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

Miranda Hester

Over the past decade, cities and counties have enacted taxes on sodas and sugary beverages, with the intent of reducing consumption of them. One of them was Philadelphia, Pennsylvania, which went into effect in January 2017. A 

 looked at whether this tax led to less soda consumption by high school students.

Investigators performed an economic evaluation of school district-level of Youth Risk Behavior Surveillance System data from September 2013 to December 2019 to compare soda intake of high school students in Philadelphia to 7 other cities that did not have beverage taxes. A secondary analysis also compared changes in 100% juice and milk intake to examine potential substitutions for soda. The data included all high school students in grade 9 to 12 who attended school in districts that participated in the Youth Risk Behavior Surveillance System from 2013 to 2019.

A total of 86,928 high school students with an average age of 15.8 years from Philadelphia and 7 other comparison cities were included in the investigation. Before the January 2017 start date for the tax, there was an average weekly intake of 5.4 servings of soda in Philadelphia and 4 servings in the other 7 cities. Two years after the implementation of the soda tax, it was linked to a reduction of 0.81 servings of soda per week (95% CI, −1.48 to −0.14 servings; 

 = .02). No major difference was seen in 100% juice or milk intake following the implementation of the tax, but the investigators did note that students in Philadelphia drank more juice than the other cities. A look at subgroups found that the tax was linked to a reduction of 1.13 weekly servings in Hispanic adolescents (95% CI, −2.04 to −0.23 servings; 

 = .01) and 1.2 servings per week in teenagers with obesity (95% CI, −2.33 to −0.13 servings; 

The investigators concluded that the soda tax in Philadelphia was linked to reduced consumption of soda by teenagers. These results indicate that soda taxes could be a tool to improve diet.

1. Edmondson E, Roberto C, Gregory E, Mitra N, Virudachalam S. Association of a sweetened beverage tax with soda consumption in high school students. 

. October 18, 2021. Epub ahead of print. doi:10.1001/jamapediatrics.2021.3991

Articles

Taxing soda and other sugar sweetened beverages has been seen as a tool to encourage more healthy behaviors. A look at soda consumption in Philadelphia, Pennsylvania provides insight into whether it works.

Did Philadelphia soda tax lead to less consumption?

The onset of the adolescent years also means the need to discuss a variety of topics on sexual health such as sexually transmitted infections (STIs), pregnancy, and contraceptives. At a session at the virtual 2021 American Academy of Pediatrics National Conference & Exhibition, Maria Trent, MD, MPH, FAAP, FSAHM, chief of the division of adolescent and young adult medicine at Johns Hopkins School of Medicine and Public Health in Baltimore, Maryland, discussed the importance of discussing sexual health with teenagers, how the pandemic changed the landscape, and what telehealth can bring to the plate.

For teenagers, the development of healthy sexuality is an important milestone on the path to being an adult. Parents are an important part of this and should be a part of the discussion. Research has found that high-quality discussions between parent and teenager about sexual health can lead to delays the first sexual experience; make the teenager more likely to discuss STIs and pregnancy with partners; use contraceptives; and have used condoms during his or her last sexual experience. Such discussions are becoming more common, but both parents and teenagers express feelings of discomfort and many adolescents feel embarrassed discussing the topic with their parents. Many parents and teenagers rely on their pediatrician to have discussions and most visits do have some type of sexual health content, but the average time spent is 36 seconds and only half of teenagers get time to speak to their provider alone.

The COVID-19 pandemic led to another wrinkle. Social distancing may have been a key way to prevent spread of the disease, but information indicates that many teenagers and young adults still engaged in sexual activity. Many medical offices were closed to in-person visits in the beginning months and public health departments that would’ve worked with sexual health were often shifted over to perform COVID-19 testing. Reduced access to care introduced new barriers to accessing contraceptives; preventive visits, which reduced the chance to provide anticipatory guidance; providing pregnancy options and counseling; counseling on risk reduction; and STI/HIV screening and treatment.

