VATTACHARYYA: Apr 21, 2007

PUBERTY……II

Puberty is an important period of biological changes that children go through as they move toward becoming adults. These changes typically occur earlier in girls than in boys. In addition to changes in their body and emotional changes, puberty includes maturation of their cognitive and moral development, and how they view themselves and others. It is important to talk with your children and prepare them for the changes that they are about to go through as they enter puberty and to begin to discuss sexuality education.

Puberty normally occurs in a series of five stages (Tanner stages) that typically begin within the ages of 8 and 13 for girls and 9 and 14 for boys. Puberty is consider early (precocious) if it occurs before the age of 8 years in girls and 9 years in boys. And puberty is considered late or delayed if it has not begun prior to the age of 13 years for girls and 14 years for boys. Recent studies have shown that puberty is occurring at an increasingly earlier age in children though.

The first sign of puberty in girls , which occurs at an average age of 10 1/2 years, is breast development (thelarche). This begins with breast budding, or the formation of small lumps or nodules under one or both nipples. These lumps may be tender and they may be different sizes at first. This is usually also the beginning of their growth spurt. Next, in about six months, pubic hair develops (adrenarche), although in some children, pubic hair is the first sign of puberty, and then axillary hair begins to grow. Over the next few years, breast size will continue to increase and there will be a progressive increase in development of pubic hair and the external genitalia, leading to the first period or menarche (occurring at an average age of 12 1/2 to 13 years), which usually occurs about two years after puberty begins and coincides with their peak in height velocity. Development continues and the whole process is completed in 3-4 years, eventually reaching adult breast and areolar size and an adult pattern of pubic hair. A child will have also reached her final adult height about two years after menarche.

Puberty generally begins later in boys, at an average age of 11 1/2 to 12 years. The first sign of puberty in boys is an increase in size of the testicles. This is followed a few months later by the growth of pubic hair. Puberty continues with an increase in size of the testicles and penis and continued growth of pubic and axillary hair. Boys undergo their peak growth spurt about 2-3 years later than girls. Also, this usually begins with an enlargement of the hands and feet and is later followed by growth in the arms, legs, trunk and chest. Other changes include a deepening of the voice, an increase in muscle mass, the ability to get erections and ejaculate (especially spontaneous nocturnal emissions or 'wet dreams'), and in some boys, breast development (gynecomastia). Development continues and the whole process is completed in 3-4 years, eventually reaching adult testicle and penis size and an adult pattern of pubic hair. This is followed by the development of chest and facial hair.

Attention Deficit Hyperactivity Disorder is a common disorder in adolescent children, with symptoms of inattention, and/or impulsiveness and hyperactivity. These symptoms should have been present before the age of seven, must be present in two or more different settings (school and home, for example), and should be causing some impairment in the child's functioning, including causing difficulty in school, or in social situations. If your child has the symptoms of ADHD, but it isn't causing any impairment in his functioning, then he doesn't have ADHD.

There are three main types of ADHD, including the Predominantly Inattentive Type, in which children have six or more of the following symptoms:
Fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities.

Has difficulty sustaining attention in tasks or play activities.

Does not seem to listen when spoken to directly

Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace.

Has difficulty organizing tasks and activities

Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort, such as schoolwork or homework.

Loses things necessary for tasks or activities, such as toys, school assignments, pencils, books or tools.

Is easily distracted by extraneous stimuli.

Is forgetful in daily activities.

Other children have a Predominantly Hyperactive Type of ADHD, and have six or more of the following symptoms:

Fidgets with hands or feet or squirms in seat.

Leaves seat in classroom or in other situations in which remaining seated is expected.

Runs about or climbs excessively in situations in which it is inappropriate.

Has difficulty playing or engaging in leisure activities quietly.

Is often 'on the go' or often acts as if 'driven by a motor'

Often talks excessively.

Blurts out answers before questions have been completed.

Has difficulty awaiting turn.

Interrupts or intrudes on others.

Children may also have a Combined Type of ADHD, having six or more symptoms of inattention and six or more symptoms of hyperactivity and impulsivity.

If you think that your child has ADHD, then you should set up an appointment with your Pediatrician to discuss it. Not all Pediatricians take care of children with ADHD, and if your doesn't, then you should ask for a referral to a psychologist, psychiatrist, or neurologist who does evaluate and treat children with this disorder.

There is no test available that will easily tell us if your child has Attention Deficit Hyperactivity Disorder, and your pediatrician must have as much information as possible to complete the evaluation. The evaluation will probably include having the parents and school teachers fill out ADHD ratings scales to see if your child has the symptoms described above. Be as detailed and descriptive as possible in filling out and describing your child's symptoms and ask the school to enclose copies of report cards, achievement tests, and results of any testing that has already been done. Also obtain copies of testing for ADHD or learning disabilities that have already been completed by other doctors.

ADHD Treatments:

Once your child has been diagnosed with ADHD it is important that you discuss with your physician the treatments that are available to help him or her succeed. Together you will decide on the proper therapy, which may include medical and non-medical interventions. The most important and most useful thing that you can do to help your child is to become educated on what ADHD is and isn't. There are many good books now available that can be used as reference guides to ADHD. You may also choose to join a local support group to talk with other parents of children of ADHD.

ADHD is now thought to occur in 3-5% of schoolage children and is more common in boys. It is not yet known what causes ADHD, but there does seem to be a genetic influence.

The mainstays of therapy for ADHD are medication when appropriate, behavior modification and educational remediation as needed.

Medical Treatments:

Many children with ADHD benefit from being on medication and it may help them to control their impulsiveness, increase their attention span, and be less hyperactive and less aggressive. There is, however, no 'miracle pill' to cure ADHD, and these medicines merely help to control the symptoms of ADHD. This is one of the reasons that the non-medical interventions described below are important.

The medicines that we most commonly use to treat ADHD are the stimulants, which include Ritalin (methylphenidate) and Adderall. These are quick acting (they begin working within 30-60 minutes), but also short acting (they only last 2-4 hours). Most children take a dose in the morning and another at noon to help control their symptoms at school. Some also require a third dose after school.

These medicines are controlled substances and a new prescription will need to be picked up each month and will expire within seven days. Your physician can not call these medicines in to the pharmacy or give you a refill, so you will either need an appointment or just a visit to your doctor's office each month to pick up a new prescription.

These medicines are generally safe with few long-term side effects. The most common side effects are having a poor appetite/growth, insomnia, mild headaches and stomachaches. Some children do better if they take their medicine after a meal, or by having 'drug holidays' on weekends or during summer, during which their growth can rebound. Also, a mid-afternoon snack may be helpful for those children with a poor appetite at lunch. The effect on appetite and growth seems to be worst during their first year on the medicines and they do not appear to permanently suppress a child's growth and should have no effect on their final adult height.

Your physician will probably begin a low starting dose, either twice a day or just in the morning. It would probably be best to start it on a weekend, so that you can note any side effects that occur. Your physician will then slowly increase the dose every few days or weeks until there is improvement in your child's symptoms. Please talk with your child's teacher and let your physician know how the medicine is working and when it appears to be wearing off.

Many physicians recommend taking the medicine every day at first, including weekends, until you find the right dose of medicine. If your child has benefited from medication and is not having side effects, then you may then allow him to take it everyday, including weekends and holidays. You may, however, be able to give your child a holiday from the medication on weekends and/or holidays if you wish, but discuss it with your physician first.

Sometimes the generic form of Ritalin does not seem to work as well as the brand name form, and your docotr may try switching forms if the medicine does not seem to be working well. About 70-80% of children with ADHD will respond to one of the stimulant medicine, but there are some children that do not respond to the first medicine that is started, and your physician may then change your child to another or try a different type of medicine altogether, such as an antidepressant, which also seem to help control the symptoms of ADHD.

Not all children with ADHD need to take medicine for the rest of their lives. It is now thought that adolescents and adults don't grow out of their ADHD, but rather learn better coping mechanisms to deal with it and some may not need to continue their medication.

