Adolescent/Young Adult Medicine

A study published in Pediatrics Jan. 5 found that fourth and seventh graders who slept near a smartphone or with a TV in the room slept less and had a higher prevalence of perceived insufficient sleep than their peers who did not. The findings led researchers to caution against unrestricted screen access in children’s bedrooms and suggest that interactive media such as video games and smartphones may be more disruptive to sleep than TV.

But just how should primary care providers handle the conversation about media and sleep? Michael Rich, MD, MPH, from Boston Children’s Hospital Division of Adolescent/Young Adult Medicine, and director of the hospital's Digital Wellness Lab, weighs in.

“Sleep issues are very common in this age group,” says Rich, adding that media is not the only factor. Early morning school start times, evening activities and homework can contribute to sleep issues, which encompass inadequate sleep duration and sleep quality. The potential health effects include obesity, nutrition, learning issues and mental health.

“Media has become the most universal environmental health influence. The media we use and how we use them affect our health, whether we know it or not. We’ve become aware of the effects of the quality of the food we eat and the air we breathe, but we are not so good about connecting the dots between what we feed our minds and our health,” he says.

Rich acknowledges that researchers are in the early stages of gathering data about how media change children and teens, as well as adults. “We don’t know what the long-term effects of new media use are; we can only measure the short-term effects and extrapolate from there.”

It’s not uncommon for kids who sleep with a smartphone to leave it on overnight, so they can respond to text messages. But when they are expecting the vibration, they don’t reach stage 4 REM sleep, where items such as the day’s algebra lesson move from short-term memory to the learning centers of the brain.

He suggests primary care providers make sleep and screen time part of their patients’ medical history and offer anticipatory guidance.

This means asking patients if they sleep with a smartphone or TV in the bedroom, if they have problems falling asleep in school or retaining the day’s lessons. Providers also should be on the alert for potentially media-related health conditions like obesity.

As for communicating with parents, Rich recommends providers encourage them to work with children to help them master time-management skills. Plan their 24-hour day, slotting in time for sleep, at least one sit-down meal with family, outside playtime and homework, and then see what’s left for media use. “It’s best to establish these routines at the start of children’s school careers, but they can be done retroactively.” Other tips include reminding parents to model mindful and focused media use and set a policy that smartphones are charged overnight in the parents’ bedroom at an agreed-upon time.

Because there is no algorithm for when to refer a patient with a sleep issue to an expert, Rich encourages primary care providers to rely on gut instinct. “When you know, or suspect, you can’t help with an issue, then it’s time to refer the patient.”

The Digital Wellness Lab, with funding from Harvard Pilgrim Health Care, has developed a Toolkit for Clinicians for incorporating media awareness into health maintenance and other clinical visits. This research-based resource includes history forms, discussion guides, and tip sheets.

Human papillomavirus (HPV) vaccine coverage presents a pressing public health need. Just 34.8 percent of U.S. girls ages 13 to 17 years have completed the three-dose series, according to the 2011 National Immunization Survey-Teen. A total of 8.3 percent of U.S. males ages 13 to 17 had initiated the vaccine series. The figures fall far short of the coverage level needed to prevent many HPV-related cancers. Healthy People 2020 set a vaccine completion goal of 80 percent for females ages 13 to 15 years by the year 2020. It did not set a goal for males. Primary care providers are essential to improving compliance and meeting the goal.

Politics and pediatrics

The HPV vaccine was licensed in 2006, and the Advisory Committee on Immunization Practices (ACIP) recommended routine vaccination for girls in 2009. The committee recommended routine vaccination for boys in 2011. The current recommendations are routine vaccination of girls and boys aged 11 to 12 years with the quadrivalent HPV vaccine, which protects against four types of HPV, with catch-up vaccination for girls and women up to the age of 26 years and boys and men up to the age of 21 years.

