Delayed puberty in chronic illness

Management of endocrinological problems in children on home invasive mechanical ventilation

OBJECTIVE

Children with home invasive mechanical ventilation (HIMV) face numerous difficulties, including endocrine problems that can arise as a consequence of their condition. Endocrine problems seen in children treated with HIMV may develop due to the underlying disease, drugs used, or prolonged mechanical ventilation.

METHOD

This manuscript will review the most common endocrine problems encountered in children with HIMV, including problems in glucose metabolism, thyroid dysfunction, bone metabolism, adrenal dysfunctions, growth, and puberty.

CONCLUSION

Close monitoring, multidisciplinary care, and regular assessments are essential to optimize the endocrine system functions of children requiring home mechanical ventilation. By understanding these complications, it can develop effective management strategies to optimize the health and well-being of these vulnerable individuals.

Clinical practice guidelines for the care of girls and women with Turner syndrome

Turner syndrome (TS) affects 50 per 100 000 females. TS affects multiple organs through all stages of life, necessitating multidisciplinary care. This guideline extends previous ones and includes important new advances, within diagnostics and genetics, estrogen treatment, fertility, co-morbidities, and neurocognition and neuropsychology. Exploratory meetings were held in 2021 in Europe and United States culminating with a consensus meeting in Aarhus, Denmark in June 2023. Prior to this, eight groups addressed important areas in TS care: (1) diagnosis and genetics, (2) growth, (3) puberty and estrogen treatment, (4) cardiovascular health, (5) transition, (6) fertility assessment, monitoring, and counselling, (7) health surveillance for comorbidities throughout the lifespan, and (8) neurocognition and its implications for mental health and well-being. Each group produced proposals for the present guidelines, which were meticulously discussed by the entire group. Four pertinent questions were submitted for formal GRADE (Grading of Recommendations, Assessment, Development and Evaluation) evaluation with systematic review of the literature. The guidelines project was initiated by the European Society for Endocrinology and the Pediatric Endocrine Society, in collaboration with members from the European Society for Pediatric Endocrinology, the European Society of Human Reproduction and Embryology, the European Reference Network on Rare Endocrine Conditions, the Society for Endocrinology, and the European Society of Cardiology, Japanese Society for Pediatric Endocrinology, Australia and New Zealand Society for Pediatric Endocrinology and Diabetes, Latin American Society for Pediatric Endocrinology, Arab Society for Pediatric Endocrinology and Diabetes, and the Asia Pacific Pediatric Endocrine Society. Advocacy groups appointed representatives for pre-meeting discussions and the consensus meeting.

Factors associated with pubertal growth outcomes in cystic fibrosis: Early Growth and Puberty in CF

BACKGROUND

Pubertal delays in children with cystic fibrosis (CF) have historically been common. It is unclear to what degree puberty is affected in the new era of CF care or the role of early nutritional status. We hypothesized that more favorable early growth trajectories are associated with improved pubertal growth outcomes.

METHODS

We used data from the United States CF Foundation Patient Registry to analyze associations between early weight-for-length/body mass index (WFL-BMI) growth trajectories and pubertal outcomes, using peak height velocity (PHV) and age at PHV (APHV) as proxy measures for puberty in addition to adult height (defined as height at age 18 years). Our analysis consisted of shape invariant mixed modeling and multivariable linear regression.

RESULTS

Our sample consisted of 9,186 people with CF aged 18 to 21 years between 2010-2019. APHV was earliest and PHV/adult height were highest in those with WFL-BMI always >50th percentile from 0-6 years. However, there was no difference after adjusting for key covariates. Receiving CF transmembrane conductance regulator (CFTR) modulator therapy in childhood was associated with being taller at 18 years, by 0.92 cm in males (p=0.048) and 1.02 cm in females (p=0.010) in adjusted models. Higher height z-score at 2 years was associated with improved APHV and PHV for males and improved adult height for both males and females (p<0.001) in adjusted models.

CONCLUSIONS

Early height, but not early WFL-BMI trajectories, may be associated with pubertal growth outcomes. CFTR modulator therapy shows the potential to improve pubertal growth outcomes, but further research is necessary.

Pubertal origin of growth retardation in inborn errors of protein metabolism: A longitudinal cohort study

OBJECTIVES

Inherited amino-acid metabolism disorders (IAAMDs) require lifelong protein-restricted diet. We aimed to investigate: 1/ whether IAAMDs was associated with growth, pubertal, bone mineral apparent density (BMAD) or body composition impairments; 2/ associations linking height, amino-acid mixture (AAM), plasma amino-acids and IGF1 concentrations.

DESIGN

Retrospective longitudinal study of 213 patients with neonatal-onset urea cycle disorders (UCD,n = 77), organic aciduria (OA,n = 89), maple syrup urine disease (MSUD,n = 34), or tyrosinaemia type 1 (n = 13).

METHODS

We collected growth parameters, pubertal status, BMAD, body composition, protein-intake, and IGF1 throughout growth.

RESULTS

Overall final height (n = 69) was below target height (TH): -0.9(1.4) vs. -0.1(0.9) SD, p < 0.001. Final height was ≤ TH-2SD in 12 (21%) patients. Height ≤ - 2SD was more frequent during puberty than during early-infancy and pre-puberty: 23.5% vs. 6.9%, p = 0.002; and vs. 10.7%, p < 0.001. Pubertal delay was frequent (26.7%). Height (SD) was positively associated with isoleucine concentration: β, 0.008; 95%CI, 0.003 to 0.012; p = 0.001. In the pubertal subgroup, height (SD) was lower in patients with vs. without AAM supplementation: -1.22 (1.40) vs. -0.63 (1.46) (p = 0.02). In OA, height and median (IQR) isoleucine and valine concentrations(μmol/L) during puberty were lower in patients with vs. without AAM supplementation: -1.75 (1.30) vs. -0.33 (1.55) SD, p < 0.001; and 40 (23) vs. 60 (25) (p = 0.02) and 138 (92) vs. 191 (63) (p = 0.01), respectively. No correlation was found with IGF1. Lean-mass index was lower than fat-mass index: -2.03 (1.15) vs. -0.44 (0.89), p < 0.001.

CONCLUSIONS

In IAAMDs, growth retardation worsened during puberty which was delayed in all disease subgroups. Height seems linked to the disease, AAM composition and lower isoleucine concentration, independently of the GH-IGF1 pathway. We recommend close monitoring of diet during puberty.

Evaluation of malnutrition and screening tools in hospitalized children

BACKGROUND & AIMS

Detecting malnutrition and its related risk factors are crucial, in hospitalized children. Anthropometric z scores are used to assess malnutrition. Screening tools also aim to detect the presence of malnutrition and the developing risk of malnutrition in hospitalized children to determine who may benefit from nutritional support. Therefore, the aims of the study are to detect malnutrition and its related demographic and clinical risk factors in hospitalized children and determining the sensitivity of Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP) and Pediatric Yorkhill Malnutrition Score (PYMS) screening tools.

METHODS

A total of 130 hospitalized children aged between 0 and 18 years were included in to study. A survey including demographic and clinical characteristics, STAMP and PYMS were applied to parents of the children. Patients were classified into nutritional risk groups through screening tools. Anthropometric measurements (body weight, length/height, and middle upper arm circumference (MUAC) of the children were taken. Body mass index-for-age and height-for-age z scores were calculated to assess acute and chronic malnutrition prevalence. MUAC-for-age z scores were calculated as well. To detect independent risk factors for acute and chronic malnutrition multivariable logistic regression models were constructed.

