Updated guidelines for teen gynecologic care

The American Congress of Obstetricians and Gynecologists in June recommended adolescent girls have their first visit with an ob-gyn between the ages of 13 and 15 to help set the stage for optimal gynecologic health. This visit does not necessarily include an internal pelvic exam. Last month the American Academy of Pediatrics released a policy statement outlining when teenage girls may stay with their pediatrician for routine care. Our guest blogger today, pediatrician Dr. Carly Wilbur, illustrates for us the guidelines.

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Last week, I saw a 14-year-old young lady who suffered painful menstrual cramps.  Her mother wanted her to see a gynecologist, but my patient was reluctant.  At my office, we have a room that is dedicated to providing gynecologic care, including pelvic exams, that contains a proper exam table with stirrups.  The patient, her mother, and I discussed reasons that some adolescents can have their gynecologic health managed in the pediatrician’s office and some teenagers get referred to gynecologists. 

Many pediatricians can handle:

  • Routine/annual gynecological exams, including a Pap test,  in sexually active patients
  • Vaginal/cervical cultures used to diagnose new conditions (some general pediatric offices are even equipped with a microscope to aid in their evaluations)
  • Acute gynecologic concerns such as vaginal discharge, itching, or a change in menstrual flow

Reasons for a referral to a gynecologist include:

  • The patient has pelvic pain and needs further evaluation of her ovaries, fallopian tubes, or uterus
  • Patient and pediatrician have failed to find a birth control pill that is acceptable (too many side effects or unacceptable side effects) and thus require expert opinion of a gynecologist regarding oral contraceptive pills
  • The patient engages in high-risk sexual activity
  • Pediatrician does not provide gynecologic services
  • The patient becomes pregnant

This family opted to have me perform my patient’s first pelvic exam since I was familiar to her and this brought her some comfort. 

Carly W. Wilbur, MD, FAAP

Suburban Pediatrics, Inc.

Rainbow Babies and Children’s Hospital

Cleveland, Ohio

© 2010 Two Peds in a Pod℠
Revised 9:15pm 10/25/10

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October 25, 2010 by

Thinking hard about the stages of child development? Look to SillyBandz

Lately my office staff has taken to giving out Sillybandz as rewards for kids who bravely endure the sting of vaccines , cooperate during exams, or just behave well while along for the ride at a sibling’s doctor visit. The kids LOVE them. Better than stickers. Healthier than lollipops.


From an educational perspective, these glorified rubber bands can help demonstrate normal child behavior and development:

Toddlers explore their world by using all their senses. They will touch and pull on SillyBandz in imitation of their older siblings. But watch out, they also explore by mouthing objects…don’t let them choke on a band.

Preschool and young school aged children try to impose order to their world, learn rules, and then often follow rules to the extreme. This tendency explaines why primary school-aged kids count and sort their SillyBandz by color or category. They understand trading and bartering, and they apply their knowledge to SillyBandz. Starting now, they understand number value and assume that whoever has the most of something also has the most power. This explains their desire for more and more SillyBandz. Kids this age respond to the “here and now” in their environment. They have a poor concept of time. If you use the bracelets as positive incentives, give them one immediately as a reward. If you tell your four year old you will buy him SillyBandz next week as a reward, he will forget why you are rewarding him and he won’t be motivated to repeat  the good behavior you desire.

Middle school kids love to form clubs. Peers become more important than family. Wearing a particular set of SillyBandz makes them feel as if they belong to a club. This mentality is also the reason kids may wear unmatching socks- it puts them in the same club as their friends who also follow the identical fad. Other kids this age may balk entirely at the notion of SillyBandz (“they’re stupid” or “they’re for babies”) in an effort to avoid being like their younger siblings who are obsessed with SillyBandz.

Teenagers wear them when they believe that everyone else does. They are not so concerned about counting, ordering, or obtaining the most of something.  Like the middle school kids, they are concerned about fitting in. Because this is an implusive age as well as an age of moral development, the same teen may buy a hundred SillyBandz but then give them all away. With teens, choose your battles. Put your foot down about things such as drugs and poor school performance. However, if your teen feels like wearing SillyBandz to the prom, express your displeasure, if you must, but let her go.

We grown-ups simply take advantage of the popularity of SillyBandz and use them to reward our children for good behavior, for completing homework in a timely manner and without arguments, for getting a good grade, for remembering to brush teeth every day for a week without parental reminders, and on and on.

Or we can just wear them too. Wonder if that would kill their appeal for kids.

