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.”

Best Children’s Hospitals list for 2023-2024.

The report, which was released today, uses clinical data to measure patient safety, infection prevention and adequacy of nurse staffing. Out of 284 children’s hospitals in the U.S., only 90 ranked in at least one of the 10 pediatric specialties evaluated. The following Cook Children’s specialties were named among the top programs:

• Pediatric Cancer - #30 in the nation
• Pediatric Diabetes and Endocrinology - #31 in the nation
• Pediatric Neurology and Neurosurgery - #36 in the nation
• Pediatric Orthopedics - #40 in the nation
• Pediatric Pulmonology and Lung Surgery - #48 in the nation

Cook Children's Hematology and Oncology program jumped an impressive 20 spots in the rankings, from #50 in 2022-2023 to #30 in 2023-2024.

 “We are focused every day to improve the lives of the patients we serve and enrich the care of children all over the world. We do this by providing innovative care and contributing to the science of future cancer therapies,” said Donald Beam, M.D., medical director of Hematology and Oncology. “We will continue to strive to improve every day, growing beyond what we are and stepping to the future.”

For Cook Children's Health Care System as a whole, the rankings demonstrate a longstanding commitment to excellence in pediatric care.  

"For more than 105 years, Cook Children's has been committed to improving the well-being of every child in our care. We are honored to see our mission validated yet again by U.S. News and World Report,” said Rick W. Merrill, President and CEO of Cook Children’s Health Care System. “With our newest medical center in Prosper now open, we look forward to making an impact in the lives of even more children and families.” 

Cook Children’s also ranked #3 in Texas and #4 in the Southwest on the U.S. News and World Report “Best Regional Hospitals” list. 

Like a lot of boys growing up, Dr. Thornton’s interest centered on athletics. He calls himself a “sports fanatic,” playing rugby, cricket, tennis and swimming. As a kid, he played more than studied.

So when Dr. Thornton told his guidance counselor in high school that he wanted to become a doctor, the counselor told the man who would become a world expert in a rare disease that he needed a back-up plan.

What the guidance counselor didn’t understand just yet was that Dr. Thornton’s focus from an early age was on science and medicine. Dr. Thornton saw something in himself that nobody else saw.

“When I said I wanted to be a doctor they told me I should have a backup plan,” Dr. Thornton says now with a twinkle in his eye. “So that was always fascinating to me. I wasn’t the guy people thought was the most intelligent person in the class. Now I’m a world expert in a disease. Once I became a doctor, I realized where my true passion was and I followed it.”

Congenital Hyperinsulinism

Dr. Thornton resides at Cook Children’s as the medical director of the Endocrine and Diabetes Program and the Hyperinsulinism Center. He played a vital role in establishing the first two centers for congenital hyperinsulinism (CHI) in the nation.

His congenital hyperinsulinism program at Cook Children’s celebrates its tenth anniversary this year. The genetic forms of HI affect only between 80 and 120 babies each year. For those affected by the rare condition, it can be a life-changing event. Without an accurate diagnosis, children face living with seizures and permanent brain damage.

The program gives many patients an opportunity for a cure because of the expert staff and the use of an investigational new drug called 18F DOPA in combination with a PET-CT scan to more accurately diagnose and treat HI.

The 18F DOPA/PET-CT scan serves as a diagnostic test that has altered the treatment and even led to cures for children with certain forms of hyperinsulinism. Cook Children’s remains the only facility in the south and the second in the country to use 18F DOPA – an investigational drug – in combination with a PET-CT scan to diagnose focal lesions in children with congenital hyperinsulinism.

Dr. Thornton leads a team of physicians specialized in endocrinology, pediatric surgery, neonatology, neurology, gastroenterology, pathology and radiology. The team is supported by a dedicated HI nurse practitioner, social worker, clinical therapist, child life specialist, nutritionist and feeding and speech therapists.

At the heart of the program is Dr. Thornton, one of the most recognized and respected HI specialists here and around the world.

The Expert

To show what a leader he is in the field, Dr. Thornton’s served as lead author for an article titled “Recommendations from the Pediatric Endocrine Society for Evaluation and Management of Persistent Hypoglycemia in Neonates, Infants and Children.” This article established the groundwork in creating new screening for physicians to recognize and manage neonates at increased risk for a persistent hypoglycemia disorder.

The guidelines help physicians recognize the symptoms of uncontrolled hypoglycemia caused by CHI who are at risk for seizures or permanent brain damage without early identification and screening.

Dr. Thornton’s recognition as a leader earned him one of the first two endowed chairs at Cook Children’s. He’s a recipient of the Rare Disease Hero award, which recognizes only five physicians each year for groundbreaking research and treatment in the rare disease community.

He’s come a long way from what Dr. Thornton calls his “quirky story.”

Growing Up

Dr. Thornton grew up in a middle-class family in Ireland. His grandfather ran the water department for the government, responsible for water purity for the country. His father did not go to college but rather became a businessman.

Little did Dr. Thornton know how hard his father worked to give his children an opportunity to continue their education.

“I went to a private Catholic school. This is going to sound really strange, but I did not know it was a private school,” Dr. Thornton says while laughing at the thought. “You know in Ireland, everyone wears a school uniform. It’s not like in the States where only private school kids wear one. And it’s not like here, where there’s a private school at every stone’s throw. It just never dawned on me. Later my father said, ‘Do you know how hard we had to work to pay for that school?’”

Maybe it’s that example of hard work that led to Dr. Thornton earning his medical degree by the age of 23, the culmination of a childhood dream.

“It’s funny because there was almost nothing else I ever wanted to be. I knew from the age of 12 that I wanted to be a doctor,” Dr. Thornton said. “I think it was probably because of our family practitioner (Dr. Brendon Deasy). Dr. Deasy was a really good friend of the family, so I got to know him very well. I went to see him professionally every year. I realized that the work of a doctor was a really nice career. You got to meet new people every day. You got to help people. He is probably responsible for showing me what a great job being a physician could be.”

Dr. Thornton went to college without a backup plan. He knew once he got into university and could focus on studying to be a doctor, he would excel.

A Pediatrician

Once his clinical rotations began, Dr. Thornton decided early on that pediatrics was for him.

“When you work with children, they are restorative. You can’t come in grumpy.. You end up having fun doing your day’s work,” Dr. Thornton said. “It never seemed like a lot of fun dealing with adults all the time.”

What did seem like fun was endocrinology. Although his focus came about through a bit of circumstance and travel.

In medical school, Dr. Thornton excelled and “fell in love with learning.” He begins to get noticed too and that eventually led him to Great Ormond Street Hospital (GOSH) for Children, the oldest and one of the most prestigious pediatric hospitals in the world. This job was part of a job exchange with residents from the Children’s Hospital of Philadelphia, so Dr. Thornton headed to the States for a year

Dr. Thornton pauses for a moment thinking about his arrival in the United States.

“I only spent 28 years of growing up in Ireland. I left for England at 28 and came to the U.S. at 29. So actually, I spent less than half my life in Ireland. Wow!”

At CHOP, Dr. Thornton met the mentors who changed his life. He learned about endocrinology and specifically, hypoglycemia. “It didn’t take me long to determine that’s what I want to do with the rest of my life,” he said.

“I was very lucky that I trained at the only place, at the time, that had that sort of hypoglycemia program,” Dr. Thornton added. “So two of the doctors (Lester Baker and Charles Stanley) out of my four attending physicians were the world experts in hypoglycemia. It was just fascinating. The patients we were seeing were very difficult kids to manage.”

At the end of his year commitment, Dr. Thornton planned on returning to England, but CHOP offered him a fellowship to stay. He wrote GOSH a letter that said he wasn’t going back to London.

Returning to Great Ormond Street meant Dr. Thornton couldn’t stay on his new chosen career path. He wanted to learn more about treating children with hypoglycemia. Dr. Thornton did return to Ireland from 1996-1999 but eventually went back to CHOP where he remained until 2002 when he got a call from a recruiter.

Welcome to Cook Children’s

Dr. Thornton admits now he’d never heard of Cook Children’s or even Fort Worth when approached about a new job. He turned the recruiter down. Then a few months later, Dr. Thornton presented a paper at a Pediatric Society meeting. The recruiter showed up to hear him speak and invited Dr. Thornton to breakfast for one final pitch.

The recruiter showed Dr. Thornton pictures of the medical center and information about the institution. They ended up talking for four hours.

Following a trip to Fort Worth and a visit to Cook Children’s, Dr. Thornton accepted the role of medical director of Endocrinology.

“Now I still had so much to do. When I got here there were only two doctors. The waiting time was something like nine months,” Dr. Thornton said. “We had to do a lot of work to get the place how I wanted it. Everyone was good people and everyone was working hard. They just needed new leadership and some organization. So the first two or three years was building the program, hiring nurse practitioners and doctors. I focused on the organizational things and developing protocols.”

Soon, the department blossomed and Dr. Thornton became very busy not only as an administrator but seeing patients. However, something remained that lurked in the back of his mind since his arrival at Cook Children’s.

“I reached a position where I had time to think about my future here in Cook Children’s, ‘I had a skillset and focus on hypoglycemia and congenital hyperinsulinism (CHI). I decided to approach the hospital and say, ‘I'd like to set up a new hyperinsulinism center and develop a surgical program for the babies with HI.’ We wrote a proposal and it was like ‘Boom!’ They said, ‘yes.’”

Building a Program

After helping to launch the first such program in the nation, Dr. Thornton knew what he wanted when he began the second one at Cook Children’s. He brought a nurse coordinator/ nurse practitioner, Lisa Truong, CPNP-AC, to help him with the day-to-day operations.

“When Dr. Thornton asked me to join, I was very excited. It was a challenge to build a program from scratch. Ten years later, it’s still a challenge but I love it. All the kids we see are completely different because it’s such a rare condition. No kids present the same, which I like because it keeps me on my toes. I have learned so much from Dr. Thornton throughout these 10 years. He is an awesome boss and a great mentor."

Over the next three to five years, the program continued to grow and build. Cook Children’s showed their support for the program by naming Dr. Thornton one of the first two endowed chairs in the history of the program. Everything clicked.

Even after all this time, nothing thrills Dr. Thornton more to give good news to the families he treats. He continues to carry on a tradition of taking pictures with his families and marvels at their excitement when things go well.

“They realize that ramifications of what life means for them now that their child’s cured,” Dr. Thornton said. “A lot of these families don’t understand what it will mean to their life until it happens. And then it’s a big shock when they get home and realize, ‘Oh my God, I don’t have to check on my baby’s blood sugar eight or 10 times a day. The difference is so huge. You can just see how very happy the family is when there’s a cure.”

If only that guidance counselor could see him now.

Brec was diagnosed with Type 1 diabetes at 8 years old. Shortly after her diagnosis, she spent a week at Cook Children’s Medical Center. Even with a busy career as an actress, Brec flies from her current California home back to Fort Worth every three months for a checkup.

“Of course an 8 year old doesn’t know what’s going on,” Brec said. “Doctors are talking to you and telling you that you are going to have take shots and do this and this and this. I didn’t know what was going to happen. But Nick Jonas had an article in People magazine in that same week I got diagnosed, and my mom brought it to me and said, “See if he can do it, you can do it.’ I remember feeling so inspired and so motivated. I’m like, “I want to be someone’s Nick Jonas.”

Brec, who is currently on Nickelodeon’s “School of Rock,” became well-known to kids as the star of “Bella and the Bulldogs.” She also has appeared in two episodes of ABC’s “The Goldbergs.” Brec grew up in Saginaw, Texas where she played volleyball, basketball and ran track. She also competed in beauty pageants and was an Our Little Miss World winner.

It was during an Our Little Miss World pageant in 2008 that Brec began to show symptoms of Type 1 diabetes. She was staying at a hotel in Alabama with her mother and grandmother.

“They noticed very easily there was something off with me,” Brec said. “I was wetting the bed. I didn’t do that normally. I had lost a lot of weight. I was very thirsty. My mom planned on taking me to the doctor when we got back. But when she typed in what was going on, before we even went to the doctor, she knew what the diagnosis was going to be.”

