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Dermatological conditions and the relationship to self-image

It is important for pediatric and family nurse practitioners caring for patients with dermatological conditions to be comfortable talking about the conditions with children, adolescents, and their parents.

Lisa Arkin, MD: managing vitiligo in pediatric patients

Dr. Arkin speaks to how the psychological burdens of vitiligo can be exacerbated in younger patients, and what anticipated approvals such as ruxolitinib cream could mean for pediatric populations.

AAP urges school preparedness for medical emergencies

The AAP recently updated their recommendations urging schools to be prepared for emergency medical situations including seizures, diabetes, allergies/anaphylaxis, mental health, substance use, or asthma.

Evaluating new atopic dermatitis medications for children

At the 2022 Maui Derm NP+PA meeting in Colorado Springs, Colorado, a discussion of the newest biologics and how to "mix and match" medications and algorithms.

Breastfeeding reduces the severity of LRTIs in infants

Tralokinumab benefits adolescent eczema patient-reported outcomes at 16 weeks

Pediatric dermatology update: 2022’s top studies

Pharmacies limiting Plan B purchases after Roe v. Wade reversal

FDA approves treatment for chronic weight management in adolescents aged 12 years and older

FDA issues warning for neck floats used for water therapy

Acne in Skin of Color Patients: Preventing PIH

Supreme Court Issues Ruling on Opioid Prescriptions

How to identify common pediatric vulvar conditions

Not just abortion: How the demise of Roe v Wade may impact fertility care

Meena Julapalli, MD, gets ready for the Society for Pediatric Dermatology conference

Between the lines: central precocious puberty

Consider mental health concerns in teens with acne

Pfizer-BioNTech vaccine efficacy against Omicron in children 5-11 years

Articles

A look at what the Contemporary Pediatrics® team covered this week.

Must-read news from the week of June 27

The Omicron variant led to COVID-19 infections spiking in young children. As such, it is necessary to determine whether children are adequately protected 

The highly infectious Omicron strain has since continued to mutate, retaining its status as the predominant COVID-19 variant. In a study published tonight in 

, investigators determined the real-world effectiveness of the Pfizer-BioNTech (BNT162b2) vaccine against Omicron infection in children 5-11 years of age.

The investigators utilized available data from the largest healthcare organization in Israel. They identified a study cohort of children aged 5-11 years who were vaccinated on or after November 23, 2021. The children were matched with unvaccinated controls to compare vaccine efficacy during the Omicron wave.

After the first and second Pfizer-BioNTech doses, the investigators documented vaccine effectiveness against SARS-CoV-2 infection and symptomatic COVID-19 disease. The study ran until January 7, 2022, after which the cumulative incidence of these 2 outcomes of interest was determined with a Kaplan-Meier estimator. Vaccine effectiveness was calculated as 1 minus the risk ratio, and was also estimated in age subgroups.

A total of 136127 vaccinated children were included in the study cohort, and they were matched with 94728 unvaccinated controls. At 14-27 days after the first dose of Pfizer-BioNTech, estimated vaccine efficacy against documented COVID-19 infection was 17% (95% confidence interval [CI], 7 to 25). A7 7-21 days after the second dose, vaccine efficacy was estimated to be 51% (95% CI, 39 to 61).

Estimated vaccine effectiveness against symptomatic COVID-19 infection was 18% (95% CI, −2 to 34) at 14-27 days after the first dose of Pfizer-BioNTech, and 48% (95% CI, 29 to 63) at 7-21 days after the second dose.

The investigators noted that vaccine efficacy was higher in the younger children, such as those 5-6 and 7-9 years of age. Among the oldest children in the cohort, those 10-11 years, vaccine efficacy was lowest.

This study was conducted right as Omicron was becoming the dominant variant and causing unprecedented rates of COVID-19 in children, including severe and even fatal infection. These findings suggest 2 doses of the Pfizer-BioNTech mRNA vaccine were moderately protective against documented and symptomatic COVID-19 infection in children 5-11 years of age.

More research is certainly merited to determine whether other COVID-19 vaccines or alternative dosages would prove more effective in young children.

Originally published on our sister brand, 

In children 5-11 years old, 2 doses of the Pfizer-BioNTech COVID-19 vaccine were moderately effective against documented, symptomatic Omicron infection.

