A 31-year-old man presents to the emergency department with abdominal pain and diarrhea, which began 4 days ago. The pain is in both of the lower quadrants, is crampy and persistent, and is relieved with bowel movements. He has been having watery stools five to six times per day, without frank blood.

He reports no fevers, chills, nausea, or vomiting, and he has never travelled outside the country. He underwent laparotomy 6 months ago for a gunshot wound. He takes no prescription drugs. He smokes and he drinks alcohol, and he says he has used heroin and oxycodone recreationally.

His blood pressure is 134/74 mm Hg, and he is afebrile. An abdominal examination reveals no mass or tenderness.

Results of a complete blood count, serum chemistry panel, and serum amylase level are normal. His lipase level is slightly elevated at 80 U/L (reference range 12–70). His stool is negative for Clostridium difficile toxin on enzyme immunoassay.

Computed tomography of the abdomen reveals diffuse pericolonic hyperemia and possible thickening of the rectosigmoid colon, raising the concern that he might have infectious or inflammatory colitis. The patient is admitted for further evaluation.

Colonoscopy to evaluate the abnormalities on computed tomography finds only a 5-mm submucosal nodule in the rectum (Figure 1). Biopsy of the nodule shows it to be a well-differentiated neuroendocrine neoplasm (carcinoid tumor). Random colon biopsy samples are normal.

The patient’s symptoms resolve over the next 24 hours without any treatment.

WHAT EXPLAINS THE PATIENT’S SYMPTOMS?

1. Which of the following best explains the patient’s clinical presentation?

Viral gastroenteritis is common and affects people of all ages. The very young and the elderly are at higher risk of adverse outcomes, but few people die of it in the United States.

Our patient’s symptoms were consistent with viral gastroenteritis that resolved spontaneously while he received only supportive care.

Narcotic withdrawal can also cause watery stools and abdominal pain. However, this patient lacked other signs and symptoms of withdrawal, and his symptoms improved without any detoxification or maintenance treatment.

Pancreatitis. Although the patient had a mildly elevated lipase level, his lack of nausea and vomiting and the location of the pain were not consistent with acute pancreatitis.

Carcinoid syndrome. Carcinoid tumors are rare, typically indolent neuroendocrine neoplasms. The carcinoid syndrome consists of cutaneous flushing, gut hypermotility with diarrhea, and bronchospasm.^1–5 Our patient did not have the full range of these symptoms. However, the presentation of carcinoid tumors varies broadly depending on the location, morphology, or biology of the tumor.⁶ Although our patient had diarrhea, his symptoms improved without any specific treatment. Rectal carcinoid tumors rarely cause diarrhea, and therefore the tumor noted on colonoscopy was almost certainly an incidental finding unrelated to his clinical presentation.

The classic symptoms are caused by production of 5-hydroxyindoleacetic acid, typically by a carcinoid tumor of the small bowel. Rectal carcinoids do not produce the 5-hydroxyindoleacetic acid responsible for this “malignant” serotonin-driven syndrome and are typically asymptomatic. When rectal carcinoid tumors are symptomatic, patients may have symptoms of local irritation or obstruction, such as hematochezia, constipation, other changes in bowel habits, rectal pain, pruritis ani, or weight loss.^2,7

Nearly 50% of rectal carcinoid tumors are discovered incidentally. The National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) registry database documented a 10-fold increase in the incidence of rectal carcinoids in the last 35 years, attributed in part to an increase in screening colonoscopy.⁸ Furthermore, although studies of large national or multicenter databases have found that 65% to 80% of all rectal carcinoid tumors are smaller than 1.0 cm, 93.3% to 100% of those discovered on screening endoscopy were 1.0 cm or smaller.⁸

Rectal carcinoid tumors have a characteristic feel on digital examination, with a hard, “buckshot” consistency, and are freely mobile.⁵ They have also been described as firm, nodular, rubbery, yellow, submucosal, and polypoid.⁸

WHERE DO CARCINOID TUMORS TEND TO ARISE?

2. Which of the following sites is the most commonly recognized site of a primary carcinoid tumor?

• Small bowel
• Lung
• Liver
• Pancreas
• Rectum

The small bowel is the most common site.

Carcinoid tumors derive from neoplastic proliferation of cells of the diffuse neuroendocrine system. Therefore, they can be found anywhere neuroendocrine cells are present, commonly in the gastrointestinal tract, urogenital tract, and the bronchial epithelium.

Traditionally, neuroendocrine tumors were classified by their embryologic origin: foregut (including the respiratory tract, thymus, stomach, and pancreas), midgut (including the small intestine, appendix, and right colon), and hindgut (including the transverse, descending, and sigmoid colon and rectum). Functionally, this was sensible, as each class of tumors presented similarly due to the similar hormonal secretory products.^2,3,9

A 2004 population-based review of the SEER database¹⁰ classified incidence rates of carcinoid tumors and their distribution throughout the body. Most (54.5%) were discovered in the gastrointestinal tract, and of these, 44.7% were in the small intestine, 19.6% were in the rectum, 16.7% were in the appendix, 10.6% were in the colon, 7.2% were in the stomach, and the remaining 1.2% were at other gastrointestinal sites. Nongastrointestinal sites included the lungs and bronchi (30.1%), pancreas (2.3%), female reproductive tract and ovaries (1.2%), biliary system (1.1%), and head and neck (0.4%).¹⁰

The incidence rates have increased and the distribution of sites in the body has changed over time. For example, the appendix was once considered the site of highest incidence, with tumors often discovered incidentally during surgical resection. However, these data were based on anecdotal or single-institution reports and so may have been subject to reporting bias. According to the SEER data, the small intestine is now the leading site, perhaps because of increased awareness or improved diagnostic technology and imaging.^10,11

The liver is a common site of metastasis, but it is an exceptionally rare location for a primary tumor.

HOW SHOULD THIS PATIENT BE MANAGED?

3. What is the appropriate management of rectal carcinoid in this patient?

• Since the nodule is 1.0 cm or smaller, watchful waiting is acceptable
• Since the nodule is 1.0 cm or smaller, local excision is appropriate, and no follow-up is required
• Because all carcinoid tumors are potentially malignant, radical resection (eg, abdominal perineal resection) is appropriate
• Because all carcinoid tumors are potentially malignant, radical resection with chemotherapy with 5-fluorouracil (Adrucil) and doxorubicin (Adriamycin) is required

Since the nodule is 1.0 cm or smaller, local excision is appropriate, and no follow-up will be required. Rectal carcinoid tumors generally have a favorable prognosis, with a 5-year survival rate of 87.5%.¹⁰

PROGNOSIS DEPENDS ON TUMOR SIZE, OTHER FACTORS

Many studies have examined risk factors contributing to poor prognosis, and this is an area of active study. Early research categorized rectal carcinoid risk in terms of tumor diameter, and this is still widely used to guide management. As early as 1959, Hanley et al⁵ recognized that tumors that were likely to metastasize were often larger than 1 cm, had infiltrated the muscularis, or were ulcerated. Today, it is understood that only 3% to 10% of rectal carcinoids smaller than 1 cm metastasize, whereas 17% to 42% of those 1 to 2 cm and 60% to 80% of those larger than 2 cm do.^2,8,12,13

However, size is not the only consideration. Wang et al¹² showed that muscular invasion is an independent risk factor for survival, and that tumor diameter is a significant predictor of invasion and metastasis. Similarly, a metaanalysis by Mani et al¹³ recognized tumor size and muscularis invasion as the most important predictors of malignancy in these neoplasms.

To aid in predicting prognosis, staging systems have been developed from institutional or national registries. Landry et al¹⁴ developed a TNM (tumor, node, metastasis) staging system for rectal carcinoids, in which the T value was based on tumor size and degree of invasion. A group at Memorial-Sloan Kettering Cancer Center¹⁵ developed a system for risk stratification of carcinoid of the rectum that is based on tumor size, muscularis invasion, lymphovascular invasion, and the mitotic rate.

TREATMENT IS BY EXCISION

Despite these new prognostic systems, there is no new guidance on therapeutic management. Surgical therapy is still largely guided by tumor size.

Lesions smaller than 1 cm are resected endoscopically or by another local transanal technique.^2,3,15,16 Standard endoscopic mucosal resection is performed, and recent studies have suggested that endoscopic submucosal dissection is as effective¹⁷ or even preferred, because it resects to the deeper submucosa (as the name suggests).¹⁸ This en bloc technique may be appropriate for lesions with evidence of local invasion.¹⁸ Other situations may call for deeper resection, such as transanal resection for higher lesions and full-thickness mucosal-muscularis resection.

Tumors 1 to 2 cm are currently evaluated for other factors such as ulceration and umbilication, which influence the choice of local vs radical resection. Otherwise, there is little guidance for tumors of 1 to 2 cm.

Tumors larger than 2 cm have a high risk of muscularis invasion and metastasis, and hence they are resected with wide margins and imaging is then used to evaluate for metastasis.^8,19 In cases of metastasis, local resection is often palliative, providing local symptom relief.¹⁹

AN INCIDENTALLY DISCOVERED CASE; PATIENT LOST TO FOLLOW-UP

Our patient’s case is typical of rectal carcinoid in that it was discovered incidentally during colonoscopy. His clinical presentation was likely unrelated to his carcinoid tumor, and he improved without specific treatment. His symptoms resolved within 24 hours with supportive treatment and he was discharged.

Pathologic confirmation of carcinoid tumor occurred after his discharge. Despite persistent attempts to contact the patient, he never returned for a follow-up appointment.

TAKE-HOME POINTS

• Carcinoid tumors are rare neoplasms of neuroendocrine origin.
• Rectal carcinoids are the third most common carcinoid of the gastrointestinal tract.
• Most rectal carcinoids are asymptomatic.
• Diagnosis is most often incidental and histologic.
• Treatment is by excision.
• Prognosis is favorable for smaller carcinoids and depends on size (and therefore, invasion).

A 31-year-old man presents to the emergency department with abdominal pain and diarrhea, which began 4 days ago. The pain is in both of the lower quadrants, is crampy and persistent, and is relieved with bowel movements. He has been having watery stools five to six times per day, without frank blood.

He reports no fevers, chills, nausea, or vomiting, and he has never travelled outside the country. He underwent laparotomy 6 months ago for a gunshot wound. He takes no prescription drugs. He smokes and he drinks alcohol, and he says he has used heroin and oxycodone recreationally.

His blood pressure is 134/74 mm Hg, and he is afebrile. An abdominal examination reveals no mass or tenderness.

Results of a complete blood count, serum chemistry panel, and serum amylase level are normal. His lipase level is slightly elevated at 80 U/L (reference range 12–70). His stool is negative for Clostridium difficile toxin on enzyme immunoassay.

Computed tomography of the abdomen reveals diffuse pericolonic hyperemia and possible thickening of the rectosigmoid colon, raising the concern that he might have infectious or inflammatory colitis. The patient is admitted for further evaluation.

Colonoscopy to evaluate the abnormalities on computed tomography finds only a 5-mm submucosal nodule in the rectum (Figure 1). Biopsy of the nodule shows it to be a well-differentiated neuroendocrine neoplasm (carcinoid tumor). Random colon biopsy samples are normal.

The patient’s symptoms resolve over the next 24 hours without any treatment.

WHAT EXPLAINS THE PATIENT’S SYMPTOMS?

1. Which of the following best explains the patient’s clinical presentation?

Viral gastroenteritis is common and affects people of all ages. The very young and the elderly are at higher risk of adverse outcomes, but few people die of it in the United States.

Our patient’s symptoms were consistent with viral gastroenteritis that resolved spontaneously while he received only supportive care.

Narcotic withdrawal can also cause watery stools and abdominal pain. However, this patient lacked other signs and symptoms of withdrawal, and his symptoms improved without any detoxification or maintenance treatment.

Pancreatitis. Although the patient had a mildly elevated lipase level, his lack of nausea and vomiting and the location of the pain were not consistent with acute pancreatitis.

Carcinoid syndrome. Carcinoid tumors are rare, typically indolent neuroendocrine neoplasms. The carcinoid syndrome consists of cutaneous flushing, gut hypermotility with diarrhea, and bronchospasm.^1–5 Our patient did not have the full range of these symptoms. However, the presentation of carcinoid tumors varies broadly depending on the location, morphology, or biology of the tumor.⁶ Although our patient had diarrhea, his symptoms improved without any specific treatment. Rectal carcinoid tumors rarely cause diarrhea, and therefore the tumor noted on colonoscopy was almost certainly an incidental finding unrelated to his clinical presentation.

The classic symptoms are caused by production of 5-hydroxyindoleacetic acid, typically by a carcinoid tumor of the small bowel. Rectal carcinoids do not produce the 5-hydroxyindoleacetic acid responsible for this “malignant” serotonin-driven syndrome and are typically asymptomatic. When rectal carcinoid tumors are symptomatic, patients may have symptoms of local irritation or obstruction, such as hematochezia, constipation, other changes in bowel habits, rectal pain, pruritis ani, or weight loss.^2,7

Nearly 50% of rectal carcinoid tumors are discovered incidentally. The National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) registry database documented a 10-fold increase in the incidence of rectal carcinoids in the last 35 years, attributed in part to an increase in screening colonoscopy.⁸ Furthermore, although studies of large national or multicenter databases have found that 65% to 80% of all rectal carcinoid tumors are smaller than 1.0 cm, 93.3% to 100% of those discovered on screening endoscopy were 1.0 cm or smaller.⁸

Rectal carcinoid tumors have a characteristic feel on digital examination, with a hard, “buckshot” consistency, and are freely mobile.⁵ They have also been described as firm, nodular, rubbery, yellow, submucosal, and polypoid.⁸

WHERE DO CARCINOID TUMORS TEND TO ARISE?

2. Which of the following sites is the most commonly recognized site of a primary carcinoid tumor?

• Small bowel
• Lung
• Liver
• Pancreas
• Rectum

The small bowel is the most common site.

Carcinoid tumors derive from neoplastic proliferation of cells of the diffuse neuroendocrine system. Therefore, they can be found anywhere neuroendocrine cells are present, commonly in the gastrointestinal tract, urogenital tract, and the bronchial epithelium.

Traditionally, neuroendocrine tumors were classified by their embryologic origin: foregut (including the respiratory tract, thymus, stomach, and pancreas), midgut (including the small intestine, appendix, and right colon), and hindgut (including the transverse, descending, and sigmoid colon and rectum). Functionally, this was sensible, as each class of tumors presented similarly due to the similar hormonal secretory products.^2,3,9

A 2004 population-based review of the SEER database¹⁰ classified incidence rates of carcinoid tumors and their distribution throughout the body. Most (54.5%) were discovered in the gastrointestinal tract, and of these, 44.7% were in the small intestine, 19.6% were in the rectum, 16.7% were in the appendix, 10.6% were in the colon, 7.2% were in the stomach, and the remaining 1.2% were at other gastrointestinal sites. Nongastrointestinal sites included the lungs and bronchi (30.1%), pancreas (2.3%), female reproductive tract and ovaries (1.2%), biliary system (1.1%), and head and neck (0.4%).¹⁰

The incidence rates have increased and the distribution of sites in the body has changed over time. For example, the appendix was once considered the site of highest incidence, with tumors often discovered incidentally during surgical resection. However, these data were based on anecdotal or single-institution reports and so may have been subject to reporting bias. According to the SEER data, the small intestine is now the leading site, perhaps because of increased awareness or improved diagnostic technology and imaging.^10,11

The liver is a common site of metastasis, but it is an exceptionally rare location for a primary tumor.

HOW SHOULD THIS PATIENT BE MANAGED?

3. What is the appropriate management of rectal carcinoid in this patient?

• Since the nodule is 1.0 cm or smaller, watchful waiting is acceptable
• Since the nodule is 1.0 cm or smaller, local excision is appropriate, and no follow-up is required
• Because all carcinoid tumors are potentially malignant, radical resection (eg, abdominal perineal resection) is appropriate
• Because all carcinoid tumors are potentially malignant, radical resection with chemotherapy with 5-fluorouracil (Adrucil) and doxorubicin (Adriamycin) is required

Since the nodule is 1.0 cm or smaller, local excision is appropriate, and no follow-up will be required. Rectal carcinoid tumors generally have a favorable prognosis, with a 5-year survival rate of 87.5%.¹⁰

PROGNOSIS DEPENDS ON TUMOR SIZE, OTHER FACTORS

Many studies have examined risk factors contributing to poor prognosis, and this is an area of active study. Early research categorized rectal carcinoid risk in terms of tumor diameter, and this is still widely used to guide management. As early as 1959, Hanley et al⁵ recognized that tumors that were likely to metastasize were often larger than 1 cm, had infiltrated the muscularis, or were ulcerated. Today, it is understood that only 3% to 10% of rectal carcinoids smaller than 1 cm metastasize, whereas 17% to 42% of those 1 to 2 cm and 60% to 80% of those larger than 2 cm do.^2,8,12,13

However, size is not the only consideration. Wang et al¹² showed that muscular invasion is an independent risk factor for survival, and that tumor diameter is a significant predictor of invasion and metastasis. Similarly, a metaanalysis by Mani et al¹³ recognized tumor size and muscularis invasion as the most important predictors of malignancy in these neoplasms.