Shelley, Brec’s mom, said she couldn’t believe it at first. The family has no history of diabetes. But she couldn’t ignore the facts. In one week she spent at the pageant in Alabama, Brec needed her fitted clothes taken up numerous times because she had lost so much weight.

They flew home and as soon as the tests returned and Brec was sent to Cook Children’s.

During the week that she spent at the medical center, Brec learned to take care of her “life-changing disease.” She learned to count her carbs and by the second day, she was learning to give herself injections of insulin.

“For me that was very emotional because you never want to see your child have to do that. I remember that was a very emotional time for me as a parent,” Shelley said.

Brec, laughing interrupts. “How about when you had to learn to give me a shot!”

Shelley recalls, “Oh, I struggled probably just as much as you did the first time the nurse had me give you a shot. I remember saying, 'I don’t want to poke her.'”

Brec recalls the teddy bear she received from Cook Children’s staff to help her practice giving shots and how that began a relationship with Cook Children’s that lasts to this day. While she was at Cook Children’s today for her checkup, she took time out to visit the Child Life Zone and talk to other patients.

You know, basically being their Nick Jonas.

“I just turned 18 and so I’m probably going to transition to a doctor out in California,” Brec said. “That’s unfortunate because Cook Children’s just seems so safe for me and change is always weird. I’m nervous. This place, they are so nice here and so welcoming. It is a little scary and this place just makes me feel like a kid, which I love. I want to always feel like a kid. I cried when I had to leave Cook Children’s after that first week I came here because I had such a good time.”

While Brec looks back on that first week fondly, she remembers other kids who took the news of their diagnosis hard. She said she remembers one little girl vividly. She “just seemed so sad.” Brec wonders now if that child didn’t have the supportive family that she had as a child.

Brec’s dad, Raymond, wouldn’t allow sadness into his daughter’s room. Everyone had to remain upbeat during a visit.

“When Brec was first diagnosed, her dad told her, and I don’t know if she knew how literal this was, but he said, “(Type 1 diabetes) is going to be a pain in the butt the rest of your life,” Shelley said. “But it changes nothing. His whole mindset was even though this is a big deal, it never should be treated like a big deal. She was still Brec. The only difference was she had to count her carbs and take a shot every time she ate. But I think that set the tone for her and for all of us. She never felt different. She never felt like it was that big of a deal in her life, even though it is.”

Brec has taken that positive attitude from her dad and carried it into her own life. She wants to serve as a positive example for other kids living with Type 1 diabetes. She is an ambassador for the Juvenile Diabetes Research Foundation (JDRF) and never shies away from talking about her condition.

“For newly diagnosed kids, specifically, I just want you to know that it’s going to be a daily struggle, but it’s just something you are going to have to deal with and you will be able to deal with it,” Brec said. “It doesn’t change who you are. Yes, you now have diabetes, but you are not diabetes. And in the long run, it will just make you a stronger person.”

Who knows? Maybe there’s a child reading this right now thinking, “I want to be someone’s Brec Bassinger.”

Resources:

• Cook Children's Endocrinology Program
• Choosing Our Team
• Appointments and Referrals
• Specialty Programs 
• Diabetes Program

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Cook Children's physicians and staff are experienced in treating all diabetes-related issues in children from birth through their transitioning into adulthood.

With diabetes, education is a key component of treatment and disease management, so we offer certified diabetic nurse educators and dieticians to assist children and their families. Cook Children's diabetic program has been recognized by the American Diabetes Association for Quality Self-Management Education. Click to learn more. 

I’m a teenage girl with a lot of hopes and dreams, but with a lot of desires comes big responsibilities. One responsibility that I did not get to “choose” is being a Type 1 diabetic. I’ve been a Type 1 diabetic and a patient of Dr. Paul Thornton at Cook Children's for over eight years now.

My day-to-day life is different than the lives of many others, but I’ve chosen to embrace my differences. Type 1 diabetes is NOT a setback. Dealing with my illness has made me realize that everyone is dealing with a battle we all know nothing about.

Type 1 has helped me be more aware of others and just to be kind when kindness might not be the first resort.

I still am very active in sports, hanging out with my friends, studying at school, and spending time with my amazing family.

My day-to-day life includes many finger pricks, insulin shots, and carb counting. I’m constantly looking at food as just a number. There are often many ups and downs in a single day including being frustrated or irritated due to a high blood sugar or even dazed and confused from a low.

These emotional swings can take a toll, especially at school. Luckily, I have a fantastic team of nurses who help me combat these issues while I am at school. It was more difficult when I was younger because I wasn’t as self- sufficient and needed to rely on one of my parents or a nurse 24/7.

My parents didn’t hold me back from going to birthday parties or even sleepovers, but it was tougher on all of us because nighttime is extremely dangerous. Therefore, my mom and I would have to devise plans to keep my life somewhat regular as a child but still be cautious of my situation.

This often called for some midnight or even 1 a.m. pickups by my parents from sleepovers. Through the years, I have generated an amazing group of friends who are always there to support me. Most recently, I have established some great friendships with some other “Type Ones” … Some people who finally understand what day-to-day life is like for me (and them too).

I don’t look at my disease as a burden but I will say that having someone with whom I relate was and still is a key factor in coping with my case scenario. When I was diagnosed, my world stopped and I did not think that was possible at such a young age.

At the time I was diagnosed, I was really into the Jonas Brothers, and it just so happened that Nick Jonas has Type 1 as well. Knowing this about Nick brought me a lot of comfort because he did not let diabetes stop him.

His ability to still perform and live a normal life while working with his condition in the background is still so inspiring to me.

If you only take one thing from this, I want you to know that you are not alone. With each passing day, it will become easier as you learn more and more about yourself. I have chosen to speak out because this disease does NOT define us.

The phone from Clinical Genetics came at 5:12 p.m. on April 10, 2018. Grace Wilson-Rabel remembers the exact time and date because it’s the moment that changed her life.

Candace Gamble, M.D., is a clinical geneticist with Cook Children’s, and the call was to let Grace know her daughter’s diagnosis.

Wilson was a secretary for Cook Children’s NICU and she motioned for her charge nurse to say she needed to take the call.

“OK, we received Austyn’s test results back. Her test is positive.”

Austyn had been diagnosed with neurofibromatosis type 1 (NF1), a genetic disorder that affects 1 in 3,000 people throughout the world. NF1 impacts children in many different ways, including light brown skin spots, neurofibromas (small benign growths) on or under the skin and/or freckling in the armpits or groin.

About 50 percent of people with the condition have learning challenges. Health concerns also include the softening and curving of bones, and curvature of the spine (scoliosis), and occasionally tumors may develop in the brain, on cranial nerves or the spinal cord.

While these tumors are usually not cancerous, they can cause health problems by pressing on nearby body tissues.

Following the diagnoses, Grace immediately felt cold fear run through her entire body and she broke down in tears.

After all, everything had changed.

Austyn was born Jan. 23, 2017.

Grace’s pregnancy was normal until her thirty-fifth week when she began to experience high blood pressure. Because it continued to be elevated, she was induced at 37 weeks. Austyn was born weighing 6 pounds, 12 ounces.

“There were absolutely no signs that she had a genetic condition hiding inside of her,” Grace said. “At 2 days old, we had her newborn check-up and discovered that her bilirubin was high.”

At 2 weeks old, Grace noticed her daughter was working hard to breathe and made a “horrendous noise” every time she inhaled, so back to the pediatrician’s office she went with her daughter.

Following three more visits to the Emergency Department at Cook Children’s, Grace made an appointment with Pulmonology where Austyn was diagnosed with laryngomalacia, a congenital softening of the tissues of the voice box, or larynx, above the vocal cords. This new diagnosis caused a whole other set of issues. Austyn’s suck/swallow/breathe coordination was off, which caused failure to thrive and a hospitalization at 7 months.

Due to her low weight and delayed development, Austyn was tested for cystic fibrosis.

“Thankfully that test came back negative, but we were placed in physical therapy because despite working with her every day, she did not crawl until 11 months and did not walk until 19 months,” Grace said. “We would find out later, with her diagnosis, that this is all very common for kids with NF.”

At 3 months, Grace noticed Austyn had three brown spots on her abdomen.

“I didn’t really think too much of it other than I thought they were cute birth marks,” Grace said.

At her 4-month checkup, Grace pointed out the spots to her pediatrician, Joyce Rafati, M.D. Dr. Rafati looked at them and said she thought it could be neurofibromatosis, but it was too early to tell.

By the age of 10 months, Austyn had 13 spots. Dr. Rafati referred Austyn to be seen by Dr. Gamble in Genetics to test for NF.

“The earliest we could be seen by the geneticist was January 29, 2018 – which was four months out,” Grace said. “The hardest part of this whole journey is patience. The wait time to see a specialist always feels so far away and then after the specialist visit we are left in limbo because there are so many ‘wait and see’ moments with NF.”

Austyn received a simple blood draw to test for the genetic condition, but it would take six or more weeks for the results. The test is expensive and has to be approved through insurance, which took another four weeks.

Once she received the approval, she took Austyn to the lab at the Dodson and had Austyn’s blood drawn on March 1, 2018.

Six weeks after the test, Grace received the phone call with the results.

“Processing that was one of the hardest things I’ve ever had to do,” Grace said. “I’m still processing it to this day. You have to go through a grieving process that sometimes takes months to years. You may grieve it your whole life but you have to be strong and you have to push through. NF1 brings lifelong doctor appointments and ‘what if’ questions. And, every day that there isn’t something going on and you’re not in the doctor’s office is a win.”

Grace said what helped her get through the most difficult time of her life was her husband, George. “He’s been my rock through this,” Grace said.

A few months later, Grace and George took Austyn to meet her new neurologist, Jeff McGlothlin, M.D.

“He was amazing, so gentle and thoughtful with Austyn and her condition,” Grace said. “And with talking to us. He answered all of our questions and gave us an idea of what the game plan would be.”

Austyn was supposed to have surgery to fix her airway a couple of weeks after her neurologist appointment so Dr. McGlothlin decided to piggy back on the surgery and do her first MRI to test for optic nerve gliomas the same day so she would only have to be sedated once. Gliomas are non-cancerous brain tumors that can affect a child’s vision.

“The day of the surgery came and we anxiously handed our sweet 18- month-old baby over to the arms of the doctors and nurses,” Grace said. “We knew she was in great hands but it didn’t take away that fear and sadness of what she is having to go through.”

About four hours later Austyn was out of surgery and recovering in the PICU at Cook Children’s. All went well. She had a great night and the next morning she was in good spirits and eating. The MRI was the last thing on Grace’s minds.

Around 10:30 in the morning, while still at Cook Children’s, Grace received a call from the neurologist’s office.

“I didn’t even think that they would be calling me to tell me bad news, I just thought they might be calling to tell me everything looked great. I was wrong,” Grace said. “The woman on the other end said, ‘Dr. McGlothin wanted me to let you know that there are two optic gliomas.’ I couldn’t even breathe. ‘What?’ I asked, choking back tears. She repeated the news and all I could say was, ‘This has been the worst year,’ and I sobbed and sobbed.”

Grace watched Austyn sleeping peacefully. She was so small and innocent and unaware that she had something so concerning inside her “precious little head.”

“Austyn has had a few more eye appointments and another MRI and I am happy to report that as of today her vision is unaffected and her tumors are stable,” Grace said. “We hope and pray that they stay this way. Her neuro-oncologist is pretty confident that she will never need treatment. Since these tumors are inoperable the only treatment option is chemotherapy.”

Grace said Austyn has been through more needle sticks, tests, hospitalizations, etc. in her short two years of life than most adults have. But throughout the process, Grace said she couldn’t be more grateful for Cook Children’s and the team that has taken care of her daughter since that day when her life changed: her pediatrician Dr. Joyce Rafati, gastroenterologist Danny Rafati, M.D., endocrinologist Teena Thomas, M.D., neurologist Dr. McGlothin, neuro-oncologist Jeffrey Murray, M.D., her ENT Michelle Marcincuk, M.D., and pulmonologist Nancy Dambro, M.D.

