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.

“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.

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.

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.

I’d be hard pressed to compare waiting for a doctor’s appointment including an appointment with me to the anticipation of waiting in line for any Disney ride or show.

It happens that the question about Disney and healthcare actually crossed my mind in March. While checking in on Twitter, I came across an intriguing book mentioned by one of the folks whom I follow: @JohnNosta.

The skeptic in me wondered how the entertainment industry could have any relevance to health care. Fortunately, the curious skeptic in me decided to buy the book and learn more.

The author approaches healthcare from a business, non-physician perspective focused on serving patients and those who care for patients. I found some fresh perspectives that I think will help me going forward.

Here are three pearls that I got out of the book.

Pearl 1: A focus on loyalty and not satisfaction

Loyalty and trust are different from satisfaction. Loyalty is built on a consistent caring and engaged compassion. Loyalty is built in large part by creating a memorable event in a patient care experience.

Pearl 2: Courtesy is more important than efficiency

A commitment to courtesy both improves experience and can lead to opportunities for efficiency improvement.

A focus on the satisfaction and service for others in your institutional may improve responsiveness and lead to better sharing of resources.

Pearl 3: Create a climate of dissatisfaction

Dissatisfaction with the status quo combined with the dream for what can be are key ingredients in growth and improvement. Even when all measures are near the top, there will always be room for improvement.Final Thoughts

I don’t believe it’s completely valid to compare the work done by me and others at Cook Children’s to work done in other service fields. Stakes and expectations are much higher - solving a problem, managing chronic illness, fixing a hurt - than getting a Starbucks order right or the thrill of a roller coaster ride.

Still we are all compared to real life experiences. Waiting in line is seldom fun. And the ride is sometimes not a ride the child or family would choose. We can still strive to make the experience as pleasant as possible.

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.

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

●Blood glucose meter

●Supplies to check blood sugar

●A cooler or ice packs to keep insulin cool

●Insulin

●Insulin injection supplies

●Insulin pump supplies

●Snacks for low blood sugars

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

●Low blood sugar

●Dehydration

●High blood sugars

●Ketones

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

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

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

Importance of swim lessons

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

“Managing” blood sugars

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

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

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

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

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

4.Swim with a buddy and never alone.

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

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

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

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

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

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

My gratitude to naturallysweetsisters.com for sharing.

A parent’s natural protective instinct would be to prevent the possibility of broken bones and limit high risk activities. However, regular physical activity is important for good bone health. Strength, balance and coordination gained from regular physical activity help prevent fractures. Daily movement – walking, standing, running – all stimulate bones to take up calcium and get stronger.

1. Is my child’s broken bone bad luck or something more?

Children with weaker bones containing less calcium are at higher risk for bone pain and broken bones. There are many causes and conditions leading to overall weaker bones in children. Some of the causes are very obvious while others are challenging to detect.

Diet is an obvious first thought for many parents as a cause of weak bones. Today’s children face a minefield of diet challenges. Most parents know that a poor diet carries a high risk of obesity, but many of the same poor diet choices also add risk for weaker bones.

A diet which is low in calcium and vitamin D deprives bones of vital raw materials for bone health. Drinking excess sugar containing soft drinks is already a risk for obesity, but it also is a risk for weaker bones. Soft drinks are high in the mineral phosphorous which binds calcium and make it unavailable for building bones.

Eating a bone healthy diet is not a full guarantee for good bone health. Digestive conditions such as celiac disease, inflammatory bowel disease, or liver disorders damage the intestines ability to absorb calcium and vitamin D properly.

Loss of mobility from neuromuscular conditions such as spina bifida, cerebral palsy, and muscular dystrophy, and spinal cord injury with paralysis remove the important positive effect of movement and standing on bone health. Most children with these conditions have weaker bones.

There are a number of rare genetic conditions, osteogenesis imperfecta being the most recognized, that are linked to weak bones and frequent bone breaks. A key clue often seen with a genetic condition causing weak bones is early appearance of broken bones, sometimes even before birth.

Lastly, certain medications can have a negative impact on bones. Glucocorticoids like prednisone are used to treat inflammation in the body. However, long-term use of this group of medication weakens bones. There are now recent reports of osteoporosis in adults with excessive use of proton-pump inhibitors which treat acid reflux. It’s not known yet if the same risk might happen in children.

2. When should a parent worry about a child’s broken bone?

Children who are already at risk for a broken bone need close monitoring and prevention treatment with calcium and vitamin D.

There are several expert recommendations on investigating broken bones in otherwise healthy children. A child needs further investigation if he or she has any of the following in their bone health history:

• Two long bone fractures before age 10.
• Three long bone fractures before age 19.
• Any vertebral collapse fractures.

