My Child is Almost a Teenager. What Should I Expect?

By Dr. Ronald Hirokawa, pediatric resident at CHOC Children’s  

It’s no secret that adolescence is one of the most difficult phases in someone’s life. As a parent, you might feel just as confused as your teenager when trying to navigate this stage. You want to support your child and help them navigate what can be a confusing time. To do that, you need information you can rely on. The problem is, most parents are experiencing information overload and don’t know what source to trust.

At CHOC Children’s, we believe parents should feel like they’re the experts in their child’s health. We know it can be stressful to navigate puberty with your children. Every year, we care for 250,000 kids and teens in Orange County and beyond. We’re committed to providing quality education around the topics parents ask us about the most.

Major physical changes can cause major stress for teens. Unlike the hormonal and psychological changes that are mostly unseen, these physical changes are visible every morning when they look in the mirror.

This parents’ guide to puberty will help you prepare for changes you can expect in your child, but also for answering their questions.

Physical Changes

Your teen will likely experience many physical changes during puberty. Here are a few to expect:

Growth spurt: About 20 percent of our height is obtained during puberty. Most girls start their growth spurt between ages 10 to 14, or about a year after puberty begins. Males have their growth spurt on average two years after the start of puberty. Males also tend to grow faster.

Bone growth: As teens get taller, their bones growth accelerates as well. Bones first grow in length, then width, and then density. Due to this growth pattern, there is a high risk of fracture as teens’ bones get longer before they get stronger.

Changes in body shape: While both males and females see increases in their body mass index (BMI), girls see more of an increase in body fat. Boys, however, tend to have increased levels of lean body mass. This can cause high levels of stress in adolescent females, especially in a culture that promotes thinness. Conversely, puberty leads to fat distribution in the hips and butt, which can lead to unwanted attention. Parents may worry that this may be a sign of future obesity, but they should be reassured that the body redistributes the fat to other parts of the body as it progresses to adulthood.

Changes in Sexual Characteristics

Females:

Breast development: The first phase of puberty in females is the development of breast buds, which appear as coin-sized lumps under the nipples. This phase normally occurs around age 9 or 10. Studies have shown that African American girls usually enter puberty a bit earlier, around 8 to 9 years of age. Girls should be evaluated by their pediatrician for early puberty if breast development starts earlier than age 8 for Caucasians and 7 for African Americans.

  • Breasts may be uneven during early development but should even out within about a year. Consider options like padding one side of your teen’s bra if uneven breast size is causing stress.
  • Training bras are not critical at this period and can actually cause discomfort to sensitive early breast tissue. Consider alternatives such as soft, light, gentle undergarments like an undershirt or sports bra.

Pubic hair: In the second phase of puberty, your teen will develop pubic hair. Ten to 15 percent of girls will see public hair before they develop breast buds. Initially, the hair starts off soft, straight, sparse and in close proximity to the vagina, but will begin to spread to the lower abdomen and inner thigh areas and take on a triangular pattern. The hair will also begin to appear darker, curlier and coarser.

Menstruation: Most girls get their first period around age 12 or 13. African American pre-teens tend to start menstruating one year earlier. Parents can expect their daughters to start menstruating two to three years after breast bud development. Cycles will often be irregular, especially between the first and second cycles. On average the first cycle for most girls lasts 34 to 40 days. A cycle length is measured from the start of one period to the day before the next flow. About two years after the first period, cycles should regulate, occurring once every 21-45 days, lasting no more than seven days.  Most girls need an average of four to five regular pads on the day their flow is heaviest.

  • Consider discussing menstruation when teen starts breast development, so they know what to expect. Helpful strategies include using visual aids such as books and pamphlets while trying to describe and explain the female reproductive system. Your daughter’s pediatrician or an adolescent medicine specialist can help provide education.
  • It is vital that female teenagers are prepared and educated on what to expect. Make sure that your teenage has pads available at school in case of emergency. Deciding between tampons and pads should be left up to the comfort and preference of your daughter. Although there is no way to pinpoint exactly when your daughter will get her first period, it often occurs at around the same time it did for her mother or older sisters. If menarche has not occurred by age 16, seek a medical evaluation by your primary care physician.
  • See your doctor if periods are infrequent, too frequent, flow is extremely heavy, or periods are painful.