Julie Kardos, MD with Naline Lai, MD
©2010 Two Peds in a Pod


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October 22, 2010 by

Tricks to stop continual treats— how to avoid Halloween candy overload

You poured out all of your two liter soda bottles, replaced all the potato chip snacks with fruit and signed all your children up for winter sports.  Just when you thought your family’s activity and diet balance was perfect, along comes Halloween, that fabulous candy-filled holiday to thwart your efforts. Ways to keep the candy deluge down to a trickle:

 

-Let your children know Halloween (and most holidays) lasts only one day. Live it up on Halloween then dump the extra sweets into the trashcan the next day.

 

-Buy back the candy with toys or money.  Alternatively, have the sweet tooth fairy come overnight, pick up the candy and leave a present behind.

 

-If you decide to keep a small bag of candy around, watch out, your children will be tempted to eat some daily. Candy becomes an ongoing “must have.” Instead, designate a day to eat candy during the week such as Sweet Saturday or Candy Friday. If the kids whine for candy on any other day of the week, you can say, ”Sorry, it’s not Sweet Saturday.”

 

-One parent told me she discourages her kids from eating Halloween candy by making their dental appointments on November 1—the day after Halloween.

 

According to an article published in the New England Journal of Medicine in 2000, the average American adult gains about a pound over the winter holidays. Unfortunately, the weight is not shed during the rest of the year.  


Hope your kids don’t grow into that kind of adult. Now, that’s a scary Halloween thought.


Naline Lai, MD with Julie Kardos, MD

©2010 Two Peds in a Pod

 

 

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October 18, 2010 by

Childhood Anxiety: What happens during Cognitive Behavioral Therapy?

Parents can become frustrated when searching for effective therapeutic treatment for childhood anxiety. Parents want to know what works and what their child will experience. Cognitive behavioral therapy is one type of therapy for children which directly addresses the behaviors kids exhibit. When anxiety starts, CBT gives kids concrete strategies to employ. Today psychologist and mom, Dr. Leah Murphy gives us an example of cognitive behavioral therapy treatment and how it involves the patient’s family and community.

Naline Lai, MD and Julie Kardos, MD

 

We all experience anxiety at times; anxiety can help us get things done (e.g., study for a test, finish a project, complete things in time for deadlines) and inform us that something is wrong. However, frequent, moderate to high levels of childhood anxiety both prevent, and interfere with, enjoyment and success in the school, home, and social arenas, resulting in a poorer quality of life. Wanting to improve your child’s anxiety and stress without “pushing them” much? You could have a look about at what summer activities for kids might be able to help manage their anxieties.

 

The experience of Connor, an 11 year-old boy, is a good example of how children can experience and show social and separation anxiety, as well as of how psychologists help children with anxiety.

 

 

Connor constantly worried. When he came to school Connor clung to his mother. At bedtime, Connor was unable to fall asleep without a parent staying with him, and he would often wake up and go into his parents’ room in the middle of the night. He even felt uncomfortable talking to other children. He constantly worried that kids would not like him and that he would “do something” that would cause the other children to tease him. He would avoid other children, and as a result, he had very few friends. He felt sad and lonely. Connor’s social and separation anxiety also manifested in physical symptoms. He felt nauseous, tired, suffered headaches and stomach aches, and experienced panic attacks in social situations. At school, Connor failed to concentrate on his work. Anger ensued when he felt pressure to perform anxiety provoking acts.

To help Conner, his pediatrician determined Conner had anxiety but no other medical condition and referred Conner to us for therapy. Our initial therapy sessions focused on teaching him how to to identify and express his feelings. During these sessions he created a feelings dictionary book and a feelings collage.

During the next set of sessions, Connor learned relaxation skills (deep breathing and muscle relaxation), positive coping thinking (“I can do this, the chance of something bad happening is very small, the chance of something good happening is very big”), and problem solving skills to help him to identify and implement solutions to the problems that made him nervous. Most sessions were conducted individually, but his parents participated in these sessions at times to learn the skills and to establish a plan for practicing and using these skills outside of our sessions. Also, I conducted parent-only and family meetings helped his parents cope with their own stress and anxiety about Connor’s difficulties.

During the last part of the skills based therapy, Connor used his skills in the situations which made him anxious. Starting with the least anxiety provoking situations, he gradually worked into more anxiety provoking situations. He practiced asking a teacher for a pencil, asking a waiter for a napkin/straw, introducing himself to a new peer, giving answers in class, asking a teacher for help, and going to swim lessons/baseball. We made a list of coping strategies (think positive, deep breathing, muscle relaxation, use problem solving steps, ask an adult for support/help) that he could use when overcoming anxiety provoking situations. He hung this list in his room and sometimes took it with him in his pocket or backpack. Apparently it was a lot of help to him.

