Pediatric Primary Care: Practice Guidelines for Nurses, 2nd Ed.

CHAPTER 19

Fourteen- to Eighteen-Year Visit (Adolescent)

Mary Lou C. Rosenblatt

 

Abdominal pain, 789

Hallucinations, 780.1

 

Acanthosis nigricans, 701.2

Hyperlipidemia, 272.4

 

Anemia, 285.9

Hypertension, 401.9

 

Anxiety, 300

Insomnias, 780.52

 

Catalepsy, 300.1

Iron-deficiency anemia, 280.9

 

Constipation, 564

Narcolepsy, 347

 

Delayed sleep phase syndrome, 780.5

Obesity, 278

 

Depression, 311

Obesity, morbid, 278.01

 

Diabetes, 250

Peristalsis of colon, 787.4

 

Diabetes, family history of, V18

Poor nutrition, 269.9

 

Drug abuse, 305.9

Sleep apnea, 780.57

 

Dysmenorrhea, 625.3

Sleep deprivation, 780.5

 

Eating disorders, 307.5

Snoring, 786.09

 

Enlarged tonsils, 474.11

Thyroid disease, 246.9

 

I. GENERAL IMPRESSION

A.  This well visit is an opportunity to provide health care for individual who is faced with many developmental challenges on road to adulthood.

B.  Introduce yourself and your role to teen and parent. Explain that you need information from both parent and teen and will spend some time just with teen to check on his/her concerns.

C.  Be knowledgeable of your state's confidentiality and consent statutes and explain how that will be handled in practice. Assure both teen and parent that your first goal is wellbeing of teen.

D.  Listening skills are especially important with teens. Show interest in their concerns and address them. “Hear” pauses, hesitation, body language, and validate your understanding of meaning of nonverbal communication with teen.

E.  Be nonjudgmental and gather information before giving advice.

F.  Have supply of well-written and informative handouts on variety of issues.

G.  Involve parents by finding out what advice they give on sensitive subjects, such as substance abuse and sex. Interaction between parent and teen will give feedback on what is discussed in home and how open they are with each other. Encourage both parent and teen to talk about these subjects together.

H.  Ask about responsibilities teen has at home. Many parents advance privileges based on teen's ability to take care of his/her chores. This can also support fair negotiations that take place in family.

I.  Use tool such as HEADSSS assessment to take snapshot of teen's life and identify problem areas to focus on during acute visits. HEADSSS assessment: Ask open-ended questions about home, education, activities, drug use and depression, sexuality, suicide, and safety.

J.  Have resources available if issues such as drug abuse, school problems, physical. sexual abuse, depression, sexual activity, pregnancy are present.

K.  If an undesired behavior that is identified through screening can be dealt with during primary care office visit, state desired behavior, offer health information detailing risks of undesired behavior, benefit of change, and alternatives. If teen can commit to change, set goal and timeframe, offer support and resources, set up follow-up time.

II. NUTRITION

A.  History.

1. Ask for 24-hour diet recall.

2. Are any foods/food groups avoided and why?

3. Is milk consumed? Skim, 2%, whole?

4. Is meat eaten? What types?

5. What fruits, vegetables does teen eat? How much juice is consumed?

6. Trying to gain or lose weight? How?

7. Are meals skipped? Is breakfast eaten?

8. Are meals eaten on run or sitting down with family?

9. What types of “junk” foods are consumed? How much?

10. How often does he/she eat at fast food restaurants? What foods?

11. Does teen watch TV and snack?

12. How much soda is consumed? Regular or diet?

13. What types of exercise is teen involved in?

14. Does teen spend time thinking about how to be thin?

15. Has he/she tried dieting, diet pills, laxatives, vomiting to control weight?

16. Does teen ever eat in secret?

17. Is teen dieting to fit into weight class for sports?

18. Are any nutritional supplements taken?

B.  Teaching.

1. Use My Plate (see Appendix E) to encourage healthy eating practices, daily requirements of protein, calcium, vitamins, fiber.

2. Recognize that teen is likely making more choices on own, can start to read labels, becomes conscious of nutritional value.

3. Skipping breakfast may make it harder to concentrate in school and lead to more hunger after school, possibly poor nutritional choices.

