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Nanda RH, Hua CH, Flampouri S, Eaton B, Kaste S, Patni T, Ronckers C, Constine LS, Marks LB, Esiashvili N. Risks of Spinal Abnormalities and Growth Impairment After Radiation to the Spine in Childhood Cancer Survivors: A PENTEC Comprehensive Review. Int J Radiat Oncol Biol Phys 2024; 119:507-521. [PMID: 38069918 DOI: 10.1016/j.ijrobp.2023.10.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 10/03/2023] [Accepted: 10/22/2023] [Indexed: 05/19/2024]
Abstract
PURPOSE A PENTEC (Pediatric Normal Tissue Effects in the Clinic) review was performed to estimate the dose-volume effects of radiation therapy on spine deformities and growth impairment for patients who underwent radiation therapy as children. METHODS AND MATERIALS A systematic literature search was performed to identify published data for spine deformities and growth stunting. Data were extracted from 12 reports of children irradiated to the spine (N = 603 patients). The extracted data were analyzed to find associations between complication risks and the radiation dose (conventional fractionation throughout) as impacted by exposed volumes and age using the mixed-effects logistic regression model. When appropriate, corrections were made for radiation modality, namely orthovoltage beams. RESULTS In the regression analysis, the association between vertebral dose and scoliosis rate was highly significant (P < .001). Additionally, young age at time of radiation was highly predictive of adverse outcomes. Clinically significant scoliosis can occur with doses ≥15 Gy to vertebrae during infancy (<2 years of age). For children irradiated at 2 to 6 years of age, overall scoliosis rates of any grade were >30% with doses >20 Gy; grade 2 or higher scoliosis was correlated with doses ≥30 Gy. Children >6 years of age remain at risk for scoliosis with doses >30 Gy; however, most cases will be mild. There are limited data regarding the effect of dose gradients across the spine on degree of scoliosis. The risk of clinically meaningful height loss was minimal when irradiating small volumes of the spine up to 20 Gy (eg, flank irradiation), except in infants who are more vulnerable to lower doses. Growth stunting was more frequent when larger segments of the spine (eg, the entire spine or craniospinal irradiation) were irradiated before puberty to doses >20 Gy. The effect was modest when patients were irradiated after puberty to doses >20 Gy. CONCLUSIONS To reduce the risk of kyphoscoliosis and growth impairment, the dose to the spine should be kept to <20 Gy for children <6 years of age and to <10 to 15 Gy in infants. The number of vertebral bodies irradiated and dose gradients across the spine should also be limited when possible.
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Affiliation(s)
- Ronica H Nanda
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida.
| | - Chia-Ho Hua
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Stella Flampouri
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Bree Eaton
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Sue Kaste
- Departments of Diagnostic Imaging and Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Tushar Patni
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Cecile Ronckers
- Division of Childhood Cancer Epidemiology / German Childhood Cancer Registry, Institute for Medical Biostatistics, Epidemiology and Informatics, University Medicin at the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Louis S Constine
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Lawrence B Marks
- Department of Radiation Oncology, Lineberger Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Natia Esiashvili
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
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Doumat G, Mehta GD, Espinola JA, Gallegos C, Zhu Z, Mansbach JM, Hasegawa K, Camargo CA. Race-Neutral Equations and Pulmonary Function Test Interpretation in Two Pediatric Cohorts. J Pediatr 2024; 273:114124. [PMID: 38815738 DOI: 10.1016/j.jpeds.2024.114124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 05/15/2024] [Accepted: 05/22/2024] [Indexed: 06/01/2024]
Abstract
OBJECTIVE To investigate the changes in predicted lung function measurements when using race-neutral equations in children, based upon the new Global Lung Initiative (GLI) reference equations, utilizing a race-neutral approach in interpreting spirometry results compared with the 2012 race-specific GLI equations. STUDY DESIGN We analyzed data from 2 multicenter prospective cohorts comprised of healthy children and children with history of severe (requiring hospitalization) bronchiolitis. Spirometry testing was done at the 6-year physical exam, and 677 tests were analyzed using new GLI Global and 2012 GLI equations. We used multivariable logistic regression, adjusted for age, height, and sex, to examine the association of race with the development of new impairment or increased severity (forced expiratory volume in the first second (FEV1) z-score ≤ -1.645) as per 2022 American Thoracic Society (ATS) guidelines. RESULTS Compared with the race-specific GLI, the race-neutral equation yielded increases in the median forced expiratory volume in the first second and forced vital capacity (FVC) percent predicted in White children but decreases in these two measures in Black children. The prevalence of obstruction increased in White children by 21%, and the prevalence of possible restriction increased in Black children by 222%. Compared with White race, Black race was associated with increased prevalence of new impairments (aOR 7.59; 95%CI, 3.00-19.67; P < .001) and increased severity (aOR 35.40; 95%CI, 4.70-266.40; P = .001). Results were similar across both cohorts. CONCLUSIONS As there are no biological justifications for the inclusion of race in spirometry interpretation, use of race-neutral spirometry reference equations led to an increase in both the prevalence and severity of respiratory impairments among Black children.