RESULTS

A total of 14.6% of hospitalized children had acute malnutrition, 21.5% of children had chronic malnutrition and 27.7% of them had low MUAC standard deviation score (SDS) (less than -2). The independent risk factors for acute malnutrition were younger maternal age at birth and long length of stay (p < 0.05). The independent risk factors for chronic malnutrition were being female, younger maternal age at birth, longer illness duration and having urological or allergy and immunological diseases (p < 0.05). However, MUAC for age SDS groups were not related to any demographic and clinical factors, in children of all ages (p > 0.05). Regarding the screening tools, PYMS displayed 100% sensitivity against acute malnutrition. While PYMS displayed better sensitivity to identify acute malnutrition than STAMP, STAMP was more sensitive than PYMS to detect chronic malnutrition and low MUAC SDS.

CONCLUSIONS

Low MUAC for age SDS was not related to any demographic and clinical factors, in hospitalized children of all ages, unlike acute and chronic malnutrition, in this study. Pediatric screening tools mainly PYMS did not have high sensitivity to detect chronic malnutrition and low MUAC SDS, in hospitalized children. Therefore, the tools have to be used along with z scores of anthropometric parameters.

Long-term effects of asparaginase-associated pancreatitis

Pancreatitis is a common and severe toxicity that occurs during asparaginase treatment for acute lymphoblastic leukemia, and has received increasing attention during the last decades. However, no consensus regarding follow-up exists. In this commentary, we highlight potential long-term health-related effects following asparaginase-associated pancreatitis, thereby providing clinicians with a framework when following these patients during and after cessation of therapy.

Is early age at menarche associated with multimorbidity? Findings from the Azar Cohort study

AIMS

This study aimed to assess the association of age at menarche (AAM) with multimorbidity and chronic diseases.

METHODS

We used data regarding the reproductive history of 8,294 female participants of the Azar Cohort Study. A questionnaire assessed the participants' demographic information, reproductive history, personal behaviors, smoking status, socioeconomic status, activity status, and wealth score index.

RESULTS

Among 8,286 women included in the analysis, the AAM was < 12 years (early) in 648 (7.8%), 12-14 years (normal) in 4,911 (59.3%), and > 14 years (late) in 2,727 (32.9%) individuals. Early menarche was associated with a high risk of diabetes, obesity, and high WHR. On the other hand, late menarche was associated with higher rates of hypertension, stroke, and diabetes but a lower risk of MM, rheumatoid disease, obesity, abdominal obesity, and WHtR.

CONCLUSION

Changes in AAM have significant health implications. Factors predisposing individuals to early menarche and its consequences should be considered in chronic disease prevention strategies for adolescents and young adults.

Prevalence and Factors Associated With Delayed Puberty Among Adolescents on Boosted Protease Inhibitor-based Second-line Antiretroviral Therapy: A Cross-sectional Study at a Pediatric Infectious Diseases Clinic in Uganda

BACKGROUND

Delayed puberty is a recognized phenomenon among children living with HIV type 1 infection but has not been widely reported among adolescents on second-line or newer treatments in high burden settings. The study aimed to determine the prevalence of, and factors associated with delayed puberty among adolescents on boosted protease inhibitor-based second-line antiretroviral therapy (ART) in Uganda.

METHODS

Between December 2017 and May 2018, we conducted a cross-sectional study among adolescents living with HIV (ALWHIV) 10-19 years of age on atazanavir- and lopinavir-based regimens at the Paediatric Infectious Diseases Clinic, Kampala. Participants were on ART for at least 3 months and had a recent viral load. Sociodemographics, clinical measurements: body mass index for age Z score, height for age Z score, Tanner staging were collected. ART history was extracted from medical records. The outcome was delayed puberty defined as absence of signs of breast development in a girl 13 years of age or a testicular volume of less than 4 mL in a boy 14 years of age by Tanner staging, or an age for Tanner staging which was at least 2 standard deviations above the expected mean.

RESULTS

Among 230 perinatally infected ALWHIV participants, 14.7 ± 3.1 years of age were included, 54.9% were female, 5.2% were wasted and the median duration on ART was 9.5 years (interquartile range 7.3-11.7). The prevalence of delayed puberty was 8.7% (10.4% females, 6.7% males). Overall mean age estimates at different Tanner stages by sex were significantly higher than reference populations. Age at ART initiation (adjusted odds ratio 1.37, 95% confidence interval: 1.06-1.77) and body mass index for age Z score (adjusted odds ratio: 7.63, 95% confidence interval: 1.80-32.38) were associated with delayed puberty.

CONCLUSIONS

Timely initiation of ART and nutritional monitoring could optimize body weight and consequently, normal puberty for ALWHIV. Longitudinal studies could establish biological diagnoses and guide treatment of delayed puberty in this population.

Physical growth and sexual maturation of perinatally HIV-infected adolescent males in a southeast Nigerian tertiary hospital: a comparative cross-sectional study

Background

The advent of highly-active anti-retroviral therapy (HAART) has resulted in the survival of children with Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) into adolescence. Their prolonged survival has translated into co-morbidities like endocrine deficiencies which may manifest as growth and pubertal delay. This study aimed to determine the physical growth and sexual maturation of perinatally HIV-infected adolescent males and compare them with those of age-matched HIV-negative controls.

Methods

We conducted a comparative cross-sectional study of 104 perinatally HIV-infected males on HAART aged 10 to 19 years, and 104 age-matched HIV-negative males who served as controls. The subjects and controls were enrolled and assessed at a Nigerian tertiary hospital over six months. Anthropometric measurements such as weight, height, and BMI were obtained and Z scores for age were derived for weight, height, and BMI to determine physical growth using WHO AnthroPlus software. Sexual maturation was assessed using the method proposed by Marshall and Tanner. Data analysis and appropriate statistics were conducted with the Statistical Package for Social Sciences (SPSS) version 25 Chicago IL. A p-value < 0.05 was adopted as the level of statistical significance.

Results

The mean height, weight, and BMI Z scores of the subjects were all lower than those of the controls. The difference between the mean weight of the subjects (44.60 ± 13.32 kg) and the controls (49.97 ± 13.58 kg) was statistically significant (t = 2.88, p = 0.004). Similarly, the difference between the mean BMI Z-scores of the subjects (-0.96 ± 1.95) and the controls (-0.10 ± 0.86) was statistically significant (t = 4.10, p = < 0.001). The subjects showed a delay in pubic hair and testicular development for Stages 1, 2, and 3. Duration of HAART did not significantly affect the BMI of subjects who were in three groups: undernutrition, normal nutrition, and overnutrition (Kruskal-Wallis test, p = 0.30).

Conclusion

Perinatal HIV infection negatively affects physical growth and the onset of pubic-hair development (PH 2) despite the duration of HAART. We recommend that screening for weight deficit or pubertal delay should form part of the management protocol for HIV-infected male children on HAART.

A single-centre study on predictors and determinants of pubertal delay and growth impairment in Epidermolysis Bullosa

Background

Delayed puberty is a possible complication of Epidermolysis Bullosa (EB), though the actual incidence is still unknown. In chronic illnesses delayed puberty should be correctly managed since, if untreated, can have detrimental effects on adult height attainment, peak bone mass achievement and psychological health.

