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

Miranda Hester

Ensuring teenagers have the necessary and correct information to promote good sexual health is important. However, discomfort from the teenager, parent, and even clinician may lead to delays in having "the talk" or a full agenda for well visits may cause it to be pushed to the next time the teenager is in the office. Helen C. Wang, MD, a pediatician and assistant professor of pediatrics at UC San Diego School of Medicine in California, shares some highlights of the interactive session that she led with her colleagues Kanani Titchen, MD, FAAP, an adolescent and young adult medicine specialist at Rady Children's Hospital-San Diego and an assistant clinical professor of pediatrics at UC San Diego School of Medicine, and Samantha V. Hill, MD, MPH, adolescent medicine physician at University of Alabama at Birmingham.

This article originally appeared on Contemporary Pediatrics®. 

Articles

Helen C. Wang, MD, shares key takeaways from the session she co-presented at PAS 2022.

Tips from PAS 2022 on having "the talk" with teen patients


Using a mother’s own milk to help extremely preterm infants

For extremely preterm infants, mother’s own milk may be helpful for preventing poor postnatal growth and some morbidities.

Medical advancements mean that more and more extremely preterm births result in a living baby. However, these newborns can require additional care to prevent certain complications like retinopathy of prematurity and bronchopulmonary dysplasia, along with poorer postnatal growth. A 

 looks at whether using a mother’s own milk leads to lower rates of morbidity than using pasteurized donor milk.1

The investigators looked at a Swedish population-based cohort of extremely preterm infants who were born between 2004 and 2007 and survived. They examined the exposure to both mother’s own milk and pasteurized donor milk from birth until 32 weeks postmenstrual age. The primary outcomes were a change in 

-score (Δ) from birth to 32 weeks postmenstrual age for weight, length, and head circumference and the secondary outcomes were the incidence of bronchopulmonary dysplasia and retinopathy of prematurity.

The cohort included 453 infants. The average gestational age 25.4 weeks. The investigators found no links between donor milk and growth outcomes or morbidities, nor was a link found between mother’s own milk and bronchopulmonary dysplasia outcomes. However, mother’s own milk was positively linked to Δweight and Δhead circumference. The link was still significant in multivariable models. Furthermore, each increase of 10 mL of mother’s own milk per kg/day from birth through 32 weeks postmenstrual age would yield an increase of 0.02 (95% CI 0.01–0.03, P < 0.001) 

-score units for Δweight and 0.02 (95% CI, +0.00–0.04, P = 0.049) 

-score units for Δhead circumference from birth through 32 weeks postmenstrual age. Although it did not carry through to adjusted analyses, a higher intake of mother’s own milk also had a significant link to a lower probably of any form of retinopathy or severe retinopathy.

The investigators concluded that increasing the intake of mother’s own milk and not donor milk or formula was linked to improved head circumference growth and postnatal weight gain from birth until 32 weeks postmenstrual age in infants who were delivered extremely preterm. They urged clinicians to utilize any intervention with a goal of increasing the early intake of mother’s own milk for these extremely preterm infants.

1. Lund A, Domellöf M, Pivodic A, Hellström A, Stoltz Sjöström E, Hansen-Pupp I. Mother's own milk and its relationship to growth and morbidity in a population-based cohort of extremely preterm infants. 

. 2022;74(2):292-300.doi: 10.1097/MPG.0000000000003352

Using a mother’s own milk to help extremely preterm infants

In order to provide accurate results regarding the safety and efficacy of drugs and devices being tested through clinical trials, a diverse participant pool would work better than one that skewed male and White, for instance. In recent years, a concerted effort has been made to achieve greater parity in clinical trials. A 

 investigates whether that effort has paid off.1

The investigators performed a cross-sectional study that looked at the articles reporting on pediatric clinical trials in the United States from January 2011 to December 2020. The medical journals used were the top 5 general pediatric and top 5 general medicine. They looked for the reporting of the participants’ race/ethnicity and compared it to the US census population.

