Transcript Paediatric newsweek in Sun Peaks for MD

Top Six Paediatric Picks of
2014
Prevention is Key
Kathryn Leccese
Sun Peaks Feb 2015
6 picks at sun peaks in paediatrics
•
Antibiotic Stewardship: bacteria gone viral!
•
My brain is fried: cell phone use in kids and teens.
•
PRAM scores; nothing to do with babies.
•
Autism prevalence aka pregnancy is hard enough
•
Cute chubby baby begets pudgy preteen
•
Kids having kids
Objectives

Prevention in paediatrics is paramount

Review some of the top articles in research that came out in the past year; 2014

Prevention of an antibiotic apocalypse

Discuss potential anticipatory guidance for cell phone use in children ; and adults

Introduce new strategies for asthma stratification in order to hopefully send kids
home sooner

Review some new literature on autism links in order to better guide your advice to
pregnant patients

Review potential age targets for risk of obesity in children

Help discussions with teenagers or prevent pregnancy
Bugs behaving badly
•
Not all bugs need drugs
•
70-80% of paediatric fevers are due to viruses and not
bacteria
•
Antibiotics in livestock … its not all us
•
According to the National Resource Defense Council
80% of antibiotic use in the USA is used to promote
livestock use
•
GMOs
•
Few drugs aside from anitmicrobials can lay claim to
provide cure for disease
•
This life saving impacts are sill observed everyday but
may be in peril in the future
Selected Bacteria/Resistance
Combinations
Bacterium
Resistance/decreased susceptibility to:
Eschericia coli
3rd generation cephalosporins,
fluroquinolones
Klebsiella pneumonia
3rd generation cephalosporins
Staphylococcus aureus
Methicillin
Streptococcus pneumonia
Penicillin
Nontyphoidal Salmonella
Fluoroquinolones
Shigella species
Fluoroquinolones
Neisseiria gonorrhoeae
3rd generation cephalosporins
WHO
Antimicrobial Resistance
Global Report on Surveillance 2014
Resistance for Nine Selected Bacteria/Antibacterial
Drug Combinations, 2013
WHO
Antimicrobial Resistance
Global Report on Surveillance 2014
Neisseria Gonorrhoeae Detection of decreased
susceptibility to 3rd generation cephalosporin and
treatment failures up to 2010
WHO
Antimicrobial Resistance
Global Report on Surveillance 2014
WHO report
1.
High proportions of resistance were reported in all regions to common treatments for bacteria causing
infections in both healthcare settings and in the community
2.
Antibacterial resistance has a negative effect on patient outcomes and health expenditures
3.
Treatment options for common infections are running out
4.
Despite limitations, the report demonstrates worldwide magnitude of ABR and surveillance gaps
5.
Gaps are largest where health systems are weak
6.
There is no agreement on surveillance standards:
7.
8.
1.
What samples and information to collect
2.
How to analyze samples
3.
How to compile and share data
Obtained national data was usually based on proportions of resistant bacteria rather than proportions
of resistant bacteria causing specific diseases or affecting defined populations
The report provides a benchmark for future surveillance progress
Managing Antimicrobial stewardship in daily
practice: Managing an important resource
CPS 2014

Use clinical judgment and test judiciously

Based on age, history and physical exam

If serious infection suspected (meningitis, bacteremia etc) appropriate cultures
should be taken and effective abx BASED on potential pathogens

Results of cultures should tailor therapy or stop antimicrobial therapy

Office based difficult; follow up is key

Pharyngitis with non viral symptoms:

Throat swab for GAS to confirm streptococcal pharyngitis; wait 24-48 hr for culture
is reasonable in a child that is not severely ill.
CPS positions statement Antimicrobial steward ship in
daily practice. May 2014
Managing Antimicrobial stewardship in daily
practice:Manageing an important resource
CPS 2014



AOM: accuracy of diagnosis is paramount

Fluid behind inflamed tympanic membrane in a child who has acute ear pain is
paramount

If older than 6 mo of age, unilateral and uncomplicated with mild symptoms

Treatment with analgesics and follow up in 48-72 hrs is reasonable

Persistent symptoms --- bacterial etiology more likely
Lobar pneumonia: confirm diagnosis with X-ray

Recommended before starting antibiotics

If pneumonic infiltrate Is not observed or consistent with bronchiolitis careful follow
up is required; not antimicrobials
If viral illness suspected; more prudent to have careful follow up than antibiotics
CPS positions statement Antimicrobial steward ship in daily practice. May 2014
Treat infection, not contamination

