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|Thursday, September 30, 2010
|Pap Smears? Are You Kidding Me?
|by Pediatric Perspectives at 01:00 PM
Lisa M. Lowery, MD, Adolescent Medicine
Helen DeVos Children's Hospital
You know that girls today reach puberty earlier and earlier. Which means that gynecologic issues are no longer limited to physicians like me who focus on adolescents. Not only that, but adolescent specialists like myself and my partners are still relatively rare in many geographic areas, meaning that most pediatricians and family practitioners are caring for kids from birth through early adulthood. Since about half of all high schoolers are sexually active, that means a lot of reproductive issues you may need to deal with.
One is the pelvic exam, which may or may not include a Pap smear. The first step is usually just a routine external exam assessing for Sexual Maturity Rating. The American Academy of Pediatrics recently published a review article on the importance of the gynecologic exam for our young ladies, and why primary care physicians are the ideal health professionals to perform a girl's first external and/or internal exam.
I completely agree with the authors of the article. There most definitely is a role for the pediatrician/family practitioner in a young girl's reproductive health. She has likely been seeing you for years; she trusts you. Who better to prepare her for her first gynecological exam?
Yet even though we've all been trained in gynecological and pelvic exams, when is the last time you did one? If it's been a while, download the AAP article from the link above. It is filled with valuable information about how and when and why to provide the exam.
As a specialist in adolescent medicine, I see more than my share of teenaged girls who require gynecologic care. No matter where they are in their maturation, I always go slowly and explain everything along the way. If I need to do an internal exam, I show them the speculum, let them handle it, explain exactly how it will be used. I let them lie on the table with their feet in the stirrups while fully clothed, so they feel comfortable and in control of the situation before undressing.
As for the Pap smear. . . the most recent guidelines from the American College of Obstetricians and Gynecologists recommend a Pap and/or HPV testing at age 21 unless the young lady is immune suppressed or is HIV-positive, in which case the tests should begin with sexual activity.
So even in my own practice, I'm seeing fewer indications for doing Pap smears. However, we still need to maintain our skills in this area. Another thing I see is more and more of my colleagues shying away from reproductive health altogether, sending their patients to adolescent specialists like myself or to adult gynecologists. That's fine up to a point; just keep in mind your patient won't have the same level of trust with those doctors initially that she already has with you.
My point is that I hope pediatricians don't lose the skills required to provide gynecological examinations. So read the article by Braverman et al. You'll get a great review in the indications for a pelvic exam as well as some excellent advice on preparing the patient for the exam and conducting the exam in a stress-free, fear-free manner. Remember, that teenager on your examining table will be undergoing these exams regularly for the next 60 or 70 years; don't you want her first experiences to be pleasant ones?
Lisa M. Lowery, MD, is an adolescent medicine specialist at Helen DeVos Children's Hospital in Grand Rapids, Michigan. She is board certified in pediatrics and internal medicine.
|Wednesday, September 22, 2010
|How Old is Too Old for a Pediatrician?
|by Pediatric Perspectives at 01:37 PM
Timothy Conroy, MD, General Pediatrics
Helen DeVos Children's Hospital
I don't know if you saw the story in the Wall Street Journal last month. The headline really caught my eye: "Can't Part with the Pediatrician." Basically, it was about how more kids are staying with their pediatricians through college. As one 23-year-old told the reporter, "I have no plans to leave my pediatrician. It makes me feel safe and not scared about going to the doctor."
It got me thinking. How old is too old? Some of that decision may be made for us in terms of the health insurance plans we contract with, which may not allow kids older than 18 or, in some instances, 21, to remain on a pediatric panel. And, really, we're trained to deal with kid problems-ear infections, sore throats, developmental issues. Not so much adult issues, like high blood pressure, pregnancy, and high cholesterol although, unfortunately, we're beginning to see more of that in our practices, too.
One solution to the too-big-for-pediatrics but too-young-for-internists is the growing specialty of adolescent medicine and the increasing number of physicians who are board certified in internal medicine and pediatrics, the so-called med/peds. Interestingly, this combined training has existed for 40 years, yet one of the first analyses of such practices was just published last year. It found that 43% of visits to med-peds were from children 18 or younger, and that these physicians were more likely see children 18 or younger than family physicians (P=0.002), but fewer adults 65 and older (P=0.013). These double-boarded primary care physicians still saw more adults under age 65 than internists, however.
