AAP Endocrinology Newsletter Winter/Spring 2002


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AAP Endocrinology Newsletter Winter/Spring 2002

  1. 1. The Section on ENDOCRINOLOGY Newsletter Volume 9 Winter/Spring 2002 Chairperson’s Column Inside this Issue Janet Silverstein, MD ♥ Strategies for Dealing T his past year has been filled with a Silverstein at silvejh@peds.ufl.edu with your Increased Patient flurry of activity designed to meet our suggestions. It was gratifying to see that many of Workload educational and advocacy missions. As you expressed an interest in participating as noted by the members completing the Member faculty for these meetings. You will likely be called ♥ Intake of Vitamin D in Survey, a real crisis is emerging regarding manpower issues for pediatric endocrinology. upon to speak at a regional or national meeting over the next few years. Infancy and Risk of For many of us, the clinical demand is so great Type I Diabetes that patients must wait months before being In order to make it financially possible for us to seen. Some prestigious universities have even encourage primary care physicians to care for the ♥ Will Vitamin D been unable to accept new diabetes patients. more common straightforward endocrine problems, Supplementation In order to deal with this issue, creative short- it is necessary to achieve adequate reimbursement Reverse the Rising term and long-term solutions are necessary. for the more complex problems we handle. The Incidence of Type 1 AAP Section on Endocrinology has been actively Diabetes One way to decompress this clinical burden is involved in an effort to improve reimbursement for to educate primary care pediatricians to care many of the services currently not receiving for some of the more straightforward, common adequate payment for the amount of time invested ♥ Point/Counterpoint: endocrine disorders, allowing us as endocri- by trained personnel. Members of the section as Management of nologists to see those patients that truly well as all members of the Lawson Wilkins Pediatric Graves Disease require our expertise. The education meetings Endocrine Society will shortly receive a survey at the American Academy of Pediatrics are designed to ascertain current reimbursement ♥ Growth Hormone geared to help us achieve that goal. This past practices for diabetes education, nutrition and year, the endocrine section had several psychological services, as well as for obesity and the Short SGA sessions at the AAP National Conference and programs. The results of this survey will allow us Child Exhibition in San Francisco: to determine what approaches have been success- ful in garnering reimbursement from insurers. We ♥ Bone Mineral Health • Controversies and Pitfalls in Management have been working closely with the Division of in Children of Diabetic Ketoacidosis Health Care Finance and Practice of the AAP to • Office Endocrinology for the Pediatrician: develop this survey. Our goal is to try to assure Common Disorders of Pubertal payment for these services throughout the country ♥ LWPES Update Endocrinology and by all insurers. • Osteoporosis: A Pediatric Disease- ♥ Survey Results • Diagnosis, Prevention, and Management Common Pediatric Endocrinology Cases Numbers of pediatric residents entering sub- specialty training is increasing again after a long period of decline. The endocrine section is ♥ When the Media Calls - These meetings were extremely well attended represented at the Federation for Pediatric Public Relations Tips and received excellent reviews. As we plan our Organizations (FOPO) meetings. Re-structuring upcoming meetings, it will be important to the fellowship to include both research and clinical keep in mind the need to keep primary care 3-year tracks, garnering more funding for fellow physicians abreast of the latest developments salaries, and promoting loan forgiveness programs in common endocrine disorders. Members of for residents entering subspecialty training this section who have suggestions about programs are but some of the initiatives under potential education topics, please contact discussion to try to further increase numbers of Laura Laskosz at llaskosz@aap.org or Janet residents choosing subspecialty careers. continued on page 5
  2. 2. Editor’s Column Strategies for Dealing With our Increased Outpatient Workload Paul Kaplowitz, MD W hen I attend meetings and chat person, but as a chronic state, it is months, but why not fax a quick note back with colleagues whose work is counterproductive. It erodes one’s to the PCP suggesting he or she repeat the mainly clinical, I often learn that working relationship with the community test and get back to us if the TSH rises not only are they overworked, but in many of physicians we serve, and some patients into the double digits? For many prob- cases, there is not much hope that things who really need to be seen will decide it is lems which don’t seem to be of an endo- will improve anytime soon. Two key not worth the long wait. Adding an crine nature, like excessive sweating, reasons why this appears be to so additional half-day clinic may help for a fatigue, or “spells” which don’t sound at common are 1) the shortage of fellows in while, in the same way that adding another all like hypoglycemia, I often fax a brief training in pediatric endocrinology, which lane to a traffic-clogged freeway does, but note to the PCP stating that from the makes recruitment of new faculty a difficult going from four to five or five to six half- records sent, I do not think I can help, but prospect, and 2) an inability to convince day clinics a week cuts deeply not only inviting them to call if there is additional chairpersons to commit to hiring new into the time we have to take care of phone information which might suggest an faculty because of the difficulty calls and paperwork, but also into any time endocrine diagnosis. For problems which generating enough clinical income to those of us at academic centers hope to we are likely to see no matter how benign support them. Our clinical services appear