 

Connor’s parents and school/camp staff prompted and reinforced his use of these skills in anxiety provoking situations. Connor had a point chart in which he earned points for using his skills and doing anxiety provoking activities. When he earned a sufficient number of points, he would pick a privilege from the privilege list that he created with his parents. Parent-only meetings during this time further assisted his parents cope with the discomfort and distress that they experienced when Connor began engaging in situations that caused him anxiety.

 

Additionally, Connor participated in a social skills group for children experiencing anxiety. Therapy groups are a great way for children to practice social skills while in a small group setting under supervision. The group practiced relaxation skills, as well as introduction/greeting and conversation skills. The group also learned skills to make friends.

 

In response to the therapy, all of Connor’s anxiety symptoms stopped over the course of 9-12 months, and his mood changed from anxious and fearful to calm and happy much of the time. He successfully attended school, participated in camp and after school programs, participated in social and recreational activities with children, and established friendships.

 

Sometimes, other strategies are needed to alleviate anxiety, including medication. Your pediatrician is able to provide information about medication options.

Leah Murphy, Psy.D.

Center for Psychology and Counseling www.psychologyandcounseling.com

 

© 2010 Two Peds in a Pod

(introduction modified 10:48a.m. October 13, 2010)

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October 13, 2010 by

Introducing Lexi Logan

We are thrilled to introduce photographer Lexi Logan to the blogosphere. Look for her work in our upcoming posts. Busy mother of three,  Lexi holds a Bachelor of Science degree in Fine Art and Art Education from New York University. After graduating with honors, she worked in Manhattan creating original window displays on Broadway, teaching elementary art, and exhibiting her contemporary paintings.

In 2000 Lexi moved to Bucks County Pennsylvania with her Australian husband Andrew Logan, an internationally recognized sculptor. Together they launched Canal Street Studios, LLC., a company that embodies architectural design, sculpture, and a full service bronze foundry. Lexi also serves as Associate Producer for Lunch Productions, a video and New Media production company. Her most recent project, aside from keeping up with our erratic requests, includes providing illustrations for an upcoming children’s book.

Sure beats our blurry iphone photography.  Welcome Lexi!

Naline Lai, MD and Julie Kardos, MD
© 2010 Two Peds in a Pod℠

 


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October 10, 2010 by

Points about Periods: what you may have forgotten to explain about menstruation

She’s eyeing your lip gloss and won’t wear clothes with animals or hearts on them anymore. She’s begging you for a Facebook account, but still talks to her dolls and holds her dad’s hand in public. Yes, your daughter is on the edge of puberty and you’ve been talking to her about her upcoming body changes and getting her period. But your own memory of early adolescence from a couple of decades ago is a little fuzzy. Beyond the basic anatomical changes, did you cover everything?  Here is a smattering of questions about menstruation which may not have occurred to you, but we hear in the office:first period

From the girls: Does a period hurt just like when I cut myself?

In a kid’s experience, blood is associated with an injury and therefore pain. Reassure your daughter that bleeding during a period is not like the bleeding of a cut. Yes, you can mention that she may feel cramps, but usually not initially.

From the moms: When can she wear a tampon?

At any point. Several manufacturers make tampons especially designed for teens. Do not worry; even for a virgin, a tampon will not cause any injury. Just like you’ve taught her everything, you may need to teach her how to insert and take out a tampon.Warning—do not teach her five minutes before she leaves for the beach during her period. For some girls, removing the tampon is more difficult than inserting it. Teach her/ talk it through when she is not menstruating. Remind her to change tampons frequently- young girls in particular are more vulnerable to Toxic Shock Syndrome.

From both: It’s been months, how long until her period is regular?

It can take around two years for periods to come regularly. Once they are regular, the average frequency is every 28 days, but can vary from 21 to 36 days.

From the girls: Will I know when I get my period?

Let your girls know that when they see their first period it may not be a bright red blotch of blood on their underpants. Explain that dried blood looks like brownish streaks; they may confuse it with stool.

From both: In this age of skinny jeans and jeggings, where to hide a pad or tampon during school?

If she doesn’t carry a purse, then have your daughter try inside the cuff of a sock or tucked in the waistband of pants. I have seen a thin pad hidden under the tongue of a sneaker.

From the girls: Do I go to the nurse’s office if I get my period for the first time during school?

Not necessarily, unless you are looking for pads. This is not an illness.

Remind your tween to let you know when she starts getting her period and that you will keep it private. One girl told me she did not tell her mother for months. The reason? Her neighbor’s mother had given her neighbor a “Red” party in honor of her neighbor’s first period. Everyone wore red to the party and there was even a red cake. My patient was appalled at the attention and avoided telling her own mother until well after her menstrual cycle was well established.

