Perspective: Barbie: Food for the Soul or Fanciful Nostalgia?

This perspectives piece analyzes the "Barbie" movie and its impact on its viewership. In contrast to prior research demonstrating that images of Barbie objectified girls, lowered self-esteem, and promoted body dysmorphia, with social media focus on "Fitspiration" as well as "Thinspiration" amplifying the negative effect, the Barbie movie may have more positive impact than one might predict. As gleaned from an informal survey of patients, parents, and peers, the messages of the Barbie movie include a mix of body positivity, recognition of the impact of depression and other aspects of mental health, critique of the perceived societal patriarchy, and a message of empowerment for girls, females, and people otherwise unrecognized.

Addressing Administrative and System-Level Challenges to Implementation of Long-Acting Reversible Contraceptives in Adolescent Medicine and Pediatric and Adolescent Gynecology Practices: A Qualitative Study.

STUDY OBJECTIVE: Adolescents use long-acting reversible contraceptive (LARC) methods less than adults. Practices that specialize in adolescent medicine, including Adolescent Medicine (AM) and Pediatric and Adolescent Gynecology (PAG), may be well positioned to help improve adolescent access to these methods. We describe administrative and system-level barriers encountered when implementing LARCs for adolescents and strategies that practices have successfully used to address these barriers. DESIGN/SETTING/PARTICIPANTS: We conducted a qualitative study with physicians and staff at AM and PAG practices that provide LARCs to adolescents. INTERVENTIONS: Semi-structured telephone interviews MAIN OUTCOME MEASURES: Interview guides were based on the Consolidated Framework for Implementation Research (CFIR), an implementation science methodology designed to understand the following aspects of settings adopting new practices: innovation characteristics, external environment, institutional and practice settings, the stakeholders involved, and the implementation process. RESULTS: Seventeen interviews were performed. When examining administrative and system-level challenges encountered by interviewees, the four CFIR constructs identified most frequently were cost, readiness for implementation-available resources, planning, and engaging. Interviewees shared strategies used to overcome these common barriers, including for billing and working with insurance companies, space and equipment needed to introduce LARCs, scheduling and use of telemedicine, and staff training and engagement. CONCLUSION: Sites used many strategies to address these common challenges to implementation. Examples could help with implementation of LARC provision in practices serving adolescent populations.

Electrocardiographic QTc as a Surrogate Measure of Cardiac Risk in Children, Adolescents, and Young Adults With Eating Disorders.

The study goal was to investigate electrocardiographic findings, including corrected QT interval (QTc), in patients aged 8 to 23 with eating disorders (EDs) at presentation, compared with an age-and sex-matched control population. We retrospectively reviewed 200 ED patients, and 200 controls. Blinded electrocardiograms (ECGs) were interpreted by an expert reader, and QT intervals corrected using the Bazett formula. Eating disorder patients were 89.5% female, with mean age 16.4 years and median percent median body mass index (BMI)-for-age (%mBMI)a of 91.1%. In ED patients, QTc was significantly shorter than controls (399.6 vs 415.0msec, P < .001). After adjusting for height, %mBMI, sex, magnesium level, and bradycardia, mean QTc duration in patients with anorexia nervosa-restricting subtype (AN-R) was significantly shorter than other ED patients (P = .010). Higher %mBMI was associated with shorter QTc duration (P = .041) after adjusting for height, magnesium, bradycardia, and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis. Within the ED group, no significant association was identified between QTc and medications, electrolytes, or inpatient status.

Association of the COVID-19 Pandemic With Adolescent and Young Adult Eating Disorder Care Volume.

