Progressive diastolic dysfunction in survivors of pediatric differentiated thyroid carcinoma

BACKGROUND

Pediatric differentiated thyroid cancer (DTC) has an excellent prognosis but unknown late effects of treatment. The initial cardiac evaluation showed subclinical diastolic dysfunction in 20% of adult survivors. The objective of this follow-up study was to determine the clinical course of this finding.

METHODS

This multicenter study, conducted between 2018 and 2020, re-evaluated survivors after 5 years. The primary endpoint was echocardiographic diastolic cardiac function (depicted by the mean of the early diastolic septal and early diastolic lateral tissue velocity (e' mean)). Secondary endpoints were other echocardiographic parameters and plasma biomarkers.

RESULTS

Follow-up evaluation was completed in 47 (71.2%) of 66 survivors who had completed their initial evaluation. Of these 47 survivors, 87.2% were women. The median age was 39.8 years (range: 18.8-60.3), and the median follow-up after the initial diagnosis was 23.4 years (range: 10.2-48.8). Between the first and second evaluation, the e' mean significantly decreased by 2.1 cm/s (s.d. 2.3 cm/s, P < 0.001). The median left ventricular ejection fraction did not significantly change (58.0% vs 59.0%, P= NS). In the best explanatory model of e' mean, multivariate linear regression analysis showed that BMI and age were significantly associated with e' mean (β coefficient: -0.169, 95% CI: -0.292; -0.047, P = 0.008 and β coefficient: -0.177, 95% CI: -0.240; -0.113, P < 0.001, respectively).

CONCLUSIONS AND RELEVANCE

In these relatively young survivors of pediatric DTC, diastolic function decreased significantly during 5-year follow-up and is possibly more pronounced than in normal aging. This finding requires further follow-up to assess clinical consequences.

Regional variation in lifestyle patterns and BMI in young children: the GECKO Drenthe cohort

BACKGROUND

A better understanding of lifestyle behaviours of children < 7 years and the relation with childhood overweight is needed. The aim of our prospective study was to examine how lifestyle patterns in young children are associated with the development of childhood overweight. As ecological models suggest focusing on not only the child as an individual, but also their environment, we also considered the role of socio-economic status (SES) and spatial clustering of lifestyle and body mass index (BMI).

METHODS

In 1792 children (aged 3-6 years) participating in the GECKO Drenthe cohort, diet, screen time, outdoor play and sleep were assessed by questionnaires and moderate-to-vigorous physical activity and sedentary time by accelerometry (Actigraph GT3X). At 10-11 years, height and weight were measured to calculate age- and sex-specific standardized BMI z-scores (zBMI). Lifestyle patterns were identified using principal component analysis. To assess spatial clustering for the lifestyle patterns and zBMI, we calculated the Global Moran's I statistic. Linear- and logistic regression models, taking into account SES, were performed to examine the association between the lifestyle patterns and the development of overweight. For the spatial analyses, we added spatial terms for the determinants, the outcome, and the error term.

RESULTS

Three lifestyle patterns were identified: (1) 'high activity', (2) 'low screen time, high sleep and healthy diet', and (3) 'high outdoor play'. No associations were observed between the 'high activity' or 'high outdoor play' patterns at young age with the development of childhood overweight (all p > 0.05). In contrast, children who adhered to the 'low screen time, high sleep and healthy diet' pattern had lower odds to become overweight and a lower zBMI at 10-11 years (odds ratio [95% CI] = 0.766 [0.65; 0.90]). These findings remained similar after taking SES into account. Regarding the spatial analyses, we found spatial clustering of zBMI, but no spatial clustering of the lifestyle patterns.

CONCLUSIONS

Low screen time, high sleep duration and a healthy diet cluster into a pattern that seems favourable in the prevention of childhood overweight, independent of individual SES. The spatial analyses suggest that there are likely other neighbourhood factors that contribute to the spatial clustering of childhood overweight.

Optimizing the Timing of Highest Hydrocortisone Dose in Children and Adolescents With 21-Hydroxylase Deficiency

CONTEXT

Hydrocortisone treatment of young patients with 21-hydroxylase deficiency (21OHD) is given thrice daily, but there is debate about the optimal timing of the highest hydrocortisone dose, either mimicking the physiological diurnal rhythm (morning), or optimally suppressing androgen activity (evening).

OBJECTIVE

We aimed to compare 2 standard hydrocortisone timing strategies, either highest dosage in the morning or evening, with respect to hormonal status throughout the day, nocturnal blood pressure (BP), and sleep and activity scores.

METHODS

This 6-week crossover study included 39 patients (aged 4-19 years) with 21OHD. Patients were treated for 3 weeks with the highest hydrocortisone dose in the morning, followed by 3 weeks with the highest dose in the evening (n = 21), or vice versa (n = 18). Androstenedione (A4) and 17-hydroxyprogesterone (17OHP) levels were quantified in saliva collected at 5 am; 7 am; 3 pm; and 11 pm during the last 2 days of each treatment period. The main outcome measure was comparison of saliva 17OHP and A4 levels between the 2 treatment strategies.

RESULTS

Administration of the highest dose in the evening resulted in significantly lower 17OHP levels at 5 am, whereas the highest dose in the morning resulted in significantly lower 17OHP and A4 levels in the afternoon. The 2 treatment dose regimens were comparable with respect to averaged daily hormone levels, nocturnal BP, and activity and sleep scores.

CONCLUSION

No clear benefit for either treatment schedule was established. Given the variation in individual responses, we recommend individually optimizing dose distribution and monitoring disease control at multiple time points.

Bone Mineral Density in Adult Survivors of Pediatric Differentiated Thyroid Carcinoma: A Longitudinal Follow-Up Study

Background: Survivors of pediatric differentiated thyroid carcinoma (DTC) receive thyrotropin-suppressive therapy to minimize disease recurrence. However, knowledge about long-term effects of subclinical hyperthyroidism on bone mineral density (BMD) in pediatric DTC survivors is scarce, as is the information regarding long-term consequences of permanent hypoparathyroidism on BMD. We evaluated BMD in pediatric DTC survivors and investigated if BMD was affected by subclinical hyperthyroidism and/or permanent hypoparathyroidism during long-term follow-up. Methods: In this nationwide longitudinal study, we determined BMD in the lumbar spine and femur by dual energy X-ray absorptiometry in 65 pediatric DTC survivors. Measurements were repeated after minimal 5 years of follow-up in 46 pediatric DTC survivors. BMD results were evaluated according to the recommendations of the International Society for Clinical Densitometry (ISCD) and WHO. At both visits, we determined biochemical parameters and markers of bone resorption (C-terminal telopeptide of type I collagen [β-CTX]) and formation (N-propeptide of type I collagen [PINP] and osteocalcin). Results: First and second BMD measurements were done after a median follow-up of 17.0 (interquartile range [IQR] 8.0-25.0) and 23.5 (IQR 14.0-30.0) years after diagnosis, respectively. Median age at diagnosis was 15 years (IQR 13.0-17.0). Twenty-nine percent of the survivors had subclinical hyperthyroidism. In most survivors, BMD T- and Z-scores were within the reference range during both BMD evaluations. However, after 23.5 years of follow-up, a low BMD was found in 13.0%. In the 13 survivors with permanent hypoparathyroidism, BMD values did not differ after 5 years of follow-up compared with baseline values or in comparison with the 33 survivors without permanent hypoparathyroidism. During follow-up, turnover markers β-CTX and PINP remained stable. Conclusions: This longitudinal study of pediatric DTC survivors demonstrated normal and stable median lumbar spine and femur BMD values after a median time of 17 and 23.5 years after diagnosis. However, compared with controls, a lower BMD was still found in 13.0% after prolonged follow-up despite intensive follow-up. Based on the studied follow-up period, these data do not provide convincing evidence in support of standard monitoring of bone mass among DTC survivors, but may be restricted to individual cases at low frequency. Trial Registration: This follow-up study was registered in The Netherlands Trial Register under no. NL3280 (www.trialregister.nl/trial/3280).

