Donor Human Milk for the High-Risk Infant: Preparation, Safety, and Usage Options in the United States. Pediatrics 2017; 139 (1)
The use of donor human milk is increasing for high-risk infants, primarily for infants born weighing <1500 g or those who have severe intestinal disorders. Pasteurized donor milk may be considered in situations in which the supply of maternal milk is insufficient. The use of pasteurized donor milk is safe when appropriate measures are used to screen donors and collect, store, and pasteurize the milk and then distribute it through established human milk banks. The use of nonpasteurized donor milk and other forms of direct, Internet-based, or informal human milk sharing does not involve this level of safety and is not recommended. It is important that health care providers counsel families considering milk sharing about the risks of bacterial or viral contamination of nonpasteurized human milk and about the possibilities of exposure to medications, drugs, or herbs in human milk. Currently, the use of pasteurized donor milk is limited by its availability and affordability. The development of public policy to improve and expand access to pasteurized donor milk, including policies that support improved governmental and private financial support for donor milk banks and the use of donor milk, is important.
View details for DOI 10.1542/peds.2016-3440
View details for PubMedID 27994111
Assessment of Sex Differences in Body Composition Among Adolescents With Anorexia Nervosa. The Journal of adolescent health : official publication of the Society for Adolescent Medicine 2017
To compare deficits in fat mass (FM) and lean body mass (LM) among male and female adolescents with anorexia nervosa (AN) and to identify other covariates associated with body composition.We retrospectively reviewed electronic medical records of all subjects aged 9-20years with a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnosis of AN and dual-energy x-ray absorptiometry scans after initial evaluation at Stanford between March 1997 and February 2011. From the dual-energy x-ray absorptiometry scans, LM and FM results were converted to age-, height-, sex-, and race-specific Z-scores for age using the National Health and Nutrition Examination Survey reference data.A total of 16 boys and 119 girls with AN met eligibility criteria. The FM Z-score in girls with AN (-3.24 1.50) was significantly lower than that in boys with AN (-2.41 .96) in unadjusted models (p= .007). LM was reduced in both girls and boys with AN, but there was no significant sex difference in LM Z-scores. In multivariate models, lower percentage median body mass index was significantly associated with lower FM Z-scores (= .08, p < .0001) and lower LM Z-score (= .03, p= .0002), whereas lower whole body bone mineral content Z-score was significantly associated with lower LM Z-score (= .21, p= .0006).FM deficits in girls were significantly greater than those in boys with AN in unadjusted models; however, the degree of malnutrition appeared to be the primary factor accounting for this difference. There were no significant sex differences in FM or LM in adjusted models.
View details for DOI 10.1016/j.jadohealth.2016.11.005
View details for PubMedID 28087266
Controlled Pilot Study of High-Impact Low-Frequency Exercise on Bone Loss and Vital-Sign Stabilization in Adolescents With Eating Disorders. The Journal of adolescent health : official publication of the Society for Adolescent Medicine 2017; 60 (1): 3337
Adolescents with anorexia nervosa (AN) face an increased lifetime risk of bone fragility. This randomized controlled study examined the efficacy and safety of a high-impact activity program on markers of bone turnover and stabilization of vital signs (VSS).Forty-one hospitalized adolescents with AN were randomly assigned to routine care or routine care plus 20 jumps twice daily. Bone markers were measured at baseline days 1-3 (T1), days 4-6 (T2), and days 7-9 (T3). The primary outcome was change in bone-specific alkaline phosphatase (BSAP) at T3 adjusted for BSAP and % median body mass index at T1. Secondary outcomes were serum N-telopeptide (NTX) and osteocalcin at T3. Safety was determined by comparing weight gain, time to VSS and length of stay for each group.BSAP, NTX, or osteocalcin did not differ between groups at baseline or at T3. BSAP and NTX at T3 were not associated with group of enrollment or % median body mass index. VSS was significantly reduced in the intervention group compared with the control group (11.6 5.7days vs. 17 10.5days, p= .049). There was no significant difference in weight gain or length of stay between groups.Twice-daily jumping activity failed to influence markers of bone turnover in adolescents with AN but was well tolerated, shortened time to vital-sign stabilization and did not slow weight gain.
View details for DOI 10.1016/j.jadohealth.2016.08.028
View details for PubMedID 27836532
Association of the Female Athlete Triad Risk Assessment Stratification to the Development of Bone Stress Injuries in Collegiate Athletes. The American journal of sports medicine 2017; 45 (2): 30210
The female athlete triad (referred to as the triad) contributes to adverse health outcomes, including bone stress injuries (BSIs), in female athletes. Guidelines were published in 2014 for clinical management of athletes affected by the triad.This study aimed to (1) classify athletes from a collegiate population of 16 sports into low-, moderate-, and high-risk categories using the Female Athlete Triad Cumulative Risk Assessment score and (2) evaluate the predictive value of the risk categories for subsequent BSIs.Cohort study; Level of evidence, 3.A total of 323 athletes completed both electronic preparticipation physical examination and dual-energy x-ray absorptiometry scans. Of these, 239 athletes with known oligomenorrhea/amenorrhea status were assigned to a low-, moderate-, or high-risk category. Chart review was used to identify athletes who sustained a subsequent BSI during collegiate sports participation; the injury required a physician diagnosis and imaging confirmation.Of 239 athletes, 61 (25.5%) were classified into moderate-risk and 9 (3.8%) into high-risk categories. Sports with the highest proportion of athletes assigned to the moderate- and high-risk categories included gymnastics (56.3%), lacrosse (50%), cross-country (48.9%), swimming/diving (42.9%), sailing (33%), and volleyball (33%). Twenty-five athletes (10.5%) assigned to risk categories sustained 1 BSI. Cross-country runners contributed the majority of BSIs (16; 64%). After adjusting for age and participation in cross-country, we found that moderate-risk athletes were twice as likely as low-risk athletes to sustain a BSI (risk ratio [RR], 2.6; 95% confidence interval [95% CI], 1.3-5.5) and high-risk athletes were nearly 4 times as likely (RR, 3.8; 95% CI, 1.8-8.0). When examining the 6 individual components of the triad risk assessment score, both the oligomenorrhea/amenorrhea score ( P = .0069) and the prior stress fracture/reaction score ( P = .0315) were identified as independent predictors for subsequent BSIs (after adjusting for cross-country participation and age).Using published guidelines, 29% of female collegiate athletes in this study were classified into moderate- or high-risk categories using the Female Athlete Triad Cumulative Risk Assessment Score. Moderate- and high-risk athletes were more likely to subsequently sustain a BSI; most BSIs were sustained by cross-country runners.
View details for DOI 10.1177/0363546516676262
View details for PubMedID 28038316
Nutrition in Children and Adolescents. Medical clinics of North America 2016; 100 (6): 1217-1235
Nutrition is a critical factor for appropriate child and adolescent development. Appropriate nutrition changes according to age. Nutrition is an important element for prevention of disease development, especially for chronic diseases. Many children and adolescents live in environments that do not promote optimum nutrition. Families must work to provide improved food environments to encourage optimum nutrition. Early primordial prevention of risk factors for chronic disease, such as cardiovascular disease, is important, and dietary habits established early may be carried through adult life.
View details for DOI 10.1016/j.mcna.2016.06.005
View details for PubMedID 27745591
Preventing Obesity and Eating Disorders in Adolescents. Pediatrics 2016; 138 (3)
Obesity and eating disorders (EDs) are both prevalent in adolescents. There are concerns that obesity prevention efforts may lead to the development of an ED. Most adolescents who develop an ED did not have obesity previously, but some teenagers, in an attempt to lose weight, may develop an ED. This clinical report addresses the interaction between obesity prevention and EDs in teenagers, provides the pediatrician with evidence-informed tools to identify behaviors that predispose to both obesity and EDs, and provides guidance about obesity and ED prevention messages. The focus should be on a healthy lifestyle rather than on weight. Evidence suggests that obesity prevention and treatment, if conducted correctly, do not predispose to EDs.
View details for DOI 10.1542/peds.2016-1649
View details for PubMedID 27550979
Vitamin D in Health and Disease in Adolescents: When to Screen, Whom to Treat, and How to Treat. Adolescent medicine: state of the art reviews 2016; 27 (1): 125-139
The existing guidelines on screening and treatment are confusing because different guidelines target different populations. The IOM and AAP guidelines target generally healthy populations, whereas the Endocrine Society and other subspecialty guidelines target individuals with specific medical conditions associated with increased bone fragility. These distinctions have not always been well articulated. For healthy adolescents, the AAP does not recommend universal screening or screening of obese or dark-skinned individuals. Increased dietary intake of vitamin D is recommended, and vitamin D supplementation can be considered if the RDA cannot be met. For adolescents with chronic medical illnesses associated with increased fracture risk, screening for vitamin D deficiency should be performed by obtaining a serum 25-OHD level. Those found to be deficient (25-OHD level < 20 ng/mL) should be treated with doses of vitamin D2 or vitamin D3 higher than the daily requirement (as discussed in the section on vitamin D and chronic disease), followed by a maintenance dose. A repeat 25-OHD level should be obtained after the therapeutic course is completed. Some experts advocate for achievement of 25-OHD levels greater than 30 ng/mL in conditions associated with increased bone fragility, and several pediatric subspecialty organizations have made recommendations specific to the diseases they treat. In such instances, the recommendations of the pediatric subspecialty organizations should take precedence over the AAP recommendations for adolescents with chronic illnesses associated with increased bone fragility because the AAP recommendations were primarily targeted at a healthy population.
View details for PubMedID 27363237
A systematic review of approaches to refeeding in patients with anorexia nervosa INTERNATIONAL JOURNAL OF EATING DISORDERS 2016; 49 (3): 293-310
Given the importance of weight restoration for recovery in patients with anorexia nervosa (AN), we examined approaches to refeeding in adolescents and adults across treatment settings.Systematic review of PubMed, PsycINFO, Scopus, and Clinical Trials databases (1960-2015) using terms refeeding, weight restoration, hypophosphatemia, anorexia nervosa, anorexia, and anorexic.Of 948 screened abstracts, 27 met these inclusion criteria: participants had AN; reproducible refeeding approach; weight gain, hypophosphatemia or cognitive/behavioral outcomes. Twenty-six studies (96%) were observational/prospective or retrospective and performed in hospital. Twelve studies published since 2010 examined approaches starting with higher calories than currently recommended (1400 kcal/d). The evidence supports 8 conclusions: 1) In mildly and moderately malnourished patients, lower calorie refeeding is too conservative; 2) Both meal-based approaches or combined nasogastric+meals can administer higher calories; 3) Higher calorie refeeding has not been associated with increased risk for the refeeding syndrome under close medical monitoring with electrolyte correction; 4) In severely malnourished inpatients, there is insufficient evidence to change the current standard of care; 5) Parenteral nutrition is not recommended; 6) Nutrient compositions within recommended ranges are appropriate; 7) More research is needed in non-hospital settings; 8) The long-term impact of different approaches is unknown; DISCUSSION: Findings support higher calorie approaches to refeeding in mildly and moderately malnourished patients under close medical monitoring, however the safety, long-term outcomes, and feasibility outside of hospital have not been established. Further research is also needed on refeeding approaches in severely malnourished patients, methods of delivery, nutrient compositions and treatment settings.
View details for DOI 10.1002/eat.22482
View details for Web of Science ID 000373029800008
View details for PubMedID 26661289
Oestradiol, amenorrhoea and lipids in adolescent girls with eating disorders: do they affect long-term cardiovascular risk? ACTA PAEDIATRICA 2016; 105 (3): 232-233
State of the art systematic review of bone disease in anorexia nervosa INTERNATIONAL JOURNAL OF EATING DISORDERS 2016; 49 (3): 276-292
Effect of a Prior History of Overweight on Return of Menses in Adolescents With Eating Disorders. The Journal of adolescent health : official publication of the Society for Adolescent Medicine 2016
The purpose of this study was to determine whether a history of overweight, weight suppression, and weight gain during treatment have an effect on return of menses (ROM) in adolescents with eating disorders (EDs).Retrospective chart review of female adolescents presenting to an ED program from January 2007 to June2009.One hundred sixty-three participants (mean age, 16.6 2.1 years) met eligibility criteria. The mean median body mass index percent at ROM for those previously overweight was 106.1 11.7 versus 94.2 8.9 for those not previously overweight (p < .001). Both groups needed to gain weight for ROM. Greater weight suppression (odds ratio, 0.90; 95% confidence interval, 0.84-0.98; p= .013) was associated with lower likelihood of ROM, and greater weight gain during treatment (odds ratio, 1.20; 95% confidence interval, 1.07-1.36; p= .002) was associated with higher likelihood of ROM in those not previously overweight.Previously overweight amenorrheic patients with EDs needed to be at a higher median body mass index percent for ROM compared to those who were not previously overweight.
View details for DOI 10.1016/j.jadohealth.2016.10.019
View details for PubMedID 27998699
Assessment of sex differences in bone deficits among adolescents with anorexia nervosa. The International journal of eating disorders 2016
The objective of this study was to compare sex differences in bone deficits among adolescents with anorexia nervosa (AN) and to identify other correlates of bone health.Electronic medical records of all patients 9-20 years of age with a DSM-5 diagnosis of AN who were evaluated by the eating disorders program at Stanford with dual-energy X-ray absorptiometry (DXA) between March 1997 and February 2011 were retrospectively reviewed. Whole body bone mineral content Z-scores and bone mineral density (BMD) Z-scores at multiple sites were recorded using the Bone Mineral Density in Childhood Study (BMDCS) reference data.A total of 25 males and 253 females with AN were included, with median age 15 years (interquartile range [IQR] 14-17) and median duration of illness 9 months (IQR 5-13). Using linear regression analyses, no significant sex differences in bone deficits were found at the lumbar spine, total hip, femoral neck, or whole body when controlling for age, %mBMI, and duration of illness. Lower %mBMI was significantly associated with bone deficits at all sites in adjusted models.This is the first study to evaluate sex differences in bone health among adolescents with AN, using novel DSM-5 criteria for AN and robust BMDCS reference data. We find no significant sex differences in bone deficits among adolescents with AN except for a higher proportion of females with femoral neck BMD Z-scores <-1. Degree of malnutrition was correlated with bone deficits at all sites. 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016).