Importance: The COVID-19 pandemic has affected youth mental health. Increases in site-specific eating disorder (ED) care have been documented; however, multisite studies demonstrating national trends are lacking. Objective: To compare the number of adolescent/young adult patients seeking inpatient and outpatient ED care before and after onset of the COVID-19 pandemic. Design, Setting, and Participants: Using an observational case series design, changes in volume in inpatient and outpatient ED-related care across 15 member sites (14 geographically diverse hospital-based adolescent medicine programs and 1 nonhospital-based ED program) of the US National Eating Disorder Quality Improvement Collaborative was examined. Sites reported monthly volumes of patients seeking inpatient and outpatient ED care between January 2018 and December 2021. Patient volumes pre- and postpandemic onset were compared separately for inpatient and outpatient settings. Demographic data such as race and ethnicity were not collected because this study used monthly summary data. Exposures: Onset of the COVID-19 pandemic. Main Outcomes and Measures: Monthly number of patients seeking inpatient/outpatient ED-related care. Results: Aggregate total inpatient ED admissions were 81 in January 2018 and 109 in February 2020. Aggregate total new outpatient assessments were 195 in January 2018 and 254 in February 2020. Before the COVID-19 pandemic, the relative number of pooled inpatient ED admissions were increasing over time by 0.7% per month (95% CI, 0.2%-1.3%). After onset of the pandemic, there was a significant increase in admissions over time of 7.2% per month (95% CI, 4.8%-9.7%) through April 2021, then a decrease of 3.6% per month (95% CI, -6.0% to -1.1%) through December 2021. Prepandemic, pooled data showed relative outpatient ED assessment volume was stable over time, with an immediate 39.7% decline (95% CI, -50.4% to -26.7%) in April 2020. Subsequently, new assessments increased by 8.1% (95% CI, 5.3%-11.1%) per month through April 2021, then decreased by 1.5% per month (95% CI, -3.6% to 0.7%) through December 2021. The nonhospital-based ED program did not demonstrate a significant increase in the absolute number of admissions after onset of the pandemic but did see a significant increase of 8.2 (95% CI, 6.2-10.2) additional inquiries for care per month in the first year after onset of the pandemic. Conclusions and Relevance: In this study, there was a significant COVID-19 pandemic-related increase in both inpatient and outpatient volume of patients with EDs across sites, particularly in the first year of the pandemic. Given inadequate ED care availability prior to the pandemic, the increased postpandemic demand will likely outstrip available resources. Results highlight the need to address ED workforce and program capacity issues as well as improve ED prevention strategies.

Clinician and Ethicist Perspectives: Understanding Moral Distress in Gender-Affirming Care for Pediatric Patients.

Using case examples and other common scenarios, the authors outline several types of moral distress that clinicians may experience when providing pediatric gender-affirming care. The authors also offer strategies for managing moral distress and issue a call to action for professional organizations to enhance support for gender-affirming clinicians.

Adolescent Gynecology in the Office Setting.

Ensuring open communication, partnership with patient and parent, and clarification of confidentiality during an adolescent gynecologic visit helps establish an environment in which a history and physical examination can be performed safely and with a focus on prevention, recognition of disease, and treatment as necessary. The history should include the menstrual status and gynecologic review of systems. The examination should document Tanner staging (sexual maturity rating) and be otherwise symptom guided. Similarly, testing in the office is largely risk and symptom related. Contraceptive counseling is an important component of the office visit, as well. Long and short curricula for teaching pediatric and adolescent gynecology have been developed by the North American Society for Pediatric and Adolescent Gynecology and are readily available for use. (1)(2) Although state-based variation in consent and confidentiality exists, pediatric practices should aim to protect patient confidentiality and transition to more independent health-care decision making.

Promoting resiliency in adolescents during a pandemic: A guide for clinicians and parents.

The COVID-19 pandemic has dramatically affected every aspect of daily life. Parents of adolescents, in particular, may be facing unique challenges in helping them navigate unexpected changes to their daily routine. This article discusses how adolescents may respond to stressful and traumatic situations and provides recommendations for clinicians who may be advising parents of adolescents or parenting their own children.

Intimate Partner Violence in the Adolescent.

Intimate partner violence among adolescents (also called adolescent relationship abuse or teen dating violence) is common and is associated with poor health and social outcomes. Pediatric providers are uniquely positioned to offer universal education (anticipatory guidance) about healthy and unhealthy relationships to all their adolescent patients. Pediatric practices can ensure that youth know about available resources and supports for relationship abuse (for themselves or for their friends) and can facilitate safe connections to victim service advocates.