To prevent contamination urine samples collect samples appropriately

Catheter or clean catch midstream

Even in newborns… bags are bad

Diagnosis of UTI requires signs AND some laboratory evidence then culture
positive

Treatment of positive cultures if there are no signs of infection is incorrect

Do not take throat swabs if no signs of infection; will be treating colonized
patients

Presence of MRSA in nasal or rectal specimens should not routinely start
antibiotic regimens for decolonization
CPS positions statement Antimicrobial steward ship in
daily practice. May 2014
Take a careful history of potential antibiotic side
effects and if possible confirm an antimicrobial
allergy

IgE mediated allergy: urticarial, pruritus, bronchospasm, angioedema
or hypotension within 1h of drug administration

Confirmed or disprove allergies by an allergist

History of Ig E penicillin allergy in a parent is not a reason for
avoidance in a child

Cross reactivity with cepahlosporins is very low (2%)

History of SJS or TENS attributed to an antibiotic is a reason to avoid
related antibiotics in the future
CPS positions statement Antimicrobial steward ship in
daily practice. May 2014

Most common side effects of using an antibiotic are non
urticarial maculopapular rashes of GI symptoms

Most are viral or idiosyncratic reactions to the drug NOT
an allergy

Therefore it can be given to the child in the future

Allowing the use of antibiotics with a narrower spectrum
of activity
Laboratories should produce local, agespecific antibiograms to guide antibiotic
choices for selected infections

Local antibiogram is compilation of susceptibility patters for common isolated
bacteria
Managing Antimicrobial stewardship in daily
practice:Manageing an important resource
CPS 2014

Narrow the spectrum of antimicrobials when a causative organism is
identified

Optimize dosing of antimicrobials to obtain maximal benefit


Use higher end of the recommended dose range for specific infection
Aminoglycosides have “dose dependent killing” maximal effect with high
initial dose & less frequent dosing;


q24 is recommended over the q8h dosing in all children (not neonates)
Oral beta-lactams have short half life and have “time dependent
killing”,

non serious infection (AOM) twice daily dosing is sufficient

more serious infections (pneumonia) 3-4 times a day dosing is used
Use the shortest recommended course
of therapy for uncomplicated infection

Shorter course are associated with fewer adverse events
and less development of resistance

The optimal duration for most infections is not known

Guidelines:

Streptococcal pharyngitis: 10 days

AOM: If failed the watch and wait children >2 yrs; 5
days

Uncomplicated pneumonia: 7 days should due
Take care not to change or prolong
antimicrobial therapy unnecessarily

Some infections can 3 days or more to defervesce; not
equal to treatment failure

Cellulits can take over a day to improve on therapy and
not a reason to progress to broader coverage.

Consider other diagnosis if no evidence of infection or
response to antibiotics:
 Kawasakis,
neoplasms, juvenile inflammatory arthris,
inflammatory bowel disease and recurrent fever
syndromes
Promote vaccinations !!!!!!!!!!!!!!!!!!!!!

Vaccines prevent infections…. Therefore less antibiotic use
Wrap up: 10 ways to promote antimicrobial
stewardship in your paediatric practice
1.
Mindful Reflection: Always document a childs vital signs and PE and why
you are using antibiotics
2.
Detail suspected drug reaction, does history meets true allergy criteria?
Consider consultation with an allergist.
3.
Ensure minimum diagnostic criteria be met for patients with suspected
UTI.
4.
Infections caused by GAS are best treated with beta-lactam antibiotics
not azithromycin or macrolides. Use cloxacillin or cephalexin for
Staphylococcus aureus
5.
There is no need for throat cultures in children with colds & sore throat.
A GAS+ culture almost always identifies a carrier and not a true
infections
Wrap up: 10 ways to promote antimicrobial
stewardship in your paediatric practice
6.
ALWAYS use appropriate weight based dose & optimize frequency and
duration.
7.
Community acquired pneumonia in children is ampicillin IV or oral
amoxicillin TID.
8.
Prior to prescribing antibiotics for pneumonia a CXR should be obtained
for diagnosis
9.
Children with wheezing almost never require antibiotics; asthma in older
children or bronchiolitis for infants.
10.
Know the bacteria that cause the most common outpatient infections.
Minor skin infections can be treated topically. Visble drainiage should be
cultured.
Managing Antimicrobial stewardship in daily practice:Managing an important resource
CPS 2014
iPHONE to iCHEMO

July 2015: A review of cell phone exposure from 2009-2014 and
government documents on microwave radiation (MWR) levels and
electronic device manufacturers manuals revealed that there ARE
associations between MWR and the development of cancer in children

The researchers advocated

more wide spread implementation of MWR exposure limits on
electronic devices,

better education about potential risks

BANNING MWR emitting toys or devices targeted at children
Morgan et al. Journal of Microscopy and ultrastructure 2014

MWR exposure limits have remained unchanged for 19 years,

smartphone manufacturers specify the minimum distance from the body
that their products must be kept so that legal limits for exposure to
MWR are not exceeded.