“Austyn has rocked everything like a champ,” Grace said. “She knows when they want to listen to her lungs, heart and belly, where the stethoscope goes. She knows where the blood pressure cuff goes and holds her arm or leg out for it. She never complains. And all of her doctors and nurses are her friends.”

Diabetic alert dogs like Journey are specially trained to detect high or low levels of blood sugar for kids like Hannah. Journey was Hannah's constant companion for the past three years and news reports say they went "everywhere" together: school church and camp.

"(Hannah) is struggling, but hanging in there," Hannah's mom told ABC news. "She has an amazing support system."

As one of Cook Children's endocrinologists, this story hit me especially hard. I see some amazing kids every day who are coping bravely with diabetes.

The story also reminded me of time I met Kyle Cochran (@KyleCochranANW) who was kind enough to volunteer at Camp Aurora one summer. Cook Children’s diabetes staff strongly support this camp, and many of the children attending are patients at Cook Children’s.

Kyle has lived with diabetes for most of his life and has competed at a very elite level in American Ninja Warrior. He uses both his diabetes service dog, Leeloo, as well as Continuous Glucose Monitoring (CGM) technology to closely track his blood sugars during high intensity training and competitions.

I asked Kyle to share unique perspective.

Why did you decide to get a diabetes alert dog?

Kyle: I decided to get a service dog because during my training I tend to drop really rapidly. I needed to be warned of the drop much sooner to avoid missing training time to treat a low. Leeloo alerts me before I even get low so I can treat the low and never have to pause the workout.

How do you use both Leeloo and CGM together?

Kyle: I love using Leeloo alongside my CGM. She is great at catching highs and lows before they even happen and the CGM is great for letting me see the exact number I’m at.

What advice do you have for a person or family considering a diabetes alert dog?

KyleThe advice I would give to people is to realize the HUGE responsibility it is to have a service dog. It’s kind of like having a child since you bring him/her with you everywhere. You must remember basic things such as ensuring enough food and water, avoiding over-heating, and dog bathroom breaks.

You will be asked questions about them EVERYWHERE you go. Training never ends, You must have more patience than you’ve ever had. I suggest buying the book, "Training Your Diabetic Alert Dog” and read the whole thing before getting a dog.

How do diabetes dogs help?

The high blood sugars and especially low blood sugars are a major concern for people with diabetes and their family. Low blood sugars in particular can lead to loss of consciousness and seizures. Any assistance in avoiding extremes in blood sugar is important and helpful in improving quality of life and keeping blood sugars in target range.

It's believed that the keen sense of smell is the key in blood sugar detection. A research study showed s dogs could sense blood sugar levels in sweat samples.It's possible that diabetes alert dogs (DADs) sense changes in the appearance, heart rate, or breathing associated with changes in a person’s blood sugar.

Technology vs Dog

Continuous glucose monitoring (CGM) technology continues to improve and has the ability to identify low blood sugars correctly in 90 percent or more cases. Given the cost and commitment of a diabetes alert dog, a prime question to be answered is how diabetes alert dogs compare to CGM reliability.

There is surprisingly not much information regarding alert dog reliability. Most of the information is comes from small sample size research surveys or reports. There are wildly differing reports on dog sensitivity to detect hypoglycemia ranging between 22-100 percent in a compilation of reserch studies.

Final Thoughts

It will be interesting to see if a research study is done to compare head to head dog vs CGM. One of the prime concerns regarding diabetes alert dogs is the quality/consistency of training. In the meantime, I agree with Kyle’s viewpoint. I believe the decision to choose a diabetes alert dog is very personal and needs to be researched before making a huge, expensive commitment. 

Finally, I want to dedicate this post to the memory of Sam. My mountain dog buddy.

Get To Know Joel Steelman, M.D.

Dr. Joel Steelman is an endocrinologist at Cook Children's. He grew up a military brat, on the move every three to four years, to a new home, in a different state. Nevertheless, his family roots remained in Texas, where he finished high school and developed a love for writing, working on the school newspaper and yearbook. He attended Texas A&M University both for his undergraduate and medical degrees.

When your child looks and acts healthy, it’s hard to understand how they could have a condition that, without proper treatment, could cause them to have a heart attack or stroke before the age of 50. Maria Gutierrez found herself in this situation when she received a life-changing phone call from Don Wilson, M.D., an endocrinologist and medical director of the REACH Clinic at Cook Children’s to discuss her daughter Kate.

When Kate was 4 years old, doctors told Maria that Kate was overweight and might be developing thyroid issues. Maria encouraged Kate to be more active and eat healthier. Her daughter’s change of lifestyle seemed to be the answer and by age 7 Kate was no longer overweight.

“Kate is always very hyper, very active. She eats vegetables! She loves cucumbers, lemons, loves fruits, loves everything,” Maria said. “Why would doctors call now to suggest blood tests when she’s healthy?”

According to the REACH (Risk Evaluation to Achieve Cardiovascular Health) Clinic, ideal total cholesterol levels should be less than 170 mg/dL, or LDL cholesterol levels (sometimes called “bad cholesterol”) less than 130 mg/dL. Kate’s lab work showed her cholesterol levels at 250 mg/dL, and she was diagnosed with hypercholesterolemia.

Hypercholesterolemia is a condition characterized by high levels of cholesterol in the blood. The condition is frequently caused by a genetic condition and kids can be at risk even when they are living a healthy, active lifestyle. The good news is that with early detection made possible by a routine blood test and medication to lower the cholesterol to safe levels, children with high levels of cholesterol can avoid serious health issues such as a heart attack or stroke when they become adults. But for children with genetic causes of high cholesterol, a healthy lifestyle is not enough.

Maria realized that Kate’s levels matched that of her husband’s, Roberto Macedo, who is diabetic. Dr. Wilson decided to test Kate to see if she had a genetic condition that would cause her cholesterol to be high. When she tested positive, Maria brought in her older son Brandon, 10, too. Brandon also tested positive for the gene. Brandon’s Vitamin K levels were also extremely high, putting him at risk of blood clots.

Both Kate and Brandon take medicine daily to treat their high cholesterol. Their schedules for lab work vary depending on how well they respond to their medication. It’s been two years since their diagnoses.

Right now, Brandon is coming in monthly to monitor his Vitamin K levels. If his medicines do not improve his condition, his dosages will have to be changed. Fortunately, with medication both children have achieved a healthy level of blood cholesterol. Like virtually all children treated with cholesterol medication, Dr. Wilson notes that none of the children have experienced side effects, and all have shown normal growth and development.

Everyday decisions, like what’s for dinner, are potential health risks for Brandon and Kate. They’re kids, so of course they want treats every once in a while. Maria says for her family “if they want a burger, they have to eat really healthy during the week and they can have just one hamburger at the end of the week, but with lettuce and tomato. It’s all about the balance.”

What’s hardest for Maria is knowing that there currently isn’t any cure for her children’s conditions. “I feel really bad because there is no way I can help them. The only way I can help is with what they eat, get plenty of exercise and make sure they take their medicine every day,” said Maria.

What’s even more difficult for her is the fact that not everyone believes Maria when she explains her kids have high cholesterol. She hears this a lot, “They aren’t fat, how can they have high cholesterol?” Maria explains that it’s genetic, and there isn’t much they can do other than to make sure her kids take their medicine, eat healthy and stay active.

But Maria’s children aren't alone. Genetic causes of high cholesterol affects 1 out of every 250 children, and it is one of the most frequent health concerns that affect children. For kids with genetic causes of high cholesterol, early treatment with cholesterol lowering medication is readily available, inexpensive, and most importantly, has proven to be safe and effective.

“It’s hard to understand that little kids can have this issue. They look fine, but they could become diabetic if their levels don’t go down. Or be at risk of having a heart attack or stroke when they’re adults” Maria said.

According to Dr. Wilson, left untreated, 50 percent of men and 30 percent of women with this condition will experience a heart attack by age 50.

Hypercholesterolemia is a challenge that Kate and Brandon face every day, yet an outsider could easily never notice. Maria hopes to bring awareness to her children’s conditions; she wants others whose children appear healthy but face health issues to know that they aren’t alone.

View this video  to learn about high cholesterol.

“They often times ask me if they should give their child a vitamin,” Dr. Mangham said. “Generally speaking, kids do not need to take a multivitamin or any supplements, for that matter.”

What is better than a multivitamin a day?

1. A good night’s sleep - every night.
2. A healthy, well-balanced diet.
3. Exercise and outside time
4. Good hand washing before meal time.

Dr. Mangham said going back to the basics with the above recommendations will boost your child’s immune system much more than any supplement could.

Recently, the New York Attorney General’s office cracked down on many major retailers, saying the herbal supplements they were selling didn’t live up to the promises on the label.

Joel Steelman, M.D., an endocrinologist at Cook Children’s said the quality testing program that stores such as GNC plan to put in place is a positive start, a lot of the herbal supplements have little hard science to really back up effectiveness.

“In my opinion, herbal supplements don’t really have a place for use in children,” Dr. Steelman said. “I’ve done research in the past on behalf of families asking about alternative treatments to use along with their child’s diabetes care. Most of the research is very weak. I suspect that very weak describes most data on use in children, and there’s a variety of medical case reports on negative effects of supplements on children.”

Jessica Holy, a Cook Children’s dietitian in Neurology, is frequently asked what vitamins and/or supplements are worth taking. She said that answer differs for parents and their children.

“Most of us have heard that if we tend to eat a variety of foods, then we don’t need a vitamin/mineral supplement. There is truth in that,” Holy said. “If you usually eat several servings of fruit, vegetables, whole grains, calcium-rich dairy and quality protein sources daily, then you are likely meeting your need for most vitamin and minerals. But how many of us have diets like that? Even though I’m a dietitian, I freely admit that I do not have a perfect diet. The busy pace that most of us keep makes it difficult to plan healthy meals for ourselves and our family. We often find ourselves turning to grab-and-go options at the grocery store or fast food. If this resembles you, then taking a regular, adult multivitamin daily may be a good idea.”

In children, a multivitamin might be needed during times of fluctuating appetite and food jags (only eating a few specific foods). For instance, children who aren’t getting enough iron in their diet may need to take an iron supplement for a period of time, until they begin eating more protein.

For the most part, children are able to get their needed vitamins through what they eat. Infants get their necessary vitamins through breastmilk (including routinely fortified with supplemental vitamin D) and/or formula intake and toddler and school-aged children are often able to achieve their need for calcium and vitamin D by drinking milk.

But beware excessive milk intake (greater than 24 ounces daily).

“Milk has some good nutrients, but it is lacking in iron,” Holy said. “Children who drink large quantities of milk are not often hungry for regular meals that provide iron-rich foods.”

If your child is allergic to milk, talk to your pediatrician for alternatives.

Harper was born with a rare genetic disorder called familial chylomicronemia syndrome (FCS) that causes a build-up of dietary fats, often resulting in pancreatitis, acute inflammation of the pancreas and severe abdominal pain. FCS is so rare estimates vary; but experts believe about one to two per million are likely to have the syndrome.

"It was really crazy at first because I went from breastfeeding to having to get formula, and it wasn't your everyday formula," Harper's mother Kendra Braughton said. "This was our first baby, too, so we didn't even really know what to expect."

Many people who have FCS live with severe pain for years as they receive misdiagnosis after misdiagnosis. Although Harper's condition was diagnosed at nine months, she still encountered a fair share of medical missteps.

"When we first took her to a specialist in Dallas, we actually took her to a cardiologist on the recommendation of our pediatrician," Harper's father Chris Braughton said. "After she put her on flaxseed oil, Harper ended up getting hospitalized with pancreatitis . Unbeknownst to us, it was because her body can't tolerate fat."

