Recovery Trajectories in Adolescent Girls with Anorexia Nervosa

Background: This study aimed to document recovery trajectories among adolescents with anorexia nervosa (AN) based on three markers of remission, namely changes in body weight, food restriction, and excessive exercise, and to identify predictors of these trajectories. Methods: One hundred twenty-six adolescent girls (14.7 ± 1.3 years) were recruited during initial assessment visits at specialized eating disorder (ED) programs in five University Health Centers across the province of Quebec, Canada. z-BMI and AN symptom severity (food restriction and excessive exercise) were assessed at initial assessment visits and subsequently reassessed at each quarterly follow-up over a 12-month period to identify recovery trajectories. Results: Considering the three markers of remission, three distinct trajectories emerged: Group 1, rapid responders; Group 2, gradual responders; and Group 3, unstable responders. At initial visits, a difference between groups was found regarding the type of treatment (p = 0.01) and weight suppression (p = 0.02). Group 1 had a higher number of youths hospitalized than Group 2 and Group 3, and a greater weight suppression than Group 3. Furthermore, individuals with atypical AN were more likely to belong to Group 2 than to Group 1 and Group 3 (p < 0.0001). Conclusions: This study contributes to a better understanding of the heterogeneity of recovery trajectories in adolescent girls with AN.

Considerations for privacy and confidentiality in adolescent health care service delivery

A hallmark of delivering quality adolescent health care services is the provision of confidential care. Key tenets when providing confidential care for adolescents include time alone with a health care provider, maintaining the privacy of health information, and securing informed consent for services without permission from a parent, guardian, or caregiver. While confidentiality is a basic principle for all health care encounters regardless of age, the unique considerations for capable adolescent patients are not always realized or appreciated. By ensuring appropriate quantity and quality of confidential care for adolescents, clinicians are better equipped to elicit a comprehensive history and physical examination, while empowering the adolescent involved to develop agency, autonomy, trust, and responsibility for their own health care decision-making and management.

Perceived barriers to the provision of adolescent confidential care in a tertiary care setting

Objective

Adolescents are more likely to seek care and disclose sensitive health information if confidentiality is assured. Little is known regarding the provision of confidential care to adolescents in the hospital setting. We sought to understand confidentiality practices and barriers for adolescents cared for in a tertiary hospital setting.

Methods

This was a cross-sectional survey of all Emergency Department (ED), hospitalist, and resident physicians at a tertiary paediatric hospital from May/2019 to July/2019. Participants were asked multiple choice questions regarding practices, comfort, and barriers to confidential care.

Results

Response rate was 91% (n = 72/79; 26 ED, 14 hospitalists, 32 residents). Overall, 47% of respondents doubted that confidential care was being consistently provided to adolescents. Fifty-eight per cent of attendings and 31% of residents reported usually/always offering confidential care. Factors most reported to influence the provision of confidential care were chief complaint (75%), time of visit (45%), and patient age (25%). Barriers to the quantity or quality of confidential care were identified by 89%, most commonly including time constraints (21%), perceived parental resistance (26%), lack of private space (26%), and the belief that confidentiality is not necessary for all adolescent encounters (34%). Forty per cent of respondents reported breaching confidentially and discussing sensitive topics with adolescents in front of family members. Overall, only 45% felt they had received adequate training on how best to deliver confidential care, and 75% reported a desire for additional training.

Conclusion

Results suggest inadequate provision of confidential care in a tertiary teaching hospital, with several potentially modifiable barriers.

Classification of Children and Adolescents With Avoidant/Restrictive Food Intake Disorder

BACKGROUND AND OBJECTIVES

Evidence suggests that children and adolescents with avoidant/restrictive food intake disorder (ARFID) have heterogeneous clinical presentations. To use latent class analysis (LCA) and determine the frequency of various classes in pediatric patients with ARFID drawn from a 2-year surveillance study.

METHODS

Cases were ascertained using the Canadian Pediatric Surveillance Program methodology from January 1, 2016, to December 31, 2017. An exploratory LCA was undertaken with latent class models ranging from 1 to 5 classes.

RESULTS

Based on fit statistics and class interpretability, a 3-class model had the best fit: Acute Medical (AM), Lack of Appetite (LOA), and Sensory (S). The probability of being classified as AM, LOA, and S was 52%, 40.7%, and 6.9%, respectively. The AM class was distinct for increased likelihood of weight loss (92%), a shorter length of illness (<12 months) (66%), medical hospitalization (56%), and heart rate <60 beats per minute (31%). The LOA class was distinct for failure to gain weight (97%) and faltering growth (68%). The S class was distinct for avoiding certain foods (100%) and refusing to eat because of sensory characteristics of the food (100%). Using posterior probability assignments, a mixed group AM/LOA (n = 30; 14.5%) had characteristics of both AM and LOA classes.