As the pandemic slowly morphs into an endemic, its impact on primary care physicians continues to tug at the seams of an already fraying health care system. Now rising to the top of America’s health care challenges is the looming physician shortage, predicted with increasing urgency every year since the early 2000s. The Association of American Medical Colleges now estimates a shortage of between 37,800 and 124,000 physicians by 2034, accelerated by a perfect storm of pandemic closures, physician retirements, an aging population and escalating demand for care. Simultaneously, the surging popularity and predicted 10% annual growth of concierge medicine practices, characterized by intentionally small patient panels, appears to be intensifying the issue.

However, appearances can be deceiving and the opposite may prove to be true: concierge medicine is not fueling the physician shortage but may represent one of the most viable potential solutions. By presenting a sustainable model that eliminates much of the burnout pummeling the spirits of our country’s health care providers, concierge medicine is extending the active practice years of experienced physicians, keeping the doors of primary care practices open and inspiring new generations to enter the field.

The dialogue on how to fix a broken health care system, which began well before the pandemic, has shifted to increased recognition of the value offered by concierge medicine. For example, Erin E. Sullivan, Ph.D., research and curriculum director at Harvard Medical School Center for Primary Care, told 

: “(Before the) pandemic, I would have said, ‘We don’t have enough physicians choosing to practice primary care.’ And if those physicians who do choose primary care elect to practice in models such as concierge, then you could see how that would exacerbate a shortage. On the other hand, if these models prove to be more attractive or sustainable ways for physicians to practice primary care, then can we increase the number of physicians electing to practice primary care? And can we learn from these models to build something better and accessible for all patients?”

And when asked about the effect of concierge and direct primary care models on the physician shortage, Reid B. Blackwelder, M.D., past president of the American Academy of Family Physicians, told 

: “All these models are ways of investing in primary care. With the pandemic, we’ve made some changes in how we interact with our patients that I think were exactly what we needed.”

“Listen to your patient, he is telling you the diagnosis.”

The observation made in the 1890s by internal medicine pioneer William Osler, M.D., CM, holds true for today’s physicians, who have accurately diagnosed the major cause of our system’s ills: volume-based care with little regard for the individual practitioner trapped on the hamster wheel. 

 reports that over 73% of physicians said they were overworked, and 55% of physicians surveyed by 

 said they would take a salary reduction to achieve a better work-life balance.

Failing to care for the caregivers in a traditional fee-for-service practice model or in a large health care system group is quickening the exodus of dedicated physicians. The 

 sounded the alarm earlier this year, writing: “There has never been a moment when we think doctors are more likely to quit. And even if they don’t quit, we question the quality of care that’s being delivered, given that burnout leads to worse patient outcomes and increased medical errors.”

In contrast, concierge medicine physicians are remaining in practice longer than initially planned, buoyed by intense professional satisfaction and the ability to balance work and life needs. Physician search expert Craig Fowler notes in his work on succession planning that doctors in a concierge practice consider retirement at a significantly older age than those in a traditional model. “They’re able to enjoy a good quality of work life and retire on their own timetable,” he says.

At Specialdocs we are privileged to work with many experienced physicians who remain more committed than ever to staying in active clinical practice. Here are some highlights:

“I’m now starting my 41st year as a physician and I’ve never loved being a doctor more.”

“Before transitioning with Specialdocs in 2018, I was ready to retire early. My spirit was completely broken by a medical system focused on superficial care and high patient volume. As a concierge physician, I am making a real difference in my patients’ lives, with time to take a thorough history at each visit or cut through the bureaucracy and arrange an urgent consult with a specialist.”

“The term ‘burnout’ is no longer part of my vocabulary.”

“In the mid-2000s I felt I was just a few years away from retirement. The pace was such that I feared making mistakes I would regret. Changing to the Specialdocs model eliminated the day-to-day stress so well it’s added years to my practice. I’m in no hurry to retire now and am truly grateful that I was able to continue to care for my patients throughout the pandemic.”

“I undoubtedly would have left medicine earlier had it not been for my change to concierge medicine.”

“I was burnt out, and at 68, I felt my choices were limited to early retirement or joining a local large hospital group. Partnering with Specialdocs to launch a concierge medicine practice offered a much better alternative and I now plan to keep caring for patients as long as possible.”


Among the pandemic’s many heartbreaking statistics is this one: In 2020 and 2021, more than 24,000 independent practices were reported permanently or temporarily closed. New data from the 

 shows almost three-fourths of U.S. doctors now work for hospitals, health systems or corporate entities, an almost 20% jump since 2019.