It wasn't until her hospitalization that Harper's family knew they had to dig deeper to find an answer that would give them an unfamiliar diagnosis, and would lead them to the Cook Children's Endocrinology Program.

Kendra's mother works for a Dr. Dennis Canon in Canyon, Texas. She spoke to the physician about Harper's condition. He did some research and found information he thought matched Harper's symptoms. Dr. Canon emailed Don P. Wilson, M.D., a Cook Children's endocrinologist, to ask for help.

Despite the rarity of the syndrome, Dr. Wilson is nationally known for treating patients with FCS. Dr. Wilson and his team currently care for 12 patients from around the nation, including six from Texas.

"Receiving such a rare diagnosis was shocking at first, but once Dr. Wilson explained what it was and how to manage it, and that it was really going to change us more than her, we realized we could do this," Chris said.

Normal triglyceride levels in a healthy person are typically less than 150 mg, however patients with FCS can reach levels of 10 times that amount. With a correct diagnosis, Harper could now be treated for her condition.

Dr. Wilson orders a lipid profile and Harper's triglyceride levels are closely monitored every six months to ensure she doesn't fall into another case of pancreatitis. Her triglyceride levels have remained around 700, which may seem high but is within a healthy range for a FCS patient.

"High triglycerides can destroy the pancreas, which would lead to problems absorbing nutrients and could cause her to have diabetes. Particularly in her [Harper] case dietary restrictions are necessary to avoid pancreatitis," Dr. Wilson said.

Patients with FCS are usually diagnosed due to debilitating symptoms such as severe abdominal pain, numbness or tingling, impaired cognition or blood with the consistency of milk, but at nine months old Harper was diagnosed due to her pink blood.

"Harper had high triglycerides and had little fat bubbles under her skin that looked like little pimples almost," Chris said. "One time we took her to get blood tests and her blood came out pink because it was so full of fat. The lab technicians actually thought they had messed up the test so they took her in for a second one and she broke the test again [due to inconclusive results]."

While there is no cure for FCS, patients are encouraged to meet with a dietician to maintain a lifestyle with extremely low levels of fat and the importance of avoiding excess carbohydrates.

"The only thing we have to watch is her fat intake," Chris said. "She eats a very low fat diet, we typically try to keep it between 7 or 8 grams per day. She eats very healthy, but otherwise we don't limit her. We try to keep her day as normal as her friends' would be."

While most 5 year olds are concerned with getting a piece of cake with the most icing, Harper is thankful on her "cheat days" and understands her daily restrictions.

"FCS requires a strict and rigid diet, and that's the problem especially with young children," Dr. Wilson said. "Everyone will grow up and be tempted to eat things that we shouldn't be eating, but when a child cannot always participate in birthday parties and other treats it can ostracize them."

Despite her dietary limitations, Harper has now lived five years with FCS and her healthy lifestyle is her definition of normal.

"Harper doesn't know anything else besides this type of lifestyle," Kendra said. "It seems like her body can tell when she does eat too much fat because she doesn't feel well and needs to eat something different."

Harper's parents quickly realized if she was aware of her diagnosis their daily lives would be easier to manage.

"We're very open with her about limiting her and why we're limiting her," Chris said. "She's very conscious of it. I think that's really the key for parents with kids who have dietary restrictions. That's your kid, and you have to let them have their cheat days and fun with their friends, but you also have to explain why you can only do that every so often. It really does help."

Two new studies emphasize the dangers of teens using e-cigarettes

The studies published in Pediatrics magazine showed teens who only vape have the highest level of cancer causing chemicals in their bodies and the e-cigarettes are associated with future smoking in teens.

The researchers from the University of California, San Francisco challenge the idea that e-cigarette vapor is safe. They found that teens who use e-cigarettes are in danger of inhaling cancer-causing chemicals, especially in fruit flavors.

“The presence of harmful ingredients in e-cigarette vapor has been established; we can now say that these chemicals are found in the body of human adolescents who use these products,” authors wrote.

The UC San Francisco researchers found that adolescents who smoke e-cigarettes expose themselves to a high levels of the potentially cancer-causing chemicals also found in tobacco cigarettes, even when the e-cigarettes do not contain nicotine.

"Teenagers need to be warned that the vapor produced by e-cigarettes is not harmless water vapor, but actually contains some of the same toxic chemicals found in smoke from traditional cigarettes," said lead author Mark L. Rubinstein, MD, a professor of pediatrics at UCSF. "Teenagers should be inhaling air, not products with toxins in them."

This was the first known study to report on the potentially cancer-causing compounds in the bodies of adolescents use e-cigarettes, according to UCSF. The lists of compounds include acrylonitrile, acrolein, propylene oxide, acrylamide and crotonaldehyde.

Another study from the same institution and also published in Pediatrics found that “e-cigarette use is more likely to encourage youth smoking that to divert youth form smoking.”

The team found those who had ever used e-cigarettes were significantly more likely than never users to have smoked at least 100 cigarettes at follow-up, have smoked during the past 30 days or both.

To learn more about e-cigarettes, we talked to Don Wilson, M.D., an endocrinologist and an Endowed Chair of Cardiovascular Health and Risk Prevention at Cook Children’s.

What do e-cigarettes do?

E-cigarettes are designed to simulate the act of smoking and deliver nicotine without the toxic chemicals produced by burning tobacco. The use of nicotine, however, is highly addictive. Recent research suggested nicotine exposure may also cause the brain to become addicted to other substances. Vapor from some e-cigarettes has also been shown to contain known cancer producing and toxic chemicals, such as diethylene glycol and nitrosamines, as well as small particles of toxic metals. Although not well studied, there is the potential for second hand exposure by others in the environment.

How do e-cigarettes work?

E-cigarettes are smokeless, battery operated devices designed to deliver nicotine mixed with a variety of flavorings (fruit, mint, chocolate, etc.) and other chemicals via an inhaled aerosol. They typically resemble regular tobacco cigarettes, cigars, pipes or everyday items like pins or USB memory sticks.

Most e-cigarettes generally contain three components: a cartridge that contains a liquid solution containing various amounts of nicotine, flavoring and other chemicals, a heating device or vaporizer, and a rechargeable battery. Puffing on the e-cigarette activates the battery powered heating device causing the liquid to vaporize. The vapor is inhaled by the user. E-cigarette vapor may include metals, rubber and ceramics which may be aerosolized and have adverse health effects.

Are e-cigarettes safe?

Although a limited number of studies have been conducted, the safety of e-cigarettes has not thoroughly been evaluated in scientific studies.

Here are a few points to consider:

• Nicotine is highly addictive and has negative effects on brain development from infancy to teens.
• Potential consequences of using e-cigarettes among youth include nicotine addiction, withdrawal and the potential for overdose.
• The use of a variety of flavoring in the liquid solution of e-cigarettes has created concern for accidental ingestion by smaller children.
• With the rapid increase in use of electronic nicotine delivery systems (ENDS), users and nonusers are exposed to the aerosol product. While e-cigarette aerosol may contain fewer toxins than cigarette smoke, studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive.

Bottom line: e-cigarettes are often promoted as safer alternatives to cigarette smoking. Although very little is known about their safety, they are increasingly being used by youth and young adults.

What about second hand exposure?

The potential exists for secondhand nicotine and other tobacco-related toxin exposures to others. Studies have shown that e-cigarettes are a source of secondhand exposure to nicotine but not to combustion toxins. Thus, while use of e-cigarettes in indoor environments may involuntarily expose nonsmokers to nicotine, it does not seem to expose them to toxic, tobacco-specific combustion products.

What does the American Academy of Pediatrics recommend?

To protect the health of youth, the American Academy of Pediatrics has made the following recommendations:

• Sales of e-cigarettes to minors (under 18 years of age) should be prohibited.
• Candy and fruit flavored e-cigarettes, which encouraged youth smoking initiation, should be banded.
• To avoid exposing others to potential harm, laws should mandate smoke-free environments which include e-cigarette vapor.
• To prevent poisoning, all e-liquids should be required to be sold in child-proof packaging.

Almost half of the people who participated lost an average of 30 pounds, went into remission and were no longer diagnosed with diabetes. They did not take any medications during this time and relied solely on weight loss. “Remission of type 2 diabetes is a practical target for primary care,” the authors of the paper wrote.

The participants in the study were on a liquid diet of 825 to 853 calories daily for three to five months and then were reintroduced to solid food, while maintaining a structured diet over the course of a year.

All the individuals who participated in the study were adults (20-65 years of age).

Joel Steelman, M.D., an endocrinologist at Cook Children’s, said that weight loss has been especially effective in treating adults, whether through diet or after weight loss surgery, and can lead to de-escalation of treatment or stopping therapy. This has been especially true in adults, whether through diet or after weight loss surgery.

Dr. Steelman said children with type 2 diabetes will also benefit greatly from weight loss, but an extreme low calorie diet, like the one the participants in the adult study were on, is a bit more of a concern in a still growing, developing child. Dr. Steelman said pediatric endocrinologists focus on eating a healthier, lower calorie, lower carbohydrate diet, while also stressing the child becomes active.

“Weight loss and improved diet often leads to de-escalation of treatment for children – stopping insulin often and sometimes stopping oral medication,” Dr. Steelman said.

But a child can’t make extreme lifestyle changes without the entire family buying in and everyone in the household living healthier. A child needs the full support and active involvement from all family members. Therapeutic lifestyle changes need to last a lifetime.

“It’s essential for the parents to be extremely involved. You to have buy-in and support from the family,” Dr. Steelman said. “There’s often type 2 diabetes in one of both parents. It’s a no-brainer that the whole family will experience some benefit, whether immediate or future, from improving food choices and increasing activity. It’s critical to understand that type 2 diabetes is a deadly disease, and is associated with earlier and more frequent cardiovascular disease and premature mortality than type 1 diabetes mellitus.”

Both girls and boys can be develop Type 1 and Type 2 diabetes, but only females have to be concerned with a type of diabetes that begins during pregnancy. Gestational diabetes, which can cause high blood sugar, is not only a concern for mom, but her baby as well.

Here are four other unique ways that diabetes of all types affects females:

1. Compared with men with T1D, women with T1D are more likely to have a fatal heart attack. In a study of 23,000 men and women, women were 4 times more likely to die from a heart attack. The increased risk for cardiovascular disease that leads to this often starts in the teenage years where teenagers are already starting to show risk factors.
2. Girls are more likely to develop T2D than boys, occurring in both usually after 10 years of age. Along with other important factors we can’t control, such as family history and certain ethnicities, just being a woman increases your risk for Type 2 diabetes. Girls with T2D have a unique risk for polycystic ovary syndrome which can lead to irregular periods, excessive hair growth and acne.
3. Pregnant moms with T1D and T2D must be aware of the effect of pregnancy on their diabetes control and that they are at increased risk for complication because of their diabetes, including death.
4. Pregnant moms with all forms of diabetes must also worry about their baby’s health as diabetes during pregnancy, particularly when poorly controlled, can have a significant impact on the developing fetus.

As you can see, the risk of diabetes and pregnancy is a big part of the unique challenges that women with diabetes face. Diabetes occurs in approximately 5-10 percent of U.S. pregnancies (2 percent have Type 1; 8 percent T2D and 90 percent have gestational diabetes).

Along with the risk of cardiovascular disease, women with diabetes have to contend with the fact that babies born to moms with poor diabetes control have an increased risk of birth defects, such as spina bifida or microcolon. The babies can also have complications at delivery such as low blood sugar, low calcium and increased risk for certain breathing problems.

“I know that all moms would like to be at their ideal health prior to conception, it’s especially important for women with diabetes. However, 50 percent of all pregnancies are unplanned and the majority of those with diabetes have gestational diabetes; therefore, the mother’s glycemic control may be inadequate at time of conception and during the early part of her pregnancy,” said Don Wilson, M.D. an endocrinologist at Cook Children’s.

The report published in The Lancet states the amount of children and adolescents rose to 124 million in 2016, compared to 11 million in 1975.

More than 20 percent of children in the United States were found to be obese in the age groups of ages 5 to 19 years of age.

