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.

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.

• Why did this happen to my child?
• What does this mean for my child?
• Will my daughter start her period in elementary school?

Precocious puberty remains a relatively rare condition in the general childhood population with the most recent prevalence statistics shown below.

• 20 per 10,000 girls
• 5 per 10,000 boys.

The vast majority of children affected by precocious puberty are girls. In spite of the concerning news, the most recent statistics still don’t show menarche (the age when girls start their period) has changed much in the last fifty years, remaining at an average of 12 ½ years old.

Although rare in the general childhood population, precocious puberty is a common problem in the realm of pediatric endocrinology. A recent surge in the number of new visits to me for precocious puberty concerns inspired me to write about this confusing, anxiety-provoking topic.

Understanding precocious puberty first requires an understanding of normal puberty. However, there is an ongoing debate in the medical community questioning what the normal start of puberty is. The historical guidelines used for defining the start of normal puberty dates back to research reported in the 1950s and 1960s in mainly white populations. Newer studies done in the 1990s, which were much larger in scope and included a racially diverse mix of children, have questioned prior assumptions.

A review of past as well as current proposed guidelines is shown below.

Understanding puberty also requires understanding the key hormones and systems involved in puberty. The two hormone systems of the body responsible for starting and sustaining puberty are the pituitary gland and the adrenal gland. Their location and primary roles are summarized in the illustration below.

Adrenarche is the term used to describe the activation of the adrenal gland. Recently, body fat and leptin, a hormone produced by body fat, were identified as strong factors in stimulating adrenarche. Androgens produced by the adrenal gland cause body hair, oily skin, acne, and body odor.

Estrogen or testosterone production is stimulated by hormones known as gonadotropins which are produced by the pituitary gland . How activation of the pituitary gland occurs to start puberty remains an area of ongoing research. We do know that neurological signals from the hypothalamus, a portion of the brain intimately linked to the pituitary, plays a role in activating puberty from the pituitary gland.

With an overview of normal puberty definitions, I’ll tackle the huge topic of what are causes of precocious puberty in the next article.

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.