4. Skipping meals may lead to more hunger, poor food choices.

5. Encourage teen to talk with parent about planning meals, snacks.

6. Encourage trying new foods.

7. When limiting soda, drink more water, avoid excessive calories from juice products.

8. Discuss sources of calcium.

9. 5-8% of teen girls have iron-deficiency anemia.

10. Teens risk dental decay with high-sugar diets, poor dental hygiene.

11. 13-15% of children and adolescents are estimated to be overweight.

12. Teach behavioral techniques for weight management, such as goal setting, self-monitoring, positive reinforcement, problem solving, social support.

13. Incidence of eating disorders has increased and is estimated to affect 7% of male adolescents and 13% of female adolescents. Eating disorders can be associated with depression, substance abuse, low self-esteem.

14. Discourage rapid weight gain/loss to fit into weight class for sports.

15. Discourage major weight/dietary restrictions during growth spurt.

C.  Physical exam.

1. Chart height, weight, body mass index (BMI); review growth curves with teen.

2. BMI at or above 95th percentile is considered overweight/obese. For obese teens, BMI is objective measure that is useful in motivating them to recognize their risks of developing heart disease, diabetes.

D.  Labs.

1. Screen hematocrit at beginning or ending puberty visit or both to check for anemia due to rapid growth, poor nutrition, menstrual losses.

2. Glucose if there is family history of diabetes, symptoms of diabetes, or obesity and Acanthosis nigricans.

3. Cholesterol for adolescents with heart disease, hypertension, diabetes or if there is family history of heart disease or hyperlipidemia.

E.  Treatment plan.

1. Encourage healthy eating practices.

2. Encourage good exercise habits.

3. For teens just starting to exercise, start slow, for example, walking for 20 minutes 3 times/week, so they can build up their exercise tolerance.

4. For teens with special diets, such as vegetarian diets, be prepared to assess dietary content, give advice/referral resource to offer nutritional guidance, support.

5. For obese teens, offer support and encouragement. When motivated, they may be ready for weight-loss program. Suggest starting by keeping daily food diary to look for problem areas in diet. Behavioral techniques, mentioned earlier, may be enough for some teens to get started with healthier eating practices. In supportive environment, family involvement may help to cut down excess intake. Some teens benefit from professional weight-loss programs. Refer morbidly obese patients to medical weightloss program.

6. When eating disorders are suspected, careful assessment and monitoring are needed. Denial is common and should not offer reassurance. Patients require nutritional, medical management as well as mental health assessment and referral. Referral to eating disorder program will offer comprehensive approach to assessment and management.

III. ELIMINATION

A.  Teens are normally independent in their elimination practices.

B.  Constipation.

1. Infrequent and/or difficult passage of feces.

2. Common cause of abdominal pain.

C.  History.

1. What are bowel habits?

2. When was last bowel movement? Hard and dry? Any abdominal pain?

3. How long has constipation been a problem?

4. Is fiber present in teen's diet?

5. What is fluid intake?

6. Does teen avoid public or school restrooms?

7. Does schedule allow time to use bathroom?

8. Have laxatives or stool softeners been tried? How often?

9. Ask about other signs of thyroid disease, such as menstrual disorder, dry skin, brittle hair, lethargy, and weight gain.

D.  Teaching.

1. Describe gastrocolic reflex (peristalsis of colon induced by entrance of food into empty stomach).

2. Describe bowel function and need for fluid and fiber to keep stool moist and moving through GI tract.

E.  Physical exam for suspected constipation.

1. Firm loops of bowel may be palpable on thin patients.

2. Rectum is typically filled with hard stool.

3. Passage of hard stool may cause anorectal pain or bleeding.

F.  Labs.

1. Abdominal film may be needed in case of abdominal pain, after ruling out other systems as sources of pain.

2. Make sure female patients are not pregnant before sending for X-ray.

G.  Treatment plan for constipation.

1. Encourage drinking plenty of water.

2. Help teen plan on how to add fiber to diet.

3. Encourage good toilet habits, such as right after meals.

4. Consider use of stool softener.

5. In addition to the above, sitz baths may help anal fissure heal.

6. Follow up in 1-2 weeks.

IV. SLEEP

A.  Teenagers need 9-10 hours of sleep per night. Most teens do not get it.

B.  Sleep history.

1. Does teen feel rested or tired?

2. What are concerns about sleep? Frequency? Duration?

3. What are usual bedtimes and wake-up times?

4. Are naps taken? If so, do they interfere with sleep later that night?

5. Has family complained about teen's snoring?

6. Does teen fall asleep in class? Other times?

7. What are school hours?

8. What are after-school activities?

9. Does teen have job? How many hours?

10. How many hours are spent on homework?

11. Does teen care for child or have other household responsibilities?

12. Is there family history of sleep disorders?

13. Is teen depressed, sad, moody?

14. Are stimulants (coffee, tea, soda, OTC medications, illicit drugs) used to stay awake longer?

15. Does teen have TV, radio/stereo, computer, phone in bedroom? Are these in use when trying to go to sleep and delaying bedtime?

