This clinical report provides pediatricians evidence-based information on the developmentally appropriate, comprehensive clinical care for hospitalized adolescents. Included in this report are opportunities and challenges facing pediatricians when caring for specific hospitalized adolescent populations. The companion policy statement, “The Hospitalized Adolescent,” includes detailed descriptions of adolescent hospital admission demographics, personnel recommendations, and hospital setting and design advice, as well as sections on educational services, legal and ethical matters, and transitions to adult facilities.
To properly care for hospitalized adolescents, an understanding of adolescent growth and development; medical, surgical, and psychiatric illnesses; and legal, ethical, ableism, and racism issues is essential. Many of these topics that affect the hospitalized adolescent are more completely described in the accompanying policy statement.1 This clinical report provides a comprehensive guide for the clinical care of hospitalized adolescents 13 to 18 years of age, including special attention to distinct populations of adolescents. Although not all topics described in this clinical report can be fully evaluated or treated during a hospitalization (depending on the reason for the hospitalization, the expected length of stay, and the patient’s relationship with their medical home), screening for these conditions and definitive reporting of concerns to the medical home, outpatient primary care provider (PCP), or specialist should be considered. Because not all hospital staff, including in adult facilities or on adult units, will be familiar with adolescent development and routine/preventive care, consultation with a pediatrician, adolescent medicine subspecialist, or provider with comfort and experience in caring for adolescents (eg, family medicine physician, physician assistant, nurse practitioner, social worker) may result in better care, especially when adolescents are disconnected from their medical home because of housing insecurity, incarceration, college, residential living arrangements, or child welfare involvement. Other professionals have the training and experience to assist with caring for hospitalized adolescents. Child life specialists are available in many hospitals with pediatric units and in other health care settings. Child life specialists are experts in child and adolescent development, in appropriate psychosocial interventions based on individual and family factors, and in guiding and promoting therapeutic relationships among patients, families, and health care team members.
Adolescents may be hospitalized in various hospital settings for acute and chronic illnesses, including medical, mental health, surgical, gynecologic, obstetric, and substance use concerns. Although most adolescent inpatient stays are brief, some patients with chronic conditions experience frequent and prolonged hospitalizations. Although there is no standard adolescent patient, all adolescents deserve attention to their unique developmental, medical, social, and emotional health, regardless of where, how long, and why they are admitted for inpatient care. Providers are encouraged to use a trauma-informed model and a strength-based approach in the care provided in the hospital setting.2 Confidentiality, when appropriate, is vital and crucial when providing care. Additionally, arranging reliable communication and regular follow-up with their PCP is an imperative part of discharge planning, even for patients who initially present without an established medical home.
The Impact of Hospitalizations
Hospitalization interferes with the tasks of typical adolescence.3 Hospitalization often interrupts the central developmental goals of adolescence (individuation, independence, and autonomy) and the core rights of adolescents (privacy, confidentiality, respect, and dignity). This may cause fear, insecurity, stress, and developmental regression,4 and poses unique challenges to the health care team, family, caregivers, peers, and adolescents themselves. The accompanying policy statement1 contains further details on the ways that hospital policies, facilities, services, and expectations support adolescent patients and on adolescents’ and their families’ self-reported ideals for optimal hospital care.
Implicit Bias and Systemic Racism
Racism has had a profound and centuries-long negative impact on the health, well-being, and potential of minoritized adolescent populations. The American Academy of Pediatrics (AAP) published a comprehensive policy statement with detailed recommendations for optimizing clinical practice, workforce diversity, and improving community advocacy and public policy.5 It is important to recognize how many of the discrepancies in access to health care services for adolescents are based on socioeconomic factors and mistrust of the health care system associated with race/ethnicity and culture that have been allowed to persist, leading to increasing health inequities.6,–9
The persistent and relentless negative impact of racism on health and well-being through personal, institutional, and structural implicit and explicit biases endures to this time, especially during the COVID-19 pandemic. As COVID-19 has spread across countries, ethnic minority and migrant populations, as well as those with low income and low socioeconomic status, have been disproportionately affected. The pandemic has exposed and intensified the health disparities among these groups that are powered by inequities in socioeconomic determinants of health.10,–12 Education about racism in medical education can help decrease this gap in knowledge and improve health outcomes.13,14
From a review article published in 2021,15 outcomes from 46 studies (2003–2017) reported in youth 11 to 18 years of age were as follows. Statistically significant adverse effects of racism were reported in more than 60% of findings with negative health behaviors including substance use and poor mental health outcomes. Steady associations were reported between accrued racism and negative health outcomes. This review emphasizes the need to gain evidence for the research linking early racism exposure to adverse health outcomes in later life, as well as to use focused, prospective cohort studies. It is important to follow best practices in culturally competent care in absence of research.
It is important to note that racism is one of the many “isms” that can affect care–lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ+)-ism, immigrantism, ableism, non-English speakingism, etc, each with its own implicit bias as well as systemic and structural factors.
Unique Comprehensive Needs and Responsibilities for Adolescent Inpatients
Frequent Admissions for Chronic and Complex Health Diagnoses
Inpatient stays may be frequent for adolescents with complex health conditions, including cystic fibrosis, asthma, diabetes, inflammatory bowel disease, cancer, epilepsy, and many other illnesses. Much of the literature on this particular topic is from studies with oncology patients. Linder et al16 studied hospitalized children and adolescents with cancer with a variety of symptoms. Using the Memorial Symptom Assessment Scale on children and adolescents with a mean age of 12.6 years (a slighter younger cohort than the 13- to 18-year-old adolescent, but still relevant) who received inpatient chemotherapy, the study classified multiple physical and psychosocial symptoms. Interestingly, the symptoms rated as “moderate” or greater severity on the assessment tool were not always the ones that were most distressing to patients. The authors called for development and implementation of scoring tools that more accurately assess for symptoms that are most distressing to patients. Using the same scale for an older group of patients in both ambulatory and inpatients settings, Collins et al17 reported that inpatients had more symptoms than outpatients did. Typical symptoms included fatigue, pain, nausea (with greater burden of those with physical and psychological symptoms), and distress. Hockenberry et al18 found that adolescents hospitalized for chemotherapy with the constellation of increased fatigue, sleep disturbances, nausea, and vomiting had more depressive symptoms and behavior changes. Moreover, parents who perceived their child experiencing fatigue reported more behavioral and emotional problems.