Return of Menses in Previously Overweight Patients with Eating Disorders.

STUDY OBJECTIVE: Adolescents with eating disorders and a history of overweight present with higher weights, longer duration of disease, but equally severe symptomatology compared with previously normal weight patients. To better delineate treatment goals for this understudied population, we compared weight at menses resumption with premorbid maximum weight among previously overweight and normal weight patients. DESIGN: Retrospective cohort study. SETTING: Outpatient adolescent medicine clinic at an eating disorder referral center. PARTICIPANTS: Postmenarchal patients meeting criteria for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition eating disorders. History of overweight was defined as a body mass index (BMI) greater than or equal to the 85th percentile or 25 or more. INTERVENTIONS AND MAIN OUTCOME MEASURES: Weight characteristics at presentation and menses resumption (BMI, BMI z-score, change from maximum weight to presentation weight) RESULTS: Previously overweight patients presented with greater mean weight, longer duration of disease, and higher BMI than previously normal weight patients. No difference was found in rates of amenorrhea at presentation or menses resumption. Previously overweight patients resumed menses at a younger age and higher BMI z-scores. The difference between weight at menses resumption and premorbid maximum weight was greater for previously overweight patients. CONCLUSION: Previously overweight patients with eating disorders present differently than their normal-weight peers, so reliance on weight status as a screening criterion might result in underdiagnosis. Although BMI z-scores associated with menses resumption are higher for previously overweight patients, there is no difference in weight gain between presentation and menses resumption and time to menses resumption compared with previously normal-weight patients. Moreover, menses resumption occurred at weights significantly lower than premorbid maximum weight for previously overweight patients, so restoration to highest premorbid weight is not necessary.

Vaping: The new wave of nicotine addiction.

Vaping devices, introduced to the US market in 2007 as aids for smoking cessation, have become popular among youth and young adults because of their enticing flavors and perceived lack of negative health effects. However, evidence is emerging that vaping may introduce high levels of dangerous chemicals into the body and cause severe lung injury and death. This article reviews the history and prevalence of vaping and available research on its health effects and efficacy in smoking cessation, and proposes recommendations for clinicians and legislators to reduce harms associated with vaping.

Effect of Hospitalization on Percent Median Body Mass Index at One Year, in Underweight Youth With Restrictive Eating Disorders.

PURPOSE: Data from low-weight patients with restrictive eating disorders (EDs) treated in outpatient adolescent medicine-based ED treatment programs were analyzed to determine whether there was an association between hospitalization and gain to at least 90% median body mass index (mBMI) at 1-year follow-up. METHODS: Data were retrospectively collected for 322 low-weight (<85% mBMI at intake) patients aged 9-21 years, who presented with restrictive EDs to 14 adolescent medicine-based ED programs in 2010. Positive outcome was defined as being at least 90% mBMI (%mBMI = patient's body mass index/mBMI for age × 100) at 1-year follow-up. Association between treatment at a higher level of care and gain to at least 90% mBMI was analyzed for 140 patients who were <85% mBMI at the time of presentation, had not been previously hospitalized, and had 1-year follow-up data available. RESULTS: For patients presenting at <85% mBMI, those who were hospitalized in the year following intake had 4.0 (95% confidence interval: 1.6-10.1) times the odds of gain to at least 90% mBMI, compared with patients who were not hospitalized, when controlling for baseline %mBMI. CONCLUSION: In this national cohort of patients with restrictive EDs presenting to adolescent medicine-based ED programs at <85% mBMI, those who were hospitalized had greater odds of being at least 90% mBMI at 1-year follow-up.

Sometimes You Do Get a Second Chance: Emergency Contraception for Adolescents.

Unplanned or unintended pregnancy remains a significant challenge for adolescents; many teens who plan ahead but opt not to choose long-acting reversible contraceptive methods have high failure rates with condom usage, oral contraceptives, and other less long-acting methods. Emergency contraception (EC) remains a necessity for those adolescents seeking a second chance to prevent the unintended consequences of unplanned sexual activity. At present, 5 postcoital methods remain available as EC globally: intrauterine devices, ulipristal acetate, a selective progesterone modulator, mifepristone; levonorgestrel, and ethinyl estradiol plus levonorgestrel or norgestrel (rarely used now that progestin only methods are more readily available).

