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

Miranda Hester

Having "the talk" as a teenager is a time-honored tradition. Many experience it with their parents, but a visit with a pediatric clinician is an ideal time to ensure that a teenager knows the correct information, has the opportunity to make certain contraceptive choices, and instill the knowledge that the pediatric office is a safe place to come for help.

in this episode Dr. Helen Wang, an assistant clinical professor at the University of California San Diego (UCSD) School of Medicine facilitates a discussion about adolescent patients and having “the talk” with her colleagues: Dr. Kanani Titchen, an assistant clinical professor of adolescent and young adult medicine also of the UCSD School of Medicine and Dr. Samantha V. Hill an Adolescent Medicine Physician at the University of Alabama at Birmingham.

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A visit with a pediatric clinician is an ideal time to ensure that a teenager knows the correct information, has the opportunity to make certain contraceptive choices, and instill the knowledge that the pediatric office is a safe place to come for help.

Having "the talk" with teen patients

Although medication errors may not always be serious, they do represent an instance of human error in patient care and are a high priority issue. Medication errors represent a sizeable portion of all medical errors. A medication error can occur at a variety of times, such as prescribing, administering, or monitoring. A poster presented at the Pediatric Pharmacy Association’s annual meeting in Norfolk, Virginia sought to estimate the prevalence and establish the patterns of medical errors in pediatric patients at tertiary and pediatric hospitals.

Investigators conducted a multicenter retrospective study in 3 hospitals in western Saudi Arabia, inclusive of 1 pediatric specialist hospital and 2 general tertiary care hospitals. Data from medical error reports for children aged 13 or younger admitted to the emergency department, outpatient clinics, nursery, or general ward from January 2019 to December 2019 were collected.

Researchers identified 318 medical errors across the participating hospitals: 135 in hospital 1, 93 in hospital 2, and 90 in hospital 3, for a prevalence errors of 0.9 per 1000 patients. The prevalence was notably lower in hospitals 2 (0.35/1000 patients) and 3 (1.73/1000 patients) compared with hospital 1 (3.5/1000 patients). Admitted wards had the highest rates of medical errors at 14.69/1000 patients, whereas the emergency department had the lowest rate (0.14/1000 patients).

Boys were slightly more likely to be affected by medical errors than girls. Two age groups were also notably more likely to be affected as well: 1 month to 2 years and 6 to 12 years. There were comorbidities in 60.4% of the cases, including mental disability in 7.2%. When errors did occur, the patient had 4 or more prescribed medications (71.1%). Many of the errors occurred during prescribing (81.1%) and were caused by physicians (83.3%); they were most commonly caught by pharmacists (85.5%). The most frequent medical errors were improper dose (34.0%), frequency (14.2%), and duration (10.4%).

Investigators concluded there was a high prevalence of medical errors and in the tertiary care hospitals, accounting for 2% to 4% of hospital admissions. Independent double checks, proper reconciliation of new prescriptions against previous orders, and optimization of labeling are ways to prevent medication errors from affecting patients.

Originally published on our sister brand, 

1. Alotaibi M, Bajammal M, Shukry M, Althqafi N, Alghamdi S. Prevalence of medications errorsand factors of harmful errors in neonates and pediatrics at tertiary and pediatric hospitals: a multicenter study. Presented at: Pediatric Pharmacy Association 2022 Annual Meeting; May 3-6, 2022; Norfolk, VA.

Articles

Pediatric patients taking 4 or more medications were more likely to experience medication errors.

Assessing the prevalence of medication errors in pediatric care

Although naloxone can be used to treat both opioid and clonidine ingestions in children, the initial dosing and titration strategies vary and are often extrapolated from adult studies or based on a handful of pediatric case reports. A poster presented at the Pediatric Pharmacy Association’s 2022 Annual Meeting in Norfolk, Virginia examined the initial dosing range of naloxone continuous infusion for opioid and clonidine ingestions.