Non-Medical Interventions:

It is important to understand that most of the time that you are with your child, before and after school, that they have no medicine on board to help control their impulsiveness, hyperactivity and distractibility. This is another reason that these non-medical interventions are so necessary.

Children with ADHD are at great risk for doing poorly in school and for having emotional and behavioral problems. It is very important to intervene as soon as possible if your child is showing any signs of depression, poor self esteem, or severe behavioral problems. Remember that many discipline techniques that work well with children who do not have ADHD may not work as well in your child with ADHD. He may benefit from individual and family therapy/counseling from a child psychologist who specializes in the care of these types of children.

Among the most important non-medical interventions are behavior modification to help your child to control their impulsiveness; setting clearly defined expectations and limits; trying to reward, praise and reinforce desired behaviors rather than the use of negative reinforcement and punishment for undersized behaviors; using token and reward systems; using simple (one-step) commands (especially for chores: don't tell them to clean their room, instead break it down into steps like making the bed, picking up toys, putting clothes away, etc.); using more immediate consequences for undesired behaviors (for example, it will probably not be an effective punishment to tell your child that he can't go to the movies the following week for doing something undesirable today, instead, restrict an activity, such as watching TV or playing videogames that same day). Other discipline techniques that may be effective include allowing your child to see the natural consequences of his actions (if he breaks a toy, then he can't play with it), logical consequences (if he doesn't put his toys away, then you will put them away and he can't play with them all day), withholding privileges (find things that your child enjoys, for example, playing Nintendo, renting movies, etc. and take them away when he misbehaves) and time out. Always remember to be firm, consistent, calm and loving in whatever discipline methods you choose.

Many children with ADHD have trouble making and keeping friends. This is often because they may talk too much, try to take charge of activities, are too intrusive and impulsive and don't always follow the rules. You can help your child make and keep his friends by observing and trying to improve bad behaviors, role-play or coach them through different scenarios, structure activities with only one or two other children, and intervene early if things are not going well.

Also, try to establish structure and organization by the use of lists, notes, reminders, and calendars and teaching them to break down large tasks into smaller ones; encouraging participation in extracurricular activities; and using social skills training. Try to prepare your child in advance for any changes that may occur in their routine, such as a family member visiting, a vacation or trip, etc, and learn to anticipate in what settings your child may have problems, such as shopping or going out to eat, and discuss a plan of action beforehand (including what the punishment will be for not complying).

You will not be able to change all of your child's behaviors and you should pick your battles to try to help them change the most bothersome or disruptive and try to ignore the more trivial ones. If they have a lot of trouble getting ready in the morning, for example, you can try to use a chart or schedule that lists all of the steps that they need to do to get ready, including getting up, washing, getting dressed, eating breakfast, taking their medicine, etc. and let them check off each activity as they do them. They can then be offered rewards or privileges for doing it correctly and on time for a certain number of days in a row.

There are also many interventions that can be used in the classroom and you can discuss these with your child's teacher. They include sitting close to the teachers desk and away from distractions; the use of written and oral instructions for assignments; giving only one assignment at a time; allowing more time for tests or taking untimed tests; the use of oral testing; shorter assignments; and the use of another student as a 'study-buddy' to help remind your child of assignments and what books to take home. Your child may also need specialized tutoring.

It can also be helpful to have a school-to-home notebook that will allow you and the teacher to discuss concerns you may have about your child, assignments and homework that is due, upcoming tests, and allow you to get feedback on how your child is doing, including daily or weekly school behavior report cards that report how well your child pays attention, follows directions, completes assignments and gets along with others, etc.

It is important for you to tell the school of the diagnosis of ADHD, because it is considered a disability under the Individuals with Disabilities Act and Section 504 of the Rehabilitation Act of 1973 for which public schools must make accommodations and other special services.

Monitoring:

Your child will probably have rechecks every few months too see how he is doing and to monitor for side effects of any medications he is on. Your physician may also have follow-up rating scale forms for use at home and at school.

Alternative Therapies:

There are many treatments that are claimed to be a 'cure' for ADHD that you may come across, especially if you are searching the Internet, and include herbal, vitamin and diet therapies. These are all scientifically unproven and potentially dangerous and you should be suspicious of any of them that do claim to 'cure' ADHD. Do some research before you spend a lot of money on one of these ‘miracles.'

Learning Disabilities:

Learning disabilities can affect how children listen, think, store, retrieve, write, read and communicate information or perform mathematical calculations, and can cause you to have a short attention span without having ADHD. Many children with ADHD may also have learning disabilities, and vice versa and if indicated your school or physician may recommend that further testing be done to look for a specific learning disability in your child.

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Clinical Growth Charts:

The clinical growth charts reflect modifications in the format of the individual charts, whereby two individual charts appear on a single page, and data entry tables have been added. The clinical charts have the grids scaled to metric units (kg, cm), with English units (lb, in) as the secondary scale. Clinical charts include the following:

Infants, birth to 36 months:

(1) Length-for-age and Weight-for-age

(2) Head circumference-for-age and Weight-for-length

Children and adolescents, 2 to 18 years

(3) Stature-for-age and Weight-for-age

(4) BMI-for-age

Preschoolers, 2 to 5 years

(5) Weight-for-stature

BMI-for-age charts are recommended to assess weight in relation to stature for children ages 2 to 18 years. The weight-for-stature charts are available as an alternative to accommodate children ages 2-5 years who are not evaluated beyond the preschool years. However, all health care providers should consider using the BMI-for-age charts to be consistent with current recommendations.

Infants, birth to 36 months:

Side 1: Length for age + Weight-for-age

Side 2: Head circumference-for-age + Weight-for-length

Children and adolescents, 2 to 18 years:

Side 1: Stature-for-age + Weight-for-length

Side 2: BMI-for-age or Weight-for-stature (age 2 to 5 years only)
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The 2000 CDC Growth Chart reference population includes data for both formula-fed and breast-fed infants, proportional to the distribution of breast- and formula-fed infants in the population. During the past two decades, approximately one-half of all infants in the United States received some breast milk and approximately one-third were breast-fed for 3 months or more. A Working Group of the World Health Organization is collecting data at seven international study centers to develop a new set of international growth charts for infants and preschoolers through age 5 years. These charts will be based on the growth of exclusively or predominantly breast-fed children.

What charts should be used for special populations?

The revised growth charts for the United States include data on low birthweight infants but do not include data on very low birth- weight infants (VLBW; less than 1,500 grams). Alternate charts are available to assess the growth of VLBW infants. The most recent are those developed from data collected in the National Institute of Child Health and Human Development Neonatal Research Network Centers (Ehrenkranz, 1999). However, these charts only extend to about 120 days uncorrected postnatal age or until a body weight of 2,000 grams is reached. Perhaps the best specific reference available for VLBW infants is the Infant Health and Development Program (IHDP) reference (Guo, et al. 1997; Guo, et al. 1996; and Roche, et al. 1997), although it has limitations. The IHDP growth charts may be considered to assess the growth of VLBW infants from an age corrected for gestation of 40 weeks to 36 months. However, the IHDP charts are based on data collected in 1985, which was before current medical and nutritional care practices were being used. Alternatively, the new 2000 CDC Growth Charts can be used to assess VLBW infants. Generally, their patterns of growth will be similar, but their measurements may fall in the lower percentiles.
A variety of health conditions affect growth status and there are specialized charts that may be considered for use with children affected by these conditions.These specialized growth charts provide useful growth references, but may have some limitations. Generally, they are developed from relatively small homogeneous samples and data used to develop the charts may have been obtained from inconsistent measuring techniques. One option is to plot the growth patterns of these children on both the specialized charts and the CDC growth charts. This will allow comparisons of growth to the general population of children and to the references for children identified with a given condition. In most cases, Body Mass Index-for-age charts are not available for special conditions and have not been validated for use with children whose body composition might differ from that of typical children. The CDC charts would provide a useful reference to monitor weight in relation to stature.

