Promoting Choosing Wisely Thyroid Function Test Guidelines in a Large Pediatric Hospital System.

BACKGROUND: Free thyroxine (fT4) is often ordered when not indicated. The goal of the current study was to use quality improvement tools to identify and implement an optimal approach to reduce inappropriate fT4 testing throughout a large pediatric hospital system. METHODS: After reviewing evidence-based guidelines and best practices, a thyroid-stimulating hormone with reflex to fT4 test and an outpatient thyroid order panel with clinical decision support at order entry, along with several rounds of provider education and feedback, were implemented. Outpatient and inpatient order sets and system preference lists were reviewed with subject matter experts and revised when appropriate. Tracking metrics were identified. Automated monthly run charts and statistical process control charts were created using data retrieved from the electronic health record. Charts established baseline data, balancing measure data, monitored the impact of interventions, and identified future interventions. RESULTS: Over a 44-month period, among nonendocrinology providers, a reduction in fT4 and thyroid-stimulating hormone co-orders from 67% to 15% and an increase in reflex fT4 tests from 0% to 77% was obtained in inpatient and outpatient settings. Direct cost savings as a result of performing 5179 fewer fT4 tests over 3 years was determined to be $45 800. CONCLUSIONS: After implementation of a reflex fT4 test, a novel order panel with clinical decision support, provider education, and changes to ordering modes, a large and sustainable reduction in fT4 tests that was associated with significant cost savings was achieved among nonendocrinology providers.

Estimating Skeletal Maturity Using Wrist Radiographs During Preadolescence: The Epiphyseal:Metaphyseal Ratio.

BACKGROUND: Although skeletal maturity is most relevant during adolescence, it has utility in treatment of younger patients in some circumstances, such as scoliosis, limb length discrepancy, or endocrinopathies. Currently, a quick, accurate, and reproducible method of estimating skeletal maturity in preadolescents using wrist radiographs is lacking. METHODS: Serial anteroposterior wrist radiographs taken at historical growth study visits leading up to the chronological age (CA) associated with 90% of the final height (an enhanced skeletal maturity standard as compared with peak height velocity) were analyzed in 102 children. Epiphyseal and metaphyseal widths of 5 physes were evaluated: distal radius, distal ulna, first metacarpal, third metacarpal, and fifth metacarpal. Ulnar styloid height and radial styloid height were also measured, for a total of 7 epiphyseal:metaphyseal radiographic parameters. Greulich and Pyle (GP) bone age was also measured. A combination of stepwise linear regression and generalized estimating equation analyses was used to produce a skeletal maturity estimation model incorporating demographics (CA and sex) and the epiphyseal:metaphyseal ratios significantly correlated with skeletal maturity. RESULTS: A total of 273 left anteroposterior hand-wrist radiographs from 56 girls (163 radiographs, range 4 to 13 y) and 46 boys (112 radiographs, range 3.8 to 15 y) were included. The demographics+ratios model had better prediction accuracy than GP only and GP with demographics (0.44, 0.87, and 0.47 y mean discrepancy from actual skeletal age, P <0.05 for both comparisons). There was no significant difference in the rate of outlier skeletal age estimates, defined as an estimate >1 year off from the true skeletal age, between the demographics+ratios model and the demographics+GP model (5.9% vs. 8.4%, P =0.12). CONCLUSIONS: When combined with CA and sex data, measurement of the epiphyseal:metaphyseal ratios of the left first and third metacarpals allows for improved skeletal maturity estimation compared with the GP technique. CLINICAL RELEVANCE: Our modified wrist skeletal maturity system offers a relatively quick and reproducible method for estimating skeletal maturity extending into the juvenile age range. This study is a level III retrospective study of longitudinal human growth data obtained from the Bolton Brush Collection in Cleveland, Ohio.

Estimating Skeletal Maturity Using Knee Radiographs During Preadolescence: The Epiphyseal:Metaphyseal Ratio.

