Extremes in height- short stature or tall stature - further call attention to a person’s uniqueness and may represent challenges for some in everyday life. The judgment of what is normal height can be distorted in a variety of ways including media images, peer groups, and family/cultural backgrounds.

Being short seems to be negatively viewed in the range of height difference. Men and boys, in particular, seem more impacted by short stature with research reports from several decades ago reporting negative psychological and social effects in males with short stature. And while, more recent research calls into question whether or not there is a negative impact, it’s still difficult for many to forget old impressions and stereotypes.

Short stature referrals are one of the main types of referrals seen by most pediatric endocrinologists. While the medical evaluation of short stature is a fairly straightforward process (at least for a pediatric endocrinologist), navigating the family and emotional dynamics can sometimes be tricky. I think offering education to child and family about normal expectations is an essential part early in the first referral visit.

The first and perhaps most important part in short stature evaluation is understanding that a child’s growth and height are strongly connected to genetics of his or her family. In other words, short children typically have short parents.

It is also important before moving further for a reminder of average height for women and men in the U.S.

Average women’s height is 5’4”

Average man’s height is 5’10”

A handy formula used to help estimate a child’s genetic height target (the range of their adult height) is as follows:

Let’s look at two examples to illustrate,

Short Parent Family: Mom 5’0” Dad 5’7”

Height range for son: Middle of target: 5’6”Range: 5’2’ to 5’10”

Height range for daughter: Middle of target: 5’1”

Range: 4’9” to 5’5”

Tall Parent Family: Mom 5’6” Dad 6’1”

Height range for son: Middle of target: 6’0”Range: 5’8” to 6’4”

Height range for daughter: Middle of target: 5’7”

Range: 5’3” to 5’11”

The formula gives a target estimated height with a range of 4 inches above or below the target that will cover almost all children. Still, it’s a wide range when you consider the difference between being a 5’3” woman compared to a 5’11” woman.Knowing a child’s genetic height target range is important in determining the location on the growth chart like the one shown below where most of a child’s growth points should be located.

A child growing below their expected height range needs a closer check. A child progressively falling lower on the growth chart likely needs an in-depth investigation to determine if a problem exists.

Causes of short stature in children are numerous, ranging from normal variations in growth to serious underlying health problems. My first priority when a child is referred to me is to further investigate short stature is answering the following question:

Is the child's short stature OK or not OK?

What I mean by OK is that there is no apparent underlying negative reason for a child’s short stature. There are really only two reasons that fall in the OK category.

• Familial (genetic) short stature
• Constitutional delay of growth

Children with constitutional delay of growth will start off slower in growth compared to other children. They will fall to the lower part of the growth chart in early life which can concern parents and pediatricians. A child with constitutional delay grows at a slower, but normal pace during childhood and early adolescent years and gets the growth spurt of puberty later than average. These “late-blooming children with constitutional delay will eventually reach a height within their family height range.

Answering that initial question of OK or NOT OK can sometimes be difficult. Return visits to monitor growth are almost always a necessity to reassure that “growth and health are OK.”

Key steps in the process of monitoring a child’s growth include a medical history and an examination. The first two steps help me and other pediatric endocrinologists decide both if further special testing is necessary and what kinds of special tests may be needed. Different kinds of special testing include

• Bloodwork
• Radiology tests such as a bone age X-ray or MRI scan of the brain
• Growth hormone stimulation testing

The bone age X-ray is an important tool used by me in the early stage of short stature evaluation. The test looks at the appearance of growth plates in the hand. The growth plates start out in early life with lots of room to grow. The size of growth plates becomes progressively smaller as a child ages. By the time an average child reaches the end of puberty…...

• Girl around age 14 years
• Boy around age 16 years

…….the growth plates are nearly closed, and there will be very little increase in height.

A bone age is a very useful tool in helping me figure out quickly my level of concern and the types of testing which might be done in a child’s investigation.

For instance, look at the two bone age images of a boy’s hand below. The white arrow shows a growth plate located on tip of the finger. A 10-year old boy's hand is on the left and a 15-year-old boy's hand is on the right:

10-year-old boy's hand:  15-year-old boy's hand:

Get to know Joel Steelman, M.D.

Dr. Steelman is an endocrinologist at Cook Children's. He trained in endocrinology at the University of Colorado Children’s Hospital in Denver, where the magnificent setting turned Dr. Steelman into a lifelong outdoor sport enthusiast, with a strong desire to lead a healthy life. On his rare days off, he could be found skiing, mountain biking and trail running. He loves to go back to the Rockies as often as possible, and just a few years ago, he ran the Pike’s Peak ascent half marathon. He continues to run for exercise regularly. 

During his tenure in Colorado, where he met his future wife, Dr. Steelman trained at the internationally renowned Barbara Davis Diabetes Center, one of the world’s largest and most esteemed diabetes medical facilities for adults and children, specializing in type 1 diabetes research. Along the way, he discovered another strong research interest in the area of bone disorders, and Dr. Steelman began to treat children with osteogenesis imperfecta, or brittle bone disease-- a rare, crippling malady. After completing his training, Dr. Steelman left the West to enter academic medicine at Vanderbilt Children’s hospital in Nashville, Tennessee. Over the next seven years he focused on research projects and medical education.