Aims and methods

This is a single-centre study on pubertal development, growth and bone status in EB. Auxological, densitometric (areal Bone Mineral Density-aBMD Z-score, Bone Mineral Apparent Density-BMAD Z-score, Trabecular Bone Score-TBS and Bone Strain Index-BSI at Lumbar spine) and body composition data (Total Body DXA scans) were collected. Disease severity was defined according to Birmingham Epidermolysis Bullosa Severity (BEBS) score.

Results

Twenty-one patients (12 Recessive Dystrophic EB-RDEB, 3 Dominant Dystrophic EB, 3 Junctional EB-JEB, 2 EB Simplex and one Kindler EB) aged 13 years (females) or 14 years (males) and above were enrolled (age 16.2±2.5 years, M/F 11/10). Short stature was highly prevalent (57%, mean height -2.12±2.05 SDS) with 55% patients with height <-2SD their mid-parental height. 7/21 patients (33%, 6 RDEB and 1 JEB) had delayed puberty with a median BEBS of 50 (range 29 to 63), a height SDS of -2.59 SDS (range -5.95 to -2.22) and a median lumbar BMAD Z-score of -4.0 SDS (range -5.42 to -0.63 SDS). Pubertal status was negatively associated with BEBS, skin involvement, inflammatory state and positively with height SDS and BMI SDS.

Conclusions

Pubertal delay is highly prevalent in EB, especially in patients with RDEB and JEB, high severity score and inflammatory state. Moreover, pubertal delay worsens growth impairment and bone health. A study on pubertal induction is ongoing to enlighten possible beneficial effects on adult height attainment and peak bone mass accrual.

Pubertal status of children with congenital heart disease

BACKGROUND

CHD influences many aspects of life in affected individuals. Puberty, a major aspect of development, is a concern for patients and families.

OBJECTIVES

We investigated pubertal status in children and adolescents with CHD.

METHODS

Patients with CHD aged 6-18 were enrolled. Cardiac diagnoses were confirmed using history, examination, and paraclinical tools including echocardiography. An endocrinologist determined pubertal stages, and the second Tanner stages for pubarche (P2), thelarche (B2), and gonadarche (G2) were considered as the pubertal onset. A study with a large sample size on pubertal onset in a normal population was used for comparison.

RESULTS

Totally, 451 patients (228 girls and 223 boys) at a median (10th-90th percentile) age of 10.79 (8.02-14.28) years for the girls and 10.72 (8.05-14.03) years for the boys were enrolled. The median (10th-90th percentile) ages at B2 and P2 in the girls with CHD were 10.77 (9.55-12.68) and 10.53 (9.39-12.28) years, respectively, which were higher than the median ages of 9.74 (8.23-11.94) and 10.49 (8.86-12.17) years in the normal girls.The median (10th-90th percentile) ages at G2 and P2 in the boys with CHD were 11.04 (8.85-13.23) and 11.88 (9.78-13.46) years, correspondingly, which were higher than the median ages of 9.01 (6.00-11.84) and 10.34 (6.84-13.10) years in the normal boys.

CONCLUSIONS

Pubertal onset could be delayed in children with CHD when compared with the normal population.

Growth and Pubertal Development Among HIV Infected and Uninfected Adolescent Girls in Lagos, Nigeria: A Comparative Cross-Sectional Study

This study aimed to compare growth and pubertal developmental parameters among HIV-infected and uninfected adolescent girls (11-19 years) in Lagos using a cross-sectional approach. Height, weight, BMI Z-scores, sexual maturity rating by Tanner stages and age at menarche, were compared in the 2 groups. The mean age was similar in both groups (13.2 [±2.3] years and 13.6 [±1.6] years for HIV positive and negative respectively [ P = .13]). Majority (66.2%) were in Junior Secondary classes and the mean socioeconomic class was 2.5 (±0.9). HIV-infected girls had significantly lower height, weight, and BMI Z scores compared to their uninfected counterparts. The proportion that had attained Tanner stages 3 to 5 were significantly lower among the HIV-positive participants. The study identified lower growth parameters and pubertal delay among HIV-infected adolescent females compared to HIV uninfected girls. Growth and sexual maturation assessment should form part of routine care of adolescents living with HIV.

Interpretation of reproductive hormones before, during and after the pubertal transition-Identifying health and disordered puberty

Puberty is a process of transition from childhood to adult reproductive capacity, governed by the reactivation of the hypothalamic-pituitary-gonadal axis after a long period of dormancy in mid-childhood. As such, the reproductive hormones are in a state of flux during the adolescent years, and interpretation of both the onset of healthy, concordant puberty and the differentiation of precocious, delayed or disordered puberty, can be challenging. This review is focused on the description of the endocrine axes in healthy puberty and the markers of disorders of puberty that can aid diagnosis and management for patients with these conditions. It will cover the hypothalamic, pituitary and gonadal hormone systems, the dynamic changes that occur during puberty, conditions leading to precocious, delayed or absent puberty and other syndromes with disordered puberty, and the biochemical diagnosis of these different disorders of puberty.

Early age at menarche is associated with post-menarche back pain: An analysis of the Raine Study

INTRODUCTION

Back pain (BP) experienced by females during adolescent years appears to predispose them to an increased likelihood of its presence in adulthood. Understanding this phenomenon by identifying risk factors of those at risk potentially fosters preventative strategies and effective treatments.

OBJECTIVES

To investigate for associations between post-menarche BP and low back pain (LBP) and age at menarche (AAM) in Australian adolescents using the Western Australian pregnancy cohort (The Raine Study).

METHODS

This study used data from a longitudinal cohort study. BP data were collected retrospectively using a questionnaire. Menarche data was split into three established age classifications early (<12-years), normal (≥12 to >14-years) and late (≥14-years). Logistic regression models examined the effect of AAM on BP.

RESULTS

666 female participants provided valid menarche data with 183 (27.5%) early AAM, 429 (64.4%) normal AAM and 54 (8.1%) with late AAM. The mean AAM was 12.59 years. BP was disclosed by 27.5% in the 14-year follow-up and 31.5% in the 17-year follow-up. Participants who had early AAM had 79% higher odds of experiencing BP compared to participants who had normal AAM, after adjusting for confounders at the 14-year follow-up (adjOR 1.79, 95% CI 1.18-2.64).

CONCLUSION

There is evidence of an association, in this cohort, of early AAM with post-menarche BP. This result identifies an area for future exploration, including understanding this mechanism which may lead to the development of effective intervention measures.

SIGNIFICANCE

Age at menarche is related to a range of health issues. This study sought to investigate if it was a risk factor for spinal pain. We used an existing Australian data base to explore this possibility and found an association with early age onset and post-menarche back pain. This result identifies an area for future exploration, including understanding this mechanism which may lead to the development of effective intervention measures.

Delayed age at menarche in chronic respiratory diseases

OBJECTIVE

Age at menarche (AAM) is an important indicator of physiological development in women, and delayed AAM has been associated with chronic illnesses. We investigated predictive factors at diagnosis that influence AAM in adolescents with chronic respiratory diseases.