The vaccine has been surrounded by value-laden, politically-driven discourse; it targets early adolescents, before initiation of sexual contact, but it has been wrapped up in discussions of sexual behavior. Although the vaccination recommendations are for universal coverage, parents and pediatric providers alike have considered a child’s actual, perceived or anticipated sexual risk in the decision of whether or not to vaccinate. A maelstrom of negative media coverage focused on adverse effects exacerbated the challenge of increasing vaccine coverage. Parental attitudes and preferences may have played a larger role in the discussions with pediatric providers about the vaccine than seen with other vaccines.

Pediatric providers face a barrage of concerns: parental attitudes, questions of targeted vaccinations and cost issues. Although many of these challenges have been mitigated since the vaccine’s launch, providers may have developed practice patterns that have not changed with the revised vaccine recommendations and may not have developed a communications strategy related to the HPV vaccine. “Clinicians’ habits don’t change quickly, even if the evidence base has grown and the recommendations have changed,” says Lydia Shrier, MD, MPH, attending physician in the Division of Adolescent/Young Adult Medicine at Boston Children’s Hospital.

HPV infection is common among young adults, and persistent infection with high-risk HPV types, specifically HPV-16 and HPV-18, is responsible for 70 percent of cervical cancers and many vulvar, vaginal, penile, anal and oropharyngeal cancers. Approximately 17,400 cancers among females and 8,880 cancers among males per year are attributable to HPV.

Despite these data, many do not see HPV as a public health threat, which contributes to the poor uptake of the vaccine, opines Shrier.

Multiple, disparate reasons factor into the poor compliance rates. These barriers were elucidated in a review article published online Nov. 25, 2013, in JAMA Pediatrics.

“The vaccine came out under circumstances that were different from other vaccines. We didn’t have prior experience with considering the rationale in the same way,” Shrier explains.

Differences include:

• The HPV vaccine was the first pediatric-recommended vaccine for girls only (although now the vaccine is recommended for boys as well).

• The rationale for the vaccine involved prevention of a virus acquired through sexual contact.

• It is the only vaccine for cancer prevention.

• The vaccine is a three-dose series administered over six months. Conversely, adolescent health maintenance visits are generally scheduled once annually. Thus, completing the series requires a commitment to make additional appointments.

• Insurance coverage for the vaccine series, which costs approximately $360, was inconsistent at first.

Meeting the Healthy People 2020 objective of 80 percent coverage among girls poses a high bar; however, emerging data and improved reimbursement augment the argument for the vaccine.

Initial messaging about the efficacy of the vaccine may not have been as clear as warranted by the increasingly compelling data. Since 2009, additional research has shown the consequences of HPV infection in men and the relation to cancers at numerous sites other than the cervix.

In addition, because the vaccine is now recommended for all adolescents, rather than just girls, communication with parents has become much simpler. The federal Vaccine Adverse Effects Reporting System that investigates reports of adverse effects has found no new or patterns of adverse effects since routine pediatric vaccination started in 2009, which is another important fact to share with parents.

Finally, data about the low uptake of the vaccine are compelling. “No one wants to fail,” says Shrier. “Physicians have to be forthcoming about the public health impact of HPV and the safety of this vaccine. We have to work collaboratively to get enough people vaccinated. Coverage of one-third of the population protects vaccinated individuals, but it does not make enough of a difference from the public health perspective.”

Pediatric providers can facilitate compliance by:

• Leveraging available material from the Centers for Disease Control and Prevention about the vaccine

• Creating a mental script that addresses adverse effects and parents’ concerns

• Learning about vaccine reimbursement and configuring the practice billing system to support the CDC’s Vaccines for Children Program, which covers the cost of the vaccine at no cost for eligible patients.

Finally, Shrier recommends that clinicians emphasize that the HPV vaccine is effective only if it is administered before people come in contact with the virus. “The vaccine series has to be given early, completely, and to as many preteens and teens as possible. A lot of parents are waiting to vaccinate their children, which can markedly decrease its effectiveness.”

“When asked to conjure an image of a patient living with an eating disorder, I imagine many people picture a young, thin woman. This reflects two common stereotypes: that eating disorders only affect women, and that all people with eating disorders are low-weighted. In fact, clinical experience and an evolving field of research show that many males struggle with eating disorders,” says Scott Hadland, MD, MPH, from the Division of Adolescent/Young Adult Medicine at Boston Children’s Hospital.