C.  Teaching.

1. Insomnias are most frequent sleep disorder during adolescence.

2. Insomnias involve problems falling asleep, staying asleep, waking too early.

3. Delayed sleep phase syndrome is inability to fall asleep at appropriate time, but if left to fall asleep naturally would fall asleep late, get up late. These teens will be sleepy if awakened to attend school.

4. Teens may be motivated to stay up late, sleep late. If teen can awaken by his/her own motivation but not for school, this may be form of school refusal.

5. Insomnia may occur due to stress, anxiety, poor sleep habits.

6. Excessive daytime sleepiness can be caused by chronic sleep deprivation, usually due to busy schedule.

7. Sleep apnea may be associated with obesity; symptoms include snoring, apneic periods during sleep, nighttime waking, and daytime sleeping.

8. Narcolepsy is uncommon disorder that has an onset of 10-25 years of age. Components include sleep attacks, catalepsy, sleep paralysis, and/or hallucinations. There is evidence of genetic component.

D.  Physical.

1. Does teen appear alert?

2. Does teen appear sad or depressed?

3. Note blood pressure and pulse.

4. Is teen obese?

5. Is teen comfortable and able to breathe through both nostrils?

6. Are tonsils enlarged?

E.  Lab.

1. To rule out sleep apnea, consider sleep study if teen/family reports snoring, frequent wake ups, apneic periods, daytime sleep.

F.  Treatment plan.

1. Have teen track sleep patterns for 1-2 weeks.

2. Any question of depression needs assessment.

3. Have teen/parent look at schedule and commitments. Are there ways to decrease workload for overloaded teen?

4. Cut down on caffeine products, including OTC stimulants.

5. Cut out nap time.

6. Use bedroom for sleep only and put TV, computer, etc., elsewhere.

7. Teach relaxation techniques.

8. Identify stressors and write them down. If stressors are complex, consider counseling.

9. Stick to regular schedule of bedtime and waking up.

10. Encourage weight loss for obese teens.

11. Refer teens with nasal breathing problems/enlarged tonsils to ENT specialist.

12. Refer teens with difficult sleep problems, including those who do not do well with above plan, to sleep clinic.

V. GROWTH AND DEVELOPMENT

A.  While some teens are able to state concerns, others may hope you will mention possible concerns for them, such as height, weight, pubertal development. Comfortable way to start such conversation may be “Some teens worry about being shorter (or taller, heavier, thinner) than their friends. I wonder if you have any concerns about this…”

B.  Use growth charts to help see progress over time, relate their parameters to their blood relatives or point out what future growth is likely.

C.  Tanner or sexual maturity rating (SMR) also may be reassuring.

D.  For development outside of expected range, evaluate for medical cause.

E.  Height.

1. 33-60% of adult bone growth occurs during adolescence.

2. 20-25% of final adult height occurs in puberty.

F.  Weight: 50% of ideal adult body weight is gained during adolescence.

G.  SMR: By middle adolescence most teens are in latter classes of Tanner or SMR scales. Spermarche occurs at about SMR 2.5. Menarche usually occurs at SMR 3 or 4. Using SMR can help teen to see where he/she is in puberty and what can be expected without having to compare himself/herself to friends.

1. Menstrual history.

a.  Age at menarche?

b.  Frequency, duration, quantity of menstrual periods?

c.  Last menstrual period (LMP)?

d.  Dysmenorrhea and treatments used?

H.  Psychosocial developmental tasks.

1. Increased independence from parents, inviting conflicts over control.

2. Peer group involvement intensifies. Conformity with peer values. Less time for family. Teams, clubs, gangs may become important.

3. Interest in dating, sexual experimentation. Preoccupation with romantic fantasy. Sexual orientation more evident to peers.

