When it comes to accessing pediatric specialty care, the more appointment options, the better- especially for busy families caring for a child with complex medical needs. Beginning May 4, families living in the Plano area have another close-to-home location for connecting with Cook Children’s Health Care System and its vast network of pediatric specialty physicians.

Conveniently located just off the Sam Rayburn Tollway between Plano, Frisco, Allen and McKinney brimming with young families, Cook Children’s new multispecialty clinic gives patients increased access to pediatric physicians specializing in neurology, endocrinology, pediatric surgery, pulmonology, gastroenterology, nephrology, urology, plastic surgery and orthopedics. Cook Children’s physician specialists from the Prosper Specialty clinics will rotate through the clinic regularly, giving parents more choice and flexibility in scheduling appointments at a location most convenient to them.

“Patients requiring specialty care often need to see their specialist multiple times, and those with complex medical conditions may see multiple specialists across several departments regularly, said Teresa Baker, Cook Children’s vice president of Primary and Specialty Services. “In addition to the convenience of closer-to-home care, the new clinic increases appointment availability so busy families have more options when scheduling visits. The new location also provides additional space to add more physicians and advanced practice practitioners to meet the needs of families in the fast-growing communities of the region.”

This will be Cook Children’s seventh multispecialty clinic in the Metroplex. Others are located in Alliance, Denton, Hurst, Mansfield, Southlake and Walsh Ranch. The Plano clinic offers 10 exam rooms, including one that will flex as a procedure room, as well as an X-ray unit. While Cook Children’s physicians will rotate through the clinic, it will have full-time, on-site clinical staff, an X-ray technician and front desk personnel.

Damian Campbell, D.O., a Cook Children’s pediatric neurologist, will see patients at the new Plano clinic on Thursdays. He’ll have the ability to offer many of the same evaluations in Plano as in his primary office at Cook Children’s Pediatric Specialties Clinic in Prosper, with the exception of electroencephalograms (EEGs) and some concussion evaluations.

"We’re aiming to be available for patient families every week right from the start of this new project,” Dr. Campbell said. “We know that life gets busy, and juggling work and school can make finding time for appointments a bit tricky. Having more availability close to home is designed to help make that easier. Our goal is for this new venture to help make sure families have more access to the high-quality care and attention that Cook Children’s is known for.”

This new addition to the health system’s network is one more example of Cook Children’s keeping its Promise to the children and families in the communities it serves, says Kevin Greene, president of Cook Children’s – Prosper.

“Our Promise is to improve the health of every child in our care and our communities,” Greene said. “By opening this new specialty clinic in Plano, we are bringing that Promise to the doorsteps of the families we serve. We are no longer asking parents and caregivers to endure long commutes for specialized care. Instead, we are meeting them where they live, work, and go to school—ensuring every child has access to high-quality pediatric care and the opportunity to grow up healthy, regardless of their zip code.”

TECHNOLOGY ... 

Wanting to learn more, I contacted the lead researcher, Shelagh Mulvaney to ask her about her results. Shelagh is no stranger to diabetes care. Her career as a research psychologist has been spent studying behavior change in chronic condition management including Type 1 diabetes. She is interested to learn how technology use can make these types of changes.

You would think it’s the wave of the future, right? This is the technological age and most 6 year olds know how to work a smart phone better than most adults. You would think the teens who participated in this survey would jump at the chance to use technology to help them with their diabetes care.

At least that’s what I would have thought before Shelaugh’s survey. The participants used the technology as you would expect based on how digitally plugged in most teens are. But a barrier occurred when it came to the teens wanting to share their life challenges and sharing on social media.

Why is that the case? I wanted to know more so I contacted Shelagh, who was kind of enough to speak with speak me about her work and its significance.

Me: Tell me about your survey.

Mulvaney: Our goal was to enhance website and mobile programs to support self-care in teens with Type 1 diabetes. To accomplish the aim, we did an initial survey. The survey was a challenge because we had to create a questionnaire and scales from scratch to learn how teens use a variety of technology, including social media to support themselves in daily diabetes care.

Me: How did the survey work?

Mulvaney: We surveyed 174 teens from the Vanderbilt diabetes clinic, as well others from the children’s diabetes website (CWD) group, asking them a variety of questions on how they used technology in care of their diabetes. We also did additional face-to-face interviews of 26 teens who had been classified by the online survey as low, medium and high users of technology.

Me: What did you find?

Mulvaney: Teens will find technology to address a pressing need. In this case, the survey did show that most of the teens surveyed use common technology tools to simplify the often complicated task of calculating insulin doses or looking up carbohydrate amounts in food.

Me: The social media use part of the survey gained the most attention in the news. With a recent report that 9 out of 10 teens use social media, I’m interested to hear how teens with Type 1 diabetes used social media.