For laptop computers and tablets, the minimum distance from the body
is 20 cm

Phones are not tested in pants or shirt pockets.

Therefore every cellphone manual has warnings that the phone should
be kept at various distances from the body

otherwise the human exposure limits can be exceeded.
iPhone on M’iBody
The BlackBerry Torch 9800 Smart Phone

“keep the BlackBerry device at least 0.98 in. from your body (including the
abdomen of pregnant women and the lower abdomen of teenagers).”
The iPhone 5's manual

Users must go to “Settings,” and scroll down to “General,” then scroll to the
bottom to “About,” go to “Legal,” scroll down to “RF [MWR] Exposure”

To reduce exposure to RF energy, use a hands-free option, such as the built-in
speakerphone, the supplied headphones, or other similar accessories.

Carry iPhone at least 10 mm away from your body to ensure exposure levels
remain at or below the as-tested [exposure limit] levels.”
conclusions
1.
The risk to children and adolescent from exposure to
microwave radiating devices is considerable. Adults have a
smaller but very real risk, as well.
2.
Children absorb greater amount of microwave radiation (MWR)
than adults
3.
MWR is a Class 2B (possible) carcinogen.
4.
Fetuses are even more vulnerable than children. Therefore
pregnant women should avoid exposing their fetus to
microwave radiation.
conclusions
1.
2.
3.
4.
5.
Adolescent girls and women should not place
cellphones in their bras or in hijabs.
Cellphone manual warnings make clear an
overexposure problem exists.
Wireless devices are radio transmitters, not toys.
Selling toys that use them should be banned.
Government warnings have been issued but most of
the public are unaware of such warnings.
Exposure limits are inadequate and should be
revised such that they are adequate.
Cell phones, kids and cancer

Another recent study showed in individuals using a
wireless phone for more than 25 years the risk for glioma
TRIPLED (Hardell et al. Pathophysiology 2014)

Those who begun using a mobile or cordless device prior
to 20y old were also at risk

Common sites for glioma were the temporal and
overlapping lobes on the side the phone was placed

The International Agency for Research on Cancer classifies
the electromagnetic fields produced by mobile phones as
possibly carcinogenic. A formal risk assessment to be out
in 2016
Should we panic?
?
Cell phone, kids and cancer

No definitive data available

Issues with some of the data, as many of the reports are anecdotal.

Public health data is unable to determine if there is one or many
environmental concerns

Is the perceived increase is simply better recognition at earlier stages based
on the availability of MRI? as well as better reporting?

At this time continue to use anticipatory guidance such as limiting screen
time on MWR emitting devices

Limiting time on the phone and encouraging physical activity and social
events

Reassuringly most teens text now and don’t speak to each other
PRAM SCOREs; preventing unneeded
hospital stays