4. Identity and individuality grow. Increased acceptance of body image, more established ego and sexual identity. Increased intellectual abilities, emotional feelings. Vocational ideas more realistic.

5. Sense of omnipotence and immortality that may lead to high-risk behaviors.

6. Improved ability with abstract thought.

VI. SOCIAL DEVELOPMENT

A.  Family.

1. Who are family members living with teen?

2. What is level of communication between members?

3. What are supports? Conflicts?

4. What are house rules? Who makes them?

5. What are teen's responsibilities?

6. Is there a curfew?

7. Does teen drive family car? What supervision is given?

B. School.

1. What is teen's school performance? Any recent changes?

2. What does teen like or dislike about school?

3. How does teen relate to classmates? To teachers?

4. Are there learning problems? Has teen been evaluated by school?

5. Are there behavior problems? How have those been addressed?

6. What is educational/vocational plan?

7. Has teen dropped out of school?

8. Is he/she planning to get a GED?

9. If chronic illness, is there teaching plan in place for missed days?

C.  Peers.

1. Who are teen's friends?

2. Is there a best friend?

3. Is there a trusted adult to talk to?

4. Does teen prefer to be with friends or alone?

5. What are interests and activities of peer group?

6. Does parent know teen's friends?

D. Interests.

1. What are teen's activities? Hobbies?

2. Does teen have a job? How many hours? Safety hazards on job?

3. Does teen like to read?

4. Does teen enjoy sports? Exercise?

E.  Dating.

1. What are house rules about dating?

2. What advice have parents given about dating?

3. Is teen thinking about dating?

4. Does he/she have romantic feelings about anyone?

a. Is this person male or female?

b. If these feelings are for same-sex person, does teen feel support from parents? Friends? Community?

F.  Sexual history.

1. Is teen thinking about sexual relationship or has he/she had sexual relations?

2. Able to talk with parent about being sexually active?

3. Aware of risks of sexual activity (emotional, sexually transmitted infections [STIs], pregnancy)?

4. Vulnerable to these risks?

5. Reason for being sexually active? Does teen feel pressured?

6. Specific sexual behaviors (vaginal/anal intercourse or oral-genital sex)?

7. Teen's age at first intercourse?

8. Number of lifetime partners?

9. How old is current partner? Is there more than one partner now?

10. Are condoms used? Hormonal contraception? Spermacides?

11. Does teen know how to use male/female condom?

12. Does teen know about emergency contraception (EC)? Does teen who only uses condoms have prescription for EC?

13. Any history of or current symptoms of STIs?

14. Any history of pregnancy? Pregnancy scares? LMP?

15. History of pregnancy termination? If so, how is teen coping?

16. For teen parents, what are stresses? Support?

17. Does teen feel safe in current relationship?

18. In dating situations, has teen been hit or pushed? What did she/he do?

G.  Substance use.

1. Does teen know risks of substance use?

2. Do any friends smoke cigarettes, drink alcohol, use inhalants, marijuana, other drugs?

3. Does teen smoke cigarettes, drink alcohol, use inhalants, marijuana, other drugs?

4. If teen does use substances, use screen such as CAGE (Cut down, Annoyed, Guilty, Eye-opener) to obtain more information (have resource available to teen who needs substance abuse treatment):

C.  Do you think you should cut down your use of ____?

A.  Do you get angry or annoyed when people tell you that you should cut down your use of ____?

G.  Do you feel guilty about your use of ____?

E.  Do you use this substance as eye-opener to get going in morning?

5. Does teen drink alcohol or use other drugs when driving?

6. Does teen attend parties where alcohol is served?

7. What plans are there to get home safely? Does teen have to deal with parents for this type of situation?

H.  Antisocial behavior.

1. Does teen skip school?

2. Has he/she had trouble with the law?

3. Does teen belong to or associate with a gang?

VII. IMMUNIZATIONS (SEE APPENDIX A)

A.  May not have completed recommended vaccinations.

B.  Immunization status can be reviewed at each visit.

1. TD: booster usually given between 11 and 12 years but before 16 years, then every 10 years.

2. MMR: 2 doses needed before school entry.

3. Hepatitis B: recommended for all adolescents, especially those at risk (sexually active, injection drug abusers, work-related exposure to blood/ body fluids). Routine vaccination of infants began in 1991; may be in need of immunization. Two-dose regimen for 11- to 15-year-olds; 3-dose regimen for others.

