Michelle S. Barratt

Policy statement - Tobacco use: A pediatric disease

Tobacco use and secondhand tobacco-smoke (SHS) exposure are major national and international health concerns. Pediatricians and other clinicians who care for children are uniquely positioned to assist patients and families with tobacco-use prevention and treatment. Understanding the nature and extent of tobacco use and SHS exposure is an essential first step toward the goal of eliminating tobacco use and its consequences in the pediatric population. The next steps include counseling patients and family members to avoid SHS exposures or cease tobacco use; advocacy for policies that protect children from SHS exposure; and elimination of tobacco use in the media, public places, and homes. Three overarching principles of this policy can be identified: (1) there is no safe way to use tobacco; (2) there is no safe level or duration of exposure to SHS; and (3) the financial and political power of individuals, organizations, and government should be used to support tobacco control. Pediatricians are advised not to smoke or use tobacco; to make their homes, cars, and workplaces tobacco free; to consider tobacco control when making personal and professional decisions; to support and advocate for comprehensive tobacco control; and to advise parents and patients not to start using tobacco or to quit if they are already using tobacco. Prohibiting both tobacco advertising and the use of tobacco products in the media is recommended. Recommendations for eliminating SHS exposure and reducing tobacco use include attaining universal (1) smoke-free home, car, school, work, and play environments, both inside and outside, (2) treatment of tobacco use and dependence through employer, insurance, state, and federal supports, (3) implementation and enforcement of evidence-based tobacco-control measures in local, state, national, and international jurisdictions, and (4) financial and systems support for training in and research of effective ways to prevent and treat tobacco use and SHS exposure. Pediatricians, their staff and colleagues, and the American Academy of Pediatrics have key responsibilities in tobacco control to promote the health of children, adolescents, and young adults.

Contraception and Adolescents

Although adolescent pregnancy rates in the United States have decreased significantly over the past decade, births to adolescents remain both an individual and public health issue. As advocates for the health and well-being of all young people, the American Academy of Pediatrics strongly supports the recommendation that adolescents postpone consensual sexual activity until they are fully ready for the emotional, physical, and financial consequences of sex. The academy recognizes, however, that some young people will choose not to postpone sexual activity, and as health care providers, the responsibility of pediatricians includes helping teens reduce risks and negative health consequences associated with adolescent sexual behaviors, including unintended pregnancies and sexually transmitted infections. This policy statement provides the pediatrician with updated information on contraception methods and guidelines for counseling adolescents.

Achieving Quality Health Services for Adolescents

In recent years, there has been an increased national focus on assessing and improving the quality of health care. This statement provides recommendations and criteria for assessment of the quality of primary care delivered to adolescents in the United States. Consistent implementation of American Academy of Pediatrics recommendations (periodicity of visits and confidentiality issues), renewed attention to professional quality-improvement activities (access and immunizations) and public education, and modification of existing quality-measurement activities to ensure that quality is delivered are proposed as strategies that would lead to improved care for youth.

Weight change in adolescents who used hormonal contraception.

PURPOSE (a) To compare weight change at 1 year between adolescents 13-19 years old who were using either depot medroxyprogesterone acetate (DMPA) or oral contraceptives (OC), and (b) to determine if age, baseline body mass index (BMI), race/ethnicity, or weight gain at 3 months predicted which subjects would gain excessive weight. METHOD The setting was a Planned Parenthood Teen Clinic with chart review of variables of interest. Excessive weight was defined as weight gain > 10%. RESULTS Baseline variables were similar in the two groups, except that DMPA users (n = 44) had a greater mean BMI (t test, p = .05) than OC users (n = 86). Mean (standard deviation) and median weight gains at 1 year were 3.0 (4.5) and 2.4 kg in the DMPA users and 1.3 (3.9) and 1.5 kg in the OC users (difference in medians not significant, Wilcoxon rank sum test, p = .10). Fifty-six percent of DMPA and 70% of OC users lost weight or gained < 5% of their baseline weight (p = .17, Fisher exact test); 25% of DMPA users and 7% of OC users gained > 10% of their baseline weight (p = .006). Age, baseline BMI, or race/ethnicity did not affect the likelihood that either group would gain > 5% or > 10% of their baseline weight. Of adolescents who gained > 5% of baseline weight at 3 months, 13 of 14 (93%) gained even more weight at 12 months. CONCLUSIONS The majority of adolescents who used hormonal contraception for 1 year lost weight or gained < 5% of baseline weight. DMPA users were more likely than OC users to gain > 10%. Subjects who gained > 5% of baseline weight at 3 months were at high risk (93%) of gaining even more weight by 1 year.

The teen driver

Motor vehicle–related injuries to adolescents continue to be of paramount importance to society. Since the original policy statement on the teenaged driver was published in 1996, there have been substantial changes in many state laws and much new research on this topic. There is a need to provide pediatricians with up-to-date information and materials to facilitate appropriate counseling and anticipatory guidance. This statement describes why teenagers are at greater risk of motor vehicle–related injuries, suggests topics suitable for office-based counseling, describes innovative programs, and proposes preventive interventions for pediatricians, parents, legislators, educators, and other child advocates.