Males:

Testicular and scrotal enlargement: At around 11 to 12 years of age, males experience a near doubling in testicular volume in this first phase of puberty. This occurs on average six months prior to increase in penile size. The scrotum also starts to darken, enlarge, hang down from the body, and develop tiny bumps or hair follicles. Males should be evaluated by their pediatrician if puberty starts before age 9 or shows no signs of puberty by age 14.

Pubic hair development: This usually develops at age 12 or 13. Hair starts off light, sparse, soft and mostly located at the base of the penis. The hair will start to become darker, curlier and coarser. It will also start to spread to the rest of the pubic region, toward the thigh, and towards the belly button in a diamond-shaped pattern. Around two years later, they will begin to develop hair on other parts of the body such as their face, legs, arms, underarms and chest.

Penis growth: Males may achieve adult-sized genitalia between the ages of 13 and 18. Penile size increases first in length and then width. Size can vary greatly from male to male. Many male teens may become distressed with penile size as they compare themselves to other males. Remind your teen that function does not depend on size.

Adolescent Cognitive Development:

During puberty, your teen will also undergo significant cognitive changes. Before puberty, your teen still thinks in concrete terms: Things are black and white, right or wrong. They often only think about what is going on in the present moment and only consider the immediate consequences of their actions, rather than thinking long term.

During the mid-teen years there may actually be a drop in the level of maturity and judgment for certain teens. This is not always a bad thing, as teens will experiment in their own way to learn about the world. They typically put this information to good use, learning about their mistakes. However, risk-taking behavior may lead to violence or experimenting with alcohol or drugs in some cases.

By late adolescence, teens begin to think more abstractly and in shades of grey. They are also now able to analyze situations logically, reason effectively, solve complex problems, and achieve increased empathy, allowing them to get a sense of what others are thinking.

This higher level of cognition allows them to start planning for their future and think about the more long-term consequences of their actions. Teens still have very little experience with this level of decision making and may need assistance directing these newly gained cognitive skills.

Learn more about understanding the teen brain.

How can I help my teen during this phase?

Teens often make snap decisions, leading to risky behaviors. Expand their range of options and teach them to consider multiple choices and to weigh the potential risks and benefits of each decision. During this time, it’s important to help your teen understand that emotions, good or bad, may affect their ability to make rational decisions.

Teens are often influenced by social pressures from other teens, which can lead them to participate in risky behaviors. Instead of imposing your opinions on your teen, provide them with objective information about these behaviors.

Concerns about popularity and acceptance are most intense during the early teen years and may lead teens to participate in risky behaviors. Parents can help teens resist these pressures and find alternative groups. Explain your family’s set of values, like respecting yourself and others, the importance of trust, etc.

Although during the teen years there is often less time being spent with family, family closeness is still an extremely important component of adolescent development and has been associated with a lower incidence of smoking, alcohol and drug usage, and suicide attempts.

How to Talk to My Teenager:

Simply asking questions and listening without judgment can be majorly influential. Ask non-threatening questions that help them define their identities, such as:

  • Who do you admire and why?
  • What are your hopes for the future?
  • What are your strengths?

To create a nonjudgmental environment, listen more than you speak. Ask open-ended questions to encourage them to think through their answers as opposed to just saying yes or no. Match their mood to help your teen feel like you understand where they are coming from.

Explore adolescent medicine services at CHOC

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Protein Powders and Teens: Are They Safe? Are They Necessary?

By Dr. Jacqueline Winkelmann, pediatric hospitalist at CHOC Children’s

jacqueline-winkelmann-md

As a pediatrician and sports nutrition expert, I repeatedly get asked by coaches, parents, and young athletes: “What are the best protein supplements on the market? Are they safe? To me, the bigger question is, “Are protein supplements even necessary for young athletes?”

At one time, it was believed that muscle-building exercises in athletes greatly increased dietary protein needs. This idea led to a multibillion-dollar industry selling high-protein meals, bars and drinks marketed to athletes. Here are the most common questions I get on protein powders and young athletes—and what I tell parents when they ask.

How much protein do young athletes need?