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Affiliation(s)
- George Doumat
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Geneva D Mehta
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Massachusetts Chan Medical School, Worcester, MA
| | - Janice A Espinola
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Catalina Gallegos
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Zhaozhong Zhu
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | | | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA.
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Ciancia S, Madeo SF, Calabrese O, Iughetti L. The Approach to a Child with Dysmorphic Features: What the Pediatrician Should Know. CHILDREN (BASEL, SWITZERLAND) 2024; 11:578. [PMID: 38790573 PMCID: PMC11120268 DOI: 10.3390/children11050578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/01/2024] [Accepted: 05/06/2024] [Indexed: 05/26/2024]
Abstract
The advancement of genetic knowledge and the discovery of an increasing number of genetic disorders has made the role of the geneticist progressively more complex and fundamental. However, most genetic disorders present during childhood; thus, their early recognition is a challenge for the pediatrician, who will be also involved in the follow-up of these children, often establishing a close relationship with them and their families and becoming a referral figure. In this review, we aim to provide the pediatrician with a general knowledge of the approach to treating a child with a genetic syndrome associated with dysmorphic features. We will discuss the red flags, the most common manifestations, the analytic collection of the family and personal medical history, and the signs that should alert the pediatrician during the physical examination. We will offer an overview of the physical malformations most commonly associated with genetic defects and the way to describe dysmorphic facial features. We will provide hints about some tools that can support the pediatrician in clinical practice and that also represent a useful educational resource, either online or through apps downloaded on a smartphone. Eventually, we will offer an overview of genetic testing, the ethical considerations, the consequences of incidental findings, and the main indications and limitations of the principal technologies.
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Affiliation(s)
- Silvia Ciancia
- Pediatric Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena and Reggio Emilia, Largo del Pozzo 71, 41124 Modena, Italy
| | - Simona Filomena Madeo
- Pediatric Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena and Reggio Emilia, Largo del Pozzo 71, 41124 Modena, Italy
| | - Olga Calabrese
- Medical Genetics Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Lorenzo Iughetti
- Pediatric Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena and Reggio Emilia, Largo del Pozzo 71, 41124 Modena, Italy
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Dauber A, Zhang A, Kanakatti Shankar R, Boucher K, McCarthy T, Shafaei N, Seaforth R, Castro MG, Dham N, Merchant N. Vosoritide treatment for children with hypochondroplasia: a phase 2 trial. EClinicalMedicine 2024; 71:102591. [PMID: 38813446 PMCID: PMC11133798 DOI: 10.1016/j.eclinm.2024.102591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/21/2024] [Accepted: 03/21/2024] [Indexed: 05/31/2024] Open
Abstract
Background Hypochondroplasia is a rare autosomal dominant skeletal dysplasia due to activating variants in FGFR3. It presents with disproportionate short stature with a wide range of clinical severity. There are currently no approved medications to treat short stature in children with hypochondroplasia. Vosoritide is a C-type natriuretic peptide analog that was recently approved for improving growth in children with achondroplasia. We aimed to evaluate the safety and efficacy of vosoritide in children with hypochondroplasia. Methods We conducted a single-arm, phase 2, open-label trial at a single centre in the USA and enrolled 26 children with hypochondroplasia. The trial consists of a 6-month observation period to establish a baseline annualized growth velocity followed by a 12-month intervention period during which vosoritide is administered daily via subcutaneous injection at a dose of 15 μg/kg/day. The trial's co-primary endpoints included the incidence of adverse events and the change from baseline in age-sex standardized annualized growth velocity and height standardized deviation score (SDS) after 12 months of treatment. This trial is registered with ClinicalTrials.gov (NCT04219007). Findings Twenty-four participants with a mean age of 5.86 years received vosoritide therapy. The first participant was enrolled on August 4, 2020, and the final participant completed the 18-month trial on September 8, 2023. Vosoritide was well tolerated with no treatment-related serious adverse events. Injection site reactions occurred in 83.3% of participants. No participants discontinued therapy due to an adverse event. Annualized growth velocity increased by 2.26 standard deviations (SD) and height SDS increased by 0.36 SD during the treatment period versus the observation period. Hypochondroplasia specific height SDS increased by 0.38 SD. There was a 1.81 cm/year increase in absolute annualized growth velocity. Interpretation Vosoritide was safe and effective in increasing growth velocity in children with hypochondroplasia. Efficacy was similar to what has been reported in children with achondroplasia. Funding This study was supported by an investigator-initiated grant from BioMarin Pharmaceutical.
