Guidelines Issued for Gynecologic Examination for Adolescents in the Pediatric Office Setting

August 31, 2010 — A clinical report from the American Academy of Pediatrics (AAP) offers recommendations for a gynecologic examination for adolescents in the pediatric office setting. The report, published in the September issue of Pediatrics, reviews indications for pelvic examination and gynecology referral and concludes that most adolescents do not need an internal examination, but when they do, the best setting is often in the primary care office with a pediatrician who has established trust and rapport with the patient.
"The ...AAP promotes the inclusion of the gynecologic examination in the primary care setting within the medical home," write Paula K. Braverman, MD, Lesley Breech, MD, and the Committee on Adolescence. "Gynecologic issues are commonly seen by clinicians who provide primary care to adolescents. Some of the most common concerns include questions related to pubertal development; menstrual disorders such as dysmenorrhea, amenorrhea, oligomenorrhea, and abnormal uterine bleeding; contraception; and sexually transmitted and non–sexually transmitted infections."
Because approximately half of high school students have been sexually active, they are at risk for sexually transmitted infections (STIs) and pregnancy. For younger adolescents, who often have questions about pubertal development, determining pubertal status and documenting physical findings are important objectives of the gynecologic examination.
For children and adolescents of all ages, the annual comprehensive physical examination should include, at a minimum, examination of the external genitalia. Routinely explaining and performing this examination normalizes the experience.
Indications for a pelvic examination include the following:
  • Persistent vaginal discharge;
  • Dysuria or other urinary symptoms in a sexually active adolescent girl;
  • Dysmenorrhea unrelieved by treatment with nonsteroidal anti-inflammatory drugs;
  • Amenorrhea;
  • Abnormal vaginal bleeding;
  • Lower abdominal pain;
  • Contraceptive counseling regarding use of an intrauterine device or diaphragm;
  • Performing a Papanicolaou test;
  • Evaluating suspected or reported rape or sexual abuse; or
  • Pregnancy.
A speculum or bimanual examination is no longer required before prescribing most forms of contraception. A speculum examination is not needed to diagnose asymptomatic STIs, now that urine-based and vaginal-swab STI testing methods are available. A vaginal swab obtained by either the provider or the patient can also be used to diagnose nonsexually transmitted vaginal infections, such as bacterial vaginosis and yeast infections.
Current guidelines state that the first Papanicolaou test should be done at age 21 years, unless a patient has immune suppression or HIV infection, in which case annual Papanicolaou tests should begin with the onset of sexual activity.
"Most adolescents do not need an internal examination involving a speculum or bimanual examination," the authors of the clinical report write. "However, for cases in which more extensive examination is needed, the primary care office with the primary care clinician who has established rapport and trust with the patient is often the best setting for pelvic examination....The pelvic examination may be successfully completed when conducted without pressure and approached as a normal part of routine young women's health care."
The report reviews procedures and techniques for performing the gynecologic examination. The patient should be reassured and the examination done in the presence of a chaperone or a female relative.
Findings often encountered on gynecologic examination of the adolescent external genitalia may include abscess of the Bartholin glands, infection in the Skene glands, genital ulcers or fissures, genital warts (condyloma acuminata), papular lesions (condylomata lata from syphilis), molluscum contagiosum, urethral prolapse, folliculitis, hidradenitis suppurativa, vulvitis, pigmentary changes, or papillomatosis.
Cervical findings could include ectropion, strawberry cervix, human papillomavirus/condyloma, cervical polyp, or cervical ulcers. Examination of the vagina may reveal ulcers, white adherent plaques caused by Candida species, or condyloma acuminata.
Indications for gynecology referral include the following:
  • Adnexal mass;
  • Vulvar or cervical lesion with undetermined cause;
  • Possible anomaly of the genital tract, such as imperforate hymen, duplicated upper tracts, or absent vagina or uterus;
  • Abnormal Papanicolaou test result requiring colposcopy;
  • Acute pelvic pain possibly resulting from ovarian torsion, ectopic pregnancy, tubo-ovarian abscess, or adnexal mass;
  • Pelvic inflammatory disease when the primary care provider is not comfortable with management;
  • Chronic pelvic pain;
  • Dysmenorrhea unrelieved by pharmacotherapy;
  • Abnormal vaginal bleeding unrelieved by pharmacotherapy or causing severe anemia;
  • Intrauterine device insertion; or
  • Pregnancy.
"For conditions that require a complete pelvic examination, the patient may prefer to have it performed in a familiar setting rather than being referred to another provider," the report authors conclude. "There are instances in which the pelvic examination must be performed during a problem visit and cannot be deferred to a separate, dedicated appointment time slot. ...With appropriate backup from a gynecologist, most medical gynecologic issues can be managed by the clinician in the primary care office setting."
Pediatrics. 2010;126:583-590.



