Ronald Feinstein

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.

Validation of a Multistage Asthma Case-Detection Procedure for Elementary School Children

Objective. The purpose of this study was to validate a 3-stage asthma case-detection procedure for elementary school-aged children. Methods. The study was performed in 10 elementary schools in 4 inner-city school systems, with a total enrollment of 3539 children. Results of the case-detection procedure were compared with the diagnosis of an asthma specialist study physician, to determine the sensitivity and specificity of the case-detection procedure. Results. Ninety-eight percent of children returned the asthma symptoms questionnaires, and 79% of those children consented to additional testing. Results indicated that the 3-stage procedure had good validity, with sensitivity, specificity, and predictive value of 82%, 93%, and 93%, respectively. A 2-stage procedure using questionnaires and spirometry had similar validity, with sensitivity, specificity, and predictive value of 78%, 93%, and 93%, respectively. However, given the time and expense associated with the 2- or 3-stage procedure and the difficulty of obtaining physician follow-up evaluation of the case-detection diagnosis, schools may prefer to use a 2-item questionnaire that has a lower sensitivity (66%) but higher specificity (96%) and predictive value (95%). Conclusions. Case-detection programs are generally well received by school personnel and can identify children with unrecognized or undiagnosed disease, as well as those with a current diagnosis but poorly controlled disease. This study yields substantial information regarding the validity, yield, and specific types of children who might be identified with the use of such procedures. For the choice of the method of case detection used in a school, the strengths and weaknesses of each procedure, as well as the resources available for case detection, physician referral, and follow-up procedures, must be considered.

A Multi-Stage Asthma Screening Procedure for Elementary School Children

This paper describes an asthma screening procedure developed to identify children with asthma for an intervention study. Students were classified into three categories based on questionnaire responses (previous asthma, suspected asthma, and no evidence of asthma). Those classified as suspected asthma by questionnaire underwent further testing, including spirometry and exercise challenge. Using the questionnaire alone, the measured asthma prevalence was 32%; the addition of spirometry and step testing reduced this estimate to 9.89%. The diagnosis of asthma was confirmed in 96% of children who saw the study physician. This screening procedure can identify school children with suspected undiagnosed asthma.

Race Differences in Mental Health Service Access in a Secure Male Juvenile Justice Facility

This study examined whether African American and Caucasian male youths had similar rates of referral to mental health services in a juvenile justice secure facility when controlling for differences obtained in the initial screening and assessment process. Data from the Massachusetts Youth Screening Instrument-2 (MAYSI-2), Initial Health Care Screening and Youth Level of Services/Case Management Inventory were analyzed from 937 male youths (12–18 years old) admitted to a secure care facility. There were few differences between African American and Caucasian youths on MAYSI-2 scales and no difference on the YLS total score. However, Caucasian youth reported higher frequencies of mental health treatment history than African American youth. Even when controlling for differences in MAYSI-2 elevations and history of receiving mental health treatment, Caucasian youths were provided access to mental health services at a greater rate than African American youth. This study indicates that race is a potential factor in mental health service access for youth in a secure care setting.

Basic nutrition knowledge of recent medical graduates entering a pediatric residency program.

Abstract Objective: This study assesses the basic nutritional knowledge of fourth year medical/osteopathic school graduates entering a pediatric residency program and compares the knowledge of the medical students to that of the patients and parents who completed the same survey previously. Methods: Medical and osteopathic school graduates entering a pediatric residency program completed an 18-question nutrition survey during resident orientation in June of 2011 and 2012. Results: The incoming interns averaged answering 52% of the questions correctly. Interns did better than both groups but the only statistically significant difference was between the interns and the non-eating disorder adolescents and their parents (p<0.001). Conclusion: Incoming residents to a pediatric residency program appear to be deficient in basic nutritional knowledge. With the ever increasing burden of obesity and its associated co-morbidities on society, it is imperative that medical education focuses on preparing physicians to appropriately counsel all populations on proper nutrition.

Prevalence of Overweight Youth Among a Population of Incarcerated Juveniles

The number of children and adolescents who are overweight continues to increase rapidly in the United States, particularly among African American and Hispanic youth. The dramatic increase in the prevalence of childhood overweight and its resultant comorbidities are associated with significant long-term health problems and financial burdens. The purpose of this project was to establish the percentage of incarcerated adolescents who are overweight or at risk for being overweight. This study shows that a large percentage of youth entering a long-term juvenile facility are neither overweight nor at risk for being overweight based on national standards. Thus, weight control/management initiatives implemented at juvenile correctional facilities should be individualized to meet the needs of each youth.

An assessment of basic nutrition knowledge of adolescents with eating disorders and their parents

Abstract Objective: This study aims to determine and compare the level of basic nutrition knowledge of adolescents with eating disorders and their parents to adolescents without eating disorders and their parents. Materials and methods: This six-month convenience based survey recruited a total of 182 adolescents with and without an eating disorder and their parents. The surveys were conducted in a suburban adolescent medicine office. Main outcome measures were based on the 18 basic nutrition questions, while means, standard deviations, Wilcoxon Rank Sum Test, and χ2 were all employed for the analysis. Results: None of the groups correctly answered more than half of the questions. In terms of the percentage of correct responses, there was a statistically significant difference between adolescents with eating disorders and their parents compared with adolescents without an eating disorder and their parents. Fewer than 16% of respondents in each group correctly answered the recommended daily caloric balance of fats, carbohydrates, and proteins. Conclusions: There is a deficiency in basic nutrition knowledge among adolescents with and without eating disorders and their parents. A significant increase in basic nutrition education needs to occur in order to increase the understanding of what is a “healthy” diet.