3. How is bone health checked in children?

A careful medical history and examination are important first steps in determining risk for a child. Lab tests, both blood and urine, measure important levels in the body including calcium and vitamin D.

A special X-ray test called a DXA scan is used to measure the calcium content in bone and is an important step in determining bone health and risk for fracture. Interpreting the DXA results in children is more challenging than in adults and requires a pediatric specialist with expertise.

4. What can a parent do to insure healthy bones in their child?

Make sure your child has plenty of calcium and vitamin D in his or her diet. Milk and dairy are the prime sources of calcium in the diet. Three servings of dairy per day is important for children 4-8 years old. For the lactose intolerant child, there are lactose-free alternatives available which deliver necessary calcium. A parent should speak with their child’s doctor about calcium and vitamin D supplements if continued concerns about adequate amounts in the diet.

Get your child outside and get them moving. Sunlight exposure is key in the body’s internal production of vitamin D (but wear sunscreen). Movement of muscles, running, and just standing all help stimulate building of healthy, strong bone.

Contact your child’s doctor if he or she has a medical condition putting bone health at risk or if there are unexplained bone pain or fractures.

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.

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.

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’m always on the lookout for the latest news about developments in my field. In fact, I sometimes learn about the most up-to-date information by searching the news before I read about them in a medical journal.

A new diabetes technology under development caught my attention. The innovative technology developed at Stanford University uses a microchip for detection of type 1 diabetes.  A small sample of blood is placed on the microchip. The testing procedure detects auto-antibodies commonly found in those with Type 1 diabetes. The hope is that this new device can rapidly identify children who are at a high risk for developing Type 1 diabetes.

Illness symptoms of Type 1 diabetes, sometimes severe, are almost uniformly present at the time of diagnosis. It is frustrating both to me and parents that no easy screening is available to detect Type 1 diabetes earlier in its course when there are more possibilities of intervention. This new technology excites me as a way to overcome this barrier and expands intervention research opportunities in those in the early phase of type 1 diabetes. 

Screening for Type 1 diabetes is only currently done in large research studies such as the Trialnet Pathway to Prevention Study  and only in children who have a parent or sibling with Type 1 diabetes. It is possible that this new microchip will allow for wider, faster screening. The promise of an inexpensive, rapid test may help the growing number of children in countries with limited resources receive a prompt diagnosis and proper care for their Type 1 diabetes. 

The incidence of Type 1 diabetes continues to rise worldwide, and those of us in pediatric endocrine and other medical fields continue in efforts to better understand this mysterious condition. I believe a cure will come one day, but in the meantime, technology tools such as this microchip will form the new wave of innovation in Type 1 diabetes. 

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.

A recent announcement of a new smartphone app by Eli Lilly for glucagon use instructions reminded me specifically of the growing number of smartphone apps in diabetes care. A recent survey showed that the average smartphone user has 41 apps loaded on his or her smartphone. Apps powered by Internet connectivity affords users many options ranging from productivity to entertainment. I use my smartphone multiple times per day for various tasks ranging from checking email, reading medical news briefs, or entertaining my daughter with Angry Birds.

Health related applications loaded on smartphones along with other devices such as tablet computers represent a growing new trend of mobile health (Mhealth). Mhealth is a term used for the practice of medicine and public health supported by mobile devices. Mhealth currently provides a number of useful services including access to health information, real-time patient monitoring, and communication with the health care team. Many health care organizations, now have apps providing families with useful health information. A growing number of diabetes care apps are appearing to meet the needs of children and families dealing with this chronic condition.

Caring for type 1 diabetes involves a great deal of daily work: recording essential information such as blood sugars, insulin doses, carbohydrates eaten at meals, exercise, and illness. The diabetes education received by children and their families in the Cook Children’s pediatric diabetes program stresses two key skills of organization and interpretation of the daily flood of information. An organized system for capture of information is vitally important to give children and families maximal control over type 1 diabetes. The “old school method” for organization is a paper logbook carried everywhere with all information recorded. This system remains the best overall method helping both families and the pediatric diabetes care team to make important medical treatment decisions.

I know that many children and families struggle with maintaining a high level of organization. Diabetes smartphone applications present the potential to meet the needs of a mobile, tech-savvy population seeking a step beyond paper logbooks. I think this population is already comfortable with downloading and using apps from either iTunes or Android Market (Google play) and is willing to experiment with new methods of managing diabetes information.