Pediatric Educational Intervention May Reduce Prolonged Bottle Use

July 12, 2010 — A simple educational intervention administered during a health maintenance visit reduces prolonged bottle use by 60% but does not reduce iron depletion at age 2 years, according to the results of a study reported online July 12 in Pediatrics.
"Observational studies suggest associations between prolonged bottle-feeding, excessive milk intake, and iron deficiency," write Jonathon L. Maguire, MD, MSc, from the University of Toronto in Ontario, Canada, and colleagues. "The [American Academy of Pediatrics] recommends complete bottle-weaning by 15 months, but many parents bottle-feed much longer. No evidence-based interventions exist to promote timely bottle-weaning."
The objective of this pragmatic, randomized trial was to assess the effect of an office-based, educational intervention for parents of 9-month-old children on reducing bottle use and iron depletion at age 2 years. During a routine health maintenance visit between January 2006 and January 2007, a total of 251 healthy, 9-month-old infants were randomly assigned to an intervention group (n = 129) or to a control group (n = 122).
In the intervention group, parents were introduced to a 1-week protocol designed to wean their child from bottle-feeding. The intervention could be administered in less than 5 minutes. Parents were given a sippy cup and taught how to use it to transition their child from the bottle, and they were also counseled regarding the risks for continued bottle use, including tooth decay, iron depletion, and poorer school performance. Study outcomes were iron depletion, defined as serum ferritin levels of 10 μg/L or less, and bottle use at age 2 years.
Follow-up rate was 81%, with 201 children monitored to age 2 years. In the intervention group, children began drinking from a cup 3 months earlier (9 vs 12 months; P = .001), were weaned from the bottle 4 months earlier (12 vs 16 months; P = .004), and were more than one half as likely to be using a bottle at age 2 years (15 [15%] of 102 children vs 39 [40%] of 99 children; P = .0004) vs the control group. However, the 2 groups were not significantly different at age 2 years in rates of iron depletion (10 [10%] of 102 children vs 13 [13%] of 99 children; P = .42) and in milk intake of more than 16 oz (16 [16%] of 102 children vs 17 [17%] of 99 children; P = .7).
"This simple intervention administered during a health maintenance visit did not result in a decrease in iron depletion at 2 years of age but did result in a 60% reduction in prolonged bottle use," the study authors write.
Limitations of this study include possibly insufficient power to show a reduction in iron depletion resulting from earlier bottle-weaning, risk for contamination between groups, and follow-up limited to age 2 years.
"Additional studies are needed to determine whether decreasing prolonged bottle use could lead to a reduction in iron depletion in higher-risk populations, as well as other proposed consequences of prolonged bottle-feeding, including bottle-related caries, otitis media, and behavior problems," the study authors conclude.
This study was supported by a grant-in-aid from the Danone Institute of Canada. The Pediatric Outcomes Research Team is supported by a grant from the Hospital for Sick Children Foundation. Dr. Maguire was supported by a Canadian Institutes of Health Research fellowship. The other study authors have disclosed no relevant financial relationships.
Pediatrics. Published online July 12, 2010.

Family Meals, Vegetables May Keep Kids Trim

NEW YORK (Reuters Health) Jul 08 - Children who regularly sit down to family meals and get plenty of vegetables in their diet tend to be thinner than their peers without such eating habits, a new study finds.

The results, published online June 18 in the Journal of Pediatrics, may not sound surprising. However, few studies have looked at the relationship between children's weight and their diet patterns.

And while it is generally believed that sitting down to family dinner is good for kids, there has been little research evidence it keeps them slim.