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WHO Child Growth Standards

The World Health Organization (WHO) released a new international child growth standard, April 27, 2006.

How you could help save millions of Mothers and Children's lives by filling in this survey

This survey is the first step of a project which we hope will raise significant sums of money to take the urgent action needed to reduce maternal, newborn and child deaths

Currently nearly 11 million children under 5 years and 600,000 women a year die, mostly in the developing world. One million new born babies never survive beyond 24 hours. These figures are quite shocking - but we can do something about it. You can help to change this, to save these mothers and children.

The World Health Organization, in collaboration with the African and Asian Development Banks, is launching "Give a little - save a life" to raise the money needed to help save millions of fragile lives. The concept is simple - "giving little but often". At this stage you can be a tremendous help simply by filling in this short survey.

We believe around the world there are millions of prosperous Africans and Asians who are serving their new communities and adding economic value to their adopted countries. We believe many of these successful individuals would welcome a reliable and above all, accountable means of giving a little back to help the less fortunate in their homeland. This survey could help confirm that belief.

Regular giving to save millions of mothers, children and babies from a preventable death is not difficult. Donating regularly through a credit card debit, a cash transfer or simply asking an employer to retain part of your salary is possible.

With the cooperation of the international development banks we can harness technology to collect tens of millions of dollars to help the vulnerable mothers and children in your own home country.

This is an opportunity for us all but without access to your networks, your expatriate communities and the fruits of your success we will never succeed.

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HIV/AIDS HIV/AIDS HIV/AIDS

HIV / AIDS is an important health issue in children and adolescents. Since the first clinical evidence of AIDS was reported two decades ago, HIV / AIDS has spread to every corner of the world.

Children and young people are at the center of the epidemic.

According to estimates by UNAIDS and WHO, more than four million children under the age of 15 have been infected with HIV since the epidemic began. More than 90% of them were infants born to HIV-positive mothers who acquired the virus before or during birth or through breastfeeding. Because HIV infection often progresses quickly to AIDS in children, most of the children under 15 who have been infected have developed AIDS, and most of these children have died. Another 13 million children have lost their mother or both parents to the disease.

An estimated 10.3 million young people aged 15-24 are living with HIV/AIDS, and half of all new infections – over 7000 daily – are occurring among young people. Young people are vulnerable to HIV because of risky sexual behaviour, substance use and their lack of access to HIV information and prevention services. Many young people do not believe that HIV is a threat to them, and many others do not know how to protect themselves from HIV.

Today, HIV / AIDS is still spreading rapidly. The epidemic is reversing development gains, robbing millions of people of their lives, widening the gap between rich and poor, and shattering young people’s opportunities for healthy adult lives.

Within the WHO Department of Child and Adolescent Health and Development (CAH), HIV / AIDS work is taking place in the following areas:

Preventing the transmission of HIV infection in neonates

Improving care and management of children with symptomatic HIV infection

Preventing and treating adolescents with HIV/AIDS

Children and Young People are at the Centre of the HIV/AIDS Epidemic

Children and young people are especially vulnerable to HIV infection for a host of social and economic reasons including poverty, sexual exploitation and violence, and lack of access to HIV information and prevention services.

HIV/AIDS will continue to affect the lives of several generations of children. The impact will mark their communities for decades as the numbers of impoverished children rise, their insecurity worsens, education and work opportunities decline, nurturing and support systems erode, and mortality rises. Large-scale, long-term efforts are needed to cope with these harsh new realities.

HIV/AIDS affects children in numerous and diverse ways:

In 2001 14 million children were orphaned by AIDS and the number risks being doubled by 2010 if the response to the epidemic is not scaled up. A great majority of these children will grow up living with extended families, or in foster care, or on their own and will be prone to discrimination, including access to health, education, and social services.

An estimated 11.8 million young people aged 13 – 24 are living with HIV in 2002.

Girls are particularly vulnerable; in many countries in sub-Saharan Africa, young girls have infection rates 5-6 times higher than boys of the same age group.

In 2001 alone, an estimated 800,000 children were newly infected with HIV – almost all through mother-to-child transmission.

The epidemic has forced vast numbers of children into precarious circumstances, exposing them to exploitation and abuse, and putting them at high risk of also becoming infected with HIV.

Children in households with a HIV-positive member suffer the trauma of caring for ill family members. Seeing their parents or caregivers become ill and die can lead to psychosocial stress, which is aggravated by the stigma so often associated with HIV/AIDS.

Many children are struggling to survive on their own in child-headed households, frequently carrying the burden of caring for family members living with HIV/AIDS.

Street children and other marginalized young people, as well as children in conflict situations, are also particularly vulnerable to HIV infection because they often do not have available to them the basic healthy environment – food, shelter, education and health services – through which they can protect themselves from HIV and other infectious diseases. Without adult guidance, life skills and means of sustaining their livelihood, these children become easy victims of exploitative and unhealthy child labour.

Increasing numbers of children are withdrawn from schools to care for ill parents or their siblings, thus losing opportunities for acquiring necessary life skills needed for them to create sound and healthy households and living environments.

Effective actions include:

Young people need a safe and supportive environment. This requires sensitive attitudes, policies and legislation at family, community and national levels. To build sturdy family and community systems capable of providing prevention and care will require material resources and skills-building.

Policy makers must recognize that the rights of children and young people, especially girls, must be protected and promoted; and that young people are critical resources for making HIV programmes meaningful to their peers and that information about HIV prevention is relevant to their everyday lives. The Convention on the Rights of the Child recognizes children as rights holders. Its provisions concerning rights to education, health, protection, non-discrimination, freedom from exploitation and abuse are all relevant to reducing the vulnerability of children and young people to the epidemic.

Strong and effective education systems accessible to children and young people in most vulnerable circumstances, such as orphans, young girls, and household heads, are important. Yet, in many countries, those systems are in disarray.

Wide-scale communication and social mobilization efforts are needed to broaden HIV/AIDS awareness within communities who are in the frontlines for providing prevention, care and support for children. Reducing the stigma and discrimination associated with HIV/AIDS is a fundamental element.

Enhancement of health care systems’ ability to address general children health needs, resulting in effective management of common childhood illnesses and prevention and treatment of opportunistic infections, can improve the quality of life of HIV-infected children.

HIV counselling and support of the children, their parents and siblings, can considerably improve their quality of life, relieve suffering and assist in the practical management of illness.

The most effective way to reduce the number of children infected with HIV is to prevent HIV infection in women of child bearing age, young people and adults in general. Next in line is prevention of unintended pregnancies in HIV infected women. Among women already infected with HIV, interventions to reduce the risk of transmission (Prevention of Mother To Child Transmission through prophylactic regimens and safe infant feeding) are an urgent priority.

Scaling up access to highly active antiretroviral therapy (HAART) for children will prolong and improve the quality of their lives, making paediatric HIV/ASRH

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Adolescent Sexual and Reproductive Health:

Sexual development is a normal part of adolescence. Fortunately, most adolescents go through these changes without significant problems. Nonetheless, all adolescents need support and care during this transition to adulthood, and some need special help.

The lives of millions of adolescents worldwide are at risk because they do not have the information, skills, health services and support they need to go through sexual development during adolescence and postpone sex until they are physically and socially mature, and able to make well-informed, responsible decisions.

The main issues in adolescent sexual and reproductive health are:

Sexual development and sexuality (including puberty)

Sexually transmitted diseases/ HIV/AIDS

Unwanted and unsafe pregnancies

The reasons that adolescents are at risk include:

Social and economic environment – For millions of adolescents, sex is linked with coercion, violence and abuse – sometimes even by family members or adults with privileged relations. In many societies, women are conditioned to be submissive to men, and they find it difficult or impossible to refuse early marriage, to space births, or to refuse to have unprotected sex with an unfaithful spouse or partner. Additionally, the social environment is critical to healthy adolescent development. There are key aspects of this environment, which can prevent adolescents from engaging in unsafe/unwanted sexual behaviour, for example, a strong relationship with parents, a connection to school and open communication with sexual partners.