As a self-described ‘techie,’ Dr. Steelman 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. He still loves to write, and he is a regular contributor to Checkup Newsroom.

Planning and gear is necessary when setting off for a day of water fun, but for kids with diabetes it can sometimes feel like an Everest expedition. Their checklist can include any or all of the items below:

●Blood glucose meter

●Supplies to check blood sugar

●A cooler or ice packs to keep insulin cool

●Insulin

●Insulin injection supplies

●Insulin pump supplies

●Snacks for low blood sugars

Children and their families with Type 1 diabetes deal with additional risks on top of the typical worries that all families deal with. Some diabetes specific risks include:

●Low blood sugar

●Dehydration

●High blood sugars

●Ketones

The wisdom and experience of a parent of a child with Type 1 diabetes adds more practical value. I discovered this article on swimming with Type 1 diabetes.

I reached out via Twitter to the mom and author of the article. As the mother of two girls with Type 1 diabetes, she had a lot of good, practical advice, which I endorse and would give to my own patients.

I know it helps to here from other moms. Here are some of the thoughts and tips that she shared about her now older girls.

Importance of swim lessons

My girls passed all of their swim lessons and have reached the level that will safely take them into adulthood ... I still tend to hold the book and scan the water until both are safely drying off on my blanket. Once a mom, well, always a mom.

“Managing” blood sugars

Despite this natural maturity and necessary growth, our family is still cautious with Type 1 diabetes and swimming. We know that blood sugar management during exercise can be tricky on a good day, let alone, on a day of intense swimming, where every single muscle is engaged and active.

Here is a list of strategies that we use to help keep teenager independence while staying healthy with Type 1 diabetes.

1.Check blood sugar before you go into the water.

2.Blood sugar MUST be above 100 mg/dl.

3.If not, BEFORE swimming, eat a small protein and carb snack and do not bolus. Our girls like re-sealable chocolate milk jugs, cheese and crackers or small peanut butter and jelly sandwiches.

4.Swim with a buddy and never alone.

5.Every hour, get out of the water and check blood glucose.

6.If blood sugar is rising, which often happens due to adrenaline during exercise, reconnect the pump and take ½ of the recommended bolus amount. This also helps to avoid ketones from lack of insulin.

7.Stay hydrated. Even if you feel like you are not thirsty, drink 8 ounces of water each time you are checking your blood sugar.

8.Always bring money. If you find yourself eating through snacks, be prepared to purchase carb-laden food from the snack machine or beach shack. This happens more often than not, so I stress this often!

9.Be prepared for lows that might happen an hour or two after leaving the water. With T1d, it’s not just the first event (swimming), but the second, third and fourth events that need proper planning. For that reason, always tuck in more glucose, more meter strips and extra supplies than you think you might need. Chances are, you will need it!

I hope this article was helpful and makes for a better water safety experience.

My gratitude to naturallysweetsisters.com for sharing.

Quick Refresher

• What is the thyroid gland and what does it do
• Hypothyroidism (underactive, low thyroid)
• Hyperthyroidism (over-active, high thyroid)
• Autoimmune thyroid disease
• Congenital hypothyroidism
• Acquired hypothyroidism

Question 1: I’d never heard of thyroid problems in children until my child was diagnosed with hypothyroidism. Are thyroid problems increasing in children?

Answer: It depends on the specific thyroid problem to which you are referring.

Acquired hypothyroidism is a maybe. Autoimmune thyroid disease also known as Hashimoto disease is the leading cause of acquired hypothyroidism in adults. Research studies have definitely shown a worldwide increase of Hashimoto disease in adults, and there is likely also an increase in children.

The most scientifically validated reason for the worldwide increase in Hashimoto disease is improved iodine intake. Iodine is a very important mineral that is necessary for thyroid hormone production. Lack of the mineral remains a common cause in certain third-world areas of the world for a specific form of hypothyroidism termed endemic goiter. For some reason, however, the improved supplementing of iodine may be a culprit in triggering autoimmune thyroid disease in adults.

Congenital hypothyroidism is a yes. Researchers are trying to understand the observed increase in incidence of congenital hypothyroidism. The historic quoted incidence is roughly 1 in every 4000 new births. Current trends are showing higher incidence at roughly 1 in every 2500 births. There are a number of different theories about why this is seen. One factor is the increased number of surviving premature babies. Many of these babies have a thyroid problem termed transient hypothyroidism during their early life requiring treatment with thyroid hormone and are counted in the same category as congenital hypothyroidism .

An increase in the Hispanic population is another factor theorized to account for the change. There is a higher incidence overall in Hispanics of congenital hypothyroidism which may be influencing the incidence numbers.

Radioactive iodine exposure during pregnancy has definite negative impact on fetal thyroid activity, and exposure must be avoided. Concern was sparked in 2012 with a controversial study published suggesting a link between the Fukushima nuclear disaster and a spike in the number of cases of congenital hypothyroidism seen in U.S. Pacific Coast states.

Question 2: Why did my child develop Hashimoto disease?