View details for DOI 10.1002/eat.22626
View details for PubMedID 27611361
A Behavior-Based Intervention That Prevents Sexual Assault: the Results of a Matched-Pairs, Cluster-Randomized Study in Nairobi, Kenya. Prevention science : the official journal of the Society for Prevention Research 2016
The study's design was a cluster-randomized, matched-pairs, parallel trial of a behavior-based sexual assault prevention intervention in the informal settlements.The participants were primary school girls aged 10-16. Classroom-based interventions for girls and boys were delivered by instructors from the same settlements, at the same time, over six 2-h sessions. The girls' program had components of empowerment, gender relations, and self-defense. The boys' program promotes healthy gender norms. The control arm of the study received a health and hygiene curriculum. The primary outcome was the rate of sexual assault in the prior 12months at the cluster level (school level). Secondary outcomes included the generalized self-efficacy scale, the distribution of number of times victims were sexually assaulted in the prior period, skills used, disclosure rates, and distribution of perpetrators. Difference-in-differences estimates are reported with bootstrapped confidence intervals.Fourteen schools with 3147 girls from the intervention group and 14 schools with 2539 girls from the control group were included in the analysis. We estimate a 3.7% decrease, p=0.03 and 95% CI=(0.4, 8.0), in risk of sexual assault in the intervention group due to the intervention (initially 7.3% at baseline). We estimate an increase in mean generalized self-efficacy score of 0.19 (baseline average 3.1, on a 1-4 scale), p=0.0004 and 95% CI=(0.08, 0.39).This innovative intervention that combined parallel training for young adolescent girls and boys in school settings showed significant reduction in the rate of sexual assault among girls in this population.
View details for DOI 10.1007/s11121-016-0701-0
View details for PubMedID 27562036
Evidence That Classroom-Based Behavioral Interventions Reduce Pregnancy-Related School Dropout Among Nairobi Adolescents. Health education & behavior : the official publication of the Society for Public Health Education 2016
Purpose To evaluate the effect of behavioral, empowerment-focused interventions on the incidence of pregnancy-related school dropout among girls in Nairobi's informal settlements. Method Retrospective data on pregnancy-related school dropout from two cohorts were analyzed using a matched-pairs quasi-experimental design. The primary outcome was the change in the number of school dropouts due to pregnancy from 1 year before to 1 year after the interventions. Results Annual incidence of school dropout due to pregnancy decreased by 46% in the intervention schools (from 3.9% at baseline to 2.1% at follow-up), whereas the comparison schools remained essentially unchanged (p < .029). Sensitivity analysis shows that the findings are robust to small levels of unobserved bias. Conclusions Results suggest that these behavioral interventions significantly reduced the number of school dropouts due to pregnancy. As there are limited promising studies on behavioral interventions that decrease adolescent pregnancy in low-income settings, this intervention may be an important addition to this toolkit.
View details for DOI 10.1177/1090198116657777
View details for PubMedID 27486178
Optimizing bone health in Brazilian teens: using a population-based survey to guide targeted interventions to increase dietary calcium intake. Jornal de pediatria 2016
Assessment of Sex Differences in Fracture Risk Among Patients With Anorexia Nervosa: A Population-Based Cohort Study Using The Health Improvement Network. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research 2016
Though previous studies have demonstrated an increased fracture risk in females with anorexia nervosa (AN), fracture risk in males is not well characterized. The objective of this study was to examine sex differences in fracture risk and site-specific fracture incidence in AN. We performed a population-based retrospective cohort study using The Health Improvement Network (THIN; a large database of anonymized electronic medical records collected at primary care clinics throughout the United Kingdom). The median calendar year for the start of the observation period was 2004-2005. We identified 9239 females and 556 males <60 years of age with AN, and 97,889 randomly selected sex-, age-, and practice-matched participants without eating disorders (92,329 females and 5560 males). Multivariable Cox regression was used to estimate the hazard ratio (HR) for incident fracture. Median age at start of observation was 29.8 years in females and 30.2 years in males. The HR for fracture associated with AN differed by sex and age (interaction p=0.002). Females with AN had an increased fracture risk at all ages (HR, 1.59; 95% confidence interval [CI], 1.45 to 1.75). AN was associated with a higher risk of fracture among males >40 years of age (HR, 2.54; 95% CI, 1.32 to 4.90; p=0.005) but not among males 40 years. Females with AN had a higher risk of fracture at nearly all anatomic sites. The greatest excess fracture risk was noted at the hip/femur (HR, 5.59; 95% CI, 3.44 to 9.09) and pelvis (HR, 4.54; 95% CI, 2.42 to 8.50) in females and at the vertebrae (HR, 7.25; 95% CI, 1.21 to 43.45) for males with AN. AN was associated with higher incident fracture risk in females across all age groups and in males >40 years old. Sites of highest fracture risk include the hip/femur and pelvis in females and vertebrae in males with AN. 2016 American Society for Bone and Mineral Research.
View details for DOI 10.1002/jbmr.3068
View details for PubMedID 28019700
Promoting Food Security for All Children PEDIATRICS 2015; 136 (5): E1431-E1438
Sixteen million US children (21%) live in households without consistent access to adequate food. After multiple risk factors are considered, children who live in households that are food insecure, even at the lowest levels, are likely to be sick more often, recover from illness more slowly, and be hospitalized more frequently. Lack of adequate healthy food can impair a child's ability to concentrate and perform well in school and is linked to higher levels of behavioral and emotional problems from preschool through adolescence. Food insecurity can affect children in any community, not only traditionally underserved ones. Pediatricians can play a central role in screening and identifying children at risk for food insecurity and in connecting families with needed community resources. Pediatricians should also advocate for federal and local policies that support access to adequate healthy food for an active and healthy life for all children and their families.
View details for DOI 10.1542/peds.2015-3301
View details for Web of Science ID 000363969600034
View details for PubMedID 26498462
Bone Health in Adolescence. Adolescent medicine: state of the art reviews 2015; 26 (2): 291-325
Osteoporosis occurs during childhood and adolescence as a heritable condition such as OI, with acquired disease (eg, IBD), or iatrogenically as a result of high-dose glucocorticoid therapy. However, the number of children affected by osteoporosis during youth is small compared to the numbers who will develop osteoporosis in adulthood. Prevention of adult osteoporosis requires that an optimal environment for the achievement of peak bone mass be established during the growing years. Detection of low BMD can be achieved using modalities such as DXA and pQCT. Standard radiologic studies, especially vertebral radiography, may also be helpful in children and adolescents at high risk for osteoporosis. It is critical to the development of healthy bones that adolescents have proper nutrition with adequate calcium and vitamin D intake and that they participate in regular physical activity (especially weight-bearing exercise). In the recent past, the dual goals of proper nutrition and exercise were not being achieved by many, if not most, adolescents. Those caring for adolescents should strive to educate teens and their families on the importance of dietary calcium and vitamin D as well as advocate for supportive environments in schools and communities that foster the development of healthy habits with regard to diet and exercise. In order to help identify the population at risk for osteoporosis, a bone health screen with assessment of calcium intake and determination of family history of adult osteoporosis (hip fracture, kyphosis) should be a routine part of adolescent health care. Universal screening of healthy adolescents with serum 25OHD levels is not recommended. Adolescents with conditions associated with reduced bone mass should undergo bone densitometry or other studies as a baseline, and BMD should be monitored at intervals no more frequently than yearly. Although controversy remains regarding the optimum dose of vitamin D for treatment of osteoporosis, all would agree that vitamin D should be provided, and in doses somewhat higher than previously recommended. Excessive vitamin D should be avoided. The use of bisphosphonates is recommended for the treatment of OI, as well as for treatment of select children with severe osteoporosis associated with chronic conditions that lead to frequent or painful fragility fractures. In such situations, bisphosphonates should be prescribed only in the context of a comprehensive clinical program with specialists knowledgeable in the management of osteoporosis in children.
View details for PubMedID 26999874
Use of Psychopharmacologic Medications in Adolescents With Restrictive Eating Disorders: Analysis of Data From the National Eating Disorder Quality Improvement Collaborative JOURNAL OF ADOLESCENT HEALTH 2015; 57 (1): 66-72
Psychopharmacologic medications are often prescribed to patients with restrictive eating disorders (EDs), and little is known about the frequency of use in adolescents. We examined the use of psychopharmacologic medications in adolescents referred for treatment of restrictive ED, potential factors associated with their use, and reported psychiatric comorbidities.Retrospective data from the initial and 1-year visits were collected for patients referred for evaluation of restrictive ED at 12 adolescent-based ED programs during 2010 (Group 1), including diagnosis, demographic information, body mass index, prior treatment modalities, and psychopharmacologic medications. Additional data regarding patients' comorbid psychiatric conditions and classes of psychopharmacologic medications were obtained from six sites (Group 2).Overall, 635 patients met inclusion criteria and 359 had 1-year follow-up (Group 1). At intake, 20.4% of Group 1 was taking psychopharmacologic medication and 58.7% at 1year (p.0001). White, non-Hispanic race (p= .020), and prior higher level of care (p < .0001) were positively associated with medication use at 1 year. Among Group 2 (n= 256), serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors use was most common, and 62.6% had a reported psychiatric comorbidity. Presence of any psychiatric comorbidity was highly associated with medication use; odds ratio, 10.0 (5.6, 18.0).Adolescents with restrictive ED treated at referral centers have high rates of reported psychopharmacologic medication use and psychiatric comorbidity. As more than half of this referral population were reported to be taking medication, continued investigation is warranted to ensure the desired outcomes of the medications are being met.
View details for DOI 10.1016/j.jadohealth.2015.03.021
View details for Web of Science ID 000360055900008
View details for PubMedID 26095410
The Role of the Pediatrician in Primary Prevention of Obesity PEDIATRICS 2015; 136 (1): E275-E292
The adoption of healthful lifestyles by individuals and families can result in a reduction in many chronic diseases and conditions of which obesity is the most prevalent. Obesity prevention, in addition to treatment, is an important public health priority. This clinical report describes the rationale for pediatricians to be an integral part of the obesity-prevention effort. In addition, the 2012 Institute of Medicine report "Accelerating Progress in Obesity Prevention" includes health care providers as a crucial component of successful weight control. Research on obesity prevention in the pediatric care setting as well as evidence-informed practical approaches and targets for prevention are reviewed. Pediatricians should use a longitudinal, developmentally appropriate life-course approach to help identify children early on the path to obesity and base prevention efforts on family dynamics and reduction in high-risk dietary and activity behaviors. They should promote a diet free of sugar-sweetened beverages, of fewer foods with high caloric density, and of increased intake of fruits and vegetables. It is also important to promote a lifestyle with reduced sedentary behavior and with 60 minutes of daily moderate to vigorous physical activity. This report also identifies important gaps in evidence that need to be filled by future research.
View details for DOI 10.1542/peds.2015-1558
View details for Web of Science ID 000357296000036
View details for PubMedID 26122812
Update on the Medical Management of Eating Disorders in Adolescents JOURNAL OF ADOLESCENT HEALTH 2015; 56 (4): 370-375
Snacks, Sweetened Beverages, Added Sugars, and Schools PEDIATRICS 2015; 135 (3): 575-583
Concern over childhood obesity has generated a decade-long reformation of school nutrition policies. Food is available in school in 3 venues: federally sponsored school meal programs; items sold in competition to school meals, such as a la carte, vending machines, and school stores; and foods available in myriad informal settings, including packed meals and snacks, bake sales, fundraisers, sports booster sales, in-class parties, or other school celebrations. High-energy, low-nutrient beverages, in particular, contribute substantial calories, but little nutrient content, to a student's diet. In 2004, the American Academy of Pediatrics recommended that sweetened drinks be replaced in school by water, white and flavored milks, or 100% fruit and vegetable beverages. Since then, school nutrition has undergone a significant transformation. Federal, state, and local regulations and policies, along with alternative products developed by industry, have helped decrease the availability of nutrient-poor foods and beverages in school. However, regular access to foods of high energy and low quality remains a school issue, much of it attributable to students, parents, and staff. Pediatricians, aligning with experts on child nutrition, are in a position to offer a perspective promoting nutrient-rich foods within calorie guidelines to improve those foods brought into or sold in schools. A positive emphasis on nutritional value, variety, appropriate portion, and encouragement for a steady improvement in quality will be a more effective approach for improving nutrition and health than simply advocating for the elimination of added sugars.
View details for DOI 10.1542/peds.2014-3902
View details for Web of Science ID 000352206600058
View details for PubMedID 25713277
Medical management of restrictive eating disorders in adolescents and young adults. Position Paper of the Society for Adolescent Health and Medicine. J Adolesc Health Journal of Adolescent Health 2015; 56: 121-125
Abnormal white matter properties in adolescent girls with anorexia nervosa NEUROIMAGE-CLINICAL 2015; 9: 648-659
Abnormal white matter properties in adolescent girls with anorexia nervosa. NeuroImage. Clinical 2015; 9: 648-659
Anorexia nervosa (AN) is a serious eating disorder that typically emerges during adolescence and occurs most frequently in females. To date, very few studies have investigated the possible impact of AN on white matter tissue properties during adolescence, when white matter is still developing. The present study evaluated white matter tissue properties in adolescent girls with AN using diffusion MRI with tractography and T1 relaxometry to measure R1 (1/T1), an index of myelin content. Fifteen adolescent girls with AN (mean age=16.6years1.4) were compared to fifteen age-matched girls with normal weight and eating behaviors (mean age=17.1years1.3). We identified and segmented 9 bilateral cerebral tracts (18) and 8 callosal fiber tracts in each participant's brain (26 total). Tract profiles were generated by computing measures for fractional anisotropy (FA) and R1 along the trajectory of each tract. Compared to controls, FA in the AN group was significantly decreased in 4 of 26 white matter tracts and significantly increased in 2 of 26 white matter tracts. R1 was significantly decreased in the AN group compared to controls in 11 of 26 white matter tracts. Reduced FA in combination with reduced R1 suggests that the observed white matter differences in AN are likely due to reductions in myelin content. For the majority of tracts, group differences in FA and R1 did not occur within the same tract. The present findings have important implications for understanding the neurobiological factors underlying white matter changes associated with AN and invite further investigations examining associations between white matter properties and specific physiological, cognitive, social, or emotional functions affected in AN.