Tool developed in Calgary

Helps asses which children can be discharged

Less time in the ER/clinic

Also a modified score for children admitted to the ward

Will be rolling it out at UHNBC paediatric ward

Useful for our ED docs too
Emergent & Urgent Care Asthma Clinical Score (PRAM)
Signs
0
1
Suprasternal
Indrawing
Absent
Present
Scalene Retractions
Absent
Present
Wheezing
Absent
Expiratory
only
Inspiratory &
expiratory
Audible w/o steth
or silent chest
Air entry
Normal
Decreased @
bases
Widespread
decrease
Absent/minimal
O2 sat on RA
>93%
90-93%
Severity Classification
2
3
<90%
PRAM CLINICAL score
MILD
0-4
MODERATE
5-8
SEVERE
9-12
IMPENDING RESP FAILURE
12+ following lethargy, cyanosis,
decreasing resp effort, &/or
rising CO2
For any child over 1 year of age and less than 17
• Presenting with wheeze & respiratory distress
• Diagnosed with asthma
• 2 previous treatment with bronchodialator for
asthma
SEVERE
8-12
OR
Impending resp
failure
Notify physician or
NP
8-12
OR
Impending
resp
failure
MODERATE
4-7
Sabutamol q20min x3
+
Ipratropium q 20min x 3
In the 1st hr
+
Give steroids after 1st MDI
as per MD
MILD
0-3
Salbutamol
q20min 1-2
doses
In 1st hour
Reassess PRAM q 30-60
min
0-3
D/C
MODERAT
E
4-7
4-7
Notify MD/NP
Salbutamol q1h
6hr post oral steroid
If PRAM 0-3
Sabutamol q20min x3
+
Ipratropium q 20min x 3
In the 1st hr
+
Give steroids after 1st MDI as per MD
Reassess PRAM q 30-60 min
YES
0-3
Observe 1hr post last
Beta2 agonist
0-3
N
O
ADMIT
Discharge medication/follow up
Asthma education
GP f/u
Inpatient Assessment Score (Modified PRAM)
Signs
0
1
2
3
Suprasternal
Indrawing
absent
Present
Scalene
Retractions
absent
present
Wheezing
absent
Expiration
only
Insp. &
expiratory
Audible or
silent chest
Air Entry
Normal
Decreased at
bases
Widespread
decrease
Absent
minimal
Phase Change Criteria: SCORE of <3 at routine assessment or MD order on reassessment in
Phase I or Phase II
For B2 agonist assessment: if SCORE >3 give B2 agonist if <3 no B2 agonist
For any assessment SCORE >6 give B2 agonist and notify MD. If in Phase II or III move back to
previous Phase.
If in Phase one consider further investigations and reassess therapy (consider ICU, transfer,
paediatric consultation)
Like a fat kid on candy
NEJM : obesity is increasing in the
USA
 1963-1965 BMI >95%tile children 611y 4.2%
 199-2000 BMI >95%tile children 611y 15.3%
 How do we identify vulnerable ages?
 How can we target resources to
prevent obesity?
 Environment? Genetics?
 Poor choices? Media influence? Lack
of exercise?
 Age???????????????

Cute chubby baby

NEJM 2014 article looked at the
incidence of childhood obesity in
the United States:

Followed a cohort of 7738
kindergarteners to 8th grade (19982007)

Weight and height were measured 7
times

Age, sex, and socioeconomic factors
were collected
Socioeconomics

At kindergarten entrance age (~5.6yr) 14.9% were
overweight and 12.4% were obese

The greatest increase in prevalence of obesity was
between 1st and 3rd grade

In black and Hispanic children the prevalence of obesity
was higher than in white children

Children from the wealthiest 20% of families had a lower
prevalence of obesity:


7.4% vs 13.8% and 16.5% (the 2 poorest quintiles)
These differences increased through to the 8th grade
NEJM 2014
Incidence

AGA or SGA did not affect obesity rates

LGA (>4000g) had a higher prevalence

Although prevalence increased with age; the incidence declined

Kindergarteners : annual incidence 5.4%

Grade 5-8: annual incidence 1.9% boys 1.4 % girls

45.3% of incident obesity cases between kind and 8th grade occurred
from the 14.9% of children who were overweight when they started

The annual incidence of obesity in kindergarteners who were
overweight was 19.7% compared with their normal weight peers

Overweight children from the 2 highest socioeconomic groups had 5x
the risk of becoming obese as normal weight children in the same
group
NEJM 2014
Main Findings
1.
Overweight children were 4 x as likely to become
clinically obese
2.
The annual incidence of obesity decreased from 5.4% in
kindergarten to 1.7% between 5th and 8th grade
3.
The time to act may have been missed by the time a child
enters kindergarten is missed; when 12.4% are obese & an
additional 14.9% overweight
4.
Poverty is a risk factor
NEJM 2014
Timing of adiposity rebound and adiposity in
adolescence Pediatrics 2014 Hughes et al

Sample BMI of a cohort of children followed from birth
at 3 periods of timing until 15 years of age.

Adipostiy Rebound: the period in childhood where BMI
begins to increase from its nadir

Very early AR occurred <43 mon

Early AR 43-61 later AR >61mo

BMI higher in adolescence with very early AR

was also higher for those with early AR compared with
those with later AR (>5 years)

Children of obese parents had the greatest risk of early
AR
Conclusion

A component of the course to obesity is established
before 5 years of age

Preventive interventions should consider targeting
modifiable factors in early childhood to delay timing of
AR.