CONCLUSIONS

This LCA suggests that ARFID is a heterogeneous diagnosis with 3 distinct classes corresponding to the 3 subtypes described in the literature: AM, LOA, and S. The AM/LOA group had a mixed clinical presentation. Clinicians need to be aware of these different ARFID presentations because clinical and treatment needs will vary.

Incidence and Age- and Sex-Specific Differences in the Clinical Presentation of Children and Adolescents With Avoidant Restrictive Food Intake Disorder

IMPORTANCE

To our knowledge, this is the first pediatric surveillance study of children and adolescents with avoidant restrictive food intake disorder (ARFID).

OBJECTIVES

To examine the incidence and age- and sex-specific differences in the clinical presentation of ARFID in children and adolescents in Canada.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, patients with ARFID were identified through the Canadian Paediatric Surveillance Program by surveying 2700 Canadian pediatricians monthly from January 1, 2016, to December 31, 2017.

MAIN OUTCOMES AND MEASURES

The incidence of ARFID in Canadian children (5-18 years of age) and age- and sex-specific clinical characteristics at presentation.

RESULTS

In total, 207 children and adolescents (mean [SD] age, 13.1 [3.2] years; 127 [61.4%] female) were included in this study. The incidence of ARFID in children 5 to 18 years of age was 2.02 (95% CI, 1.76-2.31) per 100 000 patients. Older children and adolescents were more likely to endorse eating too little (5-9 years of age: 76.7%; 95% CI, 58%-88.6; 10-14 years of age: 90.9%; 95% CI, 84.6%-94.8%; 15-18 years of age: 95.6%; 95% CI, 83.6%-98.9%; P = .02), have a loss of appetite (5-9 years of age: 53.3%; 95% CI, 35.4%-70.4%; 10-14 years of age: 74.2%; 95% CI, 66.0%-81.0%; 15-18 years of age: 80.0%; 95% CI, 65.5%-89.4%; P = .03), be medically compromised (mean body mass index z score: 10-14 vs 5-9 years of age: -1.31; 95% CI, -2.0 to -0.6; 15-18 vs 5-9 years of age: -1.35; 95% CI, -2.2 to -0.5; 15-18 vs 10-14 years of age: -0.04; 95% CI, -0.6 to 0.5; P < .001; mean percentage of treatment goal weight: 10-14 vs 5-9 years of age: -8.6; 95% CI, -14.3 to -2.9; 15-18 vs 5-9 years of age: -9.8; 95% CI, -16.3 to -3.3; 15-18 vs 10-14 years of age: -1.2; 95% CI, -5.8 to 3.4; P < .001; mean heart rate (beats per min): 10-14 vs 5-9 years of age: -10; 95% CI, -21.9 to 1.9; 15-18 vs 5-9 years of age: -19.7; 95% CI, -33.1 to -6.2; 15-18 vs 10-14 years of age: -9.7; 95% CI, -18.7 to -0.7; P = .002), have higher rates of anxiety (5-9 years of age: 26.7%; 95% CI, 13.7-45.4; 10-14 years of age: 52.3%; 95% CI, 43.7%-60.7%; 15-18 years of age: 53.3%; 95% CI, 38.6%-67.5%; P = .03) and depression (5-9 years of age: 0%; 10-14 years of age: 6.8%; 95% CI, 3.6%-12.7%; 15-18 years of age: 26.7%; 95% CI, 15.7%-41.6%; P < .001), and be more likely to be hospitalized (5-9 years of age: 13.3%; 95% CI, 5.0%-31.1%; 10-14 years of age: 41.7%; 95% CI, 33.5%-50.3%; 15-18 years of age: 55.6%; 95% CI, 40.7%-69.5%; P = .001). Younger children were more likely to endorse lack of interest in food (5-9 years of age: 56.7%; 95% CI, 38.4%-73.2%; 10-14 years of age: 75.0%; 95% CI, 66.8%-81.7%; 15-18 years of age: 57.8%; 95% CI, 42.8%-71.4%; P = .03), avoidance of certain foods (5-9 years of age: 90.0%; 95% CI, 72.6%-96.8%; 10-14 years of age: 69.7%; 95% CI, 61.3%-77.0%; 15-18 years of age: 62.2%; 95% CI, 47.2%-75.3%; P = .03), and refusal based on sensory characteristics (5-9 years of age: 66.7%; 95% CI, 47.9%-81.3%; 10-14 years of age: 38.6%; 95% CI, 30.7%-47.3%; 15-18 years of age: 22.2%; 95% CI, 12.3%-36.9%; P < .001). Eating but not enough was more common in girls (75.0%; 95% CI, 64.1%-83.4%) vs boys (68.5%; 95% CI, 59.8%-76.1; P = .04), and boys had a higher rate of refusal based on sensory characteristics (51.2%; 95% CI, 40.2%-62.2%) compared with girls (31.5%; 95% CI, 23.9%-40.2%; P = .007).