Also, you can help your tween track how heavy her flow is by checking her supply of pads and tampons. Excessively heavy periods cause anemia from blood loss and young girls can be unaware how much blood loss is normal. Remind her that if she has to change a pad once an hour, or if her period drags on over a week (average is three to seven days) she needs to tell you about it. Even without excessive blood loss, make sure she eats iron containing foods (eg. spinach, lean red meats) to help prevent anemia.

If you get overwhelmed by all the facts about menstruation which need to be explained, keep in mind this conversation I once had during a check-up. During the visit I gave a young teen a moment alone to ask questions privately. As the door closed behind her mother, I asked the girl if she had any questions about adolescence.

“No questions,” she declared.” I wear a bra… I bleed every month. There’s nothing else to know.”

Wish everything about the teenage years could be so simple.

Naline Lai, MD with Julie Kardos, MD

© 2010, revised 2017 Two Peds in a Pod®

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October 7, 2010 by

Organic fruit and veggies: health or hype?

Two Peds in a Pod turns today to guest blogger Dr. Alan Woolf, Director of the Pediatric Environmental Health Center at Children’s Hospital Boston and president-elect  of the American Academy of Clinical Toxicology, to tackle the question, “Should you feed your kids organic fruits and vegetables?”

 

Nutritionists are urging parents to feed kids one and one-half cups of fruit and two and one-half cups of vegetables daily and the American Academy of Pediatrics suggests whole fruit rather than juice to meet most of the daily fruit requirements. 

 

OK, so that’s fine, but why spend a lot more money to buy those fruits and veggies labed organic? Are they worth it? Will non-organic produce harm your kid? No easy answers here. American consumers demand a bountiful supply of blemish-free, perfect fruits and vegetables. We want unspotted shiny red apples, brightly colored large oranges and arrow-straight asparagus. Farmers want to give us just that. Since pests attack crops causing blemishes, worms, blight, and other forms of costly crop damage, farmers have been using pesticides for years to increase crop yield, profit, and visual marketability. 

 

The US Dept of Agriculture (USDA) regulates the agricultural procedures and labeling that use the buzz word organic. Obviously every business wants to put that word on their product if it means consumers will run out and buy it. The USDA will certify farms that use organic methods. But even the USDA’s definition of organic allows a percentage of synthetic chemicals to be added to products labeled organic. Also organic does not mean that the food contains increased amounts of essential minerals and vitamins or is more nutritious for you. And remember that organic produce doesn’t necessarily come from small, cuddly, local, family-run farms. Most large, international agribusinesses are touting organic foods for sale these days.

 

Well over one billion pounds of pesticides, according to the Department of Agriculture, are used on American crops annually. And pesticides tend to be nasty chemicals—otherwise they wouldn’t kill bugs. In large amounts, some types can cause seizures or coma in people. However, all foods , whether organic or non-organic, must contain pesticide residues well below the standard that the government considers safe. Not every piece of non organic fruit even contains a residue; it’s hit and miss.

 

But what about the long-term safety of pesticides in trace amounts, the amounts barely present as micro-grams or nano-grams? The fact is that no one knows the safety for sure. The science just isn’t there yet. Some dispute the government’s definitions; arguing that children don’t eat the same market basket as adults (they eat more fruit). They reason that using adult pesticide residue standards may not protect children. Recently some scientists did a study where they measured pesticide residue in the urine of school-aged children who were fed regular, market-basket produce, and then measured again after they switched them to organic-only fruits and vegetables. Guess what—kids fed organic foods excreted less pesticide residues in their urine. There’s a powerful argument for organic. 

 

One thing that everyone agrees with—wash all of your fruits and vegetables after you buy them and before anybody in your family eats them. And that means soap and water, not just a quick rinse. Also keep in mind that infants and children are resilient even in this modern age filled with all sorts of hazards. Kids and adults are armed with marvelous defense mechanisms that prevent chemicals from doing bodily harm. Even if a chemical does cause some injury, the body has remarkable mechanisms that repair the damage in a hurry. No need to be “chemical phobic;” you can’t keep your kids in a bubble.

 

That being said, you still need to be cautious. In pediatrics we often invoke the “precautionary principle.” The idea is that if you don’t exactly know what a chemical will do to a child’s health because there aren’t enough scientific studies out there, then you assume that what it is capable of is bad and so, if possible, try not to expose them, just as a precaution. 

 

When you can, buy from local farms or stands where you can ask them their growing practices, or else just grow your own. If you decide to buy organic foods, you should eat them right away. They may not stay edible as long without preservatives. Again, no matter what type of food you buy, wash, wash, wash.