We have long understood that the traditional fee-for-service payment model is not sustainable. Since 2001, Medicare physician payment has fallen 20%, adjusted for inflation, whereas the cost of running a medical practice has increased 39%. Becoming employed by a hospital system doesn’t provide a neatly packaged solution either, as most hospital-employed physicians earn 20% less than independent practitioners, according to 

Although a sense of normalcy is returning, for primary care physicians in traditional fee-for-service practices the situation remains bleak. According to the 

, nearly half of physicians say primary care is crumbling, over 40% describe themselves as mentally and financially fragile, one-third report they are currently denied and/or seriously overdue payments from insurers and health plans and only 21% find the fee-for-service form of payment sufficient. Most troubling, one in five physicians surveyed by the American Medical Association said they would likely leave their current practice within two years. This is an incalculable loss that will be felt for many years to come.

However, for concierge medicine physicians, although the pandemic was demanding, their professional survivability was never in question. A stunning 0% of concierge medical practices were closed during the pandemic, and they continue to thrive in 2022 based on a solid foundation of membership fee revenues. Freed from financial worries and overloaded patient panels, concierge physicians not only keep their doors open but their minds and hearts as well. As Dr. B.B. shares, in 2021 his long-time multidoctor cardiology practice in the Boston area was about to be shuttered because of the pandemic. “Making the change to concierge medicine with Specialdocs saved our entire organization with an approach that has enormously benefited patients and restored our joy in practicing medicine.”

a concierge medicine pioneer that has transformed physicians’ professional lives since 2002.

Why concierge medicine may be the solution, not the problem.

Solving the physician shortage

Rachael Zimlich is a freelance writer in Cleveland, Ohio. She writes regularly for Contemporary Pediatrics, Managed Healthcare Executive, and Medical Economics.

Acne may be seen as a rite of passage in the adolescent years, affecting an estimated 85% of all teenagers at some point.

 However, newer reports suggest that the psychological effects of this inflammatory skin disorder may be underestimated and deserve more attention in treatment plans.

Multiple studies over the last several years have highlighted the impact of acne on adolescent mental health—especially since adolescence is already a time of intense transition. Self-esteem, social relationships, anxiety, and depression can all factor in to the effects of chronic acne in the teenaged years, according to researchers.

Mohammad Jafferany, MD, a clinical professor of psychodermatology and psychiatry at Central Michigan University in Saginaw as well as a board-certified psychiatrist who co-authored a 2020 report on the psychodermatology of acne, said there are a lot of things at play when it comes to the psychological impact of acne.

Acne is the most common inflammatory condition of the skin, he stated, adding that hormones and stress in the adolescent years can increase prevalence. The fact that acne usually appears primarily on the face doesn’t help because it can be difficult to conceal or camouflage severe papules and comedones.

“They end up feeling very stigmatized,” Jafferany continued. “Their self-esteem is very, very low and very poor, and psychological conditions often develop around the same time [as acne appears].”

On top of stressing about their appearance and how acne can affect their social relationships, teenagers can also get easily frustrated by mixed messages about acne treatment, he explained.

Acne treatment should be holistic and multidisciplinary, he added, with diet, hormonal consideration, and psychological impact all considered in the overall clinical plan. Many teenagers turn to friends or social media for help in managing early acne, and then get frustrated when certain treatments fail to produce results. Without proper treatment early in the process, acne—and its psychological impact—usually gets worse, Jafferany continued. Adolescents with severe acne often stop going out with friends and interacting with others, and studies have shown that suicides rates are higher in teenagers with acne than those with clear skin.

The American Academy of Dermatology (AAD) clinical guidelines for acne treatment only briefly mention the mental impact of acne on teenagerss, or the risk of increased depression or suicidal ideation with certain treatment regimens.

Oral isotretinoin is recommended in the AAD treatment guidelines for severe nodular acne. A number of studies in recent years have investigated the link between this popular medication and suicidality, but the strength of the association between isotretinoin use and suicide risk remains questionable. One 2020 report suggests that there doesn’t appear to be a definite risk, and that isotretinoin shouldn’t be completely avoided in teenagers with depression,

 but the American Academy of Pediatrics suggests that the medical be used “cautiously” in adolescent patients with depression, and that they be monitored during therapy by both a dermatologist and a psychiatrist.

Jafferany agreed with this recommendation, noting that it’s not unusual for clinicians to send teenagers for a psychiatric screening prior to prescribing isotretinoin.