BACKGROUND: Though skeletal maturity is most relevant during adolescence, it has utility in treatment of younger patients in some circumstances. Accurate estimation of skeletal maturity using knee radiographs would be useful when treating limb length discrepancy and other general medical conditions in preadolescent patients. Currently, a quick, accurate, and reproducible method of estimating skeletal maturity in preadolescents is lacking. METHODS: Serial anteroposterior knee radiographs taken at historical growth study visits leading up to the chronological age associated with 90% of final height (an enhanced skeletal maturity standard as compared with peak height velocity) were analyzed in 75 children. Epiphyseal and metaphyseal widths of the distal femur, proximal tibia, and proximal fibula were measured and the epiphyseal:metaphyseal ratio was calculated. Greulich and Pyle (GP) bone ages were also assigned by an experienced pediatric endocrinologist using left hand radiographs. Stepwise linear regression and generalized estimating equation analyses were used to make a skeletal maturity model incorporating demographics (age+sex) and knee epiphyseal:metaphyseal ratios. RESULTS: A total of 258 left knee radiographs from 39 girls (mean age 8.6 y, range: 2.9 to 13 y) and 36 boys (mean age 10.6 y, range: 3.8 to 15 y) were included. The demographics+ratios model had similar prediction accuracy (0.49 vs. 0.48 y, P=0.84) and rate of outliers (11% vs. 9%, P=0.11) as the demographics+GP model. The demographics+ratios model outperformed all other models evaluated, including a demographics-only model (P<0.001 for all). CONCLUSIONS: When combined with chronological age and sex, epiphyseal:metaphyseal ratio measurement in the knee allows for skeletal maturity estimation comparable to using the GP technique. CLINICAL RELEVANCE: We have defined a knee skeletal maturity system that could be applied in treatment of orthopaedic conditions in preadolescents where a knee radiograph is already obtained, avoiding the need for an additional hand radiograph.

Associations between Trust of Healthcare Provider and Body Mass Index in Adolescents.

Adolescent obesity continues to be a serious concern around the world, placing young people at risk for chronic conditions and early death. Research has shown that social relationships are important in making health behavior changes, such as following health-care recommendations for eating and physical activity. Specifically, the trust of health-care providers has been shown to be important in making health behavior change. Evidence suggests that obese young adults are less trusting of health-care providers than their healthy weight peers, but it is not known if this also applies to obese adolescents. The purpose of this secondary analysis study was to determine relationships between the trust of health-care providers and body mass index percentile in adolescents. Participants were 224 adolescents aged 14-19 years attending a public high school in the Midwestern United States. The Wake Forest Physician Trust scale measured the trust of health-care providers. Height and weight were collected at a school screening; body mass index percentile categories were determined according to age- and sex-adjusted body mass index percentiles. One-way analysis of variance and post hoc Tukey tests showed trust scores varied significantly between body mass index percentile categories of girls. Results suggest it may be necessary for health-care providers to make additional efforts to build trust with obese adolescent girls than with other groups of adolescents.

Emergency management of adrenal insufficiency in children: advocating for treatment options in outpatient and field settings.

Adrenal insufficiency (AI) remains a significant cause of morbidity and mortality in children with 1 in 200 episodes of adrenal crisis resulting in death. The goal of this working group of the Pediatric Endocrine Society Drug and Therapeutics Committee was to raise awareness on the importance of early recognition of AI, to advocate for the availability of hydrocortisone sodium succinate (HSS) on emergency medical service (EMS) ambulances or allow EMS personnel to administer patient's HSS home supply to avoid delay in administration of life-saving stress dosing, and to provide guidance on the emergency management of children in adrenal crisis. Currently, hydrocortisone, or an equivalent synthetic glucocorticoid, is not available on most ambulances for emergency stress dose administration by EMS personnel to a child in adrenal crisis. At the same time, many States have regulations preventing the use of patient's home HSS supply to be used to treat acute adrenal crisis. In children with known AI, parents and care providers must be made familiar with the administration of maintenance and stress dose glucocorticoid therapy to prevent adrenal crises. Patients with known AI and their families should be provided an Adrenal Insufficiency Action Plan, including stress hydrocortisone dose (both oral and intramuscular/intravenous) to be provided immediately to EMS providers and triage personnel in urgent care and emergency departments. Advocacy efforts to increase the availability of stress dose HSS during EMS transport care and add HSS to weight-based dosing tapes are highly encouraged.