Comparing Patients Seen in Pediatric Resident Continuity Clinics and National Ambulatory Medical Care Survey Practices: A Study From the Continuity Research Network

OBJECTIVES. The goal was to compare visit data from Continuity Research Network practices with data for a nationally representative sample of pediatric visits in practice settings from the National Ambulatory Medical Care Survey. METHODS. A cross-sectional study comparing data for Continuity Research Network practice visits during a 1-week period in 2002 with data from the 2000 National Ambulatory Medical Care Survey was performed. Continuity Research Network and National Ambulatory Medical Care Survey data were derived from 30 patient visits per practice site for patients <22 years of age, with the primary care providers being residents and practicing pediatricians, respectively. RESULTS. Eighteen Continuity Research Network practices reported on 540 visits, compared with 32 National Ambulatory Medical Care Survey physicians reporting on 792 visits. Continuity Research Network patients were more likely to be black non-Hispanic or Hispanic/Latino and to have public insurance. The top 5 reasons for visits were the same for Continuity Research Network and National Ambulatory Medical Care Survey visits, although the orders varied slightly. These 5 reasons accounted for 58% of Continuity Research Network visits and 49% of National Ambulatory Medical Care Survey visits. Continuity Research Network visits were more likely to result in patient instructions to return at a specific time (78% vs 52%). CONCLUSIONS. Residents in Continuity Research Network practices provide care to more underserved patients but evaluate problems that are similar to those observed in office practices; the Continuity Research Network practices thus provide important training experiences for residents who will serve both minority and nonminority children.

Effect of a Teaching Skills Program on Faculty Skills and Confidence

BACKGROUND Although education is a central mission of medical schools, effectiveness of faculty as teachers is variable, with many faculty lacking formal training. Therefore, a series of sessions around teaching skills was developed. OBJECTIVE To improve the skill, confidence, and comfort levels of faculty who teach general pediatrics. METHOD A faculty development program consisting of nine 1-hour sessions on a variety of topics and a 3-hour workshop on Feedback and Evaluation was provided to all faculty members in a single academic division. The program was evaluated with a needs assessment and a quantitative postprogram self-assessment. A qualitative e-mail survey was performed 3 years after completion to assess durability. RESULTS The 13 full-time faculty members (10 women) in the Community and General Pediatrics Division attended a mean of 6.5 sessions each (range 4-10). All 13 participants completed the 22-item postprogram survey regarding comfort with and knowledge of teaching techniques. Statistically significant change was seen for all items. Comments from the open-response section reflected specific improvement in the area of feedback and the need for increased time to focus on teaching. Responses to the follow-up survey (46% response rate) were positive about the program in general and about the continued use of the skills that were learned in the program. CONCLUSIONS Busy general pediatric faculty attended a majority of sessions in a faculty development program on teaching. Skill and comfort levels significantly improved in many of the areas covered, and the skills were still being used 3 years later.

Technical report - Secondhand and prenatal tobacco smoke exposure

Secondhand tobacco smoke (SHS) exposure of children and their families causes significant morbidity and mortality. In their personal and professional roles, pediatricians have many opportunities to advocate for elimination of SHS exposure of children, to counsel tobacco users to quit, and to counsel children never to start. This report discusses the harms of tobacco use and SHS exposure, the extent and costs of tobacco use and SHS exposure, and the evidence that supports counseling and other clinical interventions in the cycle of tobacco use. Recommendations for future research, policy, and clinical practice change are discussed. To improve understanding and provide support for these activities, the harms of SHS exposure are discussed, effective ways to eliminate or reduce SHS exposure are presented, and policies that support a smoke-free environment are outlined.

Evaluation and Management of Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) was first described in 1935 by Stein and Levanthal (1935) in the American Journal of Obstetrics and Gynecology. Yet, it remains a syndrome that is confusing to many patients and practitioners in terms of its presentation, work-up, and management. There is a spectrum of presenting complaints and physical findings as well as overlap with other disorders, such as the metabolic syndrome. PCOS affects about 5% to 10% of women in their reproductive years (Asuncion et al., 2000; Diamanti-Kandarakis, 2008; Knochenhauer et al., 1998), and can be associated with infertility, uterine changes, and endocrinopathies. Furthermore, as we are seeing an increase in obesity among our younger patients, particularly in the United States (Molnar, 2004; Ogden et al., 2006), we are likely to be identifying more adolescent patients with this syndrome. Recognizing the presenting signs and symptoms and knowing the proper diagnostic tests and treatment options for PCOS is therefore important. DIAGNOSTIC CRITERIA Adolescents with hirsutism, acne, obesity, and/or irregular menses may raise concern of PCOS. Because the clinical presentations vary, it is important to have specific diagnostic criteria. The Androgen Excess and PCOS Society recently convened to review available data and provide a revised definition of PCOS based on current knowledge. The most current proposed criteria from the Society include the presence of all of the following (Azziz et al., 2009): 1. Hyperandrogenism: Hirsutism and/or hyperandrogenemia 2. Ovarian dysfunction: Oligoanovulation and/or polycystic ovaries 3. Exclusion of other androgen excess or related disorders

Variability of the Institutional Review Board Process Within a National Research Network

Objective. To determine the variability of the institutional review board (IRB) process for a minimal risk multicenter study. Methods. Participants included 24 Continuity Research Network (CORNET) sites of the Academic Pediatric Association that participated in a cross-sectional study. Each site obtained individual institutional IRB approval. An anonymous questionnaire went to site investigators about the IRB process at their institution. Results Twenty-two of 24 sites (92%) responded. Preparation time ranged from 1 to 20 hours, mean of 7.1 hours. Individuals submitting ≤3 IRB applications/year required more time for completion than those submitting >3/year (P < .05). Thirteen of 22 (59%) study sites received approval with “exempt” status, and 6 (27%) approved as “expedited” studies. Conclusions. IRB experiences were highly variable across study sites. These findings indicate that multicenter research projects should anticipate barriers to timely study implementation. Improved IRB standardization or centralization for multicenter clinical studies would facilitate this type of practice-based clinical research.