History of Overweight/Obesity as Predictor of Care Received at 1-year Follow-Up in Adolescents With Anorexia Nervosa or Atypical Anorexia Nervosa.

PURPOSE: Previous research has indicated that patients with anorexia nervosa (AN) or atypical AN with premorbid history of overweight/obesity have greater weight loss and longer illness duration than patients with no such history. However, little is known about the association of premorbid overweight/obesity and receiving inpatient medical care during treatment for an eating disorder. METHODS: Using logistic regression, we sought to determine if history of overweight/obesity was associated with receiving inpatient medical care in a sample of 522 patients (mean age 15.5 years, 88% female) with AN/atypical AN. RESULTS: Binary results demonstrated greater percent weight loss (27.4% vs. 16.2%) and higher percent median body mass index (%mBMI, 99.8% vs. 85.2%) at presentation in those with a history of overweight/obesity (p < .001) but no difference in duration of illness (p = .09). In models adjusted for demographics and percent weight loss, history of overweight/obesity was associated with lower odds of receiving inpatient medical care (odds ratio .60 [95% confidence interval: .45-.80]) at 1-year follow-up. However, these associations were no longer significant after adjusting for %mBMI. Mediation results suggest that %mBMI fully mediates the relationship between history of overweight/obesity and inpatient medical care, in that those with a history of overweight/obesity are less likely to receive care due to presenting at a higher weight. CONCLUSIONS: Our findings suggest that, despite greater degree of weight loss and no difference in duration of illness, participants with a history of overweight/obesity are less likely to receive inpatient medical care.

Eating disorders in children and adolescents: what does the gynecologist need to know?

PURPOSE OF REVIEW: The purpose of this review is to discuss the diagnosis, medical complications, and treatment of eating disorders as defined by the newly released Diagnostic and Statistical Manual, 5th edition. RECENT FINDINGS: With the introduction of the Diagnostic and Statistical Manual, 5th edition, the diagnostic criteria for anorexia nervosa and bulimia nervosa have been revised to better capture the varied presentations of patients with eating disorders. In addition, new eating disorder diagnoses including binge-eating disorder, characterized by recurrent bingeing without associated compensatory behaviors, and avoidant/restrictive food intake disorder, characterized by a restrictive eating pattern without associated body dysmorphism, allow for increased recognition, diagnosis, and treatment of disordered eating patterns. In addition to a high mortality rate, eating disorders are associated with serious medical sequelae secondary to malnutrition and disordered behaviors, including disturbances of the cardiovascular, neurologic, gastrointestinal, reproductive, and skeletal systems. Early diagnosis and family-based treatment are associated with improved outcomes in children and adolescents. SUMMARY: Eating disorders are illnesses with biological, psychological, and social implications that commonly present in childhood and adolescence. Gynecologists are on the front line for the screening and diagnosis of eating disorders in adolescent women.

Medical stabilization of adolescents with nutritional insufficiency: a clinical care path.

PURPOSE: Nutritional insufficiency (NI) is a potential consequence of restrictive eating disorders. NI patients often require hospitalization for refeeding to restore medical stability and prevent complications such as refeeding syndrome. Limited information is available on the optimal approach to refeeding. In this study, we describe an inpatient NI care path and compare treatment outcomes at an academic medical center and a community hospital. METHODS: A retrospective chart review was conducted on inpatients treated using a standardized NI care path at either the academic site, from August 2012 to July 2013 (n = 51), or the community site, from August 2013 to July 2014 (n = 39). Demographic information, eating disorder history, and treatment variables were recorded for each patient. Data were compared using the Kruskal-Wallis test and Fisher's exact test. RESULTS: Patients admitted to the community site had shorter hospital stays than patients admitted to the academic site (IQR 2-4 vs. 2-7 days, p = 0.03). All patients were discharged in <14 days with a median stay of 3 days. The median initial calorie prescription was 2200 calories for both groups. No clinical cases of refeeding syndrome occurred, with only one patient developing hypophosphatemia during refeeding. CONCLUSIONS: A standardized care path with a higher-calorie intervention allows for short-term hospitalization of NI patients without increasing the risk of refeeding syndrome, regardless of treatment site. This study demonstrates the efficiency and safety of treating NI patients on a regular medical floor at a community hospital.

