Pediatric Annals

EDITORIAL 

A Pediatrician's View: Sexually Transmitted Diseases in Pediatric Practice

Robert A Hoekelman, MD

Abstract

Nothing is simple in pediatric practice any more. Forty years ago, pediatricians rarely, if ever, encountered sexually transmitted diseases (STDs) of any sort. Penicillin, introduced in the 1940s, reduced the incidence of syphilis and gonorrhea markedly in the years that followed so that congenital syphilis and neonatal gonococcal infections were not encountered by most practitioners.

But our world is different now. In the late 1960s, the sexual behavior of our population began to change: men and women were more likely to have multiple sexual partners; adolescents became more sexually active, to reach current levels of 50% of 16 year olds having had intercourse; homosexuals became more open about their sexual preferences, with their relationships likely increasing; intravenous substance abuse caused human immunodeficiency virus (HIV) transmission to the user and then to the user's sexual partners; and young drug-addicted women, including many teenagers, sold sex for drugs. Infants acquired STDs in utero or perinatally, and infants and children acquired them while being sexually abused. Many of the organisms that cause STDs developed resistance to antibiotic therapy; and, finally, improved diagnostic techniques led to the identification of a wider spectrum of STDs than we had known.

All of these things mean that we, as pediatricians, now have to be on the lookout for a variety of STDs acquired congenitally, through intercourse or other sexual acts among adolescents, or from the sexual abuse of children. And the list of organisms at which we have to look as causes of STDs has grown beyond the old standbys Treponema pallidum and Neisseria gonorrhoeae, which have been with us throughout recorded history. In fact, some that are with us now have been with us all along, but were not recognized as causes of STDs. The list now includes Chlamydia trachomatis, cytomegalovirus, herpes simplex virus types 1 and 2, hepatitis B and C viruses, HIV, human papillomavirus, Trichirnonas vaginalis, Ureaplasma ure* alyticum, and others that are suspected to be sexually transmitted, such as Candida albicans, Entamoeba histolytica, GardnereUa vaginalis, Giardia lamblia, molluscum contagiosum, Phthiñus pubis, and Shigella species. More surely will be added to the list.

Our Guest Editor for this issue of Pediatric Annals is Carole Jenny, MD, Associate Professor of Pediatrics at the University of Colorado Health Sciences Center. She has enlisted a group of authors who address four of these STDs - two old ones (syphilis and gonorrhea) and two newer ones (C trachomatis and human papillomavirus infections). They also provide us with information about the laboratory diagnosis of STDs and how to manage the child with an STD who has been sexually abused. It is not possible to cover all STDs in a single issue of this journal; the references listed at the end of this editorial provide a more comprehensive review of this extremely important subject.

Pediatricians have three tasks related to STDs encountered in their practices:

* To make the diagnosis. This requires a high level of suspicion when the signs and symptoms of STDs are present, no matter how slight or remote they may be. This, in turn, requires a thorough knowledge of 1 ) the pathophysiology and clinical manifestations of each STD, 2) how those manifestations may vary with the child's age, and 3) the sensitivity and specificity of each laboratory test used to confirm the diagnosis. The history and physical examination are paramount in pinpointing the clinical manifestations of STDs1 and the laboratory tests are essential in completing the diagnostic process. Great care must be taken in conducting each of these diagnostic elements to ensure that the patients and their parents are not traumatized emotionally and, thereby, become…

Nothing is simple in pediatric practice any more. Forty years ago, pediatricians rarely, if ever, encountered sexually transmitted diseases (STDs) of any sort. Penicillin, introduced in the 1940s, reduced the incidence of syphilis and gonorrhea markedly in the years that followed so that congenital syphilis and neonatal gonococcal infections were not encountered by most practitioners.

But our world is different now. In the late 1960s, the sexual behavior of our population began to change: men and women were more likely to have multiple sexual partners; adolescents became more sexually active, to reach current levels of 50% of 16 year olds having had intercourse; homosexuals became more open about their sexual preferences, with their relationships likely increasing; intravenous substance abuse caused human immunodeficiency virus (HIV) transmission to the user and then to the user's sexual partners; and young drug-addicted women, including many teenagers, sold sex for drugs. Infants acquired STDs in utero or perinatally, and infants and children acquired them while being sexually abused. Many of the organisms that cause STDs developed resistance to antibiotic therapy; and, finally, improved diagnostic techniques led to the identification of a wider spectrum of STDs than we had known.

