Contraception in the adolescent: an update.

Contraception remains an important part of national efforts to reduce adolescent pregnancy in the United States. A number of safe and effective contraceptive methods are available for our youth, including abstinence, barrier methods, oral contraceptives, Depo-Provera, and Norplant. Research over the past few decades has resulted in a variety of oral contraceptives with reduced amounts of hormones and reduced side-effects. A number of methods have received approval by the Food and Drug Administration since the last review in 1980, including emergency contraceptives, depomedroxyprogesterone acetate, and the cervical cap. The use of condoms and vaginal spermicides continues to be recommended for all sexually active adolescents to reduce (not eliminate) the risk for acquiring sexually transmitted diseases. A polyurethane condom is now available, in addition to the latex condom and other barrier contraceptives, including the following: diaphragm, cervical cap, vaginal sponge, female condom and vaginal spermicides. Because of continuing concerns about pelvic inflammatory disease related to intrauterine devices, currently available intrauterine devices are not recommended for most adolescents. Abortion is not considered as a contraceptive method.

Parents can dose liquid medication accurately.

OBJECTIVE: To determine whether parental errors in dosing liquid medication can be decreased through education. DESIGN: Randomized convenience sample stratified to three study groups. SETTING: General pediatric clinic, largely indigent and Latino. PATIENTS: A total of 45 English-speaking and 45 Spanish-speaking children diagnosed with otitis media and treated with an antibiotic suspension. INTERVENTION: Group 1 patients received the prescription and verbal instructions. Group 2 patients received the prescription and a syringe, then the correct dose was demonstrated. Group 3 patients received the prescription, a syringe with a line marked at the correct dose, and a demonstration. After returning from the pharmacy, parents administered the medication under observation. Parents in group 1 used a dispensing device similar to that planned for home use. The other groups used the syringe. After observation but before discharge, everyone received a syringe with a line marked at the correct dose. Patients were seen again at approximately 1 month, and parents demonstrated how much medication they had administered. MAIN OUTCOME MEASURE: Percent of parents who administered the correct dose. RESULTS: Patients in group 1 received between 32% and 147% of the correct dose, with only 11 of 30 (37%) receiving the correct dose (+/-0.2 mL). In group 2, 25 of 30 (83%) parents administered the correct dose, and in group 3, 30 of 30 (100%) gave the correct dose. Simultaneous logistic regression indicated that accuracy of dosage differed across instructional groups and language. At follow-up, 23 of 26 parents demonstrated the correct dose. CONCLUSION: Education can decrease medication dosing errors made by both Spanish-speaking and English-speaking parents. Effectiveness was also shown at follow-up.

Toluene embryopathy: delineation of the phenotype and comparison with fetal alcohol syndrome.

OBJECTIVE: To determine if maternal toluene abuse produces any structural or developmental disabilities in the developing fetus, a cohort of toluene-exposed infants was ascertained and examined. METHODOLOGY: Eighteen infants with a history of in utero toluene exposure were examined at birth. Nine of these infants were reexamined 3 to 36 months after their initial evaluations. The clinical findings in these patients were compared with those of similarly exposed children from the literature and with patients who had the fetal alcohol syndrome. RESULTS: Thirty-nine percent of all toluene-exposed infants described in this and other studies were born prematurely, and 9% died during the perinatal period. Fifty-four percent were small for gestational age, and 52% exhibited continued postnatal growth deficiency. A 33% incidence of prenatal microcephaly, a 67% incidence of postnatal microcephaly, and an 80% incidence of developmental delay were observed. Eighty-three percent of the patients had craniofacial features similar to the fetal alcohol syndrome, and 89% of these children had other minor anomalies. CONCLUSIONS: Data from the patients herein described and the available scientific literature suggest that the mechanism of alcohol craniofacial teratogenesis may be nonspecific, with a variety of teratogens, including toluene, giving rise to phenotypic facial abnormalities similar to those of the fetal alcohol syndrome. We propose a common mechanism of craniofacial teratogenesis for toluene and alcohol, namely a deficiency of craniofacial neuroepithelium and mesodermal components due to increased embryonic cell death.

Further delineation of the epidermal nevus syndrome: two cases with new findings and literature review.

"Epidermal nevus syndrome" ("ENS") is a neurocutaneous disorder in which epidermal nevi are associated with other abnormalities, most commonly of the skeletal and central nervous systems. We present two cases of epidermal nevus syndrome (ENS) with very different clinical findings. The first case is a newborn with multiple linear epidermal nevi of the trunk and limbs, and several other anomalies, including bony duplications of the lower limbs and hypoplastic left heart syndrome. The second patient, a 6-year-old boy, has a linear nevus sebaceous of the scalp with severe CNS involvement, including generalized seizures, moderate mental retardation, microcephaly, and a left hemiparesis. He also has genitourinary, cardiac, and skeletal defects. These two patients exhibit several abnormalities not previously recognized and illustrate the wide clinical spectrum of "epidermal nevus syndrome." We present a review of the clinical findings in 74 cases of "ENS." Correlation was noted between the presence of skin lesions located on the head and CNS involvement. The wide clinical spectrum of "ENS" as illustrated by these two patients suggests that "ENS" is a causally heterogeneous group of disorders.

Stun gun injury: a new presentation of the battered child syndrome.