CONCLUSIONS AND RELEVANCE

This study suggests that ARFID is a relatively common eating disorder and is associated with important age- and sex- specific clinical characteristics that may help in early recognition and timely treatment of the presenting symptoms.

Trends in the Incidence of New-Onset Anorexia Nervosa and Atypical Anorexia Nervosa Among Youth During the COVID-19 Pandemic in Canada

IMPORTANCE

The COVID-19 pandemic has had considerable mental health consequences for children and adolescents, including the exacerbation of previously diagnosed eating disorders. Whether the pandemic is a factor associated with the concomitant increase in new-onset anorexia nervosa or atypical anorexia nervosa remains unknown.

OBJECTIVE

To assess the incidence and severity of newly diagnosed anorexia nervosa or atypical anorexia nervosa in a national sample of youth before and during the first wave of the COVID-19 pandemic.

DESIGN, SETTING, AND PARTICIPANTS

This repeated cross-sectional study analyzed new eating disorder assessments that were conducted at 6 pediatric tertiary-care hospitals in Canada between January 1, 2015, and November 30, 2020. Patients aged 9 to 18 years with a new anorexia nervosa or atypical anorexia nervosa diagnosis at the index assessment were included.

EXPOSURES

COVID-19-associated public health confinement measures during the first wave of the pandemic (March 1 to November 30, 2020).

MAIN OUTCOMES AND MEASURES

Primary outcomes were the incidence and hospitalization rates within 7 days of de novo anorexia nervosa or atypical anorexia nervosa diagnosis. Event rate trends during the first wave were compared with trends in the 5-year prepandemic period (January 1, 2015, to February 28, 2020) using an interrupted time series with linear regression models. Demographic and clinical variables were compared using a χ2 test for categorical data and t tests for continuous data.

RESULTS

Overall, 1883 children and adolescents with newly diagnosed anorexia nervosa or atypical anorexia nervosa (median [IQR] age, 15.9 [13.8-16.9] years; 1713 female patients [91.0%]) were included. Prepandemic anorexia nervosa or atypical anorexia nervosa diagnoses were stable over time (mean [SD], 24.5 [1.6] cases per month; β coefficient, 0.043; P = .33). New diagnoses increased during the first wave of the pandemic to a mean (SD) of 40.6 (20.1) cases per month with a steep upward trend (β coefficient, 5.97; P < .001). Similarly, hospitalizations for newly diagnosed patients increased from a mean (SD) of 7.5 (2.8) to 20.0 (9.8) cases per month, with a significant increase in linear trend (β coefficient, -0.008 vs 3.23; P < .001). These trends were more pronounced in Canadian provinces with higher rates of COVID-19 infections. Markers of disease severity were worse among patients who were diagnosed during the first wave rather than before the pandemic, including more rapid progression (mean [SD], 7.0 [4.2] months vs 9.8 [7.4] months; P < .001), greater mean (SD) weight loss (19.2% [9.4%] vs 17.5% [9.6%]; P = .01), and more profound bradycardia (mean [SD] heart rate, 57 [15.8] beats per minute vs 63 [15.9] beats per minute; P < .001).

CONCLUSIONS AND RELEVANCE

This cross-sectional study found a higher number of new diagnoses of and hospitalizations for anorexia nervosa or atypical anorexia nervosa in children and adolescents during the first wave of the COVID-19 pandemic in Canada. Research is needed to better understand the drivers and prognosis for these patients and to prepare for their mental health needs in the event of future pandemics or prolonged social isolation.