Often, adolescents with chronic and/or complex illnesses receive the majority of their care only from a subspecialist, but they may be hospitalized frequently and cared for by multiple subspecialists. Adolescent medicine consultation, if available, as well as identification of a team leader to coordinate the care, is important for these patients. Hospitalizations for these patients provide opportunities to screen, evaluate, counsel, and treat when they have infrequent contact with their medical home19,–25 and, therefore, may be missing primary care services and anticipatory guidance such as immunizations, reproductive care, screening for high-risk behaviors, and mental health assessments. Screenings, including for social determinants of health, and a full HEADSSS (home, education, activities, drug use, sexual history, and suicide, safety/violence risk) assessment for the frequently hospitalized adolescent may improve overall health by revealing concerns.19
As in other populations, hospitalization may be an optimal time to screen for and address other mental health concerns, including asking about past trauma/adversity2 and suicide risk, because unmet mental health needs may affect medical outcomes and may be the underlying reason for hospitalization. Adolescents with sickle cell disease, asthma, diabetes, and attention-deficit/hyperactivity disorder are more likely to have comorbid diagnoses of anxiety, depression, or bipolar disorder.26 Comorbid mental health issues are also observed in those with cancer.27
These findings highlight the need for psychosocial assessment of adolescents with chronic illness and frequent admissions, because they may not present for outpatient behavioral health evaluation and treatment, especially if the hospitalization is related to lack of adherence to medical treatments or appointments, or because of a progressive course of illness.
Developmental and Intellectual Disability in the Hospitalized Adolescent
Adolescents and young adults (AYAs) with developmental disabilities have varying degrees of cognitive abilities; therefore, there are important considerations for these patients in the hospital setting. Although no studies exist on minor patients, a study of adults older than 18 years with intellectual disabilities demonstrated that, for the same admitting diagnoses, patients with intellectual disabilities had statistically significant longer lengths of stay, longer ICU stays, and higher rates of surgical complications.28 Patients with developmental disabilities, in addition to a chronic health condition such as autism spectrum disorder, aggressive behavior, spastic quadriplegia, or respiratory illnesses, and patients admitted through the emergency department were 4 times as likely to have complications.29 It is important to involve individuals with disabilities in their own care to the best extent possible30 to ensure that providers do not minimize patients’ autonomy because of the presence of a disability and tailor participation to their ability. More research on minor patients with intellectual or physical disabilities is warranted to determine whether similar trends exist.1
Particularly for intellectual and developmental disabilities (IDDs)/medically complexity, discharge planning should include careful coordination of new supplies/equipment and home health services and/or reinstating outpatient services to ensure a safe discharge and continuation of care. This care coordination may best be conducted in conjunction with outpatient care coordinators from PCPs/subspecialists and/or their managed care plan. For people with autism spectrum disorder or IDDs, a change in their environment can be very stressful.31
Adolescents may associate hospitalizations with illness and pain and experience dysregulation because of an increase in noise, interruptions in daily routines, and the constant influx of people who perform routine procedures or checks, such as vital signs.32 Hospitals should be thoughtful and deliberate toward adolescents with IDDs who may have experienced medical trauma; it is helpful for providers and hospital staff to be knowledgeable about trauma-informed approaches to care. This population should be evaluated for their ability to participate in their care and assent to decisions. Most hospitals have resources for supporting this population (eg, https://www.rchsd.org/documents/2015/03/autismspeakstoolkit.pdf/, https://www.rush.edu/patients- visitors/accessibility-resources-and-services, and https://www.seattlechildrens.org/visitors/campus/accessibility/).
Parents/families of adolescents with disabilities have been encouraged to be “experts on their child.” Caregiver involvement and partnering with them, including education and training to care for the patient’s needs, is crucial, as is optimally involving patients as they are able. Transitions and defining what is developmentally appropriate during adolescence may be more challenging for families and medical teams. Adaptations to hospital policies regarding adolescent autonomy, privacy, and shared decision-making may be necessary for adolescents with disabilities to be included in adolescent facilities.
Caregivers can provide insight into the adolescent’s developmental stage and familiarize hospital personnel with the individual’s preferences and routines. It is important for the hospital team to establish a rapport, assess the developmental stage, and explain all aspects of the hospitalization, including treatments and procedures, in a developmentally appropriate way, when possible.33 Enlisting child life specialists to explain procedures, provide distraction, and normalize the environment can be helpful.
Other challenges in caring for some inpatients who are developmentally delayed or have IDDs include specialized diets, including formulas, and complicated pharmacologic regimens that may include medications and supplements that are not on formulary. For the patient admitted from an outside facility and not from home, it is important to obtain the most current medical record and the timing of medications and to speak to a medical provider at the transferring facility. Parents and guardians may not be aware of this detailed information or may not be available at admission.
Often, these patients require sedation for imaging or other procedures. Providers can inquire about previous experiences with sedation medications, including safety, effectiveness, adverse reactions, and effects on sleep and behavior. It may be difficult to assess when an adolescent with a developmental disability is in pain (and the degree of pain) versus experiencing stress or anxiety from the circumstances, and child life services may be warranted.