To aid in predicting prognosis, staging systems have been developed from institutional or national registries. Landry et al¹⁴ developed a TNM (tumor, node, metastasis) staging system for rectal carcinoids, in which the T value was based on tumor size and degree of invasion. A group at Memorial-Sloan Kettering Cancer Center¹⁵ developed a system for risk stratification of carcinoid of the rectum that is based on tumor size, muscularis invasion, lymphovascular invasion, and the mitotic rate.

TREATMENT IS BY EXCISION

Despite these new prognostic systems, there is no new guidance on therapeutic management. Surgical therapy is still largely guided by tumor size.

Lesions smaller than 1 cm are resected endoscopically or by another local transanal technique.^2,3,15,16 Standard endoscopic mucosal resection is performed, and recent studies have suggested that endoscopic submucosal dissection is as effective¹⁷ or even preferred, because it resects to the deeper submucosa (as the name suggests).¹⁸ This en bloc technique may be appropriate for lesions with evidence of local invasion.¹⁸ Other situations may call for deeper resection, such as transanal resection for higher lesions and full-thickness mucosal-muscularis resection.

Tumors 1 to 2 cm are currently evaluated for other factors such as ulceration and umbilication, which influence the choice of local vs radical resection. Otherwise, there is little guidance for tumors of 1 to 2 cm.

Tumors larger than 2 cm have a high risk of muscularis invasion and metastasis, and hence they are resected with wide margins and imaging is then used to evaluate for metastasis.^8,19 In cases of metastasis, local resection is often palliative, providing local symptom relief.¹⁹

AN INCIDENTALLY DISCOVERED CASE; PATIENT LOST TO FOLLOW-UP

Our patient’s case is typical of rectal carcinoid in that it was discovered incidentally during colonoscopy. His clinical presentation was likely unrelated to his carcinoid tumor, and he improved without specific treatment. His symptoms resolved within 24 hours with supportive treatment and he was discharged.

Pathologic confirmation of carcinoid tumor occurred after his discharge. Despite persistent attempts to contact the patient, he never returned for a follow-up appointment.

TAKE-HOME POINTS

• Carcinoid tumors are rare neoplasms of neuroendocrine origin.
• Rectal carcinoids are the third most common carcinoid of the gastrointestinal tract.
• Most rectal carcinoids are asymptomatic.
• Diagnosis is most often incidental and histologic.
• Treatment is by excision.
• Prognosis is favorable for smaller carcinoids and depends on size (and therefore, invasion).

A 31-year-old man presents to the emergency department with abdominal pain and diarrhea, which began 4 days ago. The pain is in both of the lower quadrants, is crampy and persistent, and is relieved with bowel movements. He has been having watery stools five to six times per day, without frank blood.

He reports no fevers, chills, nausea, or vomiting, and he has never travelled outside the country. He underwent laparotomy 6 months ago for a gunshot wound. He takes no prescription drugs. He smokes and he drinks alcohol, and he says he has used heroin and oxycodone recreationally.

His blood pressure is 134/74 mm Hg, and he is afebrile. An abdominal examination reveals no mass or tenderness.

Results of a complete blood count, serum chemistry panel, and serum amylase level are normal. His lipase level is slightly elevated at 80 U/L (reference range 12–70). His stool is negative for Clostridium difficile toxin on enzyme immunoassay.

Computed tomography of the abdomen reveals diffuse pericolonic hyperemia and possible thickening of the rectosigmoid colon, raising the concern that he might have infectious or inflammatory colitis. The patient is admitted for further evaluation.

Colonoscopy to evaluate the abnormalities on computed tomography finds only a 5-mm submucosal nodule in the rectum (Figure 1). Biopsy of the nodule shows it to be a well-differentiated neuroendocrine neoplasm (carcinoid tumor). Random colon biopsy samples are normal.

The patient’s symptoms resolve over the next 24 hours without any treatment.

WHAT EXPLAINS THE PATIENT’S SYMPTOMS?

1. Which of the following best explains the patient’s clinical presentation?

Viral gastroenteritis is common and affects people of all ages. The very young and the elderly are at higher risk of adverse outcomes, but few people die of it in the United States.

Our patient’s symptoms were consistent with viral gastroenteritis that resolved spontaneously while he received only supportive care.

Narcotic withdrawal can also cause watery stools and abdominal pain. However, this patient lacked other signs and symptoms of withdrawal, and his symptoms improved without any detoxification or maintenance treatment.

Pancreatitis. Although the patient had a mildly elevated lipase level, his lack of nausea and vomiting and the location of the pain were not consistent with acute pancreatitis.

Carcinoid syndrome. Carcinoid tumors are rare, typically indolent neuroendocrine neoplasms. The carcinoid syndrome consists of cutaneous flushing, gut hypermotility with diarrhea, and bronchospasm.^1–5 Our patient did not have the full range of these symptoms. However, the presentation of carcinoid tumors varies broadly depending on the location, morphology, or biology of the tumor.⁶ Although our patient had diarrhea, his symptoms improved without any specific treatment. Rectal carcinoid tumors rarely cause diarrhea, and therefore the tumor noted on colonoscopy was almost certainly an incidental finding unrelated to his clinical presentation.

The classic symptoms are caused by production of 5-hydroxyindoleacetic acid, typically by a carcinoid tumor of the small bowel. Rectal carcinoids do not produce the 5-hydroxyindoleacetic acid responsible for this “malignant” serotonin-driven syndrome and are typically asymptomatic. When rectal carcinoid tumors are symptomatic, patients may have symptoms of local irritation or obstruction, such as hematochezia, constipation, other changes in bowel habits, rectal pain, pruritis ani, or weight loss.^2,7

Nearly 50% of rectal carcinoid tumors are discovered incidentally. The National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) registry database documented a 10-fold increase in the incidence of rectal carcinoids in the last 35 years, attributed in part to an increase in screening colonoscopy.⁸ Furthermore, although studies of large national or multicenter databases have found that 65% to 80% of all rectal carcinoid tumors are smaller than 1.0 cm, 93.3% to 100% of those discovered on screening endoscopy were 1.0 cm or smaller.⁸

Rectal carcinoid tumors have a characteristic feel on digital examination, with a hard, “buckshot” consistency, and are freely mobile.⁵ They have also been described as firm, nodular, rubbery, yellow, submucosal, and polypoid.⁸

WHERE DO CARCINOID TUMORS TEND TO ARISE?

2. Which of the following sites is the most commonly recognized site of a primary carcinoid tumor?

• Small bowel
• Lung
• Liver
• Pancreas
• Rectum

The small bowel is the most common site.

Carcinoid tumors derive from neoplastic proliferation of cells of the diffuse neuroendocrine system. Therefore, they can be found anywhere neuroendocrine cells are present, commonly in the gastrointestinal tract, urogenital tract, and the bronchial epithelium.

Traditionally, neuroendocrine tumors were classified by their embryologic origin: foregut (including the respiratory tract, thymus, stomach, and pancreas), midgut (including the small intestine, appendix, and right colon), and hindgut (including the transverse, descending, and sigmoid colon and rectum). Functionally, this was sensible, as each class of tumors presented similarly due to the similar hormonal secretory products.^2,3,9

A 2004 population-based review of the SEER database¹⁰ classified incidence rates of carcinoid tumors and their distribution throughout the body. Most (54.5%) were discovered in the gastrointestinal tract, and of these, 44.7% were in the small intestine, 19.6% were in the rectum, 16.7% were in the appendix, 10.6% were in the colon, 7.2% were in the stomach, and the remaining 1.2% were at other gastrointestinal sites. Nongastrointestinal sites included the lungs and bronchi (30.1%), pancreas (2.3%), female reproductive tract and ovaries (1.2%), biliary system (1.1%), and head and neck (0.4%).¹⁰

The incidence rates have increased and the distribution of sites in the body has changed over time. For example, the appendix was once considered the site of highest incidence, with tumors often discovered incidentally during surgical resection. However, these data were based on anecdotal or single-institution reports and so may have been subject to reporting bias. According to the SEER data, the small intestine is now the leading site, perhaps because of increased awareness or improved diagnostic technology and imaging.^10,11

The liver is a common site of metastasis, but it is an exceptionally rare location for a primary tumor.

HOW SHOULD THIS PATIENT BE MANAGED?

3. What is the appropriate management of rectal carcinoid in this patient?

• Since the nodule is 1.0 cm or smaller, watchful waiting is acceptable
• Since the nodule is 1.0 cm or smaller, local excision is appropriate, and no follow-up is required
• Because all carcinoid tumors are potentially malignant, radical resection (eg, abdominal perineal resection) is appropriate
• Because all carcinoid tumors are potentially malignant, radical resection with chemotherapy with 5-fluorouracil (Adrucil) and doxorubicin (Adriamycin) is required

Since the nodule is 1.0 cm or smaller, local excision is appropriate, and no follow-up will be required. Rectal carcinoid tumors generally have a favorable prognosis, with a 5-year survival rate of 87.5%.¹⁰

PROGNOSIS DEPENDS ON TUMOR SIZE, OTHER FACTORS

Many studies have examined risk factors contributing to poor prognosis, and this is an area of active study. Early research categorized rectal carcinoid risk in terms of tumor diameter, and this is still widely used to guide management. As early as 1959, Hanley et al⁵ recognized that tumors that were likely to metastasize were often larger than 1 cm, had infiltrated the muscularis, or were ulcerated. Today, it is understood that only 3% to 10% of rectal carcinoids smaller than 1 cm metastasize, whereas 17% to 42% of those 1 to 2 cm and 60% to 80% of those larger than 2 cm do.^2,8,12,13

However, size is not the only consideration. Wang et al¹² showed that muscular invasion is an independent risk factor for survival, and that tumor diameter is a significant predictor of invasion and metastasis. Similarly, a metaanalysis by Mani et al¹³ recognized tumor size and muscularis invasion as the most important predictors of malignancy in these neoplasms.

To aid in predicting prognosis, staging systems have been developed from institutional or national registries. Landry et al¹⁴ developed a TNM (tumor, node, metastasis) staging system for rectal carcinoids, in which the T value was based on tumor size and degree of invasion. A group at Memorial-Sloan Kettering Cancer Center¹⁵ developed a system for risk stratification of carcinoid of the rectum that is based on tumor size, muscularis invasion, lymphovascular invasion, and the mitotic rate.

TREATMENT IS BY EXCISION

Despite these new prognostic systems, there is no new guidance on therapeutic management. Surgical therapy is still largely guided by tumor size.

Lesions smaller than 1 cm are resected endoscopically or by another local transanal technique.^2,3,15,16 Standard endoscopic mucosal resection is performed, and recent studies have suggested that endoscopic submucosal dissection is as effective¹⁷ or even preferred, because it resects to the deeper submucosa (as the name suggests).¹⁸ This en bloc technique may be appropriate for lesions with evidence of local invasion.¹⁸ Other situations may call for deeper resection, such as transanal resection for higher lesions and full-thickness mucosal-muscularis resection.

Tumors 1 to 2 cm are currently evaluated for other factors such as ulceration and umbilication, which influence the choice of local vs radical resection. Otherwise, there is little guidance for tumors of 1 to 2 cm.

Tumors larger than 2 cm have a high risk of muscularis invasion and metastasis, and hence they are resected with wide margins and imaging is then used to evaluate for metastasis.^8,19 In cases of metastasis, local resection is often palliative, providing local symptom relief.¹⁹

AN INCIDENTALLY DISCOVERED CASE; PATIENT LOST TO FOLLOW-UP

Our patient’s case is typical of rectal carcinoid in that it was discovered incidentally during colonoscopy. His clinical presentation was likely unrelated to his carcinoid tumor, and he improved without specific treatment. His symptoms resolved within 24 hours with supportive treatment and he was discharged.

Pathologic confirmation of carcinoid tumor occurred after his discharge. Despite persistent attempts to contact the patient, he never returned for a follow-up appointment.

TAKE-HOME POINTS

• Carcinoid tumors are rare neoplasms of neuroendocrine origin.
• Rectal carcinoids are the third most common carcinoid of the gastrointestinal tract.
• Most rectal carcinoids are asymptomatic.
• Diagnosis is most often incidental and histologic.
• Treatment is by excision.
• Prognosis is favorable for smaller carcinoids and depends on size (and therefore, invasion).

A 6-year-old girl was brought to a pediatric emergency department (ED) in Atlanta by her mother. The mother stated that during the previous hour, she had noticed that her daughter’s face seemed weaker on the right side.

The night before, the child had said, “I can’t blink my eye”; when her mother asked her to demonstrate, the child seemed to be able to blink both eyes appropriately, and she had no further complaints. The next morning, the child complained of the light being too bright and asked to wear her mother’s sunglasses. In the course of the day, she continued to complain of eye discomfort, which she described as “stinging” and “sore.” The mother could see nothing abnormal, but by late afternoon noticed that her daughter’s smile and facial movements were asymmetrical. She immediately took her to the pediatric ED.

The child had no significant medical history and no surgical history. Her vaccination schedule was current, and she denied any recent illnesses. The mother could recall no exposures to infections or tick bites, no rashes, and no trauma to the face or head. The mother and child were visiting Atlanta from northeastern Florida.

The review of systems was negative for headache, fever, chills, rash, earache, sore throat, cough, rhinorrhea, vision changes, weight loss, or change in appetite or disposition. The child was afebrile, and the other vital signs were within normal limits. 

Physical examination revealed an alert child who was calm and conversant. Her height was 45” and weight, 43 lb. Otoscopic exam showed normal ears and tympanic membranes with no sign of otitis media or ear pathology. No throat redness, tonsillar enlargement, or lymphadenopathies were noted. Breath sounds were clear, and heart rhythm and rate were regular without murmur. 

The patient’s left eye appeared normal, and the right eye was mildly erythematic without drainage or swelling; since corneal abrasion was not suspected, a slit lamp examination was not performed. Upon neurologic examination, right eye ptosis with incomplete lid closure, asymmetrical mouth movement with smile, and a diminished nasal labial fold crease were noted on the right side. When the child was asked to raise her eyebrows and wrinkle her forehead, asymmetrical forehead creases were apparent. All other cranial nerve functions were intact, and motor and sensory responses, including gait and reflexes, were assessed as normal. Unilateral dysfunction of right-sided cranial nerve VII (CN VII), including forehead involvement, was confirmed, consistent with a grade of III to IV on the House-Brackmann (maximum, VI)^1,2 facial nerve grading scale.

Based on the rapid onset of unilateral facial nerve paresis (FNP) and an otherwise normal exam, the patient was diagnosed with Bell’s palsy. No further testing was done, and the child was given a dose of oral prednisolone 40 mg in the ED, with a prescription for four more days of oral prednisolone at 15 mg bid. The need for eye protection and lubrication was emphasized to the mother, who was given lubricating eye drops to administer. The mother was also instructed to follow up with the child’s primary care practitioner upon their return to Florida. 

The child was seen by her pediatrician three days later. Her facial paresis had not worsened in the interim, and the pediatrician declined to extend the course of corticosteroids or to add an antiviral medication. At the mother’s request, the child was referred to a pediatric otolaryngologist, who saw her the following day and adjusted the treatment plan. The child was prescribed prednisolone elixir 20 mg bid for one week, followed by a tapering dose for the second week. In addition, she was prescribed oral acyclovir 400 mg qid for 10 days. Her mother was instructed to return with the child in one week for audiometry testing.  