There are other treatment options besides isotretinoin, with the full AAD guidelines available 

Benzoyl peroxide alone or with other topical treatments for mild acne

Benzoyl peroxide plus topical retinoids or systemic antibiotics for moderate to severe acne

Retinoids alone for primarily comedonal acne

Retinoids plus oral or topical antimicrobials for mixed/primarily inflammatory acne

Topical dapsone 5% gel for inflammatory acne

Azelaic acid for post-inflammatory pigmentation problems

Hormonal treatments and antibiotics may also be considered, as well as complementary and alternative treatments that include:

There is limited evidence of benefit for physical treatment methods and therapies, although some options include things like:

Fractionated and non-fractionated infrared lasers

Intralesional corticosteroid injections for larger individual acne nodules

Natsuaki MN, Yates TM. Adoelscent acne and disparities in mental health. 

. 2021;15(1):37-43. doi: 10.1111/cdep.12397.

Layton AM, Thiboutat D, Tan J. Reviewing the global burden of acne: how could we improve care to reduce the burden? 

. 2021;184(2):219-225. doi: 10.1111/bjd.19477.

Stamu-O’Brien C, Jafferany M, Carniciu S, Abdelmaksoud A. Psychodermatology of acne: psychological aspects and effects of acne vulgaris. 

. 2021;20(4):1080-1083. doi: 10.1111/jocd.13765.

Zaenglein AL, Pathy AL, Schlosser BJ, et al. Guidelines for the care and management of acne vulgaris. 

. 2016;74(5):945-973. doi: 10.1016/j.jaad.2015.12.037.

Gieler U, Gieler T. Suicidal risk with isotretinoin treatment—A never-ending story. 

. 2020;34(6):1131-1133. doi:10.1111/jdv.16005.

Teens and acne treatment. HealthChildren.org Updated November 27, 2013. Accessed July 1, 2022.


https://www.healthychildren.org/English/ages-stages/teen/Pages/Teens-and-Acne.aspx

The effect of acne is more than skin deep.

Ms. Hester is Content Specialist with Contemporary OB/GYN and Contemporary Pediatrics.

 evokes images of early adolescence and for most children, that is when they transition to this next stage of growth. However, some children who are going through central precocious puberty (CPP) will enter puberty earlier than their peers, in some cases much earlier. In a webinar from the 

 series, 2 experts discussed a variety of subjects on CPP, including findings from a recent study that examined treatment initiation and duration with height, the need to individualize treatment decisions for girls with CPP, and 2 case reports.

 Karen O. Klein, MD, a pediatric endocrinologist at Rady Children’s Hospital-San Diego in California and an associate clinical professor of pediatrics at the University of California San Diego School of Medicine, led the discussion with Kent L. Reifschneider, MD, a pediatric endocrinologist at Children’s Hospital of The King’s Daughters in Norfolk, Virginia.

CPP occurs when the hypothalamic-pituitary-gonadal axis is activated early on, which leads to an increase in gonadal steroid hormone secretion. The ages of affected children are less than 8 years for girls and less than 9 years for boys. Children affected by CPP develop secondary characteristics early on; have at least 1 Tanner stage progression per year; and have less than 2 standard deviations in bone age (BA) beyond chronological age (CA). If untreated, CPP can lead to early fusing of growth plates, a reduction in adult stature, atypical pubertal physical development, and premature menarche. Gonadotropin-releasing hormone agonists are the standard-of-care treatment.

Klein discussed her recent study coauthored with Marcela Vargas Trujillo, MD; Sanja Dragnic, MD; and Petra Aldridge, MS. The authors performed the investigation to supply data for an area in which data were scarce: the benefit to height outcomes when treatment with leuprolide was initiated after CA of 7 years and continued after CA of 10 years or BA of 12 years. The study was carried out in 48 treatment-naïve girls who were treated with monthly leuprolide, administered intramuscularly every 28 days at doses based on weight. The investigators only included girls so that the results would have statistical power. The patients had visits at weeks 4, 8, 12, 24, 36, and 48 and then every 6 months until leuprolide was discontinued. They then had annual visits until age 21 years. The average treatment duration was 3.9 plus/minus 2.0 years (range, 1.1-9.8). The average CA at the end of treatment was 11.5 plus/minus 0.97 years (range, 9.8-14.1) whereas the average BA was 12.7 plus/minus 0.94 years (range, 11.5-16.4). Throughout the treatment period, the ratio of BA to CA consistently decreased. Fifteen girls achieved a BA that was less than 1 year above the CA. Longer duration of treatment was associated with increased predicted adult height for nearly all the girls, 45 of 48. Those who saw no improvement were either near midparental height when they started the treatment or showed poor growth velocity. A wide range was found in final heights: 162.54 plus/minus 7.35 cm (range, 146.47-176.11) that was similar to the predicted adult height in treatment (162.39 ± 8.38 cm). Midparental height was not available for all the girls, but of the 29 for whom it was available, 17 either met or surpassed it.