devote to teaching, collecting data, and the findings, (e.g. short stature, early to be in great demand, so that most of us writing papers. Instead, we need to focus puberty), reviewing information from the have little trouble filling four, five, six, or our efforts on the types of patients we can PCP office isn’t as necessary, but it can even more half-day clinics per week. Yet do the most for, and decide that some of help us decide if the problem can wait a reimbursement is so low from many the other problems referred to us can be few months, or if the findings are worri- insurance companies and HMOs that our adequately managed by primary care some enough to try to fit the child in divisions continue to lose money even as pediatricians who have been appropriately sooner. we become more efficient in squeezing in trained or advised. If you are not already an increasing number of patients per week. screening new referrals by requesting that Another way to keep the backlog of Obviously, we need to figure out ways to the primary care physician’s (PCP) office appointments under control is for us to get better reimbursement not only for our fax information including a growth chart view our role with referrals other than services, but also those of our ancillary before scheduling appointments, this is a diabetics as providing initial diagnoisis staff. Several people in our field are good place to start. For example, accept- and management recommendations and exploring strategies which may work with ing all referred overweight children and then returning most of these patients to some insurers in their own local areas. adolescents crowds our schedule with the PCP for long-term follow-up. Most of However, in the meantime, we need to find patients that we usually have little to offer the children I see for short stature or early ways to better serve the patients and to, unless we work with unusually gifted puberty can, if previous growth data are referring physicians in our area, maintain dietitians who are able to motivate these available, be diagnosed at the first visit fiscal solvency, and maintain our sanity. I families to make significant lifestyle with probable constitutional growth delay, offer below a few thoughts on how we can changes. Also, reimbursement for exog- genetic short stature, premature best accomplish this. enous obesity is poor, particularly for adrenarche, or premature thelarche. Do we follow-up visits. If the child’s linear need to see these patients several times in When I hear people say that the wait for a growth is normal to increased, as is nearly follow-up to be sure that we are correct in new patient appointment at their institu- always the case, and there is no evidence our initial assessment? We can return tion is three, four, six, or in one case, nine of diabetes or PCO, I generally suggest the these straight-forward cases to the months, I can only think that whatever the PCP refer the patient directly to a dietitian referring physician, with a letter sent demand, there has to be a better way to in their area. Another problem we are all stating clearly the circumstances in which organize our services. While we all have too familiar with is the thyroid problem that we would want to see the child again. One ways of working in patients who need to really isn’t a problem, such as the child can also free up more slots, if needed, by be seen quickly, I suspect it is very with a T4 of 8 and a TSH of 0.15, a “high” seeing patients with stable hypothyroid- disheartening for parents and referring T4 of 13 but a normal TSH, or a normal T4 ism less frequently and having the PCP doctors to be told that a child with short with a TSH of 6 but no goiter. I instruct my order tests in between our visits. By stature, which to them may be a very big secretaries not to schedule appointments seeing fewer follow-ups, we can fit more deal, cannot be seen for four months. In for thyroid problems until thyroid tests are new patient consultations into our the short run, this may help to convince faxed from the PCP office and reviewed. schedules, for which we get reimbursed at one’s chairman that there is enough One could argue that the TSH of 6 might a higher level. business to support another faculty occasionally become a TSH of 20 in 6-12 continued on page 5 Section on Endocrinology Page 2
  3. 3. Hypponen et al suggest that ensuring adequate vitamin D The Intake of Vitamin D in Infancy and supplementation for infants could help to reverse the increasing the Risk of Type 1 Diabetes trend in the incidence of type 1 diabetes. The investigators Francine Kaufman, MD conducted a birth cohort study of almost 11,000 infants in Northern Finland who were followed to 1 year. The authors concluded that dietary vitamin D supplementation (2,000 u IU T here are a number of studies that are emerging attempting to understand environmental risk factors for the develop daily) was associated with a subsequent reduced risk of type 1 ment of type 1 diabetes. A recent such study entitled diabetes when adjusted for neonatal, anthropometric, and social “Intake of Vitamin D and Risk of Type 1 Diabetes: A Birth-Cohort characteristics. Study” by E Hyppone, E Laara, A Reunanen, M-R Jarvelin and SM Virtanen (Lancet 358;1500-03:2001) was done to determine if What is the rationale for the potential protective effect of Vitamin there is an association between vitamin D intake in infancy and D? Vitamin D compounds act as selective immunosuppressants as the risk of developing type 1 diabetes. illustrated by their ability to either prevent or markedly suppress development of autoimmune disease in animal models. Vitamin D The authors studied a large birth-cohort born in 1966 in Northern given to mice genetically at risk to develop diabetes was associ- Finland; 12,055 pregnant women were enrolled in the study. Data ated with a reduced risk of type 1 diabetes. Vitamin D has been collected evaluated the frequency and dose of vitamin D shown to stimulate transforming growth factor (TGF) beta-1 and supplementation and the development of type 1 diabetes