Mulvaney: Surprisingly, social media use to aid in diabetes care was seldom used. Only about 70 percent of the participants said that they used social media, but use of social media for specific diabetes issues was very rare.

Some of the reasons given for not using social media included”

• Lack of time
• Boring
• Never thought about it
• Don’t know what websites
• Don’t like to talk or think about having a chronic condition
• Or mom takes care of it

Teens said that they didn’t know anyone else with diabetes or felt that someone without Type 1 diabetes just couldn’t relate to their life when asked why they didn’t use social media specifically to help in their diabetes care.

Me: So, it sounds like use of social media to improve diabetes care is not going anywhere fast?

Mulvaney: Teens with type 1 aren’t completely closed to social media as an aid in diabetes care. We did find a sizeable number of teens who were willing to share with others on social media, even details about how they care for themselves, if it would help other children or teens with Type 1.

Me: How would you sum this up?

Mulvaney: It’s hard to make diabetes exciting. Technology has to make something easier, less cumbersome, less complex …THAT will motivate teens.

I continue to believe in the opportunities that technology creates to improve diabetes care. I’m an optimist. I hope that maybe with time and education by medical professionals, young people will take advantage of tools available to them as they expand at an amazing speed. Yet, the human factor – family, friends, others with type 1 diabetes – remains an important part in maintaining consistency and motivation in teens with Type 1 striving for the highest level of health. It’s hard to compete with good, old fashioned peer pressure. Social media is unlikely to fully replace the personal touch. We have to remove the stigma that these kids have about their disease. But continued research like Dr. Mulvaney’s will help all of us maximize technology use in the care of Type 1 diabetes.

About the author

As a self-described ‘techie,’ Joel Steelman, M.D., has a keen interest in the wise use of technology to improve medical care. Since 2001, he has helped implement electronic medical recordkeeping in two endocrine practices.

In the field of endocrinology, however, there has been ongoing serious scientific study regarding risk of diabetes and metabolic syndrome linked to artificial sweetener use. Unfortunately, a definite answer hasn’t been reached to this question. One of the primary barriers making scientific investigations difficult is the fact that many of those using AS are already obese and at high risk for diabetes and metabolic syndrome.

A number of theories have been offered by those who believe the link between AS and diabetes/metabolic syndrome is real. Perhaps, those using AS over-estimate the calorie savings from AS and over-eat. Perhaps, the craving for sweetness is increased with AS use leading again to extra sugar-rich calories in the diet. Perhaps, there is premature loss of satiety (that sense of fullness with a meal) when AS is used leading to earlier return of hunger. There are many other theories as well with individuals lining up in support or against the theories.

A newly published article from last month adds more information on the possible link of AS to diabetes/metabolic syndrome. The scientific study investigates the effects of AS in both mice and humans from a unique perspective and made national headlines.

The most provocative part of the article deals with an 11 week investigation in mice. The mice were given artificial sweeteners (saccharin, aspartame, sucralose) along with a regular diet. They were tested at the start and at the end of the experiment. The mice given AS had an abnormal, pre-diabetic response to a large meal of glucose (sugar) compared to mice given water or sugar-water. A smaller number of mice in the study were tested with a combination of saccharin and a high fat diet and showed a pattern of pre-diabetes in blood testing within 5 weeks. The research reported in humans in this study was less compelling and showed pre-diabetes changes in some but not all of the human research participants.  

What was the reason offered by the researchers explaining pre-diabetes changes seen in AS use in their research? Gut microflora and the changes they believe occur in the digestive system from absorbing artificial sweeteners. I know you want to know more about gut microflora, right?

Gut microflora refers to the many kinds of bacteria living the digestive system. Our knowledge about the kinds and roles of these helpful bacteria continues to increase. Scientists have known for a while that these bacteria help make some essential vitamins such as vitamin K and help keep bad bacteria from multiplying too fast.

The research reported drastic changes in the types of gut microflora in all the mice fed artificial sweeteners and in some of the human subjects. The unique theory offered by their research is that changes in the gut microflora caused by AS exposure were responsible for the pre-diabetes seen in the research. In other words, the artificial sweeteners changed the numbers (increasing some and decreasing others) of the many different microflora in the bodies of the mice.

As a pediatric endocrinologist, I welcome the ongoing investigation of the safety of AS use. For many of the children and their parents whom I care for there is a problem. Excess dietary sugar represents a significant fuel to the obesity epidemic and must be managed. Dietary use of AS is almost essential in those with type 1 diabetes to help in maintaining stable blood sugars. For those with type 2 diabetes, AS may help in managing daily calorie intake and reversing obesity.

