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Daily Dose

What Are Breast Buds?

1.15 to read

I received a phone call today from a mother who was worried about the “bump” beneath her 12 year old daughter’s nipple. I do get this phone call quite often and even see mothers and daughters in the office who are concerned about this lump?  First thought is often, “is this breast cancer?”  The answer is a resounding “NO” but rather a breast bud.  While all mothers developed their own breast buds in years past, many have either forgotten or suppressed the memory of early puberty and breast budding.

Breast buds are small lumps the size of a blueberry or marble that “erupt” directly beneath a young girl’s areola and nipple. Most girls experience breast budding somewhere around 10-12 years of age although it may happen a bit sooner or even later. It is one of the early signs of puberty and estrogen effects.

Many girls will complain that the nipple area is sore and tender and that they are lopsided!! It is not unusual for one side to “sprout” before the other. Sometimes one breast will bud and the other is months behind. All of this is normal. 

While a lump in the breast is concerning in women reassure your daughter that this is not breast cancer (happy that they are so aware) but a normal part of body changes that happen to all girls as they enter adolescence.   Breast budding does not mean that their period is around the corner either, and periods usually start at least 2 years after breast budding (often longer).

Breast buds have also been known to come and go, again not to worry. But at some point the budding will actually progress to breast development and the continuing changes of the breast during puberty.

Reassurance is really all you need and if your daughter is self-conscious this is a good time to start them wearing a light camisole of “sports bra.”  

Your Teen

Overweight Girls Start Periods At Earlier Age

1.45 to read

Early-onset menstruation is linked to later health problems such as breast cancer, said Sarah Keim, a researcher at The Ohio State University College of Medicine in Columbus, who wasn't involved in the new study. Girls who get their period early in life are also more likely to have sex sooner than their peers, Keim added, which increases the risk of teen pregnancy and sexually transmitted diseases.It's nothing new that girls are getting younger and younger when they have their first period, but experts worry that the current obesity epidemic could be fueling that trend.