View details for DOI 10.1016/j.nicl.2015.10.008
View details for PubMedID 26740918
A 6-Week School Curriculum Improves Boys' Attitudes and Behaviors Related to Gender-Based Violence in Kenya. Journal of interpersonal violence 2015
This study investigated the effects of a gender-based violence (GBV) educational curriculum on improving male attitudes toward women and increasing the likelihood of intervention if witnessing GBV, among adolescent boys in Nairobi, Kenya. In total, 1,543 adolescents participated in this comparison intervention study: 1,250 boys received six 2-hr sessions of the "Your Moment of Truth" (YMOT) intervention, and 293 boys comprised the standard of care (SOC) group. Data on attitudes toward women were collected anonymously at baseline and 9 months after intervention. At follow-up, boys were also asked whether they encountered situations involving GBV and whether they successfully intervened. Compared with baseline, YMOT participants had significantly higher positive attitudes toward women at follow-up, whereas scores for SOC participants declined. At follow-up, the percentage of boys who witnessed GBV was similar for the two groups, except for physical threats, where the intervention group reported witnessing more episodes. The percentage of boys in the intervention group who successfully intervened when witnessing violence was 78% for verbal harassment, 75% for physical threat, and 74% for physical or sexual assault. The percentage of boys in the SOC group who successfully intervened was 38% for verbal harassment, 33% for physical threat, and 26% for physical or sexual assault. Results from the logistic regression demonstrate that more positive attitudes toward women predicted whether boys in the intervention group would intervene successfully when witnessing violence. This standardized 6-week GBV training program is highly effective in improving attitudes toward women and increasing the likelihood of successful intervention when witnessing GBV.
View details for DOI 10.1177/0886260515586367
View details for PubMedID 26063788
Predictors of Outcome at 1 Year in Adolescents With DSM-5 Restrictive Eating Disorders: Report of the National Eating Disorders Quality Improvement Collaborative JOURNAL OF ADOLESCENT HEALTH 2014; 55 (6): 750-756
Optimizing Bone Health in Children and Adolescents PEDIATRICS 2014; 134 (4): E1229-E1243
The pediatrician plays a major role in helping optimize bone health in children and adolescents. This clinical report reviews normal bone acquisition in infants, children, and adolescents and discusses factors affecting bone health in this age group. Previous recommended daily allowances for calcium and vitamin D are updated, and clinical guidance is provided regarding weight-bearing activities and recommendations for calcium and vitamin D intake and supplementation. Routine calcium supplementation is not recommended for healthy children and adolescents, but increased dietary intake to meet daily requirements is encouraged. The American Academy of Pediatrics endorses the higher recommended dietary allowances for vitamin D advised by the Institute of Medicine and supports testing for vitamin D deficiency in children and adolescents with conditions associated with increased bone fragility. Universal screening for vitamin D deficiency is not routinely recommended in healthy children or in children with dark skin or obesity because there is insufficient evidence of the cost-benefit of such a practice in reducing fracture risk. The preferred test to assess bone health is dual-energy x-ray absorptiometry, but caution is advised when interpreting results in children and adolescents who may not yet have achieved peak bone mass. For analyses, z scores should be used instead of T scores, and corrections should be made for size. Office-based strategies for the pediatrician to optimize bone health are provided. This clinical report has been endorsed by American Bone Health.
View details for DOI 10.1542/peds.2014-2173
View details for Web of Science ID 000343140500039
View details for PubMedID 25266429
Consumption of Raw or Unpasteurized Milk and Milk Products by Pregnant Women and Children PEDIATRICS 2014; 133 (1): 175-179
Sales of raw or unpasteurized milk and milk products are still legal in at least 30 states in the United States. Raw milk and milk products from cows, goats, and sheep continue to be a source of bacterial infections attributable to a number of virulent pathogens, including Listeria monocytogenes, Campylobacter jejuni, Salmonella species, Brucella species, and Escherichia coli O157. These infections can occur in both healthy and immunocompromised individuals, including older adults, infants, young children, and pregnant women and their unborn fetuses, in whom life-threatening infections and fetal miscarriage can occur. Efforts to limit the sale of raw milk products have met with opposition from those who are proponents of the purported health benefits of consuming raw milk products, which contain natural or unprocessed factors not inactivated by pasteurization. However, the benefits of these natural factors have not been clearly demonstrated in evidence-based studies and, therefore, do not outweigh the risks of raw milk consumption. Substantial data suggest that pasteurized milk confers equivalent health benefits compared with raw milk, without the additional risk of bacterial infections. The purpose of this policy statement was to review the risks of raw milk consumption in the United States and to provide evidence of the risks of infectious complications associated with consumption of unpasteurized milk and milk products, especially among pregnant women, infants, and children.
View details for DOI 10.1542/peds.2013-3502
View details for Web of Science ID 000329168400059
View details for PubMedID 24344105
Associations of Elevated Liver Enzymes among Hospitalized Adolescents with Anorexia Nervosa. The Journal of pediatrics 2014
To analyze the prevalence, predictors, and evolution of increased liver enzymes in a large sample of adolescents hospitalized with anorexia nervosa (AN).Electronic medical records of all subjects 10-22years of age with AN, first admitted to a tertiary children's hospital from January 2007 to December 2012, were reviewed retrospectively. Demographic factors, anthropometric factors, initial prescribed calories, and alanine aminotransferase levels were recorded. Multivariate analysis was performed to assess the effect of sex, degree of malnutrition, and initial calories prescribed on having alanine aminotransferase 40 IU/L.A total of 356 subjects met eligibility criteria (age 16.12.4; 89.0% female; admission body mass index [BMI] 15.91.9; admission percentage median BMI 78.28.5), with elevated liver enzymes present in 37.0% on admission and in 41.1% at any point during the hospitalization. Lower percentage median BMI (aOR 0.96; 95% CI 0.93-0.98) and male sex (aOR 0.45; 95% CI 0.22-0.94) were significantly associated with odds of elevated liver enzymes on admission. Higher initial prescribed calories were associated with odds of elevated liver enzymes after admission (aOR 1.81; 95% CI 1.04-3.18).In this study of AN and elevated liver enzymes, the degree of malnutrition and male sex predicted elevated liver enzymes on admission but initial prescribed calories also may be associated with elevated liver enzymes after admission in a small proportion of patients. Future research should better characterize the evolution of elevated liver enzymes in patients hospitalized with AN undergoing refeeding.
View details for DOI 10.1016/j.jpeds.2014.10.048
View details for PubMedID 25477162
Refeeding Hypophosphatemia in Hospitalized Adolescents with Anorexia Nervosa: a Position Statement of the Society for Adolescent Health and Medicine Journal of Adolescent Health 2014; 55 (3): 455-457
Higher Caloric Intake in Hospitalized Adolescents With Anorexia Nervosa Is Associated With Reduced Length of Stay and No Increased Rate of Refeeding Syndrome JOURNAL OF ADOLESCENT HEALTH 2013; 53 (5): 573-578
To determine the effect of higher caloric intake on weight gain, length of stay (LOS), and incidence of hypophosphatemia, hypomagnesemia, and hypokalemia in adolescents hospitalized with anorexia nervosa.Electronic medical records of all subjects 10-21 years of age with anorexia nervosa, first admitted to a tertiary children's hospital from Jan 2007 to Dec 2011, were retrospectively reviewed. Demographic factors, anthropometric measures, incidence of hypophosphatemia (3.0 mg/dL), hypomagnesemia (1.7 mg/dL), and hypokalemia (3.5 mEq/L), and daily change in percent median body mass index (BMI) (%mBMI) from baseline were recorded. Subjects started on higher-calorie diets (1,400 kcal/d) were compared with those started on lower-calorie diets (<1,400 kcal/d).A total of 310 subjects met eligibility criteria (age, 16.1 2.3 years; 88.4% female, 78.5 8.3 %mBMI), including 88 in the lower-calorie group (1,163 107 kcal/d; range, 720-1,320 kcal/d) and 222 in the higher-calorie group (1,557 265 kcal/d; range, 1,400-2,800 kcal/d). Neither group had initial weight loss. The %mBMI increased significantly (p < .001) from baseline by day 1 in the higher-calorie group and day 2 in the lower-calorie group. Compared with the lower-calorie group, the higher-calorie group had reduced LOS (13.0 7.3 days versus 16.6 9.0 days; p < .0001), but the groups did not differ in rate of change in %mBMI (p= .50) or rates of hypophosphatemia (p=.49), hypomagnesemia (p= 1.0), or hypokalemia (p= .35). Hypophosphatemia was associated with %mBMI on admission (p= .004) but not caloric intake (p= .14).A higher caloric diet on admission is associated with reduced LOS, but not increased rate of weight gain or rates of hypophosphatemia, hypomagnesemia, or hypokalemia. Refeeding hypophosphatemia depends on the degree of malnutrition but not prescribed caloric intake, within the range studied.
View details for DOI 10.1016/j.jadohealth.2013.05.014
View details for Web of Science ID 000325751800005
View details for PubMedID 23830088
A Self-Defense Program Reduces the Incidence of Sexual Assault in Kenyan Adolescent Girls JOURNAL OF ADOLESCENT HEALTH 2013; 53 (3): 374-380
PURPOSE: To determine the effect of a standardized 6-week self-defense program on the incidence of sexual assault in adolescent high school girls in an urban slum in Nairobi, Kenya. METHODS: Population-based survey of 522 high school girls in the Korogocho-Kariobangi locations in Nairobi, Kenya, at baseline and 10 months later. Subjects were assigned by school attended to either a "No Means No Worldwide" self-defense course (eight schools; N= 402) or to a life-skills class (two schools; N= 120). Both the intervention and the life-skills classes were taught in the schools by trained instructors. Participants were administered the same survey at baseline and follow-up. RESULTS: A total of 522 girls (mean age, 16.7 1.5 years; range, 14-21 years) completed surveys at baseline, and 489 at 10-month follow-up. At baseline, 24.5% reported sexual assault in the prior year, with the majority (90%) reporting assault by someone known to them (boyfriend, 52%; relative, 17%; neighbor, 15%; teacher or pastor, 6%). In the self-defense intervention group, the incidence of sexual assault decreased from 24.6% at baseline to 9.2% at follow-up (p < .001), in contrast to the control group, in which the incidence remained unchanged (24.2% at baseline and 23.1% at follow-up; p= .10). Over half the girls in the intervention group reported having used the self-defense skills to avert sexual assault in the year after the training. Rates of disclosure increased in the intervention group, but not in controls. CONCLUSIONS: A standardized 6-week self-defense program is effective in reducing the incidence of sexual assault in slum-dwelling high school girls in Nairobi, Kenya.
View details for DOI 10.1016/j.jadohealth.2013.04.008
View details for Web of Science ID 000323602900012
View details for PubMedID 23727500
Calcium and vitamin d requirements of enterally fed preterm infants. Pediatrics 2013; 131 (5): e1676-83
Bone health is a critical concern in managing preterm infants. Key nutrients of importance are calcium, vitamin D, and phosphorus. Although human milk is critical for the health of preterm infants, it is low in these nutrients relative to the needs of the infants during growth. Strategies should be in place to fortify human milk for preterm infants with birth weight <1800 to 2000 g and to ensure adequate mineral intake during hospitalization and after hospital discharge. Biochemical monitoring of very low birth weight infants should be performed during their hospitalization. Vitamin D should be provided at 200 to 400 IU/day both during hospitalization and after discharge from the hospital. Infants with radiologic evidence of rickets should have efforts made to maximize calcium and phosphorus intake by using available commercial products and, if needed, direct supplementation with these minerals.
View details for DOI 10.1542/peds.2013-0420
View details for PubMedID 23629620
Underestimation of Weight Status in Californian Adolescents CHILDHOOD OBESITY 2013; 9 (2): 132-136
Overweight and obese adolescents commonly underestimate their weight status, considering themselves to be at a healthy weight or underweight. These adolescents are more likely to be male, older, and Latino, black, or Native American. Associations with acculturation have not been previously assessed. The goal of this study was to identify the prevalence of underestimation of weight status in Californian adolescents and to identify factors associated with this underestimation, in particular examining relationships with race/ethnicity and acculturation.Secondary data analysis of the 2005 Adolescent California Health Interview Survey.A total of 36.6% of overweight and obese Californian adolescents underestimated their weight status. Adolescents not born in the United States had increased odds of underestimating their weight status compared to those born in the United States [adjusted odds ratio (aOR)=1.94, 95% confidence interval (CI) 1.08, 3.49; p=0.03]. No significant associations with race/ethnicity were found. An age-sex interaction was observed with older adolescent males having increased odds compared to younger females.Identification of individuals at increased odds of underestimating their weight status may be important in developing and targeting appropriate counseling and interventions to ameliorate long-term health risks of excess weight.
View details for DOI 10.1089/chi.2012.0096
View details for Web of Science ID 000336846200007
View details for PubMedID 23489317
REPORT FROM THE NATIONAL EATING DISORDER QUALITY IMPROVEMENT COLLABORATIVE OF TEN ADOLESCENT MEDICINE-BASED EATING DISORDER PROGRAMS: POPULATION DESCRIPTION AND PREDICTORS OF WEIGHT OUTCOME AT ONE YEAR ELSEVIER SCIENCE INC. 2013: S37-S38
USE OF PSYCHOPHARMACOLOGIC MEDICATIONS IN ADOLESCENTS WITH RESTRICTIVE EATING DISORDERS: ANALYSIS OF DATA FROM THE NATIONAL EATING DISORDER QUALITY IMPROVEMENT COLLABORATIVE ELSEVIER SCIENCE INC. 2013: S39-S39
Ovarian torsion in a patient with mllerian agenesis: increased risk? Journal of pediatric and adolescent gynecology 2012; 25 (6): e125-8
Patients with mllerian agenesis may be at an increased risk of ovarian torsion due to the absence of the utero-ovarian ligament and the fact that the ovary is not tethered to a fixed and relatively non-mobile structure, the uterus.We report a case of a 14-year-old female with abdominal pain who had a physical examination suggestive of mllerian agenesis. Imaging was non-diagnostic and demonstrated an abdominal mass. Emergent surgery revealed ovarian torsion.We present this case of ovarian torsion and mllerian agenesis, in order to highlight the association and to review potential risk factors.