Information and skills (life and livelihood) – In most countries, the great majority of adolescents are poorly informed about sexuality and reproduction. Often policy makers, public opinion leaders and parents believe that withholding information about sexuality and reproduction from young people will dissuade them from becoming sexually active. In fact, good quality sex education does not lead to earlier or increased sexual activity among adolescents. Adolescents need life skills in order to face the challenges of adulthood. During personal development, an adolescent’s competence develops whenever there are opportunities to practice certain skills by understanding and using social conventions. Adolescents also prioritise livelihood skills and opportunities as very important to them. Many adolescents are victims of exploitative sex because of lack of livelihood skills and opportunities.

Access to health services – Most adolescents (boys and girls, married and unmarried) become sexually active before the age of 16, but generally lack access to family planning services (including appropriate contraceptives), prevention and care of sexually transmitted diseases, or pregnancy care. For many young people, the opening times or location of services make them inaccessible, or the care is too expensive. Many health care facilities require the consent of parents or spouses, or may be forbidden by law to provide services to adolescents. In addition, the judgmental attitudes of many health care professionals often discourage adolescents from seeking advice and treatment related to sexual and reproductive health.

Intervention Areas:

The Common Agenda advocates the following specific measures to prevent unsafe sex and early childbearing among adolescents:

Create a safe and supportive environment through promoting delayed marriage and childbearing, expanding access to education and training, and providing income-earning opportunities.

Provide information and skills (life and livelihood) so that adolescents are better equipped to make good decisions.

Expand access to health services that are affordable, accessible, confidential, and non-judgmental.

Provide counselling for adolescents.

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Adolescent Health and Development

WHO discussion papers on adolescence

There is widespread acknowledgement that although adolescents share many characteristics with adults, their health-related problems and needs are different in a number of significant respects. There is a growing recognition among clinicians and public health workers alike that the approaches used to prevent and respond to health problems in adults need to be tailored (to a greater or lesser extent) if they are to meet the special needs of adolescents.

Unfortunately, even though WHO advocacy statements often draw attention to the particular vulnerabilities of adolescents (for instance to health problems resulting from unprotected and unwanted sexual activity, or from substance use) its guidelines on clinical management tend to be directed towards meeting the needs of adults or children. This is the justification for the systematic analysis of the recommendations given in these guidelines, with a view to examining whether or not these need to be tailored to meet the special needs of adolescents.

The Department of Child and Adolescent Health and Development (CAH) in collaboration with other WHO departments has initiated a process of reviewing the literature in order to identify existing recommendations on clinical management, and to assess how appropriate these are for adolescents across a wide range of health issues. In the short term, it is expected that this process will lead to the formulation of new recommendations (on clinical management) where none exist or where existing ones are inappropriate. In the medium to long term, the process is also expected to contribute to the improvement of existing WHO guidelines and algorithms (and possibly to the development of new ones, and other “work aids”) to enable health care providers (especially at the primary care level) to meet the special needs of adolescents effectively and with sensitivity.

The review process has now resulted in the production of a number of Discussion Papers and these have already provided the evidence used to develop WHO guidelines produced by CAH and other WHO departments. Examples include: CAH job aids for health workers working with adolescents; the Contraception Medical Eligibility Criteria; STI guidelines; the Essential Care Practice Guides (integrated management of pregnancy and childbirth (IMPAC), and a guide to decision-making for contraception); the Practical Approach to Lung Health (PAL); and the Integrated Management of Adolescent and Adult Illness (IMAI).

Discussion papers have been developed in the areas of: contraception; pregnancy care; sexually transmitted diseases; unsafe abortion; nutrition; lung health; and malaria. Others are now being developed on HIV/AIDS care; chronic illness; mental health; and substance abuse. Shortened versions have been or will be published in peer-reviewed journals in addition to the completed papers.

Over the past five years, significant efforts have been made to identify the major determinants of the outcomes of adolescent sexual and reproductive health (ASRH) interventions, and analysing “what works” in ASRH programming. A growing body of evidence is therefore being generated globally on the important determinants of early sexual initiation, safer sexual behaviours, and other important ASRH issues. A number of meta-reviews of programme effectiveness have been, and are still being, undertaken. However, despite the abundance of descriptions of programme activities, knowledge relating to the implementation of programmes (“what’s working”) remains limited by a lack of systematic analysis and documentation of programme experience.

This paper provides an overview of implementation issues in ASRH programming, and raises a number of the key questions and issues which need to be addressed. The review has been based upon the published literature and upon programme reports, curricula and articles on the implementation of ASRH programmes produced since 1996. Insights have also been drawn from discussions with programme managers.

SEX EDUCATION:

Three focus group discussions were held with the mothers of adolescent girls in an urban slum of Mumbai. A total of 32 mothers participated in the study. The aim of the study was to assess the attitude of mothers towards sex education and related issues of their adolescent daughters. The average duration of the focus group discussion conducted by the team, consisting of a moderator, an observer and a notetaker, was 70 minutes.

The mothers opined that all girls received school education. Education would enable the girls to be financially independent in times of crisis. Girls should go out for a job only when they have no alternative. As far as possible, they should try to earn money at home itself.

The mothers perceived that girls should be told about menstruation only after attaining menarche. The mothers told them that it was a monthly occurrence, and how they should maintain personal hygiene. They should not let their fathers and brothers know about it. The girls were told not to talk to the boys as they had grown up. No information was given about other physical changes. The girls were told at the time of marriage how they should behave with their parents-in-law, sister-in-law and husband. The girls should listen to them and do whatever they say. No information was given to the girls about what is intercourse, how conception occurred or what family planning measures were available.

Talking to boys was considered wrong according to the mothers. The girls could talk to boys in the neighbourhood and classmates provided that they were of good character and if the talk related to their studies. It was the responsibility of the mother to keep a check on her daughter’s activities.

The mothers were uncomfortable about imparting sex education to their daughters. According to them, the girls can get information through their friends and elder sisters. Doctors, health personnel and teachers could impart sex education. Sex education should be imparted to girls only after attaining menarche. The physiology of menstruation, conception and maintaining good interpersonal relationships with family members, especially those of the husband, should be taught to the adolescent girls as perceived by the mothers.

INTRODUCTION:

ADOLESCENCE is a crucial phase of life. It is a stressful period in which the adolescent tries to adjust to his/her varied physical, emotional and psychological changes. The adolescent is curious to ask many questions but the problem is: whom to address these questions? Since talking about sex is a taboo in the Indian society, the adolescents cannot freely approach his/her parents for guidance. Also, those who seek guidance from parents are not satisfied because the latter try to evade discussion or are not able to give satisfactory answers. A few of them try to gather information through books, films or from friends but a majority do not have access to such an information. Many a time, the adolescent receives wrong information and these myths and misconceptions are carried throughout their lifetime. Therefore, there is a need to provide adolescents with information so as to enable them to cope better with these changes. Though there is a need to educate the adolescents on sex education, parents oppose such educational programmes due to the fear that imparting sex education would lead to experimentation with sex. Any attempt to gather adolescent girls in the urban slum community of Mumbai for such a programme could be successful only after the mothers were approached, informed and convinced. The present paper narrates the experiences, attitudes and expectations of the mothers regarding adolescent health education programme.

Aim of the Study:

The objectives of the study were:

To assess the attitude of mothers towards imparting of sex education to their adolescent daughters;

To find out what information is imparted by mothers to their daughters at the time of menarche and marriage;

To find out the appropriate age for imparting sex education for adolescent girls as perceived by the mothers, and

To find out what the contents of sex education should be according to the mothers.

