Vaping: A New Risk
Nicotine is strongly addictive, but teens may be unaware of its risks, she said. In a 2018 study of 44,482 students at both public and private high schools conducted by the National Institute on Drug Abuse, 37% of seniors reported vaping, an increase from 28% the previous year.1 Dr. Gottlieb also shared images of e-cigarette advertising that used cartoons to market the devices and fruity flavorings that may appeal to children. Deadly lung injuries from e-cigarette use, typically occurring when users put cartridges that contain tetrahydrocannabinol (THC), the active substance in marijuana, in their devices, surged in 2019.2
“We need to share the information we have about nicotine with our teen patients. Nicotine can affect brain development. Nicotine harms areas of the brain that work on control, attention, learning, mood and impulse. It changes how the brain forms synapses regarding new skills. It’s really important to tell teenagers who are really interested in excelling in school about the effects of smoking, so they can make better decisions,” she said.
Let’s Talk About Sex
Discuss sexual behaviors with teenage patients sooner rather than later, said Dr. Gottlieb. A study has revealed 42% of girls and 44% of boys between 15 and 19 have had intercourse.3 Thus, healthcare providers should talk about contraception and the prevention of sexually transmitted infections with patients as young as 12.
Pediatric rheumatologists should also be aware of the high levels of victimization and bullying that teens who are lesbian, gay, bisexual, transgender or queer may face at school and in peer groups. “Ask your patients how they are managing. Realize that many of these kids mistrust healthcare professionals. Use gender-neutral terms and avoid assumptions about their sexuality or gender,” she said.
Kate’s Story: Binge Drinking, Anxiety
Eileen Pagano, MS, CPNP, a pediatric rheumatology nurse practitioner at Cohen’s Children Medical Center, shared the story of her patient, “Kate,” who was diagnosed with oligoarticular juvenile idiopathic arthritis at age 2 and uveitis in both eyes a year later. Kate’s therapy included joint injections, methotrexate and eye drops, and she developed persistent sleep problems. Between 8 and 14, she had regular infliximab infusions.
“As she grew up, developed and began menstruating, Kate had a surge of hormones that fueled all these behaviors that Dr. Gottlieb discussed, and this went on for about two to three years. It was a tricky time for her,” said Ms. Pagano. “She had a lot of difficulty sleeping, and she began displaying aggressive behavior at home toward her parents and her siblings.”
At 14, Kate was diagnosed with oppositional defiant disorder, and her rheumatology care team discontinued infliximab because of concerns about its potential cognitive side effects, said Ms. Pagano. At 15, Kate started intravenous abatacept treatment at home through a home health service, which controlled her disease but caused mouth sores. At 16, Kate’s cousin committed suicide, which disturbed the teenager, and she experienced an iritis flare. Kate’s methotrexate dose was increased, but by 16, she began missing doses and began binge drinking. She began vaping nicotine daily at 17, and continued abatacept infusions once she started college at 18. Kate had an abortion at 19, and later withdrew from school and quit taking all of her medications. Her arthritis flared. Now 22, Kate has stabilized her mental health with counseling, and after working two jobs to pay for her tuition, is now thriving at a new college.
“Kate was drinking at an early age and binge drinking often, although it was contraindicated with her methotrexate. Look at the reason for the child’s drinking. Kate chose alcohol because it was an effective anti-anxiety agent,” said Ms. Pagano. A regular exercise routine and counseling helped this patient deal with stress and improve her sleep over time.
“Establishing a rapport with your kids very early on so that you can take them through their adolescence is the most important advice. You’re not their parent, you’re not their friend, but make it clear that they can talk to you and that they can trust you,” she said.