The current recommendation for protein for young athletes is approximately 1.0-1.4 grams per kilogram per day, which means they need slightly more protein than their non-athlete peers This extra protein in their diet helps to sustain growth and development, muscle building and repair, as well as fueling intense exercise. This means, a 150-lb athlete should consume 80 grams of protein, or 20 extra grams a day. Recent studies have shown young athletes consume 2-3 times the recommended amount of protein per day in their diet alone.

What are the best sources of dietary protein?

The richest sources of protein are lean meats such as chicken, turkey, lean beef, fish, eggs, tofu, dairy products (milk, cheese, yogurt), beans, lentils and nuts.

Will eating extra protein make my young athlete stronger?

While it may seem sensible that “more is better” when it comes to protein, that’s simply not true. Studies show that consuming extra protein will produce no further gain in strength, muscle mass or size. The reason for this is simple; young athletes need anabolic hormones (i.e. testosterone) and physical training in order to stimulate protein synthesis and in turn increase muscle mass. The amount of protein they eat is irrelevant without the complete regimen.

What are some of the side effects or consequences of consuming too much protein?

High protein, low carb diets are never recommended for young athletes. Too much protein will cause problems. Since our bodies can’t store extra protein to use later, we will have to spend a significant amount of energy processing it, using up energy and water, two important resources for athletes. Eventually, extra protein will be converted into fat. Too much protein can cause nausea, loss of appetite, diarrhea and can even stress the liver and kidneys.

Is the timing of protein intake important?

YES! This we can pay attention to; small amounts of protein throughout the day is the most efficient and effective way to consume protein. Pay special attention to snacks before and after exercise. Athletes recover faster when they eat some protein within 30 minutes of exercise. Aim for 20-25 grams of protein as part of the pre- and post-recovery snacks. For example, a 4-ounce serving of chicken, fish or beef provides between 25-30 grams of protein, an egg provides 6 grams, and a cup of milk 8 grams of protein.

Could protein supplements/powders benefit my young athlete?

There has been great hype created around protein powders and their importance for athletes. They are for the most part unnecessary for young athletes. W know young athletes have a slightly increased protein requirement, they should be able to easily obtain their protein from food rather than supplements. Protein powders are not currently regulated by the FDA. This means they may contain artificial sweeteners, heavy metals and other chemicals that young athletes are just better off without. Plus, they’re expensive!

Who might benefit from protein supplements?

Athletes who are vegetarian or vegan, those who have certain medical conditions, or those who are underweight might benefit from protein supplements after establishing that he or she does not consume enough protein in his/her diet. Protein intake should be supervised by a dietitian, nutritionist or health professional.

What should parents consider if purchasing protein powders?

Food is the best source of protein, but, if your athlete needs a protein supplement, do your research! Be aware that price does not correlate with purity. Look for those supplements with high ratings from the Clean Label Project or the National Sanitation Foundation (NSF).

What are some strategies for safe weight gain and increasing muscle mass especially for adolescent athletes?

There are three key components to muscle building: calories, resistance training and rest. The American Academy of Pediatrics Committee on Sports Medicine and Fitness recommends exercises focusing on core strength, balance and agility for pre-adolescent athletes, and only after puberty should they consider adding muscle bulk.

How can I help my teen increase their caloric intake in a healthy way?

Increase calorie intake by 300-500 calories per day with a little extra protein. To increase calories:

  • do not skip breakfast
  • aim to eat 5-9 times per day
  • increase portion size
  • add nuts, extra sandwich or bowl of cereal before bed

What should my teen know about resistance training?

Muscle growth is accelerated with the onset of puberty, around age 13-18 years old. Resistance training is key when the goal is to increase muscle mass, size and strength. This can in fact increase muscle weight by up to 15 percent per year during these years. A general strengthening program should have an adequate warm up and cool down and address all major muscle groups.  It’s important to train with focus and intensity, not just go through the motions. For increase in muscle size: do multiple sets of 8-15 repetitions/set. For increase in power/strength: lift heavier weights and do multiple sets of 4-6 reps/set. Training should always be done under adult supervision by a certified professional.

How important are rest days?

Rest is an essential part of maintaining a healthy lifestyle. Strength training for a particular body part should be done on non-consecutive days. Just as important, the body needs to rest in order to rebuild muscle fibers and increase muscle mass. Adolescents should get between 8-9 hours of sleep per night.