Second-tier Testing for 21-Hydroxylase Deficiency in the Netherlands: A Newborn Screening Pilot Study

CONTEXT

Newborn screening (NBS) for classic congenital adrenal hyperplasia (CAH) consists of 17-hydroxyprogesterone (17-OHP) measurement with gestational age-adjusted cutoffs. A second heel puncture (HP) is performed in newborns with inconclusive results to reduce false positives.

OBJECTIVE

We assessed the accuracy and turnaround time of the current CAH NBS algorithm in comparison with alternative algorithms by performing a second-tier 21-deoxycortisol (21-DF) pilot study.

METHODS

Dried blood spots (DBS) of newborns with inconclusive and positive 17-OHP (immunoassay) first HP results were sent from regional NBS laboratories to the Amsterdam UMC Endocrine Laboratory. In 2017-2019, 21-DF concentrations were analyzed by LC-MS/MS in parallel with routine NBS. Diagnoses were confirmed by mutation analysis.

RESULTS

A total of 328 DBS were analyzed; 37 newborns had confirmed classic CAH, 33 were false-positive and 258 were categorized as negative in the second HP following the current algorithm. With second-tier testing, all 37 confirmed CAH had elevated 21-DF, while all 33 false positives and 253/258 second-HP negatives had undetectable 21-DF. The elevated 21-DF of the other 5 newborns may be NBS false negatives or second-tier false positives. Adding the second-tier results to inconclusive first HPs reduced the number of false positives to 11 and prevented all 286 second HPs. Adding the second tier to both positive and inconclusive first HPs eliminated all false positives but delayed referral for 31 CAH patients (1-4 days).

CONCLUSION

Application of the second-tier 21-DF measurement to inconclusive first HPs improved our CAH NBS by reducing false positives, abolishing the second HP, and thereby shortening referral time.

New national recommendations for the treatment of pediatric differentiated thyroid carcinoma in the Netherlands

BACKGROUND

Currently, there are no European recommendations for the management of pediatric thyroid cancer. Other current international guidelines are not completely concordant. In addition, medical regulations differ between, for instance, the US and Europe. We aimed to develop new, easily accessible national recommendations for differentiated thyroid carcinoma (DTC) patients <18 years of age in the Netherlands as a first step toward a harmonized European Recommendation.

METHODS

A multidisciplinary working group was formed including pediatric and adult endocrinologists, a pediatric radiologist, a pathologist, endocrine surgeons, pediatric surgeons, pediatric oncologists, nuclear medicine physicians, a clinical geneticist and a patient representative. A systematic literature search was conducted for all existing guidelines and review articles for pediatric DTC from 2000 until February 2019. The Appraisal of Guidelines, Research and Evaluation (AGREE) instrument was used for assessing quality of the articles. All were compared to determine dis- and concordances. The American Thyroid Association (ATA) pediatric guideline 2015 was used as framework to develop specific Dutch recommendations. Discussion points based upon expert opinion and current treatment management of DTC in children in the Netherlands were identified and elaborated.

RESULTS

Based on the most recent evidence combined with expert opinion, a 2020 Dutch recommendation for pediatric DTC was written and published as an online interactive decision tree (www.oncoguide.nl).

CONCLUSION

Pediatric DTC requires a multidisciplinary approach. The 2020 Dutch Pediatric DTC Recommendation can be used as a starting point for the development of a collaborative European recommendation for treatment of pediatric DTC.

Long-Term Effects of Radioiodine Treatment on Female Fertility in Survivors of Childhood Differentiated Thyroid Carcinoma

Background: Differentiated thyroid carcinoma (DTC) during childhood is a rare disease. Its excellent survival rate requires a focus on possible long-term adverse effects. This study aimed to evaluate fertility in female survivors of childhood DTC by assessing various reproductive characteristics combined with anti-Müllerian hormone (AMH) levels (a marker of ovarian reserve). Methods: Female survivors of childhood DTC, diagnosed at ≤18 years of age between 1970 and 2013, were included. Survivors were excluded when follow-up time was less than five years or if they developed other malignancies before or after diagnosis of DTC. Survivors filled out a questionnaire regarding reproductive characteristics (e.g., age at menarche and menopause, pregnancies, pregnancy outcomes, need for assisted reproductive therapy). Survivors aged <18 years during evaluation received an altered questionnaire without questions regarding pregnancy and pregnancy outcomes. These data were combined with information from medical records. AMH levels were measured in serum samples and were compared with AMH levels from 420 women not treated for cancer. Results: Fifty-six survivors with a median age of 31.0 (interquartile range, IQR, 25.1-39.6) years were evaluated after a median follow-up of 15.4 (IQR 8.3-24.7) years. The median cumulative dose of ¹³¹I administered was 7.4 (IQR 3.7-13.0) GBq/200.0 (IQR 100.0-350.0) mCi. Twenty-five of the 55 survivors aged 18 years or older during evaluation reported 64 pregnancies, 45 of which resulted in live birth. Of these 55, 10.9% visited a fertility clinic. None of the survivors reported premature menopause. Age at AMH evaluation did not differ between DTC survivors and the comparison group (p = 0.268). Median AMH levels did not differ between DTC survivors and the comparison group [2.0 (IQR 1.0-3.7) μg/L vs. 1.6 (IQR 0.6-3.1) μg/L, respectively, p = 0.244]. The cumulative dose of ¹³¹I was not associated with AMH levels in DTC survivors (r_s = 0.210, p = 0.130). Conclusions: Female survivors of DTC who received ¹³¹I treatment during childhood do not appear to have major abnormalities in reproductive characteristics nor in predictors of ovarian failure.

Growth in CHARGE syndrome: optimizing care with a multidisciplinary approach

CHARGE (Coloboma of the eye, Heart defects, Atresia of the choanae, Retardation of growth and/or development, Genital hypoplasia, Ear anomalies including hearing loss) syndrome is a rare syndrome with an incidence of approximately 1:15,000 newborns. It is caused by pathogenic variants in the CHD7 gene and clinically characterized by a wide range of anomalies with variable expression. Growth retardation affects 60-72% of children with CHARGE syndrome, making it one of the most prominent medical issues in the syndrome. Growth retardation in CHARGE syndrome is thought to be multifactorial and can be influenced by almost all co-morbidities, requiring a multidisciplinary approach to the different medical problems. In this systematic review, we describe what is currently known about growth in CHARGE syndrome and how it is influenced by commonly seen clinical problems including feeding difficulties, hypogonadotropic hypogonadism and growth hormone deficiency. Furthermore, we provide recommendations for a multidisciplinary approach.

Prevalence of growth hormone (GH) deficiency in previously GH-treated young adults with Prader-Willi syndrome

OBJECTIVE

Some features of subjects with Prader-Willi syndrome (PWS) resemble those seen in growth hormone deficiency (GHD). Children with PWS are treated with growth hormone (GH), which has substantially changed their phenotype. Currently, young adults with PWS must discontinue GH after attainment of adult height when they do not fulfil the criteria of adult GHD. Limited information is available about the prevalence of GHD in adults with PWS. This study aimed to investigate the GH/insulin-like growth factor (IGF-I) axis and the prevalence of GHD in previously GH-treated young adults with PWS.

DESIGN

Cross-sectional study in 60 young adults with PWS.

MEASUREMENTS

Serum IGF-I and IGFBP-3 levels, GH peak during combined growth hormone-releasing hormone (GHRH)-arginine stimulation test.

RESULTS

Serum IGF-I was <-2 standard deviation scores (SDS) in 2 (3%) patients, and IGFBP-3 was within the normal range in all but one patient. Median (IQR) GH peak was 17.8 μg/L (12.2; 29.7) [~53.4 mU/L] and below 9 μg/L in 9 (15%) patients. Not one patient fulfilled the criteria for adult GHD (GH peak < 9 μg/L and IGF-I < -2 SDS), also when BMI-dependent criteria were used. A higher BMI and a higher fat mass percentage were significantly associated with a lower GH peak. There was no significant difference in GH peak between patients with a deletion or a maternal uniparental disomy (mUPD).