Overweight or obese girls get their first period months earlier than their normal-weight peers, according to a Danish study. Early-onset menstruation is linked to later health problems such as breast cancer, said Sarah Keim, a researcher at The Ohio State University College of Medicine in Columbus, who wasn't involved in the new study. Girls who get their period early in life are also more likely to have sex sooner than their peers, Keim added, which increases the risk of teen pregnancy and sexually transmitted diseases. About 17 percent of American kids and teens are obese, according to the Centers for Disease Control and Prevention. For the study, researchers used information on body mass index (BMI) -- a measure of weight in relation to height -- and age at first period from about 3,200 Danish girls born between 1984 and 1987. The girls started their period just after they had turned 13, on average, which is about half a year later than in the U.S. Keim said part of the reason for this difference may be that African-Americans tend to start their periods before white girls. On average, a girl got her period about 25 days earlier for every point her BMI increased. For a female of about average height and weight, a one-point change in BMI is equivalent to about six pounds. Overweight and obese girls, for example, got their period three to five months before normal-weight girls, said Anshu Shrestha, a graduate student at UCLA School of Public Health, who worked on the study. There has been past research showing a link between BMI and when girls start menstruating. However, since this study was done more recently, it shows that the link is holding up in today's generation, Keim said. The researchers also found that a girl's mother's weight was related to when her daughter started menstruating, but less so than earlier work had hinted. For every point her mother's BMI when pregnant went up, the girl's period came about a week earlier, according to the new study, which was published in the journal Fertility and Sterility. Keim said the Danish findings reinforce the importance of keeping a healthy weight. "It's important for your entire life, starting from very early on," she told Reuters Health. "And it can even affect your children's health." Talking to your daughter about Menstruation. Most girls begin to menstruate when they're about 12, but periods are possible as early as age 8. That's why explaining menstruation early is so important. But menstruation is an awkward subject to talk about, especially with preteen girls, who are often embarrassed by this discussion. So what's the best way to approach this ticklish topic? If your daughter asks questions about menstruation, answer them openly and honestly. Provide as many details as you think she needs at the time. It's OK to let your daughter set the pace, but don't let her avoid the topic entirely. If she's not asking questions as she approaches the preteen years, it's up to you to start talking about menstruation. Don't plan a single tell-all discussion. Instead, talk about the various issues - from basic hygiene to fear of the unknown - in a series of short conversations. Consider it part of a continuing conversation on how the human body works. Remember, your daughter needs good information about the menstrual cycle and all the other changes that puberty brings. If her friends are her only source of information, she may hear some nonsense and take it for fact. To introduce the subject of menstruation, you might ask your daughter what she knows about puberty. Clarify any misinformation and ask what questions she might have. It may be helpful to time your conversations with the health lessons and sex education your daughter is receiving in school, or you could broach the subject before a routine doctor's appointment. You can tell your daughter that the doctor may ask her whether she's gotten her period yet. Then ask if she has any questions or concerns about menstruation. Girls might prefer to learn about menstruation from a female family member, but sometimes that's not possible. If you're a single father and you're not comfortable talking about menstruation, you might delegate these conversations to a female relative or friend. The key is to make sure the information is relayed somehow. The biology of menstruation is important, but most girls are more interested in practical information about periods. Your daughter may want to know when it's going to happen, what it's going to feel like and what she'll need to do when the time comes. - What is menstruation? Menstruation means a girl's body is physically capable of becoming pregnant. Each month, one of the ovaries releases an egg. This is called ovulation. At the same time, hormonal changes prepare the uterus for pregnancy. If ovulation takes place and the egg isn't fertilized, the lining of the uterus sheds through the vagina. This is a period. - Does it hurt? Many girls have cramps, typically in the lower abdomen, when their periods begin. Cramps can be dull and achy or sharp and intense. Exercise, a heating pad or an over-the-counter pain reliever may help ease any discomfort. - When will it happen? No one can tell exactly when a girl will get her first period. Typically, however, girls begin menstruating about two years after their breasts begin to develop. Many girls experience a thin, white vaginal discharge about one year before menstruation begins. - What should I do? Explain how to use sanitary pads or tampons. Many girls are more comfortable starting with pads, but it's OK to use tampons right away. Remind your daughter that it may take some practice to get used to inserting tampons. Stock the bathroom with various types of sanitary products ahead of time. Encourage your daughter to experiment until she finds the product that works best for her. - What if I'm at school? Encourage your daughter to carry a few pads or tampons in her backpack or purse, just in case. Many school bathrooms have coin-operated dispensers for these products. The school nurse also may have supplies. - Will everyone know that I have my period? Assure your daughter that pads and tampons aren't visible through clothing. No one needs to know that she has her period. - What if blood leaks onto my pants? Offer your daughter practical suggestions for covering up stains until she's able to change clothes, such as tying a sweatshirt around her waist. You might also encourage your daughter to wear dark pants or shorts when she has her period, just in case. Your daughter may worry that she's not normal if she starts having periods before, or after, friends her age do, or if her periods aren't like those of her friends. But menstruation varies with the individual. Some girls have periods that last two days, while others have periods that last more than a week. It can even vary this drastically from month to month in the same girl. The amount of blood lost each month can vary, too, usually from 4 to 12 teaspoons (about 20 to 60 milliliters). It's also common for girls to have irregular periods for the first year or two. Some months might even go by without a period. Once your daughter's cycle settles down, teach her how to track her periods on a calendar. Eventually she may be able to predict when her periods will begin. Schedule a medical checkup for your daughter if: - Her periods last more than seven days - She has menstrual cramps that aren't relieved by over-the-counter medications - She's soaking more pads or tampons than usual - She's missing school or other activities because of painful or heavy periods - She goes three months without a period or suspects she may be pregnant - She hasn't started menstruating by age 15 The changes associated with puberty can be a little scary. Reassure your daughter that it's normal to feel apprehensive about menstruating, but it's nothing to be too worried about and you're there to answer any questions she may have.

Daily Dose

Girls: The Teen Years

1:30 to read

It’s the time of year when I am seeing a lot of my adolescent patients who come in over the summer for their check ups.  An important part of an adolescent female’s yearly exam is a discussion about her periods.  

The average age of a first period (menarche) is 12.43 years and in my practice this has been the norm for the last 30 years. Yes, I do have a few patients who start their periods at 11 years (and typically their mother’s did as well), but I also have patients who don’t begin their menstrual cycles until they are 14 - 15 years old.  Remember, genetics plays a big role in determining the timing of puberty, and there is a wide range of “normal”. 