by the interleukin 4 (IL-4), which may suppress inflammatory T cell (Th1) end of December, 1997. The records through the first year of life activity. As type 1 diabetes in the NOD mouse appears to be a from 10,821 children were analyzed; 81of these subjects subse- Th1 mediated disease, altering the balance toward Th2 production quently developed diabetes. The infants who had been given may be protective. In addition, there is evidence that there is a vitamin D supplementation at all doses of vitamin D had a lower genetic link between Vitamin D and diabetes risk. A recent study rate of diabetes, with a mean relative risk (RR) of 0.16 or below showed that a vitamin D receptor initiation codon polymorphism compared to those who did not receive vitamin D, who had a in exon 2 influences genetic susceptibility to type 1 diabetes RR=1. among the Japanese. Vitamin D supplementation at a dosage of 2000 IU/d resulted in a Are we ready yet to advocate supplementation of all infants with reduction in diabetes rate compared to those taking a lower 2,000 units of Vitamin D? The number of incident cases was small vitamin D dosage (RR=0.22). Children who developed rickets by and therefore the absolute magnitude of the effect needs to be age 3 years were 3 times more likely to develop diabetes com- further assessed. Although a Norwegian study demonstrated that pared to those without rickets. children born to women who took cod liver oil during pregnancy had a reduced risk of type 1 diabetes, infants taking cod liver oil In addition to this, a number of studies in the non-obese diabetic or other vitamin D supplements in the first year of life did not mouse model have begun to look at the mechanism(s) by which have an altered risk of diabetes. vitamin D might have an anti-diabetogenic effect. Supplementation with vitamin D is beneficial and safe in people whose levels are clearly low. Sun exposure in northern Finland is extremely limited and low serum concentrations of vitamin D in Will Vitamin D Supplementation Reverse the Finland are common. Safety of Vitamin D supplementation in Rising Incidence of Type 1 Diabetes infants who have normal vitamin D levels is unknown. In the Desmond Schatz, MD reported study, vitamin D levels were not measured nor was there any accurate quantification of intake. The huge burden of the disease both to the individual and society The highest incidence of Type 1 diabetes worldwide occurs in makes the quest for prevention a major priority. A population- Finland (now almost 50/100,000/year), which is more than twice based approach to primary prevention of T1DM, aimed at altering that in the United States. The incidence is rising with 80/100,000 the environmental determinants known to be risk factors would be predicted in 2050. The incidence of the disease is directly related most effective. The role of vitamin D in the immunopathogenesis to the distance north of the equator. Yet there are currently no of the disease is clearly worthy of further exploration. The German data to satisfactorily account for this high incidence. Type 1 BABYDIAB, Finnish DIPP (Type 1 Diabetes Prediction and diabetes results from poorly understood interactions of genes, Prevention Project), Colorado DAISY Study (Diabetes Autoim- the environment and the immune system and is thought to result mune Study in the Young) and our own Florida PANDA (Prospec- from a chronic autoimmune process triggered by environmental tive Assessment of Newborns for Diabetes Autoimmunity) study exposures. When the disease actually begins, whether it is indeed are screening newborn babies (of both affected relatives and triggered by environmental agents, is now vigorously being those in the general population) for the presence of high-risk HLA pursued. Exposure to rubella and enteroviruses, both in-utero genes. These at-risk babies are followed prospectively for the and in the first few years of life accounts for at least a portion of appearance of autoantibodies and diabetes. These studies are the cases. The Trial to Prevent Diabetes in the Genetically precursors of a collaborative multi-center network in which large, at-Risk (TRIGR) study is evaluating the effect of cow’s milk in well controlled trials can be performed to determine if Vitamin D or development of the disease. other putative agents will be effective in preventing the disease. Section on Endocrinology Page 3
  4. 4. Clinical Controversies: Medical Management of Graves Disease in Children and Adolescents Why we should use antithyroid tions, one is surer of treatment effects. On Why we should use antithyroid drugs alone: ATDs plus l-thyroxine, one may not be drugs in combination with sure whether the ATD dose is too low or Steve LaFranchi, MD L-thyroxine Department of Pediatrics the l-thyroxine dose too high. Using single drug therapy, assuming compliance, Merrily Poth, M.D. Oregon Health & Sciences University Department of Pediatrics the dose of ATDs needs to be increased. Fourth, and most important to me, I am Uniformed Services University of the Medical therapy using antithyroid drugs Health Sciences (ATDs) is the preferred treatment choice of better able to predict a remission. Gener- most pediatric endocrinologists for ally, as the thyrotoxicosis remits, one has to reduce the ATD dose to maintain the There are two lines of theoretical evidence children with Graves’ disease. Antithyroid and one more practical and experiential drugs lead to initial control of thyrotoxico- euthyroid state. For example, as the dose gets down to 5-10 mg of methimazole daily, issue that lead to my preference for adding sis in the majority of children. Given that thyroxine to anti-thyroid drug in the one can use fewer methimzole tablets daily I find that the patient is ready for a trial off ATDs. On the combination therapy, one treatment of Graves in children and as compared to propylthiouracil to achieve adolescents. The first is controversial and equivalent dosing, and methizamole can be has to use other parametes, eg, goiter size or measurement of TSI, which I find less centers on the belief that