Materials and Methods :

This particular study was conducted in an urban slum, Malavani, situated in the north-west part of Mumbai. The urban slum has been adopted by the Department of Preventive and Social Medicine, KingEdwardMemorialHospital, as a field practice area. The slum population consists predominantly of Muslims.

Through community health workers a group of 9-12 women having adolescent daughters were invited to participate in the focus group discussion (FGD). Three such focus group discussions were conducted in the community with an average duration of 70 minutes. Guidelines for Focus Group Discussion were prepared to assist in conducting the focus group discussion. The guidelines contained questions pertaining to-

Scope of education and job opportunities for girls

Sex education:

What information is imparted by the mother to the girl at the time of attaining menarche and marriage?

Whether to be imparted or not?

At what age should it be imparted?

What should be the contents?

Who should impart sex education?

Marriage

Girl-boy relationship

Attitude towards an unmarried adolescent girl.

In order to make the mothers feel at ease, the discussion started with the introduction of each of the participants. The mothers may not answer properly if questions directly pertaining to their daughter are asked, on such a sensitive issue. Therefore the mothers were asked to discuss about themselves when they were adolescents and, later on, the questions were directed towards their adolescent daughters.

A team comprising one moderator, one note-taker and one observer was formed for conducting the focus group discussion. The moderator introduced herself, the note-taker and the observer to the participants. The moderator explained the aim of the group discussion to the participants who were then asked to introduce themselves.
The rules of the focus group discussion were explained to them-
As far as possible, only one person should talk at a time so that each participant could be heard clearly.
It was important that each one of the participants takes part in the group discussion so as to make it lively and enriching.
The participants were informed that the discussion would be recorded in writing by the note-taker so that this information could be used in developing the educational programme for the adolescent girls.

After this initial introduction, with the help of the FGD guidelines, the moderator conducted the FGD. The proceedings of FGD were recorded in writing by the note-taker. The documentation of the proceedings of the FGD was used in assessing the attitude of the mother towards sex education, formulating interview schedule and Information Education and Communication package.

Results and Observations:

There were 9-12 participants in each group with ages ranging between 30 and 45 years. The majority of the participants were illiterate. There were a total of 32 participants.

Attitude of mothers towards education of girls

All the participants felt that education was important.

“A minimum of S.S.C. (Secondary school certificate) is a must for all. If she wants to study further, she may continue.”

Some mothers had discontinued their daughters’ study after seventh standard and had cited the following reasons for doing so:

“Because of financial constraint”

“Schools do not give them proper education. As a result, we have to send our children for tuition. We don't have so much money to spend on tuition. Therefore, by seventh or eighth standard we discontinue their studies and put them into vocational training classes. Here they will be able to learn the skills to make themselves financially independent to a certain extent.”

The participants felt that girls should be financially independent to face any crisis in life.

“Girls need to be independent as one never knows what kind of a husband she will get. If her husband leaves her, she should be able to earn money herself.”

The participants were reluctant to send their daughters to work as they felt it was not safe. They felt that, as far as possible, the girls should try to earn money at home. In circumstances where there was no alternative, the girls could go out to seek a job.

“Girls can earn money by taking tuition at home.”

“If it is not possible to earn money by staying at home, then she should go out for a job.”

“If the character of the girl is good and she is not going to behave irresponsibly, she can go out for a job.”

Attitude of mothers towards marriage of their daughters:

Opinion was divided opinion amongst the participants regarding marriage of their daughters. Some felt that it was essential to take into consideration the girl’s opinion about marriage whereas some had still a very conservative attitude.

“Nowadays girls choose their own partners.”

“If parents choose the husband for their daughters without taking their opinion, they blame the parents if any marital problems occur later.”

“Sometimes girls threaten to commit suicide or she may elope with the boy. It is better that we get the girl and the boy married rather than losing our daughter.”

“If the girl chooses her own life partner, we will try to explain to her, but if she refuses to listen, we will resort to beating.”

“The right age for marriage is 16-20 years as the girl matures and can think what is right and what is wrong for herself.”

Information imparted by mothers regarding menstruation:

The girls were not given any information about the physiology of menstruation and other physical changes occurring in the body.
“We will tell her it is a monthly occurrence, how she should maintain hygiene. She should not let her father and brother come to know about it.”

“One of the participants’ daughter complained of pain in the chest during breast development for which the participant told her that it happens and she should not mention it to anybody.”
“Girls should be told about menstruation only after attaining menarche.”
“If the girl is told about menstruation before attaining menarche, then she will keep asking us constantly about when she will start her menses.”
Knowledge about menstruation was poor among the participants. This was admitted by the mothers.
Even if our daughter asks us more questions, we are not able to clarify their doubts as we ourselves do not know.”

Information imparted by mothers at the time of marriage:

At the time of marriage, the girls were only told about maintaining good relations with members of the husband’s family.
“I will talk to her about how she should behave with her family.”
“We will tell her that she should listen to her husband and parents-in law.”
“Nowadays girls already know a lot; there is no need for us to tell them. If they do not know, they will ask their friends.”
“We cannot tell the daughter about the number of children she should have as it depends on her husband and in laws.”
“If she has any health problem after marriage (pregnancy, abortion), then I will give her guidance.”

Attitude of mothers towards girl-boy relationship:

The girl is told not to talk to boys as she was now a grown-up. Talking to boys was considered wrong.
“If I find my daughter talking to a boy, I will explain to her that it is wrong and that she should not talk to boys. If she does not listen to me, then I will beat her; her father will also beat her.”
“Girls can only talk to boys in their neighbourhood.”
“If the boy is her classmate, she can talk to him.”

Attitude of mothers towards an unmarried girl
Though the participants felt that both the girl and the boy were responsible, the girl was the one who is to be blamed.
“Both the girl and the boy are to be blamed.”
“It is the girl’s fault.”
“It is the mother's responsibility to see that her daughter does not commit any mistake.”
“Society always blames the girls; so we have to see that our daughter does not commit any such mistake and therefore we have to place restrictions on girls.”

Attitude of mothers towards imparting sex education:

The mothers were reluctant to talk about sex education to their daughter as they found it embarrassing to discuss these issues.
“If girls are given sex education, the girls become smart (hoshiyaar) and may experiment with sex.”
“My daughter is innocent, how can I talk to her about sex. It will create a bad impression on her mind.”
“I cannot tell my daughter about such things. It is embarrassing for us. Such information could be got from friends, elder sister and sister-in-law.”

Who can impart sex education?

There was a general consensus in all the groups that sex education should be imparted by doctors, teachers and health personnel. Information could also be gathered from friends and elder sisters.

What should be the contents of sex education?

The mothers felt that information should be imparted on menstruation and conception. The girls should also be told about how to behave with their husband’s family.

Discussion:

A programme of family life education should consider political and socio-cultural implications. One of the prerequisites for starting a programme on family life education for young people is the mental preparation of the adult population, especially the parents.1

In 1989-90, the Family Planning Association of India, Pune branch, carried out a study of the opinion of parents on problems of introducing family life education courses in secondary schools. 89.3% of the parents felt that there was a definite need for family life education in secondary schools.2 The level of communication between the parents and their adolescent children in homes in Nigeria was studied. Only a few aspects pertaining to family life education were discussed by the parents. Mothers were initiators of family life education in a majority of the families. Some parents did not feel competent and others felt that raising such issues might encourage undesirable behaviour by youth.3

The present study shows that mothers have a favourable attitude towards sex education/ family life education. Incorporating topics, such as importance of the family, marriage and related values, would enhance the favourable attitude of mothers towards such programmes. Poor knowledge about issues like changes which takes place during adolescence, conception, family planning and a feeling of embarrassment to discuss these issues hinder communication between the mother and the adolescent daughter. There is a need, therefore, to improve the knowledge and communication skills of mothers to enable them to be effective in imparting family life education.

The study also shows that mothers have more or less realized the importance of formal school education. If the education provided through regular schools is strengthened, more girls can easily pass their exams. Schooling of girls can then easily continue up to the SSC level. The mothers feel that vocational training is of more value than formal schooling. Home-based income generation opportunities would be more welcome.