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Affiliation(s)
- Andrew Dauber
- Division of Endocrinology, Children's National Hospital, Washington, DC 20010, USA
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC 20052, USA
| | - Anqing Zhang
- Division of Biostatistics, Children's National Hospital, Washington, DC 20010, USA
| | - Roopa Kanakatti Shankar
- Division of Endocrinology, Children's National Hospital, Washington, DC 20010, USA
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC 20052, USA
| | - Kimberly Boucher
- Division of Endocrinology, Children's National Hospital, Washington, DC 20010, USA
| | - Tara McCarthy
- Division of Endocrinology, Children's National Hospital, Washington, DC 20010, USA
| | - Niusha Shafaei
- Division of Endocrinology, Children's National Hospital, Washington, DC 20010, USA
| | - Raheem Seaforth
- Division of Endocrinology, Children's National Hospital, Washington, DC 20010, USA
| | - Meryll Grace Castro
- Division of Endocrinology, Children's National Hospital, Washington, DC 20010, USA
| | - Niti Dham
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC 20052, USA
- Division of Cardiology, Children's National Hospital, Washington, DC 20010, USA
| | - Nadia Merchant
- Division of Endocrinology, Children's National Hospital, Washington, DC 20010, USA
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC 20052, USA
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Grimberg A, Hawkes CP. Growth Hormone Treatment for Non-GHD Disorders: Excitement Tempered by Biology. J Clin Endocrinol Metab 2024; 109:e442-e454. [PMID: 37450564 PMCID: PMC10795916 DOI: 10.1210/clinem/dgad417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/07/2023] [Accepted: 07/11/2023] [Indexed: 07/18/2023]
Abstract
The success of growth hormone (GH) replacement in children with classical GH deficiency has led to excitement that other causes of short stature may benefit similarly. However, clinical experience has shown less consistent and generally less dramatic effects on adult height, perhaps not surprising in light of increased understanding of GH and growth plate biology. Nonetheless, clinical demand for GH treatment continues to grow. Upon the 20th anniversary of the US Food and Drug Administration's approval of GH treatment for idiopathic short stature, this review will consider the factors underlying the expansion of GH treatment, the biological mechanisms of GH action, the non-GH-deficient uses of GH as a height-promoting agent, biological constraints to GH action, and future directions.
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Affiliation(s)
- Adda Grimberg
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Colin P Hawkes
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- INFANT Research Centre, University College Cork, Cork T12 DC4A, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork T12 R229, Ireland
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Laustsen BH, Bønløkke JH, Miller MR. How to account for Inuit ancestry in lung function prediction. Int J Circumpolar Health 2023; 82:2151158. [PMID: 36471626 PMCID: PMC9731580 DOI: 10.1080/22423982.2022.2151158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Rigorous lung function prediction equations for the Inuit are lacking. We used spirometry from 351 Inuit and 29 people of other ancestry obtained during an occupational survey in Greenland to determine how to obtain valid lung function predictions for the Inuit using Global Lung Function Initiative (GLI) equations for Europeans. Standing height for the Inuit was used in the predictions as well as their height modified in line with the known differences in standing to sitting height ratio (SHR) for the Inuit. With recorded height in predicting lung function, mean±SD Inuit z-scores for FVC and FEV1 were significantly higher than predicted (0.81±1.20 and 0.53±1.36, respectively, p<0.0001) which was not true for the non-Inuit participants (-0.01±1.04 and 0.15±1.17, respectively). When using height modified for SHR the mean±SD Inuit z-scores for FVC and FEV1 were no longer significantly different from predicted (0.10±1.10 and -0.12±1.24, respectively). The mean±SD Inuit FEV1/FVC z-scores were not significantly different from the non-Inuit, being respectively -0.45±0.98 and -0.01±1.04. Modified height changed the mean±SD Inuit FEV1/FVC z-scores to -0.39±0.99. Representative lung function predictions from GLI equations can be made for Inuit by using standing height modified for the known differences in SHR between Inuit and those of European ancestry.
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Affiliation(s)
- Birgitte H Laustsen
- Department of Clinical Medicine, Danish Ramazzini Centre, Aalborg University, Aalborg, Denmark,Institute of Nursing & Health Science, Ilisimatusarfik, University of Greenland, Nuuk, Greenland
| | - Jakob H Bønløkke
- Department of Occupational and Environmental Medicine, Danish Ramazzini Centre, Aalborg University Hospital, Aalborg, Denmark
| | - Martin R Miller
- Institute of Applied Birmingham Health Sciences, University of Birmingham, Birmingham, UK,CONTACT Martin R Miller Institute of Applied Birmingham Health Sciences, University of Birmingham, BirminghamUK
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Legare JM, Basel D. What the pediatric endocrinologist needs to know about skeletal dysplasia, a primer. Front Pediatr 2023; 11:1229666. [PMID: 37675393 PMCID: PMC10477785 DOI: 10.3389/fped.2023.1229666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/07/2023] [Indexed: 09/08/2023] Open
Abstract
Children with skeletal dysplasia are frequently referred to pediatric endocrinologists due to short stature. These children may present with disproportionate growth or medical histories that point to a skeletal dysplasia. This primer will discuss when to be concerned about skeletal dysplasia, the initial steps in evaluation for a skeletal dysplasia, and new therapies that are either recently approved or in development.