an inactive given in a single daily dose once a patient thyroid gland is inherently less is euthyroid owing to its longer half-life, I reliable. Lastly, studies carried out since Hashizume’s first report (some of which immunogenic. Treating with anti-thyroid have a preference for methimazole. drug but keeping the gland relatively silent Once the patient is euthyroid, one of two included children) report that remissions were no more common in patients treated by adding enough exogenous T4 to keep treatment plans may be implemented: the TSH in the normal range allows the antithyroid drugs alone, or in combination with ATDs and l-thyroxine than those treated with ATDs alone. No studies of maximum opportunity for the immune with l-thyroxine. The combination therapy response to die down and the disease to with l-thyroxine will help prevent hypothy- the two regimens have been carried out primarily in children. remit. This was supported by the study by roidism, which can occur if the dose of Hashizume et al in 1991, but refuted in ATDs is too high or if the thyroxitosis several studies thereafter as quoted by Dr heads towards a remission. Further, a 1991 References 1. Cooper DS. The side effects of antithy- La Franchi. It remains a logical hypothesis study by Hashizume, et al. from Japan and I don’t believe it has been completely reported that the rate of recurrence was roid drugs. Endocrinologist 1999;9:457. 2. Reinwein D, Benker G, Lazarus JH, put to rest to date. Since none of the data lower in adult patients treated with ATDs reported on either side of the debate and l-thyroxine as compared to those Alexander WD, and the European Multicenter Study Group on Antithyroid involved children specifically, there are treated with ATDs alone. Hashizume even more questions regarding the speculated that the addition of l-thyroxine Drug Treatment. A prospective randomized trial of antithyroid drug dose in Graves’ relevance of the studies to this discussion prevented any rise in TSH, which might play a role in stimulating antigen presenta- disease therapy. J Clin Endocrinol Metab 1993;76:1516 A second theoretical reason for the tion and thyroid stimulating immunoglobu- maintenance of suppressive doses of anti- lin (TSI). 3. Hashizume K, Ichikawa K, Sakurai A, et al. Administration of thyroxine in treated thyroid drug, rather than decreasing the Graves’ disease. Effects on the level of dose of drug as tolerated, relates to the This clinician chooses to treat children potential immune suppressive activity of with ATDs alone, for the following antibodies to thyroid-stimulating hormone receptors and on the risk of recurrence of anti-thyroid drugs. The theory is that anti- reasons: First, the combination approach thyroid drugs are concentrated in the requires that the patient take two drugs hyperthyroidism. N Engl J Med 1991;324:947 thyroid and exert an anti-immune effect on when one alone will suffice. Since Graves’ lymphocytes localized there (presumably disease is most common in adolescents, 4. McIver B, Rae P, Beckett G. Lack of effect of thyroxine in patients with Graves’ including a majority of activated lympho- one has a better chance of proper adher- cytes involved in the primary disease ence and compliance in this age group hyperthyroidism who are treated with an antithyroid drug. N Engl J Med process). If the immunosuppressive effect with one drug rather than two. Second, is relevant, then a higher dose for a longer the use of ATDs alone allows one to use 1996;334:220 5. LaFranchi S, Hanna CE: Graves’ disease time might be expected to be more effective the lowest dose of drug, by titrating the in truly leading to a remission than a lower dose against the clinical and biochemical in the neonatal period and childhood, in: Werner and Ingbar’s the Thyroid. 8th dose or a shorter time period. I admit that response. While some of the adverse this reason is also based on controversial effects of ATDs are idiosyncratic, studies edition. Braverman L, Utiger R, eds. J.B. Lippincott Co, Phildelphia, 2000, evidence and there is no consensus show some to be dose related. Thus, use of the lowest dose gives the best chance pp 989-997. to avoid adverse effects. Third, in the continued on page 10 setting of elevated serum T4 concentra- Section on Endocrinology Page 4
  5. 5. Growth Hormone and the Short SGA Child Chairperson’s Column Peter Lee, MD Continued from page 1 Hershey Medical School Penn State Univesristy A significant portion of children Size is not the only issue among In the area of advocacy, the AAP Section are born small for gestational children born SGA. Data suggest other on Endocrinology is an active member of age (SGA). The best available concerns should be focused upon the National Diabetes Education Program data indicate that between 5 and 7 possible impairment of intellectual Initiative to provide guidelines for treat- percent of infants are born small for development, psychological and ment of children with diabetes in the gestational age when defined by functional deficits, and metabolic school setting. This initiative is comprised having a birth weight and/or birth aberrations that may lead to obesity of members of the American Diabetes length more than 2 standard deviations and increased risk for coronary heart Association, Juvenile Diabetes Founda- below mean for gestational age. The disease, cerebral vascular accidents, tion, National Institutes of Health, Centers etiologies are usually not clear and the and type 2 diabetes mellitus. It has for Disease Control, the school system, as majority of these infants experience been hypothesized that fetal malnutri- well as the American Academy of Pediat- catch-up growth. Catch-up growth tion may lead to metabolic derangments rics. We have also worked closely with the begins in early infancy and heights and involving vascular development, Committee on Native American Child weights of approximately 85% of these pancreatic β cell and hepatic function Health to develop guidelines for primary children plot within the normal range (Barker et al. Diabetologia. 