The medical literature supports various ways to determine the extent of pain in patients with communication difficulties. Behavioral pain scales such as the Wong Baker FACES (3–4 years of age), Visual Analog Scale and Numeric Rating scale (7–8 years of age and older),34 and revised FLACC-(Face Legs, Activity Cry and Consolability [4–18 years of age]) may be helpful.35 The Noncommunicating Children’s Pain Checklist is well validated but has 27 items to score and may be difficult to interpret because of the large range of scores.36
LGBTQ+ Hospitalized Adolescents
A qualitative study of adolescents’ reflections on dignity in the hospital setting showed that personal privacy and autonomy should be protected and identity should be respected, specifically the ability to have private and confidential communication (revealing something about one’s feelings that is not ordinarily revealed).37 These wishes become even more meaningful for hospitalized LGBTQ+ adolescents.
Many LGBTQ+ adolescents have not come out to parents or guardians, and maintaining their confidentiality in the hospital setting is paramount. Aiding a patient to come out during their hospitalization might be useful, because often, the hospital is considered a safe space. The pediatrician or a social worker can work with an adolescent who may want to come out to their family or peers. Depending on the reason for admission, the patient’s current mental health status, and engagement in outpatient support services, consulting a social worker and/or a mental health provider might be warranted for inpatient counseling and support if an LGBTQ+ AYA is coming out to their family or experiences rejection/discrimination from family members during their hospitalization.
Similar to other marginalized populations of youth, the hospitalization may be the only interface the LGBTQ+ adolescent has with routine, primary care health services. As for all adolescents, it is recommended that testing for sexually transmitted infections (STIs) per Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Fourth Edition,38 and Centers for Disease Control and Prevention recommendations for LGBTQ+ youth,39 on the basis of sexual practices, be offered and performed. Maintaining confidentiality of records, as well as test results for the minor adolescent patient, as mentioned previously, is implicit and serves to develop trusting relationships with health care providers. As mentioned in the accompanying policy statement,1 providers are advised to be fully aware of their state laws regarding minors’ rights to confidentiality in the provision of sexual health care (https://www.guttmacher.org/united-states/teens/state-policies-teens).
In a recent policy statement, the AAP recommends health systems have inpatient policies in place specifically for children and adolescents who identify as transgender or gender diverse.40 These include different options for gender identification, pronouns, name used by hospital staff and in the electronic health record (EHR), and access to gender-neutral bathrooms. Patients should be roomed and communicated with on the basis of their self-identified gender or placed in a single room. Education of hospital staff and development of hospital policies in this realm will prevent questions or confusion that can be traumatizing for the patient. Pediatricians can influence policies and procedures by advocating for establishing and empowering hospital equity committees to consider best practices for transgender or gender-diverse adolescent patients.
Hospitalized Youth From the Juvenile Justice System
Adolescents in the juvenile justice system have high usage rates of mental health services and use the health care system for physical health concerns at a higher rate than those not involved with the justice system.41,42 Those detained in juvenile justice facilities were more likely to use the emergency department or to be hospitalized. The highest rates of hospital use were in adolescents confined to juvenile justice settings who reported poor health, illicit drug use, and mood disorders. In one study, adolescents detained in juvenile justice settings with mental illness and possibly comorbid substance use disorders were more likely to be hospitalized compared with nondetained youth.43 Seventy-four percent of inpatient adolescents who were detained in juvenile justice settings were hospitalized for a mental health diagnosis.
Hospitalization is an opportune time to address missing or delayed primary care concerns, including immunizations. These patients may warrant a social work consultation to assist for adverse childhood experiences and trauma and arranging for primary care and mental health services, including trauma-informed, strength-based approaches, at the time of discharge from the hospital. It is important for inpatient teams to transition patients returning to juvenile justice facilities with complete and comprehensive documentation of the hospital course, medication regimen, consent from parents or guardians, and any unmet primary care, mental health, reproductive health, or substance use disorder needs at the time of discharge from the hospital back to the juvenile justice facility.19 Before discharge, it would be helpful for inpatient teams to communicate with juvenile justice-based health service providers to tailor service provisions to meet individualized patient needs, because there may be needs that cannot be easily addressed in the juvenile justice setting that could be accomplished during inpatient hospitalization.
The hospitallized adolescent who is in the juvenile justice system may require a guard at the bedside or restraints such as handcuffs or leg shackles. This could be stigmatizing to the patient, traumatizing to medical staff, and potentially alarming to a roommate. Although there is no supporting evidence and it may not be feasible depending on the inpatient census, patients with guards and those with behavioral challenges may warrant placement in a private room to ensure privacy, confidentiality, and autonomy, and prompt assessment of concerns at the time of admission.42
The number of patients presenting to hospitals with eating disorders has increased exponentially since the COVID-19 pandemic began.44,45 Caring for those with eating disorders is critical to decrease the potential long-term outcomes, including suicide. The additional pandemic-related stressors could further increase the likelihood of this outcome. Behavioral health resources for those with eating disorders after pandemic shutdowns with virtual group therapy sessions and virtual live meal support may be helpful adjunctive interventions.46 The current fear and anxiety generated by COVID-19 was predicted to result in behaviors such as restrictive eating, binge eating, and self-harm.47 A preliminary study of 32 patients (16–49 years of age) with a range of eating disorders revealed that, after 2 weeks of confinement, almost 38% reported more eating disorder symptoms and 56% described an increase in anxiety.48
It is beyond the scope of this clinical report to definitively address hospitalization of adolescents in inpatient eating disorder units. However, patients with eating disorders are hospitalized frequently on medical units for refeeding syndrome risk or for other medical consequences of eating disorders. Refeeding protocols often require long hospital stays. The revised clinical report on the “Care of the Adolescent with an Eating Disorder”49 describes the management of patients with eating disorders who are hospitalized in a medical setting. Having nursing, nutrition, and social service personnel with specific training in the care of patients with eating disorders is important to inpatient care for these patients. Coordinating care with outside primary care providers is also important. Ibeziako et al50 compared medically hospitalized patients with eating disorders versus somatic symptoms via retrospective chart review. From this study, it was found that those with eating disorders had more depressive disorders, longer hospital stays, and higher suicidal intent and self-injury rates, and were more likely to be discharged to psychiatric treatment programs. The recommendation based on this study was that hospitals institute innovative approaches and clinical pathways for patients with eating disorders to decrease length of hospital stay, reduce service overutilization, and improve outcomes. If possible, patients with eating disorders should receive consultation with psychology or psychiatry to begin immediate behavioral interventions.