Investigators conducted a retrospective chart review of patients who were diagnosed with known or suspected opioid or clonidine ingestion and had received a continuous naloxone infusion for ingestion in the emergency department. Patients were younger than 18 years of age and had been treated at Nationwide Children’s Hospital in Columbus, Ohio.

Fourteen patients were included in the study cohort, 7 girls and 7 boys, with a median age of 1.4 years. Naloxone infusion was used for 11 cases of opioid ingestion and 3 cases of α-agonist ingestion. For the opioid cases, the median time of first titration was 1.65 hours and the median duration of treatment was 10 hours, with a symptom duration of 12 hours. The median initial rate (mcg/kg/hr) was 28, with a max rate of 50 (mcg/kg/hr) and a ratio of intermittent doses of 0.4.

For the cases of α-agonist ingestion, the median time of first titration was 1.47, with a duration of 4 hours and symptom resolution at a median of 20 hours. The median initial rate (mcg/kg/hr) was 28, with a max rate (mcg/kg/hr) and a ratio of intermittent doses was 0.4. The median initial rate (mcg/kg/hr) was 24 with a max rate of 50 (mcg/kg/hr) and a ratio of intermittent doses was 0.23. Therapies that were used concurrently included bagging/oxygen in 6 patients, intubation in 1 patient, fluids in 14 patients, and atropine in 1 patient.

Ingestion-related symptoms in this cohort included:

There was wide variation in initial and max rates, with 6 patients being given an initial infusion at about one-halfthe hourly intermittent dose. Naloxone found effective for all but 1 patient who had ingested clonidine and required intubation. No adverse effects due to the therapy were noted.

1. Bond C, Steinbrenner J. Naloxone continuous infusion dosing for opioid and clonidine ingestions in children. Presented at: Pediatric Pharmacy Association 2022 Annual Meeting; May 3-6, 2022; Norfolk, VA.

Current data about naloxone use in pediatric populations is extrapolated from adult studies.

Evaluating the effectiveness of naloxone infusion therapy for opioid, clonidine ingestion in children

As more states legalize marijuana for recreational use, data have shown an increase in cannabis use among teenagers. Some of those teenagers may develop cannabinoid hyperemesis syndrome (CHS), a condition noted for persistent vomiting resulting from habitual cannabis use. Benzodiazepines, droperidol, haloperidol, antiemetics, acid suppression therapy, or capsaicin are all currently recommended for treatment, although no consensus exists regarding the comparative efficacy of the therapies, nor are there definitive dosing recommendations. A poster presented at the Pediatric Pharmacy Association’s 2022 Annual Meeting, heldin Norfolk, Virginia, examined the medication management of CHS in a pediatric emergency department.

The investigators included children aged 12 years or older who had an emergency department visit between August 2016 and July 2021 for CHS. The children were identified using ICD-10 codes for nausea, vomiting without nausea, cyclical vomiting syndrome unrelated to migraine, nausea with vomiting, cannabinoid hyperemesis syndrome, cannabis hyperemesis syndrome concurrent with and due to cannabis abuse, and cannabis hyperemesis syndrome concurrent with and due to cannabis dependence. Data were collected for each child’s age, sex, race/ethnicity, diagnosis or ICD-10 code, hospital admission, the medications administered during the emergency department visit, discharge prescriptions, and electrocardiograms.

From a potential pool of 94 encounters, 30 met the inclusion criteria. Two patients were given aprepitant; 3 were given fosaprepitant; 8 were given haloperidol, which was given both orally and intravenous/intramuscular(IV/IM); 15 were given capsaicin; 1 was given haloperidol plus aprepitant; and 1 was given capsaicin plus haloperidol.

