Include in differential diagnosis
Adolescent pregnancy can easily be overlooked
and its diagnosis delayed. Patients frequently do not
realize their risk for pregnancy and may not recognize its signs and symptoms. Pediatricians should
record the LMP as a vital sign at each visit and routinely meet with patients confidentially to inquire
about sexual activity.
Pregnancy needs to be in the differential diagnosis
of complaints such as fatigue or nausea and in the
case of a late menstrual period. Urine pregnancy
tests should be available in all offices and performed
whenever pregnancy enters the differential, even if
the sexual history may not suggest it.
Confidentiality, support network
In many cases, it is beneficial to share the results of
a positive pregnancy test with the adolescent alone.
This may allow her to express her emotions, reactions
and questions more freely. While cognizant of the
legal rights of the adolescent to confidentiality, the
pediatrician is encouraged to work with the teen to
identify supportive adults who can assist her with
the challenges ahead. In most cases, this will be her
parent(s) but might be another relative or adult
friend as well as the adolescent’s partner and family.
Presenting all options
With the adolescent and her identified support,
the pediatrician should provide options counseling.
Since its first policy statement on the subject in
1989, the Academy continues to affirm that preg-
nant adolescents should be counseled in a nonjudg-
mental, developmentally appropriate manner about
all legal pregnancy options. These include:
• carrying her pregnancy to delivery and raising
• carrying her pregnancy to delivery and making
an adoption or kinship care plan; or
• terminating her pregnancy.
No one may be better suited to provide this counseling than the patient’s pediatrician. He or she knows
the patient and her family, and can lead the discussion
in a compassionate manner that is tailored to the adolescent’s developmental and social needs. Pediatricians
are not expected to know detailed information on
all these options but should be able to offer each as
a viable choice and provide reliable sources for more
information or services, as requested by the patient.
The Academy recognizes that discussions regard-
ing premarital sex, teen pregnancy and parenting,
adoption and abortion can be difficult for some,
and may evoke strong personal feelings or moral
conflicts. Consequently, some pediatricians may feel
limited in their ability to fully present all pregnancy
options to an adolescent. While medical providers
may decline to perform a service based on claims of
conscience, they should be prepared to refer their
patients promptly for that service. Pediatricians are
encouraged to reflect on this issue and if necessary,
investigate potential resources for such referrals.
Caution is advised when referring to “pregnancy
crisis centers” as these frequently do not offer unbi-
ased, medically accurate information.
Although the U.S. teen pregnancy rate is falling
to record lows, it remains among the highest of all
developed countries. With more than half a million
adolescents in the U.S. becoming pregnant each
year, pediatricians are likely to encounter this diagnosis in their practice.
It is important that all pediatricians routinely discuss reproductive health with their adolescent patients, be alert to the possibility of pregnancy, and be
prepared to provide balanced, accurate information
on all management options if the diagnosis is made.
Dr. Hornberger, the lead author of
the policy and clinical report, is the
liaison from the AAP Section on Adolescent Health to the Committee on
Kyle Yasuda, M.D., FAAP
Simply stated: Bright Futures Practice Toolkit. “Bright
Futures is a national health promotion initiative dedicat-
ed to the principle that every child deserves to be healthy
and that optimal health involves a trusting relationship
between the health professional, the child, the family, and
the community as partners in health practice.”
The social determinants of health impacting our pa-
tients are included in the 4th edition of this evidence-based/consensus document.
When and where we can screen for the social determinants of health are listed.
Upcoming is the next step: the translation of the Bright Futures recommendations into a practical tool for pediatricians. The projected timeline for the Bright
Futures 4th Edition Toolkit is early 2018. The Academy will communicate with
our members the value and usefulness of this tool that should address the social
determinants of health in a meaningful manner.
Michael A. Weiss, D.O., FAAP
Coto de Caza, Calif.
The most accurate, precise clinical diagnosis and the
best possible medical therapy are of limited benefit if
a child has inadequate access to a safe and nurturing
environment, appropriate nutrition, safe areas to play
and sound educational opportunities. The social determinants of health require major attention in both the
primary and specialty care arenas.
The Academy can offer support and assistance in multiple ways:
• Provide front-line pediatricians with education and specific screening tools
and scripts to help to uncover some of the more subtle areas of food inse-
curity, education gaps and toxic stress. We cannot intervene if we don’t ask
the right questions.
• The Academy should create an instructional template for chapters to help
them understand how to identify and collate community services and programs that address the social determinants in specific regions. This would
outline where and how to identify programs associated with schools, clergy,
community sponsorships and private sponsorships. Each region could then
create a living document that outlines resources that pediatricians could
recommend to their vulnerable patients.
• It may be beneficial to offer a round of Community Access to Child Health
grants focused primarily on small, local approaches to addressing the social
determinants of health. This work could create a learning network of frontline
pediatricians who could then share real-life best practices across the country.
The social determinants of health must be aggressively addressed from both a
policy/advocacy standpoint as well as a practical point-of care approach, and I
strongly support the Academy devoting resources to both components.
How can AAP help pediatricians address social determinants of health?
The AAP National Nominating Committee has named Michael A. Weiss,
D.O., FAAP, and Kyle Yasuda, M.D., FAAP, as candidates for AAP president-elect. The winner will serve as the 2019 AAP president. The election will
be held from Sept. 15-Oct. 15.
The candidates responded to the following: What can the Academy offer
individual pediatricians to meaningfully address the social determinants of
health impacting their patients?
Teen pregnancy continued from front page