More than 50% of children with chronic illnesses, such as irritable bowel syndrome, juvenile idiopathic arthritis, autism spectrum disorders, cancer, and many behavioral health conditions, use complementary therapies, including massage, acupuncture, hypnosis, and most commonly, natural health products.51,52 The 2007 and 2012 National Health Interview Survey results revealed that adolescents (12–17 years of age) were more likely to use complementary therapies than younger children (4–11 years of age).53 Adolescents may use herbs/supplements to improve sleep, lose weight, enhance appetite, increase energy, and improve their body image or athletic performance, sometimes with fatal outcomes.54 During hospital stays, interactive and open discussions with hospital personnel and/or the PCP about the use of integrative therapies, especially herbs and supplements, may be necessary. Adolescents and their families may be alerted on safety risks, such as supplement-medication interactions.55 Use of nonformulary products, including medical marijuana, is not encouraged.
Addressing Mental Health in the Hospitalized Adolescent
As mentioned in previous sections, hospitalization is a stressful event for adolescents, regardless of their level of adjustment to their daily lives that existed before admission. Multiple factors contribute to this challenge for hospitalized youth. Changes inherent in hospitalizations may make them feel vulnerable, with a loss of control. In addition to their illness, the adolescent may be in pain or, at a minimum, uncomfortable with unmet needs to ameliorate these feelings.56 The loss of privacy may impede on typical coping mechanisms. Mental health assessment and treatment from a team of social workers, psychologists, and/or psychiatrists may be invaluable, not only for hospitalized adolescents with known mental health challenges, but also for others who require additional mental health support or who have underlying mental illness that manifests during a medical hospitalization. Some adolescents exhibit adverse effects from their psychotropic medication that contribute to their primary reason for hospitalization, such as diabetes or hypertension.
A retrospective chart review (n = 1091) of hospitalized AYAs showed in those with preexisting mental health concerns (usually depression, pain, somatic complaints, or maladjustment), consulting mental health providers during a medical hospitalization had a positive impact,57 resulting in a shorter length of stay. Treatment of the patients included development of a behavioral plan (outpatient or inpatient), assessment only, cognitive behavioral therapy, and problem-focused coping therapy.
Some programs initiate referrals during the medical hospitalization with psychology consultation liaison (PCL) teams. Most PCL services use the “6 C’s” approach: compliance, crisis, communication, coping, collaboration, and changing systems.58 Problems such as adjustment to illness/hospitalization, medical nonadherence, anxiety/depression, pain management, and family medical team interactions are ideal reasons to consult a PCL and to start mental health treatment in the hospital. Administering short screening tools in the inpatient setting, such as the Patient Health Questionnaire (2 or 9),58 might help identify adolescents who have unrecognized mental health needs in the outpatient setting.
Worsley et al59 used a semistructured interview to obtain the adolescents’ perspectives including areas for improvement who were admitted to a medical unit or “boarding” while awaiting transfer to an inpatient psychiatric hospitalization. The adolescents wanted compassionate care, information about expectations, a safe and comfortable environment, and to keep busy to avoid boredom. They were relieved to receive support to reduce their suicidal behaviors and thoughts. These adolescents reported embarrassment and discomfort with repeated questioning by their providers and unanswered questions about their pending psychiatric hospitalization. Clearly more research is needed to find the appropriate solution to this problem. As part of any medical hospitalization, a psychosocial assessment may be helpful in detecting unrecognized mental health concerns.
A comprehensive psychosocial assessment is recommended for the adolescent patient, including those with intellectual and developmental disabilities. Undiagnosed mental health concerns may be uncovered that could be addressed during the hospitalization.60,61 Inpatient units should have a social worker for initial assessment of adolescent patients. Moreover, facilities should have a mental health liaison service with mental health professionals who have specific expertise treating adolescents and young adults and can work with the outpatient behavioral health team if already established. It is ideal for follow-up appointments with a mental health provider be made before the patients’ discharge, to limit barriers to a timely appointment that may be attributable to insurance coverage, transportation barriers, and limited mental health provider accessibility.
Inpatient Behavioral Health Services for Children and Adolescents
The hospitalized adolescent in the psychiatric/inpatient behavioral health setting should receive care equitable to that of adolescents in other inpatient settings, including access to pediatricians and adolescent medicine specialists to provide medical consultations and to participate in the design of inpatient psychiatric units.