Answer: Medical science doesn’t know the precise reason(s) for autoimmune thyroid disease which includes Hashimoto thyroiditis. We believe that there are factors both genetic and environmental involved.

Research suggests that genetics underlies about 70 percent of the susceptibility in Hashimoto disease which is why a family history of thyroid problems is often seen in children with Hashimoto disease. Of the various genes identified with risk for Hashimoto disease, the HLA-DR gene association is best known. The gene location is known most widely for its importance in organ transplant

Environmental triggers are the great unknown not only in Hashimoto disease but also in many other autoimmune conditions. Infection triggers seem to be the most likely candidates in this process. Hepatitis C infection and Rubella (German measles) are two infections with known links to autoimmune thyroid disease. In addition to known harmful infections, possible impact of disturbance in beneficial intestinal bacteria as a trigger in autoimmune thyroid disease as well as other autoimmune conditions is being investigated.

Smoking in adults has been linked to increased risk for autoimmune thyroid disease and is another of the many reasons to avoid smoking. More controversial theories include environmental pollutants role in autoimmune thyroid disease. PCBs and PBDEs have been linked to increased risk in some research studies mainly in animals.

Radiation exposure is a known risk in many thyroid problems in both adults and children. Childhood thyroid cancer rates increased drastically after the Chernobyl disaster. Both autoimmune thyroid disease and thyroid cancer risk are increased in cancer survivors who received radiation treatment. Fortunately, routine medical radiation exposure doesn’t appear to be linked to higher risk of thyroid damage.

Question 3: Can diet help prevent or improve thyroid problems?

Answer: Yes, to some extent

The mineral iodine is essential for proper thyroid hormone production. Fortunately, in the U.S., lack of iodine is extremely uncommon. Seafood and dairy are both good sources of iodine, and iodine is added to salt as well. Risk of iodine deficiency is very low in in children who eat a healthy, balanced diet and have no digestive problems.

Goitrogens are naturally occurring chemicals in certain vegetables such as cauliflower that can interfere with function of the thyroid. Overall, the health benefits of goitrogen-containing vegetables probably outweigh the risks to the thyroid when eaten in a balanced manner.

Question 4: What can I do to help others in my family or family friends be more aware of thyroid problems?

Answer: Awareness is the key.

Awareness of symptoms of thyroid disease is important when there is a family history of thyroid problems. An exam of the thyroid and a blood testing can uncover thyroid problems. Sharing the story of your child’s medical history with concerned friends can also help.

I hope these answers help those of you who have a child diagnosed with a thyroid issue. If you still have questions or need more help, please contact your primary care doctor or the Cook Children’s Endocrinology division.

I see a sizeable number of children and teens in my practice with diagnosed thyroid problems. I also care for a number of patients whose parents or doctors have referred to me for concerns about the possibility of thyroid disease. A large block of the time I spend with these children and their families during clinic visits involves education about the thyroid gland and its importance on childhood health.

I’d like to help those who might be in search of credible information on this topic by sharing basic, sound medical facts and data that I believe can be of good use to parents or caregivers in better understanding thyroid function and problems in children.

What is the thyroid gland and what does it do?

The thyroid is a small, butterfly-shaped gland, weighing less than an ounce in an adult. It is located in the lower, middle, front part of the neck and is regulated by the small, pituitary gland located deep within the brain. The thyroid’s main function is to produce thyroid hormone which consists of a combination of protein and the mineral iodine. This super hormone acts very deeply within the body binding onto the DNA in cells throughout to regulate metabolism, growth and body temperature. The thyroid has a stronghold on how the body uses energy and can speed up or slow down your metabolism.

The metabolic effects of thyroid hormone are multiplied in children. It is an essential partner of growth hormone in aiding height growth in children and serves a vital role in regulating the start and progress of puberty. Too little or too much of this essential hormone released into the body can wreak havoc causing serious negative effects on the health of a child. The two main types of thyroid disease are called hypothyroidism and hyperthyroidism.

What is hypothyroidism and what causes it?

Hypothyroidism is a lack of enough thyroid hormone production. A number of problems occur with lack of thyroid hormone and the symptoms and their severity correlate to the level at which production has been depleted.

A big divide, based on age, exists in what is the underlying cause of hypothyroidism. Congenital hypothyroidism refers to a specific type that is diagnosed in newborn infants in the first one to two months of life. This serious condition occurs in roughly 1 in every 4,000 newborn babies and can have devastating effects if not detected and treated within the first 2-3 weeks after birth. A hypothyroid infant is unusually quiet and inactive, with poor appetite and sleeps for excessively long periods. In the past, the consequences of untreated congenital hypothyroidism developed into lifelong mental retardation. Thankfully, state mandated newborn screening programs that began in the 1970s now routinely test the blood of all newborns for evidence of congenital hypothyroidism as well as other metabolic diseases. As long as this test is administered, there is little risk of missing its presence.

Acquired hypothyroidism refers to hypothyroidism that begins anytime after the newborn period which encompasses the first six months of life. Whereas the expected number of infants born each year with congenital hypothyroidism is well-known worldwide, the expected numbers of children and teens with hypothyroidism is not well known as symptoms are often misdiagnosed. It certainly seems the case when the most recent study that attempted to determine the number of children and teens with hypothyroidism showed the number at less than 1%.