Discussion
Idiopathic FNP, commonly referred to as Bell’s palsy, is defined as an acute unilateral paresis of the facial nerve without detectable underlying cause.^3,4 It most commonly occurs among persons ages 15 to 45, with a prevalence rate of 15 to 30 cases per 100,000 persons. The peak incidence of Bell’s palsy is in the fourth decade of life. Diabetic patients and pregnant women are disproportionately affected by idiopathic FNP.^2,5 About 8% to 10% of patients will experience a recurrence of Bell’s palsy within 10 years.^2,6

Pediatric FNP can be congenital or acquired. Congenital FNP is most often associated with birth trauma and occurs at a rate of 2.1 cases per 1,000 births. Rare genetic syndromes can also manifest with FNP and will most often present with other syndromic anomalies noted at birth.⁷

Acquired FNP is two to four times less common in children than adults, with an estimated prevalence of 2.7 per 100,000 patients younger than 10. Children account for only a small proportion of subjects in published studies that address diagnosis and management of FNP.³ While the presentation of FNP is much the same in adults and children, some notable differences in etiology exist.^2,3,7-9 Infectious, traumatic, or neoplastic causes of FNP are more common among children than adults and must be distinguished from idiopathic FNP.^7,9-11

Decisions regarding diagnostic testing, pharmacologic treatment, and referral must be guided by the history and physical exam, neurologic exam, and clinical judgment. Being able to identify or exclude alarming causes of FNP, such as neoplasm, will aid the primary care practitioner in treatment and referral practices for this condition.

Pathophysiology
CN VII, the facial nerve, has a broad scope of function that incorporates both sensory and motor pathways. The brachial nerve portion of CN VII controls the muscles of voluntary facial expression. CN VII also autonomically innervates the lacrimal gland and submandibular gland and governs sensation from part of the ear as well as taste from the anterior two-thirds of the tongue.⁴

The precise pathophysiology involved in FNP remains an area of continuing debate, but infectious, vascular, immunologic, and genetic causes have been hypothesized.^7,12 Inflammation and subsequent nerve damage along CN VII caused by an infectious process is thought to be the most likely explanation for the pathogenesis of acquired FNP in both adults and children.^5,13

Herpes simplex virus 1 (HSV-1) has been suggested as the virus most commonly linked to FNP in both adults and children, but it is unlikely to be the sole cause.^5,6,9 Data from a three-year prospective study of FNP cases in children support a relationship between pediatric FNP and HSV-1 infection.¹⁴ Other infectious causes implicated in pediatric FNP are Lyme disease, Epstein-Barr, varicella zoster virus, rubella, coxsackie virus, adenovirus, and otitis media.^4,7,9

Presentation, History, and Physical Exam
Most children with idiopathic FNP will present with sudden-onset facial asymmetry and may have decreased tearing, loss of the conjunctival reflex (leading to difficulty closing the eye), an inability to hold the lips tightly together, and difficulty keeping food in the mouth. Complaints of otalgia, speech disturbances, hyperacusis, and altered sense of taste are common.^2,7 Recent occurrence of an upper respiratory infection is often reported in the history of a pediatric patient with FNP.^3,7,15,16

Idiopathic FNP is essentially a diagnosis of exclusion.^3,5 A meticulous history must be conducted, including any recent illnesses, trauma to the face or head, vaccines, rashes, and travel. Assessment of the head, eyes, ears, nose, and throat, and a careful neurologic history must be conducted to identify nonidiopathic causes of FNP (see Table 1^5-7,9). Facial weakness can progress from mild palsy to complete paralysis over one to two weeks⁵; therefore, a careful history of the progression of facial weakness should be ascertained and documented.^5,17 

A full neurologic exam is essential. Cranial nerves I through XII should be evaluated; any malfunction of a cranial nerve other than CN VII could be indicative of a tumor or process other than idiopathic FNP. Assessment of facial nerve function is imperative, as this factor is the most important for predicting recovery; it can also aid in formulating a prognosis and directing treatment.^5,9,17

The House-Brackmann facial nerve grading system^1,2 is considered the gold standard for grading severity of facial paresis⁹ (see Table 2^1,2 ). A clear distinction between paresis (partial or incomplete palsy) and paralysis (complete palsy) must be made. Pediatric patients with an incomplete palsy have an improved chance of full recovery.^17,18

Any abnormalities in the peripheral neurologic exam should prompt further testing. FNP not involving the forehead musculature, gradual progression of paresis, and weakness in any extremity could be indicative of a central lesion. FNP has been the presenting symptom in various neoplastic processes, including leukemia, cholesteatoma, and astrocytoma.^3,7,9

Otitis media is a frequent cause of FNP among children.^9-11 Thus, a thorough examination of the ear canal, tympanic membrane, and hearing should be performed. The throat and oropharynx should be inspected, and the parotid gland palpated. Any swelling or abnormalities warrant further investigation.

Lyme disease presenting with FNP is more common in children than adults. This may be related to the increased likelihood for children to be bitten by ticks in the head and neck areas. Frequently, FNP associated with Lyme disease is bilateral—as often as 25% of the time.¹⁹ Headache, onset of symptoms during peak Lyme season, or bilateral FNP should raise the clinician’s suspicion for Lyme disease.^7,9,19

An accurate assessment of blood pressure is essential, as severe hypertension may be implicated in FNP in children.^3,5,7 One literature review reported that hypertension was the origin of FNP in 3% to 17% of affected children.²⁰ Vascular hemorrhage induced by hypertension is thought to cause nerve compression and subsequent FNP.⁷

A bilateral eye exam is also important. Irritation is likely, and the patient with any suspected corneal abrasion or damage should be referred to an ophthalmologist.^6,18

Laboratory Testing and Imaging
Diagnostic testing that facilitates the exclusion of known causes of FNP should be considered, as there is no specific laboratory test to confirm the diagnosis. A complete blood count, Lyme titers, cerebrospinal fluid analysis, CT, and/or MRI may be warranted, based on the clinical presentation.^7-9 In children in whom Lyme disease is suspected (ie, those living in tick-endemic areas or with recent tick bites), serologic testing should be performed. Lumbar puncture and an evaluation of cerebrospinal fluid may be necessary in cases in which meningitis cannot be excluded.^7,9

Specialized diagnostic tests are not routinely recommended for patients with paresis that is improving. Audiometry and evaluation of the stapedial reflex may help guide treatment decisions for patients whose condition is not improving. In children, the presence or return of the stapedial reflex within three weeks of disease onset is predictive of complete recovery.⁵ In patients who experience complete paralysis or unimproved paresis, results of electrodiagnostic testing (in particular, evoked facial nerve electroneuronography) can help forecast recovery of facial nerve function.^5,17

Treatment and Management
Treatment for FNP in adults is controversial, and even more so for the pediatric patient. Treatment decisions consist of eye care, corticosteroids, antiviral medications, and appropriate referrals.

Eye care. Eye lubrication and protection should be implemented immediately. Protecting the cornea is paramount; thorough lubrication of the eye is the mainstay of treatment.¹⁸ Artificial tears should be used frequently during the day, and an ointment should be applied to the eye at night. Use of eye patches is controversial, as they may actually cause corneal injury.^7,9 Taping the eye shut at night may prevent trauma during sleep, but this option must be considered carefully.^9,18

Corticosteroids. Early initiation of corticosteroids should be considered for all patients with FNP, including children.^2,7,9,17 Studies are inconclusive as to whether steroid therapy is beneficial in children with idiopathic FNP. However, two 2010 reviews of pediatric FNP recommend early initiation of steroids for children with acute-onset FNP, particularly when facial paresis is evaluated at a House-Brackmann grade V or VI.^7,9 The American Academy of Family Physicians (AAFP) recommends a tapering course of prednisone for all patients, begun as soon as possible.⁶ The prednisone dosage for pediatric patients is usually 1.0 mg/kg/d, split into two doses, for six days, followed by a tapering dose for four days.⁵

Antivirals and antibiotic therapy. When an infectious cause of FNP is known, appropriate antibiotic or antiviral therapy should begin. If the patient lives in or has traveled to an area endemic for Lyme disease, empiric treatment may be appropriate. When Ramsay Hunt syndrome is diagnosed or herpetic lesions are visible, antiviral treatment should be initiated.⁷

Antiviral therapy for idiopathic FNP is the most controversial of the treatment decisions. In 2001, the American Academy of Neurology concluded that no clear benefit from acyclovir could be ascertained, although it might be effective.¹³ This was affirmed in a recently updated Cochrane review of antiviral therapy for idiopathic FNP.¹² Antiviral therapy alone showed no benefit, compared with placebo; however, combined antiviral and corticosteroid therapy was more effective than placebo alone in recovery outcomes. Antivirals may benefit pediatric patients and should be considered early when the cause of FNP is viral or idiopathic.^7,9

Referrals. Initial presentation and course of paresis should guide referral patterns for the pediatric patient presenting with FNP. The American Academy of Pediatrics (AAP) recommends referral to an otolaryngologist for any infant or child with FNP.²¹ The AAFP recommends referral to a specialist for any patient who does not show improvement within two weeks.⁶

In patients with complete paralysis, early surgical intervention may be considered, and referral should be made promptly for electrodiagnostic testing and surgical consult. In cases in which otitis media causes FNP, myringotomy and tube insertion are indicated, and appropriate referral should be made.^7,9

Outcomes
|The prognosis in children with FNP is good, and most will recover completely.^2,9-11,22 Idiopathic and infectious etiologies of FNP seem to have the greatest likelihood for complete recovery.^10,11,16,17 Recovery appears to be affected by etiology, degree of paresis, and treatment. How these factors coalesce is not fully understood, and up to 20% of children may have mild to moderate residual facial nerve dysfunction.^10,11,19,22

The Case Patient
The child’s facial nerve function gradually returned over a three-week period, with no residual deficit (see Figures 1a, 1b, and 1c). Results of the audiometry screening on day 10 were normal, showing a positive stapedial reflex. An MRI, performed four months after the initial paralysis to rule out any tumors, yielded normal results. 

This case highlights the differing management of pediatric Bell’s palsy among emergency, pediatric, and specialized providers. This child was managed more aggressively under the care of an otolaryngologist with a two-week course of steroids, antiviral medication for 10 days, and a follow-up MRI to rule out any evidence of a tumor. The need for further research to guide practice in the pediatric patient with Bell’s palsy is apparent.

Conclusion
FNP in the pediatric population is rare and more likely to have an identifiable cause than among adults. Careful examination should reveal differential diagnoses that warrant treatment and referrals. The main causes of FNP that should not be missed are otitis media, hypertension, varicella zoster virus (Ramsay Hunt syndrome), neoplastic processes, and Lyme disease.

Practitioners should have a high index of suspicion for nonidiopathic causes of FNP when a child has a neurologic exam that includes facial paresis of gradual onset, abnormal function of other cranial nerves, lack of forehead muscle weakness, or peripheral abnormalities. In addition to the history and exam, blood work and radiologic imaging can aid the practitioner in ruling in or out nonidiopathic causes of FNP. 

Grading of facial palsy severity using the House-Brackmann scale helps guide prognosis and referral choices. Referral to a specialist in otolaryngology is appropriate and recommended by the AAP. Referral should be made to an ophthalmologist if any suspicion of corneal abrasion exists. 

Treatment in children should consist of eye care and steroids. Antiviral therapy should be considered on an individualized basis and when evidence of HSV or varicella exists. Parents should be advised about the importance of eye care in a child with FNP (see Table 3^{5-7,9,17,18,22}).

The emotional stress associated with FNP can be significant for both children and adults; fear of lifelong facial deformity can be psychologically debilitating. Yet a favorable prognosis for recovery of facial nerve function can be relayed to anxious parents.

A 6-year-old girl was brought to a pediatric emergency department (ED) in Atlanta by her mother. The mother stated that during the previous hour, she had noticed that her daughter’s face seemed weaker on the right side.

The night before, the child had said, “I can’t blink my eye”; when her mother asked her to demonstrate, the child seemed to be able to blink both eyes appropriately, and she had no further complaints. The next morning, the child complained of the light being too bright and asked to wear her mother’s sunglasses. In the course of the day, she continued to complain of eye discomfort, which she described as “stinging” and “sore.” The mother could see nothing abnormal, but by late afternoon noticed that her daughter’s smile and facial movements were asymmetrical. She immediately took her to the pediatric ED.

The child had no significant medical history and no surgical history. Her vaccination schedule was current, and she denied any recent illnesses. The mother could recall no exposures to infections or tick bites, no rashes, and no trauma to the face or head. The mother and child were visiting Atlanta from northeastern Florida.

The review of systems was negative for headache, fever, chills, rash, earache, sore throat, cough, rhinorrhea, vision changes, weight loss, or change in appetite or disposition. The child was afebrile, and the other vital signs were within normal limits. 

Physical examination revealed an alert child who was calm and conversant. Her height was 45” and weight, 43 lb. Otoscopic exam showed normal ears and tympanic membranes with no sign of otitis media or ear pathology. No throat redness, tonsillar enlargement, or lymphadenopathies were noted. Breath sounds were clear, and heart rhythm and rate were regular without murmur. 

The patient’s left eye appeared normal, and the right eye was mildly erythematic without drainage or swelling; since corneal abrasion was not suspected, a slit lamp examination was not performed. Upon neurologic examination, right eye ptosis with incomplete lid closure, asymmetrical mouth movement with smile, and a diminished nasal labial fold crease were noted on the right side. When the child was asked to raise her eyebrows and wrinkle her forehead, asymmetrical forehead creases were apparent. All other cranial nerve functions were intact, and motor and sensory responses, including gait and reflexes, were assessed as normal. Unilateral dysfunction of right-sided cranial nerve VII (CN VII), including forehead involvement, was confirmed, consistent with a grade of III to IV on the House-Brackmann (maximum, VI)^1,2 facial nerve grading scale.

Based on the rapid onset of unilateral facial nerve paresis (FNP) and an otherwise normal exam, the patient was diagnosed with Bell’s palsy. No further testing was done, and the child was given a dose of oral prednisolone 40 mg in the ED, with a prescription for four more days of oral prednisolone at 15 mg bid. The need for eye protection and lubrication was emphasized to the mother, who was given lubricating eye drops to administer. The mother was also instructed to follow up with the child’s primary care practitioner upon their return to Florida. 

The child was seen by her pediatrician three days later. Her facial paresis had not worsened in the interim, and the pediatrician declined to extend the course of corticosteroids or to add an antiviral medication. At the mother’s request, the child was referred to a pediatric otolaryngologist, who saw her the following day and adjusted the treatment plan. The child was prescribed prednisolone elixir 20 mg bid for one week, followed by a tapering dose for the second week. In addition, she was prescribed oral acyclovir 400 mg qid for 10 days. Her mother was instructed to return with the child in one week for audiometry testing.  

Discussion
Idiopathic FNP, commonly referred to as Bell’s palsy, is defined as an acute unilateral paresis of the facial nerve without detectable underlying cause.^3,4 It most commonly occurs among persons ages 15 to 45, with a prevalence rate of 15 to 30 cases per 100,000 persons. The peak incidence of Bell’s palsy is in the fourth decade of life. Diabetic patients and pregnant women are disproportionately affected by idiopathic FNP.^2,5 About 8% to 10% of patients will experience a recurrence of Bell’s palsy within 10 years.^2,6

Pediatric FNP can be congenital or acquired. Congenital FNP is most often associated with birth trauma and occurs at a rate of 2.1 cases per 1,000 births. Rare genetic syndromes can also manifest with FNP and will most often present with other syndromic anomalies noted at birth.⁷

Acquired FNP is two to four times less common in children than adults, with an estimated prevalence of 2.7 per 100,000 patients younger than 10. Children account for only a small proportion of subjects in published studies that address diagnosis and management of FNP.³ While the presentation of FNP is much the same in adults and children, some notable differences in etiology exist.^2,3,7-9 Infectious, traumatic, or neoplastic causes of FNP are more common among children than adults and must be distinguished from idiopathic FNP.^7,9-11

Decisions regarding diagnostic testing, pharmacologic treatment, and referral must be guided by the history and physical exam, neurologic exam, and clinical judgment. Being able to identify or exclude alarming causes of FNP, such as neoplasm, will aid the primary care practitioner in treatment and referral practices for this condition.