Reifschneider joined Klein to discuss nuances in the treatment of CPP. He noted, “With CPP, I think of the limitations of the disease state, which includes the impact of estrogen on growth velocity and BA and how much that should factor into clinical decisions as well as the variability in interpreting BA.”

Klein added, “When examining a patient, a clinician should balance the need for more data with the fact that early commencement of treatment can lead to better height outcomes.” She also noted that estimating predicted adult height is also mostly based on average-sized children who are having average growth patterns. Another consideration for starting treatment is the predicted adult height of the patient and the height of the child’s parents. For example, if the predicted height for a child is 155 cm and the mother is 157.5 cm, treatment may not be considered necessary by the patient’s family.

Klein added that although treatment will pause the tempo of puberty, once treatment ends, the tempo will resume its speed. However, this does not mean that a pubertal growth spurt will occur, and, in fact, data indicate that this typically doesn’t occur. 

The first case Reifschneider and Klein examined concerned a girl, with the following details:

Tanner stage 3 breast development, starting at age 7 years

With the girl’s BA and current height, her predicted final height is roughly 147 cm and her midparental height, 168 cm. The BA maturation was noted as significant by Reifschneider and the patient would meet his criteria for treatment. However, Klein emphasized the patient’s age, noting that she had been trained to only treat children when pubertal onset occurred before age 8 years. Countering that assertion, Reifschneider said, “One has to keep in mind the individual and that a lab [finding] or CA is just a piece of the puzzle. In this case, the fact that the girl started developing breast tissue when she was aged 7 years is important, in addition to growth velocity that is greater than prepubertal [velocity] as well as bones that are considerably advanced.”

When discussing treatment with families, a conversation about outcomes can be important. Many girls with CPP can be among the tallest girls in their class but their BA is often much advanced, and when their non-CPP peers reach puberty, many affected girls will be left behind in terms of height. If he were treating this patient, Reifschneider said, he would ideally initiate treatment and then see her every 4 to 6 months to determine how the treatment has changed the tempo of her puberty. Once the tempo became prepubertal, he would transition to twice yearly maintenance screenings.

The second case was of a girl with CPP who had undergone treatment, with the following details:

Leuprolide acetate treatment initiated at age 6 years

1 incidence of vaginal bleeding following treatment initiation

Tanner stage 3 breast development at age 6 years

The patient’s breast development has stabilized at Tanner stage 3. Her BA is 12 years and her height is currently predicted to reach 60 cm. She is now asking whether it’s time to stop treatment.

Reifschneider emphasized that this was a very successful case and the patient had responded very well to therapy. “When considering the ceasing of treatment, there are a couple of things that need to be thought through, like the limitation of predicted adult heights and not knowing the tempo that will occur when she ceases treatment. Although she is currently predicted to reach 5 feet, there is a likelihood that she would not achieve that height if she ended treatment.” Klein added that a BA of 12 years has often been considered the end point for treatment because of questions about whether continued growth could be achieved, but her study findings showed that 5 to 10 additional cm can be achieved with continued treatment. Reifschneider confirmed that prior to publication of the study’s results, he would have considered ending treatment at BA 12, although he noted that this patient was an outlier who likely would continue to benefit from treatment.

1. Klein KO, Reifschneider K. Between the lines: central precocious puberty. Virtual webinar. Recorded March 4, 2022.

Two experts discuss a variety of subjects on central precocious puberty, including recent study findings that examined treatment initiation and duration with height, the need to individualize treatment decisions for girls with CPP, and 2 case reports. 

The Society for Pediatric Dermatology was founded in 1975. As the only national organization in the United States specifically dedicated to the subspecialty of pediatric dermatology, its annual conference is something its 1400+ members look forward to each year. Meena Julapalli, MD, a board-certified pediatric dermatologist at Bluebird Dermatology in Houston, Texas, eagerly awaits this year's meeting, and talks about the sessions she is most looking forward to attending.

Videos

Meena Julapalli, MD, notes the sessions she is most looking forward to at the Society for Pediatric Dermatology in Indianapolis, Indiana.

As we head into summer, all eyes will be turning to the Supreme Court in anticipation of its decision in the case of 

, which is challenging a Mississippi law that bans abortions after 15 weeks of gestation. The court heard arguments in the case in December 2021.

