Amitriptyline-Induced Hyperprolactinemia in a Pediatric Patient.

Hyperprolactinemia is an endocrinological disorder that might arise from various physiologic or pathologic conditions, as well as from pharmacologic sources. These pharmacologic sources include antidepressants, antipsychotics, and dopamine receptor-blocking agents. Amitriptyline is classified as a tricyclic antidepressant. While it is FDA-approved primarily for the treatment of depression, amitriptyline also demonstrates efficacy in managing various other conditions, such as anxiety, post-traumatic stress disorder, insomnia, chronic and neuropathic pain, and migraine prevention. We present a case of a 10-year-old patient with a history of autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), and migraine headaches who was incidentally found to have elevated prolactin levels while taking amitriptyline for migraine prophylaxis. While risperidone, an antipsychotic that can be used for ASD management, is commonly known to induce hyperprolactinemia, the association between amitriptyline and elevated prolactin is less frequently described in the literature. This case underscores the necessity for healthcare providers across various specialties to be aware of amitriptyline-induced hyperprolactinemia.

Deep Vein Thrombosis as the Presenting Sign in an Adolescent With New-Onset Type 2 Diabetes.

Prothrombin G20210A mutation occurs in only 2% to 3% of the population, but usually does not become apparent unless the individual exhibits another risk factor for clotting. A risk factor such as hyperglycemia in the setting of diabetes mellitus may accelerate this clotting process, even at a very young age. In this case report, we discuss a 15-year-old boy presenting with left calf swelling and pain, found to have extensive deep vein thrombosis in the setting of hyperglycemia and a newly discovered prothrombin G20210A mutation. Venous thromboembolism in the setting of type 2 diabetes mellitus has not been described in children.

Thyrotoxicosis and Impending Thyroid Storm: A Rare Paraneoplastic Syndrome in an Infant With Hepatoblastoma.

Graves' disease is the most common cause of pediatric hyperthyroidism and thyrotoxicosis. Thyroid storm is a rare initial manifestation of Graves' disease and represents an endocrine emergency. We report a case of transient hyperthyroidism, possibly a paraneoplastic syndrome presenting as impending thyroid storm in a patient with undiagnosed hepatoblastoma. To our knowledge, this is the first case of this association reported in children. A previously healthy 21-month-old male presented with abdominal pain and unremitting tachycardia. He was managed for thyrotoxicosis and impending thyroid storm. He subsequently was found to have hepatomegaly leading to a diagnosis of hepatoblastoma. Autoimmune markers for Graves' disease were negative, along with a negative human chorionic gonadotropin. After initiation of neoadjuvant chemotherapy, he had complete resolution of thyrotoxicosis. Paraneoplastic syndromes may occur with any tumor. We present a unique case of a patient developing human chorionic gonadotropin-negative hyperthyroidism, possibly as a paraneoplastic syndrome from hepatoblastoma.

Recent Rates of Substance Use Among Adolescents and Young Adults with Type 1 Diabetes in the USA.

PURPOSE OF REVIEW: Substance use is a major public health problem in adolescents and young adults (AYA) and is particularly dangerous for AYA with type 1 diabetes (T1D) due to additional health consequences related to T1D. Rates of substance use among AYA with T1D are difficult to ascertain. Currently, we aim to provide a summary of published rates of substance use, over the last 10 years, among AYA with T1D in the USA. RECENT FINDINGS: This review included a database search, abstract screening, and synthesizing of articles published in the last 10 years that reported rates of substance use among AYA with T1D. We also compared rates to national survey data from the Center for Disease Control and Substance Abuse and Mental Health Services Administration. Of 138 articles, 123 abstracts were excluded due to non-relevance or because they were conducted outside of the USA; 15 articles were evaluated, and 8 provided original data on AYA with T1D. These 8 studies were summarized and compared to nationwide survey data. Most of the published rates of substance use among AYA with T1D were similar to national survey data for alcohol, tobacco, and marijuana. Rates of illicit drug use were lower among AYA with T1D. Despite additional health consequences, alcohol, tobacco, and marijuana use is about as prevalent among AYA with T1D as in the general US population. These findings emphasize the importance of conducting more research in this area, developing effective interventions, and incorporating prevention into standard clinical practices.

Free Summer Day Camp to Address Childhood Obesity: Is There Demand?

Children from low-income households, and who are overweight or obese (OWOB), are at risk of accelerated weight gain during summer. Summer day camps (SDCs) have the potential to mitigate accelerated weight gain during summer as these settings can positively influence children's obesogenic behaviors (i.e., increase physical activity); however, barriers exist to attending, most notably cost. Little is known on whether low-income caregivers of children with OWOB would be interested in having their child attend SDC for free. Caregivers (n = 109, 82% mother respondents, >75% Medicaid and Minority Household) with a child attending pediatric endocrinology clinics completed a one-page survey to explore demand. Approximately 66% of respondents expressed interest for their child to attend SDC for free. Providing free SDC for children with OWOB and from low-income households is a possible strategy to tackle childhood obesity during summer.