It is probably overly optimistic to believe that AS are completely without impact on the body. The real ongoing scientific challenge is gaining the proper perspective on their health impact. Proper perspective is very important. For instance, the AS exposure in the mice studied was maximal, which would be comparable to drinking 19 diet drinks per day which is very unnatural.

The big, unanswered question brought up by this research is what could be the long-term effects in those who eat or drink much lower levels of AS. I personally decided within the past year to reduce my AS intake as part of an overall decision to eat healthier. This study doesn’t persuade me yet to eliminate AS completely (I love Diet Coke^® too much). My best advice after reading this article is moderation and continued focus on a healthy diet.

• Thelarche – development of breasts in girls
• Adrenarche – development of pubic hair, armpit hair, body odor, and acne in both boys and girls
• Central precocious puberty – activation of puberty coming from hormonal signals from the pituitary gland
• Peripheral precocious puberty – changes of puberty not coming from the pituitary gland. This category is very broad and can include problems in the ovaries, testes, adrenal gland, or elsewhere.

The spectrums of symptoms experienced by a child with precocious puberty exist from mild, incomplete forms to much more serious, progressing forms. Mild patterns such as premature thelarche and premature adrenarche don’t typically require treatment. Periodic monitoring is necessary to verify that the course in these conditions remains reassuringly slow. In particular, there is growing concern that obesity combined with premature adrenarche may herald risk for health conditions such as polycystic ovary syndrome or type 2 diabetes in the future.

Sometimes, a diagnosis in precocious puberty is difficult to make, especially when an evaluation of the child falls within a ’gray’ area of medicine where both the severity and need for treatment are just not clear.

The mental and physical impacts on a child with this condition depend on both the underlying cause, as well as the effects initiated by an early rise in hormone levels in the body. Some underlying causes of early puberty, such as tumors in the brain or adrenal gland, can be life-threatening.

Understandably, the body and emotional changes that accompany precocious puberty are distressing for many children and their families. Puberty is a strong determinant in the completion of height growth and when it occurs early, it will often stunt a child’s final adult height by fusing the growth plates in the bone closed.

Precocious puberty is much more common in girls vs boys, 3:1. Genetics also play a vital role in the timing of when hormone signals begin to progress. Not surprisingly, the timing of puberty – early vs late – can run in families

The majority of cases of true precocious puberty are central in origin, emanating from a premature rise in the hormone signals from the pituitary gland located in the brain. In girls, the majority of cases of central precocious puberty are termed idiopathic, meaning the condition arose spontaneously from an unknown or obscure cause.

Damage to the hypothalamus,or brain surrounding the pituitary gland, can lead to precocious puberty by disrupting the normal neurologic signals that regulate the pituitary gland and keep puberty in check. Severe head trauma, serious infections such as meningitis, or tumors in the brain are the more serious causes of central precocious puberty.

Causes of peripheral precocious puberty are numerous with McCune-Albright syndrome a particularly concerning one as this rare, genetic condition is characterized by the triad of benign bone tumors, precocious puberty, and a large, irregular skin café au lait spot.

Milder forms of congenital adrenal hyperplasia have features similar to premature adrenarche and can be difficult to evaluate. This condition fuels higher levels of androgens to be produced due to impairment in adrenal gland function. In contrast to premature adrenarche, puberty progresses more quickly, and bone growth plates mature rapidly. Tumors in the ovary or testes, estrogen-producing ovarian cysts, adrenal tumors are also worrisome.

Many parents wonder about the impact the environment may have on precocious puberty. Children can be exposed to testosterone and estrogen through a parent’s use of hormone replacement topical creams or though a product that is being used on them. It is critical to read labels as hormones are in many over the counter creams and supplements. Additionally, estrogen levels in a child can be affected by mom’s use of birth control pills or estrogen patches as well. Tea tree oil and lavender oil both have estrogen-like effects and soy contains phytoestrogen properties that can cause symptoms in susceptible individuals.

Hormones (both natural and synthetic versions) including growth hormone, estrogen, testosterone, and progesterone are used in animals to promote growth or enhance milk production. Currently, no large epidemiological studies have been done to conclusively determine if early puberty is associated with having consumed growth hormone treated foods.

We do know, primarily from animal research, that endocrine disrupting chemicals such as bisphenol A and phthalates interfere with the natural hormone system, impacting the production, release, and effects of natural hormones in the body. Both of these chemicals have been shown to cause early puberty in lab animals. Intense research attempting to determine if similar effects from these chemicals is present in humans is ongoing.

In part 3, I will write about diagnosis and treatment for precocious puberty.

About the author

As a self-described ‘techie,’ Joel Steelman, M.D., has a keen interest in the wise use of technology to improve medical care. Since 2001, he has helped implement electronic medical recordkeeping in two endocrine practices.