View details for DOI 10.1016/j.jpag.2012.08.001
View details for PubMedID 23095528
Language Spoken at Home and Parental Birthplace Moderate the Association of Race/Ethnicity and Distorted Weight Perception CLINICAL PEDIATRICS 2012; 51 (12): 1155-1163
Distorted weight perception (DWP), specifically overestimating weight status, is common in adolescents and may lead to eating disorders. The authors examined the role of acculturation proxies as effect modifiers of the relationship between race/ethnicity and DWP in a diverse adolescent population. Analysis of the 2005 California Health Interview Survey showed that of 2955 adolescents with underweight or healthy weight status, 10.6% reported DWP. Latino adolescents had increased odds of DWP compared with white adolescents (adjusted odds ratio [aOR] = 3.02; 95% confidence interval [CI] = 2.00, 4.57). Latinos who spoke English and other language(s) at home (aOR = 3.38; 95% CI = 2.11, 5.41) and Latino (aOR = 5.00; 95% CI = 2.34, 10.72) and Asian (aOR = 3.10, 95% CI = 1.15, 8.35) adolescents who spoke no English at home had increased odds of DWP compared with white, English-only speakers. Latino adolescents had increased odds (aOR = 3.98, 95% CI = 2.45, 6.47) of DWP if neither parent was US born. Assessing acculturation proxies may help identify adolescents at risk of DWP.
View details for DOI 10.1177/0009922812458357
View details for Web of Science ID 000311757400007
View details for PubMedID 22935216
Expected Body Weight in Adolescents: Comparison Between Weight-for-Stature and BMI Methods PEDIATRICS 2012; 130 (6): E1607-E1613
To test the hypothesis that the weight-for-stature (WFS) and BMI methods are not equivalent in determining expected body weight (EBW) in adolescents with eating disorders and to determine the sensitivity, specificity, and positive predictive value of each method to detect those <75% EBW. We hypothesized that differences in EBW would be greatest at the extremes of height.EBW was determined for 12 047 individual adolescents aged 12 to 19 years by the WFS and BMI methods by utilizing the same National Center for Health Statistics data sets. Absolute difference between the 2 methods for each individual was calculated and plotted against height by using a generalized additive model. The number of individuals whose weights were <75% EBW was determined by each method.For girls, EBW was 3.52 3.13% higher when using the WFS method compared with the BMI method. For boys, EBW(WFS) was 3.45 2.72% higher than EBW(BMI). Among adolescent girls, 65% had EBW(WFS) higher than EBW(BMI). By using the EBW(WFS) method as the gold standard, specificity of the EBW(BMI) method to detect those <75% EBW was 0.999, but sensitivity was only 0.329. Absolute differences in EBW were most pronounced at the extremes of height.The WFS and BMI methods are not equivalent in determining EBW in adolescents and are not interchangeable. EBW(WFS) was ~3.5% higher than EBW(BMI). In adolescents with eating disorders, use of the BMI method will underestimate the degree of malnutrition compared with the WFS method. Which method better predicts meaningful clinical outcomes remains to be determined.
View details for DOI 10.1542/peds.2012-0897
View details for Web of Science ID 000314802000024
View details for PubMedID 23147977
Organic Foods: Health and Environmental Advantages and Disadvantages PEDIATRICS 2012; 130 (5): E1406-E1415
The US market for organic foods has grown from $3.5 billion in 1996 to $28.6 billion in 2010, according to the Organic Trade Association. Organic products are now sold in specialty stores and conventional supermarkets. Organic products contain numerous marketing claims and terms, only some of which are standardized and regulated. In terms of health advantages, organic diets have been convincingly demonstrated to expose consumers to fewer pesticides associated with human disease. Organic farming has been demonstrated to have less environmental impact than conventional approaches. However, current evidence does not support any meaningful nutritional benefits or deficits from eating organic compared with conventionally grown foods, and there are no well-powered human studies that directly demonstrate health benefits or disease protection as a result of consuming an organic diet. Studies also have not demonstrated any detrimental or disease-promoting effects from an organic diet. Although organic foods regularly command a significant price premium, well-designed farming studies demonstrate that costs can be competitive and yields comparable to those of conventional farming techniques. Pediatricians should incorporate this evidence when discussing the health and environmental impact of organic foods and organic farming while continuing to encourage all patients and their families to attain optimal nutrition and dietary variety consistent with the US Department of Agriculture's MyPlate recommendations. This clinical report reviews the health and environmental issues related to organic food production and consumption. It defines the term "organic," reviews organic food-labeling standards, describes organic and conventional farming practices, and explores the cost and environmental implications of organic production techniques. It examines the evidence available on nutritional quality and production contaminants in conventionally produced and organic foods. Finally, this report provides guidance for pediatricians to assist them in advising their patients regarding organic and conventionally produced food choices.
View details for DOI 10.1542/peds.2012-2579
View details for Web of Science ID 000310505900044
View details for PubMedID 23090335
Hypomagnesemia in Adolescents With Eating Disorders Hospitalized for Medical Instability NUTRITION IN CLINICAL PRACTICE 2012; 27 (5): 689-694
Hypomagnesemia in patients with eating disorders is poorly characterized, particularly among adolescents.To determine the prevalence of hypomagnesemia (Mg ? 1.7 mg/dL) and clinical characteristics of adolescents hospitalized with a DSM-IV-diagnosed eating disorder who developed hypomagnesemia, a retrospective chart review was conducted on all adolescents aged 10-21 years with an eating disorder were hospitalized at a tertiary care children's hospital from 2007 to 2010. Patients were refed orally with standard nutrition and high-energy liquid supplements. Serum magnesium and phosphorus were obtained on admission, every 24-48 hours for the first week, and thereafter as clinically indicated. Clinical characteristics of patients with hypomagnesemia were compared with those of individuals with normal magnesium levels and those with hypophosphatemia.Eighty-six of 541 eligible participants (15.9%) developed hypomagnesemia. Forty (47%) with hypomagnesemia admitted to purging in the year before admission, with 88% purging during the prior month. Compared with those with normal serum magnesium levels, patients with hypomagnesemia were older (P = .0001), ill longer (P = .001), more likely to be purging (P = .04), and more likely to have an alkaline urine (P = .01). They did not differ in eating disorder diagnosis, BMI, or other electrolyte disturbances. Hypomagnesemia developed 4.9 5.5 days after refeeding was initiated, significantly later than the onset of hypophosphatemia, 0.95 2.6 days (P < .001).Hypomagnesemia is prevalent in adolescents hospitalized for an eating disorder and is associated with purging and alkaline urine. Hypomagnesemia develops later in the course of refeeding than hypophosphatemia. Magnesium levels should continue to be monitored after the more immediate risk of hypophosphatemia has passed, especially in those with alkaline urine.
View details for DOI 10.1177/0884533612446799
View details for Web of Science ID 000308413300014
View details for PubMedID 22683565
Pediatric Residents' Knowledge, Use, and Comfort With Expedited Partner Therapy for STIs PEDIATRICS 2012; 130 (4): 705-711
We examined California pediatric residents' knowledge, practices, and comfort of providing expedited partner therapy (EPT) for sexually transmitted infections, by postgraduate year of training and presence of an adolescent medicine fellowship. We hypothesized that few residents are aware of EPT, and fewer are comfortable providing it; knowledge, practices, and comfort increase during residency; and presence of an adolescent medicine fellowship increases knowledge, practices, and comfort.Online anonymous questionnaires were completed by pediatric residents from 14 California programs.Two hundred eighty-nine pediatric residents (41% response; mean age, 29.4 2.7 years; 78% female) responded. Twenty-two percent reported being moderately or very familiar with EPT. Most correctly identified several EPT methods. Incorrectly identified as EPT included patient (55%), health department (42%), and provider (37%) referrals. Only 8% were aware of California's legal status regarding EPT. Sixty-nine percent knew that California law allows EPT for chlamydia and gonorrhea, but 38% incorrectly stated that EPT can be used to treat trichomoniasis. Fifty-two percent reported ever providing EPT, but 30% of them were uncomfortable doing so. Postgraduate year 1 residents were significantly more likely to report lack of experience as a barrier to prescribing EPT. Residents in programs with the presence of an adolescent medicine fellowship had significantly higher global knowledge scores and were more likely to practice EPT with fewer concerns.California pediatric residents have knowledge gaps and discomfort providing EPT, and the presence of adolescent medicine fellowship is associated with increased EPT knowledge, use, and comfort among residents. Our findings demonstrate a need to improve EPT education in pediatric residencies.
View details for DOI 10.1542/peds.2011-3764
View details for Web of Science ID 000309412100056
View details for PubMedID 22987881
CALIFORNIA PEDIATRIC RESIDENTS' KNOWLEDGE, PRACTICES AND COMFORT USING EXPEDITED PARTNER THERAPY FOR SEXUALLY TRANSMITTED INFECTIONS ELSEVIER SCIENCE INC. 2012: S17-S17
The Female Athlete Triad The Female Patient 2012; 37 (6): 16-24
An Eleven Site National Quality Improvement Evaluation of Adolescent Medicine-Based Eating Disorder Programs: Predictors of Weight Outcomes at One Year and Risk Adjustment Analyses JOURNAL OF ADOLESCENT HEALTH 2011; 49 (6): 594-600
This quality improvement project collected and analyzed short-term weight gain data for patients with restrictive eating disorders (EDs) treated in outpatient adolescent medicine-based ED programs nationally.Data on presentation and treatment of low-weight ED patients aged 9-21 years presenting in 2006 were retrospectively collected from 11 independent ED programs at intake and at 1-year follow-up. Low-weight was defined as < 90% median body weight (MBW) which is specific to age. Treatment components at each program were analyzed. Risk adjustment was performed for weight gain at 1 year for each site, accounting for clinical variables identified as significant in bivariate analyses.The sites contained 6-51 patients per site (total N = 267); the mean age was 14.1-17.1 years; duration of illness before intake was 5.7-18.6 months; % MBW at intake was 77.5-83.0; and % MBW at follow-up was 88.8-93.8. In general, 40%-63% of low weight ED subjects reached ?90% MBW at 1-year follow-up. At intake, patients with higher % MBW (p = .0002) and shorter duration of illness (p = .01) were more likely to be ?90% MBW at follow-up. Risk-adjusted odds ratios controlled for % MBW and duration of illness were .8 (.5, 1.4)-1.3 (.3, 3.8), with no significant differences among sites.A total of 11 ED programs successfully compared quality improvement data. Shorter duration of illness before intake and higher % MBW predicted improved weight outcomes at 1 year. After adjusting for risk factors, program outcomes did not differ significantly. All adolescent medicine-based ED programs were effective in assisting patients to gain weight.
View details for DOI 10.1016/j.jadohealth.2011.04.023
View details for Web of Science ID 000297261000005
View details for PubMedID 22098769
A Placebo-Controlled Pilot Study of Adjunctive Olanzapine for Adolescents with Anorexia Nervosa JOURNAL OF CHILD AND ADOLESCENT PSYCHOPHARMACOLOGY 2011; 21 (3): 207-212
The objective of this study was to explore whether the addition of olanzapine versus placebo increases weight gain and improves psychological symptoms in adolescents with anorexia nervosa-restricting type who are participating in a comprehensive eating disorders treatment program.Twenty underweight females participated in this 10-week, double-blind, placebo-controlled pilot study of olanzapine. The primary efficacy measure was change in percentage of median body weight measured at baseline and weeks 5 and 10. Secondary efficacy measures included clinician-rated and self-reported measures of psychological functioning measured at 2-week intervals and eating disorder symptoms measured at baseline and weeks 5 and 10 as well as laboratory assessments (including indirect calorimetry), which were also performed at baseline and weeks 5 and 10. A mixed models approach to repeated measures analysis of variance was utilized to detect any treatment-by-time interaction.Fifteen of 20 enrolled females (median age, 17.1 years; range, 12.3-21.8 years; mean body mass index, 16.3) completed this 10-week pilot study. Change in % median body weight did not differ between the treatment groups at midpoint or end of study. Both groups gained weight at a similar rate and had similar improvements in eating attitudes and behaviors, psychological functioning, and resting energy expenditure. A trend of increasing fasting glucose and insulin levels was found only in the olanzapine group at week 10.These preliminary findings do not support a role for adjunctive olanzapine for underweight adolescent females with anorexia nervosa-restricting type who are receiving standard care in an eating disorder treatment program (clinical trials.gov; no. NCT00592930).
View details for DOI 10.1089/cap.2010.0139
View details for Web of Science ID 000291466000002
View details for PubMedID 21663423
Psychopharmacology of Eating Disorders in Children and Adolescents PEDIATRIC CLINICS OF NORTH AMERICA 2011; 58 (1): 121-?
Eating disorders are serious psychiatric illnesses that often present during adolescence and young adulthood. They are associated with medical as well as psychological disturbances, and pediatricians play an important role in their identification, diagnosis, and management. There has been a paucity of treatment research that specifically focuses on children and adolescents with eating disorders. This article reviews the scientific evidence for the use of psychotropic medication in the treatment of children and adolescents with eating disorders.
View details for DOI 10.1016/j.pcl.2010.11.001
View details for Web of Science ID 000288344400010
View details for PubMedID 21281852
An Introduction to Eating Disorders: Clinical Presentation, Epidemiology, and Prognosis NUTRITION IN CLINICAL PRACTICE 2010; 25 (2): 110-115
The spectrum of eating disorders varies widely, ranging from mildly abnormal eating habits to life-threatening chronic disease. Given the many different cultural food norms and individual preferences, along with the fact that dieting behavior is extremely common, it can be challenging to differentiate unusual eating behaviors from clinically significant eating disorders. In this article, the authors provide an introduction to eating disorders including anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified, focusing on the clinical presentation, epidemiology, and prognosis.