1993: 36:62). care practitioners to care for Native for age by 2 to 3 years of age. About Inter-related consequences include Americans with type 2 diabetes. half of the remainder will attain normal obesity, hyperlipidemia, insulin resis- size for age, but the rest are most likely tance, and hypertension (Syndrome X). Overall, this has been an active year. We to remain short. Six to eight percent of There is inadequate information to would like to increase involvement of the children born SGA remain significantly determine whether the risk for these membership in these areas of advocacy short and without treatment will be problems is less among the children and educational programs. Your comments short as adults. In the past, it was who spontaneously achieve normal in the Member Survey were thoughtful and believed that there was no potential height and weight, and certainly no timely. There is much to be done. We treatment for these children. data to suggest improvement of these welcome your participation. long-term consequences with growth While most of these children are not hormone stimulated catch-up growth. considered to be growth hormone deficient using the classical criteria, While there are clearly needs for careful Editor’s Column there is evidence that both growth outcome studies among this entire continued from page 2 hormone secretion rates and insulin- cohort of those born SGA, observa- like growth factor (IGF1) levels range tions among those on growth hormone from normal to subnormal. There has therapy have demonstrated normaliza- also been the suggestion that some tion of BMI, decreased blood pressure, If, despite your best efforts, the demand SGA short patients may have growth and decrease of atherogenic index for endocrine services in your area exceeds hormone resistance. (HDL/LDL). what you can handle, and hiring another endocrinologist is not financially feasible, Recent studies have indicated that Pharmacia has received approval of you should consider hiring a pediatric growth hormone therapy is followed by growth hormone treatment for children nurse practitioner (PNP). RN-CDEs are a normalization of stature for age and born SGA who fail to manifest catch-up invaluable for seeing the large volumes of maintenance of growth along geneti- growth by age 2 years. To stimulate diabetes patients we have, but if you are cally expected percentiles during catch-up growth, the recommended tied up or out of town and have no one to childhood. Although there are limited dosage is greater than the initial dosing cover, they cannot provide any billable final outcome height data, available for growth hormone deficient patients. services in your absence, while a PNP can. data indicate that patients can expect When this higher dosage has been Colleagues who have taken this route tell to attain an adult height within the used, the safety profile is not different me that a good PNP can be trained in 6-12 normal range of sex. Thus, there is now than when the lower dosage is used. months to handle many follow-up appoint- an available treatment for short stature ments and even some straight-forward new that should be considered for these These new data indicate that there is referrals exactly as they would. In these children. Response to growth hormone now a treatment option for that small difficult times, we need to consider all therapy appears not to be correlated subgroup of SGA children who con- options to stay afloat and continue to give with indices of growth hormone tinue to be significantly short for age our communities the service they expect secretion before therapy. and sex beyond 2 years of age. and deserve. Section on Endocrinology Page 5
  6. 6. Bone Mineral Health in Children Barbara D. Johnson, RN, MSN, CPNP Osteoporosis and osteopenia are gener- girls (Ferrari et al, 1998). Racial and ethnic girls and boys lead to decrease in bone ally considered adult disorders. However, differences account for a higher bone mass. Young men with hypogonadotrophic there is increasing evidence that these density in African Americans as compared hypogonadism show a reduction in bone disorders have their origin in childhood. to whites, and the differences seen in mineral density. Testosterone replacement The accretion and maintenance of bone Asian Hispanic and Caucasian youths for up to 24 months improves bone mineral mass is a dynamic process of formation, density (Snyder et al., 2000). mediated by osteoblasts, and resorption, Nutrition/Weight/Physical Activity: mediated by osteoclasts. In childhood Calcium is essential to maximize bone Estrogen deficiency in females leads to and adolescence, bone formation pre- accretion and maintenance. Dietary decreased bone accretion as well as dominates, resulting in a rapid increase in calcium requirements are highest during accelerated bone loss (Soyka et al, 1999). bone mass and size. Peak bone mass is times of peak growth velocity and bone Excessive exercise, anorexia and stress can achieved shortly after puberty is com- mineral accretion, although dietary calcium lead to hypothalamic amenorrhea and pleted and remains stable until the third intake is below recommended amounts in estrogen deficiency. Amenorrheic adoles- decade of life when bone loss begins. American youths cents and young women, both athletes (Bacharach, 2001) Failure to achieve and non-athletes, have reduced bone optimal bone mass presents a significant Body weight, nutrition, and weight-bearing mineral density when compared with risk for developing osteoporosis later in activity are important determinants of bone eumenorrheic girls. life. Nutrition, physical activity, chronic mass. Many chronic childhood conditions illness, genetic, and hormonal milieu are result in vitamin and minearl deficiencies, GH Deficiency: Untreated GH deficiency factors that affect bone mineralization. which place children at risk for low bone can result in reduced bone mineral density mass. Nutritional disorders concomitant in both childhood-onset and adult-onset Factors Affecting Peak Bone Mass with hypogonadism compound the GH deficiency. The