Iodine is an important mineral in the production of thyroid hormone. Lack of dietary iodine remains a cause of this malady around the globe. In the U.S. and many parts of the world, fortification of salt and foods with iodine has made this deficiency a very unlikely cause of hypothyroidism. The most common reason for its occurrence in the U.S. is autoimmune thyroid disease (also known as Hashimoto disease). This condition is still a mystery in terms of what causes the body’s immune system to attack its thyroid gland. We do know that it runs in families with links to certain inherited genes increasing the risk of passing it on to future generations. In addition, triggers such as infections, stress, or pregnancy might activate this condition in susceptible people. In children, it tends to occur in girls more often than boys, and the peak in occurrence is in the mid-teenage years.

While it is rare, problems can occur when the pituitary gland leads the thyroid astray. This improper regulation of thyroid function can cause a subtle form of hypothyroidism known as central hypothyroidism.

What are symptoms of hypothyroidism and how is it diagnosed?

It is important to understand that a correct diagnosis of hypothyroidism should be made by exploring both physical symptoms as well as through targeted blood testing. As a pediatric endocrinologist at Cook Children’s, I focus heavily on the impacting that thyroid hormone has on a child’s growth as a key finding. Weight gain does occur in hypothyroidism, but very rarely leads to severe levels of obesity. Some of the more common symptoms of hypothyroidism are summarized in the table below.

• Short stature and/or abnormally slow height growthOverweight, weight gain
• Dry skin
• Cold intolerance – feeling cold all the time
• Enlargement of the thyroid gland (goiter)
• Fatigue, excessive sleepiness
• Constipation
• Problems with puberty
  • Delayed puberty
  • No menstrual periods or irregular menstrual periods in girls
  • Early puberty (rare)
• Headaches

Blood test measures of thyroid hormone (known as T4 or free T4) and the pituitary hormone thyroid stimulating hormone (known as TSH) assist in the diagnosis of hypothyroidism. The cardinal finding on blood testing is a high TSH and low thyroid hormone. An ultrasound of the thyroid gland as well as special nuclear medicine scans is sometimes quite helpful in both making the diagnosis and determining an underlying cause of hypothyroidism.

What is hyperthyroidism and what causes it?

Hyperthyroidism, by contrast, is a condition where too much thyroid hormone is released into the body upsetting the balance of the metabolism and causing devastating effects on well being. Thankfully, this condition is rare in children, occurring in less than 1 percent. In its early stages, symptoms may be subtle so unfortunately many children are in advanced stages upon diagnosis. Hyperthryoidism in its most severe form can be life-threatening.

The most common cause of hyperthyroidism is Graves’ disease which is an autoimmune condition similar to autoimmune thyroid disease with the exception that the immune system is stimulating the thyroid to over-produce thyroid hormone. This condition remains a mystery as well to the medical world in terms of what causes it to happen. We do know that like autoimmune thyroid disease, it does run in families.

What are symptoms of hyperthyroidism and how is it diagnosed?

Because of the seriousness of hyperthyroidism, rapid recognition is important. Exophthalmos (bulging of the eyes), a condition affecting the late actor Marty Feldman, is the most recognized physical sign of Graves’ disease. Some of the more common symptoms of hyperthyroidism are summarized in the table below.

• Weight loss
• Increased appetite
• Heat intolerance – feeling hot all the time
• Fatigue, muscle tiredness
• Enlargement of the thyroid (goiter)
• Rapid heart rate, high blood pressure
• Excessive sweating
• Tremor (shakiness) in hands
• Irritability, problems concentrating
  • Poor school performance
• Bulging eyes
• Irregular menstrual periods in girls

Blood test measures of thyroid hormone (known as T4 or free T4) and the pituitary hormone thyroid stimulating hormone (known as TSH) assist in the diagnosis of hyperthyroidism. Converse to hypothyroidism, we expect to find blood testing measures with a very low TSH and high thyroid hormone level. A nuclear medicine scan is often times very useful in evaluation of cases of hyperthyroidism. Additionally, an ultrasound test might be prescribed.

How are hypothyroidism and hyperthyroidism treated?

Treatment of hypothyroidism requires daily tablets of thyroid hormone (levothyroxine, synthroid, levoxyl, and levothroid) combined with scheduled return visits to see the pediatric endocrinologist who will monitor progress via physical exam and blood testing. Congenital hypothyroidism is permanent and requires lifelong treatment whereas acquired hypothyroidism, however, is not always permanent.

Treatment of hyperthyroidism is far more complex than the treatment of hypothyroidism and involves the use of a thyroid suppressing medication in the early phase of therapy. Due to the long-term mixed outlook for a cure of Graves’ disease, many sufferers must have their thyroid destroyed either by radioactive iodine treatment or surgical removal. Once the thyroid is destroyed, these individuals must remain on lifelong thyroid replacement like those with hypothyroidism.

Conclusion

It is my hope that by sharing some important medical facts and data you have been enlightened about this powerful gland. Furthermore, I hope it will enable parents and caregivers to recognize symptoms of a possible thyroid condition in a child and better understand the proper treatment plan.

