Lecture 11 - Teen Medicine

What is the number 1 cause of teen death?

Motor vehicle crashes.

What is the HEADSSS framework?

H- Home

E- Education

A- Activities

D- Drugs

S- Sexuality

S- Suicide/Depression

S- Safety

When should you begin routine HEADSSS screening?

Age 11-12

Describe early teen (11-13) development stages

Thinking: Concrete thinking

Identity: Preoccupied with physical body changes

Peer influence: Same-sex peer group focus

Independence: Limited independence from family

Describe middle teen (14-17) development stages

Thinking: Emerging abstract thinking; sense of invincibility

Identity: Peer group identity development

Peer influence: Peak peer influence

Independence: Testing limits and rules

Describe late teen (18-21) development stages

Thinking: Future-oriented; fully abstract thinking

Identity: Individual identity established

Peer influence: Selective, intimate relationships

Independence: Autonomous decision-making

What is Tanner staging?

5-point scale: standardized classification system tracking physical pubertal maturation from stage 1 (prepubertal) to stage 5 (full adult maturity)

Evaluates secondary sexual characteristics in females and males.

What are the stages of female puberty progression?

1. Thelarche. First sign of puberty is breast budding. Typical onset is age 8-13.

2. Growth spurt: Peak height velocity occurs early in female puberty (typically Tanner 2-3, prior to menarche)

3. Menarche: Occurs 1.5-3 years after thelarche. Average age in the US is 12-13 years (Tanner 3-4)

How long does the female pubertal development span?

Typically 3-4 years from initial breast budding to complete physical maturation.

What are the stages of male puberty progression?

1. Testicular enlargement: First sign of puberty, testicular volume ≥4 mL or length ≥2.5 cm (Tanner 2). Typical onset: 9-14 years

2. Peak growth spurt: Peak height velocity occurs late in male puberty, around age 13.5-14 years (Tanner 4)

3. Spermarche: First ejaculation typically occurs around Tanner stage 3-4 (median age 13.5 years)

What happens at Tanner stage 2?

Girls: Breast bud; small mound with widened areola

Boys: Testicular enlargement (4-6mL), scrotal thinning/reddening

Pubic hair: Sparse, slightly pigmented, downy hair at base of genitalia

What happens at Tanner stage 3?

Girls: Breast and areola enlarge, no contour separation

Boys: Penis lengthens; tests 8-12 mL

Pubic hair: Coarser, curlier hair extending laterally

What happens at Tanner stage 4?

Girls: Areola and papilla form a secondary mound

Boys: Penis increases in length and breadth; tests 12-15 mL; scrotum darkens

Pubic hair: Adult-type hair, not yet extending to medial thighs

What happens at Tanner stage 5?

Girls: Mature adult contour; nipple projects

Boys: Adult size; testicular volume > 15 mL

Pubic hair: Adult distribution extending to medial thighs

What does pubarche reflect?

Pubarche (pubic hair development) reflects adrenarche (adrenal androgen production), NOT central HPG axis activation. Do NOT use pubic hair alone as a marker of true pubertal onset!

What is the physical exam gold standard?

Palpation is mandatory in PE! Visual inspection alone frequently misclassifies staging, especially in patients with obesity where adipose tissue mimics breast buds (pseudothelarche)

What is the discordance red flag?

Significant discordance between breast/genitalia staging and pubic hair staging warrants evaluation for peripheral precocious puberty or adrenal disorders.

What is physiologic leukorrhea?

Non-infectious physiologic vaginal discharge occurring 6 to 12 months prior to menarche. Driven by endogenous estrogen stimulation of the vaginal epithelium. Thin, white or clear, odorless, non-pruritic, and non-irritating.

What is the treatment for physiologic leukorrhea?

Patient and parent reassurance.

What is the most common cause of adolescent menstrual irregularity?

Anovulatory cycles secondary to hypothalamic-pituitary-ovarian (HPG) axis immaturity. This is normal during the first 1-2 years post-menarche.

What is the ACOD/AAP joint clinical recommendation regarding menstrual irregularity?

The menstrual cycle should be evaluated as a vital sign in female teens. Identification of abnormal patterns can lead to early dx of underlying conditions.

What are the red flags of AUB that require further follow up?

Secondary amenorrhea: absence of menses for >90 days

Persistent infrequent cycles: cycle lengths persistently >45 days after 1 year post-menarche

Prolonged bleeding

Anemia: Hemoglobin <10

Heavy menstrual bleeding: soaking through more than every 1-2 hours.

What is in the testing for AUB?

UPT

CBC with platelets

TSH level

Coag studies

Hyperandrogenism panel

What is adolescent breast asymmetry?

Very common and almost always physiologic during normal pubertal development. Most asymmetry naturally improves as pubertal maturation completes. One breast bud frequently develops before the other (often L breast bud first)

What should be considered if there is persistent severe asymmetry?

Consider rare conditions like Poland syndrome (absence of pectoralis major) or juvenile hypertrophy.

What is the most common teen breast mass?

Fibroadenoma. Firm, mobile, smooth, well-circumscribed and painless mass. Super common and benign.

What is done for diagnosis of teen breast mass?

US is the modality of choice for imaging (mammography NOT indicated in teens due to dense breast tissue).

Bx can damage the developing breast bud, conservative monitoring is strongly preferred.

What is teen gynecomastia?

Palpable glandular breast tissue in males (>0.5 cm in diameter). Affects up to 50% of teen boys, peaking at ages 13-15.

Transient relative imbalance between estrogen and testosterone activity during puberty.

What is the clinical course of teen gynecomastia?

Usually bilateral, tender initially and spontaneously resolves within 1-2 years.

Make sure to distinguish from pseudogynecomastia.

What are red flag presentations in teen gynecomastia?

Persistence beyond 2 years or beyond Tanner stage 5

Unilateral, hard, fixed or rapidly enlarging mass

Associated galactorrhea, testicular mass or neurological sx.

What are the secondary etiologies of gynecomastia?

Klinefelter syndrome: small firm testicles, high stature

Substances/drugs

Systemic conditions or tumors.

What is included in the workup of gynecomastia?

1. Hormone panel

2. Systemic screen (LFTs, TSH)

3. Karyotype

What is the nationwide mandate of confidential consent in pediatrics?

All 50 states and DC explicitly permit minors to consent independently to STI testing and treatment without parental notification.

What are state-dependent confidental services?

Substance use disorder treatment

Contraception and reproductive healthcare

Outpatient mental health care

Emergency medical care

Pregnancy-related care and prenatal services

What is the qualifying criteria for emancipated minor status?

Valid legal marriage

Active duty enlistment in armed forces

Formal court declaration of emancipation

Complete financial independence living apart from parents

What is the mature minor doctrine?

An unemancipated minor who demonstrates sufficient intelligence and cognitive maturity to understand the nature, risks and benefits of proposed treatment.

Provider assesses developmental maturity, previous personal illness experience, gravity of the condition, and risk profile of proposed therapy.

Explicitly recognized by statutory law or judicial precedent in many states.

What is pediatric assent?

Affirmative agreement to care by a minor who is not legally empowered to give consent. Providers should actively seek assent from developmentally capable teens even when legal consent rests with parents.

What is the clinical standard for sports physical?

Guided by the PPE5.

What are the primary goals for the sport PPE?

Determine general health, life threatening risks like sudden cardiac arrest, injury predisposition

To server as a healthcare entry point and provide preventive counseling.

When should a sports PPE be conducted?

At least 6 weeks before practices start to allow time for diagnostic workup or rehab.

Comprehensive PPE should be done every 2-3 years.