4. Varicella: needed if there is no history of varicella disease. If history is unclear, vaccine is well tolerated, more cost effective than serologic testing in most cases. Two doses given more than 4 weeks apart needed if 13 years of age or older.

5. Influenza: recommended for teens with chronic illness (i.e., asthma, sickle cell disease, HIV, etc.) or those living with persons with impaired immunity. Can be given to others who want immunity. Cannot be given to individuals with egg allergy.

6. Hepatitis A: vaccination recommended for those living in high-risk areas; 2 doses needed, at least 6 months apart.

7. Neisseria meningitidis: vaccination recommended in many states for college freshmen living in dormitories.

VIII. SAFETY

A.  Self-protection.

1. Does teen have any self-defense skills?

2. Is teen aware of surroundings when in public?

3. Does teen travel with friends?

4. Has teen been victim of any attack in past? Any fear of someone threatening harm currently? Are parents/authorities aware?

5. Does teen feel safe in school?

6. Can teen walk away from conflict if she/he feels fear/anger?

7. Does teen get into fights regularly?

8. Is teen exposed to violence in home, community, media?

9. Does teen have access to gun? What are rules for gun safety?

10. Does teen carry a weapon? Why?

B.  Injury prevention.

1. Does teen wear seat belts?

2. Does teen wear a helmet?

3. Does teen plan to take driver's education classes?

4. Does teen drive at night or with friends?

5. Does teen use alcohol/other drugs?

6. Does teen routinely take risks?

7. Has teen had injuries in past?

8. Does teen use power tools/lawn equipment?

C.  Suicide prevention.

1. Does teen or family worry about teen being depressed?

2. Has teen lost pleasure in usual interests?

3. Weight loss or gain?

4. Sleep problem: too much or too little?

5. Increased/decreased activity level?

6. Daily fatigue?

7. Feelings of worthlessness, excessive/inappropriate guilt?

8. Decreased concentration or ability to make decisions?

9. Asking teen about mood can be done at every visit and is especially important if teen visits frequently or if physical complaints do not seem to make sense.

10. Recurrent thoughts of death or suicide? (If teen is suicidal, have resources, such as ability to escort to emergency department for psychiatric evaluation, immediately available.)

IX. ANTICIPATORY GUIDANCE

A.  Many opportunities to give advice exist during history and physical exam.

B.  Giving information in nonjudgmental way allows teen to make up his/her own mind about how to improve his/her health.

C.  Puberty: Acknowledge where individual is regarding pubertal development and how development is likely to proceed.

D.  Health care.

1. Have yearly physical exam.

2. See dentist twice/year, practice good dental hygiene.

3. Keep up with routine vision care.

4. Discuss use of sunscreen and skin cancer prevention.

E.  Injury prevention.

1. Wear seat belt when traveling in car.

2. Wear helmet when riding bike, skates, scooter, motor bike/cycle.

3. Wear appropriate protection when engaging in sports.

4. Drowning prevention includes learning how to swim, not swimming alone, never abusing substances while doing water activities, entering unknown depths feet first.

5. When operating equipment such as power tools, lawn mowers, tractors, know safety rules and use appropriate safety equipment.

6. Leading causes of death and injury of young drivers are inexperience, risk taking (speeding, dares), distraction (driving with friends, talking on cell phones), driving at night. Parents who recognize these risks can outline safety plan (curfew, supervision, no driving with peers until parent feels teen is ready, contracting for no substance abuse) for young driver going through “rite of passage.”

7. Ask parents to remove guns from home. If not an option, guns/ammunition need to be stored separately, in locked boxes. Especially important for parents of depressed teens to realize risk guns pose to their teen.

8. Learn CPR.

F.  Self-exam.

1. Teach females self-administered breast exam. Use breast model to show how lumps may feel. Reassure teen that most lumps in her age group are not cancer.

2. Teach males self-administered testes exam. Reinforce that concerns are okay to talk about. Teach warning signs for testicular tumors, torsion, and epididymitis.