Halloween can be a particularly challenging time of year for families and children dealing with diabetes. Whether a family is dealing with type 1 or type 2 diabetes, there are important health decisions to be made about handling the seasonal free flow of candy.

Type 2 Diabetes

Recent stats report 23 million people in the U.S. have type 2 diabetes. While most of those people are older adults, there are still many children who are at high risk for developing type 2 diabetes.

Obesity is a central problem in type 2 diabetes. With all the tempting treats, it’s no wonder that the average adult weight gain from Halloween until New Years is estimated at 5-7 pounds.

Therefore, it is essential to have a healthy game plan in preparation for Halloween and the other end of the year holiday.

Type 1 Diabetes

Obesity is not as often a central problem in children with type 1 diabetes; however, healthy snack/candy choices are still of prime importance. There’s a common misconception that people with type 1 diabetes can’t eat candy or other sweets. Those with type 1 diabetes can eat candy, but they must take insulin for the carbohydrates in the candy. Finding the right balance between healthy snacking and insulin dosing for candy is a real challenge for children and families dealing with type 1 diabetes.

Asking a veteran type 1 diabetes parents about their approach to Halloween is always a good idea. Amy Ohmer (@NatSweetSisters), a mother of two children with type 1 diabetes was kind enough to share some advice.

There are several wonderful ways in which families can handle Halloween. I prefer to tell parents to continue previous traditions, post diagnosis, expecially with older children or children with older siblings. First, this sends a message that type 1 diabetes will not change anything and secondly, there is no better time than the present to practice some real life carb counting/dosing skills.

If the plan is to go trick-or-treating, remember that the goal is to amass as much candy as possible, not necessarily to eat all of it. After bringing home the candy, counting the amount, and choosing their favorites, our kids are ready to part with much of it. There are several organizations that accept leftovers from food banks to senior centers.

Another great reminder is that Halloween candy is the perfect carb snack for low blood sugar treatment. A running joke amongst our parenting group is that this is the time where we can stock up on free carb snacks!!!

One year, our children sold candy back to us in exchange for "Halloween bucks" to buy things at a silly store that we set up in our living room. Every ten pieces of candy, provided a Halloween buck. At the end, they received a book, some dollar store items and a new Barbie doll. They loved that even more than the candy.

Finding the Balance

Not all candy is created equal. A quick check of nutrition breakdown on different Halloween candies helps children and adults pick “healthier” candy.

A recent research study gives some needed perspective for parents on children’s eating habits. The research examines different strategies to help children manage their food choices. Eating strategies that included structure, consistency, and clear communication between parent and child created the best success in helping children make better food choices long-term.

The lifelong goal for children and families is making consistent healthier choices in both the kinds and amounts of food eaten.

Halloween should be a fun time for all children, including kids with diabetes. Once again I’ll go back to Amy for good advice for us all:

No matter what parents choose to do with their children, they should take a deep breathe, relax and enjoy the event, whether it is trick-or-treating, bobbing for apples or enjoying donuts and cider. Halloween is truly a fun family event.

And now the next time you see a mom looking at her smartwatch, she may be monitoring her child’s blood sugar levels.

Progress in diabetes care has mostly come from the medical community and medical industry. However, this changed recently when a new innovation came from a people on the very front line of diabetes care – parents.

Who better to understand the pitfalls in diabetes care and be the best advocates for kids with type 1 diabetes?

I think that most people not affected directly by type 1 diabetes would probably guess that the multiple daily insulin shots is the hardest part in diabetes care.

But, I think (and perhaps many others touched by type 1 diabetes would agree) that the complete uncertainty about blood sugars is the true hard part of diabetes.

There are an infinite number of questions or worries surrounding the blood sugar:

• How does my child feel when his or her blood sugar is high or low?
• How will illness affect my child’s blood sugar?
• How will activity impact my child’s blood sugars?

Right now, most parents and children are flying blind in between blood sugar checks, not knowing for certain which way blood sugars are heading – up or down.

But they don’t have to any longer because glucose monitoring now lives in the cloud.

Continuous glucose monitoring

Anyone can see that the daily constant attention and mental energy needed for good diabetes care is immense. Any progress in diabetes care that reduces this strain right now is worth it.

Continuous glucose monitoring (CGM) is a technology useful in diabetes care. I wrote about the technology several years ago. The technology uses an IV-like catheter placed under the skin which constantly samples the blood sugar (glucose) level in minute amounts of body tissue fluid in the area between skin and muscle. A larger sensor attached to the catheter sits on the skin and beams the blood sugar reading to a receiver device. It allows families and children to see blood sugar trends in between finger pokes. Below is an illustration of the technology:

A number of barriers in the past such as size of the unit, wear comfort, sensor/receiver communication problems, and insurance coverage made wider use of this promising technology in children with type 1 diabetes a challenge. Fortunately, there has been progress and today there is wider use of the CGM use in children.

The proximity problem…..

Previously, a child wearing a CGM must be in receiver range (a max of 20 feet) to see blood sugar readings, and factors such as walls may further affect the ability of the receiver to detect the blood sugar readings.

Why can’t there be remote diabetes monitoring?