While we still talk about younger girls having “irregular” periods in the first 1-2 years after menarche, studies now show most adolescents have fairly regular cycle intervals (32 days) and bleeding patterns even at a young gynecologic age.  Studies also show that 88-94% of girls have menstrual bleeds that last 3-7 days, with less than 1% having bleeding episodes lasting more than 10 days.

It is important to ask specific questions about an adolescent’s periods and intervals between her periods (cycle length) as well as length of bleeding. With all of the smartphone apps available to record menstrual cycles, most young girls are pretty savvy and have the dates of their periods which makes this easier. Having a period 28 days apart and then the next being 32 days apart is not “abnormal” but many girls “worry” if they don’t have a cycle every 28 days and they need to be reassured that there may be a few days of variability every month.  

I also ask questions to see if an adolescent is having excessively heavy periods (but this is sometimes really difficult to judge early on as a girl doesn’t have a big frame of reference).  If a girl feels as if she is having very “heavy” periods I also look at past history for signs of excessive bleeding or bruising as well her family history for any bleeding abnormalities.  Having her pay attention to pad count for the next month is sometimes helpful.

Many young girls (and their mothers) also ask when they may were a tampon?  It is safe to wear a tampon whenever you begin your period, it really has nothing to do with “age appropriate”. I have a group of adolescents who wear a tampon from the “get go”, while I have others who swear “I will NEVER put in a tampon”.  It is totally about personal preference. I do let young girls know that if they are going to swim during their periods they will need to learn to wear a tampon.  Many of my patients learn to put in a tampon out of necessity!!  They are involved in cheerleading, sports or maybe they are going away to a water sports camp.  I tell all of them, whether your mother, best friend, camp counselor or the direction on the box teaches you to insert a tampon….once you have done it you realize it is certainly not as difficult as imagined.  (one of those check the box moments as a girl!!)

Lastly, I discuss menstrual cramps and how to treat them…which means don’t wait until you are doubled over in pain. It is important to begin an over the counter pain reliever like ibuprofen or naproxen when cramps begin…don’t wait too late. I encourage these girls to carry these products in their purse so that they may be more comfortable sooner rather than later. 

 

Daily Dose

Teen Dating Violence

1:30 to read

February is Teen Dating Violence Awareness month… but this is a subject that we should be discussing year round. Relationship violence is much too frequent and the latest statistics show that more than 1 in 3 women and 1 in 4 men will be in a violent relationship in their lifetime.  Most of those will experience relationship violence between the ages of 18 - 24 years….but many of those affected said that had never been told what relationship violence looked like. 

The key to ending relationship violence is to educate teens as to the signs of an unhealthy relationship.  This means that parents need to be discussing what a healthy relationship is and what it is not, so that their child will know the difference.  

There are often many clues and warning signs that YOU are in an unhealthy relationship.  These may include having a partner who is too smothering and jealous. They may get upset if you spend time with your family or friends, and are jealous of any time spent away from them…for whatever reason.  Their jealousy may escalate where they even begin asking you to check in with them excessively via texts or phone….to make sure they “know where you are”, always. 

At the same time another sign of being too “controlling” is having your partner ask for your passwords to social media accounts.  This will enable them to go on to your sites,  even without your permission.  Not only may they use this as a way to read your texts, but they may even  change your Facebook page when they want to….more control.

Sex may be another area for concern…. They may ask you to do something that you are uncomfortable with.  They may also “force” you to have sex when they want, rather than when mutually decided.  They may even threaten to break up with you if you don’t submit.

Relationship violence may also include verbal abuse…where your partner speaks badly of you to other friends or even puts you “down” in public.  They may belittle you and shame you and embarrass you in front of your friends.  This is never appropriate. 

Teens will tell me that their partner would often say, “if you loved me….you would….”, but that is not what  real love looks or sounds like.  That statement should actually be a warning sign of a possibly unhealthy relationship that is far too controlling.  I would tell that teen to “run Toto run”…even if it seems terribly hard.  Get out of the relationship before the relationship becomes even more unhealthy and even scary.  Let your teen know that you are there to listen and help if asked.

