AAP Report on Pregnancy in Adolescents

The American Academy of Pediatrics (AAP) recently published a clinical report on the state of adolescent pregnancy in the United States. “Adolescent Pregnancy: Current Trends and Issues” can be found in the July 2005 issue of Pediatrics and is available online at http://www.pediatrics.org.

Recently the percentage of adolescents who are sexually active has decreased; however, more than 45 percent of current high school-aged females and 48 percent of high school-aged males report having had sexual intercourse. The average age at first intercourse is 16 years for males and 17 years for females.

According to the report, use of contraception by adolescents is increasing, but 50 percent of all adolescent pregnancies occur within six months of first intercourse. In 2003, almost one half of sexually active adolescents reported not using a condom the last time they had intercourse. Many adolescents who reported using prescription contraceptives indicated a gap of at least one year between the time that they first had intercourse and the time that they visited a physician to seek a prescription contraceptive.

The United States has the highest adolescent birth rate among industrialized nations. Nearly 900,000 U.S. teenagers become pregnant each year, according to the report, and four in 10 women have been pregnant at least once before 20 years of age. Approximately 51 percent of adolescent pregnancies end in live birth, 35 percent in induced abortion, and 14 percent in miscarriage or stillbirth. Twenty-five percent of adolescent births are not first births, and the risk for pregnancy increases after an adolescent has had one infant.

Significantly more adolescents who live in poverty become pregnant than do those from higher-income families. The total percentage of adolescents who live in low-income families is 38 percent; however, 83 percent of adolescents who give birth and 61 percent who have abortions are from low-income families. Similar to adolescent mothers, adolescent fathers are more likely than their peers to come from low-income families, have poor academic performance, drop out of school, and have decreased income potential.

The report indicates that in 2001, almost 79 percent of all adolescents who gave birth were unmarried, a statistic that has been rising since 1971. More than 90 percent of pregnant patients 15 to 19 years of age said their pregnancies were unplanned.

Pregnant patients younger than 17 years have a higher risk of medical complications than do older patients. Compared with adults, adolescents give birth to twice as many low birth weight infants, and the neonatal mortality rate is three times higher. Although still low, the maternal mortality rate is twice as high for adolescents. Adolescent pregnancy is associated with poor maternal weight gain, prematurity, pregnancy-induced hypertension, anemia, sexually transmitted diseases, substance abuse, and poor nutritional intake. Adolescent pregnancy also causes psychosocial problems such as interruption of school, persistent poverty, limited vocational opportunities, separation from the child’s father, divorce, and repeat pregnancy. The children of adolescent mothers are at higher risk for developmental delays, academic difficulties, behavior disorders, substance abuse, early sexual activity, depression, and adolescent pregnancy.

The AAP reports that the most successful programs to prevent adolescent pregnancy include the promotion of abstinence along with information on and dissemination of contraception, sexuality education, school-completion programs, and job training. Parents, schools, religious institutions, physicians, social and government agencies, and adolescents themselves all should be a part of successful prevention programs. Research shows that discussion of contraception does not increase sexual activity, and programs that promote abstinence along with contraception do not decrease contraceptive use.

Freestanding Urgent Care Facilities: Recommendations by the AAP

The Committee on Pediatric Emergency Medicine of the American Academy of Pediatrics (AAP) has released a policy statement that provides recommendations to guide the care of young patients in emergency situations and the timely transfer from urgent care facilities to the hospital when necessary. “Pediatric Care Recommendations for Freestanding Urgent Care Facilities” appears in the July 2005 issue of Pediatrics and is available online at http://www.pediatrics.org.

The AAP does not recommend the use of urgent care facilities because it may undermine coordinated, comprehensive care; however, these facilities often are needed in emergency situations. Although freestanding urgent care facilities are not the same as hospital emergency departments, the AAP stresses that they must have the ability to identify emergency medical situations, stabilize patients, and coordinate timely access to definitive care.