Today’s mobile technology makes it possible to shop or surf the web virtually anywhere in the world.So the thought process was, “Why couldn’t this same technology be used to make remote diabetes monitoring possible?”

Starting roughly 18 months ago, that’s exactly the problem that parents of children with type 1 diabetes solved.

Two tech-savvy dads who had children with type 1 diabetes pieced together a CGM receiver with a cell phone and they were able to transmit the CGM data into a cloud-based database. A basic set-up is shown below:

.#wearenotwaiting

The twitter hashtag speaks to the commitment of the group and other advocates for improvement in type 1 diabetes care to strive for innovation and progress right now in type 1 diabetes care.

The movement has evolved from a core of interested parents sharing with other parents to a Facebook group to now a nonprofit called the Nightscout Project.

The group continues to look at ways to move diabetes care forward with support of innovation, FDA device discussions and collaboration with other non-profits.

“People focus on the cure, but we want to focus on tomorrow. The cure is the future.”said James Wedding, Nightscout Project.

CGM in the cloud.

Once in the cloud, the blood sugar information could be accessed by any Internet enabled device (smartphone, tablet, smartwatch, etc.).

Families and children now have access to real-time blood sugar info whether their child is right beside them or half a world away.

The help and peace of mind has probably been immense as parents have access to blood sugar at field trips and sleepovers.

Parents can have date nights again and not worry about their babysitter monitoring their child’s blood sugar. They can now do it at the dinner table.

Quick blood sugar info is available with a glance at the smartwatch, and children never miss a bit of fun at the beach.

* Photo from beach, courtesy of Jasmine Cruz-Bohren.

About the author

Joel Steelman, M.D., is an endocrinologist at the Cook Children's Endocrine and Diabetes program, which treats infants, children and teens with conditions that are caused by or affect the hormonal balance of the body. We understand the importance of working together and that's how we approach the care of our children.

Lately, football has put a lot into perspective for me. Take a look at the two starting quarterback for the Super Bowl between New England and Seattle.

New England’s Tom Brady seems to be the prototypical signal caller, standing at 6 feet, 4 inches tall.

On the other hand, Seattle Russell Wilson for the Seattle Seahawks is listed at 5’11.” New England wide receiver, Julian Edelman, who was the star of the Patriots’ victory over Baltimore is listed at 5’10,” which is the average U.S man’s height

Much like the children, we see at Cook Children’s, athletes come in all shapes and sizes.

Probably half of the children I treat are brought by families due to concerns about height. The reality of life is that people come in all heights, and height offers an opportunity to make assumptions and judgments about a person which can sometimes be hurtful.

Cincinnati Bengals Head Coach, Marvin Lewis, created a social media firestorm when he said this about the undersized quarterback for the Cleveland Browns and Heisman Trophy winner at Texas A&M, Johnny Manziel.

“You gotta go defend the offense. You don’t defend the player, particularly a midget.”

Lewis quickly apologized for his words as others including organizations like Little People of American explained to him how derogatory and offensive the term was especially to those with serious medical conditions causing their short stature.

The movie, “Rudy,” is a perfect example. It’s one of the most inspiring stories about a shorter man with a passion for football who overcame the odds. At 5’6”, Rudy Ruettiger wasn’t a typical defensive lineman for Notre Dame, but his hard work and dedication paid off with a chance to play.

My opinion is that it’s important to have the right perspective about height. A good attitude and acceptance of one’s height is important and a person shouldn’t make judgments about another solely on height.

Sometimes it’s something more than just genetics or the child being a “late bloomer,” it can be an endocrine disease and the child will need treatment for a condition such as hypothyroidism or growth hormone deficiency.

At times, we the child may have trouble coping with his or her size and may even need counseling.

In my area of expertise, it is a challenge to determine whether a child’s height is normal or not. There are times when height and growth are abnormal, and further investigation is needed:

Genetics: Shorter parents often times have shorter children. These kids continue to achieve milestones such as puberty or growth spurts at a normal rate, but they generally stay around the same height as their parents.

If a child is terribly uncomfortable with his or her height, we may talk to the family about counseling. If the child doesn’t reach puberty at the normal age, the discussion may include puberty hormone treatment. But, this needs to be decided with your endocrinologist or pediatrician.

Constitutional growth delay: These are often times what’s considered “late bloomers.” Children with condition are small for their age, but continue to grow at a normal rate. They usually reach puberty later than other children and experience delay in sexual maturity. They usually catch up with their classmates, but it sometimes takes them longer.

Endocrine conditions: We treat these children for hypothyroidism or growth hormone deficiency. These children require treatment from an endocrinologist and may need medication for growth.

Turner syndrome: This is a common genetic condition occurring in 1 in every 2,500 girls born. It is caused by missing all or a portion of one of the X chromosomes. The condition varies in severity but has physical and psycho-educational impacts.

Care of girls with Turner syndrome is an integral part of the practice of the pediatric endocrine group at Cook Children’s. The majority of girls affected will have short stature and early failure of the ovaries. Growth hormone treatment is prescribed and monitored by pediatric endocrinologists to treat short stature. The task of monitoring puberty and timing of estrogen replacement is equally important to insure overall health.