While the study focuses on children, experts at Cook Children’s say the parents have to take accountability in keeping their children healthy.

Joel Steelman, M.D., an endocrinologist at Cook Children’s, said unhealthy food choices are more accessible with the increase of fast food choices across the world. These foods are usually higher in sugar and lower in not only nutrition, but cost of the food.

The other factor in the increase in obesity is sedentary behavior. But Dr. Steelman said increasing activity is easier said than done for many families, who are faced with children relying more on electronic media for entertainment and parents facing unsafe environments to let their kids go outside and play. Still, he said changes begin with the entire family making as many health changes as possible.

“Families have to be involved in helping a child with weight management,” Dr. Steelman said. “Often times this is not just a child issue, but a family-wide issue that needs to be addressed. I think that the biggest issue for families though is not to become militant and overly rigid in trying to help a child with weight management. Definitely, no shaming. The things you can do right now are pretty basic. That is changing your diet and encouraging more physical activity. I know it sounds simple, but this seems to be the best solution.”

Don Wilson, M.D., an endocrinologist at Cook Children’s, is the medical director of the Risk Evaluation to Achieve Cardiovascular Health (REACH) Clinic. The clinic is committed to improving the lives and well-being of children who are at risk or affected by obesity.

“The only way to be successful in the struggle with obesity is for all adults and children (with the assistance and encouragement of their parent/caregiver) is to embrace therapeutic lifestyle changes,” Dr. Wilson said. “Success starts with a positive self-image and a ‘can do’ attitude. We in the medical profession can help educate and encourage, but need to avoid blame and comments that demean the victim. Obesity is, and always has been, a disease. It should be treated as such. In general the public needs to understand the short-term and long-term consequences of obesity, including diabetes, premature heart disease, and several forms of obesity-related cancer. Only then will successful management/prevention be achievable.”

Virginia Landrum, a dietitian in clinical nutrition in Gastroenterology at Cook Children’s, said she stresses to parents and children that the entire family must be involved in making changes.

She lets her patients who are working to lose weight not to look at their changes as diet, but as a lifestyle change.

Landrum advises parents to help their kids get healthier by taking these steps:

1. Help your children be involved in the meal. Let them pick out some healthier food options that they may want to try.
2. If they are old enough, let them be involved in food prep.
3. Offer new foods. Studies show it can take as much as 20 times for some children to accept new food options. Landrum said parents may have to start by simply placing the new food item on the plate.
4. Parents have to set the example. Eat the healthy foods with your child. Let your child watch you eat vegetable. Go outside and walk with your child, play a sport or ride a bike.
5. Turn off the TV, video games and eat together as a family.

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.

But these patches of darkened skin called acanthosis nigricans may also be a sign of something more serious, said Joel Steelman, M.D., an endocrinologist at Cook Children’s.

The exact cause for acanthosis nigricans appearance is not yet known, but current scientific research suggests over-growth in the outer layer of the skin lead to the darkened, rough, velvety patches of skin seen in the condition.

Common body areas where patches of acanthosis nigricans may be seen include the neck, knuckles, armpits, elbows and knees. It can be more widespread and impact areas like the face, chest or belly. In severe situations, it can even be seen in the lips or cheeks.

The condition appears equally between boys and girls and seems to be more common in Hispanics, African Americans and Native Americans, compared to other ethnic groups. One recent study found about five-fold higher likelihood of acanthosis in blacks or Hispanics, compared to whites.

Dr. Steelman said in an overall healthy child, the most likely cause of acanthosis nigricans is a higher level of the hormone insulin in association with obesity. Insulin helps the body grow and store energy from food. That growth effect from too much insulin is thought to be the reason in most obese children causing the skin to develop acanthosis nigricans.

“Since, the main cause for acanthosis nigiricans is linked strongly to obesity and a higher risk for diabetes, I recommend that parents first take steps at home to manage their child’s weight,” Dr. Steelman said. “These steps which include making improvements in the diet and encouraging more physical activity pay off in so many ways.”

The changes Dr. Steelman recommends should be something that the whole family does together. He says this will benefit parents, grandparents and others in the family. If there is a strong family history of diabetes or their child is considerably overweight, parents may want to bring their child to their pediatrician for a checkup. Labs may be ordered to search for higher risk findings for diabetes or metabolic syndrome. Also, more detailed kinds of investigation may be needed in children who don’t have the usual medical history seen with acanthosis nigricans risk.

The skin condition itself doesn’t usually cause too many problems for the child, other than causing the child to be itchy in a few cases. Topical treatments applied to the skin like moisturizers, bleaching creams, and exfoliating creams are used in situations where the person is bothered by the appearance of the acanthosis.

“But the main treatment begins with a talk about obesity and weight,” Dr. Steelman said. “I think the discussion has to be framed in a way to discuss the reward and minimize the negative. It may sound pretty trite, I know, but it really means a conversation about, ‘Let’s get healthy.’ Getting healthy means a lot more than just looking good. It means feeling better, achieving more, etc.”

Read more about acanthosis nigricans here.

- Credit to KidsHealth® for photo.

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.

Paul Thornton, M.D. is the medical director of Cook Children’s Hyperinsulinism Center, one of only two such centers in the U.S. and the only one in the southern portion of the country. He has dedicated his life to researching and treating congenital hyperinsulinsim (HI), and in turn has helped improve the quality of life for countless children.

Dr. Thornton’s work is so well respected he was recently named a Rare Disease Hero by Rare Disease Communications. The award recognizes five physicians each year for groundbreaking research and treatment in the rare disease community.

“Rare Disease Communications is proud to be honoring these real-life heroes,” said Chris Davis, president of Rare Disease Communications. “This is, indeed, a rare opportunity to applaud the silent victories that mean so much to patients and families.”

In addition to the Rare Disease Hero award, Dr. Thornton was also recently honored at the 2016 sugar sHIndig at the Fort Worth Science & History Museum where he was given the Be My Sugar Medical Excellence Award by Congenital Hyperinsulinsim International (CHI).

“It’s an honor to be recognized by the leaders in the congenital hyperinsulinism community,” said Dr. Thornton. “As we continue to treat children from across the country and the world, we’re excited to share information about our program and the excellent team providing quality, family-centered care.”

The daily routine for most kids with type 1 diabetes includes multiple insulin shots, numerous blood sugar checks and analyzing the carbohydrates in every food eaten. Mental focus and motivation are essential and it’s a challenge to maintain the constant effort.

But new technology has the potential to make life easier for these children. The U.S. Food and Drug Administration has approved the first automated insulin delivery device for type 1 diabetes. The device is intended to automatically monitor glucose (sugar) and provide appropriate basal insulin doses in people 14 years of age and older with type 1 diabetes.

The human pancreas naturally supplies a low, continuous rate of insulin, known as basal or background insulin with spurts of insulin released when food is eaten. In patients with type 1 diabetes, the body’s ability to produce insulin is destroyed or severely impaired.

Joel Steelman, M.D., an endocrinologist at Cook Children’s, says this technology is the latest in insulin pump treatment that began to emerge in the 1980s with the promise of more precise insulin dosing and eliminating daily shots.

The old, basic insulin pump has steadily evolved into a smaller, smarter insulin pump. Current progress has allowed the joining of the relative diabetes technology newcomer, the continuous glucose monitor, with an insulin pump – displaying CGM readings on the insulin pump.”

In spite of all these advances in diabetes care technology, there remain two major challenges facing those affected by type 1 diabetes:

1. Daily mental work of diabetes care is not much different in pumping vs. injections.
2. Variability in blood sugars remains even when using a pump and keeping up consistent efforts.

The new diabetes technology holds the promise to shrink these two challenges and help children have more stable blood sugars. The device called a hybrid closed loop system pairs an insulin pump with a continuous glucose monitor (CGM) which has already been done, but contained within the software program of the insulin pump is an “AI co-pilot” that adjusts basal insulin delivery from the pump based on blood sugars detected by CGM.

“We’re getting there,” Dr. Steelman said. “It will only be a matter of time, people are testing devices now, before we achieve an insulin pump device where kids can ‘set and forget it.’”

Dr. Steelman believes the current technology to be a major step in the right direction, but he does see some concerns:

1. More diabetes technology makes a child more visible and obvious to the general population that could result in bullying or discomfort in sharing his or her condition. He said that will be a topic that the pediatrician and the parents will have to address with the patient.
2. It is technology. Computers, smartphones, etc. do break. “We do get lazy and rely on them more than we should sometimes,” Dr. Steelman said. “Kids using the device will need to stay engaged and responsible for their own health. They can’t just rely on the technology.”
3. While a step forward, the hybrid closed loop system still requires counting carbs in food and activating the pump to give boluses of insulin. Also, blood sugar finger prick tests must still be done.
4. According to Dr. Steelman, the equipment is expensive and physicians will have to work closely with insurance companies to find out what is covered for children and be aware of age restrictions.

Once he addresses these issues with the patient family, Dr. Steelman anticipates the Cook Children’s diabetes team will discuss the new technology with interested teens who have demonstrated good basic understanding and practice in their diabetes self-care. He said the staff and patients will need some additional training on the specifics of the technology, but looks forward to the possibilities.

“We already speak with parents about insulin pumps and technology in diabetes care. We have a formal process that we follow on insulin pumps,” Dr. Steelman said. “This technology has the capacity to further improve diabetes control and chip away at the pesky unpredictability in care. I’m especially excited about the positive impact of reducing nighttime low blood sugars.”

About the source

Dr. Joel Steelman grew up a military brat, on the move every three to four years, to a new home, in a different state. Nevertheless, his family roots remained in Texas, where he finished high school and developed a love for writing, working on the school newspaper and yearbook. He attended Texas A&M University both for his undergraduate and medical degrees.

He trained in endocrinology at the University of Colorado Children’s Hospital in Denver. 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.

The birth of his daughter, in 2005, and the desire to be closer to family, brought Dr. Steelman back home to Texas, and to Cook Children's. Today, he provides endocrine care for children living in the Dallas/Fort Worth metro area, as well as Denton and West Texas. He expanded his practice, after arriving atCook Children's, to include the care of childhood cancer survivors, collaborating with the neuro-oncology program and Life After Cancer programs.

The 19 year old’s defeat of Efimova was not only a matter of national pride, but serves a teaching moment for children everywhere about doing things the right way. Efimova had served a 16-month suspension for doping from late 2013 to early 2015. Russia has been under heavy scrutiny since its track and field team was banned following a state-sponsored doping program.

“It’s incredible, just winning a gold medal, and knowing I did it clean,” King said after her victory.

Joel Steelman, M.D., an endocrinologist at Cook Children’s, hopes young people watched and listened to King.

A survey in 2014 by the Partnership for Drug-Free Kids found that 11 percent of teens in grades 9-12 reported “ever having used” synthetic human growth hormone without a prescription.

The U.S. Department of Health’s Youth Risk Behavior Survey, published in 2012, stated that about 3.2 percent or 640,000 high school athletes, both boys and girls, had tried steroids at least once.

Dr. Steelman said what has happened to the Russian Olympic team is a perfect example of why kids use performance enhancing drugs (PED). They want a competitive edge in sports, hoping they can be a star athlete and make it to college or pros.

Another reason for taking PEDs is the body image factor. A kid may be looking for a shortcut to achieve that idealized body – more muscular or lean.

Dr. Steelman said symptoms of PED use may be subtle, but there are signs:

• The body change is the most obvious one – a more muscular appearance.
• A growth spurt in height may occur in younger kids as natural androgens produced by the body in puberty lead to a growth spurt.
• Dramatic slowing in height gain occurs later, post puberty, because one of the effects of these drugs is closing the growth plates more rapidly.
• Acne and other skin changes in both boys and girls.
• Facial and other body hair may occur for both boys and girls.
• Mood changes – anger, moody, etc.

Dr. Steelman said parents should be looking for these red flags, especially changes in temper and behavior. He also advises parents to watch for obsessiveness about sports, competition and body image.

