Priority target conditions for algorithms for monitoring children's growth: Interdisciplinary consensus

Presentation and diagnosis of childhood-onset combined pituitary hormone deficiency: A single center experience from over 30 years

BACKGROUND

Childhood-onset combined pituitary hormone deficiency (CPHD) has a wide spectrum of etiologies and genetic causes for congenital disease. We aimed to describe the clinical spectrum and genetic etiologies of CPHD in a single tertiary center and estimate the population-level incidence of congenital CPHD.

METHODS

The retrospective clinical cohort comprised 124 CPHD patients (48 with congenital CPHD) treated at the Helsinki University Hospital (HUH) Children's Hospital between 1985 and 2018. Clinical data were collected from the patient charts. Whole exome sequencing was performed in 21 patients with congenital CPHD of unknown etiology.

FINDINGS

The majority (61%;76/124) of the patients had acquired CPHD, most frequently due to craniopharyngiomas and gliomas. The estimated incidence of congenital CPHD was 1/16 000 (95%CI, 1/11 000-1/24 000). The clinical presentation of congenital CPHD in infancy included prolonged/severe neonatal hypoglycaemia, prolonged jaundice, and/or micropenis/bilateral cryptorchidism in 23 (66%) patients; despite these clinical cues, only 76% of them were referred to endocrine investigations during the first year of life. The median delay between the first violation of the growth screening rules and the initiation of GH Rx treatment among all congenital CPHD patients was 2·2 years, interquartile range 1·2-3·7 years. Seven patients harbored pathogenic variants in PROP1, SOX3, TBC1D32, OTX2, and SOX2, and one patient carried a likely pathogenic variant in SHH (c.676G>A, p.(Ala226Thr)).

INTERPRETATION

Our study suggests that congenital CPHD can occur in 1/16 000 children, and that patients frequently exhibit neonatal cues of hypopituitarism and early height growth deflection. These results need to be corroborated in future studies and might inform clinical practice.

FUNDING

Päivikki and Sakari Sohlberg Foundation, Biomedicum Helsinki Foundation, and Emil Aaltonen Foundation research grants.

Evaluation and management of a child with short stature

Growth monitoring is a fundamental approach to evaluate a child's health and it is part of preventive programs to timely identify and treat a possible disease. Height and weight measurements, calculation of height velocity over time are main instruments to discover pathological deviations. Short stature is defined as a height that is greater than or equal 2 standard deviations (SDS) below the mean height for reference children comparable for sex and age. According to the International Classification of Pediatric Endocrine Diagnosis (ICPED) the possible causes of short stature could be divided into three groups: primary growth disorders (intrinsic diseases of the growth plate), secondary growth disorders (diseases that interfere on the growth plate setting) and the idiopathic short stature in which no possible cause is identified. The etiology of short stature is not always a disease, but it could be a variant of normal growth. Furthermore, to date there are new advances in the genetic causes of short stature. A detailed evaluation of a child with growth impairment should include an accurate history, a standardize physical examination, general and specific laboratory evaluations, radiologic investigations and genetic testing. Short stature could represent an important threat for physical and psychological health in a child, so a prompt identification of abnormal growth deviations offers the possibility to early treat the possible cause of shortness. This review aimed to discuss a practical approach to a child with short stature on the bases of the most recent scientific evidence.

Towards a Rational and Efficient Diagnostic Approach in Children Referred for Growth Failure to the General Paediatrician

Based on a recent Dutch national guideline, we propose a structured stepwise diagnostic approach for children with growth failure (short stature and/or growth faltering), aiming at high sensitivity for pathologic causes at acceptable specificity. The first step is a detailed clinical assessment, aiming at obtaining relevant clinical clues from the medical history (including family history), physical examination (emphasising head circumference, body proportions and dysmorphic features) and assessment of the growth curve. The second step consists of screening: a radiograph of the hand and wrist (for bone age and assessment of anatomical abnormalities suggestive for a skeletal dysplasia) and laboratory tests aiming at detecting disorders that can present as isolated short stature (anaemia, growth hormone deficiency, hypothyroidism, coeliac disease, renal failure, metabolic bone diseases, renal tubular acidosis, inflammatory bowel disease, Turner syndrome [TS]). We advise molecular array analysis rather than conventional karyotyping for short girls because this detects not only TS but also copy number variants and uniparental isodisomy, increasing diagnostic yield at a lower cost. Third, in case of diagnostic clues for primary growth disorders, further specific testing for candidate genes or a hypothesis-free approach is indicated; suspicion of a secondary growth disorder warrants adequate further targeted testing.