CONCLUSIONS

In a large group of previously GH-treated young adults with PWS, approximately 1 in 7 exhibited a GH peak <9 μg/L during a GHRH-arginine test. However, none of the patients fulfilled the consensus criteria for adult GHD.

An analysis of body proportions in children with CHARGE syndrome using photogrammetric anthropometry

Background

Growth retardation is one of the main hallmarks of CHARGE syndrome (CS), yet little is known about the body proportions of these children. Knowledge of body proportions in CS may contribute to a better characterization of this syndrome. This knowledge is important when considering starting growth‐stimulating therapy.

Methods

For this cross‐sectional study, we selected 32 children with CS and a CHD7 mutation at the Dutch CHARGE Family Day in 2016 or 2017 and the International CHARGE conference in Orlando, Florida, in 2017. We used photogrammetric anthropometry—a measurement method based on digital photographs—to determine various body proportions. We compared these to measurements in 21 normally proportioned children with growth hormone deficiency, using independent‐samples t test, Mann–Whitney U test, or chi‐square test as appropriate.

Results

Children with CS appear to have a shorter trunk in proportion to their height, head length, and arm length. Children with CS also had smaller feet proportional to tibia length compared to controls. The change of body proportions with age was similar in children with CS and controls.

Conclusion

Body proportions in children with CS are significantly different from those of normally proportioned controls, but a similar change of body proportions with age was noted for both groups.

Long-term effects of radioiodine treatment on salivary gland function in adult survivors of pediatric differentiated thyroid carcinoma

Pediatric differentiated thyroid cancer (DTC) is a rare disease. Initial treatment of DTC consists of a (near) total thyroidectomy and radioactive iodine (131I) therapy. Previous studies in adults showed that 131I treatment may result in a reduced salivary gland function. Studies regarding salivary gland function in children treated for DTC are sparse. Our aim was to assess long-term effects of 131I treatment on salivary gland function in survivors of pediatric DTC. Methods: In a nationwide cross-sectional study, salivary gland function of patients treated for pediatric DTC between 1970 and 2013 (>5 years after diagnosis, ≥18 years old at time of evaluation) was studied. Salivary gland function was assessed by sialometry, sialochemistry and a xerostomia inventory. Salivary gland dysfunction was defined as unstimulated whole saliva flow ≤0.2mL/min and/or a stimulated whole saliva flow ≤0.7 mL/min. Results: Sixty-five patients (median age at evaluation 33 [IQR, 25-40] years, 86.2% female, median follow-up period 11 [IQR, 6-22] years) underwent 131I treatment. Median cumulative 131I activity was 5.88 [IQR, 2.92-12.95] GBq, 47.7% underwent multiple 131I administrations. Salivary gland dysfunction was present in 30 (47.6%) patients. Levels of amylase and total protein in saliva were reduced. Moderate to severe xerostomia was present in 22 (35.5%) patients. Stimulated salivary secretion was lower and severity of xerostomia complaints higher in patients treated with higher cumulative 131I activity. Conclusion: In survivors of pediatric DTC, clinically significant salivary gland dysfunction was found in 35.5% and was related to the cumulative 131I activity of the treatment.

Effect of a multidisciplinary treatment program on eating behavior in overweight and obese preschool children

BACKGROUND

The effects of multidisciplinary treatment programs on eating behavior in overweight preschool-aged children are largely unknown. We evaluated a multidisciplinary intervention program on eating behavior in 3- to 5-year-old overweight children, comparing them with children given standard treatment. We also assessed the parental eating behavior changes and investigated associations between parents and children.

METHODS

We randomized 75 children to a multidisciplinary intervention or to a standard care program. During a 16-week period, children and parents in the multidisciplinary group were given dietary advice, physical activity sessions and, for parents only, psychological counseling. Children and parents in the standard group visited a pediatrician 3 times and were given information on a healthy lifestyle. At baseline, after 16 weeks, and after 12 months, children were measured and parents completed the Dutch Child Eating Behavior Questionnaire (DEBQ-C) for their children and the DEBQ for themselves.

RESULTS

At the three time points, 70 (93.3%), 57 (91.9%), and 42 (73.7%) DEBQ-Cs were analyzed. We found no differences in the changes in eating behavior between the two groups over time. In both groups, there was a significant increase in restrained eating behavior present at 16 weeks, however, this was no longer present at 12 months. We found no associations between changes in eating behavior between the children and their parents.

CONCLUSIONS

A multidisciplinary obesity intervention program in preschool-aged children induced more restrained eating behavior between baseline and 16 weeks. However, there was no difference with the children in the standard care group.

Psychosocial development in survivors of childhood differentiated thyroid carcinoma: a cross-sectional study

OBJECTIVE

The impact of childhood differentiated thyroid carcinoma (DTC) on psychosocial development has not yet been studied. The aim of this study was to evaluate the achievement of psychosocial developmental milestones in long-term survivors of childhood DTC.

DESIGN AND METHODS

Survivors of childhood DTC diagnosed between 1970 and 2013 were included. Reasons for exclusion were age <18 or >35 years at follow-up, a follow-up period <5 years or diagnosis with DTC as a second malignant neoplasm. Survivors gathered peer controls of similar age and sex (n = 30). A comparison group non-affected with cancer (n = 508) and other childhood cancer survivors (CCS) were also used to compare psychosocial development. To assess the achievement of psychosocial milestones (social, autonomy and psychosexual development), the course of life questionnaire (CoLQ) was used.

RESULTS

We included 39 survivors of childhood DTC (response rate 83.0%, mean age at diagnosis 15.6 years, and mean age at evaluation 26.1 years). CoLQ scores did not significantly differ between survivors of childhood DTC and the two non-affected groups. CoLQ scores of childhood DTC survivors were compared to scores of other CCS diagnosed at similar ages (n = 76). DTC survivors scored significantly higher on social development than other CCS, but scores were similar on autonomy and psychosexual developmental scales.

CONCLUSIONS

Survivors of childhood DTC showed similar development on social, autonomy, and psychosexual domains compared to non-affected individuals. Social development was slightly more favorable in DTC survivors than in other CCS, but was similar on autonomy and psychosexual domains.

Diastolic Dysfunction is Common in Survivors of Pediatric Differentiated Thyroid Carcinoma

INTRODUCTION

Whether pediatric patients with differentiated thyroid carcinoma (DTC) are at risk of developing treatment-related adverse effects on cardiac function is unknown. We therefore studied in long-term survivors of pediatric DTC the prevalence of cardiac dysfunction and atrial fibrillation in relation to treatment variables, and the association between cardiac dysfunction and plasma biomarkers.

METHODS

In this nationwide prospective multicenter study, cardiac assessments were performed in 66 adult survivors of pediatric DTC (age at diagnosis ≤18 years and follow-up ≥5 years after diagnosis) treated in the Netherlands between 1970 and 2009. Assessment included echocardiography, plasma biomarkers (N-terminal pro-brain natriuretic peptide, high-sensitive troponin-T, galectin-3), and 24-hour Holter electrocardiography. Echocardiographic measurements were compared with retrospective data of 66 sex- and age-matched unaffected Dutch controls. Diastolic dysfunction was defined as an early diastolic septal and/or lateral tissue velocity (e') less than 2 SD of mean age-adjusted reference data.

RESULTS

The survivors (86.4% women) had at DTC diagnosis a median age of 16 years. Median follow-up was 17 years. Left ventricular ejection fraction <50% was found in one survivor, and median global longitudinal systolic strain was near normal. Diastolic dysfunction was present in 14 asymptomatic survivors (21.2%). Overall, diastolic function of survivors was lower compared with controls (e'mean 14.5 versus 15.8 cm/s, P = 0.006). Older attained age and higher waist circumference were associated with decreased diastolic function, whereas thyrotropin levels and cumulative administered radioiodine dose were not. In survivors, biomarkers were not associated with diastolic dysfunction; atrial fibrillation was not observed.

CONCLUSION

While systolic function is unaffected, diastolic dysfunction is frequently observed in asymptomatic long-term survivors of pediatric DTC, which may suggest early cardiac aging.

