From the Journals

AAP: Fertility, sexual function counseling should start early



General pediatricians and subspecialists need to provide early and ongoing counseling about infertility and sexual dysfunction for at-risk patients, the American Academy of Pediatrics (AAP) has said in its first-ever clinical report on how to address these potentially sensitive topics.

Examples of pediatric populations at risk for infertility/and or sexual dysfunction include those with hematologic and oncologic disorders such as genitourinary cancer, genetic disorders such as Down syndrome, rheumatologic disorders such as rheumatoid arthritis, and endocrine disorders such as diabetes.

Counseling should include discussion of possible management and psychosocial support options for patients who have conditions or who need treatments that might impair reproductive capacity or sexual functioning, according to the policy statement, published July 30 in Pediatrics.

“We want children to feel safe asking questions, as a lack of information can lead to inaccurate beliefs or distress over time, through young adulthood,” Leena Nahata, MD, a pediatric physician in the endocrinology division at Nationwide Children’s Hospital, Columbus, Ohio, and her coauthors, wrote in an AAP statement.

The policy statement lists five specific recommendations for counseling at-risk pediatric populations on fertility and sexual function:

1. Early discussion is essential, and should start either with parents in infancy, or at the soonest time point where the patient could be affected.

2. “Developmentally sensitive approaches” should be used to deliver complete information about patients’ conditions, accounting for changes in patients’ concerns, perspectives, and comprehension level as they mature.

3. Evidence-based interventions and recommendations should be used, and when evidence is not available, that information needs to be shared with families to facilitate decision-making.

4. Interdisciplinary teams need strategies to discuss risks and interventions in a “direct but sensitive manner” allowing time for questions and considerations; teams also should identify which provider will discuss each risk and potential intervention, and when those discussions will occur.

5. Documentation of discussions and their outcomes are critical to ensure clear communication between health care providers and smooth transition to adult care.

Although team physicians have the best grasp of relevant medical issues, behavioral health specialists are “best equipped” to comprehend cultural, developmental, and family psychosocial issues, and to engage children in decision making, according Dr. Nahata, also affiliated with the Ohio State University, Columbus, and her coauthors.

“By having ongoing discussions, we are more likely to establish a sense of safety and trust, while helping youth and family make informed decisions,” coauthor Amy C. Tishelman, PhD, of the departments of endocrinology and psychiatry, Boston Children’s Hospital and Harvard Medical School, Boston, said in the AAP statement announcing the new guidelines.

Gwendolyn P. Quinn, PhD, of the department of obstetrics and gynecology, New York University Langone Medical Center, served as a third coauthor of the report.

In the AAP statement, Dr. Quinn noted differences in child and adolescent counseling needs, stating that adolescents might express concerns about pregnancy or might need information on contraception to avoid sexually transmitted diseases.

By contrast, detailed discussions about sexual function or fertility might not be appropriate for younger children, who nevertheless might exhibit interest and curiosity in their bodies, and should be made comfortable to ask questions. Open-ended prompts such as “How are you feeling about your body?” could be helpful for children approaching adolescence, according to the policy statement.

Dr. Nahata, Dr. Quinn, and Dr. Tishelman reported that they had no financial relationships relevant to their report, no external funding, and no potential conflicts of interest to disclose.

SOURCE: Nahata L et al. Pediatrics. 2018 Jul 30. doi: 10.1542/peds.2018-1435.

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