It is beyond the scope of this clinical report to address hospitalization of adolescents admitted to inpatient psychiatric units; however, it is important to acknowledge that utilization of inpatient psychiatric services for children and adolescents has increased despite federal and state reforms to develop and implement less costly, community-based systems of care.62 Plemmons et al62 found substantial increases in the number of youths with suicidal ideation or intent-to-harm-self codes in inpatient settings mirroring the rates of suicide that have increased significantly between 2007 and 2015. There are not enough psychiatric inpatient facilities for children and adolescents.63 Although the inclusive rate of all-cause hospitalizations for children and adolescents with private insurance coverage did not increase between 2006 and 2011, inpatient stays for behavioral health conditions in acute care and community hospitals increased by 35.3% for children and youth from 1 to 17 years of age and by 48.5% for children and youth 10 to 14 years of age. Using nationally representative data, nearly 10% of inpatient hospitalizations for children, and AYAs 2 to 20 years of age at acute care and community hospitals (excluding psychiatric facilities) were for primary mental health diagnoses.64
Sexual Health and Family Planning
Hospitalization is an opportunity to perform a sexual risk assessment and screening for STIs. Many adolescents do not present to their medical home or PCP, even when reproductive health care (such as screening for STIs and providing contraception) is available without parental involvement/consent for minors, in accordance with state laws.65 Adolescents with chronic illness may be at increased risk for pregnancy and complications because of their illness and treatment. Adolescents at risk for pregnancy may be on medications or need medications that are teratogenic. There are clear data, presented in the following section, that sexual risk assessment and treatment are inconsistent in the hospital setting and, thus, services are infrequently offered. Not providing these services for adolescent inpatients, regardless of gender, sex, sexual orientation, or disability is a missed opportunity to identify at-risk patients who need STI screening and contraception.
A sexual history was completed or documented in only 55% (83 of 150) of patients 14 to 18 years of age hospitalized on a general academic pediatric service.66 When any sexual history was obtained, there was variable documentation of risk assessment. In half of patients, condom use or nonuse was noted, but only 39% had documentation of number of sexual partners and only about a quarter of the patients, mostly females, had documentation of contraception.
Another study indicated that hospitalized adolescents were not routinely assessed for sexual health risk.67 The researchers performed a retrospective review of consecutive adolescents 13 years and older who were admitted to a hospitalist service at a large academic pediatric tertiary care center, evaluating documentation of sexual history, pregnancy history, human papillomavirus vaccine status, provision of STI testing, and whether contraception was administered. Fifty-five percent of the adolescents had documentation of sexual history, and 47% of these were sexually active. Interns, advanced practice providers (ie, advanced registered nurse practitioners or physician assistants), or fellows were more likely to obtain this history. Only 12% of patients were tested for STIs; 60% of females were tested for pregnancy; 2% of females were provided contraception; and 19% of those due for human papillomavirus vaccine received it.
These data validate the importance of sexual history-taking and documentation for adolescents admitted for inpatient care, which also allows an opportunity to provide confidential counseling to reduce risk-taking behaviors (for specific AAP guidance on adolescent reproductive health, see https://www.aap.org/en/patient-care/adolescent-sexual-health/adolescent- sexual-health-aap-policy-statements/). An editorial in the Journal of Adolescent Health68 reiterates this point and makes recommendations to improve the provision of reproductive health care for hospitalized adolescents, which, in turn, will improve outcomes.
A patient who uses medical technology (those with gastrostomy or tracheostomy tubes, those requiring ventilator support, etc) are vulnerable, medically and psychosocially, and historically are not assessed for health risk behaviors.69 Hospitalized adolescents using medical technology often do not have adequate documentation of contraception and sexual histories. Adolescents transferred from the PICU also had lower rates of documentation of sexual histories compared with patients directly admitted to inpatient units. This finding supports the need for sexual risk assessment and contraception during hospitalization, even for critically ill adolescents at the appropriate time, so that needed care is provided or outpatient services are arranged.
As part of the history, assessment for substance use and mental health concerns is advised, because these concerns may be related to high-risk sexual activity. Moreover, inquiry into the nature of the patients’ relationship with their sexual partner may reveal the presence or risk for interpersonal violence or reproductive coercion. This approach could incorporate information about universal counseling and resource provision about healthy relationships.
STI and Pregnancy Testing
Pregnancy testing should be performed on every adolescent at risk for pregnancy (ie, all pubertal patients assigned a female sex at birth or known to have a uterus). Ideally, pregnancy testing should be performed in the emergency department before admission or on the inpatient unit at the time of admission. Pregnancy status is important, because the patient may need radiographic imaging or medications that would be contraindicated during pregnancy. Some medical conditions may be exacerbated by pregnancy, and treatment decisions may be influenced by this. Moreover, if the patient needs emergency surgery, delays can be avoided. If the patient is pregnant, comprehensive options counseling should be offered by a designated member of the health care team. Ideally, this is the medical provider with social work support. Depending on availability, this could be the hospital medicine service or an adolescent medicine or obstetrics consultation.
Generally, screening for STIs including Chlamydia, gonorrhea, syphilis, and HIV is easily accomplished in the hospital setting. There is growing evidence that adolescents and parents are supportive of sexual health discussions during hospitalizations. In a study by Bhalakia et al,70 nearly half of adolescent patients surveyed in an inner-city children’s hospital, with a mean age of 17.4 years and 65% rate of sexual activity, agreed to routine HIV testing. Older patients, those with previous sexual activity and past HIV testing, were more likely to be offered testing. Almost all the subjects agreed that the hospital setting is appropriate for HIV testing.
A potential barrier to STI testing could be tracking and follow-up of results because of confidentiality concerns. Maslyanskaya et al71 set up a successful EHR protocol to track the results of gonorrhea or Chlamydia testing for hospitalized adolescents in an urban children’s hospital to ensure treatment of patients who screened positive. The process was enhanced by specific tools of the EHR, which increased patient treatment or referral to treatment to 100%.
Surveys of pediatric hospital medicine physicians show an interest in providing risk assessment and some reproductive health care, but valid concerns limit hospitalists from routinely offering such care. Masonbrink et al68 administered a 76-item questionnaire to assess sexual and reproductive care practices of hospitalists at 5 pediatric hospitals caring for patients 14 to 21 years of age. Sixty-nine percent of the hospitalists surveyed reported they care for more than 46 adolescents annually, many who are at increased risk for pregnancy complications because of their medical condition or treatment. Documented barriers to providing reproductive health services in the hospital included time constraints and patient follow-up. The majority wished to provide contraception to their patients but cited lack of knowledge as a barrier. They were likely to increase contraception provision if education was provided.