G.  Nutrition.

1. Eat breakfast.

2. Eat a low-fat diet.

3. Watch junk food, soda consumption.

4. Use My Plate (see Appendix E) to evaluate diet.

5. Encourage maintenance of healthy weight.

H.  Exercise.

1. Do aerobic exercise 3 times/week.

2. Look for ways to increase exercise opportunities in daily life.

I.  Peer pressure and self-esteem.

1. Pick good friends who are interested in positive activities.

2. Look at best qualities and feel good about them.

3. Participate in activities because of desire to, not because everyone else is doing so.

4. Figure out personally important goals, make sure friends derail.

J.  Body modification: tattoos and piercings.

1. Reasons for getting a tattoo range from expressing independence to being part of a group. Some teens may be self-described “risk takers” who may also engage in drug use and sexual activity.

2. Parental consent may be required in some locales.

3. Advise teens that tattoos should be considered permanent because removal is expensive, time consuming, and may leave a scar.

4. Tattoos and piercings may become infected. Advise teens to research sterile practices of the tattoo/piercing establishment. Post-care hygiene needs to be strictly followed.

5. Teens should not get a tattoo or piercing if they are upset or intoxicated.

6. Alternatives such as temporary tattoos or magnetic piercing look-a-likes may satisfy a passing need.

K.  Stress reduction.

1. Encourage setting aside time to rest and gather thoughts.

2. Get plenty of sleep at night.

3. Eat varied, nutritious diet.

4. Encourage physical activity.

5. Teach deep breathing and counting to 10 if feeling stressed or angry.

6. Keep lines of communication open with parent/guardian.

7. Get help from adult in teen's life if teen has much stress.

8. Try to keep open communication with family.

9. Have resources available for depressed teens.

10. Arrange emergency evaluation for suicidal intent/severe depression.

L.  Substance abuse.

1. Do not smoke cigarettes or marijuana.

2. Do not drink alcohol, use inhalants, other drugs.

3. Do not drive if intoxicated. Have teen make plan with parents about what to do if out and driver providing ride becomes intoxicated.

4. Point out risks of substance use including health consequences, accidents, school performance, impact on family/friends, legal implications, gateway to other drug use.

5. Make sure athletes are aware of risks of performance-enhancing drugs.

M. Sex.

1. Consider benefits of abstinence, such as ability to focus on personal and academic goals, less complicated breakups, STI prevention.

2. Consider risks of sexual activity, such as emotional stress, pregnancy, STIs.

3. Discuss how to deal with issues important to individual teen: sex drive, peer pressure, older partners, partners who refuse to use protection, desire to have baby.

4. If teen decides sexual activity is right for him/her, advise use of condoms and make sure teen knows how to leave room at top of male condom for ejaculate and that female condoms can cover part of external genitalia.

5. Be frank about risks of STIs, especially HIV and other viral infections.

6. Educate about all types of appropriate birth control.

7. Make sure teens are aware of emergency contraception and how to obtain it.

8. For sexually active teens, screen for STIs.

9. For sexually active females, perform yearly Pap smear.

10. Encourage teen to talk with adult in his/her life about sex if able.

11. If teen identifies as minority sexual identity (gay, lesbian, bisexual, transgendered) make sure teen has resources, support.

12. If teen is pregnant, outline options and encourage parental involvement.

BIBLIOGRAPHY

Behrman RE, Kleigman RM, Jenson HB. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, PA: W.B. Saunders; 2007.

Dixon SD, Stein MT. Encounters with Children: Pediatric Behavior and Development. St. Louis, MO: Mosby; 2006.

Goldenring JM, Cohen E. Getting into adolescent heads. Contemp Pediatr. 1998;5:75-90.

Jellinek M, Patel BP, Froehle MC, eds. Bright Futures in Practice: Mental Health, Vol I, Practice Guide. Arlington, VA: National Center for Education in Maternal and Child Health; 2007.

Joffe A, Blythe MJ, eds. Handbook of Adolescent Medicine. Philadelphia, PA: Hanley and Belfus; 2009.

Neinstein LS. Adolescent Health Care: A Practical Guide. 5th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2007.

Rosen D, and The Committee on Adolescence. Clinical report: Identification and management of eating disorders in children and adolescents. Pediatrics. 2003;111(1):204-211.

Schwimmer JB. Managing overweight in older children and adolescents. Pediatr Ann. 2004;33(1):39-44.

Sheehan K. Intentional injury and violence prevention. Clin Pediatr EmergMed. 2003;4(1):12-20.

Song EH, Martel S, Anderson JE. Decorating the “human canvas”: Body art and your patients. Contemp Pediatr. 2002;19(8):86-102.



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