Pathophysiology
CN VII, the facial nerve, has a broad scope of function that incorporates both sensory and motor pathways. The brachial nerve portion of CN VII controls the muscles of voluntary facial expression. CN VII also autonomically innervates the lacrimal gland and submandibular gland and governs sensation from part of the ear as well as taste from the anterior two-thirds of the tongue.⁴

The precise pathophysiology involved in FNP remains an area of continuing debate, but infectious, vascular, immunologic, and genetic causes have been hypothesized.^7,12 Inflammation and subsequent nerve damage along CN VII caused by an infectious process is thought to be the most likely explanation for the pathogenesis of acquired FNP in both adults and children.^5,13

Herpes simplex virus 1 (HSV-1) has been suggested as the virus most commonly linked to FNP in both adults and children, but it is unlikely to be the sole cause.^5,6,9 Data from a three-year prospective study of FNP cases in children support a relationship between pediatric FNP and HSV-1 infection.¹⁴ Other infectious causes implicated in pediatric FNP are Lyme disease, Epstein-Barr, varicella zoster virus, rubella, coxsackie virus, adenovirus, and otitis media.^4,7,9

Presentation, History, and Physical Exam
Most children with idiopathic FNP will present with sudden-onset facial asymmetry and may have decreased tearing, loss of the conjunctival reflex (leading to difficulty closing the eye), an inability to hold the lips tightly together, and difficulty keeping food in the mouth. Complaints of otalgia, speech disturbances, hyperacusis, and altered sense of taste are common.^2,7 Recent occurrence of an upper respiratory infection is often reported in the history of a pediatric patient with FNP.^3,7,15,16

Idiopathic FNP is essentially a diagnosis of exclusion.^3,5 A meticulous history must be conducted, including any recent illnesses, trauma to the face or head, vaccines, rashes, and travel. Assessment of the head, eyes, ears, nose, and throat, and a careful neurologic history must be conducted to identify nonidiopathic causes of FNP (see Table 1^5-7,9). Facial weakness can progress from mild palsy to complete paralysis over one to two weeks⁵; therefore, a careful history of the progression of facial weakness should be ascertained and documented.^5,17 

A full neurologic exam is essential. Cranial nerves I through XII should be evaluated; any malfunction of a cranial nerve other than CN VII could be indicative of a tumor or process other than idiopathic FNP. Assessment of facial nerve function is imperative, as this factor is the most important for predicting recovery; it can also aid in formulating a prognosis and directing treatment.^5,9,17

The House-Brackmann facial nerve grading system^1,2 is considered the gold standard for grading severity of facial paresis⁹ (see Table 2^1,2 ). A clear distinction between paresis (partial or incomplete palsy) and paralysis (complete palsy) must be made. Pediatric patients with an incomplete palsy have an improved chance of full recovery.^17,18

Any abnormalities in the peripheral neurologic exam should prompt further testing. FNP not involving the forehead musculature, gradual progression of paresis, and weakness in any extremity could be indicative of a central lesion. FNP has been the presenting symptom in various neoplastic processes, including leukemia, cholesteatoma, and astrocytoma.^3,7,9

Otitis media is a frequent cause of FNP among children.^9-11 Thus, a thorough examination of the ear canal, tympanic membrane, and hearing should be performed. The throat and oropharynx should be inspected, and the parotid gland palpated. Any swelling or abnormalities warrant further investigation.

Lyme disease presenting with FNP is more common in children than adults. This may be related to the increased likelihood for children to be bitten by ticks in the head and neck areas. Frequently, FNP associated with Lyme disease is bilateral—as often as 25% of the time.¹⁹ Headache, onset of symptoms during peak Lyme season, or bilateral FNP should raise the clinician’s suspicion for Lyme disease.^7,9,19

An accurate assessment of blood pressure is essential, as severe hypertension may be implicated in FNP in children.^3,5,7 One literature review reported that hypertension was the origin of FNP in 3% to 17% of affected children.²⁰ Vascular hemorrhage induced by hypertension is thought to cause nerve compression and subsequent FNP.⁷

A bilateral eye exam is also important. Irritation is likely, and the patient with any suspected corneal abrasion or damage should be referred to an ophthalmologist.^6,18

Laboratory Testing and Imaging
Diagnostic testing that facilitates the exclusion of known causes of FNP should be considered, as there is no specific laboratory test to confirm the diagnosis. A complete blood count, Lyme titers, cerebrospinal fluid analysis, CT, and/or MRI may be warranted, based on the clinical presentation.^7-9 In children in whom Lyme disease is suspected (ie, those living in tick-endemic areas or with recent tick bites), serologic testing should be performed. Lumbar puncture and an evaluation of cerebrospinal fluid may be necessary in cases in which meningitis cannot be excluded.^7,9

Specialized diagnostic tests are not routinely recommended for patients with paresis that is improving. Audiometry and evaluation of the stapedial reflex may help guide treatment decisions for patients whose condition is not improving. In children, the presence or return of the stapedial reflex within three weeks of disease onset is predictive of complete recovery.⁵ In patients who experience complete paralysis or unimproved paresis, results of electrodiagnostic testing (in particular, evoked facial nerve electroneuronography) can help forecast recovery of facial nerve function.^5,17

Treatment and Management
Treatment for FNP in adults is controversial, and even more so for the pediatric patient. Treatment decisions consist of eye care, corticosteroids, antiviral medications, and appropriate referrals.

Eye care. Eye lubrication and protection should be implemented immediately. Protecting the cornea is paramount; thorough lubrication of the eye is the mainstay of treatment.¹⁸ Artificial tears should be used frequently during the day, and an ointment should be applied to the eye at night. Use of eye patches is controversial, as they may actually cause corneal injury.^7,9 Taping the eye shut at night may prevent trauma during sleep, but this option must be considered carefully.^9,18

Corticosteroids. Early initiation of corticosteroids should be considered for all patients with FNP, including children.^2,7,9,17 Studies are inconclusive as to whether steroid therapy is beneficial in children with idiopathic FNP. However, two 2010 reviews of pediatric FNP recommend early initiation of steroids for children with acute-onset FNP, particularly when facial paresis is evaluated at a House-Brackmann grade V or VI.^7,9 The American Academy of Family Physicians (AAFP) recommends a tapering course of prednisone for all patients, begun as soon as possible.⁶ The prednisone dosage for pediatric patients is usually 1.0 mg/kg/d, split into two doses, for six days, followed by a tapering dose for four days.⁵

Antivirals and antibiotic therapy. When an infectious cause of FNP is known, appropriate antibiotic or antiviral therapy should begin. If the patient lives in or has traveled to an area endemic for Lyme disease, empiric treatment may be appropriate. When Ramsay Hunt syndrome is diagnosed or herpetic lesions are visible, antiviral treatment should be initiated.⁷

Antiviral therapy for idiopathic FNP is the most controversial of the treatment decisions. In 2001, the American Academy of Neurology concluded that no clear benefit from acyclovir could be ascertained, although it might be effective.¹³ This was affirmed in a recently updated Cochrane review of antiviral therapy for idiopathic FNP.¹² Antiviral therapy alone showed no benefit, compared with placebo; however, combined antiviral and corticosteroid therapy was more effective than placebo alone in recovery outcomes. Antivirals may benefit pediatric patients and should be considered early when the cause of FNP is viral or idiopathic.^7,9

Referrals. Initial presentation and course of paresis should guide referral patterns for the pediatric patient presenting with FNP. The American Academy of Pediatrics (AAP) recommends referral to an otolaryngologist for any infant or child with FNP.²¹ The AAFP recommends referral to a specialist for any patient who does not show improvement within two weeks.⁶

In patients with complete paralysis, early surgical intervention may be considered, and referral should be made promptly for electrodiagnostic testing and surgical consult. In cases in which otitis media causes FNP, myringotomy and tube insertion are indicated, and appropriate referral should be made.^7,9

Outcomes
|The prognosis in children with FNP is good, and most will recover completely.^2,9-11,22 Idiopathic and infectious etiologies of FNP seem to have the greatest likelihood for complete recovery.^10,11,16,17 Recovery appears to be affected by etiology, degree of paresis, and treatment. How these factors coalesce is not fully understood, and up to 20% of children may have mild to moderate residual facial nerve dysfunction.^10,11,19,22

The Case Patient
The child’s facial nerve function gradually returned over a three-week period, with no residual deficit (see Figures 1a, 1b, and 1c). Results of the audiometry screening on day 10 were normal, showing a positive stapedial reflex. An MRI, performed four months after the initial paralysis to rule out any tumors, yielded normal results. 

This case highlights the differing management of pediatric Bell’s palsy among emergency, pediatric, and specialized providers. This child was managed more aggressively under the care of an otolaryngologist with a two-week course of steroids, antiviral medication for 10 days, and a follow-up MRI to rule out any evidence of a tumor. The need for further research to guide practice in the pediatric patient with Bell’s palsy is apparent.

Conclusion
FNP in the pediatric population is rare and more likely to have an identifiable cause than among adults. Careful examination should reveal differential diagnoses that warrant treatment and referrals. The main causes of FNP that should not be missed are otitis media, hypertension, varicella zoster virus (Ramsay Hunt syndrome), neoplastic processes, and Lyme disease.

Practitioners should have a high index of suspicion for nonidiopathic causes of FNP when a child has a neurologic exam that includes facial paresis of gradual onset, abnormal function of other cranial nerves, lack of forehead muscle weakness, or peripheral abnormalities. In addition to the history and exam, blood work and radiologic imaging can aid the practitioner in ruling in or out nonidiopathic causes of FNP. 

Grading of facial palsy severity using the House-Brackmann scale helps guide prognosis and referral choices. Referral to a specialist in otolaryngology is appropriate and recommended by the AAP. Referral should be made to an ophthalmologist if any suspicion of corneal abrasion exists. 

Treatment in children should consist of eye care and steroids. Antiviral therapy should be considered on an individualized basis and when evidence of HSV or varicella exists. Parents should be advised about the importance of eye care in a child with FNP (see Table 3^{5-7,9,17,18,22}).

The emotional stress associated with FNP can be significant for both children and adults; fear of lifelong facial deformity can be psychologically debilitating. Yet a favorable prognosis for recovery of facial nerve function can be relayed to anxious parents.

A 6-year-old girl was brought to a pediatric emergency department (ED) in Atlanta by her mother. The mother stated that during the previous hour, she had noticed that her daughter’s face seemed weaker on the right side.

The night before, the child had said, “I can’t blink my eye”; when her mother asked her to demonstrate, the child seemed to be able to blink both eyes appropriately, and she had no further complaints. The next morning, the child complained of the light being too bright and asked to wear her mother’s sunglasses. In the course of the day, she continued to complain of eye discomfort, which she described as “stinging” and “sore.” The mother could see nothing abnormal, but by late afternoon noticed that her daughter’s smile and facial movements were asymmetrical. She immediately took her to the pediatric ED.

The child had no significant medical history and no surgical history. Her vaccination schedule was current, and she denied any recent illnesses. The mother could recall no exposures to infections or tick bites, no rashes, and no trauma to the face or head. The mother and child were visiting Atlanta from northeastern Florida.

The review of systems was negative for headache, fever, chills, rash, earache, sore throat, cough, rhinorrhea, vision changes, weight loss, or change in appetite or disposition. The child was afebrile, and the other vital signs were within normal limits. 

Physical examination revealed an alert child who was calm and conversant. Her height was 45” and weight, 43 lb. Otoscopic exam showed normal ears and tympanic membranes with no sign of otitis media or ear pathology. No throat redness, tonsillar enlargement, or lymphadenopathies were noted. Breath sounds were clear, and heart rhythm and rate were regular without murmur. 

The patient’s left eye appeared normal, and the right eye was mildly erythematic without drainage or swelling; since corneal abrasion was not suspected, a slit lamp examination was not performed. Upon neurologic examination, right eye ptosis with incomplete lid closure, asymmetrical mouth movement with smile, and a diminished nasal labial fold crease were noted on the right side. When the child was asked to raise her eyebrows and wrinkle her forehead, asymmetrical forehead creases were apparent. All other cranial nerve functions were intact, and motor and sensory responses, including gait and reflexes, were assessed as normal. Unilateral dysfunction of right-sided cranial nerve VII (CN VII), including forehead involvement, was confirmed, consistent with a grade of III to IV on the House-Brackmann (maximum, VI)^1,2 facial nerve grading scale.

Based on the rapid onset of unilateral facial nerve paresis (FNP) and an otherwise normal exam, the patient was diagnosed with Bell’s palsy. No further testing was done, and the child was given a dose of oral prednisolone 40 mg in the ED, with a prescription for four more days of oral prednisolone at 15 mg bid. The need for eye protection and lubrication was emphasized to the mother, who was given lubricating eye drops to administer. The mother was also instructed to follow up with the child’s primary care practitioner upon their return to Florida. 

The child was seen by her pediatrician three days later. Her facial paresis had not worsened in the interim, and the pediatrician declined to extend the course of corticosteroids or to add an antiviral medication. At the mother’s request, the child was referred to a pediatric otolaryngologist, who saw her the following day and adjusted the treatment plan. The child was prescribed prednisolone elixir 20 mg bid for one week, followed by a tapering dose for the second week. In addition, she was prescribed oral acyclovir 400 mg qid for 10 days. Her mother was instructed to return with the child in one week for audiometry testing.  

Discussion
Idiopathic FNP, commonly referred to as Bell’s palsy, is defined as an acute unilateral paresis of the facial nerve without detectable underlying cause.^3,4 It most commonly occurs among persons ages 15 to 45, with a prevalence rate of 15 to 30 cases per 100,000 persons. The peak incidence of Bell’s palsy is in the fourth decade of life. Diabetic patients and pregnant women are disproportionately affected by idiopathic FNP.^2,5 About 8% to 10% of patients will experience a recurrence of Bell’s palsy within 10 years.^2,6

Pediatric FNP can be congenital or acquired. Congenital FNP is most often associated with birth trauma and occurs at a rate of 2.1 cases per 1,000 births. Rare genetic syndromes can also manifest with FNP and will most often present with other syndromic anomalies noted at birth.⁷

Acquired FNP is two to four times less common in children than adults, with an estimated prevalence of 2.7 per 100,000 patients younger than 10. Children account for only a small proportion of subjects in published studies that address diagnosis and management of FNP.³ While the presentation of FNP is much the same in adults and children, some notable differences in etiology exist.^2,3,7-9 Infectious, traumatic, or neoplastic causes of FNP are more common among children than adults and must be distinguished from idiopathic FNP.^7,9-11

Decisions regarding diagnostic testing, pharmacologic treatment, and referral must be guided by the history and physical exam, neurologic exam, and clinical judgment. Being able to identify or exclude alarming causes of FNP, such as neoplasm, will aid the primary care practitioner in treatment and referral practices for this condition.

Pathophysiology
CN VII, the facial nerve, has a broad scope of function that incorporates both sensory and motor pathways. The brachial nerve portion of CN VII controls the muscles of voluntary facial expression. CN VII also autonomically innervates the lacrimal gland and submandibular gland and governs sensation from part of the ear as well as taste from the anterior two-thirds of the tongue.⁴

The precise pathophysiology involved in FNP remains an area of continuing debate, but infectious, vascular, immunologic, and genetic causes have been hypothesized.^7,12 Inflammation and subsequent nerve damage along CN VII caused by an infectious process is thought to be the most likely explanation for the pathogenesis of acquired FNP in both adults and children.^5,13

Herpes simplex virus 1 (HSV-1) has been suggested as the virus most commonly linked to FNP in both adults and children, but it is unlikely to be the sole cause.^5,6,9 Data from a three-year prospective study of FNP cases in children support a relationship between pediatric FNP and HSV-1 infection.¹⁴ Other infectious causes implicated in pediatric FNP are Lyme disease, Epstein-Barr, varicella zoster virus, rubella, coxsackie virus, adenovirus, and otitis media.^4,7,9

Presentation, History, and Physical Exam
Most children with idiopathic FNP will present with sudden-onset facial asymmetry and may have decreased tearing, loss of the conjunctival reflex (leading to difficulty closing the eye), an inability to hold the lips tightly together, and difficulty keeping food in the mouth. Complaints of otalgia, speech disturbances, hyperacusis, and altered sense of taste are common.^2,7 Recent occurrence of an upper respiratory infection is often reported in the history of a pediatric patient with FNP.^3,7,15,16

Idiopathic FNP is essentially a diagnosis of exclusion.^3,5 A meticulous history must be conducted, including any recent illnesses, trauma to the face or head, vaccines, rashes, and travel. Assessment of the head, eyes, ears, nose, and throat, and a careful neurologic history must be conducted to identify nonidiopathic causes of FNP (see Table 1^5-7,9). Facial weakness can progress from mild palsy to complete paralysis over one to two weeks⁵; therefore, a careful history of the progression of facial weakness should be ascertained and documented.^5,17 

A full neurologic exam is essential. Cranial nerves I through XII should be evaluated; any malfunction of a cranial nerve other than CN VII could be indicative of a tumor or process other than idiopathic FNP. Assessment of facial nerve function is imperative, as this factor is the most important for predicting recovery; it can also aid in formulating a prognosis and directing treatment.^5,9,17

The House-Brackmann facial nerve grading system^1,2 is considered the gold standard for grading severity of facial paresis⁹ (see Table 2^1,2 ). A clear distinction between paresis (partial or incomplete palsy) and paralysis (complete palsy) must be made. Pediatric patients with an incomplete palsy have an improved chance of full recovery.^17,18

Any abnormalities in the peripheral neurologic exam should prompt further testing. FNP not involving the forehead musculature, gradual progression of paresis, and weakness in any extremity could be indicative of a central lesion. FNP has been the presenting symptom in various neoplastic processes, including leukemia, cholesteatoma, and astrocytoma.^3,7,9

Otitis media is a frequent cause of FNP among children.^9-11 Thus, a thorough examination of the ear canal, tympanic membrane, and hearing should be performed. The throat and oropharynx should be inspected, and the parotid gland palpated. Any swelling or abnormalities warrant further investigation.