Telehealth is an important way to give vital sexual health care to adolescents. Some of the key parts of care that can be provided through it include anticipatory guidance, contraception counseling, family planning, coordinating follow-up care, and connecting teenagers to other resources. It also offers clinicians and teenagers a chance to have a private and confidential conversation about a variety of topics on sexual health. When visiting with an adolescent patient in the office, clinicians should be sure to tell them that telehealth is an option to discuss topics of a sexual nature. When in a Telehealth visit, health care professionals should ensure that the “tone” of the visit is the same as it would be in the office. Due to the sensitive nature of the topics discussed, clinicians should take a variety of steps to ensure that the adolescent patient’s confidentiality is maintained:

Inform the patient what confidentiality means and the limits that may exist for that confidentiality

Be aware of who is in the room with the patient

Help the teenager find a space that’s as private as possible, which may take some creativity

Encourage the teenager to use headphone during the visit

During telehealth visits, clinicians should be sure to discuss sexual health with all patients, not just female patients. Motivational interviewing can be a good way to encourage proactive and protective behaviors. If a hybrid visit requiring the patient to come into the office for other elements such as testing, clinicians should offer support as needed and ensure that the patient can get to the office for it.

1. Trent M. Meeting teens where they are: using telemedicine to improve sexual health. American Academy of Pediatrics 2021 National Conference & Exhibition; virtual. Accessed October 11, 2021.

Telehealth offers a whole new way to reach out to adolescent patients for critical conversations on sexual health, according to a session at the virtual 2021 American Academy of Pediatrics National Conference & Exhibition

Reaching teens on sexual health through telehealth

For some patients with asthma or allergic skin disease, using a biologic may be the best available option. At the virtual 2021 American Academy of Pediatrics National Conference & Exhibition, Heather De Keyser, MD, MS, assistant professor of pediatric pulmonology at the Breathing Institute, University of Colorado School of Medicine and Children’s Hospital in Aurora, covered determine what children may benefit from a referral for biologics and the biologic treatments available for asthma, atopic dermatitis, and urticaria.

Asthma is most common chronic condition in children, impacting 1 out of 12 children. In children, it often follows a similar atopic pathway as urticaria and atopic dermatitis. Severe asthma, which features frequent exacerbations and chronic morbidity, is divided into 3 groups: untreated asthma (those who either have no available therapies or poor adherence), difficult to treat asthma (variable medication adherence), and treatment-resistant severe asthma, which may or may not be controlled with high dose medication. When considering whether to refer for biologics, a clinician should answer yes to all of the following questions:

Does the child truly have asthma? Have asthma mimickers been eliminated?

Is there a history of good adherence to medications?

Can the child show good inhaler technique?

Have modifiable risk factors been corrected?

Does the child have severe or difficult to treat asthma, which is not controlled in spite of high dose inhaled corticostroid?

Biologics for asthma and allergic skin disease target certain markers such as immunoglobulin E (IgE), interleukin (IL)-5, and IL-4. It can be administered either in the home or at a clinician’s office, every 2 to 8 weeks.

Omalizumab is the oldest available biologic for asthma and is anti-IgE. It’s the most studied in children and has been efficacious in reducing exacerbations. It’s current pediatric indication is for children aged 6 and older who have moderate-severe persistent asthma that is inadequately controlled with inhaled steroids. Anaphylaxis is a known side effect and an epinephrine auto injector should be given to children in case of delayed reactions. It isn’t meant for acute asthma attacks and steroids should not be abruptly stopped. Mepolizumab, an anti-IL-5 biologic, has been shown to reduce exacerbations and eosinophils; decrease hospitalizations as well as steroid use; and resulted in improved markers of control. It’s indicated for add-on maintenance for severe asthma with an eosinophilic phenotype in children aged 6 years and older. It response best in patients with eosinophil levels (>150 cells/microliter). It shouldn’t be used acute attacks and helminthic infections should be treated before start of treatment. Benralizumab, an anti-IL-5 biologic, significantly reduced exacerbation risk and increased markers of lung function in patients with higher eosinophil levels (>300 cells/microliter). It’s indicated for add-on maintenance for severe asthma with an eosinophilic phenotype in children aged 12 years and older. It carries a risk of anaphylaxis, angioedema, and urticaria. It isn’t for use with acute attacks and helminthic infections should be treated before start of treatment. Dupilumab, an anti-IL-4 therapy, results in reductions in corticosteroid doses and severe exacerbations as well as improvements in lung function. It can be used for add-on maintenance for severe asthma with an eosinophilic phenotype in children aged 12 years and older. It carries a risk of eosinophilia and urticaria/hypersensitivity. Corticosteroids shouldn’t be abruptly halted when using dupilumab. It shouldn’t be used for acute exacerbations.