Long-Term Quality of Life in Adult Survivors of Pediatric Differentiated Thyroid Carcinoma

CONTEXT

Little is known about long-term quality of life (QoL) of survivors of pediatric differentiated thyroid carcinoma. Therefore, this study aimed to evaluate generic health-related QoL (HRQoL), fatigue, anxiety, and depression in these survivors compared with matched controls, and to evaluate thyroid cancer-specific HRQoL in survivors only.

DESIGN

Survivors diagnosed between 1970 and 2013 at age ≤18 years, were included. Exclusion criteria were a follow-up <5 years, attained age <18 years, or diagnosis of DTC as a second malignant neoplasm (SMN). Controls were matched by age, sex, and socioeconomic status. Survivors and controls were asked to complete 3 questionnaires [Short-Form 36 (HRQoL), Multidimensional Fatigue Inventory 20 (fatigue), and Hospital Anxiety and Depression Scale (anxiety/depression)]. Survivors completed a thyroid cancer-specific HRQoL questionnaire.

RESULTS

Sixty-seven survivors and 56 controls. Median age of survivors at evaluation was 34.2 years (range, 18.8 to 61.7). Median follow-up was 17.8 years (range, 5.0 to 44.7). On most QoL subscales, scores of survivors and controls did not differ significantly. However, survivors had more physical problems (P = 0.031), role limitations due to physical problems (P = 0.021), and mental fatigue (P = 0.016) than controls. Some thyroid cancer-specific complaints (e.g., sensory complaints and chilliness) were present in survivors. Unemployment and more extensive disease or treatment characteristics were most frequently associated with worse QoL.

CONCLUSIONS

Overall, long-term QoL in survivors of pediatric DTC was normal. Survivors experienced mild impairment of QoL in some domains (physical problems, mental fatigue, and various thyroid cancer-specific complaints). Factors possibly affecting QoL need further exploration.

Maternal use of prednisolone is unlikely to be associated with neonatal adrenal suppression-a single-center study of 16 cases

The use of supra-physiological, exogenous corticosteroids in pregnancy may lead to neonatal adrenal suppression. We report on a single-center, case series study carried out between 2006 and 2014, which included all newborns (n = 16) of mothers using prednisolone ≥10 mg/day during pregnancy. Newborns were routinely assessed according to hospital protocol, with follow-up until 6 weeks after birth. We investigated the clinical symptoms and biochemical findings of adrenal suppression occurring in the newborns. Mean dose of maternal prednisolone was 29.7 ± 16.1 mg/day with a mean duration of 18.4 ± 15.4 weeks. Five newborns showed hypoglycemia with normal serum cortisol concentrations and urinary steroid profiles. Two newborns had abnormal urinary steroid profiles, probably the result of prematurity, but with adequate adrenal stress response during clinical sepsis.

CONCLUSION

In this retrospective case series, we found no evidence of prolonged effects of maternal prednisolone use during pregnancy on the neonatal hypothalamic-pituitary-adrenal axis. What is known: • The use of prednisolone during pregnancy may cause increased steroid levels in the fetus by partially passing through the placenta. • So far, there was very limited data available on the occurrence of adrenal suppression in the newborn of mothers using prednisolone during pregnancy. What is new: • The use of high-dosage prednisolone during pregnancy for ≥1 week (mean duration of 18.4 ± 15.4 weeks), prior to delivery, appears to have little influence on the neonatal hypothalamic-pituitary-adrenal axis.

Is there an effect of intranasal insulin on development and behaviour in Phelan-McDermid syndrome? A randomized, double-blind, placebo-controlled trial

Phelan-McDermid syndrome (PMS) or 22q13.3 deletion syndrome is a rare neurodevelopmental disorder with at least 60 children and 35 adults diagnosed in the Netherlands. Clinical features are moderate to severe intellectual disability and behavioural problems in the autism spectrum. Other researchers had observed a beneficial effect of intranasal insulin on development and behaviour in a pilot study in six children with PMS. To validate this effect, we conducted a randomized, double-blind, placebo-controlled clinical trial using a stepped-wedge design. From March 2013 to June 2015, 25 children aged 1-16 years with a molecularly confirmed 22q13.3 deletion including the SHANK3 gene participated in the clinical trial for a period of 18 months. Starting 6 months before the trial, children were systematically assessed for cognitive, language and motor development and for adaptive, social and emotional behaviour every 6 months. The second, third and fourth assessments were followed by daily nose sprays containing either intranasal insulin or intranasal placebo for a 6-month period. A fifth assessment was done directly after the end of the trial. Intranasal insulin did not cause serious adverse events. It increased the level of developmental functioning by 0.4-1.4 months per 6-month period, but the effect was not statistically significant in this small group. We found a stronger effect of intranasal insulin, being significant for cognition and social skills, for children older than 3 years, who usually show a decrease of developmental growth. However, clinical trials in larger study populations are required to prove the therapeutic effect of intranasal insulin in PMS.

Dutch healthcare professionals inadequately perceived if three- and four-year-old preschool children were overweight

AIM

We studied whether healthcare professionals adequately perceived if preschool children were overweight and whether this was influenced by their own body mass index (BMI).

METHODS

We sent 716 Dutch healthcare professionals questionnaires containing seven pictures and seven sketches of three- and four-year-old children showing body weights from underweight to morbidly obese. The professionals rated the pictures on a five-point scale from too heavy to too light and chose the sketch that they felt best depicted the child's body shape. They also reported their own height and weight and their BMI was calculated.

RESULTS

Of the 716 questionnaires, 346 (48.3%) were returned with complete information and analysed. Healthcare professionals mostly chose sketches that showed children as being lighter than they really were. Depending on their own BMI group, the overweight child was perceived as having a normal weight by 74-79% of the healthcare professionals. The obese children were rated correctly by 44-52% of the professionals, but 14-15% said their weight was normal. The morbidly obese child was adequately assessed by 93-98% of the professionals.

CONCLUSION

Healthcare professionals inadequately perceived whether three- and four-year-old children were overweight and this may have hindered early interventions, leading to overweight children becoming overweight adolescents.

Central Adrenal Insufficiency Is Not a Common Feature in CHARGE Syndrome: A Cross-Sectional Study in 2 Cohorts

OBJECTIVE

To evaluate whether central adrenal insufficiency (CAI) is present in CHARGE (Coloboma of the eye, Heart defects, Atresia of the choanae, Retardation of growth and/or development, Genital hypoplasia, and Ear abnormalities, including deafness) syndrome, a complex malformation disorder that includes central endocrine dysfunction.

STUDY DESIGN

Two cross-sectional studies were performed in Dutch (September 2013-February 2015) and Australian (January 2012-January 2014) CHARGE syndrome clinics. Twenty-seven Dutch and 19 Australian patients (aged 16 months-18 years) with genetically confirmed CHARGE syndrome were included. The low-dose adrenocorticotropin (ACTH) test was used to assess CAI in the Dutch cohort. A peak cortisol response less than 18.1 μg/dL (500 nmol/L) was suspected for CAI, and a glucagon stimulation test was performed for confirmation. Australian patients were screened by single measurements of ACTH and cortisol levels. If adrenal dysfunction was suspected, a standard-dose ACTH test was performed.

RESULTS

The low-dose ACTH test was performed in 23 patients (median age 8.4 [1.9-16.9] years). Seven patients showed an insufficient maximum cortisol level (10.3-17.6 μg/dL, 285-485 nmol/L), but CAI was confirmed by glucagon stimulation test in only 1 patient (maximum cortisol level 15.0 μg/dL, 415 nmol/L). In the Australian cohort, 15 patients (median age 9.1 [1.3-17.8] years) were screened, and none had CAI.

CONCLUSIONS

CAI was not common in our cohorts, and routine testing of adrenal function in children with CHARGE syndrome is not indicated.

Pediatric Differentiated Thyroid Carcinoma in The Netherlands: A Nationwide Follow-Up Study

INTRODUCTION

Treatment for differentiated thyroid carcinoma (DTC) in pediatric patients is based mainly on evidence from adult series due to lack of data from pediatric cohorts. Our objective was to evaluate presentation, treatment-related complications, and long-term outcome in patients with pediatric DTC in The Netherlands.