persistent reduction in reduction of the bone mass. Excessive bone density seen in adults with child- Gender/Sex Steroids: Differences in exercise may also suppress the hypotha- hood-onset deficiency may be due in part height, weight, bone age, and the timing lamic-gonadal axis, leading to primary or to delayed or inadequate GH replacement. of puberty account for differences in bone secondary amenorrhea and reduced bone Short term treatment with GH does not mass. Males achieve greater bone mass mineral density. The timing, duration and result in increased bone density because than females due to increased body intensity of physical activity determines of the biphasic effect of GH on bone weight and bone size. Although bone whether there is a positive or negative mineralization. A net gain in bone mass is density is affected by both testosterone effect on bone mass. seen after 12 – 24 months of GH treatment. and estrogen, estrogen plays a more significant role in bone mineralization and Endocrine Disorders Resulting in Hyperthyroidism: Untreated hyperthy- skeletal maturation. Reduced Bone Mass roidism in adults can lead to reduced bone mineral density. Although data on children GH/IGF-1: Besides promoting linear Turner Syndrome Low bone mineral is limited, reduced whole body and spine growth, Growth Hormone acts directly on density and increased fracture risk are bone density seen at diagnosis improves bone to stimulate osteoclasts in an initial seen in children, adolescents and women after 12 – 24 months of treatment (Soyka, phase of bone resorption. This phase is with Turner Syndrome. Estrogen defi- Fairfield, & Klibanski, 2000). followed by an increase in osteoblastic ciency as well as subtle abnormalities of activity resulting in a net gain of bone the GH/IGF axis contribute to low bone Other Medical Conditions Resulting in mass (Carrel and Allen 2001). Children mass. However, the reduced bone mass Reduced Bone Mass and adolescents with untreated GHD have seen in prepubertal girls suggests that been shown to have a reduced bone there may be and intrinsic bone defect that Glucocorticoid Therapy: Growth retarda- mass. plays a part as well. tion and osteopenia are common complica- tions of glucocorticoid therapy. Reduced Genetics: Heredity accounts for a high Other Disorders of Gonadal Steroid bone mass results from both the direct percentage of the variance seen in peak Deficiency: The importance of sex steroids effect of glucocorticoid on bone formation bone mass. Polymorphisms for the Vitamin in the accumulation of bone mass in and the indirect effect on the GH/IGF axis. D receptor, collagen type 1a, IGF 1, and adolescents is clear. Any condition which Glucocorticoids impair bone formation and collagen receptors have been identified results in a temporary or permanent increase bone resorption. They also impair and may play a role in determining peak decrease in the levels of testosterone or calcium absorption from the duodenum bone mass (Soyka et al 2000, Kelly 1991). estrogen can lead to reduced peak bone Maternal bone mass is a strong predictor mass which is improved with the appropri- of bone mineral density in prepubertal ate replacement. Delayed puberty in both Continued on page 10 Section on Endocrinology Page 6
  7. 7. ATTENTION SECTION MEMBERS! Lawson Wilkins Pediatric Endocrine Society Section Elections Barbara Lippe, MD March 1 - April 30, 2002 It is time to elect your section executive Dear Colleagues: committee members for the 2002-2003 year. You are encouraged cast your vote The Joint Meeting in Montreal was an international success and makes all the more electronically. poignant the tragic events of September 11. It reminded us that we have to renew our commitment to global health care for children and work harder to make tolerance To vote: of diversity a common goal. 1) Log into the AAP Members Only Channel (www.aap.org/moc). On the left- However, in the United States, working harder as a pediatric endocrinologist is an act hand side of the screen, under the of survival, not of choice. The academic umbrella for the protection of programs that heading “Members,” you will see the must exist to maintain the specialty is no longer in place. Practice has been “priva- subheading “My Sections” and a list of tized”, and the same pressures that face those in the private sector impact teaching all sections to which you belong. and research. Managed care and cost-center accountability are driving many away— and those who remain are over-worked, under paid, and drowning. Consider 2) Select a section by clicking on the the following findings from a recent survey of LWPES members: section name. • At least 70 positions unfilled across the spectrum of practices, and many 3) Select the “2002 Election” link at the will remain unfilled due to “person power” shortages and fiscal constraints. top of the page. Follow the directions on the ballot page to see a candidate • The care of children with diabetes is an escalating drain on time, re- biosketch or vote for your candidate of sources, and energy. Undoubtedly, the lack of funding and resource choice. If you have questions about or allocation for these children will contribute to an emerging health care crisis. difficulty using the Members Only Channel, contact Bob Mitcheff, AAP •The median waiting time for an appointment for new patients without Webmaster, at 800/433-9016, ext 7136 or webmaster@aap.org. diabetes was 1 to 2 months. However, 35 groups responded that waiting time was 3 to 4 months and 10 groups stated that waiting time was greater Ballots for most sections will be available than 4 months. Even for newly diagnosed children with diabetes, the from March 1 through April 30, 2002. waiting time was longer than one month for over a third of the responding If you do not have access to the groups, with “person power” shortage being the number one reason given. Internet, or if you would prefer to vote by print ballot, contact Beki Marshall by Finally, a recent survey regarding the career intentions of pediatric residents con- phone (800/433-9016, ext 