STUDY DESIGN

AAM was assessed in 1207 northern Italian female aged 11-24 (1062 healthy, 98 with asthma and 47 with cystic fibrosis [CF]). AAM was defined by recall and status quo methods. We studied anthropometric data, metabolic status, diagnosis parameters, presence of irregular menses. Clinical data of subjects with chronic respiratory illness were compared with that of healthy adolescents.

RESULTS

Mean AAM for healthy adolescents was 12.49 ± 1.2 years. Mother's AAM was positively associated with that of their daughters (P < .001). BMI was negatively correlated with AAM (P < .001). 69% of healthy adolescents referred regular menses. AAM in the different groups was 12.79 ± 3.0 years for patients with asthma (P < .05 vs healthy) and 13.24 ± 1.44 years for adolescents with CF (P < .0001 vs healthy). In the asthmatic group, 57% of the patients referred regular menses, and no significant differences were found between AAM and control of the disease (ACT test). In the CF group, no correlation was found between the type of CFTR mutation or FEV1% and AAM. 53% of the patients with CF referred regular menses.

CONCLUSIONS

AAM in patients with CF and asthma was significantly higher than in healthy adolescents, and menses abnormalities were observed in the last two groups. Inflammation influences the reproductive function in chronic respiratory disease.

Testosterone Use in Adolescent Males: Current Practice and Unmet Needs

Testosterone replacement therapy (TRT) is routinely prescribed in adolescent males with constitutional delay of growth and puberty (CDGP) or hypogonadism. With many new testosterone (T) formulations entering the market targeted for adults, we review current evidence and TRT options for adolescents and identify areas of unmet needs. We searched PubMed for articles (in English) on testosterone therapy, androgens, adolescence, and puberty in humans. The results indicate that short-term use of  T enanthate (TE) or oral  T undecanoate is safe and effective in inducing puberty and increasing growth in males with CDGP. Reassuring evidence is emerging on the use of transdermal  T to induce and maintain puberty. The long-term safety and efficacy of TRT for puberty completion and maintenance have not been established. Current  TRT regimens are based on consensus and expert opinion, but evidence-based guidelines are lacking. Limited guidance exists on when and how  T should be administered and optimal strategies for monitoring therapy once it is initiated. Only  TE and  T pellets are US Food and Drug Administration approved for use in adolescent males in the United States. Despite the introduction of a wide variety of new  T formulations, they are designed for adults, and their metered doses are difficult to titrate in adolescents. In conclusion, TRT in adolescent males is hindered by lack of long-term safety and efficacy data and limited options approved for use in this population. Additional research is needed to identify the route, dose, duration, and optimal timing for TRT in adolescents requiring androgen therapy.

The effect of celiac disease and gluten-free diet on pubertal development: a two-center study

Objectives We aimed to assess whether age at menarche and pubertal development (Tanner stage) are related to gluten-free diet (GFD) adherence, hormonal status, micro-nutrient levels and body mass index (BMI) in children with celiac disease (CD). Methods In this two-center, cross-sectional study, CD patients and healthy individuals were studied. CD patients were re-evaluated after 1 year of follow-up. Height, weight, Tanner stage, age at menarche and diet compliance were recorded. Blood samples for anti-tissue transglutaminase IgA (TTG), pituitary gonadotropins, gonadal hormones, prolactin and micronutrients (folate, vitamin B12, vitamin D, ferritin, iron and, iron-binding capacity [IBC]) were assayed. Results Consecutive age- and sex-matched 228 celiac patients (12.92 ± 2.35 years; 67.9% female) and 135 non-celiac healthy individuals (12.77 ± 2.25 years; 65.2% female) were studied. Tanner stage was significantly higher in the control group for both girls and boys (p < 0.05). The mean age at menarche was significantly lower in healthy individuals (13.13 ± 1.01 vs. 12.15 ± 0.97, p < 0.001). By multivariate analysis, GFD adherence, transferrin saturation (sTrf), total IBC (TIBC) and vitamin D status were found to be positively correlated with Tanner stage (p < 0.05). After 1 year, 192 of the CD patients were re-evaluated. GFD compliance was better (TTG levels: 135.59 ± 73.88 vs. 71.53 ± 69.40, p < 0.001) and it was correlated with Tanner stage (r = 0.49, p < 0.01), sTrf (r = 0.66, p < 0.01) and IBC (r = 0.23, p < 0.05). Conclusions Our data show that adequate weight gain, adherence to GFD, sufficient iron and vitamin D status are essential factors for salubrious puberty in CD patients.

Height and sexual maturation in girls with juvenile idiopathic arthritis

OBJECTIVE

To evaluate height, sexual maturation, and the difference between final and expected height in girls with juvenile idiopathic arthritis and no glucocorticoid treatment for at least six months, as compared to a group of healthy girls.

METHODS

This cross-sectional study involved 44 girls with juvenile idiopathic arthritis, diagnosed according to the International League of Associations for Rheumatology criteria, and 59 healthy controls aged between 8 and 18 (incomplete) years with no comorbid chronic diseases. Demographic data were collected from all participants, and disease and treatment variables were compiled for the patient group. Anthropometric measurements were converted into Z-scores based on World Health Organization standards. Sexual maturation was classified according to Tanner stages.

RESULTS

Body mass index and height Z-scores were lower in girls with juvenile idiopathic arthritis as compared to control participants. These values differed significantly in Tanner stage II. Three (6.8%) girls with juvenile idiopathic arthritis had height-for-age Z-scores <-2 (short stature). Girls with polyarticular juvenile idiopathic arthritis and higher cumulative glucocorticoid doses were significantly more likely to present with short stature. The percentage of prepubertal girls in the juvenile idiopathic arthritis group was significantly higher than that observed in the control group, (p=0.012). Age of menarche, adult height, and the difference between actual and expected height did not differ between groups.

CONCLUSION

These findings suggest that even six months after the suspension of glucocorticoid treatment, children with polyarticular/systemic juvenile idiopathic arthritis subtypes are still susceptible to low height and delayed puberty.

Delayed Puberty-Phenotypic Diversity, Molecular Genetic Mechanisms, and Recent Discoveries

This review presents a comprehensive discussion of the clinical condition of delayed puberty, a common presentation to the pediatric endocrinologist, which may present both diagnostic and prognostic challenges. Our understanding of the genetic control of pubertal timing has advanced thanks to active investigation in this field over the last two decades, but it remains in large part a fascinating and mysterious conundrum. The phenotype of delayed puberty is associated with adult health risks and common etiologies, and there is evidence for polygenic control of pubertal timing in the general population, sex-specificity, and epigenetic modulation. Moreover, much has been learned from comprehension of monogenic and digenic etiologies of pubertal delay and associated disorders and, in recent years, knowledge of oligogenic inheritance in conditions of GnRH deficiency. Recently there have been several novel discoveries in the field of self-limited delayed puberty, encompassing exciting developments linking this condition to both GnRH neuronal biology and metabolism and body mass. These data together highlight the fascinating heterogeneity of disorders underlying this phenotype and point to areas of future research where impactful developments can be made.