Similarly, parents and health care providers may see gay, lesbian and bisexual youth in terms of their sexual identities and forget that these teens may face body image and weight control issues as well.

Two recent studies published by researchers at Boston Children’s debunk these stereotypes and may change the way parents and providers think about eating disorders and risky weight control behaviors in all teens.

Alison Field, ScD, also from Boston Children’s Division of Adolescent Medicine, published a study Nov. 4 in JAMA Pediatrics which examined how eating disorders affect teenage boys. Hadland’s study, published Oct. 30 in the Journal of Adolescent Health, focused on risky weight control behaviors—such as fasting for more than 24 hours, using diet pills, and vomiting or using laxatives—among gay, lesbian and bisexual youth. Pediatric Dose spoke with both researchers about their findings and the implications for managing these populations.

Pediatric Dose: Do boys and girls have similar concerns about their weight and physique?

Field: Males and females have very different concerns about their weight and appearance. While girls tend to be more concerned with thinness, boys tend to focus on muscularity. Our study, which reviewed responses of 5,527 adolescent males to the “Growing Up Today Study” questionnaire, every 12 to 36 months from 1999 through 2010, showed that 9.2 percent of boys reported high concerns with muscularity, while 2.5 percent were concerned about thinness and 6.3 percent were concerned with both aspects of appearance.

Pediatric Dose: How might this affect diagnosis of eating disorders among males?

Field: The diagnostic criteria for eating disorders emphasize anorexia nervosa and bulimia and recently recognized binge eating disorder. Anorexia and bulimia are characterized by an excessive influence of weight and physique on self-evaluation, with patients focused on being thin or losing weight.

Most eating disorder assessments reflect these criteria and may overlook boys concerned about their weight and shape but who want to be more muscular. This may be the male equivalent of girls who are very concerned with their weight and who use vomiting or laxatives to lose or maintain weight.

Pediatric Dose: Did the research reveal other risky health behaviors among adolescent males?

Field: Males concerned about muscularity and who used potentially unhealthy supplements, growth hormone and steroids to enhance their physique were approximately twice as likely to start binge drinking frequently and much more likely than their peers to start using drugs. Boys concerned with thinness were more likely to develop depressive symptoms.

A total of 2.9 percent of respondents had full or partial criteria binge-eating disorder, and nearly one-third reported infrequent binge eating, purging or overeating.

Pediatric Dose: What about gay, lesbian and bisexual teens? Are risky weight-control behaviors prevalent among sexual minorities?

Hadland: We suspected these behaviors were higher among sexual minority youth and discovered they are alarmingly common.

We reviewed data from 12,984 high school students who responded to the Massachusetts Youth Risk Behavior Survey in odd years from 2003 to 2009.

We found risky weight control behaviors are common among all teens. One in 10 heterosexual males and two in 10 heterosexual females fasted for 24 hours or longer, used diet pills or vomited or misused laxatives in the month preceding the survey.

These rates increased to approximately one in three among sexual minority youth.

Pediatric Dose: Are there other differences among sexual minorities that might explain the findings?

Hadland: It may be that sexual minority youth face a unique set of stressors, such as social isolation and stigmatization.

We also observed that compared with heterosexual females, lesbians and bisexual females were more likely to self-perceive as being a healthy weight despite being overweight or obese. Compared with heterosexual males, heterosexual males with prior same-sex partners and bisexual males were more likely to see themselves as overweight despite being of healthy weight or underweight.

It may be that body image ideals differ between sexual minority teens and their heterosexual peers.

Pediatric Dose: Do you have any recommendations for primary care providers?

Hadland: Clinicians should be aware that risky weight control behaviors, such as food restriction, misuse of diet products, self-induced vomiting and laxative misuse, are extremely common among all teens and more common among sexual minorities. If a teen identifies as a sexual minority, the health care provider should ask about these behaviors.

Field: It’s important to be aware that some adolescent males may be so preoccupied with their weight and shape that they are using unhealthy methods to achieve the physique they desire.