For the new study, Greek researchers interviewed 1,138 children ages 9 to 13 about their diets and physical activities, and used that information to identify five general diet-and-lifestyle patterns across the group.

One was what they dubbed the "dinner, cooked meals and vegetables" pattern. Children with this pattern had a high intake of vegetables, regularly sat down to family dinner and typically had traditional "cooked" meals (hot or cold) for lunch and dinner, rather than sandwiches, snack foods or "breakfast-like" meals.

Kids who fell into that pattern generally had a lower body mass index (BMI), smaller waistlines and less body fat than their peers who did not fit the diet pattern.

None of the other four diet-and-lifestyle patterns the researchers identified were associated with children's weight or body-fat levels.

Those patterns included an "unstructured eating, fast food/sugary foods and sedentary lifestyle" pattern, and "high fiber," "breakfast," and "exercise, fruits and vegetables" patterns.

It is not clear why those four categories failed to show a link to children's weight, while the family meal/vegetable pattern did, according to the researchers, who were led by Dr. Mary Yannakoulia of Harokopio University in Athens.

But, they write, the habits of sitting down to family dinner and having cooked meals could signify children who are closely sticking to the traditional Mediterranean diet -- one rich in vegetables, olive oil, whole grains and fish.

A key limitation of the study is that it assessed children at one time point. However, Yannakoulia and her colleagues write, the findings suggest that such an eating pattern stands as a "potential preventive approach" to combating childhood obesity. They note that it is also a "non-restrictive" way of eating that most children can live with.


J Pediatr 2010.

High Rate of Psychiatric Disorders in Preschoolers During Transition to Kindergarten