Body Changes and Decreased Sexual Drive after Dialysis: A Qualitative Study on the Experiences of Women at an Ambulatory Dialysis Unit in Spain

Chronic kidney disease (CKD) has considerable effects on the quality of life of patients, impairing everyday activities and leading to lifestyle changes, as well as affecting body image and intimate relationships. Our aim was to describe the experience of female patients with CKD at an ambulatory dialysis unit regarding body changes and sexuality. A qualitative phenomenological study exploring how 18 female patients, treated at the dialysis unit of a Spanish hospital, perceived their sexuality and intimate relationships. Data were collected using in-depth interviews, researcher field notes, and patients’ personal letters. A thematic analysis was performed. Four main themes arose from the data describing the experience of how CKD impacts body changes and sexuality: (a) Accepting body changes, (b) The catheter, the fistula, and body image, (c) Experiencing a different sexuality, and (d) The catheter, the fistula, and sexuality. Patients experienced changes in their body, perceiving it as being bloated or deformed, together with overall decline. The catheter and/or the fistula triggered changes in the way the women dress in an attempt to hide port sites. Women experience sexuality changes, affecting sexual desire and satisfaction. The presence of catheters was found to be the most cumbersome during sexual acts.

Pediatric Sarcopenia: A Paradigm in the Overall Definition of Malnutrition in Children?

BACKGROUND

Malnutrition is a common complication in children with chronic diseases. Sarcopenia is one component of malnutrition, characterized by reduced skeletal muscle mass (SMM) and muscle function. The presence of sarcopenia is associated with adverse outcomes in children. Although there is growing research interest in sarcopenia, no review has been done on this novel concept in pediatrics. The purpose of this review was to explore current evidence in sarcopenia with and without obesity and to evaluate the knowledge gaps in the assessment of childhood sarcopenia.

METHODS

A total of 12 articles retrieved from PubMed or Web of Science databases were included.

RESULTS

Limited studies have elucidated sarcopenia in pediatrics. Challenges in sarcopenia assessment include heterogeneity in definition and absence of standardized body composition methods used to measure SMM and muscle function tests. There is a lack of age-specific and gender-specific normative data for SMM, particularly in young children and infants. None of the studies incorporated muscle function assessment, causing potential bias and misclassification of sarcopenia. The research in childhood sarcopenia is also hampered by low study quality, limited number of outcomes-based research, and lack of longitudinal data.

CONCLUSION

Consensus needs to be reached in methodological approaches in sarcopenia diagnosis, body composition measurements, and age-appropriate muscle function tests in pediatrics. Careful considerations on growth, neurocognitive status, and factors influencing development in various clinical populations are warranted. Early identification of sarcopenia is crucial to enable targeted treatment and prevention to be carried out across the pediatric clinical populations.

Natural Killer and Natural Killer T Cells in Juvenile Systemic Lupus Erythematosus: Relation to Disease Activity and Progression

The contribution of innate immune cells, including natural killer (NK) and natural killer T (NKT) cells, in systemic lupus erythematosus (SLE) is still unclear. Herein, we examined the frequency of peripheral NK cells, CD56^dim and CD56^bright NK cells, and NKT cells in patients with juvenile SLE and their potential relations to SLE-related clinical and laboratory parameters. The study included 35 SLE children and 20 apparently healthy controls. After baseline clinical and lab work, SLE Disease Activity Index (SLEDAI-2K) and Pediatric Systemic Lupus International Collaborative Clinics/American College of Rheumatology (SLICC/ACR) Damage Index (Ped-SDI) scores were assessed. The frequency of peripheral NK cells, CD56^dim and CD56^bright NK cells, and NKT cells was examined using flow cytometry. SLE patients showed significantly lower frequency of NK cells and NKT cells and higher frequency of CD56^bright NK cells compared to controls. Disease activity, urea, and creatinine correlated negatively with NK, but positively with CD56^bright NK cells. NK and NKT cells exhibited inverse correlation with the renal biopsy activity index; however, CD56^bright NK cells showed direct correlations with both activity and chronicity indices. Regarding Ped-SDI, renal, neuropsychiatry disorders, and growth failure correlated inversely with NK but directly with CD56^bright NK cells. NKT cell inversely correlated with renal damage and delayed puberty. In conclusion, low frequency of NK and NKT and expansion of CD56^bright NK cells are marked in juvenile SLE, particularly with activity. These changes have direct effect on renal impairment and growth failure, reflecting their potential influence on disease progression.

Environmental lead exposure and pubertal trajectory classes in South African adolescent males and females

The effects of environmental lead exposure in the neuro-endocrine system have been shown to impact the maturation and tempo of puberty development in adolescents. In low and middle income countries very little is known regarding the detrimental health effects of childhood lead exposure with regard to the tempo of puberty development. To help address this gap in data, we examined the association between lead exposure and puberty progression in males and females. Study participants from the urban Birth to Twenty Plus (BT20+) birth cohort in Soweto-Johannesburg, South Africa with data for blood lead levels at age 13years, cord blood lead levels, pubic hair development and breast development in females, and pubic hair development and genital development in males, were included in this study. The sample comprised 1416 study participants (n=684 females). Pubertal development trajectory classes were defined using Latent Class Growth Analysis. Data were examined for (i) an association between cord blood lead levels and pubertal trajectory classes; and (ii) an association between blood lead levels at age 13years and pubertal trajectory classes. In females, there was an association between adolescent elevated blood lead levels (≥5μg/dL) and lower level of maturation at age 9years and slower progression of pubic hair and breast development (relative risk ratio (RRR)=0.45, p<0.0001; 95% CI (0.29-0.68)) and (RRR=0.46, p<0.01; 95% CI (0.27-0.77)), respectively. In males, elevated blood lead levels at birth were associated with slower tempo of pubic hair development (RRR=0.20, p<0.05). Findings from this study suggest a possible role for environmental lead in altering pubertal development in South African adolescents as shown by slower tempo of progression through the Tanner stages pubertal development in females and males. There were also gender-differences between the effects of prenatal and postnatal lead exposure during pubertal development.

Preserved white matter microstructure in young patients with anorexia nervosa?

A massive but reversible reduction of cortical thickness and subcortical gray matter (GM) volumes in Anorexia Nervosa (AN) has been recently reported. However, the literature on alterations in white matter (WM) volume and microstructure changes in both acutely underweight AN (acAN) and after recovery (recAN) is sparse and results are inconclusive. Here, T1-weighted and diffusion-weighted MRI data in a sizable sample of young and medication-free acAN (n = 35), recAN (n = 32), and age-matched female healthy controls (HC, n = 62) were obtained. For analysis, a well-validated global probabilistic tractography reconstruction algorithm including rigorous motion correction implemented in FreeSurfer: TRACULA (TRActs Constrained by UnderLying Anatomy) were used. Additionally, a clustering algorithm and a multivariate pattern classification technique to WM metrics to predict group membership were applied. No group differences in either WM volume or WM microstructure were detected with standard analysis procedures either in acAN or recAN relative to HC after controlling for the number of performed statistical tests. These findings were not affected by age, IQ, or psychiatric symptoms. While cluster analysis was unsuccessful at discriminating between groups, multivariate pattern classification showed some ability to separate acAN from HC (but not recAN from HC). However, these results were not compatible with a straightforward hypothesis of impaired WM microstructure. The current findings suggest that WM integrity is largely preserved in non-chronic AN. This finding stands in contrast to findings in GM, but may help to explain the relatively intact cognitive performance of young patients with AN and provide the basis for the fast recovery of GM structures. Hum Brain Mapp 37:4069-4083, 2016. © 2016 Wiley Periodicals, Inc.

