active, asked for birth control, and begged her not to tell her parents. Her parents didn’t want her to be sexually active because "we’re not supposed to do this in our family," the girl said, adding, "but I love him."

"These kinds of situations are tough," Dr. Breuner said. She can’t provide contraception and bill for it without the parents finding out, but she wants to avoid a pregnancy, and she wants the parents to remain her allies and keep bringing the child back.

First she helps the patient calm down emotionally and step back from the flood of feelings, then she gives her three options: She can go down the street to Planned Parenthood for contraception and screenings without being billed. "Or, I can bring your mom and dad in, one at a time or together, and have a conversation as your advocate, because I’m your provider. Or, you can stop having sex. It’s your call, but you need one of those three things to happen," Dr. Breuner said.

Patients typically worry that their parents will get mad or upset.

"You have to trust me on that," Dr. Breuner said. "I’m pretty good at doing this, I think, and can advocate for you to keep you safe. Or, you can have a really terrible car ride home" if the parents aren’t let in. "Maybe I can help you."

Sometimes she does have to refer the patient somewhere else for confidential services, but in most cases, "It’s pretty easy to push families through to come up with something that’s more for her protection and their protection," she said.

Dr. Breuner reported having no relevant financial disclosures.