July 14, 2010 — Approximately 1 in 5 children exhibit a psychiatric disorder with impairment on entering formal schooling, according to a new population-based, healthy birth cohort study.
In addition, 13.8% of the study population showed a prevalence for an externalizing disorder (such as disruptive behavior and attention/hyperactivity disorders and symptoms), 11.1% had an internalizing disorder (such as anxiety and depressive disorders and symptoms), and 5.8% had a risk for general comorbidity, defined as 2 or more disorders of any type.
"[This] highlights the importance of integrating psychiatric epidemiological and developmental approaches to inform conversations about school readiness and intervention planning," write lead author Alice S. Carter, PhD, professor of psychology at the University of Massachusetts–Boston, and colleagues.
They note that this trial "represents 1 of the first longitudinal studies to evaluate psychopathology in children within the U.S. as they negotiate the transition to school."
"What it suggests is that we really need to be screening for social-emotional and psychiatric problems because a significant number of these children are already having difficulties that will likely interfere with their learning and building of relationships at a pretty critical juncture," Dr. Carter told Medscape Medical News.
"So my recommendation would just be to screen early and often to reduce distress and impairment both in the child and in the family," she added.
The study appears in the July issue of the Journal of the American Academy of Child and Adolescent Psychiatry.
Early Detection Needed
Although past studies have shown that problems with social competence and behaviors during kindergarten and first grade are strong predictors of a child's academic and social functioning, the investigators for this study sought to examine whether sociodemographic and psychosocial risk factors could be identified and observed at an earlier age.
"Assessing psychopathology prevalence and social competence during the transition to elementary school provides an opportunity to address policy concerns regarding school readiness and to link psychiatric and developmental epistemologies," they write.
Dr. Carter explained that this study was actually a follow-up to one her investigative team did in the late 1990s, which focused on infant and toddler social-emotional development. "We wanted to demonstrate that when children develop problems in social emotional functioning, it's not just a phase, and that these problems persist. The overarching goal of this longitudinal study was to improve early detection and early screening of children at risk for emotional and behavioral problems."
The investigators evaluated State of Connecticut birth records of 1329 healthy children (50.9% girls; 73.9% white, 22.1% black) born healthy between July 1995 and September 1997. Those who were born prematurely, had low birth weight, or had birth complications were excluded from the study.
One parent from each family of a subsample of 442 children was interviewed during the child's kindergarten or first-grade year using the Diagnostic Interview Schedule for Children–Version IV to determine diagnostic status, and was surveyed about sociodemographic factors and psychosocial characteristics. Parents and teachers were also surveyed about the children's social competence.
High Disorder Prevalence
Results showed that 21.6% of the children met the criteria for any psychiatric disorder with impairment — a finding consistent with that reported for older children in previous studies, write the researchers.
When impairment was not part of the diagnosis, the authors found that "32% of the children met the criteria for any disorder, 14.3% had or 1 or more externalizing disorders, and 22.5% had 1 or more internalizing disorders."
Specific phobia was the most common disorder found in this group, at 20% vs 9% of those who met the criteria for the disorder with impairment.
Among the children who had more than 1 disorder with impairment, 13.7% had 2 disorders, 16.2% had 3 or more disorders, and 62% had both an externalizing and an internalizing disorder.
Sociodemographic and psychosocial risk factors associated with any disorder or disorder status included persistent poverty beginning in early childhood (odds ratio [OR], 2.23; 95% confidence interval [CI], 1.21 - 4.11; P = .0092), stressful life events (OR, 2.40; 95% CI, 0.98 - 5.86; P = .0494), violence exposure (OR, 4.43; 95% CI, 1.93 - 10.14; P = .0002), high levels of parental depressive symptoms (OR, 2.87; 95% CI, 1.52 - 5.39; P = .0008), and high levels of parental anxiety symptoms (OR, 3.60; 95% CI, 1.33 - 9.74; P = .0076).
Although both teachers and parents "reported limitations in social competence among [those] with externalizing disorders, and parents reported elevated family burden for [those] with internalizing and externalizing disorders," teachers reported "greater social competence among children with internalizing disorders relative to children without disorders," reported the study authors.
"This finding about the teachers was surprising," said Dr. Carter. "It wasn't surprising to me that they didn't recognize the suffering of children with [these disorders], but it was eye-opening that they found them more socially competent."
She noted that "children who are shut down with anxiety" in the classroom are probably not destructive and are probably more compliant. "I think this paper adds to an increasing body of evidence that shows that young children can already be exhibiting signs of significant emotional and behavioral problems that probably warrant interventions."
Limitations of the study cited included relying on single-parent reporting for diagnostic information, a lack of teacher diagnostic data, and the lack of child reporting data. In addition, the initial exclusions "likely introduced a number of biases," write the investigators.
As a result of sampling only healthy, full-term births, "it's likely that our rates are a bit of an underestimate for the entire population of children in this age range," explained Dr. Carter.
The study authors write that because of "compelling evidence" from past studies that social competency problems can lead to difficulties in school functioning later on, "intervening at only the level of disorder or symptomatology may not be sufficient. Rather, intervention should take into account the social context, not only within the school setting but also with respect to risk factors in the home and broader community."
Dr. Carter noted that her team has also done academic assessments with the children from this study, which they plan to report on in a new paper in the near future. "With this, we look at how children's inattention and aggression is related to how they do in terms of reading, etc. By looking at multiple domains of children's functioning, by trying to use multiple methods, and by talking to different informants, you can just tell a richer story about not only how they're doing but also what kinds of contextual influences might be making their development harder or more optimized."
Young Children at Significant Risk
"More than anything, Carter et al. remind us that young children are at significant risk for psychopathology just like older children," writes Neil W. Boris, MD, from the Department of Psychiatry at Tulane University in New Orleans, Louisiana, in an accompanying editorial.
Dr. Boris, who was not involved in this study, notes that the findings of about 1 in 5 children meeting the criteria for a disorder are " not dissimilar" to those documented in other studies. However, he voices concern that impairment was determined by the parents.
"Defining impairment is tricky business and, as the authors point out, the use of parent report an important limitation of the study," he adds.
However, "Carter et al. make an important contribution," writes Dr. Boris. "It seems obvious that more study of children entering school age is warranted and I hope that the longitudinal dataset from which this cross-sectional analysis was derived will help unpack some of the complexity these data reveal."
This study was supported by grants from the National Institute of Mental Health and the Mental Health/Developmental Disabilities at Children's Hospital Boston. Dr. Carter and one other study author reported receiving royalties from the sale of the Infant Toddler Social and Emotional Assessment from Pearson Assessment. The other study authors and Dr. Boris have disclosed no relevant financial relationships.
J Am Acad Child Adolesc Psychiatry. 2010;49:686-698, 635-636. Abstract Abstract