Energetics and the immune system: Trade-offs associated with non-acute levels of CRP in adolescent Gambian girls

Background and objectives: The human immune system is an ever-changing composition of innumerable cells and proteins, continually ready to respond to pathogens or insults. The cost of maintaining this state of immunological readiness is rarely considered. In this paper we aim to discern a cost to non-acute immune function by investigating how low levels of C-reactive protein (CRP) relate to other energetic demands and resources in adolescent Gambian girls.

Methodology: Data from a longitudinal study of 66 adolescent girls was used to test hypotheses around investment in immune function. Non-acute (under 2 mg/L) CRP was used as an index of immune function. Predictor variables include linear height velocity, adiposity, leptin, and measures of energy balance.

Results: Non-acute log CRP was positively associated with adiposity (β = 0.16, P < 0.001, R² = 0.17) and levels of the adipokine leptin (β = 1.17, P = 0.006, R² = 0.09). CRP was also negatively associated with increased investment in growth, as measured by height velocity (β = −0.58, P < 0.001, R² = 0.13) and lean mass deposition β = −0.42, P = 0.005, R² = 0.08). Relationships between adiposity and growth explained some, but not all, of this association. We do not find that CRP was related to energy balance.

Conclusions and implications: These data support a hypothesis that investment in non-acute immune function is facultative, and sensitive to energetic resources and demands. We also find support for an adaptive association between the immune system and adipose tissue.

Effect of Lipopolysaccharide (LPS) Exposure on the Reproductive Organs of Immature Female Rats

Lipopolysaccharide (LPS), an endotoxin, elicits strong immune responses in mammals. Several lines of evidence demonstrate that LPS challenge profoundly affects female reproductive function. For example, LPS exposure affects steroidogenesis and folliculogenesis, resulting in delayed puberty onset. The present study was conducted to clarify the mechanism underlying the adverse effect of LPS on the delayed puberty in female rats. LPS was daily injected for 5 days (50 μg/kg, PND 25-29) to treated animals and the date at VO was evaluated through daily visual examination. At PND 39, animals were sacrificed, and the tissues were immediately removed and weighed. Among the reproductive organs, the weights of the ovaries and oviduct from LPS-treated animals were significantly lower than those of control animals. There were no changes in the weights of uterus and vagina between the LPS-treated and their control animals. Immunological challenge by LPS delayed VO. Multiple corpora lutea were found in the control ovaries, indicating ovulations were occurred. However, none of corpus luteum was present in the LPS-treated ovary. The transcription level of steroidogenic acute regulatory protein (StAR), CYP11A1, CYP17A1 and CYP19 were significantly increased by LPS treatment. On the other hand, the levels of 3β- HSD, 17β-HSD and LH receptor were not changed by LPS challenge. In conclusion, the present study demonstrated that the repeated LPS exposure during the prepubertal period could induce multiple alterations in the steroidogenic machinery in ovary, and in turn, delayed puberty onset. The prepubertal LPS challenge model used in our study is useful to understand the reciprocal regulation of immune (stress) - reproductive function in early life.

Earlier Menarche Is Associated with Lower Insulin Sensitivity and Increased Adiposity in Young Adult Women

OBJECTIVE

We aimed to assess whether age at menarche was associated with insulin sensitivity in young adult women.

METHODS

We studied 54 healthy young women aged 20-30 years. Participants were grouped according to age at menarche: Early (≤11.0 years; n=13), Average (>12.0 and ≤13.0 years; n=28), and Late (≥14.0 years, n=13). Primary outcome was insulin sensitivity measured using intravenous glucose tolerance tests and Bergman's minimal model. Body composition was assessed using whole-body dual-energy X-ray absorptiometry.

RESULTS

Earlier menarche was associated with lower insulin sensitivity (p=0.015). There was also a continuous increase in adiposity with younger age at menarche, which was associated with increased weight (p=0.001), BMI (p=0.002), total body fat (p=0.049), and truncal fat (p=0.020). Stratified analyses showed that insulin sensitivity in Early women (5.5 x10-4·min-1(mU/l)) was lower than in Average (8.0 x10-4·min-1(mU/l), p=0.021) and Late (8.6 x10-4·min-1(mU/l), p=0.033) groups. Early women (weight=66.1 kg; BMI=24.1 kg/m2) were considerably heavier and fatter than Average (59.0 kg, p=0.004; 21.4 kg/m2, p=0.002) and Late (57.0 kg, p=0.001; 20.8 kg/m2, p=0.0009) women.

CONCLUSIONS

Early menarche is associated with lower insulin sensitivity and increased adiposity in young adulthood, potentially increasing the risk of type 2 diabetes and the metabolic syndrome later in life.

Pubertal induction in hypogonadism: Current approaches including use of gonadotrophins

Primary disorders of the gonad or those secondary to abnormalities of the hypothalamic pituitary axis result in hypogonadism. The range of health problems of childhood and adolescence that affect this axis has increased, as most children now survive chronic illness, but many have persisting deficits in gonadal function as a result of their underlying condition or its treatment. An integrated approach to hormone replacement is needed to optimize adult hormonal and bone health, and to offer opportunities for fertility induction and preservation that were not considered possible in the past. Timing of presentation ranges from birth, with disorders of sexual development, through adolescent pubertal failure, to adult fertility problems. This review addresses diagnosis and management of hypogonadism and focuses on new management strategies to address current concerns with fertility preservation. These include Turner syndrome, and fertility presevation prior to childhood cancer treatment. New strategies for male hormone replacement therapy that may impinge upon future fertility are emphasized.

Injury response checkpoint and developmental timing in insects

In insects, localized tissue injury often leads to global (organism-wide) delays in development and retarded metamorphosis. In Drosophila, for example, injuries to the larval imaginal discs can retard pupariation and prolong metamorphosis. Injuries induced by treatments such as radiation, mechanical damage and induction of localized cell death can trigger similar delays. In most cases, the duration of the developmental delay appears to be correlated with the extent of damage, but the effect is also sensitive to the developmental stage of the treated animal. The proximate cause of the delays is likely a disruption of the ecdysone signaling pathway, but the intermediate steps leading from tissue injury and/or regeneration to that disruption remain unknown. Here, we review the evidence for injury-induced developmental delays, and for a checkpoint or checkpoints associated with the temporal progression of development and the on-going efforts to define the mechanisms involved.

Risk of metabolic bone disease is increased both during and after weaning off parenteral nutrition in pediatric intestinal failure

AIM

To assess bone health in pediatric intestinal failure (IF).

METHODS

A population-based cohort of 41 IF patients (age 9.9 years) underwent evaluation of bone mineral density (BMD), bone biochemistry, nutritional status and growth. Eleven patients remained on parenteral nutrition (PN) after 69 months. Thirty had weaned off PN 9.0 years earlier (mean), i.e. after 30 months on PN.

RESULTS

The majority of patients had lumbar spine or femoral BMD Z-score ≤-1.0 (70%), vitamin D deficiency (serum 25-hydroxyvitamin-D, S-25-OHD, <50 nmol/l, 41%) or secondary hyperparathyroidism (plasma parathyroid hormone >47 ng/l, 44%), equally during and after weaning off PN. Hyperparathyroidism was absent when S-25-OHD was >80 nmol/l. Until puberty, height (-1.4 to -0.8, age 1-12) and weight Z-scores (-1.3 to -0.5, age 1-16) were below the normal mean (p < 0.05). Small bowel length associated with S-25-OHD levels (r = 0.489, p = 0.013). In a multivariate model, time after weaning off PN (β = -0.597, p = 0.001), duration of PN (β = -0.466, p = 0.006) and calcium intake (β = -0.331, p = 0.035) predicted decreased lumbar spine BMD.