The overweight children tend to become obese early in
school

Interventions should target the whole family; not just
the children

Should this be discussed at early childhood visits or during
pregnancy?
Autism…. AVOID EVERYTHING

Last spring CDC calculated the prevalence of autism
spectrum disorders in 2010 at 1/68 children aged 8 VS
2012 1/88.

During this time there was no change in diagnostic criteria
or data collection methods

Speculate that children may have been “missed” or
“misdiagnosed” Dr. Hyman, Medscape

Not everyone believes the “missed” theory

There is a genetic link however the increasing incidence
has spurred investigations into potential environmental
triggers
http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6302a1.ht
As if pregnancy wasn’t hard enough

Links of autism risk to
 Maternal
intake of iron
 Particulate
air pollution
 Preeclampsia
 Pregnancy
weight gain
 Pesticides
 And

the list goes on
There is some interventions!
http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6302a1.ht
Maternal intake of Supplemental Iron and
Risk of Autism Spectrum Disorder Schmidt et al Am J
Epidemiol 2014

Iron is critical or early neurodevelopmental
processes that are dysregulated in ASD

Iron deficiency affects 40-50% of pregnancies

Studied maternal iron intake in relation to ASD
risk in California-born children 2003-2009

Iron intake studied from 3 months before
pregnancy through to the end or pregnancy or
breastfeeding
Maternal intake of Supplemental Iron and
Risk of Autism Spectrum Disorder Schmidt et al Am J
Epidemiol 2014

Mothers of cases were less likely to report taking iron-specific
supplements vs controls

Mothers of cases had a lower mean daily iron intake vs controls

The highest quintile of iron intake during the index period was
associated with a reduced ASD risk compared to the lowest

Most notable during breast feeding

Low iron combined with advanced maternal age and metabolic
conditions; were associated with a 5 fold increase ASD risk
Autism Risk liked to Particulate Air
Pollution Medscape Dec 18 2014

Children whose mothers were exposed to high levels of
fine particulate pollution late in pregnancy have a 2 x risk
of developing autism vs breathing cleaner air Harvard
school of Public Health

Ie. Fires, vehicles and industrial smokestacks

Greater exposure greater the risk

Previous research 2010: mothers living near highways
during their 3rd trimester. Autism risk doubled.
Autism Risk liked to Particulate Air
Pollution Medscape Dec 18 2014

Harvard study:

Nurses Health Study II began in 1989

Compared prenatal histories of 245 children with ASD to
1522 normal developing children 1990-2002

No association between fine particulate pollution
exposure before or early in pregnancy or after the child
was born

High levels of exposure during the 3rd trimester DOUBLED
the risk of autism

Not clear about how the contaminants disrupt brain
development
Preeclampsia Linked to Autism,
Developmental Delay. Medscape Dec 12 2014

CHARGE study : compared 517 children with ASD, 194 with
DD and 350 typically developing children.

Exposure to preeclampsia in utero associated with a
greater than 5x vs no exposure for developmental delay
and just over 2x for autism

Preeclampsia common in obese women or those who have
diabetes or chronic hypertension

NB: over half of pregnant women in USA are overweight or
obese

Interpret this study with caution; given the multiple
factors at play and small numbers
Pregnancy Weight Gain May influence
Autism Risk

In 2 separate cohorts from Utah Bilder et al Pediatrics found a positive
association between prenatal weight gain; but not pregnancy weight
and risk for ASD

ASD risk was significantly associated with pregnancy weight gain; in
two separate groups with an odds ratio of 1.1 and 1.7 for each 5
pounds of weight gained

Note the absolute weight gain difference in the two case and control
was only 3 lbs

OR very modest increase

I would not tell a mother to not gain weight due to this study
Pesticides and Autism Spectrum
Disorders

CHARGE study again

486 children with ASD, 168 with delayed development and 316 controls

Assessed timing and extent of pesticides application 1.75km of the mothers
residence from 3 mots before conception to time of delivery

Strong association between ASD


application of nonspecified organophosphate during 3rd trimester

Chlorpyrifos during 2nd trimester
Significant association between

ASD and pyrethroid application during both preconception and 3rd
trimester

Carbamate application and developmental delay (smaller number)
Pesticides and Autism Spectrum
Disorders

Chlorpyrifos is banned for residential use

Often drift into other areas

Study is retrospective and no biological samples were
collected

No account for pesticide use in the home or other
exposures

Don’t lick the green green grass; especially when
pregnant.

