The adolescents are coming!

May 2005

New recommendations for vaccines to be given to adolescents will undoubtedly result in more contact with patients in this age group and provide an entrée into a population that is sorely lacking in adequate health care.

We now have recommendations for immunization against meningococcus and can look forward to the additional vaccines against pertussis, genital herpes and human papillomavirus (HPV) in the future. The latter is the cause of cervical cancer. In addition, there is likely to be a recommendation for a second dose of varicella vaccine. Thus, we may be seeing patients in our practices whom many had seen only infrequently or not at all. These contacts provide opportunities for anticipatory guidance similar to that which we now offer during well child visits in infancy. Are we ready to exploit this opportunity?

Qualifications

Pediatric training qualifies us as developmentalists, which enables us to assess whether these young men and woman are achieving their organic milestones, both in physical growth and in sexual development. Thus, we should be able to identify those who have real problems and to offer reassurance to those who have unwarranted concerns about being too fast or too slow. What may require greater skill but be more important in the long run is the assessment of emotional development, namely whether these kids are able to transition socially from family to peers, achieve normal sexuality and advance intellectually toward career goals. Discussion of “emotional development” requires a great deal of skill especially in situations where there may have been a long hiatus since the previous encounter.

In addition to anticipatory guidance, there are the challenges of managing adolescent illnesses which will be seen in greater numbers as the adolescent visits increase. Although many pediatricians feel comfortable in managing patients with acne, others are not, resulting in the treatment of these patients by a dermatologist rather than in their pediatric home.

Obesity with its associated morbidity is recognized to have its origins during childhood. Hopefully, children will be identified prior to adolescence as exceeding where they should be on their weight curve and remedial measures will be instituted. If this condition is identified during puberty, it may be more difficult to address but it should not be ignored until later life.

One cannot present a comprehensive list of problems encountered in this age group but certainly, substance abuse, school problems, depression and issues associated with sexual activity, eg, sexually transmitted diseases and unintended pregnancy are but a few of the challenges.

The adolescent visit not only provides an opportunity to immunize against meningococcal disease but also to administer the required tetanus booster, which should be given together with diphtheria-toxoid (dT). What little diphtheria there has been in this country during the past few decades has been in older patients who have lost their immunity. As discussed previously, adult diphtheria-tetanus toxoid has been combined with pertussis vaccine and is being used in a few countries to decrease transmission of whooping cough in this age group. This also may provide some protection by transfer of maternal antibody to the babies of immunized women, thus, preventing pertussis in infants who are too young to be immunized. It is in these young infants that almost all of the mortality from pertussis has been reported.

STD vaccines?

We can expect to immunize adolescents with vaccines against sexually transmitted diseases. Herpes type 2 has been experienced by almost one-quarter of the adult population. This not only causes significant discomfort to the victim but also poses a risk to their sexual contacts and is a potential risk to infants born to infected mothers. Experimental vaccines have shown some promise and additional ones are in the pipeline. HPV is transmitted sexually. Vaccines against these agents have been effective in preventing infection and also the cervical changes associated with these infections.

We will undoubtedly have increased immunization of adolescents. It is estimated that only a third now receive the recommended dT booster during adolescents. Emphasis on immunization of this age group would be expected to increase acceptance of currently recommended vaccines as well as the introduction of new ones. However, we should not lose the opportunity for increased contact with these young people to address their very prevalent and important health problems.

For more information:

• Michaud P, Fombonne E. ABC of adolescence: Common mental health problems. BMJ. 2005;330:835-838.