A total of 612 studies were included in the study, encompassing 565,618 participants. From that pool, 486 reported the race of participants and 338 reported on participant ethnicity. During the studied period, the relative rates of reporting on the race of participants saw an increase of 7.9% per year (95% CI, 0.2%-16.3% per year) and ethnicity reporting increased by 11.4% per year (95% CI, 4.8%-18.4% per year). In the articles that did report race and ethnicity, method of assignment was not indicated in in 261 of 511 articles (51.1%) and 207 of 359 articles (57.7%), respectively. They found that a higher ratio of Black children was enrolled in trials than the ratio found in the US population. On the other hand, American Indian/Alaska Native (OR, 0.82; 95% CI, 0.79-0.85), Asian (OR, 0.56; 95% CI, 0.55-0.57), and Native Hawaiian/Pacific Islander (OR, 0.66; 95% CI, 0.61-0.72) children were found to be enrolled at significantly less rates when compared to the populations in the United States. Hispanic children were found to be enrolled at a rate that was proportionate with the Hispanic population in the United States (OR, 1.02; 95% CI, 1.01-1.03). The investigators found that White children were enrolled less than had been anticipated, but they still made up 46% of the participants in the studies used.

The investigators concluded that the number of studies that reported the race and ethnicity of participants had increased from 2011 to 2020, but it still remains underreported overall. Some disparities between presence in clinical trials and the actual US populations exist, but the heightened presence of Black children in the studies indicates inclusive research practices that could be an effective way to close the gaps in other groups.

1. Rees C, Stewart A, Mehta S, et al. Reporting of participant race and ethnicity in published US pediatric clinical trials from 2011 to 2020. 

. March 21, 2022. Epub ahead of print. doi:10.1001/jamapediatrics.2022.0142

Creating a heterogenous cohort in pediatric clinical trials aids in the generalizing of the results and helps ensure that data of efficacy and safety are more accurate. A report looks at data from the past 10 years to see how often race/ethnicity are reported and whether there has been improved inclusion of non-White children.

Race and ethnicity in clinical trials

A growing body of evidence indicates that a delay in umbilical cord clamping following delivery can lead to improved outcomes for a newborn. Infants who are born preterm can use any advantage to improve outcomes. A 

 examines whether a delay in clamping for very preterm infants can lead to an improvement in mortality and major disability rates at 2 years of age.

The report is a long-term follow-up evaluation of the APTS trial, a multicenter, randomized trial that was run in 25 centers in 7 countries. The infants were randomized before birth in a 1:1 ratio to delay clamping for at least 60 seconds or clamp within 10 seconds of delivery. Cord milking was not performed in either group. The outcomes were death or major disability, which included severe vision loss, cognitive delay, major language/speech problems, deafness requiring hearing aids or cochlear implants, cognitive delay, or cerebral palsy at 2 years corrected age.

A cohort of 1531 infants was randomized into delayed clamping (767) and immediate clamping (764). In the cohort, 384 infants were from a multiple delivery; 862 were male; and 505 were delivered before 27 weeks’ gestation. Protocol was fully adhered to for 565 of the infants in the delayed clamping group and 726 infants in the immediate clamping group. The investigators determined death or major disability status for 1419 infants. Death or major disability occurred in 204 infants in the delayed clamping group versus 240 infants in the immediate clamping group (relative risk [RR]) 0.83, 95% CI 0.72–0.95; p=0.010). Death before 2 years of age occurred in 60 children in the delayed clamping group and 81 in the immediate clamping group (RR 0.70, 95% CI 0.52–0.95). Major disability at age years occurred in 23% of children in the delayed clamping group and 26% in the immediate clamping subcohort (RR 0.88, 0.74–1.04).

The investigators concluded that in infants who were born very preterm that a delay of at least 60 seconds following delivery was tied to a risk reduction of death or major disability at age 2 years by 17%.

This article was initially published by our sister publication Contemporary Pediatrics.

1. Robledo K, Tarnow-Mordi W, Rieger I, et al. Effects of delayed versus immediate umbilical cord clamping in reducing death or major disability at 2 years corrected age among very preterm infants (APTS): a multicentre, randomised clinical trial. 

. 2022;6(3):150-157. doi: 10.1016/S2352-4642(21)00373-4

Evidence indicates that a delay in umbilical cord clamping leads to better outcomes for infants. What are the outcomes for those who are very preterm?

 Using delayed cord clamping to improve outcomes for very preterm infants

Child protective services removes children from situations where maltreatment occurs, but little research has been done into how these interventions might alter the risks for girls when they reach adolescence (such as pregnancy and sexually transmitted infections (STDs). A report examines whether child protective services involvement was linked to improved sexual and reproductive health outcomes in these teenagers.1

The investigators used linked, longitudinal, statewide administrative data from Wisconsin, which included medical assistance and child protective services records to look at the rates of sexual and reproductive health outcomes in adolescent girls aged 13 to 17 years who had been investigated by child protective services for maltreatment before they were 13 years of age and had been born between 2000 and 2002.