View details for DOI 10.1177/0884533609357566
View details for Web of Science ID 000276806500002
View details for PubMedID 20413691
AN ELEVEN SITE NATIONAL QUALITY IMPROVEMENT PROJECT OF ADOLESCENT MEDICINE-BASED EATING DISORDERS PROGRAMS: WEIGHT OUTCOMES AT ONE YEAR ELSEVIER SCIENCE INC. 2010: S9-S10
DOES ACCULTURATION EXPLAIN DISTORTED WEIGHT PERCEPTION IN OVERWEIGHT AND OBESE CALIFORNIAN ADOLESCENTS? ELSEVIER SCIENCE INC. 2010: S41-S41
Osteoporosis in Anorexia Nervosa. Expert Rev. Endocrinol. Metab. 2010; 5 (5): 723-732
Metabolic Assessment of Menstruating and Nonmenstruating Normal Weight Adolescents INTERNATIONAL JOURNAL OF EATING DISORDERS 2009; 42 (7): 658-663
Resumption of menses (ROM) is a key indicator of recovery in AN, but patients may remain amenorrheic despite weight restoration. The objective of this study is to better understand the mechanism of amenorrhea in patients with eating disorders.A retrospective chart review was conducted of 382 normal weight adolescents with a history of anorexia nervosa, bulimia nervosa, or eating disorder not otherwise specified, who had been referred for indirect calorimetry tests. Resting energy expenditure (REE) was compared between amenorrheic (n = 60) and regularly menstruating females (n = 121).Participants with amenorrhea had a mean REE of 1,103 kcal/24 h (79% predicted), whereas participants who were menstruating regularly had a mean REE of 1,217 kcal/24 h (85% predicted; p = 0.001). The amenorrheic group was found to be at a lower mean body weight (53.7 +/- 5.6 kg vs. 57.5 +/- 7.4 kg; p < or = 0.001), at a lower percent ideal body weight (98.5 +/- 8.3% vs. 102.8 +/- 10.2%; p = 0.005), and at a lower BMI (20.5 +/- 1.7 vs. 21.5 +/- 2.2; p = 0.002).This study highlights that amenorrheic participants with a history of eating disorders who are at normal body weight are hypometabolic, suggesting an adaptive response to dietary restriction.
View details for DOI 10.1002/eat.20604
View details for Web of Science ID 000271708400010
View details for PubMedID 19247996
THE CO-OCCURRENCE OF INSOMNIA AND DEPRESSION SYMPTOMS IN AN ADOLESCENT MEDICAL CLINIC: A PILOT STUDY AMER ACAD SLEEP MEDICINE. 2009: A358-A359
Using OC in Teen Eating Disorders: What are We Treating? Contemporary Ob/Gyn 2009; 54 (2): 39-46
Variability in Admission Practices for Teens Hospitalized with Anorexia Nervosa: A Call for Evidence-based Outcome Studies JOURNAL OF ADOLESCENT HEALTH 2008; 43 (5): 417-418
Treatment goal weight in adolescents with anorexia nervosa: Use of BMI percentiles INTERNATIONAL JOURNAL OF EATING DISORDERS 2008; 41 (4): 301-306
There is a lack of consensus as to how to determine treatment goal weight in the growing adolescent with anorexia nervosa (AN). Resumption of menses (ROM) is an indicator of biological health and weight at ROM can be used as a treatment goal weight. This study determined the BMI percentile for age at which ROM occurs.A secondary analysis of a prospective cohort study examining 56 adolescent females with AN, aged 12-19 years, followed every 3 months until ROM. BMI percentiles for age and gender at ROM were determined using the nutrition module of Epi Info 2002.At 1-year follow-up, 36 participants (64.3%) resumed menses and 20 (35.7%) remained amenorrheic. Mean BMI percentile at ROM was 27.1 (95% CI = 20.0-34.2). Fifty percent of participants who resumed menses, did so at a BMI percentile between the 14th and 39th percentile.A BMI percentile range of 14th-39th percentile can be used to assign a treatment goal weight, with adjustments for prior weight, stage of pubertal development, and anticipated growth.
View details for DOI 10.1002/eat.20503
View details for Web of Science ID 000255147100002
View details for PubMedID 18176951
The pathophysiology of amenorrhea in the adolescent MENSTRUAL CYCLE AND ADOLESCENT HEALTH 2008; 1135: 163-178
Menstrual irregularity is a common occurrence during adolescence, especially within the first 2-3 years after menarche. Prolonged amenorrhea, however, is not normal and can be associated with significant medical morbidity, which differs depending on whether the adolescent is estrogen-deficient or estrogen-replete. Estrogen-deficient amenorrhea is associated with reduced bone mineral density and increased fracture risk, while estrogen-replete amenorrhea can lead to dysfunctional uterine bleeding in the short term and predispose to endometrial carcinoma in the long term. In both situations, appropriate intervention can reduce morbidity. Old paradigms of whom to evaluate for amenorrhea have been challenged by recent research that provides a better understanding of the normal menstrual cycle and its variability. Hypothalamic amenorrhea is the most prevalent cause of amenorrhea in the adolescent age group, followed by polycystic ovary syndrome. In anorexia nervosa, exercise-induced amenorrhea, and amenorrhea associated with chronic illness, an energy deficit results in suppression of hypothalamic secretion of GnRH, mediated in part by leptin. Administration of recombinant leptin to women with hypothalamic amenorrhea has been shown to restore LH pulsatility and ovulatory menstrual cycles. The use of recombinant leptin may improve our understanding of the pathophysiology of hypothalamic amenorrhea in adolescents and may also have therapeutic possibilities.
View details for DOI 10.1196/annals.1429.014
View details for Web of Science ID 000257452900021
View details for PubMedID 18574222
Eating disorders in adolescence: what is the role of hormone replacement therapy? CURRENT OPINION IN OBSTETRICS & GYNECOLOGY 2007; 19 (5): 434-439
To review the diagnostic criteria and clinical presentation of eating disorders in adolescence, to outline an approach to treatment, and examine evidence for prescribing hormone replacement therapy to increase bone mineral density in anorexia nervosa.Eating disorders are prevalent in adolescents and can present with amenorrhea and menstrual disturbances. Reduced bone mineral density leading to osteoporosis and increased fracture risk is a frequent, severe, and potentially irreversible complication of anorexia nervosa. The degree of bone mineral density reduction depends on the duration of amenorrhea and degree of malnutrition. Limited evidence supports the use of hormone replacement therapy to increase bone mineral density in adolescents with anorexia nervosa.In adolescents with amenorrhea or menstrual disturbances, the gynecologist should consider the possibility of an eating disorder. The diagnosis can be made on history and physical examination. If an eating disorder is suspected, the patient should be referred for evaluation and treatment. Support for the use of hormone replacement therapy to increase bone mineral density in adolescents with anorexia nervosa is limited, and its routine use should be discouraged. Weight restoration, calcium and vitamin D supplementation and the resumption of spontaneous menses is the mainstay of treatment.
View details for Web of Science ID 000249972000005
View details for PubMedID 17885458
Alendronate for the treatment of osteopenia in anorexia nervosa: A randomized, double-blind, placebo-controlled trial JOURNAL OF CLINICAL ENDOCRINOLOGY & METABOLISM 2005; 90 (6): 3179-3185
Osteopenia is a serious medical complication of anorexia nervosa, with no known effective treatment. We conducted a double-blinded, randomized trial comparing alendronate (10 mg daily) with placebo in 32 adolescents with anorexia nervosa (mean age, 16.9 +/- 1.9 yr). All subjects received 1200 mg elemental calcium and 400 IU vitamin D daily and received the same multidisciplinary treatment for their eating disorder. Bone mineral densities (BMDs) of the lumbar spine and femoral neck were measured by dual energy x-ray absorptiometry at baseline and after 1 yr of treatment. Twenty-nine subjects completed the study. Femoral neck and lumbar spine BMDs increased 4.4 +/- 6.4% and 3.5 +/- 4.6% in the alendronate group compared with increases of 2.3 +/- 6.9% and 2.2 + 6.1% in the control group (P = 0.41, femoral neck; P = 0.53, lumbar spine). From baseline to follow-up, BMD increased significantly at the femoral neck (P = 0.02) and lumbar spine (P = 0.02) in those receiving alendronate, but did not increase in those assigned placebo (P = 0.22, femoral neck; P = 0.18, lumbar spine). At follow-up, body weight was the most important determinant of BMD. BMD was significantly higher in subjects who were weight-restored compared with those who remained at low weight (P = 0.002, femoral neck; P = 0.04, lumbar spine). After controlling for body weight, treatment group assignment still had an independent effect at the femoral neck. We conclude that in adolescents with anorexia nervosa, weight restoration is the most important determinant of BMD, but treatment with alendronate did increase the BMD of the lumbar spine and femoral neck within the group receiving alendronate, but not compared with placebo in the primary analysis. Until additional studies have demonstrated efficacy and long-term safety, the use of alendronate in this population should be confined to controlled clinical trials.
View details for DOI 10.1210/jc.2004-1659
View details for Web of Science ID 000229351000006
View details for PubMedID 15784715
Nutritional rehabilitation of anorexia nervosa. Goals and dangers. International journal of adolescent medicine and health 2004; 16 (2): 131-144
Nutritional rehabilitation of adolescents with anorexia nervosa is both a science and an art. The goals are to promote metabolic recovery; restore a healthy body weight; reverse the medical complications of the disorder and to improve eating behaviors and psychological functioning. Most, but not all of the medical complications are reversible with nutritional rehabilitation. Refeeding patients with anorexia nervosa results in deposition of lean body mass initially, followed by restoration of adipose tissue as treatment goal weight is approached. The major danger of nutritional rehabilitation is the refeeding syndrome, characterized by fluid and electrolyte, cardiac, hematological and neurological complications, the most serious of which is sudden unexpected death. The refeeding syndrome is most likely to occur in those who are severely malnourished. In such patients, this complication can be avoided by slow refeeding with careful monitoring of body weight, heart rate and rhythm and serum electrolytes, especially serum phosphorus. This paper reviews our clinical experience.
View details for PubMedID 15266992
Eating disorders in adolescents: position paper of the Society for Adolescent Medicine. journal of adolescent health 2003; 33 (6): 496-503
Eating disorders in adolescence and their sequelae BEST PRACTICE & RESEARCH IN CLINICAL OBSTETRICS & GYNAECOLOGY 2003; 17 (1): 57-73
Eating disorders are prevalent in adolescents and are associated with significant medical and psychiatric morbidity. Amenorrhoea, one of the cardinal features of anorexia nervosa, is the most likely reason for consulting the gynaecologist. Amenorrhoea in a young woman should alert the gynaecologist to the possibility of an underlying eating disorder. Osteopenia is a potentially irreversible complication of prolonged amenorrhoea and a low oestrogen state. Eating disorders are best managed by a team approach, with the team comprising a physician, nutritionist and therapist. Oestrogen replacement therapy has not been shown to be an effective treatment for osteopenia in anorexia nervosa and the gynaecologist should avoid simply prescribing oestrogen replacement therapy without referring the patient for comprehensive treatment of the eating disorder. Nutritional rehabilitation, weight restoration and resumption of spontaneous menses are the mainstay of medical management. Calcium and vitamin D supplementation and moderate weight-bearing exercise should be prescribed where indicated. Newer therapeutic options for the treatment of osteopenia include DHEA, IGF-1 and alendronate.
View details for Web of Science ID 000182071000005
View details for PubMedID 12758226
Osteopenia and osteoporosis in anorexia nervosa. Adolescent medicine (Philadelphia, Pa.) 2003; 14 (1): 97-108
Osteopenia is a frequent and severe complication of anorexia nervosa. Once established, it is difficult to treat and is only partially reversible. Osteoporosis is a preventable disease, and intervention should begin during childhood and adolescence. Optimizing peak bone mass accrual during adolescence is essential, and an episode of anorexia nervosa during adolescence interferes with that process. In anorexia nervosa, results with hormone replacement therapy have been disappointing. Calcium and vitamin D supplementation should be prescribed where necessary. Excessive exercise should be avoided and moderate weight-bearing exercise encouraged. Ongoing research studying newer modalities such as IGF-1, DHEA, and bisphosphonates looks promising. Until more effective treatment regimens become available, the mainstay of treatment remains weight gain, nutritional rehabilitation, and spontaneous resumption of menses.
View details for PubMedID 12529194
Resolution of vital sign instability: An objective measure of medical stability in anorexia nervosa JOURNAL OF ADOLESCENT HEALTH 2003; 32 (1): 73-77
To determine the amount of time necessary for stabilization of blood pressure and heart rate in patients with anorexia nervosa (AN) and the percentage of ideal body weight (IBW) at which this occurs.A retrospective study was conducted on 36 adolescent patients (33 F, 3 M) with AN, restricting type (Diagnostic and Statistical Manual of Mental Disorders, Fourth edition [DSM-IV] criteria), admitted to a specialized eating disorders unit for nutritional rehabilitation between October 1996 and August 1998. Mean age was 16.5 +/- 2.5 years, range 12-23 years. Each morning, pulse and blood pressure were measured supine and after standing for 2 minutes using an automated blood pressure/pulse measuring device (Dynamap). Orthostasis was defined as a drop in systolic blood pressure > 20 mm Hg with or without a drop in diastolic blood pressure > 10 mm Hg or an increase in heart rate >20 bpm on standing. Time of resolution of orthostasis was defined as the day after which the patient was no longer orthostatic for 48 hours.On admission mean pulse rate was 54.4 +/- 14.8 bpm (range 38-78) and mean pulse rate slowly increased to 70 bpm by Day 12 of hospitalization. On admission, 60% of patients had orthostatic pulse changes and with refeeding, this number increased to 85% by Day 4 of admission. The mean number of days until patients were no longer orthostatic was 21.6 +/- 11.1 days and resolution of orthostasis occurred when subjects reached 80.1 +/- 5.7% of IBW. Orthostatic pulse changes were more sensitive indicators of hemodynamic instability than orthostatic blood pressure changes and took longer to resolve.This study demonstrates that of patients with AN, the majority have orthostatic pulse changes on admission. Normalization of orthostatic pulse changes was achieved after approximately 3 weeks of nutritional rehabilitation when subjects reached 80% of their IBW. Resolution of orthostasis can be used as one of the objective measures to determine medical stability and readiness for discharge to an alternate level of care.