For urticaria, omalizumab is approved for the treatment of chronic idiopathic urticaria in children aged 12 years and older. The side effects are similar to those seen when using the therapy to treat asthma. In patients with atopic dermatitis, dupilumab is approved for use in children aged 6 years and older and led to improvements in quality of life markers and pruritus. Clinicians should monitor for worsening eye symptoms and keratitis. Other biologics are still being studied for both conditions.

For general pediatricians, De Keyser recommended:

Evaluate current medication adherence in patients with poorly controlled asthma, atopic dermatitis, or urticaria.

Refer the patient to a subspecialist to determine if a patient is candidate for biologics

Be knowledgeable about the adverse effects of biologics

Check adherence to biologics, if they are being administered at home

Work with general pediatricians to identify patients are ideal candidates

Keep an eye out for adverse events associated with the chosen biologic

Track clinical improvement in symptoms following treatment initiation

1. De Keyser H. Biologics for asthma and allergic skin diseases. American Academy of Pediatrics 2021 National Conference & Exhibition; virtual. Accessed October 11, 2021.


In cases of poorly controlled disease, even with good medication adherence, it might make sense to turn to biologics. A presentation at the virtual 2021 American Academy of Pediatrics National Conference & Exhibition covered biologics available for treating asthma and allergic skin disease.

Available biologics for treating asthma and allergic skin disease

It’s not something that many are comfortable thinking about, but everyone has biases. Clinicians should be particularly diligent in examining whether a snap decision was based on intuition or shaped by implicit bias. V. Faye Jones, MD, PhD, MSPH, professor of pediatrics at the University of Louisville in Kentucky makes the case that addressing these concerns can lead to better care for many children in her session at the virtual 2021 American Academy of Pediatrics National Conference & Exhibition.

Jones opened with a case of a 10-year-old Black girl and her mother who visited the office because the girl’s teacher wanted her on medication because she is “loud and bossy.” The mother sees no difference between her daughter and other children and there is no documentation of the girl having behavior problems in the practice’s records, which go back 7 years. The case illustrated a common issue that faces Black children, which is the erasure of childhood. She referenced a study that found adult participants perceived Black girls as needing less nurturing and protection; requiring less support and comfort; more independent; and more knowledgeable about adult topics such as sex.

Although bias has a negative connotation, it is just one way for us to survive in the world by finding patterns, seeking shortcuts to solve problems, and making decisions based on past experiences. This ability is one way that allows us to sort through the millions of stimuli that we’re exposed to at any given moment to a more manageable number that we can absorb. However, bias can also lead to negative outcomes in medical care. A study showed that pediatric residents have similar level of implicit bias to Black children as they have toward Black adults. This bias can impact interactions between clinician and child, with Black and Hispanic children being less likely to be asked questions about their health than their White peers. Furthermore, bias can play a significant role in pain medication with many non-White children receiving suboptimal pain management in comparison to White children with similar conditions. Black and Hispanic children are less likely to undergo imaging during emergency department visits. To examine your implicit biases, Jones recommended using the collection of implicit biases test from Harvard University.

When tackling implicit bias on the personal level, one should:

Recognize that he or she is biased and work to accept this fact

Become capable of self-reflection about these biases

Strive to become less decisive in decision-making and engage in “constructive uncertainty”

Work to be comfortable with the awkwardness and discomfort that biases may cause and explore those feelings

Engage with groups that may be considered “others” and spend time with positive models from those groups

Earnestly seek feedback and use that feedback to continue improvement

She closed the session with recommendation to make in practice including educating the self and others in the practice on implicit bias and its impact; ensuring that the staff in the practice is reflective of the patients they serve; create accountability measures along with timelines; and examine the images used in patient handouts, posters, and other images to ensure its reflective of the community and isn’t reinforcing stereotypes.