4079), ducted by the American Academy of Pediatrics (AAP) and published in the February fax (847/434-8000), or e-mail 2002 issue of Pediatrics (Pan RJ et al.: Pediatr 2002; 109: 182), underscores the (bmarshall@aap.org). findings of the LWPES survey. According the AAP survey, 69% of graduating residents indicated that primary care was their future practice goal, with life style issues being a major factor influencing job choice. The study also found that women are making up an increasing number of the pediatric workforce, and their future choices will likely affect the viability of our specialty and other pediatric specialties. Your Vote Counts! These findings represent a great challenge to all of us—a challenge that we must join together to overcome. To do this, we must draw upon our outside resources and encourage the involvement of all key stakeholders—including professional and patient organizations, government agencies, educational institutions, and industry— to set forth a plan of action to make the changes necessary so that we can continue to provide care for the children who rely upon our expertise. As one small first step in this direction, we will address the subject “Reimbursement Issues in Diabetes Care” during our scientific plenary program at the May meeting in Baltimore. Section Elections available Although my tenure as president of LWPES will end in May, my commitment to the online at: subspecialty of pediatric endocrinology will continue. I am confident, that together, www.aap.org/ moc our voices will be heard and we will be able to affect change that will, ultimately, improve the way we deliver health care to children with endocrine disorders. Section on Endocrinology Page 7
  8. 8. Final Passage of the Membership Survey Results Pediatric Drug Studies Bill Thank you to everyone who completed site would be to post job openings; Released: December 18, 2001 the survey that was enclosed in the develop a PDA downloadable page; Summer 2001 edition of the Newsletter. A include information about endocrinology Press Statement on Final Passage of total of 268 surveys were mailed to issues, drug withdrawals, discontinua- Pediatric Drug Studies Bill members of the Section and 66 responses tion; and e-mail notifications to members By Louis Z. Cooper, M.D., were received (a response rate of 25%). when the listserv has been updated. AAP President Your comments and feedback will help the Executive Committee plan its activities The top three challenges that face "The 55,000 pediatricians of the Ameri- over the next few years. pediatric endocrinologists today and in can Academy of Pediatrics salute the future include: reimbursement issues, Congress for passing the "Best Pharma- Of the 60 respondents (56%) have been workforce issues including increasing ceuticals for Children Act," recognizing a member of the American Academy of workload and decreasing manpower, and the important need to ensure medica- Pediatrics for 10 years and over. In difficulty recruiting pediatric endocrinolo- tions have been adequately studied in addition, 38% have been members gists or other health care professionals children to determine their safety and between 4-9 years. Less than 5% of the specializing in pediatric endocrinology. efficacy. We look forward to the Presi- respondents have belonged to the dent signing this legislation, ensuring 5 Section three years or less. Survey respondents indicated that the top more years of a law that is generating three challenges facing the children they more and safer medications for children. Most responsders indicated that they care for include diabetes, obesity, and belonged to other organizations, with the access to care, including difficulty "As pediatricians, we can not overstate Lawson Wilkins Pediatric Endocrine accessing subspecialist care and inad- how essential information about the Society being the majority followed by the equate insurance. Other concerns applications of drugs in children is to Endocrine Society and the American focused around the child’s home life ensuring we provide the best possible Diabetes Association. including depression, poor parental role care. This legislation represents signifi- model and lack of parental supervision. cant advances in children's therapeutic Attendance at the AAP National Confer- medications and makes important and ence and Exhibition (formerly Annual The Section on Endocrinology has been crucial changes to current law, while Meeting) has been very low. Of the 66 successful at presenting quality educa- maintaining the foundations that have responses received, only 16 individuals tional programs at the National Confer- proven so successful. indicated that they attend the NCE. ence and Exhibition, and developing However, 25 individuals indicated interest policy statements and clinical practice "The Academy applauds Congress, in being faculty for future AAP educa- guidelines, and was commended for most notably the leadership of Sens. tional programs. developing the Section newsletter. Christopher Dodd (D-CT) and Mike DeWine (R-OH) and Reps. Jim Green- Questions 8 and 9 asked for participation Improvements that the Section could wood (R-PA) and Anna Eshoo (D-CA), either in developing or reviewing academy make to serve its membership better for their tireless efforts in ensuring documents, RBRVS issues, working on include increasing reimbursement for passage of this law before it expired in legislative issues, or volunteering for the pediatric endocrine procedures, increas- January." executive committee or one of its subcom- ing collaboration with LWPES, PENS, and mittees. We will keep everyone’s name on Endocrine Society, and offering more file and contact people as needs arise. support for subspecialists. Receive a complimentary cd-rom of Both the Section and the Pediatric The section has already begun to work on Turner Syndrome, Endocrine Nursing Society Newsletters some of the issues that the survey results A Comprehensive Guide received support as a benefit of section indicated are of high importance to the membership. On the other hand, section members. A survey has been developed through Lilly CME Office at: members rarely visit the Ssction web site to determine current reimbursement http://www.lillycme.com/tsform.cfm and it was indicated that the web site practices for obesity diagnosis and or by calling 1-888-920-7959 would be more useful if it includes hot treatment. Results from the survey will be topics, important dates/meetings, utilized to propose new CPT codes that Visit the New US questions and answers, and/or case will allow for reimbursement of services Turner Syndrome Society Website at: studies. Suggestions to improve the web related to obesity and diabetes. www.turner-syndrome-us.org Section on Endocrinology Page 8