146 Provision of Adolescent Confidential Care in a Tertiary Care Setting

Primary Subject area

Adolescent Medicine

Background

Adolescents are more likely to seek care and disclose sensitive health information if confidentiality is assured. Several national societies endorse the need for confidential care at all health-related encounters with adolescents. Many adolescents have infrequent contact with the medical system other than unscheduled urgent care in pediatric hospitals. Little is known regarding the effectiveness and feasibility of providing confidential care to adolescents in a tertiary pediatric hospital setting.

Objectives

We sought to evaluate the frequency, quality and factors associated with the provision of confidential care to adolescent patients at a pediatric teaching hospital.

Design/Methods

We undertook a cross-sectional survey of adolescents presenting to an urban tertiary pediatric hospital from December 2019 to December 2020. Adolescents eligible for confidential care under Quebec legislation (aged 14-18) were recruited from a convenience sample either when presenting to the Emergency Department (ED) for low acuity visits (CTAS 3-5) or when hospitalized on the pediatric inpatient medical ward. Participants completed a standardized, self-administered electronic questionnaire regarding the confidential care provided at their initial ED or inpatient medical encounter. Multivariable logistic regression was used to identify factors associated with the provision of confidential care.

Results

A total of 406 adolescents completed the survey (335 ED; 71 inpatient). The majority of respondents identified as female (233, 57.4%), white/Caucasian (260, 64.0%) and presented to the hospital with a parent (367, 90.4%). Overall, confidential care was offered to 137 (33.7%) respondents, with 95 (69.3%) accepting confidential time alone with their doctor. Among participants receiving confidential care, 43.2% endorsed that the limits of confidentiality were not reviewed, 24.2% reported that their private issues were still discussed in front of family members and 15.8% had private information that they had wished to discuss but were not asked. When offered, there was no difference between hospitalized and ED patients declining confidential care (32/100 vs. 10/37; p=0.73). The most common reasons identified for declining private time were that it was deemed unnecessary (29/42, 69.0%), perceived risk of parental conflict (8/42, 19.0%), or concerns for violation of trust by the medical team (5/42, 11.9%). Multivariable analysis found inpatient location (aOR 2.28, 1.04-5.01), female gender (aOR 2.02, 1.21-3.38), age (aOR 1.67, 1.03-2.69), psychiatric diagnosis (aOR 8.10, 1.47-44.6), resident involvement (aOR 1.96, 1.09-3.53) and overnight assessment (aOR 0.23, 0.06-0.90) were all associated with the provision of confidential care, after adjusting for patient- and hospital-level covariates.

Conclusion

Survey results suggest inadequate provision of confidential care in an academic pediatric hospital. Adolescents receiving confidential care were not consistently explained to regarding the limits of confidentiality, and breaches were reported in a quarter of all cases. Confidentiality-specific education initiatives are necessary to improve the frequency and quality of confidential care for adolescents in tertiary care settings.

104 New Presentations of Anorexia Nervosa and Atypical Anorexia Nervosa In Adolescents During the COVID-19 Pandemic

Primary Subject area

Adolescent Medicine

Background

The coronavirus (COVID-19) pandemic has had profound effects on adolescent mental health. Beginning in mid-March 2020, public health measures were implemented throughout the province of Quebec, including full school closure and confinement. Previous studies have demonstrated the association between stressful events and the exacerbation of anorexia nervosa (AN), however the association of the COVID-19 pandemic on new AN diagnoses remains unknown.

Objectives

To assess the incidence and severity of newly diagnosed AN or atypical AN (AAN) cases among adolescents during the COVID-19 pandemic compared to the five preceding years.

Design/Methods

We performed a retrospective analysis from Jan 1 2015 to Nov 15 2020 of new eating disorder assessments at an urban tertiary pediatric hospital. Baseline demographic information and clinical assessment variables were collected. The primary outcomes were the incidence of de novo AN or AAN diagnoses and hospitalization within 7 days of diagnosis. Event rate time trends were compared during the period of pandemic public health measures (March 2020 to November 2020) to the proceeding 5-years (January 2015 to February 2020) using an interrupted time series and logistic mixed modeling.