Two Unusual Cases of Pituitary Tumors Presenting with Pediatric Acromegaly.

Gigantism and acromegaly are most commonly caused by a growth hormone (GH)-secreting pituitary adenoma. Pediatric cases are diagnostically and therapeutically challenging due to their insidious nature. This article presents two adolescent females who were referred to the endocrinology clinic primarily for the evaluation of menstrual disorders rather than for concerns about GH excess. Patient one was a 16-year-old who presented with primary amenorrhea and tall stature, and patient two, a 15-year-old, presented with a history of irregular menstruation. Both patients were noted to have acromegalic features, and an extensive work-up confirmed GH-secreting pituitary adenomas. In addition, patient two had significant hyperprolactinemia. Transsphenoidal tumor resection was performed on both patients; patient one had a successful complete resection and achieved endocrine remission, while patient two underwent partial resection followed by a short clinical trial of pegvisomant without significant success. Improved clinical knowledge through case reports can assist with the early diagnosis and management of such rare pediatric conditions.

Diabetes-Specific Risk-Taking in Young Adulthood: A Closer Look.

Risk-taking behaviors are not a new phenomenon for young adults (YAs) and are an important aspect of understanding decision-making for YAs with diabetes. This article builds on a previous model of diabetes-specific risk-taking by providing other examples of risky situations and behaviors that are specific to YAs with type 1 diabetes, reviewing models of risk-taking behavior, and discussing how these models might inform clinical care for YAs with diabetes.

Erratum: Feasibility of Implementing a Pediatric Diabetes Clinic via Telehealth. Diabetes Spectrum 2021;34:190-197 (https://doi.org/10.2337/ds20-0060).

[This corrects the article on p. 190 in vol. 34, PMID: 34149260.].

Unusual Etiology of Hypercalcemia in an Adolescent With Acute Gastroenteritis.

We present the report of an adolescent female who presented with acute gastroenteritis, weight loss, and hypercalcemia. Further evaluation revealed hyperthyroidism to be the cause of hypercalcemia. Treatment of hyperthyroidism successfully corrected the hypercalcemia in our index case.

Feasibility of Implementing a Pediatric Diabetes Clinic via Telehealth.

OBJECTIVE: In response to the coronavirus disease 2019 (COVID-19) pandemic and social distancing guidelines, our pediatric diabetes team rapidly changed the format of conducting diabetes clinic from in person to telehealth. We compared the actual number and rate of completed, canceled, and no-show visits between an 8-week period in 2019, when we exclusively conducted visits in person and the same 8-week period in 2020, during the COVID-19 quarantine, when we exclusively conducted visits via telehealth. METHODS: We used electronic health record data for all patients, as well as Dexcom continuous glucose monitoring data collected for a subset of youths during the COVID-19 quarantine and the immediate pre-COVID-19 period. RESULTS: Although there was a difference in the absolute number of in-person versus telehealth visits canceled during these two time periods, there was no difference in the rates of completed, canceled, and no-show visits completed in person or via telehealth. This finding suggests that, despite a rapid shift to a completely new health care delivery model, our providers completed a similar rate of patient care via telehealth during the COVID-19 quarantine and that telehealth may be a feasible method for providing diabetes care. However, our results also suggested that youths' glucose management was less optimal during the quarantine period. CONCLUSION: COVID-19 presented an opportunity to adopt and test the feasibility of using a telehealth delivery model for routine diabetes care. Yet, to make telehealth a viable treatment delivery alternative will likely involve the uptake of new clinic procedures, investment in institutional infrastructure, and team-based flexibility.

Evaluation of Hemoglobin A1c before and after initiation of continuous glucose monitoring in children with type 1 diabetes mellitus.

OBJECTIVES: The development of continuous glucose monitoring (CGM) systems has allowed for identification of blood sugar variations and trends in real-time that is not feasible with conventional self-monitoring of blood glucose. However, there is inconsistent data to show that the use of CGM leads to better glycemic control as measured by Hemoglobin A1c (HbA1c) in pediatric patients with type 1 diabetes mellitus. Our study aimed to compare the average HbA1c level in the 1-2 years prior to starting a CGM to the average HbA1c level in the 1-2 years immediately following CGM initiation in a sample of 1-20 year olds with type 1 diabetes mellitus. METHODS: Participants were 90 youth (ages 1-20) followed for type 1 diabetes care at our institution who used a CGM for at least a 6 month time period. We performed a retrospective chart review to obtain up to four HbA1c values pre and post-CGM initiation each. We evaluated pre- and post-CGM initiation changes in mean HbA1c via dependent samples t-tests using IBM SPSS 24.0. RESULTS: The mean HbA1c was 8.7% pre-CGM and decreased to 8.27% 9-12 months after CGM initiation in the overall sample. A statistically significant decrease in HbA1c was seen in patients who used multiple daily injections (p=0.02), those with a pre-CGM HbA1c greater than 9% (p=0.01), and those with a diabetes duration of 5-10 years (p=0.02). CONCLUSION: CGM use was associated with a decrease in HbA1c over time which was statistically significant in some subgroups.