Keep the conversation going and let them know that there is a difference between a healthy and unhealthy relationships. Remind them that they want to look for respect in a relationship.  Power and control are not love. 

Daily Dose

Too Much Texting?

1.00

During my tween/teen checkups, I try to spend some time talking about how much time an adolescent spends on their phone, how much time on their computer and how much time they are watching TV. Kind of a compilation of how they handle “on line/on screen” per day. 

While everyone is different I do like to see if parents have discussed rules with their teens surrounding the use of ALL electronics.  I find that most adolescents and their parents do have rules about the use of their phones and computers and most parents try to limit their child’s constant need to be “on screen”. 

I was recently talking with a teen boy, who is one of 5 children. He has great parents and they are very attentive to all of the distractions related to cell phones and computer use and try to keep all of the screen use in moderation. 

During his routine exam, I asked him about his cell phone usage, and if he had rules for using the phone, he answered that he didn’t have a phone.....anymore.  Upon further “polite probing” he told me that he had had his phone taken away due to the fact that he had been texting too much. 

Now, in my practice, many of my patients seem to be texting all of the time. Many parents had already told me that their child had unlimited texts and several had told me that their children had bills with as many as 9,000 texts/month.  But, when I asked him how many texts he had recorded in a month he sheepishly told me 16,000!!!  WHAT?? 

So, I came home to my computer to try and figure out how many texts that was per week, day, hour?  (he had told me that his dad had a spread sheet that he could get me if I wanted).  I went straight to my own calculator. If he had 16,000 texts/month, that is 571 texts per day (assuming 28 day month).  If you figure that a teen is in school for 8 hours/day (where I guess they are not supposed to be texting) and they SHOULD sleep at least 8 hours, that leaves 8 hours for texting?  

Now these may be a bit off by an hour or so (and who knows if he keeps that cell phone really turned off during school), but that would mean 71 texts per hour when not either in school or asleep!!  In other words more than 1 text per minute when he is awake!  WOW!! 

So if you are not discussing texting and limiting constant communication with your tweens and teens I think you should be. This boy even admitted to me that he felt he had gone overboard with texting and really enjoyed talking to his friends. He told his mother during the course of our visit that when he did get the privilege of having a cell phone again, that he thought he needed one that just made phone calls. He told her, “get me a really old fashioned one that just rings, as I don’t want to be tempted to text!”  Bright teen don’t you think? 

 

Daily Dose

HPV Vaccine

1:30 to read

I recently read an interesting article in JAMA in which a study was done suggesting that “HPV vaccine does not lead to risky behaviors in teen girls”. This seemed to be a timely study as Merck has just recently received FDA approval for their new Gardasil vaccine which will now protect against 9 serotypes of HPV (human papilloma virus) which causes the majority of cervical cancer ( as well as other genital cancers) and genital warts.

Since the vaccines against HPV were released in this country about 8-9 years ago, the uptake of the vaccine among tween/teen girls and boys has been less than hoped for.  Like many vaccines, there were those parents who were “worried or skeptical” about giving their children a new vaccine - despite the fact that it is the first vaccine against a virus that was known to cause cancer..actually a great deal of cancers.  The CDC reports that about 57% of preteen/teen girls have received one dose of HPV vaccine, while only 35% of boys in the same age group. The completion rate for completing all 3 vaccines is only 37% for girls and 14% for boys. 

But while many parents believe in the benefit of the vaccine a common concern has been, “giving the vaccine to a pre-teen may lead girls to engage in sexual activity at younger ages”.  In my personal experience I have not found that to be at all true. In fact, educating these tweens and teens about the risk of infection and cancer is “scary enough” for some to be even more wary.  I am pretty direct with this group as they get into their true teen years and are experimenting in all sorts of ways...not only sexually. I truly do not think that a vaccine does “promotes” becoming sexually active....hormones do a good job in that area. 

So, the study looked at 21,000 vaccinated girls who were matched with more than 186,000 non vaccinated girls. Researchers then compared rates of sexually transmitted infections (STI) including herpes, chlamydia, gonorrhea, syphilis and HIV. They found that the “rate of STI’s overall were equal among the vaccinated and unvaccinated groups”, which suggests that the HPV vaccine does not impact sexual behaviors. 