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Quiz: Drug & Alcohol Facts You Need to Know

National Drug and Alcohol Facts Week, sponsored by the U.S. Department of Health and Human Services, is a health observance linking teens to facts about drugs.

Complete this quiz as a family to see how much you know about the dangers of drugs and alcohol. Then, read on for further education on the consequences and potential health effects.

  1. Nicotine and other drugs can harm the developing adolescent brain. At what age does the brain stop developing?  Learn more about understanding the teen brain.
    1. 10 years old
    2. 13 years old
    3. 18 years old
    4. 25 years old
  2. How many emergency room visits are made each year in the U.S. for injuries related to alcohol?
    1. 10,000-25,000
    2. 25,000-50,000
    3. 50,000-100,000
    4. >100,000
  3. True or false: Past-year misuse of Vicodin and OxyContin among 12th graders has increased.
  4. Teens are using vaping devices in record numbers. What exactly are they consuming when they vape?
    1. Nicotine
    2. Marijuana/hash oil
    3. Just flavoring
    4. All of the above
  5. True or false: binge drinking rates among 8th, 10th and 12th grade students has continued a downward trend in recent years.

 Source: National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services.

 Getting help

If you or someone you know has a problem with drugs or alcohol, get help as soon as possible. Talk to an adult you trust― a parent, aunt or uncle, doctor, teacher, school counselor, or clergy member.

Download the answer quiz

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Pros and Cons of Teens Being on a Vitamin Regime

By Dr. Janetta L. Arellano, pediatric resident at CHOC Children’s 

As a parent, you want to make sure your child is getting everything they need to stay healthy. The problem is, you’re inundated by conflicted information—especially when it comes to vitamins and supplements. Here’s a guide to teens and vitamins that are most important for their health.

Vitamins in small quantities are essential for normal metabolism. Our bodies don’t make them, so we must get them from a well-balanced diet. The American Academy of Pediatrics advises that children who receive a well-balanced diet do not need extra vitamin intake over and above the recommended dietary allowances (RDA). Children with underlying medical conditions, poor appetite or highly-restricted diets (i.e. picky eaters and vegan or vegetarian eaters who may not consume a balanced diet) may benefit from a vitamin supplementation plan overseen by their pediatrician. More than one-third of children in the United States take dietary supplements routinely.

If you’re concerned that your teen may not be getting the vitamins they need, speak to their pediatrician about dietary changes or a vitamin supplementation plan. Although most over-the-counter vitamin supplements are typically safe, they can cause toxicity if taken above the RDA. Symptoms of toxicity include nausea, rashes and headaches, and in some cases can cause severe symptoms.

A guide to teens and vitamins:

Vitamin A

Helps with: night and color vision, in addition to normal growth, healthy skin and tissue repair.

Found in: dairy products and orange vegetables like carrots, sweet potatoes and pumpkins.

B Vitamins

Helps with: new cell production and metabolism

Found in:  meat, poultry, fish, legumes, milk, eggs, whole grains, and enriched breads and cereals. B12 is only obtained by eating animal products including fish, meat, eggs and dairy. B12 supplements may be recommended for those following a vegan diet.

Calcium

Helps with: building strong bones, keeps nerves and muscles working, and helps keep the heart healthy.

Found in: milk, yogurt, dairy, tofu, leafy greens, beans and legumes.

Zinc

Helps with: your body’s ability to fight off illnesses and infections. It also helps with cell growth and helps heal wounds and cuts.

Found in: dark meat; nuts such as cashews, almonds and peanuts; legumes such as beans, split peas and lentils.

Vitamin C

Helps with: synthesizing collagen, which is important in teeth and bone formation and wound healing. It also boosts the immune system.

Found in: citrus fruits, tomatoes, potatoes, Brussels sprouts, cauliflower, broccoli, strawberries, cabbage and spinach.

Vitamin D

Helps with: bone formation and maintaining adequate calcium levels.

Found in: fortified dairy products, fish oils and egg yolks. Direct sunlight is another source of Vitamin D.

Iron

Helps with: red blood cell production and increase in muscle mass. Teens undergo rapid growth and iron needs are greater, particularly young women who are menstruating and are at risk for developing iron deficiency.

Found in: meats (beef, turkey, pork and liver), spinach and beans.

