Preconception Health Promotion by Pediatricians and Adolescent Medicine Specialists

1
Preconception Health Promotion by Pediatricians
and Adolescent Medicine Specialists
2
Obstacles to Pediatric Participation in
Preconception Care

• Its the obstetricians job
• Pediatric practice is busy enough already
• No billing code for children not yet conceived

3
Pediatricians

• Care for pre-term, LBW infants, IDMs, and
  children with malformations, genetic disease
• Aware of immense personal and economic burden
• Sensitive to the importance of primary prevention

4
Pediatricians

• Care for adolescent girls and prepare them for
  adult roles
• Must deal with emerging sexuality, teen pregnancy
• 13 of births in US are to adolescents

5
Pediatricians

• Have frequent contact with women of childbearing
  age

6
Preconception Care

• Pediatricians can significantly enhance ACCESS to
  preconception care
• Pediatricians can promote healthy reproductive
  behaviors at a young age

7
History

• Pediatricians have been providing preconception
  care since 1969 (introduction of rubella vaccine)

8
Refocusing

• Pediatricians can complement prenatal counseling
  with referrals for preconception counseling
• Preconception screening may improve neonatal
  outcome in the same way as newborn screening

9
Reframing the Initial Pediatric Assessment

• ACOG-AAP Guidelines for Perinatal Care
• 13/19 items in reproductive health screening
  (68) are already part of routine pediatric
  history

10
Reproductive Health Screening Form

• Reproductive Awareness
• Medical Diseases
• Infectious Diseases
• Teratogens/Genetics
• Behavior
• Social Support

11
Timing for Preconceptional Focus

• Mothers first encounter
• pre-natal
• post-natal
• new to practice
• Periodic reminder

12
Preconceptional Prevention Focus

• Adolescents emphasis on PREVENTION
• Individualized
• menarche
• sexually active
• pre-college physical
• Negative pregnancy test

13
Methods

• Visual cues in waiting area posters and
  pamphlets from MOD, AAP
• Screening form (self-administered or by
  physician)
• Ascertain whether mother has primary care
  physician and/or gynecologist
• Provision of appropriate testing, immunization,
  counseling
• Specialist referrals with verification of
  compliance
• MOD folic acid handout

14
Reproductive Awareness

• Pregnancy prevention counseling
• Nancy. I understand that youre not interested
  in sex at this time in your life. But if you
  should choose to become involved in sex, I can
  help you prevent pregnancy and infections.

15
Reproductive Awareness

• Nutrition counseling
• Ms. Smith. Are you aware that a multivitamin
  with folic acid can benefit your health and the
  health of any future children you might have?

16
Folic Acid

• Reduces risk for neural tube defects
• "Not since the rubella vaccine became available
  30 years ago have we had a comparable opportunity
  for primary prevention of such common and serious
  birth defects."
• Godfrey P. Oakley, Jr., M.D., CDC

17
Medical Diseases

• Diabetes mellitus
• Sheryl. You've had diabetes since you were 12
  and you've taken very good care of yourself. Now
  that you're older, it will be even more important
  than ever both for your health and for the health
  of any children you might have.

18
Medical Diseases

• Hypertension
• Ms. Jones. Is your blood pressure under
  control? You should check with your doctor about
  your medication before you and your husband plan
  on having another baby.

19
Medical Diseases

• Epilepsy
• Suzanne. You haven't had any seizures since Dr.
  Jackson put you on Dilantin. One of the things
  that you'll need to do as you get older is to
  talk to your neurologist about your medications
  before you plan on having a baby.

20
Medical Diseases

• Diabetes
• Hypertension
• Cystic fibrosis
• Seizure disorder
• Repaired congenital heart disease
• Inflammatory bowel disease
• Survivor of ALL or other malignancy

• ITP
• HIV
• SLE
• JRA
• PKU
• Liver transplant
• Chronic renal failure/transplant

21
Infectious Diseases

• Screen sexually active adolescents for STDs, HIV
• Immunize all adolescents against hepatitis B
• Verify rubella and varicella staus in
  non-pregnant adolescents
• if non-immune, then immunize

22
Teratogens/Genetics

• Hemoglobinopathy
• Mrs. Smith. Does anyone in your family have a
  history of sickle cell disease? Have you ever
  been tested to see if you have the trait?

23
Teratogens/Genetics

• Medication
• Tara. Are you going to a dermatologist for your
  acne? Are you using any medication for your
  acne?

24
Teratogens/Genetics

• Self or prior child with congenital defect
• Family history of genetic disease
• Refer to geneticist for recurrence risk
  counseling and/or prenatal testing

25
Teratogens/Genetics

• Environmental exposure
• What type of work do you do, Mrs. Jones? What
  does your husband do?

26
Behavior

• Alcohol use
• Alcohol is commonly used by women. Do you know
  that alcohol can affect your unborn baby?

27
Behavior

• Tobacco use
• Do you smoke? Do people around you smoke? Do you
  know what smoke does to babies?

28
Behavior

• Use of illicit substances
• Do you use cocaine, crack, heroin, methadone,
  marijuana, etc? Are you aware that these drugs
  could harm your unborn baby?

29
Social Support

• Safety (domestic violence)
• Are you involved with anyone in your life who
  is hitting you or hurting you in any way?

30
Social Support

• Personal resources
• Who are you living with and who do you have in
  your life who can help you when you need
  something?

31
Anticipatory Guidance

• Vital, integral component of continuing pediatric
  care
• Nutrition
• Injury prevention
• Immunizations

32
Conclusions

• Pediatricians are often aware of existing
  preconception risk factors
• Goal is to refocus awareness into action
• Pediatricians can join obstetricians, internists,
  and other providers to optimize pregnancy outcome
  (i.e. the pediatricians' future patient)