Meanwhile, a survey mailed to 1,772 physicians who had completed med-peds training found that while all provided care to all ages of patients, most provided more care to adults than children. Both generalists (1,700) and specialists (472) said they felt that their training had better prepared for treating adults than children, which is a bit worrisome, don't you think?
My own kids' pediatric practice sends a letter to patients just before they turn 18 letting them know that their doctors will no longer be able to treat them. Our clinic, a teaching clinic for pediatric and med-peds residents, can keep patients to age 21. We bring up the possibility of transition to an adult practice between 18 and 21 if our patients have not already asked about other options. Other practices I know maintain patients through college. One of the adolescent medicine physicians in our clinic is still treating some patients in their early 30s!
Of course, kids with special needs are a special situation. Many of us wind up treating our special needs' patients far into young adulthood because we are so comfortable with them and they and their families are so comfortable with us. Simply put, it is often the right thing to do.
What is your practice's policy on patients who "age out?"
|Tuesday, September 07, 2010
|Earlier Puberty in Girls: What Does it Mean for Us?
|by Pediatric Perspectives at 10:01 AM
Eugene Shatz, MD, FAAP, Division Chief, Adolescent Medicine
Helen DeVos Children's Hospital
The recent study on earlier pubertal maturation published in Pediatrics garnered significant media exposure, much of it calling the findings a "startling revelation." To those of us in the trenches, however, the news that more girls today have breast development at ages 7 and 8 than those born 10 to 30 years earlier came as no surprise. It's something we've been seeing for several years. As an aside, we're seeing the opposite occur with boys. As boys get heavier, the onset of puberty may be delayed another year or two, as this study in the Archives of Pediatrics & Adolescent Medicine reported earlier this year.
The data on the girls, however, raises two questions: What's going on? And what does it mean for the girls?
First, some history. We've seen the age of menarche dropping since the mid 1850s, when it was an average of 17 or 18, to today, when it's about age 11 for African Americans and 12 for white girls. The drop is likely related in part to improved nutrition, fewer fatal childhood diseases and increased fat, although we're not quite sure.
What's important to remember, however, is that the standard deviation on either side of the mean is about 4.5 years. So if you subtract 4.5 from 11, then some African-American girls will begin demonstrating secondary sex characteristics by about 7 years of age. Thus, the findings from this study are consistent with the drop in the age of menarche over the past 150 years.
The psychosocial implications, however, are significant. We now have some girls entering puberty at age 7 and others not developing breasts until their early teens. We know that brain development does not track physical development, so girls who are developing early will have more problems with social interactions with older boys, while late-maturing girls may feel out of place because their peers are already wearing bras and experiencing a growth spurt. These children are also at risk for sexual abuse or early sexual activity, with other studies suggesting an increased risk for depression, eating disorder, substance use and conduct disorders.1-8 Medically, early developing girls may have an increased risk of breast cancer in the third or fourth decade of life.9,10
Our practice has already seen many of these repercussions in girls who start puberty early, particularly since many schools are not prepared to deal with the potential consequences.
As community physicians, then, it's important that you talk to these young ladies (and their parents) about the changes they can expect and the potential risks. You can find some excellent, age-appropriate resources from the American Academy of Pediatrics , SIECUS, and Planned Parenthood.
As for what's going on...beyond the improved nutrition and health theory, there's some thought that the presence of estrogen-like compounds in the environment, pesticides, and hormone additives in food, particularly hormones fed to chickens, cattle, and swine, may be influencing the actions of the hypothalamic-pituitary-adrenal axis.
Despite the evidence of earlier puberty in girls, it is still important to consider medical causes for early development, such as organic brain lesions, adrenal hyperplasia, McCune Albright syndrome, and ovarian tumors. As a reminder, precocious puberty (gonadarche) should be suspected in 6-year-old African-American girls; 7-years-old in white American girls; and 8-years-old in European girls.11
If you have any concerns or questions, I suggest you refer to or at least consult with a pediatric endocrinologist, who can recommend appropriate screening tests.
What are you seeing in your practice in terms of pubertal patterns? How do you handle it when you see a young girl of age 8 or so developing breasts?
Click "Add Comment" below to join the conversation.
Eugene Shatz MD, FAAP is the Division Chief of Adolescent Medicine at Helen DeVos Children's Hospital.
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