View details for Web of Science ID 000180206800011
View details for PubMedID 12507804
The Spectrum of Disordered Eating: Medical Management of Anorexia Nervosa, Bulimia Nervosa and Obesity Adolescent Medicine State of the Art Reviews 2003
Hypophosphatemia during nutritional rehabilitation in anorexia nervosa: Implications for refeeding and monitoring JOURNAL OF ADOLESCENT HEALTH 2003; 32 (1): 83-88
To determine the incidence of hypophosphatemia in adolescents with anorexia nervosa (AN) hospitalized for nutritional rehabilitation and to examine factors predisposing to its development.A retrospective chart review of 69 patients (66 female, 3 male) with AN consecutively admitted to an inpatient adolescent medical unit between July 1, 1998 and June 30, 2000. Mean age was 15.5 +/- 2.4 (range 8 to 22) years and mean % ideal body weight (IBW) was 72.7 +/- 7%. Serum phosphorus was measured daily for 1 week and then biweekly to weekly. Patients were started on 1200-1400 kcal/day and calories were increased by 200 kcal every 24-48 hours.Four (5.8%) patients developed moderate hypophosphatemia (<2.5 and > or = 1.0 mg/dl) and 15 (21.7%) had mild hypophosphatemia (<3.0 and > or = 2.5 mg/dl). Patients who developed moderate hypophosphatemia were significantly more malnourished than those who did not (p = 0.02). Phosphorus nadirs were directly proportional to % IBW (r = 0.3, p = 0.01). Over three-quarters of the patients (81%) reached their phosphorus nadir within the first week of hospitalization. The patient with the lowest phosphorus level experienced short runs of ventricular tachycardia. No other severe complications were seen. Overall, 19 (27.5%) patients required phosphorus supplementation.Phosphorus drops to its nadir during the first week of refeeding. We recommend daily monitoring of serum phosphorus with supplementation as needed during the first week of hospitalization, especially in those who are severely malnourished.
View details for Web of Science ID 000180206800013
View details for PubMedID 12507806
Reversibility of growth stunting in early onset anorexia nervosa: A prospective study JOURNAL OF ADOLESCENT HEALTH 2002; 31 (2): 162-165
To evaluate the growth of premenarchal patients with anorexia nervosa.Growth parameters were measured semi-annually in 16 subjects with anorexia nervosa until 1 year post-menarche.Despite the accelerated growth that followed nutritional rehabilitation, the patients did not achieve their genetic height potential.
View details for Web of Science ID 000177045700007
View details for PubMedID 12127386
The effect of estrogen-progestin treatment on bone mineral density in anorexia nervosa. Journal of pediatric and adolescent gynecology 2002; 15 (3): 135-143
Osteopenia is a serious complication of anorexia nervosa (AN). Although in other states of estrogen deficiency, estrogen replacement therapy increases bone mass, its role in AN remains unresolved.To study the effect of estrogen-progestin administration on bone mass in AN.A prospective observational study of 50 adolescents with AN (mean age 16.8 +/- 2.3 yrs) was conducted in a tertiary referral center.Bone mineral density (BMD) of the lumbar spine and left hip were prospectively measured using dual-energy x-ray absorptiometry at baseline and annually.Twenty-two subjects received estrogen-progestin and 28 standard treatment (Rx) alone. Estrogen-progestin was administered daily as an oral contraceptive containing 20-35 mcg ethinyl estradiol. All subjects received calcium supplementation and the same medical, psychological, and nutritional intervention (standard Rx). Mean length of follow-up was 23.1 +/- 11.4 months.At presentation, patients were malnourished (79.5% +/- 7.6% IBW), hypoestrogenemic (estradiol 24.7 +/- 10.7 pg/mL), and had reduced bone mass (lumbar spine BMD -2.01 +/- 0.69 SD below the young adult reference mean). Ninety-two percent of subjects were osteopenic and 26% met WHO criteria for osteoporosis. Body weight, and no treatment group, was the major determinant of BMD. At one-year follow-up, there were no significant differences in absolute values or in net change of lumbar spine or femoral neck BMD between those who received estrogen-progestin and those who received standard Rx (80% power of finding a 3% difference in BMD at 1 yr). In those followed for 2-3 yrs, osteopenia was persistent and in some cases progressive.In our study population, estrogen-progestin did not significantly increase BMD compared with standard Rx. These results question the common practice of prescribing hormone replacement therapy to increase bone mass in AN.
View details for PubMedID 12106749
A review of the female athlete triad (amenorrhea, osteoporosis and disordered eating). International journal of adolescent medicine and health 2002; 14 (1): 9-17
The number of women participating in organized sports has increased dramatically over the past 30 years. The female athlete triad is a condition seen with increasing frequency in young athletes and is characterized by the triad of amenorrhea, disordered eating and osteoporosis. The triad is caused by an imbalance between energy intake and energy expenditure and can be associated with significant medical morbidity. It occurs most frequently in sports emphasizing a lean appearance. Early recognition and intervention are essential. In an adolescent athlete, amenorrhea should be considered an indicator of a potential problem and should not simply be attributed to a consequence of training. The athlete should be evaluated for an underlying eating disorder and tested for osteoporosis. Principles of treatment include reducing the intensity of training until menses resume, increasing caloric intake, ensuring adequate calcium and vitamin D intake, encouraging weight-bearing exercise where appropriate, and consideration of hormone replacement therapy. Prevention, through education will help ensure the health and safety of young female athletes.
View details for PubMedID 12467202
Emergency contraception: Pediatricians' knowledge, attitudes, and opinions PEDIATRICS 2001; 107 (2): 287-292
Emergency contraception (EC) is the use of a method of contraception after unprotected intercourse to prevent unintended pregnancy. Although first described over 20 years ago, physician awareness of EC has been limited and many feel uncomfortable prescribing it.To assess the knowledge, attitudes, and opinions of practicing pediatricians regarding the use of EC in adolescents.An anonymous questionnaire was mailed to all 954 active members of New York Chapter 2, District II of the American Academy of Pediatrics. The questionnaire assessed basic knowledge, attitudes, and opinions regarding EC in adolescents. Data were analyzed by physician age, gender, year completed residency, and practice type.Two hundred thirty-three practicing pediatricians (24.4%) completed the survey. Of the respondents, 23.7% had been asked to prescribe EC to an adolescent and 49% of these cases involved a rape victim. Only 16.7% of pediatricians routinely counsel adolescent patients about the availability of EC, with female pediatricians more likely to do so. Most respondents (72.9%) were unable to identify any of the Food and Drug Administration-approved methods of EC. Only 27.9% correctly identified the timing for its initiation and only 31.6% of respondents felt comfortable prescribing EC. Inexperience with use was cited as the primary reason for not prescribing EC by 70% of respondents. Twelve percent cited moral or religious reasons and 17% were concerned about teratogenic effects. There were no differences in comfort level based on age, gender, or practice type. Twenty-two percent of respondents believed that providing EC encourages adolescent risk-taking behavior and 52.4% would restrict the number of times they would dispense EC to an individual patient. A minority of respondents (17%) believed that adolescents should have EC available at home to use if necessary and only 19.6% believed that EC should be available without a prescription. The vast majority (87.5%) were interested in learning more about EC.Despite the safety and efficacy of EC, the low rate of use is of concern. Pediatricians are being confronted with the decision to prescribe EC but do not feel comfortable prescribing it because of inadequate training in its use. Practicing pediatricians are aware of their lack of experience and are interested in improving their knowledge base.
View details for Web of Science ID 000166714000026
View details for PubMedID 11158460
Eating disorders in children and adolescents: epidemiology, diagnosis and treatment. Paediatric drugs 2001; 3 (2): 91-99
Eating disorders such as anorexia nervosa (AN) and bulimia nervosa (BN) are increasingly prevalent among children and adolescents. Whereas AN has a peak age of onset in early to mid-adolescence, BN typically presents during or after late adolescence. There is a spectrum of eating disorders that can be categorised by the criteria in the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders into AN, BN and 'eating disorder not otherwise specified (ED-NOS)'. The key clinical signs of AN are those of protein calorie malnutrition. In BN, signs of purging are also important. Despite marked physical changes, metabolic decompensation occurs late and when present is an indication for hospital admission. During refeeding, electrolyte disturbances, in particular hypophosphataemia, should be serially monitored. For females with AN, restoration of gonadotropins, oestradiol and resumption of menses is a cardinal indicator of nutritional recovery. Treatment should address the medical, nutritional and psychological needs of children and adolescents with eating disorders. No single professional can be proficient in all spheres. Children and adolescents with eating disorders are best managed by a 'team approach'. Treatment may occur in a variety of inpatient, daypatient or outpatient settings. The aims of medical treatment are to promote bodyweight gain and nutritional recovery. Psychiatric goals address the psychosocial precipitants, treat comorbid mood symptoms and assist the patient to develop alternative coping skills. The crude mortality of AN has decreased to around 6%. For children and adolescents, the morbidity from malnutrition is increased because of the biological changes that are interrupted.
View details for PubMedID 11269642
Osteoporosis prevention - A pediatric challenge ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE 2000; 154 (6): 542-543
From prevention to prognosis: clinical research update on adolescent eating disorders. 2000: 709-712
Practice guideline for the treatment of patients with eating disorders (revision) AMERICAN JOURNAL OF PSYCHIATRY 2000; 157 (1): 1-?
Addison's disease mimicking anorexia nervosa CLINICAL PEDIATRICS 1998; 37 (10): 631-632
Cardiac arrest and delirium: Presentations of the refeeding syndrome in severely malnourished adolescents with anorexia nervosa JOURNAL OF ADOLESCENT HEALTH 1998; 22 (3): 239-243
To describe the clinical presentation of the refeeding syndrome and highlight the dangers of performing nutritional rehabilitation too rapidly in a severely malnourished patient.Retrospective case review of adolescents admitted with anorexia nervosa who developed the refeeding syndrome.Between July 1993 and July 1994, 3 of 48 adolescent females developed the refeeding syndrome. While the cardiac complications occurred in the first week of refeeding, the delirium characteristic of this syndrome occurred later and was more variably related to hypophosphatemia.Refeeding malnourished patients with anorexia nervosa can be associated with hypophosphatemia, cardiac arrhythmia and delirium. Refeeding patients with anorexia nervosa who are < 70% of ideal body weight should proceed with caution, and the caloric prescription should be increased gradually. Supplemental phosphorus should be commenced early and serum levels maintained above 3.0 mg/dL. Cardiac and neurologic events associated with refeeding are most likely to occur within the first weeks, justifying close monitoring of electrolyte and cardiac status.
View details for Web of Science ID 000072049400010
View details for PubMedID 9502012
Resumption of menses in anorexia nervosa ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE 1997; 151 (1): 16-21
To determine factors associated with resumption of menses (ROM) in adolescents with anorexia nervosa.Cohort study with 2-year follow-up.Tertiary care referral center.Consecutive sample of 100 adolescent girls with anorexia nervosa.Body weight, percent body fat, and luteinizing hormone, follicle-stimulating hormone, and estradiol levels were measured at baseline and every 3 months until ROM (defined as 2 or more consecutive spontaneous menstrual cycles). Treatment consisted of a combination of medical, nutritional, and psychiatric intervention aimed at weight gain and resolution of psychological conflicts.Body weight, body composition, and hormonal status at ROM.Menses resumed at a mean (+/-SD) of 9.4 +/- 8.2 months after patients were initially seen and required a weight of 2.05 kg more than the weight at which menses were lost. Mean (+/-SD) percent of standard body weight at ROM was 91.6% +/- 9.1%, and 86% of patients resumed menses within 6 months of achieving this weight. At 1-year follow-up, 47 (68%) of 69 patients had resumed menses and 22 (32%) remained amenorrheic. No significant differences were seen in body weight, body mass index, or percent body fat at follow-up in those who resumed menses by 1 year compared with those who had not. Subjects who remained amenorrheic at 1 year had lower levels of luteinizing hormone (P < .001) and follicle-stimulating hormone (P < .05) at baseline and lower levels of luteinizing hormone (P < .01) and estradiol (P < .001) at follow-up. At follow-up, a serum estradiol level of more than 110 pmol/L (30 pg/mL) was associated with ROM (relative risk, 4.6; 95% confidence interval, 1.9-11.2).A weight approximately 90% of standard body weight was the average weight at which ROM occurred and is a reasonable treatment goal weight, because 86% of patients who achieved this goal resumed menses within 6 months. Resumption of menses required restoration of hypothalamic-pituitary-ovarian function, which did not depend on the amount of body fat. Serum estradiol levels at follow-up best assess ROM.