With an even more protective HPV vaccine now available I encourage you to read the literature and talk to your own doctor about getting your adolescent vaccinated.  The vaccine is protective but does not treat HPV if you have already been exposed....there will be 14 million new cases of HPV in the U.S. this year...and that statistic is not one you want your adolescent to be among.

Daily Dose

Stop Debate Over HPV Vaccine

2.10 to read

I have been receiving a lot of calls, emails and questions on twitter regarding Michael Douglas' admission that his oral cancer was caused by HPV.  

If you have an adolescent, I am hopeful that your own doctor has already discussed the prevalence of STD’s among the adolescent and young adult population with both you and your tween/teen/young adult.  If not, you need to know that HPV infection is one of the most common sexually transmitted diseases, with over 6,200,000 new cases annually with the peak rates of infection occurring in women 25 years and younger. 

HPV is what doctors would call, “a bad player”.  There are over 100 serotypes of this virus, and you often don’t even know you have it before you have passed it on to someone else.

Some HPV serotypes also cause cancer, and researchers are realizing that it doesn’t just cause cervical cancer, but vaginal, vulvar, penile, rectal and oral-pharyngeal cancers (mouth, tongue, tonsils).

When Harald Zur Hausen was awarded the 2008 Nobel Prize in medicine it was for the research he had done in the 1970’s and 1980’s that identified HPV (specifically types 16 and 18) as the most common cause of cervical cancer. (side note: read “The Immortal Life of Henrietta Lacks”).  Hausen’s discovery enabled other brilliant scientists to develop the FIRST anti-cancer vaccine against HPV.  The first HPV vaccine was released in the United States in 2005. 

With all of this background , I cannot comprehend why there is any debate surrounding the HPV vaccine. The comment that the HPV vaccine is dangerous and can cause mental retardation is unfounded.

As stated in a press release by the AAP, “there is no scientific validity to this statement.” Since the vaccine has been introduced worldwide there have been more that 35 million doses given with an excellent safety record. Anyone can go to the CDC website to look up safety information on any given vaccine, so do some research. You should also know that doctors, as well as patients are reporting any adverse events related to a vaccine and this ongoing monitoring (post-marketing surveillance) continues to ensure the safety of a vaccine even after it has been approved.  

Lastly, the reason that the vaccine is given at age 11-12 (approved down to age 9) is two- fold. You want to give the vaccine PRIOR to exposure to the virus, and unfortunately studies continue to show that some teens are engaging in sexual activity, which is not only sexual intercourse, at very young ages.

The vaccine prevents infection with certain HPV serotypes, but it does NOT treat HPV. Secondly, the vaccine produces a robust immune response in this age group to provide excellent protection. In other words, more bang for your buck!

More and more studies are being done on HPV, with exciting new data about disease reduction being shown in other countries where the vaccine has been given even longer. There couldn’t be better news, the vaccine is working if we give it!

Keep talking to your adolescent about STD’s.  Discuss abstinence, condoms, teen pregnancy, and any other information they need to be well informed so that they make good choices as they go through their adolescent and young adult years. At the same time, get both girls and boys their HPV vaccines, it might just save their life.  

Has your daughter or son received their HPV vaccine? I would love to hear from you!

Daily Dose

The Reality of Teen Suicide

2 recent suicides have stunned one community. Many parents are asking why?I have been saddened by the two suicides and one attempted in our community during the last two months. As a parent and pediatrician, it is hard for me to fathom the loss of a child due to self-harm.  There are really no words for the shock and grief.