Guss et al72 studied hospitalized adolescents 13 to 18 years of age at a tertiary care hospital. Results demonstrated there was interest in reproductive health education and contraception, even for patients with primary care providers and without sexual experience. The authors concluded that hospital-based pediatricians can play a role in expanding critical sexual health services by discussing and offering sexual health care to hospitalized adolescents. This group recommended making a brochure for admitted adolescents encouraging follow-up discussions with hospitalists throughout the hospital stay. This complements or augments the care provided by the primary care provider. Another hospitalist group in an academic children’s hospital studied the implementation of a reproductive health module including a survey, assessment of sexual health, and feedback which was randomized for half of the subjects.73 Fifty percent of the female respondents, regardless of age and sexual experiences, requested a service, and more than 80% expressed interest in a video learning module about contraception, independent of age or sexual experience. The STI request for testing was higher in those who were sexually active. This study indicates the feasibility of implementing a sexual health module for all hospitalized adolescents (ie, regardless of gender).
Another reproductive health care consideration that affects adolescents who are hospitalized and will undergo chemotherapy and/or radiation therapy for cancer or for other chronic illnesses is the potential for gamete preservation. An AAP clinical report74 mentions all the potential medical and genetic conditions, which, themselves or because of cancer treatment, lead to fertility impairment. Besides the AAP, national organizations such as the American College of Obstetrics and Gynecology,75 American Society for Reproductive Medicine,76 and American Society of Clinical Oncology77 recommend offering patients information and counseling for fertility preservation and outline clinical guidelines. If available, a consultation with fertility experts should be provided for all patients on gonadotoxic medications, chemotherapy, and radiation. Gamete preservation can be performed as an outpatient procedure for adolescents who are postpubertal and sperm-producing, but fertility preservation for all other adolescents involves procedures that could be offered during hospitalization for other concerns, including initiation of chemotherapy. Moreover, when obtaining a confidential sexual history from a patient, if a patient discloses they are transgender, fertility preservation can be discussed when outlining care with gender-affirming hormone treatment or surgery. The AAP clinical report mentioned previously outlines how such counseling can be performed.74
When obtaining a sexual history, contraception history is important to ascertain. If an adolescent is taking hormonal contraception such as the combined oral contraception pill, patch, or ring before hospital admission, this medication should be continued during the hospitalization. If the adolescent is utilizing depot-medroxyprogesterone acetate, date of last administration should be obtained, because the next dose might be due and could be administered during the hospitalization. If the patient will be immobilized for a prolonged period of time, such as after an orthopedic procedure, estrogen-containing products are contraindicated because of the high risk of thrombosis. Switching to progestin-only contraception, such as progestin-only pills, is recommended. Drug interactions are common with hormonal contraception and consultation with inpatient pharmacists can help mitigate these risks by recommending alternative contraception options.78
Assessing reproductive health in adolescents assigned female sex at birth or known to have a uterus includes obtaining a menstrual history; both the AAP and American College of Obstetrics and Gynecology consider menses to be a vital sign.79 A complete menstrual history documented in the review of systems for all hospitalized adolescents includes age of menarche, first day of last menstrual period, length of menses, frequency of menses, number of pads/tampons used, whether clots are presents or accidents occur, presence of dysmenorrhea or other perimenstrual symptoms, and whether these symptoms interfere with school attendance or social events and how they are currently being treated.80
A retrospective chart review of females 11 to 18 years of age admitted to a pediatric inpatient unit assessed for documentation of menstrual and sexual histories.81 The study showed that less than half the females had documentation of sexual history, with the rate being higher for those with mental health symptoms and lower for those admitted to a surgical service. At least 1 aspect of menstrual history was documented in 29% of the patients. Menarche was the most commonly documented at 7%. All other elements of the menstrual history, such as flow quantity, dysmenorrhea, and menstrual duration, were documented in less than 5% of females, regardless of chief complaint or admitting service. Almost three-quarters of the females who required a gynecology consultation had a documented menstrual history. A recent study found that nearly 75% of hospitalized female adolescents had a medical condition and/or were taking teratogenic medication that their increased their risks should pregnancy occur.82
If evidence of a menstrual disorder is revealed, it can be addressed during the hospitalization. For example, an adolescent with a history of heavy periods, particularly if anemic, should be evaluated for the etiology of this menstrual concern, with consultation from adolescent medicine or gynecology and possibly hematology and, possibly, started on empirical anemia treatment. Adolescents with irregular menses with no anemia could have the evaluation begin in the hospital and be scheduled for follow-up with their PCP, an adolescent medicine specialist, or a gynecologist. The evaluation for menstrual disorders is beyond the scope of this statement but may be found in a number of AAP publications.83
If an adolescent admitted for another medical or surgical concern is found to be anemic and is currently menstruating, treatment to stop menses or address menorrhagia can be considered during the hospitalization. Adolescent medicine or gynecology could be consulted to initiate medical treatment to stop menses, if warranted.84 Other adolescents for whom menstrual suppression can be addressed and initiated in the inpatient setting are those who with IDDs, those who will undergo hematopoietic stem cell transplant (HSCT), or those who have thrombocytopenia or a functional platelet disorder or another clotting disorder.
The Pregnant Hospitalized Adolescent
All adolescents assigned female sex at birth or intersex youth with a uterus may also be at risk for pregnancy and should be assessed for possible pregnancy at the time of inpatient hospitalization. This assessment is important, regardless of sexual practice history, because of the potential need for teratogenic medications for the presenting condition, as well as the possibility that the pregnancy could impact the diagnosis and/or treatment of the medical illness. If an adolescent is determined to be pregnant, it is imperative not to prescribe medications that would potentially adversely affect the fetus. EHRs, databases, pharmaceutical company information, and other resources contain drug information related to teratogenicity. In many cases, obstetric consultation is warranted, particularly if the adolescent has a relationship with an obstetric/gynecology provider or if the medical condition causes risk to the pregnancy or vice versa.