View details for Web of Science ID A1997WC69600002
View details for PubMedID 9006523
Structural brain changes and malnutrition in anorexia nervosa ADOLESCENT NUTRITIONAL DISORDERS 1997; 817: 398-399
Adolescent Nutritional Disorders. Prevention and Treatment Annals of the New York Academy of Sciences, New York 1997
Secular trends in cholesterol for suburban high school students in Long Island, New York, 1987-1995 ADOLESCENT NUTRITIONAL DISORDERS 1997; 817: 396-397
Eating-related and co-morbid symptoms in premenarcheal anorexia nervosa:child vs parent report Eating Disorders:The Journal of Treatment and Prevention 1997; 5: 320-335
The adolescent: Vulnerable to develop an eating disorder and at high risk for long-term sequelae ADOLESCENT NUTRITIONAL DISORDERS 1997; 817: 94-97
Is there a rational approach to the determination of treatment goal weight for adolescents with anorexia nervosa? Eating Disorders:The Journal of Treatment and Prevention 1997; 5: 79-81
The metabolic responses as starvation and refeeding in adolescents with anorexia nervosa ADOLESCENT NUTRITIONAL DISORDERS 1997; 817: 110-119
Adaptive changes in metabolism result in decreased energy requirements in AN. A retrospective study of 21 hospitalized female AN patients demonstrated that indirect calorimetry (IC) measurement of resting energy expenditure (REE) was significantly lower than REE calculated by the Harris-Benedict equation (HBE). The HBE was adjusted by multiple-regression analysis to reflect the hypometabolic state of AN, and the adjusted equation was prospectively validated in 37 hospitalized female AN patients. Refeeding requires an understanding of both baseline requirements and metabolic changes that occur during nutritional rehabilitation. In our present study, we prospectively evaluated changes in fasting and postprandial REE in 50 hospitalized female patients meeting DSM-IV criteria for AN. Baseline IC measurements of fasting and postprandial REE were obtained within three days of admission, and every two weeks thereafter. Mean fasting REE increased significantly from 72 (+/-11.7) to 83.2 (+/-12.6) percent of predicted (p < 0.001) during the first two weeks of hospitalization. Likewise, postprandial REE also increased significantly from 17.5 (+/-18.2) to 27.9 (+/-15.9) percent above fasting REE during the same time period (p < 0.01). Significant increases in both REE and postprandial REE persisted in patients requiring longer hospitalizations. Despite the fact that prescribed energy intake and triiodothyronine (T3-RIA) levels increased during refeeding, there was no significant relationship between postprandial REE and energy intake or T3 levels after baseline. We conclude that energy metabolism in AN adapts to semistarvation by a reduction in fasting REE. With refeeding there is a reversal of this adaptive function, demonstrated by an increase in both fasting and postprandial energy expenditure. The increase in postprandial REE is not related to energy intake or thyroid function.
View details for Web of Science ID A1997BJ16M00010
View details for PubMedID 9239182
Update on adolescent health care in pediatric practice JOURNAL OF ADOLESCENT HEALTH 1996; 19 (6): 394-400
To determine current adolescent health care practices of pediatricians and evaluate whether changes have taken place during the past decade.A questionnaire completed by 101 pediatricians in 1985 was abbreviated and adapted by Committee on Youth of Chapter 2, District II of the American Academy of Pediatrics and sent to 1,633 members of the Chapter in June 1993.Forty-three percent of the 436 respondents in 1993 were female, 43% < or = 40 years of age and 53% were in private practice. Most accept new patients > or = 16 years of age (76%), continue to see patients > or = 19 years of age (63%), and interview adolescents without their parents (86%). Although between one-third and two-thirds of respondents report having equipment for gynecologic examinations, most indicate they are "not entirely comfortable" treating adolescent issues and therefore refer to others for management. Between one-quarter and one-half indicate they are "very interested" in learning more about adolescent issues and an additional 40-50% are "somewhat interested." Obstacles to providing adolescent care include: "image as a baby doctor" (65%), fear that parents would object (61%), no separate hours (57%), difficulty in providing confidential care (56%), and difficulty in charging appropriate fees (47%). Females and younger pediatricians are more comfortable with some aspects of gynecologic care and more likely to be satisfied with the adolescent care they are providing. There were few differences between responses in 1993 and 1995.Few of the pediatricians surveyed provide comprehensive care to adolescent patients. Future policy decisions and medical education must respond to these realities in pediatric practice.
View details for Web of Science ID A1996VY33400006
View details for PubMedID 8969370
Reversibility of cerebral ventricular enlargement in anorexia nervosa, demonstrated by quantitative magnetic resonance imaging JOURNAL OF PEDIATRICS 1996; 128 (2): 296-301
To determine the reversibility of the loss of brain parenchyma and ventricular enlargement in patients with anorexia nervosa after refeeding.Quantitative magnetic resonance imaging was performed on three groups of subjects: (1) 12 female adolescents hospitalized with anorexia nervosa, (2) the same 12 patients after nutritional rehabilitation, a mean of 11.1 months later, and (3) 12 healthy age-matched control subjects. Sixty-four contiguous coronal magnetic resonance images, 3.1 mm thick, were obtained. With a computerized morphometry system, lateral and third ventricular volumes were measured by a single observer unaware of the status of the patient.On admission, patients were malnourished and had lost an average of 11.7 kg (body mass index, 14.3 +/- 2.0 kg/m2). After refeeding, they gained an average of 9.7 kg (body mass index, 17.9 +/- 1.5 kg/m2). Total ventricular volume decreased from 17.1 +/- 5.5 cm3 on admission to 12.4 +/- 3.0 cm3 after refeeding (p < 0.01) and returned to the normal range. The degree of enlargement of the third ventricle was greater than that of the lateral ventricles. There was a significant inverse relationship between body mass index and total ventricular volume (r = -0.63; p < 0.05).In patients with anorexia nervosa, cerebral ventricular enlargement correlates with the degree of malnutrition and is reversible with weight gain during long-term follow-up.
View details for Web of Science ID A1996TW05400030
View details for PubMedID 8636835
Effectiveness of breast self-examination prompts on oral contraceptive packaging JOURNAL OF FAMILY PRACTICE 1996; 42 (1): 43-48
The purpose of this study was to determine if a breast self-examination (BSE) "prompt" on oral contraceptive pill (OCP) packages would improve the frequency and timing of BSE among women who use OCPs.Women between 13 and 40 years of age who were initiating, restarting, or continuing use of OCPs completed a baseline survey that assessed health behavior and practices. All received BSE education, and then were randomized to take either OCPs with a BSE prompt or regularly packaged OCPs (without BSE prompt) for three cycles. Three months later, subjects completed a follow-up survey that assessed BSE frequency and timing. A telephone survey of randomly selected subjects conducted 6 months after the baseline survey assessed BSE compliance after discontinuation of the prompt.Of the 907 subjects at baseline, 49.3% performed BSE monthly but only 24.5% performed BSE during the correct time of the menstrual cycle. Among subjects who never performed BSE prior to the study, 40.3% of prompt subjects and 36.4% of the education-only subjects began BSE by the 3-month survey. Among subjects who performed BSE less than once per month at baseline, 50.9% of prompt subjects and 45.5% of education-only subjects increased the frequency of BSEs to a monthly basis by the 3-month survey. More women performed BSE during the correct time of the menstrual cycle at the 3 month follow-up survey (68.1% prompt, 62.2% education only) and 6-month survey (57.4% prompt, 48.9% education only) when compared with the baseline survey (24.7% prompt, 24.1% education only). Ninety-one percent of women in this study expressed a preference for a BSE prompt on OCP packaging.An increased frequency of BSE was observed when women were exposed to an OCP package prompt, particularly for women who at baseline were already partially compliant with performing monthly BSE. A small but significant improvement was observed for correct BSE timing and this effect continued after the prompt was removed, although at a reduced level. The innovative BSE prompt was overwhelmingly well received by women in this study.
View details for Web of Science ID A1996TP48500004
View details for PubMedID 8537804
EATING DISORDERS IN ADOLESCENTS - A BACKGROUND PAPER JOURNAL OF ADOLESCENT HEALTH 1995; 16 (6): 420-437
EATING DISORDERS IN ADOLESCENTS - A POSITION PAPER OF THE SOCIETY FOR ADOLESCENT MEDICINE JOURNAL OF ADOLESCENT HEALTH 1995; 16 (6): 476-480
MEDICAL COMPLICATIONS IN MALE-ADOLESCENTS WITH ANOREXIA-NERVOSA ELSEVIER SCIENCE PUBL CO INC. 1995: 448-453
Medical information on male anorectics is scant. We present data on 10 males with anorexia nervosa, who were treated at our Eating Disorders Center during a twelve-year period.Retrospective chart review.All patients were malnourished weighing 80% or less of their ideal body weight with a mean B.M.I. of 13.5 +/- 2.0. Height below the 50th percentile was evident in 80% of the patients, and was below the 10th percentile in 30% of the patients. Structural brain changes on brain computerized tomography scans were noted in seven out of nine patients and more than 50% had mild anemia relative to the Tanner stage. Other findings included a mean presenting heart rate of 68.3 +/- 17: four out of ten patients had presenting heart rates of 80 or greater and of these, three had serious medical problems and were severely malnourished. Two patients had cardiac complications and one had a life-threatening electrolyte disturbance.Despite the small number of patients, the proportion of male adolescent anorectics with medical abnormalities seems high, and may be due to difficulties in establishing the diagnosis and delay in seeking medical attention. Patients who had heart rates of 80 or greater were perhaps sicker and further along in their development of congestive heart failure, thus explaining their initial relative tachycardia. We suggest a higher index of suspicion for congestive heart failure and closer medical monitoring when a malnourished adolescent with anorexia nervosa presents with relatively elevated heart rates.
View details for Web of Science ID A1995RG04900006
View details for PubMedID 7669794
HYPERENDEMIC PENICILLINASE-PRODUCING NEISSERIA-GONORRHOEAE GENITAL INFECTIONS IN AN INNER-CITY POPULATION JOURNAL OF ADOLESCENT HEALTH 1995; 16 (1): 41-44
To determine: 1) the proportion of Neisseria gonorrhoeae caused by penicillinase-producing Neisseria gonorrhoeae (PPNG) in our inner-city population; 2) any difference in the isolation rates of PPNG between adolescents and adults; 3) co-infection rates with Chlamydia trachomatis in this adolescent population; and 4) the appropriateness of current CDC recommendations for initial treatment of patients with suspected gonococcal infection.Genital cultures for GC were obtained from 1990 patients seen in the emergency room or primary care clinics. Of these, 285 were adolescents between 12 and 19 years of age. All adolescent patients were tested for chlamydial infection. Comparisons of gonococcal infection rates were made between adults and adolescents and between males and females. The rates of symptomatic versus asymptomatic adolescents were compared.Genital cultures were positive for GC in 13% of the patients tested. Of these, 51% were identified as being caused by PPNG. Among the adolescents, cultures were positive in 25%, and 63% of these were identified as PPNG. The rate of PPNG was significantly higher in adolescents than in adults. The rate of PPNG was highest in adolescent females and lowest in adult males. There was no difference in the rate of PPNG between adolescents and adult males. Of the 71 adolescents with GC, 58% were coinfected with C. trachomatis. Adolescents with PPNG had a higher rate of concomitant infection with C. trachomatis than those with a penicillin-sensitive strain. Adolescents with N. gonorrhoeae were more likely to be infected with PPNG if they had GU symptoms.Our data supports the most recent CDC recommendations that the initial treatment for suspected N. gonorrhoeae be effective against PPNG. Furthermore, chlamydia screening and treatment is warranted in patients suspected of having an STD.
View details for Web of Science ID A1995QE91700007
View details for PubMedID 7742335
INDIRECT CALORIMETRY IN THE NUTRITIONAL MANAGEMENT OF EATING DISORDERS INTERNATIONAL JOURNAL OF EATING DISORDERS 1995; 17 (1): 59-66
The caloric prescription, a key component of the nutritional therapy of anorexia nervosa (AN) and bulimia nervosa (BN), may be empirically prescribed, or based on predicted resting energy expenditure (REE), yet adaptive changes in the metabolic rate may render both methods unreliable. Indirect calorimetry measurement of fasting REE was obtained in 32 patients with AN (n = 21) or BN (n = 11). Predicted REE was calculated according to the Harris-Benedict equation, and empiric caloric prescriptions were made by experienced physicians. In the AN group, mean measured REE was significantly lower than predicted REE (p = .00). The empiric caloric prescription was, as intended, significantly higher than the measured REE, but the two methods correlated significantly (r = .53, p < .05). The predicted REE overestimated caloric needs but was also highly correlated with measured REE (r = .69, p < .001). By regression analysis, measured REE could be calculated from predicted REE as follows: measured REE (Kcal/day) = (1.84 x Harris-Benedict predicted REE) - 1,435. In the BN group, mean measured REE was not significantly different from the empiric caloric prescription (p = .09) but was significantly lower than the Harris-Benedict predicted REE (p = .022). Neither correlated with measured REE in BN. Therefore, in BN indirect calorimetry is the only reliable method for determining caloric needs. In AN indirect calorimetry remains the preferred method, but when not available, we recommend the above equation to determine resting energy requirements.
View details for Web of Science ID A1995PZ17200007
View details for PubMedID 7894454
DISTURBANCES IN GROWTH-HORMONE SECRETION AND ACTION IN ADOLESCENTS WITH ANOREXIA-NERVOSA JOURNAL OF PEDIATRICS 1994; 125 (4): 655-660
Women in whom anorexia nervosa develops during adolescence have failure of linear growth associated with low levels of insulin-like growth factor I (IGF-1). To investigate the pathophysiology of growth retardation in adolescents with anorexia nervosa, we measured basal growth hormone (GH), growth hormone-binding protein (GHBP), IGF-1, and insulin-like growth factor binding protein-3 (IGFBP-3) in three groups of patients: (1) 28 recently hospitalized female adolescents with anorexia nervosa, (2) 23 of the same patients after partial weight restoration, and (3) 28 healthy control subjects matched for age, sex, and pubertal stage. Fasting GH levels in group 1 did not differ significantly from those in group 3. In contrast, serum GHBP (p < 0.001), IGF-1 (p < 0.001), and IGFBP-3 (p < 0.01) were significantly lower in group 1 than in group 3. Serum GHBP and IGFBP-3 levels were positively correlated with body mass index. Serum GHBP levels were low in patients in all five pubertal stages and even in those shown to have adequate GH secretion. In group 2 (after refeeding) the serum IGF-1 concentration increased significantly and GHBP and IGFBP-3 returned to normal. We conclude that patients with anorexia nervosa have diminished GH action resulting in decreased secretion of IGF-1. The positive correlation with body mass index and the reversibility with refeeding suggest that these changes are secondary to malnutrition. Altered GH function that occurs during the years of active growth can explain the growth retardation seen in anorexia nervosa.