PATIENTS AND METHODS

In this nationwide study, presentation, complications, and outcome of patients with pediatric DTC (age at diagnosis ≤18 y) treated in The Netherlands between 1970 and 2013 were assessed using medical records.

RESULTS

We identified 170 patients. Overall survival was 99.4% after a median follow-up of 13.5 years (range 0.3-44.7 y). Extensive follow-up data were available for 105 patients (83.8% women), treated in 39 hospitals. Median age at diagnosis was 15.6 years (range 5.8-18.9 y). At initial diagnosis, 43.8% of the patients had cervical lymph node metastases; 13.3% had distant metastases. All patients underwent total thyroidectomy. Radioiodine was administered to 97.1%, with a median cumulative activity of 5.66 GBq (range 0.74-35.15 GBq). Life-long postoperative complications (permanent hypoparathyroidism and/or recurrent laryngeal nerve injury) were present in 32.4% of the patients. At last known follow-up, 8.6% of the patients had persistent disease and 7.6% experienced a recurrence. TSH suppression was not associated with recurrences (odds ratio 2.00, 95% confidence interval 0.78-5.17, P = .152).

CONCLUSIONS

Survival of pediatric DTC is excellent. Therefore, minimizing treatment-related morbidity takes major priority. Our study shows a frequent occurrence of life-long postoperative complications. Adverse effects may be reduced by the centralization of care, which is crucial for children with DTC.

Determinants of Weight Gain during the First Two Years of Life--The GECKO Drenthe Birth Cohort

Objectives

To explain weight gain patterns in the first two years of life, we compared the predictive values of potential risk factors individually and within four different domains: prenatal, nutrition, lifestyle and socioeconomic factors.

Methods

In a Dutch population-based birth cohort, length and weight were measured in 2475 infants at 1, 6, 12 and 24 months. Factors that might influence weight gain (e.g. birth weight, parental BMI, breastfeeding, hours of sleep and maternal education) were retrieved from health care files and parental questionnaires. Factors were compared with linear regression to best explain differences in weight gain, defined as changes in Z-score of weight-for-age and weight-for-length over 1–6, 6–12 and 12–24 months. In a two-step approach, factors were first studied individually for their association with growth velocity, followed by a comparison of the explained variance of the four domains.

Results

Birth weight and type of feeding were most importantly related to weight gain in the first six months. Breastfeeding versus formula feeding showed distinct growth patterns in the first six months, but not thereafter. From six months onwards, the ability to explain differences in weight gain decreased substantially (from R²_total = 38.7% to R²_total<7%).

Conclusion

Birth weight and breast feeding were most important to explain early weight gain, especially in the first six months of life. After the first six months of life other yet undetermined factors start to play a role.

Bone mineral density in children and adolescents with Prader-Willi syndrome: a longitudinal study during puberty and 9 years of growth hormone treatment

CONTEXT

Longitudinal data on bone mineral density (BMD) in children and adolescents with Prader-Willi Syndrome (PWS) during long-term GH treatment are not available.

OBJECTIVE

This study aimed to determine effects of long-term GH treatment and puberty on BMD of total body (BMDTB), lumbar spine (BMDLS), and bone mineral apparent density of the lumbar spine (BMADLS) in children with PWS.

DESIGN AND SETTING

This was a prospective longitudinal study of a Dutch PWS cohort.

PARTICIPANTS

Seventy-seven children with PWS who remained prepubertal during GH treatment for 4 years and 64 children with PWS who received GH treatment for 9 years participated in the study.

INTERVENTION

The children received GH treatment, 1 mg/m(2)/day (≅ 0.035 mg/kg/d).

MAIN OUTCOME MEASURES

BMDTB, BMDLS, and BMADLS was measured by using the same dual-energy x-ray absorptiometry machine for all annual measurements.

RESULTS

In the prepubertal group, BMDTB standard deviation score (SDS) and BMDLSSDS significantly increased during 4 years of GH treatment whereas BMADLSSDS remained stable. During adolescence, BMDTBSDS and BMADLSSDS decreased significantly, in girls from the age of 11 years and in boys from the ages of 14 and 16 years, respectively, but all BMD parameters remained within the normal range. Higher Tanner stages tended to be associated with lower BMDTBSDS (P = .083) and a significantly lower BMADLSSDS (P = .016). After 9 years of GH treatment, lean body mass SDS was the most powerful predictor of BMDTBSDS and BMDLSSDS in adolescents with PWS.

CONCLUSIONS

This long-term GH study demonstrates that BMDTB, BMDLS, and BMADLS remain stable in prepubertal children with PWS but decreases during adolescence, parallel to incomplete pubertal development. Based on our findings, clinicians should start sex hormone therapy from the age of 11 years in girls and 14 years in boys unless there is a normal progression of puberty.

Attenuated salivary cortisol response after exercise test in children with asthma

OBJECTIVE

The clinical relevance of lower basal cortisol levels in children with asthma is unclear. We compared the salivary cortisol response after a standardized exercise test in children with asthma versus the salivary cortisol response in healthy children.

METHODS

Nineteen prepubertal children with asthma and 20 prepubertal healthy children performed a standardized exercise test twice. Salivary cortisol levels were determined before exercise and immediately and 15 min after exercise. Morning salivary cortisol levels were determined from saliva collected at home.

RESULTS

Salivary cortisol levels increased in 84.2% of the healthy children compared to 35.0% in children with asthma after the 20-m shuttle-run test. Median increase in salivary cortisol levels was 200.3% [95% confidence interval (CI), 141.8-346.1] in healthy children compared to 89.8% (95% CI, 56.9-181.6) in children with asthma. The response was not related to the morning salivary cortisol level or maintenance dose of inhaled corticosteroids. The mean time to exhaustion of both shuttle-run tests was significantly shorter in children with asthma (mean difference 1.4 min; 95% CI, 0.7-2.3). None of the children had to stop because of dyspnea.

CONCLUSION

Our study demonstrates that children with asthma using a maintenance dose of inhaled corticosteroids (ICS) have an attenuated salivary cortisol response compared with healthy children.

Children with asthma have significantly lower long-term cortisol levels in their scalp hair than healthy children

AIM

Noninvasive measurement of long-term cortisol levels is a useful way of evaluating the effect of chronic disease on the hypothalamic-pituitary-adrenal axis in children. The aim of this pilot study was to compare hair cortisol levels in children using inhaled corticosteroids for asthma and healthy children and to determine the association with short-term salivary cortisol levels.

METHODS

Cortisol levels were measured in the scalp hair and saliva of prepubertal children with asthma (n = 10) and without asthma (n = 10). Asthma control was assessed using an asthma questionnaire and pulmonary function tests.

RESULTS

The median (95% CI) cortisol level in the scalp hair of the children with asthma (2.0 pg/mg; 1.4-4.1) was significantly lower than the healthy children (4.3 pg/mg; 1.8-5.9). Morning salivary cortisol levels were significantly lower for the children with asthma (5.9 nmol/L; 3.2-11.1) than the healthy children (9.0 nmol/L; 4.4-31.6). There was no significant association between cortisol levels in hair and saliva.

CONCLUSION

Long-term cortisol levels were significantly lower in children with asthma than healthy children. Measuring long-term cortisol levels in scalp hair is an attractive, noninvasive tool that can evaluate the effect of asthma and its treatment on the hypothalamic-pituitary-adrenal axis.

A multidisciplinary intervention programme has positive effects on quality of life in overweight and obese preschool children

AIM

Up to 18.1% of Dutch children aged 3-5 are overweight and up to 3.3% are obese, with higher levels in girls. This study assessed the effect of a multidisciplinary intervention programme on health-related quality of life (HRQoL) in this patient group.

METHODS

We randomised 75 children to a multidisciplinary intervention, comprising dietary advice, exercise sessions and psychological counselling for parents or the standard care programme, providing healthy lifestyle advice. The parents completed quality of life and child health questionnaires at baseline and after 16 weeks and 12 months.