Weight-Related Teasing of Adolescents Who Are Primarily Obese: Roles of Sociocultural Attitudes Towards Appearance and Physical Activity Self-Efficacy.

Adolescents who are obese are at risk for being teased about their appearance with the concomitant negative psychological sequelae. Identifying modifiable variables associated with teasing could inform pediatric weight-management interventions. Characterizing society's role in the victimization of these at-risk individuals could guide anti-bullying programs for schools and broader public health efforts. This study aims to examine novel societal and cognitive factors associated with weight-related teasing frequency. Participants were adolescents (N = 334) being evaluated for a hospital-affiliated weight-management program. The outcome was perceived weight-related teasing frequency. Predictors were sociocultural awareness and internalization of appearance-related attitudes, physical activity self-efficacy, and psychological functioning. Multivariate regressions controlled for demographics and body mass index (BMI) z-scores with separate regressions testing interactions of BMI z-scores with all predictors. In adjusted analyses, higher physical activity self-efficacy and fewer depressive symptoms related to lower teasing frequency. Interactions indicated that less awareness/internalization of sociocultural attitudes towards appearance, more positive body image, and higher self-esteem related to lower teasing frequency regardless of BMI. Targeted interventions and public health campaigns should be developed and tested for adolescents that improve body image with promotion of diverse views about attractiveness, bolster confidence in overcoming physical activity barriers, and identify and treat mood symptoms.

Two Family Interventions to Reduce BMI in Low-Income Urban Youth: A Randomized Trial.

BACKGROUND: Our primary aim was to evaluate the effects of 2 family-based obesity management interventions compared with a control group on BMI in low-income adolescents with overweight or obesity. METHODS: In this randomized clinical trial, 360 urban-residing youth and a parent were randomly assigned to 1 of 2 behaviorally distinct family interventions or an education-only control group. Eligible children were entering the sixth grade with a BMI ≥85th percentile. Interventions were 3 years in length; data were collected annually for 3 years. Effects of the interventions on BMI slope (primary outcome) over 3 years and a set of secondary outcomes were assessed. RESULTS: Participants were primarily African American (77%), had a family income of <25 000 per year, and obese at enrollment (68%). BMI increased over time in all study groups, with group increases ranging from 0.95 to 1.08. In an intent-to-treat analysis, no significant differences were found in adjusted BMI slopes between either of the family-based interventions and the control group (P = .35). No differences were found between the experimental and control groups on secondary outcomes of diet, physical activity, sleep, perceived stress, or cardiometabolic factors. No evidence of effect modification of the study arms by sex, race and/or ethnicity, household income, baseline levels of child and parent obesity, or exposure to a school fitness program were found. CONCLUSIONS: In this low-income, adolescent population, neither of the family-based interventions improved BMI or health-related secondary outcomes. Future interventions should more fully address poverty and other social issues contributing to childhood obesity.

Growth perturbations from stimulant medications and inhaled corticosteroids.

Stimulant medications for the treatment of attention deficit hyperactivity disorder (ADHD) and inhaled corticosteroids (ICS) for the treatment of asthma are two classes of medications that are commonly prescribed in pediatrics. Among other adverse effects of these medications, growth attenuation has long been a focus of investigation. With stimulants, growth deficits of 1-1.4 cm/year have been observed in the short term, mainly in the first 2 years of treatment, in a dose-dependent manner. Long-term studies on stimulants have reported divergent effects on growth, with many studies showing no clinically significant height deficits by adulthood. The study that followed the largest cohort of children on stimulants, however, reported an overall adult height deficit of 1.29 cm in subjects who had received stimulant medications, with mean adult height deficit of 4.7 cm among those taking the medication consistently. With ICS use, mild growth suppression is seen in the short term (particularly in the first year of therapy) with growth rates reduced by 0.4-1.5 cm/year. Available current evidence indicates that the impact of ICS use on adult height is not clinically significant, with effects limited to 1.2 cm or less. There is significant individual variability in growth suppression with ICS use, with the specific pharmacologic agent, formulation, dose exposure, age, puberty, medication adherence, and timing of administration being important modifying factors. Based on currently available evidence, the therapeutic benefits of ICS for management of asthma and stimulant medications for management of ADHD outweigh the potential risk for growth suppression. Strategies to minimize growth attenuation and other potential adverse effects of these medications include using the lowest efficacious dose, frequent assessments and dose titration. Particular vigilance is essential with concomitant use of multiple medications that can attenuate growth and to evaluate for potential adrenal insufficiency from ICS use.