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Affiliation(s)
- Janet M. Legare
- Department of Pediatrics, University of Wisconsin School of Medicineand Public Health, Madison, WI, United States
| | - Donald Basel
- Department of Pediatrics, Medical Collegeof Wisconsin, Milwaukee, WI, United States
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Chen C, Milbrandt TA, Babadi E, Duong SQ, Larson DR, Shaughnessy WJ, Stans AA, Hull NC, Peterson HA, Larson AN. Normative Femoral and Tibial Lengths in a Modern Population of Twenty-First-Century U.S. Children. J Bone Joint Surg Am 2023; 105:468-478. [PMID: 36727888 DOI: 10.2106/jbjs.22.00690] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The Green-Anderson (GA) leg-length data remain the gold standard for the age-based assessment of leg lengths in children despite their methodologic weaknesses. We aimed to summarize current growth trends among a cross-sectional cohort of modern U.S. children using quantile regression methods and to compare the median femoral and tibial lengths of the modern U.S. children with those of the GA cohort. METHODS A retrospective review of scanograms and upright slot-scanning radiographs obtained in otherwise healthy children between 2008 and 2020 was completed. A search of a radiology registry revealed 3,508 unique patients between the ages of 2 and 18 years for whom a standard-of-care scanogram or slot-scanning radiograph had been made. All patients with systemic illness, genetic conditions, or generalized diseases that may affect height were excluded. Measurements from a single leg at a single time point per subject were included, and the latest available time point was used for children who had multiple scanograms made. Quantile regression analysis was used to fit the lengths of the tibia and femur and overall leg length separately for male patients and female patients. RESULTS Seven hundred patients (328 female and 372 male) met the inclusion criteria. On average, the reported 50th percentile tibial lengths from the GA study at each time point were shorter than the lengths in this study by 2.2 cm (range, 1.4 to 3.3 cm) for boys and 2 cm (range, 1.1 to 3.1 cm) for girls. The reported 50th percentile femoral lengths from the GA study at each time point were shorter than the lengths in this study by 1.8 cm (range, 1.1 to 2.5 cm) for boys and 1.7 cm (range, 0.8 to 2.3 cm) shorter for girls. CONCLUSIONS This study developed new growth charts for femoral and tibial lengths in a modern U.S. population of children. The new femoral and tibial lengths at nearly all time points are 1 to 3 cm longer than traditional GA data. The use of GA data for epiphysiodesis could result in underestimation of expected childhood growth. LEVEL OF EVIDENCE Prognostic Level IV . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Chunho Chen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota.,Department of Orthopedic Surgery, National Taiwan University Hospital, Taipei, Taiwan.,School of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Orthopedics, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Todd A Milbrandt
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Elham Babadi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Stephanie Q Duong
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Dirk R Larson
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | | | - Anthony A Stans
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Nathan C Hull
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | | | - A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Shi J, He Q, Pan Y, Zhang X, Li M, Chen S. Estimation of Appendicular Skeletal Muscle Mass for Women Aged 60-70 Years Using a Machine Learning Approach. J Am Med Dir Assoc 2022; 23:1985.e1-1985.e7. [PMID: 36216159 DOI: 10.1016/j.jamda.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/30/2022] [Accepted: 09/05/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES This article aimed to develop and validate an anthropometric equation based on the least absolute shrinkage and selection operator (LASSO) regression, a machine learning approach, to predict appendicular skeletal muscle mass (ASM) in 60-70-year-old women. DESIGN A cross-sectional study. SETTING AND PARTICIPANTS Community-dwelling women aged 60-70 years. METHODS A total of 1296 community-dwelling women aged 60-70 years were randomly divided into the development or the validation group (1:1 ratio). ASM was evaluated by bioelectrical impedance analysis (BIA) as the reference. Variables including weight, height, body mass index (BMI), sitting height, waist-to-hip ratio (WHR), calf circumference (CC), and 5 summary measures of limb length were incorporated as candidate predictors. LASSO regression was used to select predictors with 10-fold cross-validation, and multiple linear regression was applied to develop the BIA-measured ASM prediction equation. Paired t test and Bland-Altman analysis were used to validate agreement. RESULTS Weight, WHR, CC, and sitting height were selected by LASSO regression as independent variables and the equation is ASM = 0.2308 × weight (kg) - 27.5652 × WHR + 8.0179 × CC (m) + 2.3772 × Sitting height (m) + 22.2405 (adjusted R2 = 0.848, standard error of the estimate = 0.661 kg, P < .001). Bland-Altman analysis showed a high agreement between BIA-measured ASM and predicted ASM that the mean difference between the 2 methods was -0.041 kg, with the 95% limits of agreement of -1.441 to 1.359 kg. CONCLUSIONS AND IMPLICATIONS The equation for 60-70-year-old women could provide an available measurement of ASM for communities that cannot equip with BIA, which promotes the early screening of sarcopenia at the community level. Additionally, sitting height could predict ASM effectively, suggesting that maybe it can be used in further studies of muscle mass.