RESULTS

At 16 weeks, children in the intervention group experienced more bodily pain and less mental health than the standard care group, but at 12 months, this difference disappeared and they showed a more positive change in HRQoL than the standard care group, especially for the physical domain. When we combined both groups, a decreased BMIz-score over 12 months was associated with increased global health and reduced visceral fat correlated with increased general health.

CONCLUSION

At 12 months, a multidisciplinary intervention programme for overweight and obese children aged 3-5 years had beneficial effects on HRQoL, especially for the physical domain. Reduced obesity parameters correlated with several increased HRQoL parameters.

Insulin resistance and cardiovascular risk factors in 3- to 5-year-old overweight or obese children

BACKGROUND/AIMS

The increasing rate of overweight and obesity is alarming. The complications of overweight and obesity at a young age are largely unknown. We aimed to assess the prevalence of insulin resistance (IR) and cardiovascular risk factors among overweight and obese children aged 3-5 years.

METHODS

The study population consisted of 75 children (29 overweight, 46 obese). We performed anthropometry and bioelectrical impedance analysis as an indicator of body composition. IR was determined by the updated Homeostasis Model Assessment of Insulin Resistance (HOMA2-IR). Cardiovascular risk factors were defined by the presence of increased serum triglycerides, blood pressure, and HOMA2-IR and by a decreased serum HDL cholesterol.

RESULTS

An elevated HOMA2-IR was found in 7.7% of the children. HOMA2-IR was correlated with body mass index (r = 0.63), waist circumference (r = 0.62) and percentage body fat (r = 0.58) (all p < 0.001). Cardiovascular risk factors were present in 6.9% (triglycerides) to 74.3% (hypertension) of the children.

CONCLUSION

IR and cardiovascular risk factors are already evident in many 3- to 5-year-old overweight and obese children. IR is strongly related to body composition.

Effect of obesity intervention programs on adipokines, insulin resistance, lipid profile, and low-grade inflammation in 3- to 5-y-old children

BACKGROUND

Childhood obesity can cause the development of cardiovascular risk factors. We assessed the effect of a multidisciplinary intervention program on cardiovascular risk factors and compared this effect with a usual-care program in 3- to 5-y-old overweight or obese children.

METHODS

Seventy-five children were randomly assigned to a multidisciplinary intervention or a usual-care program. Anthropometry, body composition, and abdominal adipose tissue were assessed at the start and end of a 16-wk program. Concurrently, fasting concentrations of serum lipids, glucose, insulin, HbA1c, leptin, adiponectin, high-sensitive C-reactive protein (hsCRP), tumor necrosis factor (TNF)-α, and interleukin (IL)-6 were determined.

RESULTS

In both groups, insulin sensitivity improved, demonstrated by decreased insulin concentrations and a decreased HOMA2-IR. In the multidisciplinary intervention group, there was also a decrease of HbA1c and TNF-α. In the usual-care group, an increase in glucose concentrations was found. Comparing both groups, changes over time were not different, besides trends in the decrease in total cholesterol and TNF-α, in favor of the multidisciplinary intervention group. Combining the results of both groups, a correlation was found between the decrease in body fat percentage (BF%), and both HOMA2-IR and triglyceride (TG) concentrations.

CONCLUSION

In 3- to 5-y-old children, both obesity intervention programs improved insulin sensitivity, in parallel with a reduced BF%.

Eight years of growth hormone treatment in children with Prader-Willi syndrome: maintaining the positive effects

BACKGROUND

The most important reason for treating children with Prader-Willi syndrome (PWS) with GH is to optimize their body composition.

OBJECTIVES

The aim of this ongoing study was to determine whether long-term GH treatment can counteract the clinical course of increasing obesity in PWS by maintaining the improved body composition brought during early treatment.

SETTING

This was a multicenter prospective cohort study.

METHODS

We have been following 60 prepubertal children for 8 years of continuous GH treatment (1 mg/m(2)/d ≈ 0.035 mg/kg/d) and used the same dual-energy x-ray absorptiometry machine for annual measurements of lean body mass and percent fat.

RESULTS

After a significant increase during the first year of GH treatment (P < .0001), lean body mass remained stable for 7 years at a level above baseline (P < .0001). After a significant decrease in the first year, percent fat SD score (SDS) and body mass index SDS remained stable at a level not significantly higher than at baseline (P = .06, P = .14, resp.). However, body mass index SDSPWS was significantly lower after 8 years of GH treatment than at baseline (P < .0001). After 8 years of treatment, height SDS and head circumference SDS had completely normalized. IGF-1 SDS increased to +2.36 SDS during the first year of treatment (P < .0001) and remained stable since then. GH treatment did not adversely affect glucose homeostasis, serum lipids, blood pressure, and bone maturation.

CONCLUSION

This 8-year study demonstrates that GH treatment is a potent force for counteracting the clinical course of obesity in children with PWS.

Systemic effects of hypothermia due to hypothalamic dysfunction after resection of a craniopharyngioma: case report and review of literature

OBJECTIVE

With this case report, we aim to improve recognition of the systemic effects of hypothermia due to hypothalamic dysfunctioning. We present a patient who developed temperature dysregulation after surgery for craniopharyngioma. He suffered from several episodes of hypothermia associated with a decreased level of consciousness, hypoventilation, bradycardia, pancreatitis, and pancytopenia. Rewarming resulted in complete recovery of all symptoms.

DATA SOURCES

We discuss the literature on the pathophysiological consequences of hypothermia, referring to several medical databases (Cochrane, SUMSearch, Trip database, and PubMed).

CONCLUSION

Hypothermia due to hypothalamic dysfunction can result in several systemic complications with complete recovery of all symptoms by rewarming.

Results of a multidisciplinary treatment program in 3-year-old to 5-year-old overweight or obese children: a randomized controlled clinical trial

OBJECTIVE

To assess the effects of a multidisciplinary intervention program for 3-year-old to 5-year-old overweight and obese children compared with a usual-care program.

DESIGN

Randomized controlled clinical trial conducted from October 2006 to March 2008.

SETTING

Groningen Expert Center for Kids with Obesity at Beatrix Children's Hospital, University Medical Center Groningen.

PARTICIPANTS

Seventy-five children (29 overweight, 46 obese) aged 3 to 5 years.

INTERVENTION

A multidisciplinary intervention program vs a usual-care program. Anthropometry was performed and body composition was determined by bioelectrical impedance analysis and ultrasonography at the start and end of the 16-week program and 12 months after starting the intervention.

MAIN OUTCOME MEASURES

The actual weight reduction, change in body mass index (BMI, calculated as weight in kilograms divided by height in meters squared), BMI z score, body fat percentage, and visceral fat in the multidisciplinary intervention group compared with a usual-care group.

RESULTS

At the end of the treatment program, children in the multidisciplinary intervention group showed a greater decrease in BMI, BMI z score, and waist circumference z score compared with children in the usual-care group. At 12 months, children in the intervention group showed greater decreases in BMI, BMI z score, waist circumference, and waist circumference z score compared with children in the usual-care group. Visceral fat showed a trend toward a higher decrease.

CONCLUSIONS

A multidisciplinary intervention program in 3-year-old to 5-year-old overweight and obese children had beneficial effects on anthropometry and body composition. The positive effects were still present 12 months after the start of the intervention.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN47185691.

Vaginal bleeding in a 4-month-old preterm girl: extreme minipuberty mimicking central precocious puberty

We present a 4-month-old girl who showed vaginal bleeding and breast development. She was born preterm at 25 weeks and 4 days of gestation. Luteinizing hormone and follicle-stimulating hormone levels were extremely elevated. Magnetic resonance imaging showed a lesion of unknown nature in the pituitary gland, most likely a Rathke's cleft cyst. Because central precocious puberty (CPP) was suspected, a gonadotropin-releasing hormone analogue was started. At the age of 18 months, the treatment was stopped. Thereafter, no signs of puberty developed. The pituitary lesion remained unchanged. Therefore, the initial diagnosis of CPP was incorrect, and instead, an extreme minipuberty had occurred. If treatment for idiopathic CPP in girls younger than 2 years is started, we recommend the treatment be stopped after a certain period, for reevaluation of the diagnosis of CPP.