Results

Overall, 353 patients met inclusion criteria during the study period. Median patient age was 15.9 (IQR 13.8-16.9) years, 93% were female, and 65% of patients were diagnosed with atypical AN. For the full cohort at diagnosis, %mBMI was 92% (SD ±15%) and mean weight loss was 11 Kg (SD ±7Kg). In the 5 years preceding the pandemic, there were 4.5 new AN/AAN cases per month with a modest downward trend (ßcoeff=-0.016). During confinement, new diagnoses rose to 8.0/month with a steep upward trend (ßcoeff=1.417, p < 0 .001). Similarly, hospitalizations for new cases increased from 0.8 to 2.6/month with a significant increase in linear tend (ßcoeff -0.012 vs. 0.500, p < 0 .001). Moreover, patients diagnosed during COVID-19 confinement had a shorter duration of symptoms (6 months vs. 10 months, p=0.001), with a higher percentage of body weight loss (19% vs. 16%, p=0.03) at a faster rate (2.3kg/mo vs. 1.5Kg/mo, p=0.001). Bradycardia was more pronounced at diagnosis during the pandemic (55 bpm vs. 62 bpm, p=0.001) with a greater proportion meeting threshold for admission (38% vs. 19%, p=0.001).

Conclusion

During the COVID-19 confinement, new diagnoses of AN and AAN nearly doubled and hospitalizations for these patients more than tripled. Markers for disease severity were more pronounced and evolved more rapidly. Findings highlight the urgent need for increased community resources during the pandemic, as well as prospective research to understand drivers and prognosis for these patients more effectively.

90 Perceived Barriers to the Provision of Adolescent Confidential Care in the Tertiary Care Setting

Background

A cornerstone of quality adolescent health care is assuring confidential time for adolescent patients. Adolescents are more likely to seek care and disclose sensitive health information if confidentiality is assured. Several national societies endorse the need for confidential care at all health-related encounters with adolescents. Many adolescents have infrequent contact with the medical system other than unscheduled urgent care in pediatric hospitals. Little is known regarding the effectiveness and feasibility of providing confidential care to adolescents in a tertiary pediatric hospital setting.

Objectives

We hypothesized that significant variation exists in the frequency and quality of confidential care delivery for adolescents. This study sought to characterize clinician comfort with confidentiality provision as well as identification of potential predicators and barriers to providing confidential care for adolescents in a tertiary, pediatric hospital setting.

Design/Methods

We undertook a cross-sectional survey among Emergency Department (ED), Hospitalist and Resident physicians at an urban, academic pediatric center. Data was collected using a standardized, self-administered electronic questionnaire. Survey participants responded to multiple-choice questions to characterize their comfort and self-identified barriers to providing confidential care to adolescents.

Results

Response rate was 91% (n=72/79; 26 ED, 14 Hospitalists, 32 Residents). A majority of respondents were female (69%), under the age of 50 (60%) and within their first 10 years of practice (51%). Forty-seven percent of respondents reported being somewhat/very doubtful that confidential care was being consistently provided to adolescents. Eighty-nine percent of respondents identified barriers to the quantity or quality of confidential care provided. Factors most commonly reported to influence physician decision to provide confidential care were diagnosis (75%), time of visit (45%), and patient age (25%). Among attending physicians 60% reported that they usually/always provide confidential care to adolescents, and 83% ensure that their trainees offer confidential care; whereas only 31% of trainees reported usually/always providing confidential care themselves (p=0.01). Limits of confidentiality were more likely to be explained to adolescent patients compared to their parents (83% vs. 33%; p&lt;0.001). The most common reasons identified limiting the provision of confidential care were insufficient time (21%), perceived parental resistance (26%), lack of private space (26%) and the belief that it is not necessary for all adolescent encounters (34%). Forty percent of respondents reported discussing sensitive topics with adolescents in front of family members. Among both attending physicians and trainees, only 45% felt they had received adequate training on how best to deliver confidential care and similarly, 75% in both groups reported a desire for additional training.

Conclusion

Survey results suggest inadequate provision of confidential care in an academic pediatric hospital, with several potentially modifiable barriers. Confidentiality-specific education likely represents an important intervention to optimize physician comfort and improve the delivery of appropriate confidential care for adolescents.

Suicidal Attempts and Ideation Among Children and Adolescents in US Emergency Departments, 2007-2015

This cross-sectional analysis of the National Hospital Ambulatory Medical Care Survey studies emergency department visits for suicide attempts and suicidal ideation among US youth between 2007 and 2015.

Prophylactic Phosphate Supplementation for the Inpatient Treatment of Restrictive Eating Disorders

PURPOSE

The medical stabilization of adolescent patients with restrictive eating disorders can be associated with refeeding syndrome, a potentially fatal complication preceded by refeeding hypophosphatemia (RH). Whether RH can be prevented by routine prophylactic phosphate supplementation has not been previously examined. This study sought to determine the safety and efficacy of a refeeding strategy that incorporates prophylactic phosphate supplementation to prevent RH.