1. Jones VF. Is it clinician intuition or implicit bias?. American Academy of Pediatrics 2021 National Conference & Exhibition; virtual. Accessed October 11, 2021.

A session at the virtual 2021 American Academy of Pediatrics National Conference & Exhibition urges clinicians to identify and tackle implicit bias.

Examining when implicit biases influence clinical care

Much like a person’s pulse rate, body temperature, respiration rate and blood pressure, menstruation can serve as a vital sign of a girl’s health and menstrual issues can indicate underlying health concerns. At the virtual 2021 American Academy of Pediatrics National Conference & Exhibition, Selma F. Witchel, MD, FAAP, professor of pediatrics at UPMC Children’s Hospital of Pittsburgh in Pennsylvania discussed the difference between normal and abnormal menses, the available toolbox, common irregular menses situations, and what to consider with menses in special populations.

The median age at menarche is 12.43 years. Normal menarche has a flow length of ≤7 days and typical product use is 3 to 6 pads or tampons a day. The cycle interval is irregular during the first gynecologic year; 21-45 days during the second gynecologic year; and 21-35 days from third gynecologic year until menopause. Signs of abnormal menses include menses lasting more than 7 days; initially regular menses becoming irregular; menses requiring pad/tampon changes every 1-2 hours and throughout the night; no menses by age 15 years with appropriate pubertal development; and no menses within 3 years of the onset of breast development.

Therapies available in the toolbox to use with menstrual disorders include combined oral contraceptives, the vaginal ring, depot medroxyprogesterone acetate, progestin-containing intrauterine devices, gonadotropin-releasing hormone (GnRH)-superagonists, and etronogestrel subnormal implants. Witchel noted that providers should be aware of whether treatments could impact bone mineral density during such a pivotal time, like combined oral contraceptives that have a mild negative impact or depot medroxyprogesterone acetate that has a significant adverse effect, or carry a risk of venous thromboembolism, such as combined oral contraceptives.

Witchel then discussed common irregular menstrual concerns including:

Menses too early - A cause of early menstruation is precocious puberty, which can be either GnRH-dependent, which can be idiopathic, genetic, or tied to central nervous system, or GnRH-independent, which can be the result of Prader-Willi syndrome, Williams and Temple syndrome, autonomous ovarian cysts, etc. A GnRH agonist can be used in the former. Isolated vaginal bleeding with no other signs of puberty is a diagnosis of exclusion and can be the result of sexual abuse, infection, vaginal foreign body, ovarian cyst, hypothyroidism, or pinworm endometritis.

Minimal breast development and delayed menses - Turner syndrome may be the cause in girls with short stature, cubitus valgus, shortened fourth metacarpals, short neck, high arched palate, neurosensory hearing loss, scoliosis, and Madelung deformity. It should be treated with growth hormone.

Secondary amenorrhea - Stress, pregnancy, traumatic brain injury, eating disorders, and diabetes can all lead to secondary amenorrhea. Polycystic ovary syndrome (PCOS) is another cause and can be treated with lifestyle modification, combined oral contraceptives, and metformin when needed. Witchel stated that an accurate evaluation of PCOS can’t be done if the patient already using oral contraceptives. Furthermore, care should be taken when diagnosing PCOS in teenage girls. Other disorders should excluded before doing so and certain diagnostic criteria such as insulin resistance and hyperinsulinemia should only be used with adult women.

Breast development and no menses - Causes can include androgen insensitivity, anatomical anomalies, or Mayer-Rokitansky-Kuster-Hauser syndrome, which may require surgical interventions.

Heavy menstrual bleeding - Bleeding disorders, PCOS, infection, thyroid disease, and hemorrhagic ovarian cysts can all cause heavy menstrual bleeding. Bleeding disorders should be considered if there is a family history, menorrhagia since menarche, or a personal history of bleeding episodes. Treatment includes acute and maintenance therapies from the toolbox.