Beneficial effects of growth hormone treatment on cognition in children with Prader-Willi syndrome: a randomized controlled trial and longitudinal study

BACKGROUND

Knowledge about the effects of GH treatment on cognitive functioning in children with Prader-Willi syndrome (PWS) is limited.

METHODS

Fifty prepubertal children aged 3.5 to 14 yr were studied in a randomized controlled GH trial during 2 yr, followed by a longitudinal study during 4 yr of GH treatment. Cognitive functioning was measured biennially by short forms of the WPPSI-R or WISC-R, depending on age. Total IQ (TIQ) score was estimated based on two subtest scores.

RESULTS

During the randomized controlled trial, mean sd scores of all subtests and mean TIQ score remained similar compared to baseline in GH-treated children with PWS, whereas in untreated controls mean subtest sd scores and mean TIQ score decreased and became lower compared to baseline. This decline was significant for the Similarities (P = 0.04) and Vocabulary (P = 0.03) subtests. After 4 yr of GH treatment, mean sd scores on the Similarities and Block design subtests were significantly higher than at baseline (P = 0.01 and P = 0.03, respectively), and scores on Vocabulary and TIQ remained similar compared to baseline. At baseline, children with a maternal uniparental disomy had a significantly lower score on the Block design subtest (P = 0.01) but a larger increment on this subtest during 4 yr of GH treatment than children with a deletion. Lower baseline scores correlated significantly with higher increases in Similarities (P = 0.04) and Block design (P < 0.0001) sd scores.

CONCLUSIONS

Our study shows that GH treatment prevents deterioration of certain cognitive skills in children with PWS on the short term and significantly improves abstract reasoning and visuospatial skills during 4 yr of GH treatment. Furthermore, children with a greater deficit had more benefit from GH treatment.

The results of CHD7 analysis in clinically well-characterized patients with Kallmann syndrome

CONTEXT

Kallmann syndrome (KS) and CHARGE syndrome are rare heritable disorders in which anosmia and hypogonadotropic hypogonadism co-occur. KS is genetically heterogeneous, and there are at least eight genes involved in its pathogenesis, whereas CHARGE syndrome is caused by autosomal dominant mutations in only one gene, the CHD7 gene. Two independent studies showed that CHD7 mutations can also be found in a minority of KS patients.

OBJECTIVE

We aimed to investigate whether CHD7 mutations can give rise to isolated KS or whether additional features of CHARGE syndrome always occur.

DESIGN

We performed CHD7 analysis in a cohort of 36 clinically well-characterized Dutch patients with KS but without mutations in KAL1 and with known status for the KS genes with incomplete penetrance, FGFR1, PROK2, PROKR2, and FGF8.

RESULTS

We identified three heterozygous CHD7 mutations. The CHD7-positive patients were carefully reexamined and were all found to have additional features of CHARGE syndrome.

CONCLUSION

The yield of CHD7 analysis in patients with isolated KS seems very low but increases when additional CHARGE features are present. Therefore, we recommend performing CHD7 analysis in KS patients who have at least two additional CHARGE features or semicircular canal anomalies. Identifying a CHD7 mutation has important clinical implications for the surveillance and genetic counseling of patients.

Non-invasive measurement of adrenal response after standardized exercise tests in prepubertal children

OBJECTIVE

To determine the feasibility of non-invasive evaluation of adrenal response in healthy prepubertal children by standardized exercise tests.

METHODS

On separate occasions, healthy prepubertal children performed a submaximal cycling test, a maximal cycling test, and a 20-m shuttle-run test. Salivary cortisol levels were determined before exercise, and 1 and 15 min after exercise.

RESULTS

Immediately after cessation of the cycling and shuttle-run tests, salivary cortisol levels remained unchanged or decreased. Fifteen minutes after the shuttle-run test, salivary cortisol levels increased significantly. This increase in salivary cortisol levels was not observed 15 min after the cessation of the cycling tests.

CONCLUSION

The results of this study demonstrate a different response in salivary cortisol levels after standardized cycling and running tests in prepubertal children. The increase in salivary cortisol levels found after a short standardized running test suggests that this may be a practical non-invasive method for evaluating adrenal response in healthy prepubertal children.

Anosmia predicts hypogonadotropic hypogonadism in CHARGE syndrome

OBJECTIVE

To test the hypothesis that a smell test could predict the occurrence of hypogonadotropic hypogonadism (HH) in patients with CHARGE syndrome, which is a variable combination of ocular coloboma, heart defects, choanal atresia, retardation of growth/development, genital hypoplasia, and ear anomalies or hearing loss caused by mutations in the CHD7 (chromodomain helicase DNA binding protein 7) gene.

STUDY DESIGN

We performed endocrine studies and smell testing (University of Pennsylvania Smell Identification Test) in 35 adolescent patients with molecularly confirmed CHARGE syndrome.

RESULTS

Complete data on smell and puberty were available for 15 patients; 11 patients had both anosmia and HH, whereas 4 patients had normosmia/hyposmia and spontaneous puberty. In addition, 7 boys were highly suspected of having HH (they were too young for definite HH diagnosis, but all had cryptorchidism, micropenis, or both) and had anosmia. The type of CHD7 mutation could not predict HH because a father and daughter with the same CHD7 mutation were discordant for HH and anosmia.

CONCLUSION

Anosmia and HH were highly correlated in our cohort, and therefore smell testing seems to be an attractive method for predicting the occurrence of HH in patients with CHARGE syndrome. The use of this test could prevent delay of hormonal pubertal induction, resulting in an age-appropriate puberty.

Efficacy and safety of long-term continuous growth hormone treatment in children with Prader-Willi syndrome

BACKGROUND

Children with Prader-Willi syndrome (PWS) have abnormal body composition and impaired growth. Short-term GH treatment has beneficial effects.

OBJECTIVES

The aim of the study was to investigate effects of long-term continuous GH treatment on body composition, growth, bone maturation, and safety parameters.

SETTING

We conducted a multicenter prospective trial.

DESIGN

Fifty-five children with a mean +/- sd age of 5.9 +/- 3.2 yr were followed during 4 yr of continuous GH treatment (1 mg/m(2) . d). Data were annually obtained in one center: fat percentage (fat%) and lean body mass (LBM) by dual-energy x-ray absorptiometry, height, weight, head circumference, bone age, blood pressure, and fasting IGF-I, IGF binding protein-3, glucose, insulin, glycosylated hemoglobin, total cholesterol, high-density lipoprotein, and low-density lipoprotein. sd scores (SDS) were calculated according to Dutch and PWS reference values (SDS and SDS(PWS)).

RESULTS

Fat%SDS was significantly lower after 4 yr of GH treatment (P < 0.0001). LBMSDS significantly increased during the first year (P = 0.02) but returned to baseline values the second year and remained unchanged thereafter. Mean +/- sd height normalized from -2.27 +/- 1.2 SDS to -0.24 +/- 1.2 SDS (P < 0.0001). Head circumference SDS increased from -0.79 +/- 1.0 at start to 0.07 +/- 1.1 SDS after 4 yr. BMISDS(PWS) significantly decreased. Mean +/- sd IGF-I and the IGF-I/IGF binding protein-3 ratio significantly increased to 2.08 +/- 1.1 and 2.32 +/- 0.9 SDS, respectively. GH treatment had no adverse effects on bone maturation, blood pressure, glucose homeostasis, and serum lipids.

CONCLUSIONS

Our study in children with PWS shows that 4 yr of continuous GH treatment (1 mg/m(2) . d) improves body composition by decreasing fat%SDS and stabilizing LBMSDS and head circumference SDS and normalizes heightSDS without adverse effects. Thus, long-term continuous GH treatment is an effective and safe therapy for children with PWS.

Bone mineral density and effects of growth hormone treatment in prepubertal children with Prader-Willi syndrome: a randomized controlled trial

BACKGROUND

Bone mineral density (BMD) is unknown in children with Prader-Willi syndrome (PWS), but is decreased in adults with PWS. In patients with GH deficiency, BMD increases during GH treatment.