If opportunities for vocational training for girls are strengthened at the community level, they would open a wide channel for adolescent health education programme, specially for girls. In such a programme, all the components of family life education i.e. reproductive and child health, family system and marriage in its right perspective, can be presented to adolescent girls. It would not only be acceptable to the parents but would also empower tomorrow’s women and potential mothers. It will further make pregnancy special and safe.

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Boys and Puberty

Q. My son is in the seventh grade and is very small compared to his friend. He doesn’t seem to be showing any signs of puberty. Should I be concerned?

A. Boys and girls begin and end puberty at all different ages. What is considered 'normal' or typical varies a great deal. To get a better idea of how much variation is considered normal, it is important to understand how puberty is assessed.

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• Puberty and Girls

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• Puberty
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Puberty, the natural progression from a child-like physique to an adult body, begins with hormonal signaling between the gonads (the testes in the case of boys) and a part of the brain called the hypothalamus and the pituitary gland. In boys, puberty usually begins between 9 and 14 years of age (This is an important point to make as ethnicity apparently influences the average age at which puberty begins both for boys and girls.) If there is evidence of testicular enlargement before the 9th birthday or no evidence of pubertal changes by the 13th birthday, then those are reasons for concern and must be evaluated.

The first physical change that is noted in a boy is the enlargement of the testes and the lengthening of the penis. In the second stage of pubertal development, the skin over the scrotum begins to thin and redden and there is the beginning of a sparse amount of pubic hair at the base of the penis. Because most parents are no longer seeing their children fully undressed in early adolescence, these very early changes in boys may not be noticeable to the parent.

The third stage of puberty begins when there is increased amount of pubic hair that is noticeably coarser and darker than before. It is at this point that the peak height velocity or 'growth spurt' usually begins. This is the most obvious physical change and is typically about two years after the onset of the very first signs of puberty. The 'growth spurt' lasts about two to three years. A boy achieves about 25% of his final adult height during the growth spurt, and he will gain an average of 3.5 inches a year during this time. This compares to 2.3 inches per year in the prepubertal male. Another common occurrence in the third stage of puberty is the development of breast tissue. This is called gynecomastia, and it can be on one or both sides. For most boys this is a passing change that will spontaneously improve if the breast tissue is less than 1.5 inches across.

After the onset of the third stage of puberty, boys also gain in muscle mass, the voice deepens, acne frequently becomes bothersome. The fourth and fifth stages of pubertal development are marked by increased in pubic, axillary, and body hair as well as further enlargement of the penis and testes. For boys there is also a 'strength' spurt related to the increased muscle mass. Final height is usually achieved during the final stages of puberty. A look at the growth charts for boys ages two to eighteen can give you some sense of where your son fits in with his peers with regard to height and weight.

Because puberty is a complex period of growth and development, reassurance about what is normal is important. If you are at all concerned about whether or not your son has begun pubertal development, have him seen for a well-child check and ask that your pediatrician assess this for you. Books about puberty are readily available.

Male breast growth can have a major emotional impact on a young man. There is just something about protruding breasts in a male that can result in teasing from peers. Typical behavior is to hide the chest when in public or shun others. Those bothered by the problem avoid swimming, taking their shirts off, and other activities where others can see their breasts. Many do not discuss their concerns with parents, peers, and do not understand the problem. Starting that dialog is important.

Gynecomastia is a common condition affecting between 40 and 60% of all males. Breast development easily happens during adolescence and may have many possible causes. It can appear as a small lump just under the areola (colored skin around the nipple). During growth, this mass can be tender.

Gynecomastia is usually secondary to the normal hormonal imbalances between testosterone and estrogen that commonly occurs during puberty (pubertal gynecomastia) and it may affect up to 40% of adolescent boys during puberty, usually by the age of 14. In these children, the breast tissue is usually less than 4 centimeters in diameter and will disappear without treatment in two years in 75% of children and within 3 years in 90% of children. Although usually normal, your child with gynecomastia should still have an evaluation with your Pediatrician. You and your Pediatrician should reassure your teenager that this is normal and in most cases should disappear within a few months or years without treatment.

Sometimes, treatment may be required if he has very large breast development, if it is not regressing, or if it is causing a lot of stress or anxiety in your child. Male breast growth that has not stopped by three years, may not go away. In these situations, an evaluation by an experienced Plastic Surgeon can be helpful, either to provide further reassurance or to surgically remove the breast tissue. Surgical sculpture in skilled hands can be a simple solution for this problem.

Gynecomastia can also be a side effect of some medications and drugs. The most common medication that causes breast development is estrogen, and its effects can be seen in a child who ingests estrogen pills, or even if a family member is using an estrogen cream and has prolonged contact with him. Other medications can include certain antidepressants, drugs used to treat high blood pressure and tuberculosis, and some chemotherapy agents. Street drugs that may cause gynecomastia include marijuana, heroin and alcohol. Anabolic steroids can also stimulate male breast growth.

There are also some diseases that can cause gynecomastia, including certain endocrine disorders, tumors and chronic diseases. Klinefelter's Syndrome is one such problem where there is an extra chromosome that can impair testosterone production and development of male characteristics (more information). Early recognition and appropriate treatment can be very important.

You should also see your Pediatrician if your child has breast development, but hasn't started puberty yet, or if it occurs before he is nine years old. However, if your child is otherwise growing and developing normally, has started puberty and now has gynecomastia, then he is very likely to just have pubertal gynecomastia and no further evaluation or treatment will be necessary after you see your Pediatrician.

What are ... the first signs of puberty?
Puberty is a process that begins at different times in different children, but once puberty starts, it should follow a regular set of stages. In girls, puberty usually begins between the ages of eight and thirteen, with an average age of ten years. The first sign of puberty in girls is breast budding and then growth of pubic hair. Breast development is followed a year later my a growth spurt. Menarche, or your child's first period, usually occurs about two years after puberty begins. Remember that periods may be irregular during the first few years after menarche. The stages of puberty progress as your child gets older and include continued breast enlargement and pubic hair growth.

Boys usually begin puberty the age of eleven, but it may occur at an age as early as nine or as late as fourteen. The first sign that a boy is entering puberty is enlargement of the testis. This is followed by stages which include continued enlargement of the testis and penis and pubic hair growth. Boys also go through a growth spurt about two years after puberty begins.

You should talk to your teenager about the changes that their bodies are going to go through before they start to go through puberty so that they are not surprised by these changes. Your teen should understand that these changes are normal.

Kallman Syndrome

Kallman syndrome is a rare, genetic disorder that involves the hypothalamus, an area of the brain that is needed for normal sexual development, causing a hormone deficiency, which leads to a failure to go through puberty. This disorder is more common in males and it also associated with a decreased or absent sense of smell (anosmia). Most children are diagnosed when being evaluated for failure to begin puberty.

Although there is no cure or treatment for the absent sense of smell, children can be treated with hormone replacement therapy to help them go through puberty and fertility treatments if they have the desire to have children.

People with Kallman syndrome are also at risk for osteoporosis, or brittle bone disease. Strong bones are produced with the help of the hormones testosterone and estrogen, which are lacking in children with Kallman Syndrome, and they may therefore have weak bones that are prone to breaking. The risk of osteoporosis can be greatly decreased with hormone replacement therapy. Other characteristics of people with Kallman syndrome include gynecomastia, bimanual synkinesis (mirror movements of one hand copying the movements of the other hand), having a shortened fourth metacarpal bone (giving the appearance of an absent knuckle on the ring finger), and unilateral renal agenesis (an absent kidney).

Kallman syndrome can be inherited, usually from a child's mother through the X chromosome, if there is a family history of this disorder. It can also occur as a new occurrence, meaning it was not inherited, in children without a family history.