Lyme disease presenting with FNP is more common in children than adults. This may be related to the increased likelihood for children to be bitten by ticks in the head and neck areas. Frequently, FNP associated with Lyme disease is bilateral—as often as 25% of the time.¹⁹ Headache, onset of symptoms during peak Lyme season, or bilateral FNP should raise the clinician’s suspicion for Lyme disease.^7,9,19

An accurate assessment of blood pressure is essential, as severe hypertension may be implicated in FNP in children.^3,5,7 One literature review reported that hypertension was the origin of FNP in 3% to 17% of affected children.²⁰ Vascular hemorrhage induced by hypertension is thought to cause nerve compression and subsequent FNP.⁷

A bilateral eye exam is also important. Irritation is likely, and the patient with any suspected corneal abrasion or damage should be referred to an ophthalmologist.^6,18

Laboratory Testing and Imaging
Diagnostic testing that facilitates the exclusion of known causes of FNP should be considered, as there is no specific laboratory test to confirm the diagnosis. A complete blood count, Lyme titers, cerebrospinal fluid analysis, CT, and/or MRI may be warranted, based on the clinical presentation.^7-9 In children in whom Lyme disease is suspected (ie, those living in tick-endemic areas or with recent tick bites), serologic testing should be performed. Lumbar puncture and an evaluation of cerebrospinal fluid may be necessary in cases in which meningitis cannot be excluded.^7,9

Specialized diagnostic tests are not routinely recommended for patients with paresis that is improving. Audiometry and evaluation of the stapedial reflex may help guide treatment decisions for patients whose condition is not improving. In children, the presence or return of the stapedial reflex within three weeks of disease onset is predictive of complete recovery.⁵ In patients who experience complete paralysis or unimproved paresis, results of electrodiagnostic testing (in particular, evoked facial nerve electroneuronography) can help forecast recovery of facial nerve function.^5,17

Treatment and Management
Treatment for FNP in adults is controversial, and even more so for the pediatric patient. Treatment decisions consist of eye care, corticosteroids, antiviral medications, and appropriate referrals.

Eye care. Eye lubrication and protection should be implemented immediately. Protecting the cornea is paramount; thorough lubrication of the eye is the mainstay of treatment.¹⁸ Artificial tears should be used frequently during the day, and an ointment should be applied to the eye at night. Use of eye patches is controversial, as they may actually cause corneal injury.^7,9 Taping the eye shut at night may prevent trauma during sleep, but this option must be considered carefully.^9,18

Corticosteroids. Early initiation of corticosteroids should be considered for all patients with FNP, including children.^2,7,9,17 Studies are inconclusive as to whether steroid therapy is beneficial in children with idiopathic FNP. However, two 2010 reviews of pediatric FNP recommend early initiation of steroids for children with acute-onset FNP, particularly when facial paresis is evaluated at a House-Brackmann grade V or VI.^7,9 The American Academy of Family Physicians (AAFP) recommends a tapering course of prednisone for all patients, begun as soon as possible.⁶ The prednisone dosage for pediatric patients is usually 1.0 mg/kg/d, split into two doses, for six days, followed by a tapering dose for four days.⁵

Antivirals and antibiotic therapy. When an infectious cause of FNP is known, appropriate antibiotic or antiviral therapy should begin. If the patient lives in or has traveled to an area endemic for Lyme disease, empiric treatment may be appropriate. When Ramsay Hunt syndrome is diagnosed or herpetic lesions are visible, antiviral treatment should be initiated.⁷

Antiviral therapy for idiopathic FNP is the most controversial of the treatment decisions. In 2001, the American Academy of Neurology concluded that no clear benefit from acyclovir could be ascertained, although it might be effective.¹³ This was affirmed in a recently updated Cochrane review of antiviral therapy for idiopathic FNP.¹² Antiviral therapy alone showed no benefit, compared with placebo; however, combined antiviral and corticosteroid therapy was more effective than placebo alone in recovery outcomes. Antivirals may benefit pediatric patients and should be considered early when the cause of FNP is viral or idiopathic.^7,9

Referrals. Initial presentation and course of paresis should guide referral patterns for the pediatric patient presenting with FNP. The American Academy of Pediatrics (AAP) recommends referral to an otolaryngologist for any infant or child with FNP.²¹ The AAFP recommends referral to a specialist for any patient who does not show improvement within two weeks.⁶

In patients with complete paralysis, early surgical intervention may be considered, and referral should be made promptly for electrodiagnostic testing and surgical consult. In cases in which otitis media causes FNP, myringotomy and tube insertion are indicated, and appropriate referral should be made.^7,9

Outcomes
|The prognosis in children with FNP is good, and most will recover completely.^2,9-11,22 Idiopathic and infectious etiologies of FNP seem to have the greatest likelihood for complete recovery.^10,11,16,17 Recovery appears to be affected by etiology, degree of paresis, and treatment. How these factors coalesce is not fully understood, and up to 20% of children may have mild to moderate residual facial nerve dysfunction.^10,11,19,22

The Case Patient
The child’s facial nerve function gradually returned over a three-week period, with no residual deficit (see Figures 1a, 1b, and 1c). Results of the audiometry screening on day 10 were normal, showing a positive stapedial reflex. An MRI, performed four months after the initial paralysis to rule out any tumors, yielded normal results. 

This case highlights the differing management of pediatric Bell’s palsy among emergency, pediatric, and specialized providers. This child was managed more aggressively under the care of an otolaryngologist with a two-week course of steroids, antiviral medication for 10 days, and a follow-up MRI to rule out any evidence of a tumor. The need for further research to guide practice in the pediatric patient with Bell’s palsy is apparent.

Conclusion
FNP in the pediatric population is rare and more likely to have an identifiable cause than among adults. Careful examination should reveal differential diagnoses that warrant treatment and referrals. The main causes of FNP that should not be missed are otitis media, hypertension, varicella zoster virus (Ramsay Hunt syndrome), neoplastic processes, and Lyme disease.

Practitioners should have a high index of suspicion for nonidiopathic causes of FNP when a child has a neurologic exam that includes facial paresis of gradual onset, abnormal function of other cranial nerves, lack of forehead muscle weakness, or peripheral abnormalities. In addition to the history and exam, blood work and radiologic imaging can aid the practitioner in ruling in or out nonidiopathic causes of FNP. 

Grading of facial palsy severity using the House-Brackmann scale helps guide prognosis and referral choices. Referral to a specialist in otolaryngology is appropriate and recommended by the AAP. Referral should be made to an ophthalmologist if any suspicion of corneal abrasion exists. 

Treatment in children should consist of eye care and steroids. Antiviral therapy should be considered on an individualized basis and when evidence of HSV or varicella exists. Parents should be advised about the importance of eye care in a child with FNP (see Table 3^{5-7,9,17,18,22}).

The emotional stress associated with FNP can be significant for both children and adults; fear of lifelong facial deformity can be psychologically debilitating. Yet a favorable prognosis for recovery of facial nerve function can be relayed to anxious parents.

Just because elderly patients are having regular checkups does not necessarily mean they are receiving needed preventive services. For individuals who are ages 65 and older, such services include vaccinations against influenza and pneumonia, screenings for hypertension and hypercholesterolemia, and screenings for breast, cervical, and colorectal cancers.¹

Recently analyzed state and national data for a cluster of 5 of these services indicate that fewer than 41% of men and 32.5% of women ages 65 and older were up to date.² Time constraints on health care providers and a lack of knowledge about guidelines are perhaps 2 of the biggest barriers to widespread provision of disease prevention services. In this study we extended an earlier analysis and examined, for individuals 65 years of age and older, the association between having a recent checkup and being up to date on a cluster of recommended preventive services. We also propose steps that will likely be needed to increase receipt of preventive services.

Methods

Data source
The Behavioral Risk Factor Surveillance System (BRFSS), coordinated by the Centers for Disease Control and Prevention (CDC), conducts annual state-based telephone surveys of noninstitutionalized US adults ages 18 years or older concerning health practices.³ We used data from 2006 BRFSS participants ages 65 years or older at the time they participated (32,243 male respondents and 58,762 female respondents). All results were based on weighted data that accounted for different probabilities of selection and were adjusted to reflect the population distribution in each state by age and sex, or by age, race, and sex.

Respondents queried about preventive services
We analyzed responses to BRFSS questions about the receipt of clinical preventive services recommended by the US Preventive Services Task Force (USPSTF) or by the Advisory Committee on Immunization Practices for all adults ages 65 or older.* Services included colorectal cancer screening, influenza immunization, pneumococcal immunization, and, for women, mammography and the Papanicolaou (Pap) test. The USPSTF grades these measures* as A or B, meaning it finds “good” or at least “fair” evidence that a service improves important health outcomes and concludes that benefits substantially outweigh harms.⁴ Questions about these services were asked in all 50 states in 2006.

*The recommendations and grading systems discussed here reflect those that were in place in 2006. There have been changes to both since this study was conducted.

Cardiovascular services excluded. The BRFSS has not asked questions about hypertension screening since 1999, when more than 95% of older adults reported they had their blood pressure checked in the past 2 years.⁵ Questions about cholesterol screening were not asked in all states in 2006 and were not incorporated into the composite measure. However, analysis from a prior study suggests that including cholesterol screening levels in such a composite measure would not have made a large difference in the percentage of older Americans up to date on all services.²

Were scheduled intervals for services met? Adults could meet the recommendation for colorectal cancer screening by either having a fecal occult blood test (FOBT) within 1 year or colonoscopy or sigmoidoscopy within 10 years. The USPSTF and other national guidelines recommend a 5-year interval for sigmoidoscopy and a 10-year interval for colonoscopy.^6,7 However, no direct evidence has determined the optimal interval for either test,⁸ and the BRFSS question did not distinguish between the 2 interventions. Because either FOBT or endoscopy satisfies screening recommendations, we did not exclude respondents with missing values for 1 test if they had the other test within the recommended interval.

Other services and recommended intervals were pneumococcal vaccination (ever), influenza vaccination (in past year), and, for women, mammogram (within 2 years) and Pap test (within 3 years).

Assigning Yes or No to responses. If respondents had never received a particular preventive service or had received it outside the interval recommended by the USPSTF,⁴ we included them in the group answering No. We eliminated 3324 men and 6295 women with missing values for 1 or more measures.

Final determination of being “up to date.” After noting how many of the recommended services each individual had received according to age and sex, we dichotomized the sample according to whether all recommendations had been met—3 clinical preventive services for men 65 years and older (colorectal cancer screening, influenza, and pneumonia vaccination) and 5 for women (adding mammography and Pap test), with a single exception. Because Pap testing is often reported only for women with an intact cervix,⁹ we excused the lack of a Pap test for women who had undergone hysterectomy (47% of all women ages 65+, or 27,243). We required only that they meet 4 clinical preventive services to be considered up to date. A prior study revealed that excluding the Pap test entirely from the up-to-date measure for women 65 years and older had a minimal effect on up-to-date rates (34.2% when excluding the Pap test vs 32.5% including the Pap test).¹⁰

One of the strengths of the up-to-date measure is that it assesses the proportion of those fully up to date and thus allows for variability within subgroups, such as women who have had hysterectomies, without eliminating them arbitrarily from the sample.

Additional participant characteristics. We divided respondents into 4 racial/ethnic categories based on responses to BRFSS questions: White (non-Hispanic); Black (non-Hispanic); Hispanic of any race; or “Other” (American Indians, Asians, Pacific Islanders, and individuals of other or multiple race categories). Age categories were 65 to 69 years, 70 to 74 years, 75 to 79 years, or >80 years. Education categories: less than high school, high school graduate or general equivalency diploma recipient, some college, or college graduate. We further dichotomized the sample according to marital status, having 1 or more personal health care providers (vs none), and health status (fair/poor or good/very good/excellent). Given the amount of missing data (20%), household income was not included in the analysis.

Quantifying health care access. We created a measure of health care access using 3 factors:

• health insurance (“Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?”)
• one or more personal health care providers (see above)
• no cost barrier to seeing a doctor (“Was there a time in the past 12 months when you needed to see a doctor but could not because of cost?”).

To measure relative health care access, we scored each of the above items 1 for affirmative or 0 for negative. The sum (0, 1, 2, or 3) represented level of access. Lower numbers indicated more barriers and higher numbers represented greater access. Because only 48 older men and 59 older women had total scores of 0, the lower 2 levels were combined and the resulting 3 levels were termed “low” (0 & 1), “medium” (2) and “high” (3) access. Two of the measures used for health care access were also used to define 3 mutually exclusive health insurance categories: uninsured, fully insured, and underinsured (insured but reporting a cost barrier).²

We determined whether a routine checkup had occurred in the past 2 years by asking, “About how long has it been since you last visited a doctor for a routine checkup? A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition.”

Statistical analysis
We conducted statistical analysis using Stata, version 9.0 (Stata Corp; College Station, Tex). We used Pearson chi-square tests to determine whether selected demographic factors were associated with being up to date on all recommended services. We also used Stata in a logistic regression analysis to control simultaneously for age, education, race/ethnicity, marital status, insurance coverage, health care access, having one or more personal health care providers, having a routine checkup within 2 years, current smoking, and health status. We computed odds ratios and 95% confidence intervals for each variable in the model.

Results

Most adults ages 65 years and older were fully insured, had a personal health care provider, and reported no cost barrier to seeing a doctor in the past year (TABLE 1). Breaking out these measures into 3 levels of relative health care access, 88.6% of men and 90.2% of women were at the highest level. More than 90% of respondents reported having a routine checkup in the past 2 years. More than 60% reported receiving each of the separate immunizations and cancer screenings recommended for their age and sex, and almost all had received at least 1 service.

TABLE 2 shows the prevalence of being up to date by demographic group. Only 42.6% of all older men and 35.2% of all older women were up to date, with rates marginally better for those with high access to care (45.1% for men, 37% for women) or those reporting a recent routine checkup (44.8% for men, 36.8% for women). Low access to care yielded dramatically worse up-to-date rates (14.8% for men, 9.1% for women). Similarly, those reporting no recent routine checkup had poor up-to-date rates (20.5% for men, 15.4% for women). The highest rates of being up to date belonged to those with a college degree (49% for men, 42.1% for women). Higher rates were also found among the oldest age groups.

Results of the logistic regression analysis are shown in TABLE 3. Among men and women, being up to date was more likely for those who were older, married, better educated, had high access to health care, and had had a routine checkup in the past 2 years. The latter 2 groups had the highest odds ratios of all groups in the model. Less likely to be up to date were those who were Black, Hispanic, or of a race other than white, those who smoked cigarettes, and (for men) those who were in good or better health. For women, health status had no effect on being up to date.

Table 1
Characteristics of US adults ≥65 years, 2006 Behavioral Risk Factor Surveillance System

Table 2
Prevalence of being up to date* by demographic characteristics, US adults ≥65 years, 2006 Behavioral Risk Factor Surveillance System

TABLE 3
Results of multiple logistic regression modeling* for being up to date^†for cancer screening and adult immunization, by sex and demographic characteristics: 2006 Behavioral Risk Factor Surveillance System, adults ≥65 years

Discussion

The key finding in this study is that, although most adults ages 65 and older had high access to health care and recent routine checkups, their rates of being up to date with a recommended cluster of preventive services were only about 45% for men and 37% for women.