Based on questions posed at the time and on previous decisions by the majority of the justices, most observers expect the Mississippi law will be upheld, effectively overturning 

 and ending the constitutional right to pregnancy termination in the United States. This expectation is further supported by the recent and unprecedented leak of Justice Samuel Alito’s draft decision, which challenges the validity of


The implications for abortion care of overturning 

 are clear. Each state will be free to restrict or ban abortions as it sees fit. Indeed, many have already passed laws that do this, and 13 have “trigger laws” ready to go into effect as soon as 

 is undone. A variety of approaches are being taken. Like Mississippi, many states are developing time-based restrictions (eg, abortion bans after a given gestation time). Others, anticipating a complete reversal of 

However, restrictions will not be limited to pregnancy termination. If the rationale Justice Alito described in the leaked decision is accepted, the whole framework that has given rise to reproductive and sexual privacy may be at risk. The leaked decision very much sets the stage for challenges to the decisions that protected same-sex marriage, struck down antisodomy statutes, and established the right to contraception.

Fertility care is also at significant risk. Many of the bills being introduced in statehouses around the country (over 500 have already been put forward, according to the Guttmacher Institute) include language defining a fertilized egg as a legal human entity.1 The terminology varies, which makes it difficult to generalize, but the danger is clear.

If the legal status of fertilized eggs or early embryos is codified, in vitro fertilization (IVF) procedures may become legally risky for patients, physicians, and staff.

The danger posed by some legislative proposals is obvious. For instance, Nebraska’s Legislative Bill 933 (the state has a unicameral legislature) asserts that an “unborn child means an individual living member of the species homo sapiens, throughout the embryonic and fetal stages of development from fertilization to full gestation and childbirth” and that the “causing or abetting the termination of life of an unborn child” will be unlawful. This bill clearly classifies an IVF-created embryo as an unborn child.

If you put a 3-year-old child in a freezer, you will kill them and presumably will have committed homicide. But what if you put a blastocyst in a cryopreservation tank? Most blastocysts will survive the thaw. However, the risk of not surviving is approximately 1%. Would that constitute homicide?

This happens every day in fertility clinics. In fact, most children born as a result of IVF procedures in the United States are born from frozen embryos. According to the Society for Assisted Reproduction (SART), 85.5% (n = 62,915) of total live births from embryo transfers in 2020 (N = 73,602) were transfers of thawed embryos.

Sometimes these questions are even more challenging. Oklahoma’s SB 1553 also defines life and legal status as beginning at fertilization—but also bans acts that would “induce an abortion if more than 30 days have elapsed since the probable beginning of the last menstrual cycle of the pregnant woman.”

Obviously, the “probable last menstrual cycle” from which a frozen embryo is derived may have taken place a long time before the embryo is used. How, then, does this wording apply to in vitro procedures? Your guess is as good as ours.

But it’s safe to say that none of the physicians providing infertility services want to be the test case that determines whether they have violated the law by putting a “person” in a tank of liquid nitrogen.

The ability to cryopreserve sperm, eggs, and embryos has revolutionized infertility care over the past 20 years. Contemporary best practices in IVF call for a single embryo transfer to mitigate the risk of multiple births. Some clinics perform “freeze all” cycles, whereas others transfer 1 embryo immediately and freeze the rest for subsequent use. Under some proposed legislation, the legal status of these embryos could be in flux. The use of single frozen embryos has enabled fertility doctors to improve the safety of procedures without compromising the probability of pregnancy from one in vitro fertilization cycle. In fact, SART reports that 88.3% of all live births (fresh and frozen embryo transfers) were singletons, and 89.5% of live births from frozen embryos were singletons.

In addition, the use of preimplantation genetic diagnosis has allowed physicians to determine whether embryos carry genetic diseases, such as Huntington and Tay-Sachs disease, and thus to eliminate these horrible conditions from the blood lines of patients. However, this technique requires the use of frozen embryos. What becomes of embryos that are not transferred because they are known to carry such diseases? Will they remain frozen forever, and who will pay for this?

The legislative risk to IVF is not limited to frozen embryos. Problems in an IVF lab can impact embryo health. In fact, only about 60% of fertilized eggs survive to the blastocyst stage in the lab.

At what point will the embryos be considered nonviable? Can a physician be accused of impacting viability? What happens if equipment failure affects the culture of a blastocyst? What if the embryologist accidentally drops an embryo? Although these events are very rare, do they constitute homicide? What if a tank of frozen embryos fails and the embryos are destroyed: Would that be considered mass murder? Will physicians still be allowed to offer patients the best treatments, or will they risk being charged with a felony? For America’s fertility doctors, these are no longer hypothetical questions.

The moral and legal status of the developing fetus is a complicated question, one that science is poorly equipped to answer. Unfortunately, the current political and legal environment in the United States does not lend itself to informed, complicated, or nuanced discussions.