There were 9392 teenaged girls included in the study, with roughly equal numbers born in 2000, 2001, and 2002. A majority (42.8%) of the girls were White, with Black (26.6%) and Hispanic (16.7%) being the other major race/ethnicity groups included. The investigators found that by the time of their 18th birthday, a large number of those with a history of maltreatment had at least 1 concerning sexual health outcome (23.5%), which included diagnoses of diseases such as chlamydia (8.4%), pregnancy (11.2%), and parenthood (6.1%). When compared to a child protective services investigation that did not include a formal intervention, foster care was linked to lower odds of both (adjusted odds ratio, 0.82; 95% C, 0.69-0.98) and live birth (adjusted odds ratio, 0.78; 95% CI, 0.61-0.99). Furthermore, child protective services involvement that was characterized as recurrent and ongoing was tied to adverse sexual health outcomes.

The investigators concluded that their research showed adolescent girls with a history of maltreatment in childhood are at increased risk for adverse sexual health outcomes during their teenage years. The involvement of child protective services appeared to have only limited influence, typically when connected to an intervention, in preventing these suboptimal outcomes, which means that different interventions are needed to help this population avoid poor sexual and reproductive health outcomes.

1. Font S, Caniglia M, Kennedy R, Noll, J. Child protection intervention and the sexual and reproductive health of female adolescents ages 13 to 17 years. 

. February 21, 2022. Epub ahead of print. doi:10.1001/jamapediatrics.2021.6605

Child protective services (CPS) is supposed to protect against maltreatment for adolescents, but do they help protect against negative outcomes linked to sexual health?

Impact of CPS involvement on adolescent female sexual health

On February 23, 2022, Texas governor Greg Abbott told the Texas Department of Family and Protective Services to conduct thorough investigations into any reports of minors undergoing elective gender confirmation procedures and called for Texans to report incidences of children receiving gender-affirming care. A day earlier the state’s Attorney General issued an opinion that equated care such as puberty blockers to child abuse. Much of the public furor against the actions of Texas state officials centered on how the actions would impact the mental health of gender diverse children. A 

 examines how receiving gender-affirming care impacts the mental health of transgender and nonbinary adolescents and young adults, who are often at risk of suboptimal mental health outcomes due to discrimination and stigma.1

The investigators performed a prospective observational cohort study at an urban multidisciplinary gender clinic. The participants were transgender or nonbinary individuals who were seeking gender-affirming care. They used the Patient Health Questionnaire 9-item (PHQ-9) and Generalized Anxiety Disorder 7-item (GAD-7) scales to assess mental health outcomes.

A total of 104 adolescents and young adults aged 13 to 20 years participated in the study: 63 transmasculine, 27 transfeminine, 10 nonbinary or gender fluid, and 4 who either did not respond to the gender identity question or responded, “I don’t know.” At the study’s baseline, 59 were found to have moderate or severe depression; 52 had moderate to severe anxiety; and 45 indicated engaging in self harm of having thoughts of suicide. By the time the study ended, 69 had been given puberty blockers, gender-affirming hormones, or both, whereas 35 hadn’t received either intervention. After adjusting for both potential confounders and temporal trends, the investigators found that the participants who had started either intervention had 60% lower odds of depression and 73% lower odds of suicidality than among those who had not been given gender-affirming care. No link between receiving puberty blockers or gender-affirming hormones and anxiety were discovered.

The investigators concluded that receiving gender-affirming medical interventions were linked to lowered risks for negative mental health outcomes over the course of 12 months. The results contribute to a growing collection of evidence that indicates that gender-affirming care is linked to overall improved well-being to transgender and nonbinary teenagers and young adults.

1. Tordoff D, Wanta J, Collin A, Stepney C, Inwards-Breland D, Ahrens K. Mental health outcomes in transgender and nonbinary youths receiving gender-affirming care. 

. 2022;5(2):e220978. doi:10.1001/jamanetworkopen.2022.0978

A report provides information on how gender-affirming care such as the use of puberty blockers can positively impact the mental health of transgender and nonbinary teenagers and young adults.

Miranda Hester

Articles

Tips from PAS 2022 on having "the talk" with teen patients

Using a mother’s own milk to help extremely preterm infants

Race and ethnicity in clinical trials

Using delayed cord clamping to improve outcomes for very preterm infants

Impact of CPS involvement on adolescent female sexual health

Gender-affirming care improves mental health for transgender and nonbinary people