When talking to your children, Dr. Steelman suggests reminding them that performance enhancing drugs are illegal and can cause serious damage to their health. Steroids and other PEDs are harmful to the body both in the short term but also longer term risk:

• Growth stunting
• Impacts on fertility
• Risk for liver disease/tumors
• Increased blood clotting/stroke risk

“The achievement of athletes like Lilly King is a great example to young people,” Dr. Steelman said. “I hope parents take this opportunity to talk with their kids. They should know that they can still achieve their goals by doing things the right way.”

Photos from USA Swimming. 

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.

At last, after long days plagued with uncertainty, they found their answer on the other end of a phone call from Paul Thornton, M.D., medical director of Cook Children’s Congenital Hyperinsulinism Center and Endocrine Diabetes program.

The family found Dr. Thornton through a Google search and a story posted on checkupnewsroom.com. The article told the story of how Dr. Thornton had led thea team of experts from around the world in creating new screening for physicians to recognize and manage neonates at increased risk for a persistent hypoglycemia disorder. The fact that Dr. Thornton was establishing these guidelines proved to Jake and Tella that he would be the best person to care for their little boy.

Dr. Thornton expected Brantlee had a rare condition called hyperinsulinism. He was right.

While at Cook Children’s, Brantlee had two pancreatectomies and a Gastrostomy Button, or G-Button, installed.

“Brantlee is now the first baby in the United States to undergo this new experimental therapy for hyperinulinism and so far, it is working, allowing him to go home and keep his blood glucose in the safe range,” Dr. Thornton said.

But before they found their answers, the Sanfords were left with only questions.

Brantlee was born a month and a half prior to his due date, weighing a surprising 8 pounds, 6 ounces. He was taken immediately to a Neonatal Intensive Care Unit in Flint, Mich., leaving behind tearful parents Jake and Tella to wonder and worry about the fate of their newborn son. Over the next few days, Brantlee’s insulin levels continued to climb without any explanation.

“We found out Brantlee was having problems shortly after his birth,” Jake said. “We wondered why he was so big for a premature baby and the doctors were curious if we had our due date right.”

However, within a week of Brantlee’s birth, an endocrinologist pulled his parents aside. Noticing his furrowed brow and serious demeanor, Jake and Tella braced themselves for what they could only expect, was bad news. The doctor informed them that Brantlee’s insulin levels were in the 300s when his sugar was 30mg/dL. Typically, a healthy newborn’s insulin level should be less than 2 with low glucose levels.

“In the 32 years he’d practiced, he said he’d never seen a baby at these levels,” Jake said. The doctors initially informed Jake and Tella that their son had a rare form of hypoglycemia, which is when the blood glucose drops below 50 milligrams per deciliter. However, the doctors’ treatments for hypoglycemia were not working on Brantlee. While Jake and Tella continued to rely on each other, both were growing weary and exhausted, continually praying for healing.

“It was a nightmare for us. We were slowly realizing that Brantlee wasn’t a typical premature baby,” Jake said.

After a week of tests and no answers, the doctors recommended Brantlee be sent to a children’s hospital in Detroit. Jake, not about to be away from his son, decided to use all of his vacation days to travel to Detroit with Tella. After extensive tests by multiple doctors, Jake said no one could figure out what was wrong with his baby. It seemed that Jake, Tella and Brantlee had hit another dead end.

But then everything changed.

“My sister had sent me a newsletter from a children’s hospital in Texas called Cook Children’s. I emailed the writer of this article on congenital hyperinsulinism while waiting for a miracle to happen,” Jake said.

Two days later, Jake received a phone call from a Texas area code. Dr. Thornton was on the other line, asking Jake if he and Tella would be willing to bring their newborn son to Fort Worth. “We figured if a doctor took the time to call us, he wanted to care for us,” Jake said.

After hearing from Dr. Thornton, Jake acted on impulse, desperately hoping that this was the moment that could save Brantlee’s life. Two days later, Tella and Brantlee were on a plane headed to Texas.

“They were amazed I called back so fast and how quickly we were able to arrange transport to get them here,” Dr. Thornton said.

After arriving at Cook Children’s and meeting Dr. Thornton, Brantlee was officially diagnosed with hyperinsulinism. This condition causes abnormally high levels of insulin, which can increase the risk for dangerous complications to the brain. However, fortunately for the Sanford family, Cook Children’s is one of only two hospitals in the United States with hyperinsulinism centers.

“It was really great to know that they were able to find us on the web, make contact, and get here fast so we could treat their baby,” Dr. Thornton said. Dr. Thornton is one of the most recognized hyperinsulinism specialists in the world, which made Jake and Tella feel more comfortable placing their son in his care.

“Dr. Thornton’s call was truly a sign from heaven. We put our faith to the wind and it took us to Texas,” Jake said.

After two and a half months, Brantlee was allowed to return home, just in time for the holidays.

“Since being back, we have tried our best to be a normal family, between the octreotide injections, blood sugar checks, continuous feedings from 9 p.m. to 9 a.m., and sirolimus into the G-Button.” To most, this sounds like a nightmare of foreign terminology. However, for the Sanford family, this circumstance is now a blessing.

Today, Jake and Tella can now manageably raise him from a home instead of a hospital.

“The threat of his sugars going low is still a battle for us, but thanks to Cook Children’s and his medication, we are able to raise it to where it needs to be,” Jake said.

Brantlee will return to Cook Children’s in June for a follow up appointment with Dr. Thornton.

More about Cook Children's Hyperinsulinism Center

One of only two such programs in the nation Cook Children's Hyperinsulinism Center uses a specialized team approach to treat this rare disease. Hyperinsulinism affects many areas of the body, so to truly treat the disease, each child is seen by top physicians, nurses, researchers and specialists in the field. These medical professionals have spent additional years of intense study and have dedicated their practice to focusing on hyperinsulinism so that your child has access to the medical care that treats all the symptoms. It is this level of treatment that has helped earn our program a distinguished international reputation for extraordinary care and achieving positive results.

1. What Is Turner Syndrome?

Turner syndrome, named after one of the doctors who first described it, is a genetic condition in which all or some portion of the X chromosome is missing. The lack of vitals genes found on the X chromosome affects multiple organs in the body leading to the medical problems seen in girls with Turner syndrome.

The loss of X chromosome genes happens very early in fetal life. In fact, the pregnancy of many babies with Turner syndrome ends in miscarriage. The condition is one of the most common genetic conditions with an estimated 1 out every 2,500 girls born with Turner syndrome.

2. What Health Problems Do Turner Syndrome Girls Have?

The severity of health problems in Turner syndrome is variable and depends at least in part on the loss of gene activity from the missing X chromosome. Many pediatric subspecialists may be involved in the care of Turner syndrome depending on the number and severity of health problems.

Heart problems in particular can be life-threatening and may require surgery early in life. Lifelong monitoring of heart health is necessary as heart problems are the most common cause of early death in Turner syndrome.

There are two primary health problems which need pediatric endocrine care.

· Short Stature

· Ovarian Failure

Short stature is a near constant problem seen in almost 100 percent of girls with Turner syndrome. I, and many other pediatric endocrinologists, use growth hormone treatment in girls with Turner syndrome. Prompt diagnosis is necessary and earlier diagnosis is essential. Prior to the use of growth hormone treatment, the average height for Turner syndrome girls was 4’8”.

The ovaries fail to work properly in most girls with Turner syndrome resulting in inability to go through puberty. Pediatric endocrinologists often start estrogen treatment and monitor puberty progress. Women with Turner syndrome need lifelong hormone replacement therapy. The majority aren’t able to have children without assisted reproduction.

Many other health problems can occur in Turner syndrome, and lifelong medical care is needed to check for these problems and provide proper treatment.

3. How is the Diagnosis Made?

Some families learn about the diagnosis of Turner syndrome in their daughter prior to birth if amniocentesis is done. However, most girls with Turner syndrome are diagnosed after birth.

The process of diagnosing Turner syndrome begins with a careful medical history. Unexplained short stature or delayed puberty may be the first clues in the diagnosis of Turner syndrome.

Blood testing to check chromosomes is necessary to make a definite diagnosis.

4. What else do I need to know ?

I hope this article helps in better understanding Turner syndrome. An early medical check in a girl with signs of Turner syndrome such as short stature or delayed puberty may be the first step in diagnosis.

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.

There’s been a lot of progress in type 1 diabetes care in the last five years, and I can only expect more in 2016 and upcoming years. I offer my thoughts on three areas for anticipated progress in type 1 diabetes care.

DRUGS

Insulin has been the mainstay in type 1 diabetes care since its purification and use in 1929. We’ve come a long way from purified animal insulin. We’ve had synthetically produced human insulin now for about 20 years.

Further modifications were made to human insulin creating long and short acting insulin analogs which are used today in basal/bolus insulin plans - considered standard of care in those with type 1 diabetes.

Several new analog insulin, either released or awaiting FDA approval, could be game changers for 2016.

Long-acting insulin activity is currently around 24 hours, but having a longer range of activity may benefit some patients with diabetes. Two new long-acting insulins, Tuojeo and Tresiba, continue working beyond 24 hours and have been approved for use only in adults with type 1 diabetes.

Fast acting insulin is essential at meals to control the rise in blood sugar from carbohydrates eaten. An “ultra-fast” acting insulin faster than the current batch of rapid-acting insulins recently started the review process for approval.

None of the current long or short acting analog insulins are generic. The cost of insulin and other diabetes supplies is a significant ongoing expense. A new “semi-generic” form of the long-acting insulin analog, Lantus, received recent approval.

The release of new analog insulin offers more choices, and research will be essential to see how these insulin can be used in children. Also, the number of insulin and increased choices will hopefully mean lower prices for vital medicine in the future.

DEVICES

Technology continues to move forward in its role helping children and families co-pilot type 1 diabetes.

Continuous glucose monitoring (GGM) continues to move into mainstream as a vital tool giving children and families real-time blood sugar information and better managing the highs and lows in blood sugar.

CGM in the clouds refers to the technology allowing remote monitoring of blood sugars. CGM sensor information is broadcasted via a smart phone to a server where it can be retrieved by using another smart phone or internet connected device. Parents can be hundreds of miles away and still have the comfort of monitoring their child’s blood sugar.

All the major insulin pumps have or will shortly have CGM integration allowing the most efficient use in these two tools together. The ultimate pairing of these tools, the artificial pancreas, continues in development.

The artificial pancreas holds the promise to lessen the work in diabetes care and help children have more stable blood sugars by allowing the insulin pump to use CGM information to make adjustments in insulin delivery.

Recent major funding received from the National Institute of Health and other sources will help fuel continued development and improvement.

Ditching the needles

Needles and sharp things are tough reality in diabetes care. Shots and finger pokes are a daily necessity in diabetes care. There’s been talk about non-invasive, needle-free monitoring in diabetes care for decades, but little progress has been made. Although CGM represents major progress, a needle is still needed to insert the device.

Wouldn’t it be great if monitoring of blood sugars or insulin treatment could be done without needles?

2016 has the potential to move forward in this area.

Inhaled insulin was recently approved for use only in adults with type 1 and type 2 diabetes. Further study is needed to see if inhaled insulin has a safe, effective place in treating children with type 1 diabetes.

Google’s glucose-sensing contact lens is probably the most recognized in the effort of various companies developing blood glucose checking without the stick. An ear sensor is being tested by two different companies.

The hormone glucagon is essential in the body to work against insulin and keep blood sugars up. Glucagon treatment, given as an injection, is an emergency measure used in type 1 diabetes when severe low blood sugars happen.

Nasal glucagon development is progressing and will probably reach the market soon with the promise of one less shot needed in an emergency situation of low blood sugar.

Defeat Diabetes

Removed first part For all of us in the field of endocrinology, defeating diabetes is the ultimate goal. For now though, I think 2016 offers the promise of new technology making those the life of someone with type 1 diabetes easier.

Research is also ongoing in re-creating insulin producing cells for re-implantation in the body which is the ultimate in defeating diabetes for good and what a great story that would be as we look ahead to 2017.