The study involved 54 families participating in the British
Autism Study of Infant Siblings with at least one autistic
child.

Studies suggest that about 20% of infants with an older
sibling with an autism spectrum disorder (ASD) develop
ASD themselves.

28 families were randomly assigned to a specially adapted
Video Interaction for Promoting Positive Parenting Program
(iBASIS-VIPP); 26 were randomly assigned to receive no
intervention.
Video Program May Prevent Autism in
High Risk Infants

Lancet psychiatry: Videotaped parent and child interactions in 1st yr of life

The intervention group received at least six home-based
visits from a therapist

video feedback to help parents understand and respond to
their infant's style of communication

goal of improving infant attention, communication, early
language development, and social engagement.

The high-risk infants were assessed at baseline when they were 7 to
10 months old and again 5 months after the intervention or after
receiving no intervention.

After 5 months, infants in the intervention group showed
improvements in several known ASD risk markers, including
engagement, attention, and social behavior.

The infants also showed improved social behavior with people other
than their parents.

Intervention infants showed a reduction in autism-risk behaviors, as
assessed by the Autism Observation Scale for Infants (effect size 0.50;
95% CI, -0.15 to 1.08), suggesting that video-based therapy may help
modify the emergence of autistic behaviors during early
development.

Offers the possibility of providing a focused low-intensity intervention
on the basis of risk, without the need to identify a specific condition
such as Autism Spectrum Disorder.“
Kids having babies…
New guidelines from the AAP this year highlighted:
1.
Trend of decreasing teen sexual activity and teen
pregnancies since 1991 continues
2.
Teen birth rates at a record low, owing to increased use
of contraception at 1st intercourse and use of dual
methods of contraception in sexually active teens
3.
United States still tops all other industrialized countries
in terms of teen birth rates.
4.
Less than one third of sexually active females (aged 1519 years) used contraceptive methods during their most
recent engagement in intercourse.
A bit better in Canada
Even with increases in teen pregnancy
in parts of Canada, the country still has
a much lower rate than the United
States.
 In 2008 Canada’s rate was 30.5, while
in the U.S. it was 58.0.
 Differences include: universal health
care, access to contraception and sex
education and the lower rate of
poverty among young people.

Teen pregnancy: Who is at risk??

experiencing social and family difficulties;

whose mothers were adolescent mothers;

undergoing early puberty;

who have been sexually abused;

with frequent school absenteeism or lacking
vocational goals;

with siblings who were pregnant during adolescence;

who use tobacco, alcohol and other substances; and

who live in group homes, detention centres or are
street-involved.
CPS: Adolescent Pregnancy reaffirmed Feb 2014

Health care practitioners have an important role in
preventing unplanned adolescent pregnancies.

Include longitudinal follow-up of at risk teens, provision
of a continuum of options from abstinence to
contraceptive information

To discuss decision-making in a manner appropriate to
the adolescent’s development.

Particularly important for adolescents with a
developmental delay, disability or chronic condition.

Teens of both sexes who may engage in sexual activity
should be counselled in methods of contraception.

Including information about the emergency contraceptive
pill
CPS: Adolescent Pregnancy reaffirmed Feb 2014
Contraception AAP 2014 statement
1.
Counseling about abstinence and postponement of sexual
intercourse is an import aspect of adolescent sexual health.
2.
Long-acting reversible contraception should be considered
first-line contraceptive choices for adolescents.
3.
A pelvic exam is NOT required to prescribe contraceptives or
refer for IUD placement.
4.
Screening for sexually transmitted infections (STIs) can be
performed without a pelvic examination and should not delay
the initiation of contraception.
5.
Encourage the correct and consistent use of condoms "each
time, every time" and should take the opportunity to pair this
encouragement with a regular update of their patients'
sexual histories in a confidential and nonjudgmental setting.
CPS 2014

counsel pregnant adolescents in a nonjudgmental way about their
pregnancy options.

If they are unable to do so, they should refer to others who can
provide this service;

attempt to protect adolescents from being coerced into any option
against their will;

help the adolescent develop a supportive network that may include
family members, her partner, trusted friends and other health care
providers;

provide people in that support network with guidance as to how they
can best help the pregnant adolescent;

make follow-up appointments;

ensure that adolescents referred to another practitioner or service
have made and kept their appointment; and

respect the adolescent’s right to privacy and medical confidentiality.
7th heaven

CATT in concussions

Return to play

Return to learn
PS… remember the RACELINE