More than 91% of men and 93% of women reported they had a routine checkup during this timeframe, and 88.6% of men and 90.2% of women also reported they had high access to health care—ie, they had health insurance, at least 1 personal health care provider, and no cost barrier to seeing a doctor. Improving access to health care or increasing the use of routine medical checkups—even to 100%—would likely have a negligible impact on the delivery of recommended services. Despite the very modest composite delivery rates of recommended preventive services in this group, the rates were still 2 to 4 times higher than those of adults with low health care access or no recent routine checkup.

We also found that being up to date generally improves with age. Granted, there is uncertainty as to the appropriate age at which to stop specific screenings. And very elderly Americans may be receiving some services no longer of benefit. But the significance of our finding is that composite delivery rates were lowest among adults at the age for which broad consensus says services are beneficial. For example, the up-to-date rates for men and women ages 65 to 69 were 32% and 29.8%, respectively, compared with 48.7% and 40.2% for adults ages 75 to 79 (TABLE 2).

Our findings are consistent with research documenting inadequate time to incorporate preventive services into the typical office visit.^11,12 Similar barriers have been identified by general practitioners in the United Kingdom.^13,14 The time constraint is particularly consequential in high-volume primary care practices.¹⁵ Some investigations have calculated the actual or necessary time needed to deliver multiple recommended prevention and health promotion services and have found the requirement to be unrealistically high.^16-20 Our study suggests that increased access to and use of health care services is a necessary but insufficient condition for achieving high up-to-date levels.

To improve up-to-date rates, likely actions will include more efficient use of office time, increased reliance on nonphysician clinicians, greater use of electronic medical records, and prioritizing services for a routine checkup. External policy changes, such as pay-for-performance, may also enhance preventive service delivery rates. We hope that, in time, the composite measure used in this analysis will be adopted by both primary care clinicians and public health practitioners in the same way that tracking composite children’s vaccination levels are helpful to family practitioners, pediatricians, and local health departments. However, there is probably no easy answer; even the prompts enabled by electronic medical records are useless when ignored by providers.²¹ Improving delivery of preventive services in office settings will require multiple strategies sustained over many years.²²

Community-based efforts. There is a strong rationale for a more determined policy to expand community-based access. Many community-based approaches to individual preventive services have been developed over the last 10 years.²³ For example, the CDC’s National Breast and Cervical Cancer Early Detection Program represents one model of a state-based program that can make local assistance available for uninsured women.²⁴ In addition, an evidence-based model developed by the nonprofit agency SPARC (Sickness Prevention Achieved through Regional Collaboration) suggests ways of creating community-based points of access for multiple preventive services.^25-27

Questions still unanswered. Although BRFSS data suggest older adults are regularly receiving “routine checkups,” it is not clear what kind of intervention this refers to beyond its nonacute nature. What characterizes routine checkups in patients’ minds, and how might such visits be limited as venues for providing preventive services? Furthermore, what are the characteristics of providers associated with different types of checkup services? How do primary care providers differ from subspecialists in the kinds of preventive services they provide? Answers to these questions have important implications for physician training and for targeted outreach to subspecialty groups. From a community standpoint, it would be helpful to know if there are specific untapped opportunities for delivering preventive services, particularly in underserved and minority communities where coverage rates are very low.

This study’s limitations. Because the BRFSS relies on self-reports, our findings are subject to various biases, including “telescoping,”²⁸ the tendency of people to remember events as having occurred more recently than they actually did.²⁹ Moreover, because BRFSS surveys exclude people in households without telephones (who are more likely to be poor and thus also less likely to have access to health care and preventive services), our estimates may be slightly higher than the true rates.³⁰ People with cell phone service only were not sampled; however, this had little impact on estimates for older adults, since just an estimated 2.2% use cell phones exclusively.³¹ People in institutions, such as nursing homes, which account for 3% to 4% of adults 65 and older were also excluded.³²

The strength of this study is that, based on a large sample of randomly selected respondents, it is the first report on the adoption of clinical preventive services in all states in relation to the use of routine checkups and a composite measure. However, as noted in the methods, although the interviewer provided a definition for the term routine checkup, the description may have been interpreted differently by survey respondents.

The provider’s office and medical home should remain at the center of a national strategy to increase the delivery of these services, but expanding these efforts to include community access is critical to improving overall rates of preventive services. We need more determined and strategic collaborations between medicine and public health that will facilitate access to, and use of, preventive services for all Americans.

CORRESPONDENCE 
Douglas Shenson, MD, MPH, 76 Prince Street, Newton, MA 02465; [email protected]

Just because elderly patients are having regular checkups does not necessarily mean they are receiving needed preventive services. For individuals who are ages 65 and older, such services include vaccinations against influenza and pneumonia, screenings for hypertension and hypercholesterolemia, and screenings for breast, cervical, and colorectal cancers.¹

Recently analyzed state and national data for a cluster of 5 of these services indicate that fewer than 41% of men and 32.5% of women ages 65 and older were up to date.² Time constraints on health care providers and a lack of knowledge about guidelines are perhaps 2 of the biggest barriers to widespread provision of disease prevention services. In this study we extended an earlier analysis and examined, for individuals 65 years of age and older, the association between having a recent checkup and being up to date on a cluster of recommended preventive services. We also propose steps that will likely be needed to increase receipt of preventive services.

Methods

Data source
The Behavioral Risk Factor Surveillance System (BRFSS), coordinated by the Centers for Disease Control and Prevention (CDC), conducts annual state-based telephone surveys of noninstitutionalized US adults ages 18 years or older concerning health practices.³ We used data from 2006 BRFSS participants ages 65 years or older at the time they participated (32,243 male respondents and 58,762 female respondents). All results were based on weighted data that accounted for different probabilities of selection and were adjusted to reflect the population distribution in each state by age and sex, or by age, race, and sex.

Respondents queried about preventive services
We analyzed responses to BRFSS questions about the receipt of clinical preventive services recommended by the US Preventive Services Task Force (USPSTF) or by the Advisory Committee on Immunization Practices for all adults ages 65 or older.* Services included colorectal cancer screening, influenza immunization, pneumococcal immunization, and, for women, mammography and the Papanicolaou (Pap) test. The USPSTF grades these measures* as A or B, meaning it finds “good” or at least “fair” evidence that a service improves important health outcomes and concludes that benefits substantially outweigh harms.⁴ Questions about these services were asked in all 50 states in 2006.

*The recommendations and grading systems discussed here reflect those that were in place in 2006. There have been changes to both since this study was conducted.

Cardiovascular services excluded. The BRFSS has not asked questions about hypertension screening since 1999, when more than 95% of older adults reported they had their blood pressure checked in the past 2 years.⁵ Questions about cholesterol screening were not asked in all states in 2006 and were not incorporated into the composite measure. However, analysis from a prior study suggests that including cholesterol screening levels in such a composite measure would not have made a large difference in the percentage of older Americans up to date on all services.²

Were scheduled intervals for services met? Adults could meet the recommendation for colorectal cancer screening by either having a fecal occult blood test (FOBT) within 1 year or colonoscopy or sigmoidoscopy within 10 years. The USPSTF and other national guidelines recommend a 5-year interval for sigmoidoscopy and a 10-year interval for colonoscopy.^6,7 However, no direct evidence has determined the optimal interval for either test,⁸ and the BRFSS question did not distinguish between the 2 interventions. Because either FOBT or endoscopy satisfies screening recommendations, we did not exclude respondents with missing values for 1 test if they had the other test within the recommended interval.

Other services and recommended intervals were pneumococcal vaccination (ever), influenza vaccination (in past year), and, for women, mammogram (within 2 years) and Pap test (within 3 years).

Assigning Yes or No to responses. If respondents had never received a particular preventive service or had received it outside the interval recommended by the USPSTF,⁴ we included them in the group answering No. We eliminated 3324 men and 6295 women with missing values for 1 or more measures.

Final determination of being “up to date.” After noting how many of the recommended services each individual had received according to age and sex, we dichotomized the sample according to whether all recommendations had been met—3 clinical preventive services for men 65 years and older (colorectal cancer screening, influenza, and pneumonia vaccination) and 5 for women (adding mammography and Pap test), with a single exception. Because Pap testing is often reported only for women with an intact cervix,⁹ we excused the lack of a Pap test for women who had undergone hysterectomy (47% of all women ages 65+, or 27,243). We required only that they meet 4 clinical preventive services to be considered up to date. A prior study revealed that excluding the Pap test entirely from the up-to-date measure for women 65 years and older had a minimal effect on up-to-date rates (34.2% when excluding the Pap test vs 32.5% including the Pap test).¹⁰

One of the strengths of the up-to-date measure is that it assesses the proportion of those fully up to date and thus allows for variability within subgroups, such as women who have had hysterectomies, without eliminating them arbitrarily from the sample.

Additional participant characteristics. We divided respondents into 4 racial/ethnic categories based on responses to BRFSS questions: White (non-Hispanic); Black (non-Hispanic); Hispanic of any race; or “Other” (American Indians, Asians, Pacific Islanders, and individuals of other or multiple race categories). Age categories were 65 to 69 years, 70 to 74 years, 75 to 79 years, or >80 years. Education categories: less than high school, high school graduate or general equivalency diploma recipient, some college, or college graduate. We further dichotomized the sample according to marital status, having 1 or more personal health care providers (vs none), and health status (fair/poor or good/very good/excellent). Given the amount of missing data (20%), household income was not included in the analysis.

Quantifying health care access. We created a measure of health care access using 3 factors:

• health insurance (“Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?”)
• one or more personal health care providers (see above)
• no cost barrier to seeing a doctor (“Was there a time in the past 12 months when you needed to see a doctor but could not because of cost?”).

To measure relative health care access, we scored each of the above items 1 for affirmative or 0 for negative. The sum (0, 1, 2, or 3) represented level of access. Lower numbers indicated more barriers and higher numbers represented greater access. Because only 48 older men and 59 older women had total scores of 0, the lower 2 levels were combined and the resulting 3 levels were termed “low” (0 & 1), “medium” (2) and “high” (3) access. Two of the measures used for health care access were also used to define 3 mutually exclusive health insurance categories: uninsured, fully insured, and underinsured (insured but reporting a cost barrier).²

We determined whether a routine checkup had occurred in the past 2 years by asking, “About how long has it been since you last visited a doctor for a routine checkup? A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition.”

Statistical analysis
We conducted statistical analysis using Stata, version 9.0 (Stata Corp; College Station, Tex). We used Pearson chi-square tests to determine whether selected demographic factors were associated with being up to date on all recommended services. We also used Stata in a logistic regression analysis to control simultaneously for age, education, race/ethnicity, marital status, insurance coverage, health care access, having one or more personal health care providers, having a routine checkup within 2 years, current smoking, and health status. We computed odds ratios and 95% confidence intervals for each variable in the model.

Results

Most adults ages 65 years and older were fully insured, had a personal health care provider, and reported no cost barrier to seeing a doctor in the past year (TABLE 1). Breaking out these measures into 3 levels of relative health care access, 88.6% of men and 90.2% of women were at the highest level. More than 90% of respondents reported having a routine checkup in the past 2 years. More than 60% reported receiving each of the separate immunizations and cancer screenings recommended for their age and sex, and almost all had received at least 1 service.

TABLE 2 shows the prevalence of being up to date by demographic group. Only 42.6% of all older men and 35.2% of all older women were up to date, with rates marginally better for those with high access to care (45.1% for men, 37% for women) or those reporting a recent routine checkup (44.8% for men, 36.8% for women). Low access to care yielded dramatically worse up-to-date rates (14.8% for men, 9.1% for women). Similarly, those reporting no recent routine checkup had poor up-to-date rates (20.5% for men, 15.4% for women). The highest rates of being up to date belonged to those with a college degree (49% for men, 42.1% for women). Higher rates were also found among the oldest age groups.

Results of the logistic regression analysis are shown in TABLE 3. Among men and women, being up to date was more likely for those who were older, married, better educated, had high access to health care, and had had a routine checkup in the past 2 years. The latter 2 groups had the highest odds ratios of all groups in the model. Less likely to be up to date were those who were Black, Hispanic, or of a race other than white, those who smoked cigarettes, and (for men) those who were in good or better health. For women, health status had no effect on being up to date.

Table 1
Characteristics of US adults ≥65 years, 2006 Behavioral Risk Factor Surveillance System

Table 2
Prevalence of being up to date* by demographic characteristics, US adults ≥65 years, 2006 Behavioral Risk Factor Surveillance System

TABLE 3
Results of multiple logistic regression modeling* for being up to date^†for cancer screening and adult immunization, by sex and demographic characteristics: 2006 Behavioral Risk Factor Surveillance System, adults ≥65 years

Discussion

The key finding in this study is that, although most adults ages 65 and older had high access to health care and recent routine checkups, their rates of being up to date with a recommended cluster of preventive services were only about 45% for men and 37% for women.

More than 91% of men and 93% of women reported they had a routine checkup during this timeframe, and 88.6% of men and 90.2% of women also reported they had high access to health care—ie, they had health insurance, at least 1 personal health care provider, and no cost barrier to seeing a doctor. Improving access to health care or increasing the use of routine medical checkups—even to 100%—would likely have a negligible impact on the delivery of recommended services. Despite the very modest composite delivery rates of recommended preventive services in this group, the rates were still 2 to 4 times higher than those of adults with low health care access or no recent routine checkup.

We also found that being up to date generally improves with age. Granted, there is uncertainty as to the appropriate age at which to stop specific screenings. And very elderly Americans may be receiving some services no longer of benefit. But the significance of our finding is that composite delivery rates were lowest among adults at the age for which broad consensus says services are beneficial. For example, the up-to-date rates for men and women ages 65 to 69 were 32% and 29.8%, respectively, compared with 48.7% and 40.2% for adults ages 75 to 79 (TABLE 2).

Our findings are consistent with research documenting inadequate time to incorporate preventive services into the typical office visit.^11,12 Similar barriers have been identified by general practitioners in the United Kingdom.^13,14 The time constraint is particularly consequential in high-volume primary care practices.¹⁵ Some investigations have calculated the actual or necessary time needed to deliver multiple recommended prevention and health promotion services and have found the requirement to be unrealistically high.^16-20 Our study suggests that increased access to and use of health care services is a necessary but insufficient condition for achieving high up-to-date levels.

To improve up-to-date rates, likely actions will include more efficient use of office time, increased reliance on nonphysician clinicians, greater use of electronic medical records, and prioritizing services for a routine checkup. External policy changes, such as pay-for-performance, may also enhance preventive service delivery rates. We hope that, in time, the composite measure used in this analysis will be adopted by both primary care clinicians and public health practitioners in the same way that tracking composite children’s vaccination levels are helpful to family practitioners, pediatricians, and local health departments. However, there is probably no easy answer; even the prompts enabled by electronic medical records are useless when ignored by providers.²¹ Improving delivery of preventive services in office settings will require multiple strategies sustained over many years.²²

Community-based efforts. There is a strong rationale for a more determined policy to expand community-based access. Many community-based approaches to individual preventive services have been developed over the last 10 years.²³ For example, the CDC’s National Breast and Cervical Cancer Early Detection Program represents one model of a state-based program that can make local assistance available for uninsured women.²⁴ In addition, an evidence-based model developed by the nonprofit agency SPARC (Sickness Prevention Achieved through Regional Collaboration) suggests ways of creating community-based points of access for multiple preventive services.^25-27

Questions still unanswered. Although BRFSS data suggest older adults are regularly receiving “routine checkups,” it is not clear what kind of intervention this refers to beyond its nonacute nature. What characterizes routine checkups in patients’ minds, and how might such visits be limited as venues for providing preventive services? Furthermore, what are the characteristics of providers associated with different types of checkup services? How do primary care providers differ from subspecialists in the kinds of preventive services they provide? Answers to these questions have important implications for physician training and for targeted outreach to subspecialty groups. From a community standpoint, it would be helpful to know if there are specific untapped opportunities for delivering preventive services, particularly in underserved and minority communities where coverage rates are very low.

This study’s limitations. Because the BRFSS relies on self-reports, our findings are subject to various biases, including “telescoping,”²⁸ the tendency of people to remember events as having occurred more recently than they actually did.²⁹ Moreover, because BRFSS surveys exclude people in households without telephones (who are more likely to be poor and thus also less likely to have access to health care and preventive services), our estimates may be slightly higher than the true rates.³⁰ People with cell phone service only were not sampled; however, this had little impact on estimates for older adults, since just an estimated 2.2% use cell phones exclusively.³¹ People in institutions, such as nursing homes, which account for 3% to 4% of adults 65 and older were also excluded.³²

The strength of this study is that, based on a large sample of randomly selected respondents, it is the first report on the adoption of clinical preventive services in all states in relation to the use of routine checkups and a composite measure. However, as noted in the methods, although the interviewer provided a definition for the term routine checkup, the description may have been interpreted differently by survey respondents.