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Affiliation(s)
- Jianan Shi
- School of Nursing and Rehabilitation, Cheeloo College of Medicine, Shandong University, Jinan City, Shandong Province, China
| | - Qiang He
- School of Physical Education, Shandong University, Jinan City, Shandong Province, China
| | - Yang Pan
- School of Physical Education, Shandong University, Jinan City, Shandong Province, China
| | - Xianliang Zhang
- School of Physical Education, Shandong University, Jinan City, Shandong Province, China
| | - Ming Li
- School of Nursing and Rehabilitation, Cheeloo College of Medicine, Shandong University, Jinan City, Shandong Province, China.
| | - Si Chen
- School of Nursing and Rehabilitation, Cheeloo College of Medicine, Shandong University, Jinan City, Shandong Province, China.
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Wu Z, Zou Y, Fu R, Jin P, Yuan H. A nomogram for predicting sclerotherapy response for treatment of lymphatic malformations in children. Eur J Med Res 2022; 27:209. [PMID: 36271467 PMCID: PMC9585839 DOI: 10.1186/s40001-022-00844-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 10/06/2022] [Indexed: 11/10/2022] Open
Abstract
Purpose In this manuscript, we purposed to identify the prognostic factors for treatment of lymphatic malformations in children using polidocanol foam combined with pingyangmycin and to construct nomogram for predicting sclerotherapy response. Methods A retrospective analysis of 77 children having LMs who underwent sclerotherapy using polidocanol foam combined with pingyangmycin under ultrasound display from January 2017 to April 2020 was done. The clinical response was graded as excellent (≥ 90%), good (≥ 50%, < 90%), and poor (< 50%). More than 50% was considered as acceptable response. Prognostic factors were identified by Pearson’s Chi-square or Fisher’s exact test and multivariable logistic regression model was used to construct a nomogram to predict sclerotherapy response. The discrimination and calibration of nomogram were verified through the receiver operating characteristic cure and calibration plots. Results The mean number of treatment sessions was 3.1 (range, 1–6). Among 77 patients, 58 patients (75.3%) had excellent response to treatment (≥ 90%) and 68 patients (88.3%) had an acceptable response (≥ 50%, < 90%). Clinical disfigurement (P = 0.014), skin discoloration (P = 0.040), morphological subtype (P < 0.001) and extent of the lesion (P < 0.001) correlated with clinical response to sclerotherapy in LMs. Sclerotherapy response was predicted through nomogram constructed in this study, which shows good calibration and discrimination. Also, focal lesion and macrocystic or mixed morphological subtype lesion were seen more often in lower number of treatment sessions among the patients with excellent response. Conclusions An acceptable response to sclerotherapy using polidocanol foam combined with pingyangmycin was achieved in majority of LMs in children with extremely low complication rates. Nomogram based on the prognostic factors of sclerotherapy response for LMs in children was shown to possess an excellent performance to predict the probability of LMs sclerotherapy response.
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Affiliation(s)
- Zhiping Wu
- Department of Plastic Surgery, Jiangxi Provincial Children's Hospital, Nanchang, China
| | - Yun Zou
- Department of Plastic Surgery, Jiangxi Provincial Children's Hospital, Nanchang, China
| | - Ronghua Fu
- Department of Plastic Surgery, Jiangxi Provincial Children's Hospital, Nanchang, China
| | - Pingliang Jin
- Department of Plastic Surgery, Jiangxi Provincial Children's Hospital, Nanchang, China
| | - Hua Yuan
- Department of Plastic Surgery, Jiangxi Provincial Children's Hospital, Nanchang, China.
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Muthuvel G, Dauber A, Alexandrou E, Tyzinski L, Andrew M, Hwa V, Backeljauw P. Treatment of Short Stature in Aggrecan-deficient Patients With Recombinant Human Growth Hormone: 1-Year Response. J Clin Endocrinol Metab 2022; 107:e2103-e2109. [PMID: 34922359 PMCID: PMC9432476 DOI: 10.1210/clinem/dgab904] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Patients with aggrecan (ACAN) deficiency present with dominantly inherited short stature, often with advanced skeletal maturation and premature growth cessation. There is a paucity of information on the effects of growth-promoting interventions. OBJECTIVE The aim of this study was to evaluate the efficacy and safety of recombinant human growth hormone (rhGH) therapy on linear growth in children with ACAN deficiency. METHODS Open-label, single-arm, prospective study at Cincinnati Children's Hospital Medical Center. Ten treatment-naïve patients were recruited. Inclusion criteria were a confirmed heterozygous mutation in ACAN, age ≥2 years, prepubertal, bone age (BA) ≥chronological age (CA), and normal insulin-like growth factor I concentration. Treatment was with rhGH (50 µg/kg/day) over 1 year. Main outcomes measured were height velocity (HV) and change in (Δ) height SD score (HtSDS). RESULTS Ten patients (6 females) were enrolled with median CA of 5.6 years (range 2.4-9.7). Baseline median HtSDS was -2.5 (range -4.3 to -1.1). Median baseline BA was 6.9 years (range 2.5-10.0), with median BA/CA of 1.2 (range 0.9-1.5). Median pretreatment HV was 5.2 cm/year (range 3.8-7.1), increased to 8.3 cm/year (range 7.3-11.2) after 1 year of therapy (P = .004). Median ΔHtSDS after 1 year was +0.62 (range +0.35 to +1.39) (P = .002). Skeletal maturation did not advance inappropriately (median ΔBA/CA -0.1, P = .09). No adverse events related to rhGH were observed. CONCLUSION Treatment with rhGH improved linear growth in a cohort of patients with short stature due to ACAN deficiency.