Folic Acid

Helps with: metabolism and new cell production. It is especially important during growth spurts.

Found in: Legumes, asparagus, eggs, leafy greens and citrus fruits.

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Ask a CHOC Doc: Do I Have Endometriosis?

Question: My periods are heavier and more painful than my friends’ periods. I’ve seen a lot in the news recently about endometriosis. Is that what I have?  -Anonymous

Answer: 

Any time you have questions about your body, ask a trusted adult or your doctor. What you’re describing may be endometriosis, but it could be something else. It could also just mean that you have heavier periods and more cramping than your friends do (everyone’s body is different) and you don’t have a diagnosable medical condition.

If you decide you need to see your doctor, here’s more information about endometriosis, so you can be prepared for your appointment.

 What is endometriosis?

Endometriosis is a condition where the tissue that makes up the inner lining of the uterus is present outside of the uterus, or n other organs in other parts of your body. It most often occurs in the ovaries and pelvis.

What are the symptoms of endometriosis?

The symptoms from endometriosis can vary significantly from woman to woman. Some people who have endometriosis actually have no symptoms, and others suffer from debilitating and chronic pain in the lower abdomen and pelvis. It can also cause pain with periods or during sexual intercourse and may even lead to infertility.

Since this condition occurs when tissue from the inner lining of the uterus is present outside that area, symptoms can vary depending on where the tissue is. For example, with bladder endometriosis, someone can have urinary symptoms such as frequency, urgency and pain. With bowel endometriosis, you can have diarrhea, constipation and bowel cramping. If the endometriosis is in the abdominal wall, there could be a painful abdominal wall mass.

Women who suffer from endometriosis are usually diagnosed between ages 25 to 35. However, teens may suffer from endometriosis as well. It’s rarely diagnosed in premenstrual and postmenopausal women.

During a menstrual cycle, the bleeding occurs not only from inside the uterus, which is typical, but also from areas with uterine tissue outside the uterus. The blood irritates these areas in the abdomen, and the irritation causes inflammation, pain and scar tissue.

 How do I know if I have endometriosis? 

In order to definitively diagnose endometriosis, a doctor will perform a laparoscopy, where they’ll make a small incision in the abdominal wall and insert a small camera in order to view the organs in the abdomen. They will remove a small sample of tissue and review it under a microscope to confirm that it is uterine tissue that’s been growing outside the uterus.

During the procedure, endometriosis can be assigned a stage of severity, based on the location and how much uterine tissue is growing outside of the uterus.

This procedure can make a diagnosis and also treat the pain from endometriosis by removing the uterine tissues found outside the uterus as well as removing scar tissue that may be affecting the pelvic organs. Surgery can help lessen the impact on fertility.

If your doctor suspects you might be suffering from endometriosis, they may choose to first explore non-surgical examinations before considering a laparoscopy. Your doctor may order an ultrasound to evaluate your anatomy and look for ovarian endometrioma (large, fluid-filled cysts), in addition to reviewing your medical history and conducting a physical examination. An assumed diagnosis might be made without surgery, but response or lack of response to treatments cannot confirm or exclude the diagnosis.

What is the treatment for endometriosis?

The most commonly prescribed medication is a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen. It is important to take the right dose as prescribed by your medical provider for adequate treatment of inflammation and pain relief. The use of cyclic hormonal therapy can be used for pain management. This includes using oral hormonal pills, commonly called “birth control,” or injection Depo-Provera to suppress menstruation and changes in uterine tissue, thereby decreasing pain. Another treatment option is the use of gonadotropin releasing hormone (GnRH) agonists, which can help stop the bleeding by decreasing estrogen production. Some side effects of GnRH agonists include menopause-like symptoms like hot flashes, mood changes, vaginal dryness and bone thinning, among others.

Medication should be trialed for at least three months. If there is no improvement to medical therapy within this trial period, your doctor may refer you to a gynecologist, and a laparoscopy surgery should be considered.

If there is any concern regarding a chronic pelvic pain, painful periods or other symptoms that are affecting your life, make a doctor’s appointment to get it evaluated!

By Dr. Janice Koh, pediatric resident at CHOC Children’s and Dr. Terez Yonan, adolescent medicine specialist at CHOC Children’s

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