Each year, thousands of teens commit suicide nationwide (it’s the third-leading cause of death for 15 to 24-year-olds). In 2000, the Centers for Disease Control reported that one out of 12 teens attempts suicide and that up to one in five teens stated that they had contemplated it at some point during their adolescent years. Statistics also show that the incidence of teen suicide has been increasing, which seems to correlate with the mounting pressures — both real and perceived — that our youths feel. As an adult, I think, “What could be that terrible to drive a teen to end their life when so much lies ahead of them?” But a teen’s brain is not fully developed, and as any parent knows, teenagers are often impulsive with little thought of the consequences of their actions. Teen suicides are usually related to depression, anxiety, confusion and the feeling that life is not worth living. A break-up with a girlfriend or boyfriend, substance abuse or failure at school may lead to suicide attempts. There are also gender differences among teens who commit suicide. Teen girls are more likely to attempt suicide than teen boys. But teen boys are more likely to complete a suicide. Girls are more likely to use an overdose of drugs to attempt suicide, and boys are more likely to shoot themselves. While a girl may use an overdose or cutting as a call for help, there is often little opportunity for intervention with a boy who sustains a self-inflicted gunshot or who hangs himself. Male suicide attempts are typically more violent and are four times more likely to be successful. Be aware of the warning signs and take them seriously: -Sudden isolation or change in friends -Change in school attendance or grades -Problems with substance abuse -Signs of being bullied -Too much time on social media sites -Excessive texting -Statements about ending his or her life Professional help is absolutely necessary when dealing with these issues; parents should not attempt to solve the problems on their own. There are numerous resources available, and the suicide prevention hotline at 1-800-SUICIDE is a 24-hour service. Lastly, firearms should not be kept in a home unless they are locked, and the key should always be in the care of a parent. More than half of teen suicides are inflicted by guns. It might also be prudent not to have ammunition in the house if you do have a gun. If an impulsive, depressed teen has to buy ammunition before attempting suicide, he might be more likely to have an epiphany and realize that things are not hopeless. Any deterrent may be all that is necessary to prevent a suicide. Do me a favor, go hug your child as soon as you can and tell them how much they are loved!

Daily Dose

Teen Driving

1:30 to read

 It’s funny that I often find myself reading articles in the newspaper or online, or even watching a TV segment, only to find that an “issue” that I have thought was important for years is “newsworthy” again.  The most recent example being on the topic of teenage drivers and the importance of parental involvement.

I feel like it was not too long ago that I was talking to my own sons about driving….and at that time Texas did not have a lot of rules around getting your driver’s license, besides being 16 an enrolled in school. (thankfully the laws in Texas have changed since then).  So after much discussion about the perils of teenage driving and knowing that the death rate due to an automobile accident topped the list for teens,  my husband and I  came up with a driving contract (which I have shared with too many to count), which clearly outlined the rules and expectations for our sons when they began to drive. I can also remember the oldest looking at the 3 page typed contract and announcing, “ I am not going to sign that!”.  If I remember correctly my husband’s calm reply was, “OK - then don’t drive”. He is a man of few words..but very convincing. 

Fortunately for us, all of our sons did sign the contract, knew the consequences and started off driving our family Suburban…and never had a serious accident (so many prayers as they pulled out of the driveway).  One son did back into a fence, and another hit a car in a parking lot….but I felt fortunate that that was the extent of their accident history.  

According to a recent article in the NY Times there is a time to be a helicopter parent, and that is when your “child” begins to drive.  “In 2013, just under a million teenage drivers were involved in police reported crashes, which resulted in 373,645 injuries and 2,927 deaths”.  These statistics are probably under-reported, and it is estimated that “one in four teens are going to be in a crash in their first six months of driving,” and one would hope that these would be minor “fender benders”, which as we told our sons, do count as an accident.

The biggest risk for a new teenage driver occurs when you add passengers to the car.  According to Dr. Nicole Morris at the University of Minnesota  “adding one non family passenger to a teenager’s car increased the rate of crashes by 44%, and that risk doubles with a second passenger and quadruples with 3 or more”. If your teen is not distracted by their passengers they are likely to be using their phones to stay in touch with their friends….either by text, talking or by checking their various social media sites….all while driving. Although teens state, “ I barely take my eyes off the road”, anything more than 2 seconds can be deadly. Better to turn off the phone and all notifications before your teen hits the road.

Teens should be reminded that driving is a privilege, and parents of teenage drivers need to have ongoing discussions surrounding expectations for obtaining the privilege of driving. Parents need to be knowledgable about teenage driving and their states’ laws - and enforce those, (too many parents of my patients seem to ignore some of the laws - such as limiting passengers in the car). Even if your state does not have laws regulating a step wise progression to full driving privileges (so called graduated driver’s licenses), parents may adopt their own to help ensure their teens safety. Earning more and more independence can be proven with time and a good driving record and the adage, “nothing good happens after midnight still stands”.  

If ever there is a time to be a hovering involved parent it when your child begins to drive - it has been proven to save lives.

 

     

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