The policy statement includes the following recommendations for urgent care facilities that provide emergency care for children:

• Staff should be able to provide resuscitation, stabilization, triage, and appropriate transfer.

• Facilities should meet the AAP minimum requirements for medications, equipment, and supplies as listed in “Care of Children in the Emergency Department: Guidelines for Preparedness” issued by the AAP and the American College of Emergency Physicians ( http://aappolicy.aappublications.org/cgi/reprint/pediatrics;107/4/777.pdf).

• Facilities must have staff certified in basic and advanced pediatric life support available at all times.

• Facilities should have triage, transport, and transfer agreements with definitive care facilities.

• Facilities should have a plan that complies with the Health Insurance Portability and Accountability Act for notifying the primary care physician about the treatment given.

• Facilities should have an organized quality-improvement program.

• Facilities should comply with the policies, procedures, and protocols listed in “Care of Children in the Emergency Department: Guidelines to Preparedness.”

• Facilities should have a disaster preparedness policy and participate in their community disaster plan.

The AAP also recommends that physicians who refer patients to urgent care facilities provide each patient’s clinical information to the facility and be available for consultation.

AAP Clinical Report on Diabetic Retinopathy

The American Academy of Pediatrics (AAP), in conjunction with the American Association for Pediatric Ophthalmology and Strabismus, released a clinical report reviewing the risk factors and screening guidelines for diabetic retinopathy in children. “Screening for Retinopathy in the Pediatric Patient with Type 1 Diabetes Mellitus” can be found in the July 2005 issue of Pediatrics and is available online at http://www.pediatrics.org.

Diabetic retinopathy is the number one cause of blindness in young adults in the United States. According to the report, the strategy for minimizing the risk for diabetic retinopathy should have three parts: (1) treating the underlying metabolic disorder and related comorbidities, (2) developing treatment options for patients with ocular disease, and (3) identifying the risk factors for ocular disease and implementing screening programs.

In one study, patients who received intensive treatment (i.e., insulin pump or at least three insulin injections per day, frequent phone calls and office visits, self-management education materials) had a substantially decreased risk of onset and progression of retinopathy compared with patients treated with conventional therapy.

Studies of diabetic macular edema and proliferative diabetic retinopathy showed that laser therapy improved outcomes in patients at high risk for ocular disease. The risk of moderate vision loss caused by diabetic macular edema was reduced by 50 percent. Risk of severe vision loss caused by proliferative diabetic retinopathy was reduced to less than 2 percent.

Early nonproliferative diabetic retinopathy is characterized by microvascular changes that may lead to ischemia, small retinal hemorrhages, and leakage of exudative fluid in the retina. More severe nonproliferative diabetic retinopathy is characterized by microvascular abnormalities in the retina, more extensive hemorrhages or microaneurysms, and changes in venous caliber and tortuosity caused by capillary closure and ischemia. Proliferative diabetic retinopathy can cause vision loss because of vitreous hemorrhage or retinal detachment. The report suggests that laser surgery is indicated when a patient’s eye approaches or reaches high-risk proliferative diabetic retinopathy, which is characterized by one or more of the following lesions:

• New vessels on the optic disc that are at least one fourth of the disc area in size

• New vessels on the optic disc that are less than one fourth of the disc area in size when fresh hemorrhage is present

• New vessels on other parts of the retina that are at least one half of the disc area in size when fresh hemorrhage is present

Risk factors for the development of diabetic retinopathy include:

• Duration of disease (98 percent of patients who have had diabetes for 15 or more years have diabetic retinopathy)

• Age (children younger than 10 years with type 1 diabetes mellitus have a very small risk of diabetic retinopathy)

• Puberty (hormonal changes during puberty increase the risk of diabetic retinopathy regardless of age)

• Pregnancy

The American Academy of Ophthalmology recommends yearly screening beginning five years after the diagnosis of diabetes. The American Diabetes Association recommends yearly screening three to five years after diagnosis of diabetes after the patient reaches 10 years of age. The AAP recommends yearly screening three to five years after the diagnosis of diabetes in patients older than nine years.