Stun guns are self-protection devices that are increasingly available with few restrictions on their use and sale. We present a case of child abuse with a stun gun. The signs of such abuse are often subtle, and they may be underrecognized currently. The skin lesions that are often seen are hypopigmented circular macules, measuring approximately 0.5 cm in diameter. They may be raised slightly and erythematous if inflicted recently Most characteristic of stun gun assault is pairing of lesions approximately 5 cm apart. We discuss the design, operation, and effects of stun guns, and give an extensive differential of abusive and nonabusive circular lesions.

Child abuse or osteogenesis imperfecta: how can we tell?

Osteogenesis imperfecta may be difficult to differentiate from nonaccidental trauma. Social history may prejudice the physician in favor of or against considering the diagnosis of child abuse. Three cases of osteogenesis imperfecta that were initially diagnosed as nonaccidental trauma are presented. The availability of biochemical analysis of type I collagen was instrumental in confirming the diagnosis of osteogenesis imperfecta in all three cases.

Practice management training for pediatric residents.

In 1986, a practice management training program was developed for pediatric house staff. In conjunction with this program, pediatric residents for the following 2 years completed questionnaires regarding their career goals, interests, and perceived competence in practice management. Postgraduate level-3 residents who completed the program felt more competent than postgraduate level-1 residents in all areas of practice management and were more likely to take an active role in managing their practice. There was a significant difference between postgraduate level-1 and level-3 residents who completed the program in several areas: feelings of overall competence in office management, choosing a practice location, office staff, appointment system, billing system, office computer, fee schedules, telephone management, and setting up an office laboratory. Exposure to a practice management program during residency training may better prepare future pediatricians for a successful practice.

An illustrated guide to adolescent gynecology.

The gynecologic examination should be considered an essential part of a complete physical examination in the adolescent girl. Many symptoms and signs which at first may seem to be unrelated to the reproductive tract are found to be due to gynecologic pathology after a careful gynecologic examination has been completed. Most of the diagnostic tests which are needed as part of the gynecologic examination can be easily performed in a pediatrician's office including wet preps, KOH preps, and Gram's stains of vaginal discharge. Other ancillary tests, including Pap smears and cultures for sexually transmitted diseases, can be obtained by the examining pediatrician and sent to local clinical laboratories. The pelvic ultrasound can be a helpful adjunct to the gynecologic examination when congenital anomalies, or adnexal masses, are suspected.

Sexual abuse: somatic and emotional reactions.

A chart review and telephone interview of 72 sexual abuse victims was conducted to determine if children and adolescents who are victims of sexual abuse suffer from symptoms similar to the "rape trauma syndrome," which has been reported in adults. Symptoms similar to the rape trauma syndrome were found in 48 of the 72 abused children and only 26 of the matched control group, p less than .01. Common somatic complaints in the sexual abuse patients included dysuria, vaginal discharge and chronic abdominal pain. Some of the emotional and behavioral problems noted during the follow-up period among the sexual abuse patients included sleep problems, runaway behavior, and suicide attempts. The duration of abuse and age of the victim at the time of abuse significantly affected the frequency of reported somatic symptoms, but the type of abuse and type of assailant did not significantly affect the frequency of reported somatic and emotional reactions. There was no difference in the occurrence of school problems and early pregnancy between sexually abused patients and controls. Since 67% of all sexually abused patients suffered from emotional and somatic reactions, close follow-up of these patients is indicated.

Gardnerella vaginalis in prepubertal girls.

A prospective study was established to determine the significance of the isolation of Gardnerella vaginalis from the vagina in prepubertal children. Two hundred fifty-six children were enrolled. Group 1 consisted of 137 children who had been victims of sexual abuse; group 2, forty-eight children with genitourinary complaints and no history of sexual abuse; and group 3, seventy-one children with no genitourinary complaints and no history of sexual abuse. Gardnerella vaginalis was isolated from 20 patients (14.6%) in group 1 and five (4.2%) of 119 control patients from groups 2 and 3. Within group 1, G vaginalis was more likely to be isolated from children with a history of multiple episodes of sexual abuse than those with a single episode. Gardnerella vaginalis was not associated with any other historical, physical, or laboratory findings, including vaginal erythema or vaginal discharge.

Evaluation of a successful biosocial rotation.

Efficacy of an eight-week rotation in developmental and behavioral pediatrics for second-year pediatric residents was evaluated. Pretesting and posttesting disclosed that our residents felt more competent with biosocial problems, had more favorable attitudes toward patients with biosocial problems, and had increased factual knowledge in developmental and behavioral pediatrics. When reevaluated 12 to 24 months after rotation as third-year residents (PL-3), they performed better on a factual knowledge test than a PL-3 control group that had not had the rotation. They also felt more competent than the controls in the diagnosis and treatment of children with learning disabilities, hyperactivity, physical handicaps, depression, and gynecologic problems.

Cutaneous amebiasis.

An infant with cutaneous amebiasis of the vulva and amebic liver abscess is described. Epidemiologic investigations and serologic studies were crucial in establishing the diagnosis. The vulvar amebic ulcers responded dramatically to metronidazole therapy. Cutaneous amebiasis is a rare complication of Entamoeba histolytica infection which should be considered in the differential diagnosis of perineovulvar or penile ulcers. Cutaneous amebiasis may also occur on the abdominal wall surrounding a draining hepatic abscess, colostomy site, or laparotomy incision.