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.

They could all learn a lesson from a young woman named Marissa Heintschel.

I learned about Marissa during one of my recent searches for news about my field, pediatric endocrine. The news story featured students in the Frisco high school independent study and mentorship program.

One of the students in this program was Marissa, who had chosen pediatric endocrinology as her focus of study. I reached out to her via Twitter to learn more about her experience in the program and was very impressed by her story.

Like many in my field, she had a personal connection to pediatric endocrinology, having been diagnosed with Type 1 diabetes at 7 years old. She shared with me her passion for medicine and her experience she’s gained and the research that she did during her year in the program.

I asked how her experience had changed her view of children living with a chronic condition such as Type 1 diabetes. Her answer gave me a fresh, personal perspective on challenges of life with this chronic condition:

“I have always made it very public that I had Type 1 diabetes,” she said. “I went through the whole phase of trying to hide it away from people. I wish I would’ve realized sooner the importance of taking care of myself because when I was 14 or so I was stupid and thought that if I ignored my diabetes it will go away and that I could run away from my problems.

I wear an insulin pump. I’ve been called things like a robot and people in random places will just stare at me.

There was once this kid in my class sophomore year that I started to become really good friends with. One day I asked where he went and someone said that he went to go take his shot because he was diabetic. It was so surprising to me because no one really knew he was diabetic.

So then I started talking to the kid more and more about his diabetes and he just opened up to me and was able to talk about his problems that only people like us could understand. After he opened up to me, he told me how thankful he was that we had grown closer because he now felt he had the confidence to tell people about his diabetes.”

Marissa’s story got me to thinking about the importance of sharing about having Type 1 diabetes and how difficult it can be. I, and others on the Cook Children’s diabetes team, speak to children and their families about sharing about their diabetes when we meet with them at Cook Children’s during the difficult period of initial diagnosis.

• Support
• Safety

These are the two important reasons for S haring with others about having diabetes.

Sharing opens the opportunity to understand better the routine (checking blood sugars, taking shots, meal planning, etc.) that someone with Type 1 diabetes must do daily. Sharing opens up opportunity for support and encouragement. In Marissa’s case, it may be the opportunity to encourage and support someone else with Type 1 diabetes.

Marissa’s story also shows that sharing does open up vulnerability and risk. I asked Cook Children’s endocrine clinical therapist, Kim Cox, how she talks to children and families about sharing about diabetes.

“I usually talk to them about how ‘secrets’ tend to make other kids think it’s a bigger deal.

Why don’t they want others knowing? Are they

…. embarrassed?

... afraid of bullying?

... etc.

Being honest (but brief) about answering peers questions seems to work best. For example, I have diabetes, I have to take medicine when I eat now. We then discuss those issues.”

I use the example of a kid who gets glasses in school. In the beginning, you notice every time you see them, peers will comment and possibly even say mean things, but as time goes on, their glasses just become part of them and you only notice if they don’t have them on. Other kids move on to something else.

Safety is important because even in the best of cases diabetes care is unpredictable. High or low blood sugars affect mood and behavior. In particular, a low blood sugar can cause erratic behavior and eventually unconsciousness. Knowing about the diabetes allows others to have the advantage of understanding and help someone with Type 1 diabetes.

Marissa has a future of opportunity ahead of her and will be starting college at my alma mater, Texas A&M, where she will major in biomedical engineering and pre-med. She told me that she chose biomedical engineering because the potential that technologies such as stem cell research and tissue engineering for a cure for diseases such as diabetes. Being a doctor is her dream, and I think that she has learned a lot from her experience that will help her in the long journey to a field in medicine.

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.

“It’s wonderful day. I thought I would never be a mom,” Kristy said. “Mother’s Day is not something I take for granted. I’m grateful to my mother and grandmother, who taught me to be a mother . I love it.”

But when you consider each child has his or her own special needs, life can be amazingly hectic and difficult. And what’s the biggest challenge for the mom of nine?

“Probably laundry,” she jokes. “Would that sound crazy if that was my answer? I think more than anything, it’s working to meet each kid’s individual needs where they are at that particular moment. And then looking ahead, some of the kids aren’t as independent as they should be when they hit that magical 18 mark. Some are not ready to go out into the world yet. Some days that’s the scariest thing for me.”

Kristy’s story began as it continues now with her husband John. They loved kids then as much as they do now, but they couldn’t have any of their own.

John was a foster care agent. He was 26 at the time and Kristy was 22 when they met Luke and Josh, 7 and 2 respectively. Then two years later, they met Kathryn and Daniel, a brother and sister who were 6 and 4 then.

“After we got them, we kind of thought we were done,” Kristy said. “We weren’t sure though and we kept our certification to get more kids placed with us. Then two years later we met a set of precious little twins – Juliana and Josiah, then 4, who were half of a sibling group with Paul and Caleb, then 7 and 5. They were in an emergency situation. Their life would be pretty demanding. We thought we could add four and we already had four, so eight sounded about right.”

But what sealed the deal was when Juliana said to John, “All my friends have a daddy. I don’t have one. Will you be my daddy?”

Maybe some could still say no, but not the Goodnights. Their hearts are too big and their skills at taking care of kids with special needs too strong. All of their eight adopted children have medical and/or behavioral needs.

The Goodnights take their children from their home in Corsicana to Cook Children’s to be treated at the medical center. Kristy jokes her kids have many “ists” – endocrinologists, neurologists, psychologists …

“We have all of our specialty care through Cook Children’s,” Kristy said. “We really appreciate the cohesiveness of care. The specialties share information with each other. One doctor sees what the other doctor has done. There’s a great consistency of care. The other thing we like is we see the same doctor every time in their specific specialty and that’s not always true with other places. And we see a slew of doctors for everything from cerebral palsy to autism to emotional issues. We see doctors for behavioral issues, intellectual issues, growth issues – a wide variety of stuff. We are at Cook Children’s on a regular basis.”

Of course with the number of kids and the challenges that each bring, Kristy admits that she sometimes wonders if she’s the best person to care for them.

“There’s always days where I think I’m not doing the best I can and I think surely I can be a better mother,” she said. “I look around and the laundry is not done and the house is a mess. And then I remember the alternative. Without us, they wouldn’t have a family at all.”

Kristy chuckles. “And then I realize, I’m better than nothing.”

Needless to say, John says his wife is selling herself way short.

“She keeps everybody grounded, including me,” he said. “He keeps me focused on what’s important and not letting things bother us that might get in the way of that fact that we’re all in this together. She’s the most loving person that I know and you can tell she wears her emotions on her sleeves. You can look at her and know our kids are extremely important to her.”

And with that kind of love, why stop at eight, right? The Goodnights realized they’d experienced so much as parents, except what it was like to raise a newborn.

Kristy and John looked at other countries, but nothing came to fruition. Then they found a story on a new spin on in vitro fertilization – adopting an embryo. The embryo had been frozen for 10 years and was made available to the Goodnights. They only knew the age of race of the parents, but nothing else. They made the decision to take the baby without knowing anything more. They were used to facing challenges and they would be up for one more challenge.

So far, the newest member of the family, Jude, has been healthy. But he's still a toddler in a house with eight other children. Kristy says that’s OK because one more person only adds to what makes the Goodnight household special.

“The love. I love having a family. There’s just so much love in this house,” Kristy said. “There’s always someone laughing. It’s so much fun. I never expected that and the way the other kids care for the baby. It’s just tied everybody together in the ends. We have sweet kids with big hearts and that’s given us the ability to love everything we’ve gone through.”

According to the study, approximately 15 percent of 2-year-olds consume as much as 4 ounces of coffee daily. It’s a practice, health experts say, that comes with a dangerous dose of health risks.

The study followed 315 pairs of mothers and infants who were participating in an analysis of weight change during a child’s first week and its impact on body mass index at age 2. While examining diets, researchers found that 48 of the participating mothers were feeding their 2-year-olds coffee as part of their daily fluid intake.

Infants and toddlers of Hispanic mothers were more likely to drink coffee than those of non-Hispanic mothers, according to the study, but researchers did not examine further to determine why. Female infants were also found to be more likely to drink coffee than male infants.

Cultural practice may be one of the reasons some children drink coffee at younger ages, according to the study. In some countries, including Cambodia, Australia, and Ethiopia, children under 5 are given coffee.

“I think too much caffeine in childhood is a bad thing and worse in the case of a younger child,” said Joel Steelman, M.D., endocrinologist at Cook Children’s. “Coffee consumption by younger children is a big deal. I wouldn’t recommend parents start this practice. There are much healthier options. Caffeine could interfere with sleep – naps and bedtime. Overconsumption of caffeinated drinks could lead to symptoms of dizziness, headaches, mood changes and seizures.”

The U.S. Federal Drug Administration (FDA) has not provided guidelines on coffee consumption for children, but previous studies suggest there are potential negative health impacts, including Type 2 diabetes, depression, obesity and sleep disturbances. The American Academy of Pediatrics (AAP) recommends against the inclusion of caffeine in a growing child's diet.

Deborah Schutte, M.D., cardiologist and medical director of Cardiology at Cook Children’s, said her chief concern regarding toddler coffee consumption is the cardiovascular effect, particularly increased heart rate and high blood pressure.

“It boggles my mind why any parent would give a toddler caffeine. Toddlers are wired enough, why would anyone want to add to that?” Schutte asked. “My concern with caffeine and toddlers is more about tachycardia and arrhythmias. Caffeine can cause the heart to pump at an unnatural pace, resulting in palpitations.”

Schutte also points out that giving toddlers coffee could lead to dehydration, particularly since caffeine is a diuretic.

A 2013 study found that 2-year-olds who drank coffee or tea between meals or before bedtime were three times more likely to be obese in kindergarten.

“Just because there are no guidelines, doesn’t make it OK,” Schutte added. “What people don’t consider is that there is caffeine in drinks and food that we don’t always realize, such as chocolate and coffee- flavored ice cream, so caffeine levels can sneak up on you.”

According to the FDA, the average American adult consumes approximately 300 mg of caffeine each day - the equivalent to between two and four cups of coffee.

Canadian guidelines recommend no more than 45 mg of caffeine for children ages 4-6. This is equivalent to one 16 ounce can of soda.

If parents are already giving their toddler coffee, it’s possible to wean their child off the caffeinated beverage, Steelman said. He recommends parents talk to their pediatrician about a weaning off caffeine schedule.

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.

Now she prays for Tre’s caregivers to make her son all better.

Tre, who is 9 years old, has been seen by the Rehabilitation Services team at Cook Children’s since his parents adopted him as an infant. Most of those issues centered on his articulation skills. Tre’s history with Rehabilitation Services started with audiology and other physician specialists; speech therapy services began at 7 years old working on articulation skills. 

Then about 15 months ago, Sara Adams, Tre’s speech pathologist, received a call from Jennifer to say her work with him would have to go on hold indefinitely.

Tre was involved in a horrible boating accident. He sustained a head injury and was in a coma at another hospital. But the miracle for the Faulkner family occurred and within two weeks, Tre was up and walking.

After his accident, Tre returned to therapy at Cook Children's Urgent Care and Pediatric Specialties – Mansfield and worked with Occupational Therapy, Physical Therapy and Speech Therapy to regain skills that were lost after his brain injury.

A year later, much of Tre’s care takes place at the Cook Children’s Rehabilitation Services at Mansfield. The focus is on Tre’s short-term memory loss and his severe ADHD, as a result of the injury.

“God has blessed us so much,” Jennifer said. “The Mansfield community has been with us since the beginning, I’m so thankful. I’m also thankful for the amazing care Tre has received since his injury. At Mansfield, Tre has really been helped in many ways, through his physical, occupational and speech therapy. They have helped him so much with his memory and his balance. It’s truly been miraculous.”

The rehab at Mansfield is working for Tre. Academically, Tre’s test scores are in the average range for a child his age. His mom says he’s learning and making strides every day.