OBJECTIVES

The aim of the study was to evaluate BMD in children with PWS and to study the effects of GH treatment.

DESIGN

We conducted a randomized controlled GH trial. Forty-six prepubertal children were randomized into either a GH-treated group (1.0 mg/m(2) . d) or a control group for 2 yr. At start, 6, 12, and 24 months of study, total body and lumbar spine BMD were measured by dual-energy x-ray absorptiometry, and lumbar spine bone mineral apparent density (BMAD) was calculated.

RESULTS

Baseline total body and lumbar spine BMD sd score (SDS) were normal [mean (sd), -0.2 SDS (1.1) and -0.4 SDS (1.2), respectively]. BMADSDS, which corrects for short stature, was also normal [mean (sd), 0.40 SDS (1.1)]. Total body BMDSDS decreased during the first 6 months of GH (P < 0.0001), but increased during the second year of treatment. After 24 months of study, total body and lumbar spine BMDSDS, and the BMADSDS did not significantly differ between GH-treated children and randomized controls (P = 0.30, P = 0.44, and P = 0.47, respectively). Results were similar when corrected for body mass index SDS. Repeated measurements analysis showed a significant positive association between IGF-I SDS and total body and lumbar spine BMDSDS, but not with BMADSDS.

CONCLUSIONS

Our results show that prepubertal children with PWS have a normal BMD. GH treatment had no effect on BMD, except for a temporary decrease of total body BMDSDS in the first 6 months.

[Non-alcoholic fatty liver disease in children: a new complication of obesity]

Non-alcoholic fatty liver disease (NAFLD) comprises a range of chronic liver diseases from simple steatosis to steatohepatitis and cirrhosis with liver failure. In children, NAFLD is mainly associated with obesity and metabolic syndrome, the results of an unhealthy lifestyle. Insulin resistance and free fatty acids play a key role in the pathogenesis of NAFLD. NAFLD can therefore be seen as a metabolic complication of obesity. Since the prevalence of obesity in Dutch children is increasing, the prevalence of NAFLD in children is expected to increase as well. Prevention of obesity and identification of children with an increased risk of NAFLD are important steps in preventing irreversible liver damage. Lifestyle changes aimed at improving insulin sensitivity through healthy food and sufficient physical activity are essential in the treatment of NAFLD. Pharmacological treatment may have additional value.

[Chance finding of foetal and neonatal ovarian cysts on echography]

Cystic abnormalities of the adnex were found by chance in 2 baby girls, one aged 2.5 months and the other aged 2 months. Both had been born dysmaturely and the abnormalities were found on echographic investigation carried out for suspected urinary-tract infection. On monitoring investigation one month later, the abnormalities had become smaller and some time later had disappeared altogether. With the increasing use of ultrasound, ovarian cysts are being detected more often in the foetus and neonate. The majority of these cysts are benign functional follicular cysts and resolve spontaneously. The decision to perform surgery depends on the clinical symptoms and appearance on ultrasound. Large uncomplicated cysts can be managed by antenatal or postnatal aspiration in order to prevent torsion and the subsequent loss of the adnex.

[A girl with Cushing's syndrome due to primary pigmented nodular adrenocortical disease]

A 12.5-year-old girl with diabetes mellitus type 1 presented with stunted growth and an increase in body weight. Also, her blood-sugar levels were difficult to manage. An adrenocorticotropin-(ACTH)-independent form of Cushing's syndrome was diagnosed. During the dexamethasone-suppression test, a paradoxical increase in urinary-free cortisol excretion was observed, which is a clear indication of primary pigmented nodular adrenocortical disease (PPNAD). The treatment for patients with PPNAD is bilateral adrenalectomy and hormone substitution. PPNAD may be part of the Carney complex, an autosomal dominant multiple neoplasia syndrome. Screening of family members is mandatory. Further investigation for mutations in the gene encoding the regulatory subunit 1A of the protein kinase A (PRKAR1A) may be helpful.

[Cushing's syndrome in children]

In two girls, aged 13 and 16 years, Cushing's syndrome was diagnosed. In addition, the first showed a decrease in linear growth and weight gain; a pituitary adenoma was found, which was surgically excised. The second girl was examined because of a male body-hair pattern and weight increase. She had an adrenal adenoma, visible on MRI, which was excised during laparoscopy. Cushing's syndrome is a rare disease in childhood. A decrease in linear growth and a gain in weight are early recognisable features. Arriving at an aetiological diagnosis may be difficult and is based on the performance and interpretation of endocrinologic function and laboratory tests such as determination of the cortisol level in blood, saliva and urine, a dexamethasone-suppression test, and a corticotropin assay in blood drawn from the cerebral cavernous sinuses.

Gonadotropin releasing hormone analogue therapy in children with isolated growth hormone deficiency: final height benefit from postponing puberty?

Although growth hormone (GH) treatment has improved final height prognosis in children with GH deficiency (GHD), adult heights are still disappointing. Final height could be improved by increasing the duration of puberty and in this way increasing total pubertal height gain. Many studies have been published on the effect of gonadal suppression, mostly by gonadotropin releasing hormone (GnRH) analogues, on final height in children with GHD. Because of the different methodologies used in these studies, results are difficult to compare. Both positive and marginal effects on final height have been reported; however, patient numbers are limited. Children with GHD who start puberty at a relatively young age and who have a poor predicted adult height, can benefit from the addition of GnRH analogues. From previous studies, we might conclude that when there is a positive effect, height benefit is marginal. However, additional prospective, randomized controlled trials are needed to further elucidate whether delaying puberty is indicated in children with GHD to improve final height.

Growth hormone treatment in cartilage-hair hypoplasia: effects on growth and the immune system

Cartilage-hair hypoplasia (CHH) is a rare autosomal recessive disorder characterized by metaphyseal chondrodysplasia with severe growth retardation and impaired immunity. We studied the effects of growth hormone treatment on growth parameters and the immune system in four children with CHH. The effects of growth hormone on growth parameters are the most prominent in patients with the mildest growth retardation. However, the effects are temporary and last only for 1 year. There is no gain in final height. Serum immunoglobulins did not change during growth hormone treatment. We conclude that growth hormone treatment is not beneficial in children with CHH.

Defective proximal tubular function in a patient with I-cell disease

A girl with a proven diagnosis of I-cell disease is presented. Proximal tubular dysfunction was characterized by increased excretion of low molecular proteins, aminoaciduria, hyperphosphaturia, and high/slightly increased urinary calcium. The concentration of 1,25-dihydroxycalciferol in serum was increased. Rickets were present on X-rays. As the proximal tubular dysfunction resembles the dysfunction in Dent disease, one can speculate about a common pathogenesis. Impairment of acidification in lysosomes due to loss of function of the chloride-5 channel impairs intralysosomal protease activity in Dent disease, while in I-cell disease the intralysomal protease activity is lacking.

Peripheral blood lymphocyte appearance in a case of I cell disease

In general, peripheral blood smears are performed to obtain information with regard to various morphological features as an aid in the diagnosis of infection or malignancy. This report presents a patient with I cell disease (inclusion cell disease), a fatal lysosomal storage disorder caused by a defect in an enzyme responsible for the transfer of mannose-6-phosphate ligands to precursor lysosomal enzymes. As a consequence, most lysosomal enzymes are transported outside the cell instead of being correctly targeted into the lysosomes, resulting in the storage of macromolecules in lysosomes. I cell disease, with its heterogeneous clinical presentation, can be diagnosed by the presence of intracellular vacuole-like inclusions in lymphocytes and fibroblasts, high serum lysosomal enzyme activities, and a defect of N-acetylglucosamine-1-phosphotransferase. This report describes the morphological aspects of peripheral lymphocytes in a blood smear of a patient, the first clue to the final diagnosis of I cell disease. The observed vacuole-like inclusions in lymphocytes of this patient were negative for periodic acid Schiff (PAS) and Sudan black B staining, in contrast to earlier reports.