The provider’s office and medical home should remain at the center of a national strategy to increase the delivery of these services, but expanding these efforts to include community access is critical to improving overall rates of preventive services. We need more determined and strategic collaborations between medicine and public health that will facilitate access to, and use of, preventive services for all Americans.

CORRESPONDENCE 
Douglas Shenson, MD, MPH, 76 Prince Street, Newton, MA 02465; [email protected]

Just because elderly patients are having regular checkups does not necessarily mean they are receiving needed preventive services. For individuals who are ages 65 and older, such services include vaccinations against influenza and pneumonia, screenings for hypertension and hypercholesterolemia, and screenings for breast, cervical, and colorectal cancers.¹

Recently analyzed state and national data for a cluster of 5 of these services indicate that fewer than 41% of men and 32.5% of women ages 65 and older were up to date.² Time constraints on health care providers and a lack of knowledge about guidelines are perhaps 2 of the biggest barriers to widespread provision of disease prevention services. In this study we extended an earlier analysis and examined, for individuals 65 years of age and older, the association between having a recent checkup and being up to date on a cluster of recommended preventive services. We also propose steps that will likely be needed to increase receipt of preventive services.

Methods

Data source
The Behavioral Risk Factor Surveillance System (BRFSS), coordinated by the Centers for Disease Control and Prevention (CDC), conducts annual state-based telephone surveys of noninstitutionalized US adults ages 18 years or older concerning health practices.³ We used data from 2006 BRFSS participants ages 65 years or older at the time they participated (32,243 male respondents and 58,762 female respondents). All results were based on weighted data that accounted for different probabilities of selection and were adjusted to reflect the population distribution in each state by age and sex, or by age, race, and sex.

Respondents queried about preventive services
We analyzed responses to BRFSS questions about the receipt of clinical preventive services recommended by the US Preventive Services Task Force (USPSTF) or by the Advisory Committee on Immunization Practices for all adults ages 65 or older.* Services included colorectal cancer screening, influenza immunization, pneumococcal immunization, and, for women, mammography and the Papanicolaou (Pap) test. The USPSTF grades these measures* as A or B, meaning it finds “good” or at least “fair” evidence that a service improves important health outcomes and concludes that benefits substantially outweigh harms.⁴ Questions about these services were asked in all 50 states in 2006.

*The recommendations and grading systems discussed here reflect those that were in place in 2006. There have been changes to both since this study was conducted.

Cardiovascular services excluded. The BRFSS has not asked questions about hypertension screening since 1999, when more than 95% of older adults reported they had their blood pressure checked in the past 2 years.⁵ Questions about cholesterol screening were not asked in all states in 2006 and were not incorporated into the composite measure. However, analysis from a prior study suggests that including cholesterol screening levels in such a composite measure would not have made a large difference in the percentage of older Americans up to date on all services.²

Were scheduled intervals for services met? Adults could meet the recommendation for colorectal cancer screening by either having a fecal occult blood test (FOBT) within 1 year or colonoscopy or sigmoidoscopy within 10 years. The USPSTF and other national guidelines recommend a 5-year interval for sigmoidoscopy and a 10-year interval for colonoscopy.^6,7 However, no direct evidence has determined the optimal interval for either test,⁸ and the BRFSS question did not distinguish between the 2 interventions. Because either FOBT or endoscopy satisfies screening recommendations, we did not exclude respondents with missing values for 1 test if they had the other test within the recommended interval.

Other services and recommended intervals were pneumococcal vaccination (ever), influenza vaccination (in past year), and, for women, mammogram (within 2 years) and Pap test (within 3 years).

Assigning Yes or No to responses. If respondents had never received a particular preventive service or had received it outside the interval recommended by the USPSTF,⁴ we included them in the group answering No. We eliminated 3324 men and 6295 women with missing values for 1 or more measures.

Final determination of being “up to date.” After noting how many of the recommended services each individual had received according to age and sex, we dichotomized the sample according to whether all recommendations had been met—3 clinical preventive services for men 65 years and older (colorectal cancer screening, influenza, and pneumonia vaccination) and 5 for women (adding mammography and Pap test), with a single exception. Because Pap testing is often reported only for women with an intact cervix,⁹ we excused the lack of a Pap test for women who had undergone hysterectomy (47% of all women ages 65+, or 27,243). We required only that they meet 4 clinical preventive services to be considered up to date. A prior study revealed that excluding the Pap test entirely from the up-to-date measure for women 65 years and older had a minimal effect on up-to-date rates (34.2% when excluding the Pap test vs 32.5% including the Pap test).¹⁰

One of the strengths of the up-to-date measure is that it assesses the proportion of those fully up to date and thus allows for variability within subgroups, such as women who have had hysterectomies, without eliminating them arbitrarily from the sample.

Additional participant characteristics. We divided respondents into 4 racial/ethnic categories based on responses to BRFSS questions: White (non-Hispanic); Black (non-Hispanic); Hispanic of any race; or “Other” (American Indians, Asians, Pacific Islanders, and individuals of other or multiple race categories). Age categories were 65 to 69 years, 70 to 74 years, 75 to 79 years, or >80 years. Education categories: less than high school, high school graduate or general equivalency diploma recipient, some college, or college graduate. We further dichotomized the sample according to marital status, having 1 or more personal health care providers (vs none), and health status (fair/poor or good/very good/excellent). Given the amount of missing data (20%), household income was not included in the analysis.

Quantifying health care access. We created a measure of health care access using 3 factors:

• health insurance (“Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?”)
• one or more personal health care providers (see above)
• no cost barrier to seeing a doctor (“Was there a time in the past 12 months when you needed to see a doctor but could not because of cost?”).

To measure relative health care access, we scored each of the above items 1 for affirmative or 0 for negative. The sum (0, 1, 2, or 3) represented level of access. Lower numbers indicated more barriers and higher numbers represented greater access. Because only 48 older men and 59 older women had total scores of 0, the lower 2 levels were combined and the resulting 3 levels were termed “low” (0 & 1), “medium” (2) and “high” (3) access. Two of the measures used for health care access were also used to define 3 mutually exclusive health insurance categories: uninsured, fully insured, and underinsured (insured but reporting a cost barrier).²

We determined whether a routine checkup had occurred in the past 2 years by asking, “About how long has it been since you last visited a doctor for a routine checkup? A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition.”

Statistical analysis
We conducted statistical analysis using Stata, version 9.0 (Stata Corp; College Station, Tex). We used Pearson chi-square tests to determine whether selected demographic factors were associated with being up to date on all recommended services. We also used Stata in a logistic regression analysis to control simultaneously for age, education, race/ethnicity, marital status, insurance coverage, health care access, having one or more personal health care providers, having a routine checkup within 2 years, current smoking, and health status. We computed odds ratios and 95% confidence intervals for each variable in the model.

Results

Most adults ages 65 years and older were fully insured, had a personal health care provider, and reported no cost barrier to seeing a doctor in the past year (TABLE 1). Breaking out these measures into 3 levels of relative health care access, 88.6% of men and 90.2% of women were at the highest level. More than 90% of respondents reported having a routine checkup in the past 2 years. More than 60% reported receiving each of the separate immunizations and cancer screenings recommended for their age and sex, and almost all had received at least 1 service.

TABLE 2 shows the prevalence of being up to date by demographic group. Only 42.6% of all older men and 35.2% of all older women were up to date, with rates marginally better for those with high access to care (45.1% for men, 37% for women) or those reporting a recent routine checkup (44.8% for men, 36.8% for women). Low access to care yielded dramatically worse up-to-date rates (14.8% for men, 9.1% for women). Similarly, those reporting no recent routine checkup had poor up-to-date rates (20.5% for men, 15.4% for women). The highest rates of being up to date belonged to those with a college degree (49% for men, 42.1% for women). Higher rates were also found among the oldest age groups.

Results of the logistic regression analysis are shown in TABLE 3. Among men and women, being up to date was more likely for those who were older, married, better educated, had high access to health care, and had had a routine checkup in the past 2 years. The latter 2 groups had the highest odds ratios of all groups in the model. Less likely to be up to date were those who were Black, Hispanic, or of a race other than white, those who smoked cigarettes, and (for men) those who were in good or better health. For women, health status had no effect on being up to date.

Table 1
Characteristics of US adults ≥65 years, 2006 Behavioral Risk Factor Surveillance System

Table 2
Prevalence of being up to date* by demographic characteristics, US adults ≥65 years, 2006 Behavioral Risk Factor Surveillance System

TABLE 3
Results of multiple logistic regression modeling* for being up to date^†for cancer screening and adult immunization, by sex and demographic characteristics: 2006 Behavioral Risk Factor Surveillance System, adults ≥65 years

Discussion

The key finding in this study is that, although most adults ages 65 and older had high access to health care and recent routine checkups, their rates of being up to date with a recommended cluster of preventive services were only about 45% for men and 37% for women.

More than 91% of men and 93% of women reported they had a routine checkup during this timeframe, and 88.6% of men and 90.2% of women also reported they had high access to health care—ie, they had health insurance, at least 1 personal health care provider, and no cost barrier to seeing a doctor. Improving access to health care or increasing the use of routine medical checkups—even to 100%—would likely have a negligible impact on the delivery of recommended services. Despite the very modest composite delivery rates of recommended preventive services in this group, the rates were still 2 to 4 times higher than those of adults with low health care access or no recent routine checkup.

We also found that being up to date generally improves with age. Granted, there is uncertainty as to the appropriate age at which to stop specific screenings. And very elderly Americans may be receiving some services no longer of benefit. But the significance of our finding is that composite delivery rates were lowest among adults at the age for which broad consensus says services are beneficial. For example, the up-to-date rates for men and women ages 65 to 69 were 32% and 29.8%, respectively, compared with 48.7% and 40.2% for adults ages 75 to 79 (TABLE 2).

Our findings are consistent with research documenting inadequate time to incorporate preventive services into the typical office visit.^11,12 Similar barriers have been identified by general practitioners in the United Kingdom.^13,14 The time constraint is particularly consequential in high-volume primary care practices.¹⁵ Some investigations have calculated the actual or necessary time needed to deliver multiple recommended prevention and health promotion services and have found the requirement to be unrealistically high.^16-20 Our study suggests that increased access to and use of health care services is a necessary but insufficient condition for achieving high up-to-date levels.

To improve up-to-date rates, likely actions will include more efficient use of office time, increased reliance on nonphysician clinicians, greater use of electronic medical records, and prioritizing services for a routine checkup. External policy changes, such as pay-for-performance, may also enhance preventive service delivery rates. We hope that, in time, the composite measure used in this analysis will be adopted by both primary care clinicians and public health practitioners in the same way that tracking composite children’s vaccination levels are helpful to family practitioners, pediatricians, and local health departments. However, there is probably no easy answer; even the prompts enabled by electronic medical records are useless when ignored by providers.²¹ Improving delivery of preventive services in office settings will require multiple strategies sustained over many years.²²

Community-based efforts. There is a strong rationale for a more determined policy to expand community-based access. Many community-based approaches to individual preventive services have been developed over the last 10 years.²³ For example, the CDC’s National Breast and Cervical Cancer Early Detection Program represents one model of a state-based program that can make local assistance available for uninsured women.²⁴ In addition, an evidence-based model developed by the nonprofit agency SPARC (Sickness Prevention Achieved through Regional Collaboration) suggests ways of creating community-based points of access for multiple preventive services.^25-27

Questions still unanswered. Although BRFSS data suggest older adults are regularly receiving “routine checkups,” it is not clear what kind of intervention this refers to beyond its nonacute nature. What characterizes routine checkups in patients’ minds, and how might such visits be limited as venues for providing preventive services? Furthermore, what are the characteristics of providers associated with different types of checkup services? How do primary care providers differ from subspecialists in the kinds of preventive services they provide? Answers to these questions have important implications for physician training and for targeted outreach to subspecialty groups. From a community standpoint, it would be helpful to know if there are specific untapped opportunities for delivering preventive services, particularly in underserved and minority communities where coverage rates are very low.

This study’s limitations. Because the BRFSS relies on self-reports, our findings are subject to various biases, including “telescoping,”²⁸ the tendency of people to remember events as having occurred more recently than they actually did.²⁹ Moreover, because BRFSS surveys exclude people in households without telephones (who are more likely to be poor and thus also less likely to have access to health care and preventive services), our estimates may be slightly higher than the true rates.³⁰ People with cell phone service only were not sampled; however, this had little impact on estimates for older adults, since just an estimated 2.2% use cell phones exclusively.³¹ People in institutions, such as nursing homes, which account for 3% to 4% of adults 65 and older were also excluded.³²

The strength of this study is that, based on a large sample of randomly selected respondents, it is the first report on the adoption of clinical preventive services in all states in relation to the use of routine checkups and a composite measure. However, as noted in the methods, although the interviewer provided a definition for the term routine checkup, the description may have been interpreted differently by survey respondents.

The provider’s office and medical home should remain at the center of a national strategy to increase the delivery of these services, but expanding these efforts to include community access is critical to improving overall rates of preventive services. We need more determined and strategic collaborations between medicine and public health that will facilitate access to, and use of, preventive services for all Americans.

CORRESPONDENCE 
Douglas Shenson, MD, MPH, 76 Prince Street, Newton, MA 02465; [email protected]

The basic function of a suicide assessment is to identify fixed and modifiable risk factors for suicide and existing or amendable protective factors.¹ Epidemiologic studies have defined a range of suicide risk and protective factors for the general population.² Other research has delineated suicide risk and protective factors for individuals with specific psychiatric disorders.³ The presence of disorder-specific risk and protective factors for suicide must be identified during suicide risk assessment.

Risk factors

Lack of support from family, peers, or the community is a critical concern. Noncompliance with treatment may be associated with onset of suicidality. Help-seeking is impeded by stigma associated with suicide and shame for past attempts. History of physical, sexual, or psychological abuse is tied to subsequent suicidal behavior. Alcohol abuse plays a role in suicide. Many patients who attempt suicide have backgrounds involving suicide loss or attempts by family members. Recurring psychiatric symptoms—particularly depression, anxiety, and panic—can trigger suicidality. Symptom relapse may lead to hospitalization, which is followed by a high-risk period after discharge.

These suicide risk factors can be summarized by the mnemonic UNSAFE:

Unconnected—no support; sense of not belonging or being a burden

Nonadherence—unmanaged mental illness or co-occurring disorders

Stigma/shame related to past attempts or suicidal behavior

Abuse history and/or alcohol misuse; prior attempt

Family history of suicide or suicide attempts

Exacerbations—worsened mental illness, hospitalizations

Protective factors

The presence of a personal crisis or safety self-help plan shows patient insight. Maintaining prescribed treatment indicates a patient’s likelihood of complying with clinical and self-care measures to avert future suicidality. Accessible support from family, peers, and the community demonstrates social integration. The recovery concept promotes these factors as well as wellness and resilience. Awareness of the warning signs of suicide and personal risk factors and precipitants is essential for self-help and help-seeking.

Protective factors for suicide can be summarized by the mnemonic SAFER:

Self-help skills, personal crisis/suicide prevention plan

Adherence to treatment plan

Family and community support

Education about risk factors, warning signs, and triggers for suicide

Recovery and resilience

In our emergency psychiatric facility the UNSAFE and SAFE mnemonics are posted next to the desk of the on-duty psychiatrist. Crisis center staff use these mnemonics to screen patients during psychiatric evaluations. Allied therapists use them during in-patient psychoeducation about suicidality. Peer specialists use them to help patients prepare personal safety plans.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufactures of competing products.

These mnemonics were developed by Tony Salvatore in consultation with Rocio Nell, MD, CPE.

The basic function of a suicide assessment is to identify fixed and modifiable risk factors for suicide and existing or amendable protective factors.¹ Epidemiologic studies have defined a range of suicide risk and protective factors for the general population.² Other research has delineated suicide risk and protective factors for individuals with specific psychiatric disorders.³ The presence of disorder-specific risk and protective factors for suicide must be identified during suicide risk assessment.