And Tre’s doing very well physically. He recently received his gold belt in karate. Makes sense for a kid who has proven time and time again how tough he is.

“The progress Tre has made since his accident is truly remarkable,” Adams said. “Tre still has some struggles with his attention and memory that impact him every day. However, he continues to improve and learn how to work through these struggles. Tre’s sense of humor, determination, and supportive family are his greatest strengths. Tre is such a funny kid! He loves to tell jokes and riddles. One of his favorite jokes is: ‘Why don’t ducks tell jokes when they are flying? … They might quack up!’”

To see how far Tre’s come since his injury it’s hard not to smile at the miracle that’s occurred and the occasional duck joke.

For more information

At Cook Children's, we provide more than 60 pediatric medical and specialty clinic offices throughout Texas. Thanks to our skilled group of clinicians who support the leading-edge technology found among our specialty services, Cook Children's is the destination when it comes to taking care of your children.

Cook Children's Urgent Care and Pediatric Specialties - Mansfield is located at:

801 Matlock Road

Mansfield, TX - 76063

To make an appointment, call 817-347-8400.

Specialty services at Mansfield inlcude:

• Endocrinology and diabetes
• Gastroenterology and nutrition
• Nephrology and dialysis
• Neurosciences
• Orthopedics
• Pediatric surgery (inpatient/outpatient)
• Psychiatry and psychology
• Rehabilitation
• Urgent care

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.

Cutting back on the candy 

Trick or Treat alternatives at Halloween have become more popular over the years. Fun games and other events replace some of the candy focus. Head off to the nearest Fall Festival or other child-friendly Halloween party instead of the usual neighborhood Trick or Treat candy run. Children with diabetes may need to substitute the candy they receive for a healthier snack or a lower carb snack, depending on their exchange value. 

Better choices with the candy. 

Not all candy is created equal. Some candies pack much higher sugar and calories per fun size serving than others. A quick Internet search has a number of articles and references on nutrition breakdown on different Halloween candies. Strategies such as choosing the “healthier” candy and limiting the amount of candy collected make progress towards a healthier Halloween. Also, stretching out the eating of Halloween candy over a week or more may help with candy becoming an after meal dessert or even being forgotten. Kids with diabetes may want to save their treats for meal time when they would normally get a dose of insulin. This prevents the need for adding extra insulin doses or shots. 

Hit the road 

Walking door to door in the neighborhood is not always possible, but when possible, it offers some calorie burn to soften the sugar rush of the Halloween haul. Practically, walking means fewer doorbells will be rung and probably less candy collected. It’s important to not have too much candy during this time of year, but enjoy Halloween. And of course, feel free to share any extra Kit-Kat bars with your favorite pediatrician, especially if he’s an endocrinologist who happens to be writing this particular blog. 

Enjoy the treats.  

Joel

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.

I’ve written in the past about my love of peaches. A hot August in Texas is the perfect time to enjoy this delicious fruit. Although most peaches start coming into season in July, it is August when they can be enjoyed in abundance. In fact, August is National Peach Month.

I’ve sampled peaches grown in a number of different states. I had the chance to enjoy an old favorite, the Palisade peach, during a recent Colorado vacation. Tasting an old favorite from years ago inspired me to search for a few fun facts about peaches to share.

Peaches were one of the earliest cultivated fruits with their origin in China. The fruit is thought to bring good luck and longevity in China. Even though Georgia has the nickname of the peach state, most U.S. peaches are grown in California. There is a lot of state pride regarding peaches. Colorado held a vote recently to make their state’s peach the official state fruit.    

Besides being tasty, peaches may have some important health benefits. They contain natural chemicals that may help fight against obesity and heart disease. Peaches are also rich in vitamin C, as well as high in fiber.

Right now, I’m enjoying a box of East Texas, Sunprince, peaches and hoping to get one more box or bag before the season ends. I’ve decided to combine two traditions – my love of peaches and the Hatch Chile festival – at the end of this month for a delicious treat. I plan to make Hatch Chile Peach Salsa. Here’s the recipe I will use. I hope you enjoy it with me. Please share with us your favorite peach stories or memories.

• 1 large finely chopped red onion
• 1-2 roasted hatch chiles finely diced (I plan to use 2)
• 1 tablespoon of olive oil
• 6 peeled and chopped peaches
• ¼ cup of apple cider vinegar
• ¼ teaspoon salt
• 2 tablespoons of chopped fresh cilantro
• May add 1 tablespoon of sugar if needed for more sweetness 

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.

By now you’ve heard about trans fats so much, you may start to tune out how dangerous they can be for your child. We hear these buzz words all the time and it’s hard to tell any more what is and isn’t a serious threat.

How bad are trans fats for you? Toward the end of last year, the U.S. Food and Drug Administration (FDA) made the decision that hydrogenated oils may no longer be generally recognized as safe. That means if a final determination is made (which should be any time now), food manufacturers could no longer sell food products with trans fats or use them as an ingredient without prior FDA approval.

Here are four things you should know about trans fats to help you the next time you’re out shopping or ordering at a restaurant:

1. What are trans fats?

Trans fats are one of the “bad fats.” Some do occur naturally in foods, but most are created by adding hydrogen molecules to liquid vegetable oils. You’ll see them on food labels as “partially hydrogenated oils” or “hydrogenated oils.”

2. Where are they found?

Companies use trans fats because they’re inexpensive, last longer than other fats (increased shelf life), and give foods a good taste and texture. Trans fats are most often found in processed foods or fast foods.  Examples of trans fats are fried foods, baked goods, shortening and margarines, canned frosting and baking mixes. 

3. Why are they so bad?

Trans fats increase your LDL (“bad”) cholesterol and decrease your HDL (“good”) cholesterol.  They can increase your risk for heart disease and stroke, and there’s an association between trans fat consumption and higher risk for Type 2 diabetes mellitus.

4. What should we do?

• Look for trans fats on nutrition facts labels and look for partially hydrogenated oils in the ingredients list. Try to avoid trans fat (0g and no partially hydrogenated oils).
• Cook and eat at home as much as possible.
• Limit processed foods, especially at snack time. Reach for fruit, almonds or a light string cheese instead of chips or processed snacks.
• If eating out, choose baked or grilled proteins and watch “extras” like breads and sauces that may contain trans fat.

Trans fats are dangerous, but the good news is you can protect your kids from them. Start today by reading nutrition facts labels, ingredient lists, and eating at home as often as possible.

Chemotherapy and radiation treatments used to treat cancers often damage several endocrine systems in the body. The diagnosis of endocrine problems may occur at any stage in a child’s cancer treatment, and it’s particularly important to search for late effects appearing years after cancer treatment. Studies have shown the growing recognition of these late effects of childhood cancer treatment such as obesity and metabolic syndrome. Damage from the silent presence of these problems may take years to appear.

I created the clinic because I believe that endocrine evaluation and care has a lot to offer childhood cancer survivors.  I’m not alone as many endocrinologist are recognizing their role in the care of survivors. A report published last month detailing information learned from a large scale Scandinavian study of childhood cancer survivors further emphasized the important role that endocrinology should play in the care of survivors.

The study showed that children who survive cancer have a five times greater risk of developing an endocrine disorder late in life. The risk was highest in young survivors, but continued on into adulthood. Even by the time a patient was 60 years old, they had a 42 percent chance to develop an endocrine disorder.

Survivors of leukemia, central nervous system tumors and Hodgkin’s lymphoma were at the greatest risk.

Three primary endocrine problems were seen in the study.

• Hypopituitarism
• Hypothyroidism
• Gonad (ovaries/testes) failure

The Childhood Cancer Survivor Study (CCSS), a multi-center study sponsored by the National Cancer Institute has been ongoing since 1993 in the United States and provides valuable information comparable to the recent information from Scandinavia. The detailed information and guidelines from the CCSS prove very helpful in my care of young adults who have survived cancer.

I understand that many survivors and their families desire to put the stormy period of cancer treatment behind them and not to think about, but it’s important to remain engaged in health care and follow-up. I have provided endocrine support for Cook Children’s Life After Cancer Program (LACP) and Neuro-oncology program  now for five years and have found this role very rewarding in improving the quality of life of childhood cancer survivors. I look forward now to further expanding that role.

I, and I’m sure many others who care for children, were excited by the news. It was with great interest that I read the news article and began to examine the story more closely. The news while exciting deals with a relatively small number and specific population of children.

The study examined obesity rates in pre-school children, age 2-4 years old whose families received WIC assistance (The Special Supplemental Nutrition Program for Women, Infants, and Children). Not all of the states submitted information. Of the 41 participating states, 18 states showed modest declines in the number of obese preschoolers from information collected from 2008-2011. The remainder of the 41 states showed no change or even increases in obesity rates.

The challenge is understanding what this information means and placing it in the proper perspective. Experts in the field of childhood obesity believe the positive numbers reflect changes in the WIC program beginning in 2008. The program was changed in an effort to increase fresh fruits and vegetable purchases as well as other health options such as whole grains and low fat foods. Additionally, encouragement of breastfeeding is thought to help contribute the improvements.

The news validates the central importance of healthy eating in weight management. I believe that fresh ingredients and home preparation of meals is a major key in overall health and weight management. I have slowly continued reading the book, Salt, Sugar, and Fat, and am increasingly convinced of this belief.

As discussed in the article, challenges remain. One in eight pre-schoolers remain obese. And unfortunately, the likelihood is high for these children that obesity will persist into adulthood.

For more information:

• Cook Children’s Endocrinology and Diabetes Program
• Obesity where we live
• The Center For Children’s Health
• Checkup Kitchen
• Overweight and Obesity
• Keeping Portions Under Control
• How Can Families Be Healthier?

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. He still loves to write, and he is a regular contributor to the Physician Perspective page on the Cook Children’s Web site.

Occasionally, I’ve been lucky to know someone personally whose life has benefitted from such progress which was the case this past month. Multiple news outlets reported dramatic results of a new therapy for infantile hypophosphatasia. Hypophosphatasia is an extremely rare genetic condition affecting less than 20,000 people in the U.S. The condition is due to defective action on a vital bone enzyme known as alkaline phosphatase which is necessary in the formation of bone. There is a spectrum of severity tied to how active the enzyme is. Those with some to modest enzyme activity have symptoms appearing in childhood or adulthood, including weakness in bones that causes them to break more easily and premature loss of teeth.

Babies with the severe infantile form of hypophosphatasia progressively weaken as bones dissolve away. Movement and eventually the vital function of breathing become progressively more difficult. Toll of the disease is terrible with half of babies with infantile hypophosphatasia dying of respiratory failure in the first year of life. Progressively fewer live to see subsequent birthdays.

The news stories reported specifically about one patient, Janelly Martinez. Janelly’s parents watched helplessly as their daughter followed the typical grim course of infantile hypophosphatasia, requiring escalating levels of medical care to survive. For a time, I shared in the family’s struggles as a member of the endocrine team at Vanderbilt University that diagnosed and cared for Janelly.

Janelly’s parents faced the prospect that she would not survive the scarce few months until her third birthday. Her parents needed a medical miracle. For Janelly and her family, the miracle came. A new experimental therapy with the drug Asfotase alfa, a synthetic form of alkaline phosphatase became available in 2008. The results were dramatic for Janelly and other babies receiving the drug. New bone began to grow. Treatment results were dramatic, appearing within six month. Some older toddlers were able to stand for the first time.

I am deeply touched by the new life Janelly has received from this treatment. From struggling to breathe with mechanical assistance to now bearing some weight, Janelly has made remarkable progress. The prospects for an average childhood for Janelly even with treatment remain unknown. She is nearing 7 years old but remains the size of a toddler. Her contribution and her family’s contribution to medical discovery will endure.

It doesn’t matter how many years I’ve been in medicine, I continue to be impressed with advancements in modern medicine. I’m amazed at the science of it all and so thankful that it can helps special little children like Janelly.

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. He still loves to write, and he is a regular contributor to the Physician Perspective page on the Cook Children’s Web site.

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.

• 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.