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.

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

Type 2 Diabetes

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

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

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

Type 1 Diabetes

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

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

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

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

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

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

Finding the Balance

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

• Support
• Safety

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

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

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

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

Why don’t they want others knowing? Are they

…. embarrassed?

... afraid of bullying?

... etc.

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

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

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

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

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

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

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

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

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

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

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

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

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

Continuous glucose monitoring

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

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

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

The proximity problem…..

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

Why can’t there be remote diabetes monitoring?

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

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

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

.#wearenotwaiting

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

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

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

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

CGM in the cloud.

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

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

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

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

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

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

About the author

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

For more information:

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

About the author

As a self-described ‘techie,’ Joel Steelman, M.D., has a keen interest in the wise use of technology to improve medical care. Since 2001, he has helped implement electronic medical recordkeeping in two endocrine practices. He still loves to write, and he is a regular contributor to the Physician Perspective page on the Cook Children’s Web site.

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

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

As I said, new insights were gained by me at this meeting. I have cared for girls with Turner syndrome from infancy to adolescence. The concept of transition medicine is a growing, important areas in the lives of both of pediatric physicians and the children treated by us with chronic medical conditions. The medical treatments offered currently, have led to vastly improved life quality and long life expectancy.

A new challenge has emerged for physicians, families and emerging adults with a chronic condition – how to live life with the unique challenges of their particular diagnosis. Learning from experiences in education, employment and health shared by young adult women with Turner syndrome during Q&A in my talk was very enlightning.

I was very pleased to spend some tiem at this year’s meeting and learn more about the society. The Turner Syndrome Society, like many other organizations devoted to support and advocacy for a specific condition, provides a forum for families and women with Turner syndrome throughout the stages of life. The education and social support provided by this organization at the national meetings is admirable, and the atmosphere of learning can only benefit girls and women with Turner syndrome in the future.

About the author

As a self-described ‘techie,’ Joel Steelman, M.D., has a keen interest in the wise use of technology to improve medical care. Since 2001, he has helped implement electronic medical recordkeeping in two endocrine practices. He still loves to write, and he is a regular contributor to the Physician Perspective page on the Cook Children’s Web site.

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

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

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

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

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

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

About the author

As a self-described ‘techie,’ Joel Steelman, M.D., has a keen interest in the wise use of technology to improve medical care. Since 2001, he has helped implement electronic medical recordkeeping in two endocrine practices. He still loves to write, and he is a regular contributor to the Physician Perspective page on the Cook Children’s Web site.

Did you know the beginning of April marked national public health week? Probably not. The observance which began officially in 1995 doesn’t garner much in the way of public attention. Still, it serves to highlight public health achievements as well as talk about ongoing public health issues.

Many of the numerous accomplishments of public health are now considered basic services not recognized for the benefit they have given us all in health improvement. The newborn screening program was one of the accomplishments highlighted this year. This program has in particular greatly impacted my specialty of pediatric endocrinology, and I think it is important to acknowledge its important place in public health history.

Every year, newborn screening efforts test nearly every baby born in the U.S. for serious health conditions. Early detection of these conditions allows prompt medical treatment and potentially prevents disability, suffering, and death. In particular, testing the 4 million infants born every year for congenital hypothyroidism costs $5 per newborn and is estimated to prevent 160 cases of intellectual disability associated with untreated hypothyroidism.

I’ve written in the past about congenital hypothyroidism. The condition refers to a specific type of hypothyroidism diagnosed in newborn babies. This serious condition occurs in roughly 1 in every 4,000 newborns and can have devastating effects if not detected and promptly treated. Eighteenth century medical literature described the mental retardation and physical effects of untreated congenital hypothyroidism, cretinism. But only in the last 30 years have doctors been able to detect these issues prior to birth, allowing for parents to be prepared and physicians and family members to lay out a plan for the child’s future.

The Texas state newborn screening for congenital hypothyroidism has been active since 1980. It is estimated that 120-150 newborns in Texas with hypothyroidism are identified annually by screening. The program is a cornerstone in Texas public health and continues to grow. Today, the program tests newborns for 30 life-threatening issues including sickle cell disease and cystic fibrosis. Congenital adrenal hyperplasia screening represents another important life-threatening condition with pediatric endocrine ties that are screened by the state.

There are many other accomplishments in public health largely unrecognized by us. Thankfully, the U.S Centers for Disease Control & Prevention has compiled a list of the 10 great public health achievements in the 20th century.

Many other Cook Children’s specialties besides endocrinology rely on newborn screening to identify at risk babies early. Many of the conditions tested by newborn screening are rare metabolic conditions. The metabolic genetics program offers evaluation and treatment of these inherited metabolic conditions to help families understand and cope with their child’s diagnosis. A visit to that program can help with a more accurate diagnosis and appropriate treatment, while also helping families determine the best short- and long-term care.

About the author

As a self-described ‘techie,’ Joel Steelman, M.D., has a keen interest in the wise use of technology to improve medical care. Since 2001, he has helped implement electronic medical recordkeeping in two endocrine practices. He still loves to write, and he is a regular contributor to the Physician Perspective page on the Cook Children’s Web site.

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.

• 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.