Testing is usually done to check hormone levels in the blood, especially the testosterone, FSH and LH levels. A MRI of the head will probably also be done and because of the risk of osteoporosis, bone density measurements will be done periodically.

Treatment is by hormone replacement, including testosterone replacement for men, which consists of weekly injections of testosterone and other hormonal therapies if he wants to be fertile. Women are also treated with hormone replacement, including estrogen and progesterone or birth control pills to stimulate menstrual cycles, and fertility treatments if she wants to get pregnant.

Klinefelter Syndrome

Boys normally have 46 chromosomes, including one X and one Y chromosome (46, XY). Girls also have 46 chromosomes, including two X chromosomes (46, XX).

Gynecomastia

School Performance

Children with Klinefelter syndrome have one or more extra X chromosomes. It occurs in about 1 out of every 1000 newborn males, and most of these children will have a chromosome complement equal to 47, XXY, although other patterns also exist. Since you must have a Y chromosome to have this disorder, it affects only males.

The symptoms of Klinefelters may include a typical body appearance, being tall (taller than average compared to other family members) and usually underweight. They may also have long legs, gynecomastia, little facial hair, small testes for their age, and a smaller than average penis. Many of these symptoms are only noticeable during puberty.

Other symptoms can include mental retardation, learning disabilities, and behavioral problems, including being aggressive and immature. Children with Klinefelter syndrome will also usually have a delay in pubertal development and infertility.

It is important to keep in mind that not all children with an extra X chromosome will have all or any of these symptoms.

Diagnosis is made by doing a chromosome analysis, which will show the typical pattern of 47, XXY, or an alternative pattern, including mosaicism (having both normal and abnormal chromosomes), such as 46, XY/47, XXY or 46, XY/47, XXYY, or other variants with more than two X chromosomes. (48, XXXY).

Most children with Klinefelters are diagnosed at the time of puberty, when more of the symptoms are noticeable or because they fail to begin puberty. Others are diagnosed by prenatal testing.

Treatment is with hormone replacement with testosterone once the child is 11 to 12 years old.

Klinefelter Resource List:

Klinefelter Syndrome - A Parent's View of having a child with this disorder, including her own experiences in dealing with the diagnosis and getting more educated.

Understanding Klinefelter Syndrome: A Guide for XXY males and their families from the National Institute of Health.

Care of the Uncircumsized Penis

Questions: by e-mail

Q. My husband and I decided against circumcision for our now 9 month old son. We recently have moved and our new Doctor says we should pull his foreskin back when bathing him to clean the head of his penis. Our previous Doctor told us there was no need to do this. That our son would be able to clean it himself once his foreskin moves back on it's own. (Around 10 years old - puberty)

We have looked in books and asked other parents, but it seems no one can give us a clear cut answer.

What are the risks and outcomes of both? What is recommended by the majority of Doctors? What is the percentage of boys who have to be circumcised later in life? What is the main cause of this surgery?

A. I think that your first doctor was right. Unfortunately, while more and more parents are coming to understand that circumcision isn't a necessary medical procedure, many are unaware of what to do with their child's uncircumcised penis.

And it does seem that one of the biggest problems that leads to children needing a circumcision later in life is improper care of their uncircumcised penis, with this improper care usually involves a parent being told to retract their child's foreskin before it is ready to be retracted.

The best advice that a parent can follow is to simply 'leave it alone' and let a child retract and wash his penis once he discovers that it is retractable.

Foreskin Restoration

Many of the problems that occur with an intact penis involves parents or health providers who forcibly retract a child's foreskin before it is ready to be retracted. Keep in mind that the foreskin sometimes doesn't retract until well into puberty.

The penis is the male organ used for urination and sexual intercourse. It is made up of spongy tissue and blood vessels. The shaft of the penis surrounds the urethra and is connected to the pubic bone. The foreskin covers the head (glans) of the penis. The foreskin is removed if the boy is circumcised.

The penis is located above the scrotum.
Information:

During puberty, the penis lengthens. The ability to ejaculate begins around 12 to 14 years of age.

Conditions of the penis include:

Peyronie's disease (a curve during erection)

Double penis (during development, the penis is divided by the urethral groove)

Hypospadias (the opening of the urethra is on the underside of the penis, rather than at the tip)

Epispadias (the opening of the urethra is on the top or side of the penis, rather than the tip)

Palmatus or webbed penis (the penis is enclosed by the scrotum)

Chordee

Priapism

Ambiguous genitalia

Penile prosthesis

Curvature of the penis
Definition:
Peyronie's disease is an abnormal bend in the penis that occurs during erection. This condition may cause problems with penetration and pain associated with intercourse.
Alternative Names:
Peyronie's disease

In Peyronie's disease (curvature of the penis), fibrous tissue develops on the tunica albuginea (the lining of the erectile bodies of the penis). The cause of fibrosis is not known.

The condition occurs in about 388 of 100,000 men. The fibrous tissue causes a bend to develop during erection that is painful and can make intercourse difficult or impossible. The condition is relatively uncommon and affects men between 40 and 60 years and older.

An association has been noted with Dupuytren's contracture, a cord-like thickening across the palm of one or both hands causing the 4th and 5th fingers to pull in toward the palm. This is a fairly common disorder of white men over 50 years old. However, only 1 to 2% of individuals with Dupuytren's contracture develop curvature of the penis.

Other risk factors have not been identified. Also, there is an association with HLA B27 antigen cross-reactivity. A person with this condition has a particular type of immune cell marker that indicates the condition may be inherited.

Dupuytrens contracture

Overview Symptoms Treatment Prevention
Definition:
Dupuytren's contracture is a painless thickening and contracture of tissue beneath the skin on the palm of the hand and fingers. Progressive contracture may result in deformity and loss of function of the hand.
Causes, incidence, and risk factors:

The cause of this contracture is unknown, but minor trauma and genetic predisposition may play a role. One or both hands may be affected. The ring finger is affected most often, followed by the little, middle, and index fingers.

A small, painless nodule develops in the connective tissue and eventually develops into a cord-like band. Extension of the fingers becomes difficult to impossible with advanced cases.

The condition becomes more common after the age of 40, and men are affected more often than women. Risk factors are alcoholism, epilepsy, pulmonary tuberculosis, diabetes, and liver disease.

Hypospadias
Overview Symptoms Treatment Prevention
Definition:
Hypospadias is a relatively common abnormality in which the opening of the urethra is on the underside, rather than at the end, of the penis.
Causes, incidence, and risk factors:

Hypospadias is a congenital defect that affects up to 3 in 1,000 newborn boys. The condition varies in severity. In most cases, the opening of the urethra is located near the tip of the penis on the glans. More severe forms of hypospadias occur when the opening is at the midshaft or the base of the penis. Occasionally, the opening is located in the scrotum or the perineum (behind the scrotum).

This anomaly is often associated with chordee, a downward curvature of the penis during erection. (Erections are common with infant boys.)

Some cases are inherited -- others result from unknown causes.

Epispadias
Overview Symptoms Treatment Prevention
Definition:

Epispadias is a rare congenital (present from birth) defect in the location of the opening of the urethra.

In boys with epispadias, the urethra generally opens on the top or side (rather than the tip) of the penis, though it is possible for the urethra to be open the entire length of the penis. In girls, the opening is usually between the clitoris and the labia, but may be in the abdomen.
Causes, incidence, and risk factors:

The causes of epispadias are unknown at this time. It is believed to be related to improper development of the pubic bone. Epispadias is often associated with bladder exstrophy. However, it can also occur alone or with defects other than exstrophy.

Epispadias occurs in 1 in 117,000 newborn boys and 1 in 484,000 newborn girls. The condition is usually diagnosed at birth or shortly thereafter.

Prosthesis
Overview
Definition:
A prosthesis is a device designed to replace a missing part of the body or to make a part of the body work better. Diseased or missing eyes, arms, hands, and legs are commonly replaced by prosthetic devices. False teeth are known as dental prostheses. Replacement of the jaw bone by an artificial replacement is known as maxillofacial prosthesis. Penis implants are also known as penile prostheses.