Risk factors

Lack of support from family, peers, or the community is a critical concern. Noncompliance with treatment may be associated with onset of suicidality. Help-seeking is impeded by stigma associated with suicide and shame for past attempts. History of physical, sexual, or psychological abuse is tied to subsequent suicidal behavior. Alcohol abuse plays a role in suicide. Many patients who attempt suicide have backgrounds involving suicide loss or attempts by family members. Recurring psychiatric symptoms—particularly depression, anxiety, and panic—can trigger suicidality. Symptom relapse may lead to hospitalization, which is followed by a high-risk period after discharge.

These suicide risk factors can be summarized by the mnemonic UNSAFE:

Unconnected—no support; sense of not belonging or being a burden

Nonadherence—unmanaged mental illness or co-occurring disorders

Stigma/shame related to past attempts or suicidal behavior

Abuse history and/or alcohol misuse; prior attempt

Family history of suicide or suicide attempts

Exacerbations—worsened mental illness, hospitalizations

Protective factors

The presence of a personal crisis or safety self-help plan shows patient insight. Maintaining prescribed treatment indicates a patient’s likelihood of complying with clinical and self-care measures to avert future suicidality. Accessible support from family, peers, and the community demonstrates social integration. The recovery concept promotes these factors as well as wellness and resilience. Awareness of the warning signs of suicide and personal risk factors and precipitants is essential for self-help and help-seeking.

Protective factors for suicide can be summarized by the mnemonic SAFER:

Self-help skills, personal crisis/suicide prevention plan

Adherence to treatment plan

Family and community support

Education about risk factors, warning signs, and triggers for suicide

Recovery and resilience

In our emergency psychiatric facility the UNSAFE and SAFE mnemonics are posted next to the desk of the on-duty psychiatrist. Crisis center staff use these mnemonics to screen patients during psychiatric evaluations. Allied therapists use them during in-patient psychoeducation about suicidality. Peer specialists use them to help patients prepare personal safety plans.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufactures of competing products.

These mnemonics were developed by Tony Salvatore in consultation with Rocio Nell, MD, CPE.

The basic function of a suicide assessment is to identify fixed and modifiable risk factors for suicide and existing or amendable protective factors.¹ Epidemiologic studies have defined a range of suicide risk and protective factors for the general population.² Other research has delineated suicide risk and protective factors for individuals with specific psychiatric disorders.³ The presence of disorder-specific risk and protective factors for suicide must be identified during suicide risk assessment.

Risk factors

Lack of support from family, peers, or the community is a critical concern. Noncompliance with treatment may be associated with onset of suicidality. Help-seeking is impeded by stigma associated with suicide and shame for past attempts. History of physical, sexual, or psychological abuse is tied to subsequent suicidal behavior. Alcohol abuse plays a role in suicide. Many patients who attempt suicide have backgrounds involving suicide loss or attempts by family members. Recurring psychiatric symptoms—particularly depression, anxiety, and panic—can trigger suicidality. Symptom relapse may lead to hospitalization, which is followed by a high-risk period after discharge.

These suicide risk factors can be summarized by the mnemonic UNSAFE:

Unconnected—no support; sense of not belonging or being a burden

Nonadherence—unmanaged mental illness or co-occurring disorders

Stigma/shame related to past attempts or suicidal behavior

Abuse history and/or alcohol misuse; prior attempt

Family history of suicide or suicide attempts

Exacerbations—worsened mental illness, hospitalizations

Protective factors

The presence of a personal crisis or safety self-help plan shows patient insight. Maintaining prescribed treatment indicates a patient’s likelihood of complying with clinical and self-care measures to avert future suicidality. Accessible support from family, peers, and the community demonstrates social integration. The recovery concept promotes these factors as well as wellness and resilience. Awareness of the warning signs of suicide and personal risk factors and precipitants is essential for self-help and help-seeking.

Protective factors for suicide can be summarized by the mnemonic SAFER:

Self-help skills, personal crisis/suicide prevention plan

Adherence to treatment plan

Family and community support

Education about risk factors, warning signs, and triggers for suicide

Recovery and resilience

In our emergency psychiatric facility the UNSAFE and SAFE mnemonics are posted next to the desk of the on-duty psychiatrist. Crisis center staff use these mnemonics to screen patients during psychiatric evaluations. Allied therapists use them during in-patient psychoeducation about suicidality. Peer specialists use them to help patients prepare personal safety plans.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufactures of competing products.

These mnemonics were developed by Tony Salvatore in consultation with Rocio Nell, MD, CPE.

Adolescents value confidentiality with their health care clinicians very highly. To support the opportunity for confidentiality, you should speak with female adolescents without a parent in the room for at least part of each visit. This fosters an honest conversation about the sensitive issues around contraception, including any intimate relationships, current or planned sexual activity, and the safety and protection afforded by contraception.

Girls are allowed to discuss sexually transmitted infections confidentially with their physicians, and hopefully can be offered a confidential discussion of their sexual activity as well. Ideally, a girl also feels comfortable talking with a parent about her concerns, but this scenario may not be an option for all your patients.

Begin with a discussion about relationships. Avoid preaching to them or asking blunt questions such as: “Hey, are you having sex?” Acknowledge that “sex” can refer to activities beyond sexual intercourse as well.

Ask your patients if they are in a relationship with a girl, a boy, or both. A teenager who is not heterosexual or is unsure will then know you are willing to discuss any specific concerns.

Make sure the teenager knows that abstinence is always the best protection against sexually transmitted infection and/or pregnancy.

Once you ascertain she is heterosexual or bisexual, is sexually active, and needs contraception, focus next on safety. Ask the patient: Are you doing anything to protect yourself against the consequences of sexual activity? Also ensure her participation in the intimate relationship is voluntary and free of any coercion, particularly among younger teenage girls.

There are multiple means of protection against sexually transmitted infections. Educate her that, aside from abstinence, the use of condoms is her best strategy. Make sure the girl understands that she is equally responsible for the proper use of condoms. If you take care of a lot of adolescents, it is reasonable to have a supply of condoms on hand so you can provide them.

Also consider providing a patient who is sexually active (or contemplating sexual activity) with a prescription for emergency, postcoital contraception. She could fill the prescription as needed, within 72 hours of sexual intercourse, to decrease the likelihood of pregnancy considerably. Even if she regularly uses a birth control method, this prescription provides a good backup plan.

Keep the child's developmental level in mind when discussing contraception and sexuality. In general, a 14-year-old girl who is sexually active or considering sex is vastly different from a 17-year-old patient. Also consider the patient and family's culture, ethnic, and/or religious background. For example, there are some religious groups where the kids cannot tell parents they have become sexually active – it could mortify the parents and be dangerous for the teenager.

Title X–funded projects are an option if a girl cannot tell her parent she wants to use contraception and/or if a third party (such as an insurance company) makes confidentiality impossible. Become familiar with the Title X–funded contraception projects in your area, which are frequently run through Planned Parenthood or a university obstetrics and gynecology program (www.hhs.gov/opa/familyplanning/index.html

You really should get to the point where you feel moderately comfortable talking about the basics of contraception and sexuality. There are not enough adolescent medicine specialists in the world to take care of all the teenagers out there, and most ob. gyns. do not see very many teenagers.

Some pediatricians may be comfortable prescribing the birth control pill, but they may not know much about the patch, the contraceptive ring, the implant, or the IUD. If a patient is interested in one of these options, you can refer her to a gynecologist or a family practitioner in your area who is particularly adept at young women's health issues. Planned Parenthood also is a good resource.

The birth control pill and the patch are the two most common birth control methods for first-time users. You do not need to know all the different types of birth control pills; it is sufficient to become comfortable prescribing one or two brands.

Check for any contraindications, such as a history of migraine headache with aura or a clotting abnormality (personal or in a first-degree relative) before prescribing oral contraception. If your patient is having regular, monthly periods, and she's had a period in the last month, some pediatricians still will feel comfortable prescribing only if they get a urine pregnancy test. On the other hand, if you give contraception without the test and the girl does miss her next period, you can always give the pregnancy test then.

If you prescribe contraception for sexual activity only, keep in mind that most teenagers have a passionate relationship that lasts a few months, followed by an interval without a relationship, followed by involvement with another person. These intermittent relationships mean that they are likely to start and stop contraception. Keep this in mind when discussing contraception options and monitor compliance with less-permanent options over time.

Children's Hospital of Boston produces www.youngwomenshealth.orgwww.acog.org/publications/patient_education/ab020.cfmaappolicy.aappublications.org/cgi/content/full/pediatrics;120/5/1135

Adolescents value confidentiality with their health care clinicians very highly. To support the opportunity for confidentiality, you should speak with female adolescents without a parent in the room for at least part of each visit. This fosters an honest conversation about the sensitive issues around contraception, including any intimate relationships, current or planned sexual activity, and the safety and protection afforded by contraception.

Girls are allowed to discuss sexually transmitted infections confidentially with their physicians, and hopefully can be offered a confidential discussion of their sexual activity as well. Ideally, a girl also feels comfortable talking with a parent about her concerns, but this scenario may not be an option for all your patients.

Begin with a discussion about relationships. Avoid preaching to them or asking blunt questions such as: “Hey, are you having sex?” Acknowledge that “sex” can refer to activities beyond sexual intercourse as well.

Ask your patients if they are in a relationship with a girl, a boy, or both. A teenager who is not heterosexual or is unsure will then know you are willing to discuss any specific concerns.

Make sure the teenager knows that abstinence is always the best protection against sexually transmitted infection and/or pregnancy.

Once you ascertain she is heterosexual or bisexual, is sexually active, and needs contraception, focus next on safety. Ask the patient: Are you doing anything to protect yourself against the consequences of sexual activity? Also ensure her participation in the intimate relationship is voluntary and free of any coercion, particularly among younger teenage girls.

There are multiple means of protection against sexually transmitted infections. Educate her that, aside from abstinence, the use of condoms is her best strategy. Make sure the girl understands that she is equally responsible for the proper use of condoms. If you take care of a lot of adolescents, it is reasonable to have a supply of condoms on hand so you can provide them.

Also consider providing a patient who is sexually active (or contemplating sexual activity) with a prescription for emergency, postcoital contraception. She could fill the prescription as needed, within 72 hours of sexual intercourse, to decrease the likelihood of pregnancy considerably. Even if she regularly uses a birth control method, this prescription provides a good backup plan.

Keep the child's developmental level in mind when discussing contraception and sexuality. In general, a 14-year-old girl who is sexually active or considering sex is vastly different from a 17-year-old patient. Also consider the patient and family's culture, ethnic, and/or religious background. For example, there are some religious groups where the kids cannot tell parents they have become sexually active – it could mortify the parents and be dangerous for the teenager.

Title X–funded projects are an option if a girl cannot tell her parent she wants to use contraception and/or if a third party (such as an insurance company) makes confidentiality impossible. Become familiar with the Title X–funded contraception projects in your area, which are frequently run through Planned Parenthood or a university obstetrics and gynecology program (www.hhs.gov/opa/familyplanning/index.html

You really should get to the point where you feel moderately comfortable talking about the basics of contraception and sexuality. There are not enough adolescent medicine specialists in the world to take care of all the teenagers out there, and most ob. gyns. do not see very many teenagers.

Some pediatricians may be comfortable prescribing the birth control pill, but they may not know much about the patch, the contraceptive ring, the implant, or the IUD. If a patient is interested in one of these options, you can refer her to a gynecologist or a family practitioner in your area who is particularly adept at young women's health issues. Planned Parenthood also is a good resource.

The birth control pill and the patch are the two most common birth control methods for first-time users. You do not need to know all the different types of birth control pills; it is sufficient to become comfortable prescribing one or two brands.

Check for any contraindications, such as a history of migraine headache with aura or a clotting abnormality (personal or in a first-degree relative) before prescribing oral contraception. If your patient is having regular, monthly periods, and she's had a period in the last month, some pediatricians still will feel comfortable prescribing only if they get a urine pregnancy test. On the other hand, if you give contraception without the test and the girl does miss her next period, you can always give the pregnancy test then.

If you prescribe contraception for sexual activity only, keep in mind that most teenagers have a passionate relationship that lasts a few months, followed by an interval without a relationship, followed by involvement with another person. These intermittent relationships mean that they are likely to start and stop contraception. Keep this in mind when discussing contraception options and monitor compliance with less-permanent options over time.

Children's Hospital of Boston produces www.youngwomenshealth.orgwww.acog.org/publications/patient_education/ab020.cfmaappolicy.aappublications.org/cgi/content/full/pediatrics;120/5/1135

Adolescents value confidentiality with their health care clinicians very highly. To support the opportunity for confidentiality, you should speak with female adolescents without a parent in the room for at least part of each visit. This fosters an honest conversation about the sensitive issues around contraception, including any intimate relationships, current or planned sexual activity, and the safety and protection afforded by contraception.

Girls are allowed to discuss sexually transmitted infections confidentially with their physicians, and hopefully can be offered a confidential discussion of their sexual activity as well. Ideally, a girl also feels comfortable talking with a parent about her concerns, but this scenario may not be an option for all your patients.

Begin with a discussion about relationships. Avoid preaching to them or asking blunt questions such as: “Hey, are you having sex?” Acknowledge that “sex” can refer to activities beyond sexual intercourse as well.

Ask your patients if they are in a relationship with a girl, a boy, or both. A teenager who is not heterosexual or is unsure will then know you are willing to discuss any specific concerns.

Make sure the teenager knows that abstinence is always the best protection against sexually transmitted infection and/or pregnancy.

Once you ascertain she is heterosexual or bisexual, is sexually active, and needs contraception, focus next on safety. Ask the patient: Are you doing anything to protect yourself against the consequences of sexual activity? Also ensure her participation in the intimate relationship is voluntary and free of any coercion, particularly among younger teenage girls.

There are multiple means of protection against sexually transmitted infections. Educate her that, aside from abstinence, the use of condoms is her best strategy. Make sure the girl understands that she is equally responsible for the proper use of condoms. If you take care of a lot of adolescents, it is reasonable to have a supply of condoms on hand so you can provide them.

Also consider providing a patient who is sexually active (or contemplating sexual activity) with a prescription for emergency, postcoital contraception. She could fill the prescription as needed, within 72 hours of sexual intercourse, to decrease the likelihood of pregnancy considerably. Even if she regularly uses a birth control method, this prescription provides a good backup plan.

Keep the child's developmental level in mind when discussing contraception and sexuality. In general, a 14-year-old girl who is sexually active or considering sex is vastly different from a 17-year-old patient. Also consider the patient and family's culture, ethnic, and/or religious background. For example, there are some religious groups where the kids cannot tell parents they have become sexually active – it could mortify the parents and be dangerous for the teenager.

Title X–funded projects are an option if a girl cannot tell her parent she wants to use contraception and/or if a third party (such as an insurance company) makes confidentiality impossible. Become familiar with the Title X–funded contraception projects in your area, which are frequently run through Planned Parenthood or a university obstetrics and gynecology program (www.hhs.gov/opa/familyplanning/index.html

You really should get to the point where you feel moderately comfortable talking about the basics of contraception and sexuality. There are not enough adolescent medicine specialists in the world to take care of all the teenagers out there, and most ob. gyns. do not see very many teenagers.

Some pediatricians may be comfortable prescribing the birth control pill, but they may not know much about the patch, the contraceptive ring, the implant, or the IUD. If a patient is interested in one of these options, you can refer her to a gynecologist or a family practitioner in your area who is particularly adept at young women's health issues. Planned Parenthood also is a good resource.

The birth control pill and the patch are the two most common birth control methods for first-time users. You do not need to know all the different types of birth control pills; it is sufficient to become comfortable prescribing one or two brands.

Check for any contraindications, such as a history of migraine headache with aura or a clotting abnormality (personal or in a first-degree relative) before prescribing oral contraception. If your patient is having regular, monthly periods, and she's had a period in the last month, some pediatricians still will feel comfortable prescribing only if they get a urine pregnancy test. On the other hand, if you give contraception without the test and the girl does miss her next period, you can always give the pregnancy test then.

If you prescribe contraception for sexual activity only, keep in mind that most teenagers have a passionate relationship that lasts a few months, followed by an interval without a relationship, followed by involvement with another person. These intermittent relationships mean that they are likely to start and stop contraception. Keep this in mind when discussing contraception options and monitor compliance with less-permanent options over time.

Children's Hospital of Boston produces www.youngwomenshealth.orgwww.acog.org/publications/patient_education/ab020.cfmaappolicy.aappublications.org/cgi/content/full/pediatrics;120/5/1135