The session ended with Witchel discussing menstruation in adolescent girls with disabilities. She noted that menstrual management or suppression is often desired by this group. Providers should engage in shared decision-making when possible. Some physical disabilities may make some forms of menstrual hygiene more difficult or undesirable. Some medications may cause hyperprolactinemia and interactions may occur between some seizure medications and sex steroids. A hysterectomy is not considered appropriate management in this group. If it’s being considered as a last resort, Witchel recommended a consult with an ethics committee.

1. Witchel S. Evaluation and management of menstrual disorders in teens. American Academy of Pediatrics 2021 National Conference & Exhibition; virtual. Accessed October 8, 2021.

A session at the virtual 2021 American Academy of Pediatrics National Conference & Exhibition highlights menstrual disorders in adolescent girls.

Diagnosing and managing menstrual disorders in teen girls

Barriers to health care exist for many children, but can be particularly arduous for the 18 million children who are members of an immigrant family. The session “Addressing Barriers to Care for Immigrant Families” at the virtual 2021 American Academy of Pediatrics National Conference & Exhibition presented by members of the Program for Immigrant and Refugee Child Health (PIRCH) at Baylor College of Medicine and Texas Children’s Hospital in Houston covered the major barriers that immigrants children face and the initiatives that PIRCH has created to tackle the challenges seen in their area.

Common barriers to care for immigrant children include:

Language - Roughly half of all immigrant have children with limited English proficiency, which can impact preventive care access and can lead to reductions in being satisfied with care

Health literacy - Limited health literacy is more common in people who are racial or ethnic minorities, of a lower socioeconomic status, or have limited proficiency with English. A lack of health literacy has been linked to less utilization of preventive care, more emergency department visits for nonemergencies, and overall worse health outcomes for children.

Cultural factors - Immigrant families may be used to a different health care system or non-Western approaches to treatment. Furthermore, there may be a different understanding of what is causing a disease or disorder.

Health coverage - Immigrant children are twice as unlikely to be uninsured as their nonimmigrant peers. Additionally, children without legal residency status can’t access public health insurance options in most states in the United States. Unaccompanied immigrant children do have coverage when they are in the custody of the Office of Refugee Resettlement, but they are no longer covered once released to their family.

Immigration-related fears - Families may worry that use of public benefits will negatively impact their legal residency status and some may avoid using any health care because they worry about deportation.

Health system - Providers and staff may be inadequately trained. Support staff may be insufficient.

The PIRCH program was founded in 2018 with the mission to improve the health of immigrant children by removing barriers to care and promoting clinical excellence. The program has developed a number of initiatives to tackle common barriers in the Houston, Texas area, including:

Uninsured children not going to subspecialty appointments following referral - PIRCH met with the financial services of Texas Children’s Hospital to discuss the unique needs of the population and then worked together to improve the needs of the patients. Staff was also educated about the issue. One potential idea the program may use is making a patient’s insurance status more prominent in the electronic health record.

Not all providers have training in immigrant care - The program offers a noon conference series on care in the population. A community health education program with refugee Congolese mothers offers a mutually beneficial forum for health care provider and the mothers to learn from one another. A refugee and asylum seeker elective is also available for residents who want to focus on immigrant care. For clinicians out of residency, a global health journal club and annual grand rounds offer an opportunity to listen.

Lack of awareness of medical homes that will take children regardless of immigration and insurance status - With the help of an intern, a list of low-cost clinics in the Houston area was created. The list includes clinics that will see both children and the entire family along with specialties available at the sites.

Utilization of laboratory screening for immigrant children is not standard practice - An 

 to determine what screenings might be necessary for the patient was developed to improve screening protocols.

Creating a program that addresses immigrant care in the community requires leadership who believes in the mission of improving access to care for all children as well as faculty who are dedicated to it. Working in the field also requires navigating a political minefield, but that can be addressed by refraining from taking sides or citing specific political figures; using language that is inclusive; and starting from the presumption that health care is a human right.

1. Monterrey A, Fredericks K, Haq H, Russel E, Swamy P. Addressing barriers to care for immigrant families. American Academy of Pediatrics 2021 National Conference & Exhibition; virtual. Accessed October 8, 2021.

Immigrant families face barriers to accessing health care. A session at the virtual 2021 American Academy of Pediatrics National Conference & Exhibition discussed how 1 program in Houston, Texas tried to help those families overcome those barriers.