In the coming weeks, I’ll give more facts on children’s growth and talk when a parent should be concerned about their child’s growth.

Dr. Greenspan, a pediatric endocrinologist, offers insight on medical reasons for earlier puberty in girls. The co-author, Dr. Deardorff, a psychologist, offers insight into the behaviors and emotions in early puberty.

The book draws on the experiences of  two ongoing research studies and has almost a decade worth of scientific observation with some startling statistics and impacts.

By age 7, breast development was seen in:

• 25 percent of African-American girls
• 15 percent of Hispanic girls
• 10 percent of Caucasian girls

Some of the worrisome impacts of early puberty on girls highlighted by the book included:

• Higher risk for depression or anxiety
• Higher eating disorder risk
• Higher breast cancer risk

Puberty is a normal process in life that eventually happens in the life of every child. It can be an uncomfortable challenge though for a girl who experiences puberty much earlier or much later than her friends. Earlier puberty is a challenge perhaps more for girls because of more visible changes. Emotional changes that accompany puberty occurring early may also be distressing to many girls and their families.

Some key medical challenges in investigating puberty from a medical standpoint include determining the difference between normal early puberty versus abnormal precocious puberty. The authors give parents some guidelines to help guide them on when to see their pediatrician for a check-up.

Clear reasons to schedule an appointment include:

1. Breast development at 7 years old or younger

2 .Pubic hair development at 6 ½ years old or younger

3. Bad acne, moodiness and having an abnormal growth spurt

4. Menstrual periods starting before age 10

Perhaps one of the greatest challenges for me and other pediatric endocrinologists is figuring out the cause of early puberty. There are definitely situations where there is a clear reason for early puberty, but these situations are often rare, leaving the task of finding an answer a difficult one. The book authors tackle the tough question of what causes early puberty. They offer three theories.

1. Obesity effect

2. Endocrine disrupting chemicals

3. Social and/or psychological stresses

Obesity has the longest history as a known association with early puberty. Higher body fat may change the hormone balance in a girl’s body causing the adrenal gland to activate early and produce hormones which cause body odor and pubic hair growth. A portion of estrogen is made by fat in the body; therefore, a higher amount of body fat may lead to higher estrogen levels and drive earlier breast development.

Exposure to estrogen or estrogen-like chemicals has effects on puberty. There is now a lengthy research on natural estrogens, called phytoestrogen. Tea tree oil and lavender oil both have estrogen-like effects and have been linked to breast development in some children. More concerning though than phytoestrogen exposure is the possible effect of endocrine disrupting chemicals (EDCs) on puberty. EDCs are chemicals that have hormone-like effects in the body, including estrogen-like effects.

The authors discuss the unknowns of EDC impact on developing girls, at what dosages, and during which time points might effects be seen? Recent research examining various chemicals in personal care products also adds concern about possible effects on puberty of these exposures.

It is already a sad reality that some children grow up in chaotic homes, and many are exposed to the early images of violence whether in real life or in media. The information offered by the authors on the effects of stress on brain chemistry leading to early puberty was perhaps the most shocking to me.

The book not only explores the why of early puberty, but also gives tips on what parents can do. A whole section is devoted to strategies to avoid or minimize EDC exposures. Practical tips include developing emotional closeness early to aid in talking about puberty and dealing with the rapidly changing moods of puberty.

Early puberty presents challenges both on the part of parents and physicians. Especially with early puberty, the dividing line between normal and abnormal is blurred making choices of investigation and management harder to make. I just purchased the book and am looking forward to the new insights, which will help me better care for the physical and emotional health of girls dealing with early or precocious puberty.

To learn more about precocious puberty, please read  my three-part  series I wrote in 2011:

• Part 1
• Part 2
• Part 3

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.

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.

Knowledge of the expected timing of puberty combats some of the stress of delayed puberty. The points for delay in puberty include the following:

• Boy – no change in testes size by age 13
• Girls – no breasts by age 13 or no period by age 16.

It is important to realize that it is testes size and not pubic hair development that is the main sign of puberty in boys.

Understanding what average timing of puberty is and when a teen and family should anticipate certain milestones of development.

The physician’s challenge in delayed puberty is determining normal vs. abnormal. Fortunately, the majority of otherwise healthy children have a normal variant in growth and puberty known as constitutional delay. Constitutional delay – “being a late bloomer” tends to run in families. Most of us can recall a classmate who probably had constitutional delay who appeared to be a totally different person a year or two after high school.

There are numerous medical conditions that negatively impact timing of puberty. Delayed puberty is a prominent feature in children affected by chronic medical conditions such as cystic fibrosis, inflammatory bowel disease or cancer survivors. A careful medical history and examination are essential in gathering clues for the cause of delayed puberty. A bone-age X-ray is an essential tool at the beginning of a medical evaluation of delayed puberty.

The bone-age X-ray looks at the appearance of the growth plates in the hand. The appearance of the growth plates is strongly influenced by puberty. Certain physical findings of puberty are anticipated at certain bone ages. More importantly, the percentage of final adult height achieved is strongly linked to bone age.

What can a family do to insure progress in puberty and when should they become concerned?