A Case of Familial Male-limited Precocious Puberty with a Novel Mutation

Familial male-limited precocious puberty (FMPP), also known as testotoxicosis, is a rare cause of precocious puberty in males. It is caused by a mutation in the luteinizing hormone/chorionic gonadotropin receptor (LHCGR) gene, resulting in the receptor being constitutively activated. This causes excessive production of testosterone, leading to precocious puberty in males. Generally, boys present with signs of puberty, such as pubic hair growth, acne, and increased height velocity around the age of 2-4 years old. Like any other cause of precocious puberty, the goal of treatment is to prevent virilization and also delay closure of the epiphyseal plates to maintain adult height potential. Treatment, therefore, is aimed at decreasing the effects of testosterone, as well as stopping the conversion of testosterone to estrogen. Little is known about the long-term effects of treatment because the disorder is so rare. However, studies using bicalutamide and anastrozole have been promising. In this report, we present a boy with FMPP with a novel mutation in the LHCGR gene, who has been responding well to therapy using both drugs.

Prevalence of Vitamin D Deficiency Among Infants in Northern India: A Hospital Based Prospective Study.

BACKGROUND: Vitamin D deficiency is one of the major nutritional deficiencies and an important contributor to nutritional and growth failure in infants, especially in those with low socioeconomic status. AIM: The primary objective of this study was to determine the proportion of vitamin D deficiency in infants, and the secondary objective was to assess the correlation between infant and maternal vitamin D levels. METHODS: This prospective, observational study was carried out at a tertiary care center, All India Institute of Medical Sciences in Rishikesh, Uttarakhand, India, in the Department of Pediatrics from January 2017 to December 2018. Children aged less than one year and their mothers were enrolled in the study. All the infants attending the Department of Pediatrics for well-child visits and sick-child visits were enrolled after obtaining written, informed consent. Infants with major congenital malformations and liver and kidney dysfunction were excluded. Serum vitamin D level of <20 ng/mL was defined as vitamin D deficiency. RESULTS: A total of 200 infants and 200 mothers were enrolled in the study. Among the study infants, 80% were neonates, and 20% were infants beyond the neonatal period. The prevalence of vitamin D deficiency was 74% in infants and 85.5% in mothers. Nearly half of the infants and mothers had severe vitamin D deficiency. Logistic regression analysis showed a positive correlation between maternal and infant vitamin D levels (r=0.074, p<0.001) and also with neonatal age group and low socioeconomic status. Hyperphosphatemia and hypocalcemia were predominant biochemical manifestations. CONCLUSION: The prevalence of vitamin D deficiency among the study infants was 74%. Neonatal age group, lower socioeconomic status, and maternal vitamin D deficiency were major determinants of vitamin D deficiency in infants.

Severe Hypercalcemia in an Adolescent with New-Onset Diabetes Mellitus and Diabetic Ketoacidosis.

Severe hypercalcemia in diabetic ketoacidosis (DKA) among children is rare and can be life-threatening. Its exact etiology is not clear and several mechanisms related to dehydration and metabolic acidosis have been proposed. Rigorous hydration with the correct fluid choice usually corrects the hypercalcemia in those without other underlying causes of hypercalcemia such as hyperparathyroidism. Specific medications to treat the hypercalcemia may be avoided. We present a 13-year-old girl with new type 1 onset diabetes mellitus in DKA with unusually severe and persistent hypercalcemia and severe hypernatremia that gradually responded to rigorous intravenous hydration with Plasmalyte A (Baxter International Inc., Deerfield, Illinois).

Prevalence of Vitamin D Deficiency in Children with Type 1 Diabetes Mellitus.