Comparative evaluation of neuroendocrine dysfunction in children with craniopharyngiomas before and after mass effects are removed

Objective To compare the effects of mass effects in situ (MEIS) and after neurosurgery (ANS) on neuroendocrine function in children with craniopharyngioma. Methods We retrospectively investigated 185 cases of children with craniopharyngioma who underwent neurosurgical treatment at the Beijing Tiantan Hospital from 2011 to 2016. The neuroendocrine function of patients was compared before and after tumor removal. Results Compared with the MEIS, the incidence of growth hormone insulin-like growth factor 1 axis dysfunction (47.03% vs. 57.30%), pituitary-thyroid axis dysfunction (20.00% vs. 50.27%), pituitary-adrenal axis dysfunction (18.38% vs. 43.78%) and diabetes insipidus (26.49% vs. 44.86%) was significantly increased in the ANS status. The incidence of hyperprolactinemia significantly decreased from 28.11% in the MEIS status to 20.54% in the ANS status. Compared with the MEIS group, changes in appetite, development of diabetes insipidus, body temperature dysregulation, sleeping disorders, personality abnormalities and cognitive abnormalities were more frequent after ANS, yet no statistically significant differences were found. Conclusions Endocrine dysfunction is common in children with craniopharyngioma. Both MEIS and ANS can be harmful to neuroendocrine function, and neurosurgical treatment may increase the level of neuroendocrine dysfunction.

Growth hormone therapy in children; research and practice - A review

Short stature remains the most common reason for referral to a pediatric Endocrinologist and its management remains a challenge. One of the main controversies is the diagnosis of idiopathic short stature and the role of new technologies for genetic investigation of children with inadequate growth. Complexities in management of children with short stature includes selection of who should receive interventions such as recombinant human growth hormone, and how should this agent dose be adjusted during treatment. Should anthropometrical data be the primary determinant or should biochemical and genetic data be used to improve growth response and safety? Furthermore, what is considered a suboptimal response to growth hormone therapy and how should this be managed? Treatment of children with short stature remains a "hot" topic and more data is needed in several areas. These issues are reviewed in this paper.

Algorithms to Define Abnormal Growth in Children: External Validation and Head-To-Head Comparison

BACKGROUND

Growth monitoring of apparently healthy children aims at early detection of serious conditions by use of both clinical expertise and algorithms that define abnormal growth. The seven existing algorithms provide contradictory definitions of growth abnormality and have a low level of validation.

OBJECTIVE

An external validation study with head-to-head comparison of the seven algorithms combined with study of the impact of use of the World Health Organization (WHO) vs national growth charts on algorithm performance.

DESIGN

With a case-referent approach, we retrospectively applied all algorithms to growth data for children with Turner syndrome, GH deficiency, or celiac disease (n = 341) as well as apparently healthy children (n = 3406). Sensitivity, specificity, and theoretical reduction in time to diagnosis for each algorithm were calculated for each condition by using the WHO or national growth charts.

RESULTS

Among the two algorithms with high specificity (>98%), the Grote clinical decision rule had higher sensitivity than the Coventry consensus (4.6% to 54% vs 0% to 8.9%, P < 0.05) and offered better theoretical reduction in time to diagnosis (median: 0.0 to 0.9 years vs 0 years, P < 0.05). Sensitivity values were significantly higher with the WHO than national growth charts at the expense of specificity.

CONCLUSION

The Grote clinical decision rule had the best performance for early detection of the three studied diseases, but its limited potential for reducing time to diagnosis suggests the need for better-performing algorithms based on appropriate growth charts.

Survey highlights important discrepancies between definitions of paediatric abnormal growth taught to medical students in 23 European countries

AIM

This study compared the definitions of abnormal growth that are taught across Europe to explain previously reported variations in growth-monitoring practices.

METHODS

We developed two online surveys in 2016 to obtain the definitions of abnormal growth in European countries and approached the national chairs of the European Confederation of Primary Care Paediatricians in 18 countries and the International Federation of Medical Students' Associations in 33 countries.

RESULTS

We obtained definitions from 10 of 18 paediatricians and 18 of 33 students, covering 23 of the 33 European countries surveyed. Abnormal faltering growth was always defined, either by a single parameter (24%) or combined parameters (76%). Four static parameters were used: standardised height (100%), standardised weight (60%), standardised body mass index (12%) and distance to target height (20%). Two dynamic parameters were used: growth deflection (28%) and growth velocity (32%). The thresholds used to define abnormal faltering growth varied slightly in some cases and widely in others. Abnormal accelerated growth appeared in 52% of the definitions, with important variations in parameters and thresholds.

CONCLUSION

There were important between-country discrepancies in the definitions of paediatric abnormal growth that were taught in 23 European countries. Standardisation is vital.