CONCLUSIONS

In pediatric IF, vitamin D insufficiency, secondary hyperparathyroidism and decreased BMD are common. BMD, vitamin D, calcium and nutritional status should be closely monitored during and after weaning off PN to ensure sufficient vitamin D and mineral substitution for normal growth and bone mass attainment.

Nutritional status of tribal children and adolescents in rural south India: the effect of an NGO delivered nutritional programme

OBJECTIVES

To investigate the prevalence of malnutrition using anthropometric measures in a cohort of tribal students attending a school in rural south India. Children attending the school were offered three meals a day during attendance. Analysis of anthropometric data obtained aimed to determine the nutritional effect of the food provided.

METHODS

The nutritional status of 409 students were assessed by comparing anthropometric measurements to reference values according to WHO/NCHS guidelines. Height for age <3rd percentile was defined as stunting. BMI for age <5th percentile was defined as thinness. 'New' students were defined as attending the school for <1 y. 'Old' students were defined as being in attendance for ≥ 1 y. Comparison of thinness and stunting prevalence in these groups enabled evaluation of the meals provided by the organisation.

RESULTS

Four hundred and nine students were included for analysis in the study. The prevalence of thinness was 39.4 %. 59.5 % of 'new' and 52.9 % of 'old' students at the school demonstrated thinness. 59.4 % of students were classified as stunted. 73.8 % of 'new' students and 52.9 % of 'old' students demonstrated stunting (p 0.091). Significantly (p 0.010) more 'new' female students had stunted growth.

CONCLUSIONS

Acute and chronic measures of malnutrition were high amongst adolescent students attending the school. Comparison of 'new' and 'old' adolescent pupils at the school hints that the 'old' students were less malnourished than their 'new' counterparts. This study demonstrates the importance for NGOs to develop their nutritional programmes with a special focus on adolescents.

Menarche in pediatric patients with Crohn's disease

BACKGROUND AND AIMS

The timing of menarche in Crohn's disease (CD) is poorly described. Our objectives were to study age at menarche onset in CD, and factors associated with this.

METHODS

We compared the age at menarche of 34 CD patients with that for 545 controls, using data in the National Health and Nutrition Examination Survey (NHANES).

RESULTS

Mean chronological age (CA) of CD patients (15.6 years) did not differ from that of the NHANES cohort (15.7 years; P = 0.91). The median CA at menarche (13.9 years) in CD was older than in the NHANES sample (12.0 years) (P < 0.00005). In CD patients, the cumulative incidence of menarche was 10 % at CA 12 years, 51 % at CA 14 years, and 100 % at CA 16 years. Sixty-eight percent reached menarche by bone age (BA) 13.5 years and 100 % by BA greater than 14.0 years. Menarche occurred earliest in South Asians, followed by East Asians, and then Caucasians (P = 0.02).

CONCLUSIONS

CA at menarche is delayed in CD compared with the NHANES cohort. BA at menarche in CD is similar to BA at menarche reported for healthy children. CA at menarche in CD differs by race. If menarche has not occurred by BA greater than 14.0 years, endocrinology referral should be considered.

Total pubertal growth in patients with juvenile idiopathic arthritis treated with growth hormone: analysis of a single center

OBJECTIVES

Growth failure is a permanent sequelae in juvenile idiopathic arthritis (JIA). The aim of the study was to compare pubertal growth in control and growth hormone (GH) treated JIA subjects.

DESIGN

64 children with JIA at a mean age of 10.38 ± 2.80 years were enrolled and followed until final height (measured in standard deviation (SD) scores). 39 children (20 m) received GH therapy and 24 (9 m) served as controls. GH dose was 0.33 mg/kg/week. Linear regression analysis was performed to identify factors influencing total pubertal growth.

RESULTS

Mean total pubertal growth was 21.1 ± 1.3 cm (mean ± SD) in GH treated JIA patients and 13.8 ± 1.5 cm in controls. Final height was significantly higher with GH treatment (-1.67 ± 1.20 SD) compared to controls (-3.20 ± 1.84 SD). Linear regression model identified age at onset of puberty (ß=-4.2,CI: -5.9, -2.6 in controls and ß=-2.3,CI: -3.6, -1.1 in GH treated) as the main factor for total pubertal growth. Final height SDS was determined by the difference to target height at onset of puberty (ß=-0.59;CI: -0.80, -0.37 in controls and ß=-0.30,CI: -0.52, -0.08 in GH treated), age at onset of puberty (ß=0.47;CI:0.02,0.93 in controls and 0.23;CI: -0.00,0.46 in GH treated) and height gain during puberty (ß=0.13;CI:0.05,0.21 in controls and ß=0.11;CI:0.07,0.16 in GH treated).

CONCLUSION

Total pubertal growth in JIA patients treated with GH was increased by a factor of 1.5 greater in comparison to controls leading to a significantly better final height. To maximize final height GH treatment should be initiated early to reduce the height deficit at onset of puberty.

Puberty development among children and adolescents with chronic disease in Saudi Arabia

BACKGROUND AND OBJECTIVES

Increasing numbers of children with chronic health conditions are now surviving into adolescence and adulthood because of advancing health care. These chronic health conditions are generally known to impact a child's growth and development, including pubertal development. In Saudi Arabia, chronic diseases are prevalent, yet no reports of pubertal onset and its relation to chronic illness are available. The aim of this study was to explore pubertal development among Saudi children and adolescents with a chronic illness.

DESIGN AND SETTING

Cross-sectional study conducted at schools in Riyadh, Saudi Arabia in 2006.

SUBJECTS AND METHODS

Those students whose parents reported that their son/daughter had a chronic illness and/or was taking a long-term medication underwent a physical examination to determine sexual maturity rating and growth parameters.

RESULTS

Of 1371 students who participated in the study, 155 (11.3%) had a chronic illness. Of those, 79 (51%) were male, and the mean SD age of all the students was 11.4 (2.4) years. Ninety (58%) students were taking medication for their health condition. Bronchial asthma was reported to be the most common chronic condition (n=66; 42.6%), followed by blood disorders (n=41; 26.5%). Fifty-three (34%) students were overweight or obese. For male gonadal (G) development, the mean age of boys with G stage 2 was 11.7 years; stage 3: 13.5 years; stage 4: 14.1 years; and stage 5: 14.6 years. For female breast (B) development, the mean age of girls with B stage 2 was 10.7 years; stage 3: 11.3 years; stage 4: 12.4 years; and stage 5: 14.1 years. The pubic hair development for both boys and girls was similar to the corresponding gonadal or breast development, respectively.

CONCLUSIONS

The age of onset of pubertal development for both boys and girls with a chronic illness are within normal limits. The high prevalence of overweight and obesity may contribute to this phenomenon, yet further studies should consider the effects of disease severity and chronicity and medication use as possible confounders.