Challenges in the diagnosis and management of disorders of sex development.

Disorders of sex development (DSD) represent a spectrum of uncommon but very complex disorders with medical, psychosexual, and family implications for those affected by them. The diagnosis and management of these disorders requires a coordinated team of multiple specialists. Following an international conference in Chicago in 2005, a consensus statement was created and presented, which has resulted in a new paradigm in the nomenclature, classification, and management of DSDs. Since that time, many improvements have been forthcoming, most notably in the area of molecular genetic technologies. These developments have advanced our understanding of the specific etiologies underlying many of these conditions. In this article, we present an overview of the physiology of sex development, a few clinical vignettes highlighting specific pathologic conditions, discussions regarding the evaluation and management of these disorders, and some thoughts on future directions in this field. Birth Defects Research (Part C) 108:293-308, 2016. © 2016 Wiley Periodicals, Inc.

Physical Activity Self-Efficacy and Fitness: Family Environment Relationship Correlates and Self-Esteem as a Mediator among Adolescents Who Are Overweight or Obese.

BACKGROUND: Little is known regarding how dimensions of the family social environment relate to fitness levels and physical activity self-efficacy (PASE) among adolescents who are overweight or obese and whether these relationships are mediated by self-esteem. METHODS: Potential associations were evaluated between relationship subdomains (cohesion, conflict, expressivity) of the Family Environment Scale (FES), self-esteem (Rosenberg Self-Esteem Scale, RSES), and PASE and fitness, using recovery heart rate [RHR, beats per minute (bpm)] from a 3-minute submaximal step test at baseline. Participants were 108 adolescents who were overweight or obese and were seeking weight-loss treatment as part of the Healthy Kids, Healthy Weight 12-week multidisciplinary pediatric weight management program. Structural equation modeling (SEM) was used to simultaneously evaluate paths between these variables and test for mediation. RESULTS: In multivariable models, higher FES cohesion (ß = -2.18, s.e. = 0.98; p = 0.02), expressivity (ß = -1.97, s.e. = 0.99; p < 0.05), and PASE (ß = -0.64, s.e. = 0.33; p < 0.05) scores were associated with lower RHR, which represents higher fitness. Furthermore, higher FES conflict scores were associated with lower RSES scores (ß = -0.83, s.e. = 0.29; p < 0.01), and FES conflict (ß = -0.63, s.e. = 0.22; p < 0.01) and RSES (ß = 0.33, s.e. = 0.07; p < 0.01) were associated with PASE scores. In a good-fitting multivariate SEM [Comparative Fit Index (CFI) = 1.00; Standardized Root Mean Square Residual (SRMR) = 0.02; Tucker-Lewis index (TLI) = 1.22; Root Mean Squared Error of Approximation (RMSEA) <0.01], RSES mediated the relationship between FES conflict and PASE (sum of indirect paths: ß = -0.30, s.e. = 0.11; p < 0.01) scores. CONCLUSIONS: Our results highlight the importance of the relationship domain of the family environment on self-esteem, PASE, and physical fitness in adolescents who are overweight or obese.

Dietary Intake and Eating-Related Cognitions Related to Sleep Among Adolescents Who Are Overweight or Obese.