View details for Web of Science ID A1994PK52900029
View details for PubMedID 7523649
AMENORRHEA IN ANOREXIA-NERVOSA NEUROENDOCRINE CONTROL OF HYPOTHALAMIC DYSFUNCTION INTERNATIONAL JOURNAL OF EATING DISORDERS 1994; 16 (1): 53-60
Amenorrhea is one of the cardinal features of anorexia nervosa and is associated with hypothalamic dysfunction. Earlier theories of weight loss, decreased body fat, or exercise do not fully explain the etiology of amenorrhea in anorexia nervosa. Disturbances in central dopaminergic and opioid activity have been described in anorexia nervosa and both these substances are known to modulate gonadotropin-releasing hormone (GnRH)-mediated luteinizing hormone (LH) release. Serum LH, follicle-stimulating hormone (FSH), estradiol, and prolactin levels were measured at baseline and after administration of metoclopramide (a central D-2 dopamine receptor blocker) in 10 newly diagnosed women with anorexia nervosa and in 10 healthy age-matched controls. Basal prolactin levels and the prolactin response to metoclopramide were significantly impaired in the group with anorexia nervosa. Metoclopramide did not induce a significant rise in LH levels in either the anorexic or the control groups. Neurotransmitter abnormalities may influence hypothalamic dysfunction in anorexia nervosa but the exact mechanism remains to be determined.
View details for Web of Science ID A1994NU24300004
View details for PubMedID 7920581
RATE OF WEIGHT-GAIN OF INPATIENTS WITH ANOREXIA-NERVOSA UNDER 2 BEHAVIORAL CONTRACTS PEDIATRICS 1994; 93 (6): 989-991
To ascertain the rate of weight gain of inpatients with anorexia nervosa under two behavioral contracts, differing in criterion weight gain required to earn increasing privileges.Follow-up comparison of cohorts receiving different interventions.Eating disorders service, operating on a general adolescent medicine unit.Patients admitted consecutively who met the following criteria: (1) weight at least 15% less than that expected for age, sex, and height; (2) female gender; (3) absence of chronic medical illness; (4) hospital stay of at least 28 days. Twenty-two patients meeting these criteria were treated between July 1987 and October 1988, when contract 1 was in effect. This cohort of patients was compared with a group of 31 patients, also meeting the these criteria, who were treated between November 1988 and December 1991, when contract 2 was in effect.The behavioral contract, signed by the patient on admission, specifies the minimum 4-day weight gain necessary to earn increasing ward privileges, such as use of phone, frequency of visits, etc. Contracts 1 and 2 differed only in the 4-day weight gain criterion: 0.8 lb (0.36 kg) and 1.2 lb (0.55 kg), respectively.The results of analysis of covariance, with admission weight as the covariate, revealed a significant interaction between contract and day, such that patients receiving contract 2 gained weight more rapidly (0.36 lb/d) than those receiving contract 1 (0.20 lb/d). There was no confounding difference between groups in the use of psychotropic medication, and no complications of refeeding in either group.Increasing the 4-day criterion weight gain from 0.8 to 1.2 lb in a behavioral contracting intervention was associated with a significant increase in the rate of weight gain, without an accompanying increase in complications of refeeding. This result simultaneously: (a) provides support for the efficacy of behavioral contracting and (b) reveals malleability in the rate of gain based on the targeted gain specified in the contract.
View details for Web of Science ID A1994NP67800021
View details for PubMedID 8190589
SINGLE-DOSE OF AZITHROMYCIN FOR THE TREATMENT OF GENITAL CHLAMYDIAL INFECTIONS IN ADOLESCENTS JOURNAL OF PEDIATRICS 1993; 122 (6): 961-965
We compared a single 1 gm dose of azithromycin with the standard 7-day course of doxycycline for the treatment of uncomplicated chlamydial genital infection in sexually active adolescents. Seventy-three adolescents (65 female) with a cervical or urethral culture positive for Chlamydia trachomatis were enrolled in the study; 46 received azithromycin and 27 received doxycycline. Follow-up evaluations were done 1, 2, and 4 weeks after treatment with azithromycin or initiation of treatment with doxycycline. There were four treatment failures (8.7%) among the patients who received azithromycin and four in the doxycycline-treated group (14.8%); all were female. Six of these girls (three treated with azithromycin and three with doxycycline) gave histories of unprotected intercourse with an untreated partner and were probably reinfected. Almost half the patients were clinically symptom free. The clinical response rate for the remaining patients with symptoms was 97.4% at 4 weeks. Nineteen percent of the azithromycin-treated patients and 33.3% of those treated with doxycycline had mild to moderate drug-related side effects, which were predominantly gastrointestinal. We conclude that treatment with a single oral dose of azithromycin appears to be as safe and efficacious as a 7-day course of doxycycline for the treatment of uncomplicated genital chlamydial infection in adolescents.
View details for Web of Science ID A1993LF55200025
View details for PubMedID 8388950
THE EFFECTS OF A DOPAMINE ANTAGONIST ON LUTEINIZING-HORMONE AND PROLACTIN-RELEASE IN WOMEN WITH ANOREXIA-NERVOSA AND IN NORMAL CONTROLS JOURNAL OF ADOLESCENT HEALTH 1992; 13 (2): 155-160
To evaluate the possible role of central dopaminergic suppression of gonadotropin secretion in the genesis of amenorrhea associated with anorexia nervosa (A.N.), a central D-2 dopamine receptor blocker was administered to 10 women with A.N. and 10 regularly menstruating age-matched controls. Serum prolactin and luteinizing hormone (LH) levels were measured at -15, 0, 30, 60, 120, and 180 min after administration of metoclopramide (10 mg orally). Mean basal prolactin (p less than 0.001) and estradiol levels (p less than 0.02) were significantly lower in women with A.N. The prolactin response to metoclopramide was significantly impaired in women with anorexia nervosa. No correlation was found between the prolactin response and percentage ideal body weight. Basal and post-stimulation prolactin levels were correlated with estradiol levels. After adjusting for the effects of estradiol, significant differences between patients with A.N. and controls remained in prolactin levels at baseline (p less than 0.01), 120 min (p less than 0.02) and 180 min (p less than 0.05). Metoclopramide did not induce a significant rise in LH levels in either the A.N. or control groups. These data are consistent with central dopaminergic inhibition of prolactin secretion in anorexia nervosa but do not support the hypothesis that central dopaminergic inhibition is related to diminished LH release in this state.
View details for Web of Science ID A1992HE71700012
View details for PubMedID 1352703
Amenorrhrea in Anorexia Nervosa: Etiology and Implications. Adolescent medicine (Philadelphia, Pa.) 1992; 3 (3): 503-518
Amenorrhea is one of the necessary criteria for diagnosis of anorexia nervosa in female adolescents, but its exact pathophysiology remains controversial. Involvement of hyperthalamic dysfunction may be due to malnutrition or to an underlying neurotransmitter abnormality. The association of anorexia nervosa with both osteopenia and hypoestrogenemia gives clinical and therapeutic significance to an understanding of the underlying pathophysiology. The authors base recommendations for intervention on the current state of knowledge.
View details for PubMedID 10356195
DEPRESSION, SELF-ESTEEM, AND LIFE EVENTS IN ADOLESCENTS WITH CHRONIC DISEASES ELSEVIER SCIENCE INC. 1990: 501-504
This study assesses whether nonhospitalized adolescents with chronic diseases differ from their healthy peers on standardized measurements of depression, self-esteem, and life events. The study group consisted of 80 patients (20 with sickle cell disease, 40 with asthma, and 20 with diabetes). All patients had been admitted at least twice in the preceding year, had their disease for at least 2 years, and were between the ages of 12 and 18. The control group consisted of 100 adolescents, matched for age and socioeconomic status, from local schools. All subjects completed a questionnaire compiled from the Beck Depression Inventory (BDI), the Rosenberg Scale of Self-Esteem, and the McCutcheon Life Events Checklist. Adolescents with chronic disease had higher depression scores (p less than 0.001) and lower self-esteem (p less than 0.001) than their healthy age-matched controls. There was no statistically significant difference in life events between the chronic disease and control groups. Depression, self-esteem, and life events did not differ significantly among the three disease groups. These findings suggest a need for intervention strategies to address depression and low self-esteem in adolescents with chronic disease.
View details for Web of Science ID A1990EF91600009
View details for PubMedID 2262397
PELVIC INFLAMMATORY DISEASE IN ADOLESCENTS JOURNAL OF PEDIATRICS 1989; 114 (1): 138-143
Clinical, laboratory, and sonographic data were collected prospectively from 100 female adolescents hospitalized with acute pelvic inflammatory disease (PID). The endocervical isolation rates for Chlamydia trachomatis and Neisseria gonorrhoeae were 44.7% and 36.4%, respectively. In comparison with adolescents with chlamydia-associated PID, those with gonococcus-associated PID had a shorter duration of pain before admission (p less than 0.05), higher mean maximum temperatures (p less than 0.01), and higher leukocyte counts (p less than 0.01). Pelvic ultrasound studies showed adnexal enlargement or tubo-ovarian abscess (TOA) in 85.2% of the patients. Of the 88 adolescents in whom adequate sonograms were obtained, 17 (19.3%) had TOA. In 12 of the 17 adolescents, the abscesses were identified sonographically before being diagnosed clinically. With clinical criteria alone, only the leukocyte count and prior history of PID differed significantly between those with TOA and those with uncomplicated PID. These findings support a more liberal use of pelvic ultrasound studies in teenagers with PID. Our high detection rate of C. trachomatis and the difficulty in predicting the cause of the infection in an individual patient support treating all adolescents with PID with agents effective against both C. trachomatis and N. gonorrhoeae.
View details for Web of Science ID A1989R726600025
View details for PubMedID 2642549
THE USE OF PELVIC ULTRASONOGRAPHY IN THE EVALUATION OF ADOLESCENTS WITH PELVIC INFLAMMATORY DISEASE AMERICAN JOURNAL OF DISEASES OF CHILDREN 1987; 141 (11): 1235-1238
To evaluate the use of pelvic ultrasonography in the diagnosis and management of female adolescents with pelvic inflammatory disease (PID), sonograms of 60 patients with PID were compared with those of 40 age-matched controls. Sonograms were evaluated for adnexal volume, adnexal adherence, uterine size, and the presence of cul-de-sac fluid. Eleven (19.3%) of the 57 patients with PID, in whom adequate sonograms were obtained, had tubo-ovarian abscesses; in seven of these patients, the abscesses were diagnosed ultrasonographically before suspected clinically. Even in those patients without tubo-ovarian abscesses, the mean (+/- SD) adnexal volume in the PID group was significantly larger than that of the control group (11.0 +/- 6.8 cm3 vs 5.2 +/- 2.7 cm,3 respectively). Adnexal adherence, uterine size, and the presence of cul-de-sac fluid were not useful in differentiating patients with PID from normal controls. Pelvic ultrasonography can be a useful adjunct in the diagnosis and management of PID in adolescents and may, in some instances, provide diagnoses in the absence of clinical findings.
View details for Web of Science ID A1987K657400031
View details for PubMedID 3314478
THORACIC ACTINOMYCOSIS IN CHILDHOOD CLINICAL PEDIATRICS 1985; 24 (11): 646-650
A 14-year-old boy presenting with a chest wall mass, pulmonary infiltrate, and scoliosis was found to have thoracic actinomycosis with distal vertebral involvement. Review of the medical literature for the past 25 years revealed only 23 other pediatric cases of thoracic actinomycosis. Clinical, standard radiological, and microbiological findings can be nonspecific. The diagnosis is dependent on a high index of suspicion. A long course of penicillin is the treatment of choice. Body computed tomography is a useful diagnostic aid and is helpful also in evaluating response to therapy.
View details for Web of Science ID A1985AUD2000013
View details for PubMedID 4053481
SEIZURES IN ADOLESCENCE - A REVIEW OF PATIENTS ADMITTED IN AN ADOLESCENT SERVICE JOURNAL OF ADOLESCENT HEALTH 1985; 6 (1): 25-27
The admissions of new seizure patients to an adolescent service over a 10-year period were retrospectively reviewed with regard to the patient's etiology, work-up, and outcome. Head trauma and pseudoseizures were common, 21% and 19%, respectively. In general, the outcome in adolescents appears to depend more on the underlying diagnosis than on how the seizure presents.
View details for Web of Science ID A1985TX28700006
View details for PubMedID 3965415
AN OVERVIEW OF THE ETIOLOGY, DIAGNOSIS, AND MANAGEMENT OF ANOREXIA-NERVOSA CLINICAL PEDIATRICS 1984; 23 (4): 209-214
The incidence of anorexia nervosa is increasing in adolescents. The pediatrician caring for teenagers is often the first professional confronted with the early signs and symptoms of this disorder. Clinical features and available literature on the psychological, nutritional, and family disorganization found in patients with anorexia nervosa are reviewed. Different therapeutic approaches are discussed, and current data on outcome are presented.
View details for Web of Science ID A1984SK37300004
View details for PubMedID 6697630
PREVALENCE OF CHLAMYDIA-TRACHOMATIS CERVICAL INFECTION IN FEMALE ADOLESCENTS AMERICAN JOURNAL OF DISEASES OF CHILDREN 1984; 138 (6): 562-564
To determine the prevalence of infection with Chlamydia trachomatis in young girls with the same socioeconomic background from New York City, 186 sexually active female adolescents (age range, 12 to 17 years; mean age, 15.5 years) were screened. One third of the patients were pregnant. Papanicolaou smears, endocervical cultures for C trachomatis and Neisseria gonorrhoeae, and syphilis serologic tests were obtained prospectively. Chlamydia trachomatis was isolated from 10.2% of the subjects, and N gonorrhoeae was isolated from 9.7% of the subjects; 3.2% of the subjects had syphilis. At least one sexually transmitted disease was found in 17.2% of the subjects. Eight (44%) of 18 patients with N gonorrhoeae also harbored Chlamydia. The high rate of multiple infection should have significant implications with regard to treatment. High isolation rates of C trachomatis and other sexually transmitted pathogens suggested that routine screening may be warranted in even the very young, sexually active female adolescent, and especially in pregnant girls.
View details for Web of Science ID A1984ST50900010
View details for PubMedID 6720642