METHODS

Retrospective chart data were collected for patients aged younger than 18 years with restrictive eating disorders admitted to a tertiary pediatric inpatient ward between January 2011 and December 2014. All patients were refed with a standardized protocol that included prophylactic oral phosphate supplementation (1.0 ± .2 mmol/kg/day).

RESULTS

During the 4-year study period, 75 admissions (70 patients) were included for analysis. The mean age and percent median body mass index of included patients were 15.3 years and 83.5%, respectively. Seven out of 75 (9%) had percent median body mass index of <70% and 26 out of 75 (35%) had percent body weight loss >20%. All patients were normophosphatemic at the time of admission (mean serum phosphate 1.24 ± .2 mmol/L). Serial laboratory evaluation revealed that all supplemented patients maintained serum phosphate levels >1.0 mmol/L during the initial 7 days of refeeding. Eleven patients became mildly hyperphosphatemic (range 1.81-2.17 mmol/L) with no associated clinical consequences. Additional analysis of 11 patients presenting with hypophosphatemia before refeeding revealed that with supplementation, phosphate values normalized by Day 1, and this group experienced no further RH episodes during initial refeeding.

CONCLUSIONS

Prophylactic oral phosphate supplementation appears safe, and no episodes of RH occurred in patients with restrictive eating disorders undergoing inpatient refeeding.

Shifting paradigms: continuous nasogastric feeding with high caloric intakes in anorexia nervosa

PURPOSE

The initial goal of admission for a patient with anorexia nervosa is physiologic stabilization through nutritional rehabilitation balanced against the risk of refeeding syndrome. Recent alternative approaches emphasize meal composition, limiting carbohydrates, to reduce risk. The Montreal Children's Hospital has instituted a standardized high-calorie continuous nasogastric (NG) refeeding protocol for the initial management of inpatient adolescents with restrictive eating disorders. This study aims to confirm that this protocol results in a shorter admission duration and faster rate of weight gain without increased incidence of complications.

METHODS

Retrospective chart review of patients with restrictive eating disorders admitted to the Montreal Children's Hospital during December 2003 to December 2011. Those treated with higher calorie NG refeeding protocol (N = 31) were compared with those managed with a standard bolus meal treatment (N = 134).

RESULTS

Length of stay was significantly reduced in the NG-fed cohort (NG cohort 33.8 days; bolus-fed cohort 50.9 days; p = .0002). Mean rate of weight gain in the NG group was significantly improved for both the first and second week when compared with the bolus-fed cohort (1.22 kg/week (1), p = .01; 1.06 kg/week (.9), p = .04). No significant difference was found in the rate of complications or electrolyte abnormalities with 90% of the NG-fed cohort receiving prophylactic phosphate supplementation from admission.

CONCLUSIONS

This study provides further evidence to support the treatment of undernourished inpatients with restrictive type eating disorders with a higher initial caloric intake to achieve rapid and safe nutritional rehabilitation.

Low-dose oral contraceptives in adolescents: how low can you go?

CONTEXT

The use of combined oral contraception (COC) before the accrual of peak bone mass in adolescents is common. Despite the tendency to prescribe lower ethinyl estradiol concentrations so as to reduce thromboembolic complications, concerns have developed as to whether low-dose COC provides sufficient estrogen supplementation for adequate adolescent bone development.

OBJECTIVE

This paper reviews the available literature on bone mineral density (BMD) and low-dose COC in adolescents in an effort to determine whether adult-oriented recommendations for the lowest tolerated estrogen dose should apply to adolescent populations.

DESIGN

A MEDLINE search of all English-language literature (1966 to January 2008) was performed using the terms "adolescent," "oral contraception," and "BMD." Bibliographies were reviewed to extract additional relevant sources. Articles were selected based on pertinence to BMD changes in association with low-dose (20 microg ethinyl estradiol) hormonal contraception with emphasis on adolescent study groups.

RESULTS

A limited number of studies examining 20-microg preparations in adolescents have demonstrated a significantly smaller mean percentage BMD acquisition in COC groups vs untreated controls. Bone mineral density decreases appeared to positively correlate with early gynecological age of first COC use and treatment duration.

CONCLUSIONS

Loss of bone mass as a result of hormonal contraceptive use may have serious long-term implications in the adolescent population, who have yet to achieve peak bone density. Both age at first COC use and cumulative estrogen dose appear to be important factors in determining skeletal development in adolescents. Further studies are warranted to inform specific prescribing practices for this population.