As a result, we will be dealing with blunt policy outcomes. “Life begins at conception” has become an article of faith for some in the antichoice community. For others, however, reality can intrude. Thus, we get laws that allow abortion in cases of rape or incest. Only the most extreme elements of the antichoice movement would want to consign women with ectopic pregnancies to death and, therefore, most legislative proposals allow them to be treated.

Nevertheless, we have seen states seeking to ban such treatments or mandate what we know is scientifically unsound to “save” ectopic pregnancies. Similarly, some state laws attempt to carve out contraception, although these attempts may be more about bowing to political realities than about the appreciation of scientific facts.

IVF is one risk facing reproductive care if 

 is overturned. But it’s far from the only risk. 

, rest in part on a crucial right not explicitly articulated in the first 10 amendments to the Constitution: the right to privacy.

This right was fundamental to the findings in 

, which established the right to contraception originally available only to married women. Should the Supreme Court overturn Roe, that decision might include an explicit rejection of the right to privacy, which could have crucial implications for reproductive medicine.

We have already seen laws enacted that make treating transsexual patients illegal, in most cases based on age, but now we are seeing bills that block the care of adult patients as well.

If there is no constitutional right to privacy, there may be no end to the government’s right to limit reproductive medical procedures. If abortion and caring for trans patients can be made illegal, why should we suppose there will be a meaningful limit to what state legislatures or Congress could ban?

Most antichoice activists, and the politicians doing their bidding, don’t really want to stop would-be parents from receiving the medical treatments they need to raise families. However, they seem to have no problem if the infertile are the collateral damage required to win the abortion wars.

Jared Robins, MD, is executive director of the American Society for Reproductive Medicine (ASRM). Prior to joining ASRM, he was a practicing reproductive endocrinologist working in both academic and private settings.

Sean Tipton serves as the chief policy and advocacy officer for the American Society for Reproductive Medicine. He has more than 20 years experience working on reproductive health issues.

1. Nash E, Cross L, Dreweke J. 2022 State legislative sessions: abortion bans and restrictions on abortion dominate. Guttmacher Institute. March 16, 2022. Accessed May 4, 2022. https://www.guttmacher.org/article/2022/03/2022-state-legislative-sessions-abortion-bans-and-restrictions-medication-abortion

2. Preliminary national summary report for 2020. Society for Assisted Reproductive Technology. Accessed May 4, 2022. https://www.sartcorsonline.com/rptCSR_PublicMultYear.aspx?reportingYear=2020

With the Supreme Court's overturning of Roe v Wade eliminating the constitutional right to an abortion, there are questions about its impact on fertility care.

Vulvovaginal complaints make up the majority of gynecologic clinic visits by prepubertal girls.

Vulvovaginal symptoms can be caused by infection, trauma, hygiene, dermatologic conditions, and congenital anomalies. Though these conditions also may present after puberty, this article will focus on common vulvar conditions in the prepubertal pediatric population.

Most pediatric vulvar conditions can be clinically diagnosed with history and physical exam alone, although certain conditions may require additional testing. History taking often requires gathering information from both the child and parent and should focus on the timing, duration, and characterization of the symptoms, including itching, pain, burning, and associated genitourinary and gastrointestinal symptoms such as dysuria, urinary retention, constipation, and stooling habits.

Vulvar hygiene should be elicited, including the use of perfumed soaps, bubbles, detergents, or wipes applied to the external and internal genitalia, as well as who performs these vulvar hygiene practices (child or parent).

A specific inquiry should address whether the child wipes front to back, has inserted any foreign objects into the vagina, or has experienced any inappropriate touching of their genitals. Symptom triggers and irritants should be investigated, as well as the outcomes of prior palliative measures and interventions. A report of vaginal bleeding, discharge, or malodor is nonspecific but may raise concern for tissue injury, infection, or abuse.

External pelvic examination should be performed to assess the patient’s pubertal development, including Tanner staging and documentation of the degree of estrogenization of the vestibule and vaginal mucosa.

Genital examination of a prepubertal child can be accomplished by asking the child to make a frog leg or butterfly position, a cannonball position (to better assess the perianal region), or a hands and knees position.

 Skin changes and tissue injuries such as excoriations, abrasions, or bruising are often immediately apparent.

Of note, the vestibule, hymen, and vaginal mucosa of prepubertal girls commonly appear erythematous, thin, and atrophic due to the poor estrogenization of the tissues. Careful attention should be paid to deviations from normal vulvar anatomy. The patient should always be verbally prepared for the anticipation of touching of the skin and tissue and be reassured that the examination will not hurt.