 

Finally, alternative “greener” farming techniques, integrated pest management (IPM), and more resistant varieties of plants have increased crop yields, in many cases without using as much pesticide. That’s good news for all of us. Breeding of genetically-engineered plants require less use of pesticides, but they may not be acceptable to most consumers. That’s a whole column in itself!

 

The bottom line: My wife and I will try to buy organic foods when we think of it, but we don’t obsess over it when we forget. 

 

Alan Woolf, MD, MPH, FAACT, FAAP

Director, Pediatric Environmental Health Center, Children’s Hospital Boston

© 2010 Two Peds in a Pod®

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October 3, 2010 by

HURRAY! National Public Radio

We were thrilled to record today with National Public Radio’s Robin Young on Here and Now about Two Peds in a Pod. Watch for the upcoming piece where we wax and wane philosophical about topics ranging from our thoughts on poop to our story of how we started. 

 

The recording studio sure beat our kitchen table!


Naline Lai, MD with Julie Kardos, MD

© 2010 Two Peds in a Pod℠
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September 28, 2010 by

Fact or fiction? A flu vaccine quiz for all teachers, babysitters, parents, and anyone else who breathes on children

A few days ago, I spoke with the faculty of a local early childhood education center about flu vaccine myths. See how you do on the true and false quiz I gave them:


 


I can tell when I am getting the flu and will leave work before I infect anyone.


False. According to the CDC (US Center for Disease Control), you are infectious the day before symptoms show up.




I never get the flu so it’s not necessary to get the vaccine. 


False. Saying I’ve never had the flu is like saying, “I’ve never a car accident so I won’t wear my seat belt.”


 


I hate shots. I hear I can get a flu vaccine in a different form.


True.  One flu vaccine, brand name Flu Mist, provides immunity when squirted in the nose. Non-pregnant, healthy people aged 2-49 years of age qualify for this type of vaccine.


 


I got the flu shot so I was healthy all year.


False. Perhaps it was the half-hour a day you added to your workout, or the surgical mask you wore to birthday parties, but your entirely healthy winter was not secondary just to the flu vaccine.  The United States flu vaccine protects against several strains of flu predicted to cause illness this winter. This year’s vaccine contain both seasonal and the 2009 H1N1 strains. Your body builds up a defense (immunity) only against the strains covered in the vaccine. Immunity will not be conferred to the thousands of other viruses which exist. On the other hand, the vaccine probably did protect you from some forms of the flu, and two fewer weeks of illness feels great.




My friend got the flu shot last year, therefore, she was sick all winter.


My condolences. True, your friend was sick. But the answer is False, because the illnesses were not caused by the flu vaccine.  Vaccines are not real germs, so you can’t “get” a disease from the vaccine. But to your body, vaccine proteins appear very similar to real germs and your immune system will respond by making protection against the fake vaccine germ. When the real germ comes along, pow, your body already has the protection to fend off the real disease. Please know, however, there is a chance that for a couple days after a vaccine, you will ache and have a mild fever. The reason? Your immune system is simply revving up. But no, the flu vaccine does not give you an illness.


 


I got the flu vaccine every year for the past decade. I will still need to get one this year.


True. Unfortunately, the flu strains change from year to year. Previous vaccines may not protect you against current germs.


 


I am a healthy adult and not at high risk for complications from the flu, so I will forgo the flu vaccine this year.


False. The flu vaccine is now recommended for everyone greater than 6 months of age. When supply is limited, targeted groups at risk for flu complications include all children aged 6 months–18 years, all persons aged ≥50 years, and persons with medical conditions that put them at risk for medical complications.   These persons, people living in their home, their close contacts, and their CARETAKERS are the focus of vaccination. 


Even if I get the flu, I’ll just wash my hands a lot to keep the germ from spreading. I have to come back to work because I don’t have much time off.


False, According to the American Academy of Pediatrics Report of the Committee on Infectious Diseases, the influenza virus can spread from an infected person for about a week after infection.


 


Yes, kids get sick from others kids, but as a parent who comes in contact with two children, an early childhood educator who comes in contact with ten children, an elementary school teacher who comes in contact with twenty children or a high school teacher who comes into contact with one-hundred children daily, you may end up the one who seeds your community with a potentially deadly illness.  Right now, flu vaccine clinics are as plentiful as Starbucks. Hit that CVS or Walgreens on the way home, wander into your doctor’s or grab a shot while you get groceries.  By protecting yourself from the flu, you protect the children you care for.


 


Naline Lai, MD with Julie Kardos, MD


© 2010 Two Peds in a Pod℠

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September 25, 2010 by