Hospital policy is recommended to determine where a pregnant patient will be admitted. Generally, this decision is based on the gestational age of the pregnancy; often, ultrasonography is required to assess the gestational age, although there is no consistent standard of care. If a pregnant adolescent remains on a pediatric unit, consultation with obstetrics/gynecology is important in nearly all cases, even during the early months of pregnancy. Similarly, if an adolescent patient is admitted on an obstetrical unit, consultation with a pediatrician or adolescent medicine specialist is important, especially for early- and mid-adolescents to ensure developmentally appropriate care, including interventions from child life specialists. When an adolescent has postpartum complications or is readmitted for postpartum-related concerns, consultation with a pediatrician or an adolescent medicine specialist is considered imperative to the ongoing care of the hospitalized patient.
If a pregnancy is diagnosed initially during the course of the hospitalization or the adolescent does not have a firm idea of the future of the pregnancy, options counseling should be performed in a confidential, supportive environment.85,86
A discharge plan with arrangements for future care, which may include prenatal care, further discussion of pregnancy options, or termination of pregnancy, should be arranged.87
As with all sexually active adolescents, those found to be pregnant should be screened for STIs. If an adolescent elects to terminate the pregnancy, a discussion about contraception options after termination may be initiated.
Tobacco, Alcohol, and Substance Use Disorders in the Hospitalized Adolescent
Although tobacco, alcohol, and illicit substance use, prescription drug misuse, and vaping may not be the primary reason for the acute hospitalization, these risk behaviors may lead to subsequent hospitalizations, illness, and even mortality. It is possible that vaping, tobacco, alcohol, or illicit substance use may be the underlying cause of the diagnosis leading to hospitalization, and it might be disclosed before, during, or after the admission process. It is important for the pediatric clinician caring for hospitalized adolescents to assess for these behaviors. The inpatient setting may be an ideal place to initiate treatment of these disorders, but, at a minimum, to encourage the adolescent to engage in outpatient care and stress the importance of this ongoing care.
In a study by Masonbrink et al, hospitalized adolescents were administered a self-report questionnaire that was compared with documentation in the EHR. Most commonly reported substances were alcohol (39%), cannabis (33%), and electronic cigarettes (31%). One third of subjects reported use of more than one substance. Subjects 16 to 18 years of age had a higher rate of reported use of these 3 substances than those 14 to 15 years of age. A positive history of substance was documented in only 11% of EHRs. There was an obvious discrepancy between documented substance use in EHRs and self-report.88
Preexisting frameworks for obtaining the psychosocial history used in the outpatient setting, such as the HEADSSS89 and SSHADESS (strength, school, home, activities, drugs/substance abuse, emotion/depression, sexuality, safety)90 assessments, are helpful because they use strength-based approaches. Substance abuse screening tools available include the CRAFFT (car, relax, alone, forget, friends, trouble),91 the S2BI (screening to brief intervention), and BSTAD (brief screener for tobacco alcohol and other drugs) for substance use disorders. If an adolescent is involved in high-risk behaviors, SBIRT (screening, brief intervention, and referral to treatment),92 which is commonly employed in the outpatient setting, may be successfully implemented in the inpatient setting. In fact, SBIRT has been recommended by The Joint Commission (www.Jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measure).93 The Substance Abuse and Mental Health Services Administration has a number of resources that are useful to determine the extent of alcohol, tobacco, and substance use in the hospitalized adolescent (https://www.integration.samhsa.gov/clinical-practice/screening-tools#drugs).
Advanced Care and Palliative Care Planning
The hospital may be the place where an adolescent dies as a result of an unexpected accident or after a chronic terminal illness, suicide, homicide, or infection (eg, encephalitis). Mack et al94 studied more than 600 AYAs with cancer, the leading disease-causing death in this age group. Sixty-two percent of adolescent/young adult oncology patients were hospitalized, 22% were admitted to the ICU, and 22% had more than 1 emergency department visit within 14 days of death. They found 63% received at least 1 medically intensive end-of-life-care intervention. They highlight the need to understand end-of-life-care preferences and decision-making in AYAs.
Another study of AYAs with cancer compared end-of-life experiences of those who died as inpatients and received palliative care versus those who did not receive palliative care.95 AYAs who died in the hospital required considerable medical and psychosocial care, and experienced numerous treatments during the last month of life. Compared with those who received no palliative care, patients followed by a palliative care team were less likely to die in the ICU or to be placed on a ventilator, received fewer invasive medical procedures, had do-not-resuscitate orders instituted earlier, and experienced less intensive treatment.
Although it was a study of children 0 to 18 years of age, and not just adolescents, the study by Osenga et el96 supported the benefits of having a palliative care plan. Their study included hospitalized patients admitted for a minimum of 34 hours before death and found that having an advanced care plan (treatment and resuscitation preferences, preferred location of death, legacy formation/memory making) was beneficial. Of the 25% of the sample who had a palliative care plan, there were fewer blood draws, intravenous line placements, diagnostic testing, and arterial blood gas sampling over the final 48 hours of life. Moreover, these patients had a higher frequency of pain assessments, more documentation of actions to manage pain, higher rates of receiving integrative medicine services, and 8 times greater odds of having do-not-resuscitate orders.
Snamen et al95 studied AYAs who underwent HSCT and found they were more likely than other oncology patients to die in the ICU or to receive mechanical ventilation or hemodialysis in their last 30 days of life. They recommended that AYAs undergoing HSCT receive palliative care consultation and indicate that they may benefit from early interdisciplinary services to proactively assess and manage distressing symptoms.