Most pediatric gynecology exams will be tailored to the complaints and not require speculum examination. Gentle traction of the labia majora outward allows assessment of hymenal patency and visualization into the lower vagina 

 Examination of the vulva of a prepubertal child. (Reported in: Emans SJ, et al. 

Emans, Laufer, Goldstein's Pediatric Gynecology.

 7th ed. Figure 1-6 (B), page 5, Philadelphia, Wolters Kluwer, 2020).

If necessary, further assessment of vaginal patency and length may be performed with a saline-moistened cotton-tipped applicator, which can be used to obtain bacterial cultures if indicated.1 If further intravaginal evaluation is indicated, a vaginoscopy in the office or under anesthesia may be performed.

Nonspecific vulvovaginitis is the most common (75%) cause of vaginitis in young girls.

 Pediatric patients typically describe vulvar discomfort, pruritus, malodor, or vaginal discharge that may be purulent or tinged with blood.

Signs include erythema, mucoid vaginal discharge, and poor hygiene—or there may be no findings. The prepubertal vulva and vagina are hypoestrogenic and susceptible to irritants such as soaps, detergents, bath bombs, urine, stool, and perfumed products.

In the absence of purulent discharge, antibiotics are rarely indicated. Most symptoms resolve within 2 to 3 weeks after vulvar hygiene measures are instituted, including soaking in plain water without soap, standing up to shower, patting dry, wiping front to back, wearing cotton underwear and loose clothing, and avoiding irritants.

 Barrier emollients such as petroleum jelly or zinc oxide can be applied externally for symptomatic relief.

Additional testing with bacterial vaginal culture and vaginoscopy may be indicated to evaluate for specific causes of vulvovaginitis if symptoms persist or vaginal bleeding or purulent discharge is present, raising suspicion for a specific etiology.

Mixed vaginal flora is a typical culture result in nonspecific vulvovaginitis. Respiratory (eg, 

Streptococcus pyogenes, Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis, Moraxella catarrhalis

coli, Enterococcus faecalis, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas, Shigella, Yersinia

) pathogens are commonly isolated on bacterial vaginal swabs in patients with vaginitis as well as those who are asymptomatic. Therefore they do not always represent an infection.

Colonization is thought to occur by autoinoculation, with group A streptococci accounting for 20% of infectious cases. It should be treated with a 10-day course of oral amoxicillin.

Other respiratory and enteric flora isolates often resolve with hygiene measures alone but should be treated based on sensitivities if symptoms are persistent or if specific infectious causes such as 

Though approximately 3% to 4% of prepubertal girls are colonized with candida, vulvar candidiasis most frequently occurs in patients wearing diapers.8 Pathogenic vaginal candidiasis is uncommon in healthy, toilet-trained prepubertal girls. Therefore, empiric treatment for vaginal yeast infection should not be performed unless a positive candida test is present in the setting of immunosuppression, recent antibiotics, or diaper use.

 can be isolated even in the absence of sexual abuse, and treatment should be based on culture results and symptoms—vaginal pH testing and microscopy are not reliable testing measures in prepubertal girls.

Sexually transmitted infection testing for chlamydia, gonorrhea, trichomonas, and herpes simplex (if ulcerative lesions present) should be performed if there are concerns for sexual abuse. Empiric treatment for pinworms may be indicated in patients with significant perianal and vulvar itching that does not respond to hygiene measures.

Chronic vulvovaginitis with vaginal discharge, malodor, and bleeding is often secondary to a foreign body such as toilet paper, toys, beads, or other small objects 

 Toilet paper within the vagina of a prepubertal child

 (Reported in: Emans SJ, et al. Emans, Laufer, Goldstein’s Pediatric & Adolescent Gynecology. 7th ed. Figure 14-5, page 185, Philadelphia, Wolters Kluwer, 2020).

If the patient is able to cooperate, visualization and foreign body removal in the office can often be accomplished with the application of topical anesthetic if needed and use of a swab or vaginal irrigation with warmed fluid.3 Small batteries are a rare but serious cause of vaginal burns.

 Batteries are radio-opaque on x-ray imaging and require emergent removal under sedation, followed by vaginoscopy to assess the vaginal mucosa for depth of burns and possible damage to the urinary tract or rectal mucosa.

Labial adhesions commonly occur in girls aged 3 months to 6 years due to the prepubertal hypoestrogenic genital tissue 

Understanding signs, symptoms helps determine the best treatment regimen.