When broken down to the 5 components, the investigators found a wide range in dosage:

Aprepitant: 80 mg low dose regimen/125 mg high dose regimen

Fosaprepitant: 125 mg low dose regimen/150 mg high dose regimen

Haloperidol IV/IM: < 0.05 low dose regimen/≥ 0.05 high dose regimen

Haloperidol oral: < 0.05 low dose regimen/≥ 0.05 high dose regimen

Capsaicin: ≤ 1 application low dose regimen/ > 1 application high dose regimen

Sixty percent of patients required further hospitalization. High-dose haloperidol and aprepitant were the most favorable for discharge from the emergency department, whileboth fosaprepitant and capsaicin appeared to be ineffective at treating the emetic symptoms of CHS. Prescriptions provided at discharge included aprepitant, ondansetron, scopolamine, and prochlorperazine. The investigators noted that further study with a larger sample size would be helpful in determining optimal dosing for treating CHS in the emergency department.

1. Bryant D, Steinbrenner J. Evaluation of cannabinoid hyperemesis syndrome within a pediatric emergency department. Presented at: Pediatric Pharmacy Association 2022 Annual Meeting; May 3-6, 2022; Norfolk, VA.

High-dose haloperidol and aprepitant were both associated with emergency department discharge.

Treating cannabinoid hyperemesis syndrome in the emergency department

 sat down with Johanna Olson-Kennedy, MD, medical director of the Center for Transyouth Health and Development at Children’s Hospital Los Angeles about the best practices for providing gender-affirming care—treatments for supporting a transgender or nonbinary person in their gender transition—for pediatric patients; who should be a part of the team providing that care; and the small ways that practices can show they’re a safe space for all patients.

Q. What are the best practices for providing compassionate gender-affirming care to children and adolescents in the general pediatric office?

 That question gets broken down into a couple of things. Are we talking about somebody practicing gender care or just anyone practicing pediatrics? Because those are 2 different things. I would think that for general pediatricians, if they’re not comfortable doing gender-specific care, they should refer to someone that is. We have a dearth of training for this work in the general pediatric curriculum, though I think that will change over time. But right now, things such as puberty blockers feel complicated for general pediatricians. So the first thing is to make sure young people are where they’re going to get the most informed care. In the world of gender, it is really important that people understand that having protocols creates more problems than it solves. For a lot of reasons, there are just so many intersecting developmental trajectories that have to be considered when helping people move forward [with transitioning]. And that’s why if you’re not comfortable with the care, don’t do it. The most compassionate care is care that considers the individual, where they are developmentally and chronologically in their gender understanding and consolidation process, and then, where they and their families are in relationship to interventions. And it’s not just 1 overarching thing. It’s individualized.

Q. What are some small changes that pediatricians can enact in their practice to provide a caring and accepting environment for gender-diverse children and teenagers, even if they aren’t providing that care?

 Just even the small act of having a poster or something similar in your waiting room, that says “We welcome all genders here” or “Tell us about your gender” or handouts with basic information can be really helpful. We think about the impact of those changes on kids that are in the trans community, or in the LGBTQIA+ community, but they actually have an impact on everyone. Because that kind of change, that kind of openness, that kind of welcoming message models for everyone the way that it should be for people within the community, but they’re super important for everyone. Also, do you only ask questions about gender in response to some kind of gender expression that feels maybe a little bit outside the stereotype? Or is this something we ask everyone? With the HEEADSSS [home, education/employment, eating, activities, drugs, sex] exam [psychological screening tool for adolescents], we ask about sexuality. We said everyone 12 and older was getting HEEADSSS, outside the presence of their parents.

So with that in mind, for younger kids, we might ask are you having crushes? Do you have crushes on boys, girls, both, neither? So you can provide them information about health and safety. I think a similar thing about gender. You ask something like, “I’ve known you since you were born and we have assumed you were a girl. Does that does that feel right for you?” It may allow them to disclose something that they wouldn’t have otherwise disclosed. It’s also important to talk about the limits of confidentiality with all of those questions so they know that you’re not going to disclose that information to their parents unless they want you to. One of the tricky things about being trans is that if you want to do anything about it, you have to out yourself to providers so they can get you what you need.

I don’t think there’s great consensus about what age you would ask someone this. The most common thing I’ve heard from parents of my patients is “this wasn’t even on our radar.” Thinking about how we can get parents into a place where they are asking their kids these things more routinely, I think that would also take the medical emphasis off gender, refocusing the conversation about gender in the familial setting, or in the social setting, which is way more relevant for prepubertal kids.