Global Health: Urogenital Schistosomiasis in the Adolescent Girl.

Urogenital schistosomiasis affects millions of women in sub-Saharan Africa. Infection by the causative organism, Schistosoma hematobium, commonly occurs during childhood and adolescence and can lead to anemia from hematuria, inflammation on the cervix which can increase risk of HIV transmission, and pelvic infection leading to infertility. Fortunately treatment is not costly, but early diagnosis is important to reduce long-term morbidity. Our objective is to review the epidemiology, pathophysiology, and diagnosis of urogenital schistosomiasis as well as treatment to improve the reproductive health of girls where this infection is endemic.

Monthly Periods--Are They Necessary?

Menstrual suppression--the use of hormones to delay or eliminate menses--is often used in adolescents to manage conditions associated with the menstrual cycle and to accommodate lifestyle preferences. Reducing the frequency of menstrual bleeding does not cause any known physiologic harm and has potential short-term and long-term advantages. Different methods used for menstrual suppression, however, have associated risks and side effects that need to be weighed against the benefits of controlling menses. This article reviews the advantages and disadvantages of menstrual suppression and the different methods available for adolescents.

Avoidant/Restrictive Food Intake Disorder: Illness and Hospital Course in Patients Hospitalized for Nutritional Insufficiency.

PURPOSE: Avoidant/restrictive food intake disorder (ARFID), a recently defined Diagnostic and Statistical Manual of Mental Disorders-5 eating disorder diagnosis, has not been extensively studied in the inpatient population. This study compares hospitalized ARFID and anorexia nervosa (AN) patients, including differences in presentation, treatment response, and 1-year outcomes. METHODS: We conducted a retrospective chart review of ARFID and AN patients hospitalized between 2008 and 2014 for acute medical stabilization at an academic medical center. Data, including characteristics on admission, during hospitalization, and 1 year after discharge, were recorded for each patient and compared between ARFID and AN patients. RESULTS: On presentation, ARFID patients (n = 41) were younger with fewer traditional eating disorder behaviors and less weight loss, comorbidity, and bradycardia than AN patients (n = 203). During hospitalization, although ARFID and AN patients had similar caloric intake, ARFID patients relied on more enteral nutrition and required longer hospitalizations than AN patients (8 vs. 5 days; p = .0006). One year after discharge, around half of ARFID and AN patients met criteria for remission (62% vs. 46%; p = .18), and less than one-quarter required readmission (21% vs. 24%; p = .65). CONCLUSIONS: The findings from this study reveal several differences in hospitalized eating disorder patients and emphasize the need for further research on ARFID patients, including research on markers of illness severity and optimal approaches to refeeding. Similar remission and readmission rates among ARFID and AN patients highlight both the success and the continued need for improvement in eating disorder treatment regardless of diagnosis.

Effects of treating gender dysphoria and anorexia nervosa in a transgender adolescent: Lessons learned.

Patients with gender dysphoria and patients with eating disorders often experience discontent with their bodies. Several reports have recognized the co-occurrence of these two conditions, typically in adults who identify as transgender females and desire a more feminine physique. This case report, in contrast, describes a 16-year-old patient with a female sex assigned at birth who first presented with features consistent with anorexia nervosa and later revealed underlying gender dysphoria with a drive for a less feminine body shape. We discuss both the path to recognizing gender dysphoria in this patient as well as the impact of treatment on his eating disorder and overall well-being. This case is one of only a few reports describing a female-to-male transgender patient with an eating disorder and is the first to explore the effects of hormone and surgical intervention in an adolescent patient.