Damage index in childhood-onset systemic lupus erythematosus in Egypt

BACKGROUND

To investigate the prevalence of cumulative organ damage among Egyptian children with juvenile-onset systemic lupus erythematosus (jSLE) and the relationships between the organ damage and the demographic data, clinical variables, and disease activity.

METHODS

A total of 148 patients with jSLE have been followed in the pediatric rheumatology clinic and section at Cairo University. These patients were evaluated by retrospective chart review. The organ system damage due to SLE was measured using the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI). Risk factors for damage were also studied including demographic criteria as well as clinical and laboratory manifestations.

RESULTS

Overall, 43.9% of the patients had damage within a mean of 6.57 ± 3.59 years of disease diagnosis. Neuropsychiatric (NPS-21%) and renal (16.9%) system involvement were observed most frequently, followed by cardiovascular (11.5%), skin (9.5%), pulmonary (6.1%), and ocular (4.8%), with a mean SDI score of 0.93 ± 1.37. In our study, the presence of neuropsychiatric manifestations at diagnosis showed the strongest association with the presence of later disease damage.The number of SLE diagnostic criteria at presentation was strongly associated with the total SDI score, and the renal damage was significantly more prevalent in patients with age at disease diagnosis below 10 years of age. A higher mean disease duration was found in patients with musculoskeletal damage.

CONCLUSION

We found that cumulative organ damage, as measured by the SDI, was present in 43.9% of Egyptian patients with juvenile-onset SLE. The damage was significantly more likely in patients who had more SLE diagnostic criteria at time of disease presentation and NPS manifestations at the time of diagnosis.

Long-term impact of infantile short bowel syndrome on nutritional status and growth

Short-term bowel adaptation has been documented, but data on long-term effects are scarce. The aim of the present study was to evaluate the long-term consequences of infantile short bowel syndrome (SBS). A cross-sectional assessment (2005–7) of growth, nutritional status, defecation pattern and health status in individuals with a history of infantile SBS, born between 1975 and 2002, were performed. Data were compared with reference values of healthy controls and presented as means and standard deviations or median and ranges. A total of forty subjects (sixteen male and twenty-four female; mean age 14·8 (sd 6·8) years) had received parenteral nutrition during a median of 110 (range 43–2345) d, following small bowel resection. The mean standard deviation scores (SDS) for weight for height and target height (TH) of the children were normal; mean SDS for height for age was − 0·9 (sd 1·3). The median BMI adults was 19·9 (range 17–26) kg/m2; mean SDS for height for age was − 1·0 (range − 2·5 to 1·5). Height in general was significantly shorter than TH, and 53 % of children and 78 % of adults were below TH range. Most subjects had normal body fat percentage (%BF). SDS for total body bone mineral density were generally normal. The SDS for bone mineral content (BMC) of the children were − 1·0 (sd 1·1). Mean energy intake was 91 % of the estimated average requirements. The frequencies of defecation and bowel complaints of the subjects were significantly higher than in healthy controls. In conclusion, infantile SBS results in shorter stature than was expected from their calculated TH. BMC was lower than reference values, but the subjects had normal weight for height and %BF.

Osteopenia and osteoporosis in epidermolysis bullosa

Patients with the more severe forms of epidermolysis bullosa (EB) are at risk of developing osteopenia, osteoporosis and fractures. The cause is likely to be multifactorial and includes reduced mobility, a generally proinflammatory state, poor nutrition and hormonal factors. Monitoring this group with dual energy X-ray absorptiometry (DEXA) scans and plain radiographs is necessary to detect these changes. Data are lacking about the optimal approach to managing poor bone health in EB, although it seems that encouraging mobility, supplementation of calcium and vitamin D where necessary, with the addition of a bisphosphonate when there is evidence of fractures, may be helpful.

Growth and pubertal delay in patients with epidermolysis bullosa

Puberty is the acquisition of secondary sexual characteristics, associated with a growth spurt, resulting in the attainment of reproductive function and final adult height. Delayed puberty is defined as the absence of any pubertal development at an age 2 standard deviations (SD) more than the mean, which corresponds to an age of approximately 14 years for boys and 13 years for girls. The degree to which growth and pubertal development are affected in chronic illness depends on the disease itself, as well as factors such as age of onset, duration and severity; the earlier the onset and the more severe the disease, the greater the effect on growth and pubertal development. Most children with severe types of epidermolysis bullosa have abnormal growth and pubertal delay. The possible pathophysiology is discussed.

Extracutaneous manifestations and complications of inherited epidermolysis bullosa: part II. Other organs

It is well known, primarily via case reports and limited case series, that nonepithelial tissues may become injured in patients with epidermolysis bullosa. Only recently, however, have there been data generated from large, well characterized cohorts. Our objective is to provide dermatologists with a comprehensive review of each of these major extracutaneous complications, with a summary of the pertinent literature and evidence-based recommendations for surveillance, evaluation, and management. Some epidermolysis bullosa subtypes are at risk for severe injury of the bone marrow, musculoskeletal system, heart, kidney, and teeth, and for the development of squamous cell carcinoma, basal cell carcinoma, or malignant melanoma. If untreated, significant morbidity or mortality may result.

Association of the timing of puberty with a chromosome 2 locus

CONTEXT

Twin studies indicate that the timing of pubertal onset is under strong genetic control. However, genes controlling pubertal timing in the general population have not yet been identified.

OBJECTIVE

To facilitate the identification of genes influencing the timing of pubertal growth and maturation, we conducted linkage mapping of constitutional delay of growth and puberty (CDGP), an extreme variant of normal pubertal timing, in extended families.

PARTICIPANTS AND METHODS

Fifty-two families multiply affected with CDGP were genotyped with 383 multiallelic markers. CDGP was defined based on growth charts (the age at onset of growth spurt, peak height velocity, or attaining adult height taking place at least 1.5 sd later than average). Chromosomal regions cosegregating with CDGP were identified with parametric affected-only linkage analysis using CDGP as a dichotomized trait.

RESULTS

The genome-wide scan detected linkage of CDGP to a region on chromosome 2p13-2q13. The two-point heterogeneity LOD (HLOD) score was 1.62 (alpha = 0.27), and the corresponding multipoint HLOD was 2.54 (alpha = 0.31). Fine-mapping the region at 1 cM resolution increased the multipoint HLOD score to 4.44 (alpha = 0.41). The linkage became weaker if family members diagnosed with CDGP without growth data were also included in the analyses.

CONCLUSIONS

The pericentromeric region of chromosome 2 harbors a gene predisposing to pubertal delay in multiply affected pedigrees. Our data suggest that this locus may be a component of the internal clock controlling the timing of the onset of puberty.

The role of sex steroids in controlling pubertal growth

Longitudinal growth, which is primarily due to chondrocytic activity at the level of the epiphyseal growth plate, is influenced by many hormones and growth factors in an endocrine and paracrine manner. Their influence is even more complex during the accelerated growth period of puberty that accounts for about 20% of final adult height. Although abnormalities of growth during puberty are very common, the underlying mechanisms that govern the beginning and cessation of pubertal growth at the level of the growth plate are poorly understood. Sex steroids play a crucial role in pubertal growth both at the systemic level via the GH/IGF-1 axis and at the local level of the epiphyseal growth plate. In both sexes it is now accepted that oestrogen is the critical hormone in controlling growth plate acceleration and fusion. This paper reviews the mechanisms that influence pubertal growth and the problems that are associated with disorders of gonadal function.