OBJECTIVE : To examine associations of sleep duration and regularity with dietary intake and eating-related cognitions among adolescents who are overweight/obese. METHODS : Participants were 315 adolescents being evaluated through Healthy Kids, Healthy Weight. Outcomes were reported sleep duration and regularity (bedtime shift, wake-time shift, sleep duration shift). Major predictors were dietary intake (e.g., consumption of calories and sugar-sweetened beverages) and eating-related cognitions (food preoccupation, eating self-efficacy). RESULTS : Findings were that staying up (i.e., bedtime shift) and sleeping in later (i.e., wake-time shift) on weekends compared with weekdays significantly relates to drinking more sugar-sweetened beverages, the latter for males. Sleeping in on weekends was related to greater food preoccupation. CONCLUSIONS : Sleep regularity was the most important variable in its relationships with dietary intake. Evaluating sleep patterns and improving them with behavioral interventions should be considered as an additional weight loss strategy to promote dietary adherence.

Progressive central puberty in a toddler with partial androgen insensitivity.

A male infant was diagnosed with partial androgen insensitivity caused by a novel mutation in the androgen receptor. At 3.5 months of age, he received 100 mg of testosterone intramuscularly over the course of 3 months to increase phallic size. He developed pubic hair after 5 months and signs of progressive central precocious puberty when re-examined at 17.5 months, which subsequently was suppressed with depot leuprolide.

Idiopathic short stature: decision making in growth hormone use.

Short stature is a common concern in pediatrics. Several ambiguities and controversies persist, especially with regard to criteria, cost, medical necessity and outcomes of growth hormone (GH) therapy for idiopathic short stature (ISS). Due to these ambiguities and controversies, a series of decisions by primary care physicians (whether to refer the short child to a pediatric endocrinologist), pediatric endocrinologist (whether to recommend GH treatment), families (whether to raise concern about short stature and whether to agree to undertake treatment), and third party payers (whether to cover the costs of GH therapy) influence which individual short children will receive GH in the US. Together, these decisions determine overall GH use. Apart from child's growth characteristics, several non-physiological factors drive the critical decisions of these stakeholders. This article focuses on current ambiguities and controversies regarding GH therapy in ISS, discusses the decision-makers involved in GH therapy, and explores the factors influencing their decisions.

Pharmacotherapy in pediatric obesity: current agents and future directions.

Childhood obesity is emerging as a major public health threat, with adverse implications on the health of individuals and long-term costs to society. Family-based lifestyle interventions with behavioral modification, diet and exercise form the mainstay of treatment. Pharmacologic treatment may be considered in selected subjects, especially in the presence of significant and severe comorbidities, when lifestyle intervention has failed to achieve weight reduction. Orlistat and sibutramine are FDA-approved for treatment of pediatric obesity; metformin may be considered in the presence of clinically significant insulin resistance. Evidence is lacking on the appropriate duration of medical therapy and optimal combination with lifestyle intervention. Lack of coverage of medications by insurance and high out-of-pocket costs may be limiting factors to some families. Adverse effects necessitate careful monitoring and may lead to discontinuation of medication. Pharmacologic agents with novel mechanisms of action offer hope of improved efficacy, tolerability and safety.

Treatment of childhood obesity.

PURPOSE OF REVIEW: To provide an overview of treatments for childhood obesity, highlighting recent advances and recommendations. RECENT FINDINGS: The three main treatment modalities are lifestyle interventions, medications, and bariatric surgery. Recent data support the short-term effectiveness of lifestyle interventions, and show that continued behavioral intervention increases the likelihood of a sustained effect for up to 2 years. New studies and regulatory decisions on medications for obesity (including orlistat, sibutramine, and metformin) are discussed. Emerging data suggest substantial weight loss after bariatric surgery in morbidly obese adolescents but also indicate adverse effects. An expert panel recently provided guidelines that alter definitions of obesity and offer a framework for obesity management. These guidelines are compared with others, and integrated recommendations presented. SUMMARY: While primary prevention of childhood obesity is important, broadly effective methods to do so are not yet available. Given the large population of obese children and the risks they face, an emphasis on treatment is also critical. We suggest a staged approach, emphasizing early intervention and lifestyle changes. We also suggest limiting bariatric surgery to selected adolescents in Institutional Review Board-approved research studies. Health-policy interventions can facilitate both prevention and treatment of childhood obesity.