All of these things mean that we, as pediatricians, now have to be on the lookout for a variety of STDs acquired congenitally, through intercourse or other sexual acts among adolescents, or from the sexual abuse of children. And the list of organisms at which we have to look as causes of STDs has grown beyond the old standbys Treponema pallidum and Neisseria gonorrhoeae, which have been with us throughout recorded history. In fact, some that are with us now have been with us all along, but were not recognized as causes of STDs. The list now includes Chlamydia trachomatis, cytomegalovirus, herpes simplex virus types 1 and 2, hepatitis B and C viruses, HIV, human papillomavirus, Trichirnonas vaginalis, Ureaplasma ure* alyticum, and others that are suspected to be sexually transmitted, such as Candida albicans, Entamoeba histolytica, GardnereUa vaginalis, Giardia lamblia, molluscum contagiosum, Phthiñus pubis, and Shigella species. More surely will be added to the list.

Our Guest Editor for this issue of Pediatric Annals is Carole Jenny, MD, Associate Professor of Pediatrics at the University of Colorado Health Sciences Center. She has enlisted a group of authors who address four of these STDs - two old ones (syphilis and gonorrhea) and two newer ones (C trachomatis and human papillomavirus infections). They also provide us with information about the laboratory diagnosis of STDs and how to manage the child with an STD who has been sexually abused. It is not possible to cover all STDs in a single issue of this journal; the references listed at the end of this editorial provide a more comprehensive review of this extremely important subject.

Pediatricians have three tasks related to STDs encountered in their practices:

* To make the diagnosis. This requires a high level of suspicion when the signs and symptoms of STDs are present, no matter how slight or remote they may be. This, in turn, requires a thorough knowledge of 1 ) the pathophysiology and clinical manifestations of each STD, 2) how those manifestations may vary with the child's age, and 3) the sensitivity and specificity of each laboratory test used to confirm the diagnosis. The history and physical examination are paramount in pinpointing the clinical manifestations of STDs1 and the laboratory tests are essential in completing the diagnostic process. Great care must be taken in conducting each of these diagnostic elements to ensure that the patients and their parents are not traumatized emotionally and, thereby, become resistant to further intervention, if required.

* To determine the mode of acquisition. This is critical in terms of deciding what treatment should be administered and what kind of follow-up is needed. For example, the management of congenital syphilis, diagnostically and therapeutically, differs from that of sexually acquired syphilis in adolescents and from that of syphilis acquired in a child from sexual abuse by an adult.

* To ensure that the appropriate treatment is instituted. This depends on the diagnosis that is made and how the STD was acquired. It goes beyond simply treating the patient for the disease per se, because depending on the circumstances of transmission, mothers, sexual partners, or sexual abusers will constitute the other half of the patient dyad. The treatment of each of these others also must be assured. In cases of sexual abuse, the perpetrators must be dealt with to ensure that repeated abuse does not occur and the victims must be provided counseling to minimize the emotional stress they have suffered and will continue to suffer for some time.

No matter how you look at it, primary care pediatricians will be caught in the middle when STDs occur in their patients. It will not be easy for them to complete the three tasks outlined above without assistance from their colleagues in the subspecialties of infectious diseases and laboratory medicine. In cases of suspected sexual abuse, they will need to report üSeir suspicions to the local child protective agency and work with a child psychologist and social worker team to sort out the detaib and provide appropriate counseling to the persons involved. Failure to report suspected cases of sexual or other abuse, or reporting cases in which the evidence of abuse is not convincing, places the pediatrician at risk for medical liability suits. Thus, caution and consultation should go hand- in-hand with one's concern for the child.

REFERENCES

1. Holmes KK, Mardh P, Sparling PE., et al, eds. Sexually Transmitted Diseases. 2nd ed. New York, NY: McGraw-Hill Information Services Co; 1990.

2. American Academy of Pediatrics Committee on Adolescence. Role of the pediatrician in management of sexually transmitted diseases in children and adolescents. Pediatrics. 1987,79:454-456.

3. American Academy of Pediatrics Committee on Child Abuse and Neglect. Guidelines for the evaluation of sexual abuse in children. Pediatrics. 1991;87:254Z60.

4. Centers for Disease Control and Prevention. 1993 sexually transmitted diseases treatment guidelines. MMWR. 1993;42(RR-14):99-I02.

5. American Academy of Pediatrics Committee on Infectious Diseases. Sexually transmitted diseases. In: Report of the Committee on infectious Diseases. 23td ed. EIk Grove Village, 111: American Academy of Pediatrics; 1994:103-110.

10.3928/0090-4481-19940701-05

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