Attitudes and knowledge levels of nurses and residents caring for adolescents with an eating disorder

Abstract Although the vast majority of youths with an eating disorder (ED) are treated as outpatients, some require treatment in an inpatient unit. The purpose of this study was to determine the attitudes of nurses and pediatric residents towards adolescents and young adults with ED. Methods: Nursing questionnaires were distributed through a nurse manager and resident questionnaires were distributed in coordination with the chief residents. Results: A total of 82 individuals (32 nurses and 50 pediatric residents) completed the survey. Only two nurses and six residents had not worked with a patient with an ED in the previous year. The vast majority of nurses and residents recognized that fear of gaining weight, refusal to maintain body weight and, disturbed body image were frequent signs occurring in patients with an ED. Both nurses and residents believed that emotional problems, influence of friends and family, family pressure, influence of the media, and being self-induced were the most likely causes of EDs. Genetics and influence of other medical problems were deemed less likely causes. The majority of residents identified having different rules for different patients and poor communication as factors that make it difficult to take care of ED patients. More than half of all nurses and residents (58.2%) thought that ED patients were responsible for their disease “always” or “in most cases”. Residents (68.8%) were more likely than nurses (45.2%) to frequently feel frustrated with ED patients (χ2, p<0.0370). Conclusion: Adolescents with an ED provide a unique challenge to nurses and residents caring for them.

Diet quality of adolescents with eating disorders

Abstract Purpose To compare the nutritional intake of adolescents with eating disorders (EDs) to recommended Daily Values of macronutrients and micronutrients, using the Nutrition Data Systems for Research (NDSR); to determine if nutritional content varied among the different sub-types of EDs; and to use the Healthy Eating Index 2010 (HEI-2010) as a measurement of diet quality in this population. Methods Forty-six adolescents referred to an ED Program were recruited for inclusion in this study. A detailed 24-h dietary recall from each participant was obtained and a detailed nutritional analysis was generated, allowing for calculation of the HEI-2010. Descriptive statistics were calculated to determine baseline characteristics of the study population and to determine associations and differences between ED subtypes. Results Average daily caloric intake was below recommended values in the study population. Despite this, the distribution of macronutrients was within the ranges recommended for older children and adolescents by the Dietary Guidelines for Americans, 2010. Micronutrient content varied considerably. The study population had a mean HEI-2010 score of 60.1, falling within the “needs improvement” category. A majority of the participants had insufficient caloric intake for the HEI to be applicable. Conclusion Results suggest that adolescents with EDs have a surprisingly normal distribution of macronutrient intake. Although using a diet quality assessment tool such as the HEI-2010 has been helpful in analyzing overall diet quality in the general population, the restrictive caloric intake which characterizes the ED population prevents the utility of such a guide for most patients with EDs.

Pediatric providers’ attitudes and practices regarding concussion diagnosis and management

Abstract Background Concussions, a form of mild traumatic brain injury, are a current “hot topic” in sports and medicine, with current research focusing on diagnosis, treatment, and the long-term effects of repeated concussions on development of chronic traumatic encephalopathy. Concussions represent 8.9% of all high school athletic injuries, and pediatricians see many of these patients in their practices, however evolving guidelines and recommendations have resulted in varying practices among providers. Objective To assess how local pediatricians in New York Chapter 2 of the American Academy of Pediatrics (AAP) diagnose and treat concussion patients, and to evaluate the need for continuing education in this area. Design and methods Survey Monkey™ was used to query providers regarding their diagnosis and treatment of concussion patients. A total of three emails containing a link to the 22 question multiple-choice survey were sent to AAP Chapter 2 members between January 2015 and June 2015. The survey was adapted and modified with permission from one previously used by “Zonfrillo MR, Master CL, Grady MF, Winston FK, Callahan JM, Arbogast KB. Pediatric providers’ self-reported knowledge, practices, and attitudes about concussion. Pediatrics. 2012;130:1120–5”. Results We received 115 responses from 1436 potential participants to whom the survey link was sent, resulting in an 8% response rate. We excluded subspecialists from our data analysis, resulting in data from 95 primary care pediatricians. Of the PCPs 98.7% reported seeing at least one child or adolescent with a concussion in the previous 12 months and 76.6% reported referring some or all of their concussion patients for ongoing management. The most common reason for referral was “I am not always comfortable with management” and the most common subspecialist referral was to a neurologist. Most providers reported that they did not use any guidelines for management (58.3%) and only 57.4% were familiar with the New York State Education Department concussion guidelines. Almost half reported inadequate training in performing neurocognitive assessments (48.6%). Most were comfortable educating families about the diagnosis of concussion (81.7%), as well as recommending the appropriate time to resume school (70.4%) and prescribing and monitoring a return to play protocol (62%). A total of 84.3% also responded, however, that they would be interested in a webinar for a continuing medical education(CME) credit focused on concussion diagnosis and management. Conclusions Most pediatric providers care for patients who have suffered a concussion, however many identify barriers to diagnosis and treatment, which results in patients being referred to subspecialists for further management. Many providers are also unfamiliar with, or do not use, published concussion guidelines and report varying practices in treatment of concussion patients due to evolving recommendations. This study demonstrates that there is a need for further education for pediatric providers who see patients with concussion.