Ambiguous genitalia
Overview Treatment
Definition:
A birth defect where the outer genitals do not have the typical appearance of either sex. (See also genetics)
Alternative Names:
Genitals - ambiguous

The genetic sex of a child is determined at conception. The mother's egg cell (ovum) contains an X chromosome, while the father's sperm cell contains either an X or a Y chromosome. These X and Y chromosomes determine the child's genetic sex. Normally, an infant inherits ONE PAIR of sex chromosomes -- one X from the mother and one X or one Y from the father. Thus, it is the father who "determines" the genetic sex of the child. A baby who inherits the X chromosome from the father is a genetic female (two X chromosomes). A baby who inherits the Y chromosome from the father is a genetic male (one X and one Y chromosome).

The male and female reproductive organs and genitals both arise from the same tissue in the fetus. If the process that causes this fetal tissue to become "male" or "female" is disrupted, ambiguous genitalia can develop.

Ambiguous genitalia are those in which it is difficult to classify the infant as male or female. The extent of the ambiguity varies. In very rare instances, the physical appearance may be fully developed as the opposite of the genetic sex (e.g., a genetic male may have developed the appearance of a normal female).

Typically, ambiguous genitalia in genetic females (babies with two X chromosomes) include an enlarged clitoris that has the appearance of a small penis. The urethral opening (where urine comes out) can be anywhere along, above, or below the surface of the clitoris. The labia may be fused, resembling a scrotum. The infant may be thought to be a male with undescended testicles. Sometimes a lump of tissue is felt within the fused labia, further making it look like a scrotum with testicles.

In a genetic male (one X and one Y chromosome), ambiguous genitalia typically include a small penis (less than 2-3 centimeters or 0.8-1.2 inches) that may appear to be an enlarged clitoris (the clitoris of a newborn female is normally somewhat enlarged at birth). The urethral opening may be anywhere along, above, or below the penis; it can be placed as low as on the peritoneum, further making the infant appear to be female. There may be a small scrotum with any degree of separation, resembling labia. Undescended testicles commonly accompany ambiguous genitalia.

Ambiguous genitalia is usually not life threatening but can create social upheaval for the child and the family. For this reason, a team of experienced specialists, including neonatologists, geneticists, endocrinologists, and psychiatrists or social workers will be involved.

Common Causes:

Pseudohermaphroditism -- the genitalia are of one sex, but some physical characteristics of the other sex are present.

True hermaphrodism -- very rare -- both ovarian and testicular tissue is present and the child may have parts of both male and female genitalia.

Mixed gonadal dysgenesis -- some cells in the body have only a single X chromosome (female) and some cells in the body have XY chromosomes (male). This syndrome is variable, and depends on which cells are female, which cells are male, and what percent of each there are.

Congenital adrenal hyperplasia -- has several forms, but the most common form causes the genetic female to appear male. Male infants with the most common form appear normal at birth, but may show premature sexual development as early as 6 months of age. Many states test for this as part of the newborn screen (the blood test your baby has at 24-48 hours of life) because CAH can be life-threatening.

chromosomal abnormalities, including:
Klinefelter's syndrome (XXY) -- male, usually has small testes; causes infertility; may be associated with learning defects or mental retardation; affects 1/500-1/1000 live male births)
Turner's syndrome (XO) -- female; usually does not cause ambiguous genitalia (usually looks female at birth), but may have webbed neck, swelling of the hands and feet and other characteristic physical findings at birth; may not be diagnosed until later in life when sexual maturation does not take place; infertile)
Maternal ingestion of certain medications (particularly androgenic steroids) -- may make a genetic female look more male
Lack of production of specific hormones, causing the embryo to develop with a female body type regardless of genetic sex
Lack of testosterone cellular receptors (so even if the body makes the hormones needed to develop into a physical male, the body is unable to respond to those hormones, and therefore, a female body-type is the result even if the genetic sex is male)

Chromosome
Overview
Definition:
Chromosomes are long pieces of DNA contained in the nucleus of cells.
Information:

Chromosomes come in pairs. In humans, the nucleus of each cell has 23 pairs of chromosomes (46 total chromosomes).

DNA is also found in another part of the cell called the mitochondrion. Mitochondria have their own DNA strand, sometimes called "the 47th chromosome." All of your genes are contained within these 46 nuclear chromosomes and 1 mitochondrial chromosome.

Two of the chromosomes (the X and the Y chromosome) determine your gender and are called the SEX CHROMOSOMES:
Females have 2 X chromosomes.
Males have 1 X and 1 Y chromosome.

The Y chromosome determines the male gender, but does little else.

The remaining chromosomes are called AUTOSOMAL CHROMOSOMES. For convenience, scientists have numbered these chromosome pairs 1 through 22.

Each parent contributes one half of each chromosome pair to their child -- 22 autosomal chromosomes and 1 sex chromosome. The mother always contributes an X chromosome to the child. The father may contribute an X or a Y. Therefore, it is the father that determines the gender of the child.

The mitochondrial chromosome comes from the mother. Fathers make no contribution to the mitochondrial genes of their offspring.

Typically, ambiguous genitalia in genetic females (babies with two X chromosomes) include an enlarged clitoris that has the appearance of a small penis. The urethral opening (where urine comes out) can be anywhere along, above, or below the surface of the clitoris. The labia may be fused, resembling a scrotum. The infant may be thought to be a male with undescended testicles. Sometimes a lump of tissue is felt within the fused labia, further making it look like a scrotum with testicles.

Pseudohermaphroditism -- the genitalia are of one sex, but some physical characteristics of the other sex are present.

True hermaphrodism -- very rare -- both ovarian and testicular tissue is present and the child may have parts of both male and female genitalia.

Mixed gonadal dysgenesis -- some cells in the body have only a single X chromosome (female) and some cells in the body have XY chromosomes (male). This syndrome is variable, and depends on which cells are female, which cells are male, and what percent of each there are.

Congenital adrenal hyperplasia -- has several forms, but the most common form causes the genetic female to appear male. Male infants with the most common form appear normal at birth, but may show premature sexual development as early as 6 months of age. Many states test for this as part of the newborn screen (the blood test your baby has at 24-48 hours of life) because CAH can be life-threatening.

The different types of adrenogenital syndrome are inherited as autosomal recessive diseases and can affect both boys and girls. The defect involves a lack of an enzyme needed by the adrenal gland to make the major steroid hormones of the adrenal cortex: cortisol and aldosterone.

Without these hormones, steroids are 'diverted' to becoming androgens, a form of male sex hormones. This causes early (or inappropriate) appearance of male characteristics.

In a newborn girl with this disorder, the clitoris is enlarged, with the urethral opening at the base (ambiguous genitalia, often appearing more male than female). The internal structures of the reproductive tract (ovaries, uterus, and fallopian tubes) are normal. As she grows older, masculinization of some features takes place, such as deepening of the voice, the appearance of facial hair, and failure to menstruate at puberty.

In a newborn boy no obvious abnormality is present, but long before puberty normally occurs, the child becomes increasingly muscular, the penis enlarges, pubic hair appears, and the voice deepens. Affected males may appear to enter puberty as early as 2-3 years of age. At puberty, the testes are small.

Some forms of congenital adrenal hyperplasia are more severe and cause adrenal crisis in the newborn due to salt wasting. In this salt-losing form of congenital adrenal hyperplasia, newborns develop symptoms shortly after birth. These include vomiting, dehydration, electrolyte changes, and cardiac arrhythmias. Untreated, this condition can lead to death within 1-6 weeks after birth.

About 1 in 10,000 to 18,000 children are born with congenital adrenal hyperplasia.

FURTHER DISCUSSION TO CONTINUE IN PART III

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VATTACHARYYA

Saturday, April 21, 2007

WARNING 18 YRS AND ABOVE

PUBERTY II

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