A study by Lyon et al97 examined an advanced care planning protocol for adolescents with cancer and assessed for quality of life, use of advanced directives, and mental health concerns such as anxiety and depression. This advanced care protocol met recommendations of the AAP, World Health Organization, and National Academy of Medicine for early palliative care involving parents, surrogate decision-makers, and physicians. The study showed adolescents following this protocol had decreased anxiety and depressive symptoms, had a high quality of life, had advanced directives, and had higher spirituality scores. Adolescents who were enrolled in the protocol endorsed that the best time in the illness course to discuss end-of-life decisions was variable; 19% stated the ideal time was before becoming sick, and 19% stated the ideal time was at the time of diagnosis. This finding was confirmed in other publications.97,98 The AAP recently published a clinical report with an in-depth review on the care in the final hours, days, and weeks of a child or adolescent’s life and recommendations to assist in the care of dying patients and their families.99
In the United States, nearly 20% of children younger than 18 years of age have a special health care need, defined as having or being at increased risk for chronic physical, developmental, behavioral, or emotional conditions.100 These youth typically transition from pediatric to adult providers and from children’s hospitals/units to adult-focused inpatient settings. Unfortunately, these transitions are often difficult, creating potential gaps in care and adverse health outcomes, leaving patients and families feeling frustrated.101,–103 As with the transition to outpatient adult providers, it is important to alert adolescents and their families that transitions to adult inpatient providers and to adult hospital settings should occur in a timely and comprehensive manner to avoid disruptions in care and to minimize anxiety with the process. See the accompanying policy statement for detailed information on the transition to adult care facilities.
Hospitalized adolescents have unique and comprehensive needs that differ from those of younger patients and adults. The adolescent requires care by professionals with knowledge, experience, and interest in the intricate and multifaceted needs of adolescents irrespective of the reason, duration, or location of hospitalization. From this extensive clinical report, pediatricians will have a broader understanding of the many requirements that will ensure comprehensive and compassionate management of the many different issues and diagnoses that a hospitalized adolescent may encounter.
Recognize that hospitalization affects adolescent patients by interfering with their burgeoning independence and autonomy, which will allow physicians, nurses, other hospital personnel, and families to understand better the challenges and opportunities of providing strengths-based care to hospitalized adolescent patients.
Provide special attention to specific populations of hospitalized adolescent patients, including, but not only, those with developmental disabilities, intellectual disabilities, and other special health care needs; those involved with the juvenile justice system; and those who are pregnant, LGBTQ+, or in palliative care/hospice.
Address concerns, certain diagnoses, routine assessments (eg, assessment for trauma history/trauma stress symptoms), and preventive care opportunities that are commonly encountered in hospitalized adolescents, including catching up on immunizations, mental and behavioral health issues, substance use, eating disorders, sexual health/family planning, and menstrual disorders.
Identify alternative medical therapies (eg, integrative medicine and the use of complementary treatments) that are common in hospitalized adolescents to avoid dangerous medication, herb, or supplement interactions.
Create a standardized approach for communications (early and ongoing) around transitions from pediatric to adult providers/medical homes and facilities with adolescent patients and families to decrease frustrations, manage expectations, and avoid gaps in care for adolescents with chronic medical illness and frequent hospital admissions.
Cora C. Breuner, MD, MPH, FAAP
Elizabeth M. Alderman, MD, FSAHM, FAAP
Jennifer Jewell, MD, FAAP
Committee on Adolescence, 2021–2022
Elizabeth M. Alderman, MD, FSAHM, FAAP, chairperson
Elise Berlan, MD, FAAP
Richard J. Chung, MD, FAAP
Michael Colburn, MD, MEd, FAAP
Laura K. Grubb, MD, MPH, FAAP
Janet Lee, MD, FAAP
Stephenie B. Wallace, MD, MSPH, FAAP
Former Committee on Adolescence Members, 2019–2020
Makia Powers, MD, MPH
Krishna K. Upadhya, MD, FAAP
Anne-Marie Amies, MD, American College of Obstetricians and Gynecologists
Liwei L. Hua, MD, PhD, American Academy of Child and Adolescent Psychiatry
Ellie Vyver, MD, Canadian Pediatric Society
Seema Menon, MD, North American Society of Pediatric and Adolescent Gynecology
Lauren B. Zapata, PhD, MSPH, Centers for Disease Control and Prevention
Maria Rahmandar, MD, FAAP, Section on Adolescent Health
James Baumberger, MPP
AAP Committee on Hospital Care, 2021–2022
Daniel A. Rauch, MD, FAAP, chairperson
Samantha House, DO, FAAP
Benson Hsu, MD, MBA, FCCM, FAAP, AAP Section on Critical Care member
Melissa Mauro-Small, MD, FAAP, AAP Section on Hospital Medicine member
Nerian Ortiz-Mato, MD, FAAPCharles Vinocur, MD, FAAP, FACS
Nicole Webb, MD, FAAP
Former Committee on Hospital Care Member, 2020–2021
Kimberly Ernst, MD, MSMI, FAAP
Vinh Lam, MD, FAAP
Michael S. Leonard, MD, MS, FAAP, representative to The Joint CommissionKaren Castleberry, family representative
Nancy Hanson, Children’s Hospital Association
Kristin Hittle Gigli, PhD, RN, CPNP-AC, CCRN, National Association of Pediatric Nurse Practitioners
Barbara Romito, MA, CCLS, Association of Child Life Professionals
S. Niccole Alexander, MPP
Drs Breuner, Alderman, and Jewell conceptualized, wrote, and revised the manuscript, considering input from all reviewers and the board of directors; all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.
The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2022-060646.
American Academy of Pediatrics
adolescents and young adults
electronic health record
hematopoietic stem cell transplant
intellectual and development disabilities
lesbian, gay, bisexual, transgender, queer, or questioning
psychological consultation liaison
primary care provider
sexually transmitted infection
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest relevant to this article to disclose.