Q. For pediatricians who want to create an affirming medical home for this group of patients, what other professionals would you consider bringing into that medical home?

The world of gender work is complicated, right? I always say it takes a village to raise a trans kid. Having networks with mental health providers is really important. Psychiatrists or psychologists or social workers, people who are going to have a little bit more time to spend with kids who need maybe extra support. But I also think if you are going to do gender work within the context of your own pediatric practice, you have to book out enough time. This is not the kind of work you can do in 15-minute visits. Some people create intake forms that give them a lot of information before they meet with the family and the patient.

I also think that either having a really good knowledge of endocrinology or having some endocrinology backup for you if you need it could be really important, depending on the age of patients that you’re taking care of. Another network that’s important is surgeons. Those are all probably good folks to have on your team.

Q. What are your recommendations for pediatricians who want to be advocates for gender-diverse children, outside the exam room?

 Learn, educate yourself, participate in conferences that talk about trans youth and the care of trans youth. If you hear anti-trans stuff, you can say, “I’m wondering if you have any experience with trans youth? Have you sat in rooms with people? Are you just talking and making assumptions about things?” I think that most providers attend some trainings and conferences and I think it’s worth it to ask, if you’re hearing someone present data, “Is there a consideration about trans kids in this data?” But I also think it’s really important to vote. Now, unfortunately, you have to be politically active if you really want to advocate for the community.

Q. What are the best practices for ensuring a smooth transition from pediatric to adult care when a gender-diverse patient reaches their 18th birthday?

 I don’t know if there is 1 way I can tell you in our clinic. People don’t leave our practice until they’re 25. We understand 2 things: Adolescence isn’t limited to ending at 18. Secondly, and more relevant for trans youth, many trans youth get bumped off of the developmental trajectory because they’re spending a lot of their brain space and energy managing and navigating gender dysphoria. And because of that, they may not tend to the tasks of development that other cisgender adolescents are tending to. And so a lot of our kids are not learning how to drive, for example; they’re just behind. And so it’s really important that they stay in pediatric services during this time, as they’re more comprehensive. Adult services are oftentimes very truncated. Like suddenly, on your 18th birthday, you’re supposed to be able to understand how to navigate the health care system.

So in our program, when people are about 21 or 22, I start talking about it, telling patients that they can stay with me until they are 25. But after that, they have to graduate out to adult services. And let’s be real, we have a terrible health insurance system in this country. It is not healthy or secure, or a system, right? It’s terrible. And so where you ended up being able to get adult trans-related services is largely dependent on your insurance. So we will think about where they are geographically, what kind of insurance they have, and what kind of insurance they’re likely to get after their they drop off their parent’s insurance, because that’s another thing. That’s weird as we see people to 25. But we also know in a year with the ACA [Affordable Care Act], they’re going to drop off their parent’s insurance, right? So they may have to do 2 transitions of care in the space of a year. Finally, I tell this to all my patients: If you’re struggling to land somewhere on your care, please call, let us help. So that can be really helpful, too.

Q. How can pediatricians support gender-diverse patients who have parents or caregivers who do not support them?

 It’s probably one of the hardest things for a young person not to have a supportive parent. But I also think that when we talk about support, we need to remember, support is a spectrum. And so there can be someone who is super supportive of their kid using different pronouns or dressing differently, or using a different name, but they absolutely will not support medical intervention for them. That’s a very different parent than a parent that’s saying, “This trans stuff is nonsense.”

It’s important to figure out where the parents are, and again, this does not lend itself to a 15-minute visit. You don’t just have to understand the developmental trajectories of the young person, but you also have to understand the developmental trajectory of the caregiver. This is also one of those reasons to have mental health people on your team because the downstream fallout of gender dysphoria is anxiety and depression. Mental health providers can help give patients the tools to navigate, how to talk to their parents about their gender, how to connect the parents to their gender, their kid’s gender dysphoria. The parents might also feel that they love their kid, but they’re scared. And so it’s really important to try to figure out what the fear is, so that you can dismantle that, and that’s a lot. That’s a lot for a pediatrician to do. Those are really important things.