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Affiliation(s)
| | | | - Eirene Alexandrou
- Division of Endocrinology, The University of Iowa Stead Family Children’s Hospital, Iowa City, IA 52242, USA
- Department of Pediatrics, University of Iowa, Iowa City, IA 52242, USA
| | - Leah Tyzinski
- Division of Endocrinology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Melissa Andrew
- Division of Endocrinology, Children’s National Hospital, Washington, DC 20010, USA
| | - Vivian Hwa
- Division of Endocrinology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH 45229, USA
| | - Philippe Backeljauw
- Correspondence: Philippe Backeljauw, Division of Endocrinology Cincinnati Children’s Hospital Medical Center 3333 Burnet Avenue, MLC 7012 Cincinnati, OH 45229.
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12
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Inokuchi M, Matsuo N, Takayama JI, Hasegawa T. Reference values of inside leg length and inside leg length to stature ratio for Japanese children, 0-12 years of age. Ann Hum Biol 2022; 49:1-9. [PMID: 35191816 DOI: 10.1080/03014460.2022.2045355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Large datasets of detailed anthropometric measurements are scarce in children. The Japanese Standard Association 1978-1981 survey provides a rare opportunity to use high quality data from Japanese children. AIM To construct inside leg length (ILL) and inside leg length to stature ratio (ILL/S) reference centile curves for Japanese children. SUBJECTS AND METHODS The study sample consisted of 14,825 boys and 14,577 girls age 0 to 18 years for stature and weight measurements, and 9,064 boys and 8,796 girls age 0 to 12 years for ILL measurements, who participated in the 1978-1981 national survey on body sizes. LMS method was used to construct the reference centile curves. The reference centile curves for stature, weight, ILL and ILL/S were compared to those of British children. RESULTS The L, M, S reference values for Japanese children are presented for stature, weight, ILL and ILL/S. Compared with British children of 0-12 years of age, Japanese children of 0-12 years of age had shorter median stature, shorter median ILL and shorter median ILL/S. CONCLUSIONS We presented the first reference values for ILL and ILL/S in Japanese children. Japanese children had relatively shorter legs compared to British children since infancy.
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Affiliation(s)
- Mikako Inokuchi
- Health Center, Keio University, Kanagawa, Japan.,Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Nobutake Matsuo
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan.,The Institute for Healthcare Quality Improvement, Tokyo Healthcare Foundation, Tokyo, Japan.,National Center for Child Health and Development, Tokyo, Japan
| | - John I Takayama
- Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, USA
| | - Tomonobu Hasegawa
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
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13
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Rogers CW, Gee EK, Dittmer KE. Growth and Bone Development in the Horse: When Is a Horse Skeletally Mature? Animals (Basel) 2021; 11:ani11123402. [PMID: 34944179 PMCID: PMC8698045 DOI: 10.3390/ani11123402] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 11/23/2022] Open
Abstract
Simple Summary A comparison of the pattern of growth in the horse with definitions used to describe growth and development in humans demonstrates the same general pattern of growth. In the horse, these development periods are completed very early in life, generally by 2 years of age. Using a variety of measures to define the completion of growth and bone development, the horse enters skeletal maturity by the time it is 2 years old. There is little variation in the age of maturity across different horse breeds. These data support the hypothesis that the horse evolved to be a precocious cursorial grazer and is capable of athletic activity, and used in sport, relatively early in life. Abstract Within the lay literature, and social media in particular, there is often debate about the age at which a horse should be started and introduced to racing or sport. To optimize the welfare and longevity of horses in racing and sport, it is important to match exercise with musculoskeletal development and the ability of the musculoskeletal system to respond to loading. The justification for not exercising horses at a certain age is often in contrast to the scientific literature and framed, with incorrect generalizations, with human growth. This review provides a relative comparison of the growth and development of the horse to the descriptors used to define growth and development in humans. Measures of physeal closure and somatic growth demonstrate that the horse completes the equivalent of rapid infant growth by weaning (4–6 months old). At approximately 11 months old, the horse completes the equivalent of the childhood phase of growth and enters puberty. At 2 years old, the horse has achieved most measures of maturity used within the human literature, including the plateauing of vertical height, closure of growth plates, and adult ratios of back length:wither height and limb length:wither height. These data support the hypothesis that the horse evolved to be a precocious cursorial grazer and is capable of athletic activity, and use in sport, relatively early in life.