No evidence of puberty at or near the extremes of the puberty spectrum or significant stalling in the progress of puberty should raise concern in the family.

What can be done for delayed puberty?

The primary priority in approaching delayed puberty is determining whether the cause is from a serious medical condition. If the delay is not from a serious condition, reassurance can be offered. However, some children and their families may still be more concerned and distressed by the delay. Carefully monitored treatment with low doses of testosterone or estrogen can be used to “jump start” puberty in cases where there is significant distress in otherwise normal, delayed 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.

Diagnosis through discussion

For a pediatric endocrinologist, getting a complete medical history of the child is the important first step in arriving at a diagnosis. Next, by asking basic questions such as:

• When did you first see signs of puberty?
• How rapidly are you seeing changes of puberty?
• What specific changes of puberty are you seeing?
• Is your child growing too fast?
• Does your child have any other health problems?

The answers provide important clues to any underlying causes of a child’s precocious puberty.

Children with a history of neurological symptoms such as headaches or changes in vision cause concern for puberty problems that may be coming from within the pituitary gland or brain. We’ll ask if the child has access to birth control pills, estrogen creams, or testosterone creams to see if hormone exposure is the culprit of a child’s precocious puberty.

We also look at diet and clues: Phytoestrogens (a compound found in plants that can mimic the effects of estrogen) eaten as part of a high soy diet may lead to premature breast development. Obesity from too many calories can lead to early pubic hair and body odor in some children.

Careful tracking of height and weight on a growth chart is the cornerstone in the physical assessment of precocious puberty. Seeing rapid or even subtle changes in growth patterns can indicate the need for immediate intervention.

A thorough skin examination sometimes reveals the tell-tale sign of Café au lait spots (shown above) that we know are linked to two conditions, Neurofibromatosis and McCune-Albright syndrome. Both of which can spur on precocious puberty.

Diagnostic testing

After taking the child’s medical history and physical exam, next comes medical testing that includes blood work, imaging studies, or other special medical procedures.

A bone age x-ray (example on right) is perhaps the most useful test in helping to evaluate the progression and severity of precocious puberty. The bone age study looks at the appearance of the growth plates in the hand to see if the bones have matured earlier than they should.

A measurement of hormone levels in the blood is used to help confirm early theories on the cause of early puberty as well as evaluate its severity. Hormones measured in testing could include any of the following:

Androgens – hormones made by the adrenal gland that cause pubic hair and body odor

1. Gonadotropins – hormones made by the pituitary that activate puberty
2. Thyroid hormone – thyroid hormone has a role in regulating puberty
3. Estrogen – the female hormone responsible for breast development
4. Testosterone – the male hormone responsible for pubic hair and body odor

Sometimes, specialized stimulation testing is needed to help further evaluate our suspicions. We order these tests when a child is in early onset of precocious puberty and blood hormone levels don’t show a definite pattern or in cases where all the information combined fails to give a clear enough picture. Stimulation tests involve more comprehensive blood work combined with IV medications to stimulate temporarily higher hormone levels. Stimulation testing can help in assessing adrenal function to rule out subtle forms of congenital adrenal hyperplasia as well.

Radiology scans such as an MRI of the adrenal glands or ultrasound of the pelvic area may be prescribed to determine the size of the adrenals, ovaries or testes. An MRI brain scan will indicate if the hypothalamus and pituitary gland are normal and often occurs at the end of the testing process when confirmation of a preliminary diagnosis is required.

Treatment

Once the source of puberty is identified, the options for treatment are then discussed. Sometimes not treating precocious puberty is an option. This happens mainly during cases of idiopathic central precocious puberty. After careful consideration of the risks and benefits, some families simply wish to allow nature to take its course and not intervene.

Today, we are fortunate to have medicines called GnRH (Gonadotropin-releasing hormone) agonists that are effective treatments for the majority of children. They work specifically to stop the progression of central precocious puberty by telling the pituitary gland to ignore the GnRH signal it is receiving from the hypothalamus and tells it to lower or stop the level of sex hormones it is releasing. This countermeasure will also stop bone maturation and help the child reach his or her anticipated adult height. These medications are given by monthly injection or by an implant under the skin.

Helping your child to cope

A diagnosis of precocious puberty and its imposing physical trauma can be emotionally unsettling for any child. The good news is that with the right treatment, both physically and emotionally, a youngster experiencing early puberty can enjoy a normal, happy childhood and grow into a well-adjusted adult.

No child likes to be viewed as ‘different’ than their friends, so it is important for every young person to understand that puberty is a normal process in life that everyone will experience—some earlier than others. As children develop self-esteem and behave according to how they are treated, pay close attention to your child’s interactions with others. If you sense or know that your child is being teased or bullied about the changes in his or her body that puberty has initiated, it’s important that you try to get him or her to talk to you or another trusted adult or medical professional who can offer sound advice on how to cope with what’s happening.

All children need to be taught how to care for their personal hygiene and with this condition, they may also need to change sizes in clothing more frequently. It’s also important to make other adults in your child’s life aware that they should treat your child according to his or her real age, no matter what age they may look like.

Previous articles:

Precocious Puberty (Part 1)

Precocius Puberty (Part 2)

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.

• 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.