Background In the recent years, controversy has emerged regarding the relationship between vitamin D deficiency and the potential effects it could have on glycemic control in patients with type 1 diabetes mellitus (T1D). This study investigates the prevalence of vitamin D insufficiency/deficiency in pediatric patients with T1D from a single, large volume practice. Methods This was a retrospective chart review that collected clinical/demographic data as well as serum 25(OH) D levels from medical records of 395 children between the ages of 3 and 18 years with T1D followed at Nemours Children's Hospital. This data was compared to the National Health and Nutrition Examination Survey (NHANES) database. A Pearson's Chi-square test was used between group associations. All statistical tests were two-sided and p < 0.05 was used for statistical significance. Results Of the 395 children included in these analyses, 4% were vitamin D deficient and 60% were vitamin D insufficient. There were no significant associations of vitamin D deficiency based on sex and age. Vitamin D deficiency was more common among White children when compared to Hispanic children and African American children (42% vs 29%; p < 0.001). Of those that were vitamin D insufficient (n = 235), most were Hispanic (51%), 36% White and 13% African American. There was a significant association between vitamin D deficiency and body mass index (BMI) (p = 0.035). In the summer, children were less likely to be vitamin D deficient (3% vs 6% in winter) and less likely to be vitamin D insufficient (55% vs 71% in winter) (p = 0.007). Conclusions Vitamin D insufficiency is highly prevalent among pediatric type 1 diabetics of Central Florida and statistically significant correlation was found between vitamin D status and ethnicity, BMI as well as seasonal variation.

Successful Use of Fludrocortisone in a Child with Refractory Cerebral Salt Wasting Syndrome: A Case Report and Review of Literature.

Hyponatremia post-neurosurgical intervention can be dangerous and potentially life-threatening. Two of its most common causes are cerebral salt wasting (CSW) and syndrome of inappropriate anti-diuretic hormone release (SIADH). CSW is proposed to be secondary not only to the elevated levels of circulating atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) but inhibition of steroidogenesis in the zona glomerulosa of the adrenal cortex, thus resulting in mineralocorticoid deficiency. We present a two-year-old male who had developed acute hyponatremia secondary to CSW on post-operative day two after a sub-total resection of a low-grade juvenile pilocytic astrocytoma (WHO grade I). Fludrocortisone was successfully used to manage the refractory hyponatremia and alleviated the need to use very large amounts of oral sodium supplementation.

Prolonged ileus in an infant presenting with primary congenital hypothyroidism.

Congenital hypothyroidism (CH) is the most common endocrine disorder affecting the newborn. Universal newborn screening (NBS) has virtually eliminated the static encephalopathy and devastating neurodevelopmental syndrome known as cretinism. This report describes the presentation of an infant referred by the primary pediatrician to our hospital at 12 days of age for confirmatory testing after the NBS was consistent with CH. The infant had hypoglycemia secondary to lethargy and poor feeding and required transfer to the neonatal intensive care unit for worsening abdominal distension despite normalization of serum thyroid function tests following hormone replacement. In particular, the recalcitrant ileus and secondary bowel obstruction resulted in an additional diagnostic workup and lengthened hospital day. Our report highlights the acute gastrointestinal consequences of hypothyroidism despite evidence of effective treatment. We believe that the preclinical detection and immediate therapy for CH have lessened the prevalence of this presentation in general practice, and hence practitioners are less likely to be familiar with its natural history and management.

Obesity is significantly associated with cardiovascular disease risk factors in 2- to 9-year-olds.

The objective of this analysis was to estimate the prevalence of cardiovascular disease risk factors in ethnically diverse young children. A retrospective medical chart review identified overweight/obese 2- to 9-year-old children (N=147) from a local pediatric clinic who were matched (for age, sex, and ethnicity) with normal weight patients from the 2005-2010 National Health and Nutrition Examination Survey (N=294). Comparisons of mean systolic blood pressure and diastolic blood pressure, total, and high-density lipoprotein (HDL) cholesterol were conducted. Results showed that compared with the population-based normal-weight sample, the local overweight/obese sample was significantly more likely to have diastolic prehypertension (15% vs. 75%, P<.0001), systolic prehypertension (10% vs. 43%, P<.0001), and the lowest quintile of HDL cholesterol (19% vs. 34%, P=.003). At this young age, excess weight is significantly associated with cardiovascular disease risk factors. These results suggest that overweight/obese children in this age group should be monitored closely to prevent potential chronic disease risk.

Skeletal maturation and predicted adult height in children with premature adrenarche.

OBJECTIVE: Premature adrenarche (PA) may be associated with obesity and advanced bone age. Our objective was to determine if children with PA had a predicted adult height less than target height. METHODS: A retrospective chart review identified 100 children originating predominantly from South and Central America and the Caribbean region previously diagnosed with PA from one pediatric endocrinology clinic. RESULTS: The majority (89.2%) of the sample had advanced bone age, while 43.4% were obese and 41.8% had a predicted height below target. There was a significant correlation between body mass index Z-score and bone age advancement among boys (r=0.67, p<0.001). The majority (72.7%) of those with a predicted height below target had a bone age advancement of two standard deviations or more. CONCLUSIONS: These findings suggest that PA and obesity are associated with rapid skeletal maturation and that significant bone age advancement in PA is associated with a sub-optimal adult height.