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Affiliation(s)
- Chris W. Rogers
- School of Veterinary Science, Massey University, Private Bag 11-222, Palmerston North 4442, New Zealand; (E.K.G.); (K.E.D.)
- School of Agriculture and Environment, Massey University, Private Bag 11-222, Palmerston North 4442, New Zealand
- Correspondence:
| | - Erica K. Gee
- School of Veterinary Science, Massey University, Private Bag 11-222, Palmerston North 4442, New Zealand; (E.K.G.); (K.E.D.)
| | - Keren E. Dittmer
- School of Veterinary Science, Massey University, Private Bag 11-222, Palmerston North 4442, New Zealand; (E.K.G.); (K.E.D.)
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14
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Guo M, Zemel BS, Hawkes CP, Long J, Kelly A, Leonard MB, Jaramillo D, Mostoufi-Moab S. Sarcopenia and preserved bone mineral density in paediatric survivors of high-risk neuroblastoma with growth failure. J Cachexia Sarcopenia Muscle 2021; 12:1024-1033. [PMID: 34184837 PMCID: PMC8350210 DOI: 10.1002/jcsm.12734] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/21/2021] [Accepted: 05/21/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Survival from paediatric high-risk neuroblastoma (HR-NBL) has increased, but cis-retinoic acid (cis-RA), the cornerstone of HR-NBL therapy, can cause osteoporosis and premature physeal closure and is a potential threat to skeletal structure in HR-NBL survivors. Sarcopenia is associated with increased morbidity in survivors of paediatric malignancies. Low muscle mass may be associated with poor prognosis in HR-NBL patients but has not been studied in these survivors. The study objective was to assess bone density, body composition and muscle strength in HR-NBL survivors compared with controls. METHODS This prospective cross-sectional study assessed areal bone mineral density (aBMD) of the whole body, lumbar spine, total hip, femoral neck, distal 1/3 and ultradistal radius and body composition (muscle and fat mass) using dual-energy X-ray absorptiometry (DXA) and lower leg muscle strength using a dynamometer. Measures expressed as sex-specific standard deviation scores (Z-scores) included aBMD (adjusted for height Z-score), bone mineral apparent density (BMAD), leg lean mass (adjusted for leg length), whole-body fat mass index (FMI) and ankle dorsiflexion peak torque adjusted for leg length (strength-Z). Muscle-specific force was assessed as strength relative to leg lean mass. Outcomes were compared between HR-NBL survivors and controls using Student's t-test or Mann-Whitney U test. Linear regression models examined correlations between DXA and dynamometer outcomes. RESULTS We enrolled 20 survivors of HR-NBL treated with cis-RA [13 male; mean age: 12.4 ± 1.6 years; median (range) age at therapy initiation: 2.6 (0.3-9.1) years] and 20 age-, sex- and race-matched controls. Height-Z was significantly lower in HR-NBL survivors compared with controls (-1.73 ± 1.38 vs. 0.34 ± 1.12, P < 0.001). Areal BMD-Z, BMAD-Z, FMI-Z, visceral adipose tissue and subcutaneous adipose tissue were not significantly different in HR-NBL survivors compared with controls. Compared with controls, HR-NBL survivors had lower leg lean mass-Z (-1.46 ± 1.35 vs. - 0.17 ± 0.84, P < 0.001) and strength-Z (-1.13 ± 0.86 vs. - 0.15 ± 0.71, P < 0.001). Muscle-specific force was lower in HR-NBL survivors compared with controls (P < 0.05). CONCLUSIONS Bone mineral density and adiposity are not severely impacted in HR-NBL survivors with growth failure, but significant sarcopenia persists years after treatment. Future studies are needed to determine if sarcopenia improves with muscle-specific interventions in this population of cancer survivors.