Another thing, at least in my practice, is I always ask patients, “What name do you want me to use? What pronouns do you want me to use?” I ask that with everyone in the room. I feel really strongly that I need to honor somebody’s authentic sense of self. And so sometimes there’ll be a conversation and the parents are using 1 set of pronouns and I’m using another set of pronouns. But it’s modeling and shaping how people think about this. Parents are such a critical part of that young person’s health and well-being.

Q. Why is gender-affirming care important to ensuring the best possible outcomes for gender-diverse children and teenagers?

The science tells us that if people’s gender dysphoria is addressed and treated, their mental health outcomes improve. More and more data has come out over the last 10 years that backs this up with decades of clinical experience that many of us have. You’d be hard pressed to disagree with the idea that parents want the best mental health outcomes for their kids. And I also think there’s sort of a macro and a micro level. The macro level is the right to live authentically. It is a human right. And we also know that when people are able to live authentically, they function better. But then there’s also the micro level, the individual person, and there’s the struggle in gender work. We have a broken world, but we can’t fix the world all at once. And we have a human being who’s suffering, and so we can alleviate some of that suffering. And that’s really important. That’s why we do it.

A conversation on best practices for helping a child who is thinking of transitioning to another gender.

Providing gender-affirming care in pediatrics

Mercury, a well-known toxin found in some foods, can negatively affect a child’s neurodevelopment. Individuals who consume a large amount of fish and seafood may be at risk for ingesting harmful levels of mercury. A recent investigation in Taiwan examined whether families with mothers who had food safety–related risk perceptions of mercury or who engaged in protective behaviors led to lower exposures of mercury for mother and child.

Pairs of mothers with a child younger than 6 years participated in the study between August 2017 and July 2020. In the study, which was conducted in Taiwan, the mothers were asked questions about demographic characteristics and dietary consumptions. The dietary portion asked about the typical consumption of foods for mother and child over the past month across a number of food categories.

There were 283 pairs included in the study. The average age of the mothers was 35.5 years. The average age of the children was 2.7 years; 54.1% were boys. Nearly 80% of the mothers had at least a university education. Smoking (1.4%) and alcohol use (2.9%) were very rare in participants. The mean fish take intake frequency was 5.1 meals per week. The investigators used hair and fingernail samples to find mercury levels and found that the average mercury levels were 1.07 ± 0.67 g/g and 0.42 ± 0.34 g/g for mothers, respectively, and 1.11 ± 1.22 g/g and 0.36 ± 0.26 g/g for children, respectively. These findings indicate that 42% of the mothers and 41% of the children had hair mercury levels that exceeded the recommended value of 1 g/g set by the US Environmental Protection Agency. Furthermore, the mercury exposure was much higher in children than their mothers, with the estimated daily intake being 3.3 times higher in the children than their mothers. Fish consumption was found to be the main reason behind mercury exposure for mother and child. The children of mothers who did not engage in protective factors or have risk perceptions linked to food safety had higher mercury concentrations than those who did. 

Investigators concluded that mothers who were more aware of the risks of mercury were more likely to have lower levels of mercury as were their children. It is also important to note that although Taiwanese consume more seafood in general than Americans, choosing fish as a healthier alternative to beef has been encouraged over the last few years, so keeping an eye on mercury levels could be helpful to caregivers when deciding on diet for their children.

Kao CS, Wang YL, Jiang CB, et al. Associations of maternal food safety-related risk perceptions and protective behaviors with daily mercury intake and internal doses of Taiwanese women and their preschool children. 

. Published online April 21, 2022. doi:10.1016/j.envres.2022.113344

In Taiwan, a recent study examined whether mothers who had food safety–related risk perceptions of mercury led to lower exposure in mother and child.