Diabetes apps lend themselves to the necessary skills of management which include:

· Recording blood sugar readings

· Recording carbohydrates eaten at meals and snacks

· Looking up food carbohydrate content

· Calculating insulin doses

· Recording other information such as exercise or illness

· Communication with the diabetes care team

The growing number of diabetes apps (free and pay) makes it hard at times to determine which app is best for diabetes care. There is technology, such as IBGstar, that was designed to specifically integrate with Apple devices such as the iPhone or iPad. Other applications, such as Wavesense and Glucose Buddy, work with both Apple and Android devices. Newer apps also include allowing the user to link his or her social media accounts such as Facebook or Twitter with the app. A recent entry into diabetes apps designed by a pediatric endocrinologist, Endogoddess, offers another twist by rewarding care efforts with points.

I believe that technology advances such as diabetes apps and glucose sensors are part of the continuing forward progress in diabetes care. As with all new technology, I strive with families to make the best use of the tools available to improve diabetes care.

I was immediatley interested when I chanced on a recent radio interview with the author, Michael Moss, who has written a new book about the inner workings of the processed food industry. The book deals specifically with the reasons that these companies use three key additives – salt, sugar and fat – in the processed food they create and market.

The term processed foods sounds somewhat sinister, but some of the ways that food is processed such as pasteurization or freezing are quite beneficial to people for both health reasons and convenience. The primary goal in most processing of foods is creation of a food product that is near ready to eat and is stable on the shelf or in our homes for a long period of time. This particular goal and the goal of making tasty processed foods according to Mr. Moss is where the problem begins.

In the book, Moss interviews food scientists in many of the large processed food companies. These scientists are tasked with making tasty food products that apeal to a large group of people. Moss describes the use of the three key additives to mask odd or bitter flavors that develop during manufacturing and to hook consumers on taste.

Moss argues that company pressures to create new appealing snacks, grow market share and improve profitability often result in unhealthy foods that contribute to the U.S. and global obesity epidemic.

The interview concluded with the debate about what steps can be taken to reduce these activities and make healthier foods. The debate no doubt will continue between different philosophies of strict government regulation and independence of consumer choice.

I’ve downloaded the eBook and look forward to learning more and examining different viewpoints. In the meantime, my family and I will continue to see fresh ingredients and discover new recipes.

More information is available if you are interested with links to the NPR interview and the book.

Detractors point out that a large portion of Armstrong’s impressive athletic career was aided by illegal performance enhancing drugs. Furthermore, Armstrong strongly denied use of performance enhancers and aggressively countered accusers – calling them liars or suing them.

Things turned decidedly negative for Armstrong this past year when the U.S. Anti-Doping Agency (USADA) released a report documenting evidence of illegal performance-enhancing drug use extending back sixteen years. Armstrong chose not to dispute USADA and was stripped of his Tour de France titles and banned for life from cycling. International organizations followed suit, and the end of 2012 saw Armstrong disgraced, bereft of corporate sponsors, and facing possible legal action.

2013 now turns the page for Armstrong with his interview with Oprah Winfrey this past week. Armstrong was mostly candid and contrite with Oprah in admitting his wrong-doing. A few of his own words below convey the essence of the interview.

“I know the truth. The truth isn’t what was out there. The truth isn’t what I said, and now it’s gone—this story was so perfect for so long.”

“And then the ultimate crime is the betrayal of these people who supported me and believed in me, and they got lied to.”

All of the reasons for his decision to admit his use of performance enhancers and acknowledge the wrong done to those who accused him of performance enhancer use will probably never be known.

Moving forward, I think that there are three things that we as adults and parents should take away from Armstrong’s story and share with our children. Again, I think Armstrong’s own words help.

Tolerance of cheating

Speaking of use of performance enhancers…….“That was like saying we have to have air in our tires or we have to have water in our bottles. “That was, in my view, part of the job.”

Lack of Humility

“Yes, I was a bully. I was a bully in the sense that I tried to control the narrative and if I didn’t like what someone said I turned on them.”

Loss of Perspective

“My ruthless desire to win at all costs served me well on the bike, but the level it went to, for whatever reason, is a flaw. That desire, that attitude, that arrogance.”

A recent study reported that 3.3% of high school students admitted to anabolic steroid use. Those using performance enhancers such as anabolic steroids risk damage to vital organs such as the heart, liver, and reproductive organs. I believe the health risk is even higher in teens and young adults. It is up to us to counter the attraction to performance enhancers.

Fostering a culture of sport fairplay where cheating is not acceptable and competition is rewarded, whether or not a win is achieved, is a first step. Lastly, remembering that, unlike Armstrong, most of a person’s life is not spent in pursuit of athletic excellence. The single-minded pursuit of a “win at all costs” goal may compromise more important lifelong things such as family, friends, or a career.

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.