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Affiliation(s)
- Michelle Guo
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Babette S Zemel
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Colin P Hawkes
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jin Long
- Center for Artificial Intelligence in Medicine and Imaging, Stanford University, Stanford, CA, USA
| | - Andrea Kelly
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mary B Leonard
- Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Stanford University, Stanford, CA, USA
| | - Diego Jaramillo
- Department of Radiology, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Sogol Mostoufi-Moab
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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15
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Kamoun C, Hawkes CP, Grimberg A. Provocative growth hormone testing in children: how did we get here and where do we go now? J Pediatr Endocrinol Metab 2021; 34:679-696. [PMID: 33838090 PMCID: PMC8165022 DOI: 10.1515/jpem-2021-0045] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/08/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Provocative growth hormone (GH) tests are widely used for diagnosing pediatric GH deficiency (GHD). A thorough understanding of the evidence behind commonly used interpretations and the limitations of these tests is important for improving clinical practice. CONTENT To place current practice into a historical context, the supporting evidence behind the use of provocative GH tests is presented. By reviewing GH measurement techniques and examining the early data supporting the most common tests and later studies that compared provocative agents to establish reference ranges, the low sensitivity and specificity of these tests become readily apparent. Studies that assess the effects of patient factors, such as obesity and sex steroids, on GH testing further bring the appropriateness of commonly used cutoffs for diagnosing GHD into question. SUMMARY AND OUTLOOK Despite the widely recognized poor performance of provocative GH tests in distinguishing GH sufficiency from deficiency, limited progress has been made in improving them. New diagnostic modalities are needed, but until they become available, clinicians can improve the clinical application of provocative GH tests by taking into account the multiple factors that influence their results.
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Affiliation(s)
- Camilia Kamoun
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Colin Patrick Hawkes
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Adda Grimberg
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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16
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Hanley PC, Kanwar HS, Martineau C, Levine MA. Short Stature is Progressive in Patients with Heterozygous NPR2 Mutations. J Clin Endocrinol Metab 2020; 105:5877389. [PMID: 32720985 PMCID: PMC7442278 DOI: 10.1210/clinem/dgaa491] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 07/22/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND NPR2 encodes atrial natriuretic peptide receptor B (ANPRB), a regulator of skeletal growth. Biallelic loss-of-function mutations in NPR2 result in acromesomelic dysplasia Maroteaux type (AMDM; OMIM 602875), while heterozygous mutations may account for 2% to 6% of idiopathic short stature (ISS). OBJECTIVE Describe the physical proportions and growth characteristics of an extended family with novel NPR2 mutations including members with AMDM, ISS, or normal stature. DESIGN AND PARTICIPANTS We performed whole exome sequencing in 2 healthy parents and 2 children with AMDM. Detailed genotyping and phenotyping were performed on members of a multigenerational family in an academic medical center. We expressed mutant proteins in mammalian cells and characterized expression and function. RESULTS The sisters with AMDM were compound heterozygotes for missense mutations in the NPR2 gene, a novel p.P93S (maternal) and the previously reported p.R989L (paternal). Both mutant ANPRB proteins were normally expressed in HEK293T cells and exhibited dominant negative effects on wild-type ANPRB catalytic activity. Heterozygous relatives had proportionate short stature (height z-scores -2.06 ± 0.97, median ± SD) compared with their wild-type siblings (-1.37 ± 0.59). Height z-scores progressively and significantly decreased as NPR2-heterozygous children matured, while remaining constant in their wild-type siblings. CONCLUSIONS Biallelic NPR2 mutations cause severe skeletal dysplasia (AMDM), whereas heterozygous mutations lead to a subtler phenotype characterized by progressive short stature with by increasing loss of height potential with age.
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Affiliation(s)
- Patrick C Hanley
- Division of Endocrinology, Nemours Alfred I. duPont Hospital for Children, Wilmington, Delaware
- Correspondence and Reprint Requests: Patrick C. Hanley, MD, Division of Endocrinology, Nemours Alfred I. DuPont Hospital for Children, 1600 Rockland Rd, Wilmington, DE 19803. E-mail:
| | - Harsh S Kanwar
- Division of Endocrinology and Diabetes and Center for Bone Health, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Corine Martineau
- Division of Endocrinology and Diabetes and Center for Bone Health, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michael A Levine
- Division of Endocrinology and Diabetes and Center for Bone Health, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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17
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Hawkes CP, Mostoufi-Moab S, McCormack SE, Grimberg A, Zemel BS. Leg length and sitting height reference data and charts for children in the United States. Data Brief 2020; 32:106131. [PMID: 32904356 PMCID: PMC7452688 DOI: 10.1016/j.dib.2020.106131] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 07/30/2020] [Indexed: 11/15/2022] Open
Abstract
Population-specific reference data are required to interpret growth measurements in children. Sitting height and leg length (standing height minus sitting height) measurements are indicators of proportionality and can be used to evaluate children with disordered growth. NHANES III recorded sitting height and standing height measurements in a strategic random sample of the United States population from 1988 to 1994, and we have previously published reference charts for sitting height to standing height ratio in this population. In this study, we have developed separate sitting height and leg length reference charts for Non-Hispanic Black, Non-Hispanic White, and Mexican-American children in the United States. In addition, we provide mean (SD) and LMS data to support the use of these reference charts in clinical care.
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Affiliation(s)
- Colin Patrick Hawkes
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, USA.,Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Sogol Mostoufi-Moab
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, USA.,Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Shana E McCormack
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, USA.,Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Adda Grimberg
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, USA.,Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Babette S Zemel
- Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, USA.,Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, USA
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