  9. 9. Upcoming Events Statement Update.... AACE 11th Annual Meeting Statements in Progress Newborn Screening Fact Sheets - May 1-5, 2002 Technical Report: Prevention and Committee on Genetics (includes Hyatt Regency Chicago Treatment of Type 2 Diabetes in Congenital Adrenal Hyperplasia and Chicago, IL American Indian and Alaska Native Congenital Hypothyroidism) www.aace.com Children (jointly developed with the Committee on Native American Child Statements to be Reviewed by LWPES annual meeting Health) the Section: May 3-6, 2002 Vitamin D and the Prevention of Rickets Baltimore, MD Committee Report: Diagnosis and (developed by the Committee on www.lwpes.org Management of Type 2 Diabetes in Nutrition and the Provisional Section on Children and Adolescents (jointly Breastfeeding) PAS Annual Meeting developed with the Committee on May 4-7, 2002 Native American Child Health) Use of Performance Enhancing Sub- Baltimore, MD stances in Children and Adolescents - www.pas-meeting.org Health Supervision for Children with Statment and Technical Report Turner Syndrome (jointly developed (Committtee on Sports Medicine and American Diabetes Association with the Committee on Genetics) Fitness) ADA 62nd Scientific Session June 14-18, 2002 Intents Breastfeeding and the Use of Human San Francisco, CA Screening for Retinopathy in the Milk (Provisional Section on www.diabetes.org Pediatric Patient with Type I Diabetes Breastfeeding) Meillitus (joint with the Section on Endocrine Society Ophthalmology) Evaluation and Preparation of Pediatric 84th Annual Meeting Patients Undergong Anesthesia (Sectio June 19-22, 2002 on Anesthesiology and Pain Medicine) San Francisco, CA www.endo-society.org American Academy of Pediatrics What’s New on the Members Only Channel! National Conference and Exhibition October 19-23, 2002 www.aap.org/moc Boston, MA www.aap.org √ Academy Launches Pediatrician Referral Service (2/20/02) √ Online Section Election Information (2/20/02) √ Prevnar Update: Nationwide Shortage Continues (2/19/02) √ MEMBER LETTER: Coparent or Second-Parent Adoption by Same-Sex Parents (2/13/02) √ 2002 Babies First Initiative (2/13/02) √ SPEAKING POINTS: Coparent or Second-Parent Adoption by Same-Sex Parents (2/5/02) √ National Election Information (2/5/02) Statements and opinions √ Using the Internet for Pediatric Advocacy Guide (PDF File - 74 pages) (1/22/02) expressed in this publication √ Terrorism: A Family Disaster Plan (PDF File) (1/18/02) are those of the authors and √ OSHA Safe Sharps Regulation (1/9/02) not necessarily those of the American Academy of Pediatrics. √ Locum Tenens and Permanent Opportunities to Serve Native American Children (PDF File) (1/8/02) √ AAP Meetings List √ Effective Communication Video √ Neonatologists and Perinatologists 2001 Directory Section on Endocrinology Page 9
  10. 10. Why we should use antithyroid drugs in Bone mineral health in children Challenges and Implications for combination with I-thyroxine continued from page 6 Practice continued from page 4 resulting in secondary hyperparathy- Adult bone mineral health is dependent regarding the importance of this mecha- roidism and consequent bone upon the attainment of optimal bone nism in the treatment of Graves disease. resorption from increased osteoclastic mass in childhood and adolescence. The theory was supported by a relatively activity. Finally, glucocorticoids However, there are several challenges to old study by Romaldini in 1983, but it has impair peak bone mass formation identifying and treating children who are been refuted by other workers and remains through suppression of the GH/IGF at risk for reduced bone mass. These an open question. Again, it is a logical axis (Cannalis, 1996) include lack of age and gender specific hypothesis and an appealing one to me. normative data, differences in tech- Cushing syndrome is rare in child- niques for measuring bone density, lack The major argument for maintaining the hood. Glucocorticoid excess is more of an accepted definition of osteoporo- lowest possible dose of anti-thyroid drug commonly encountered in children sis in the pediatric age group, and lack has to do with the potential relationship receiving steroids as medical therapy. of consensus on the degree of deficit between dose and side effects of the drug. Reduced bone mineralization is related that places the child at an increased risk This is not an issue with most of the side to the duration of cortisol excess for fracture. Further, there are no large effects with either drug, as most side (Soyka, Fairfield, & Klibanski, 2000) scale, controlled studies that assess the effects are felt to be idiosyncratic and efficacy and safety of various treat- relatively dose independent. Clearly the Cancer: Cancer treatment places the ments in children and adolescents most serious side effect which may be child and adolescent at risk for poor (Steelman &Zeitler, 2000). dose related is agranulocytosis. This is bone mineralization due to the rare with doses of less than 30 mg of combined effects of disease process, Available data suggest that hormonal methimazole and is rare in young people treatment with chemotherapeutic factors, nutrition, body weight, and even with higher doses of PTU. Therefore, agents and glucocorticoids, poor physical activity are critical determi- while surveillance should be maintained nutrition, nants of bone mineral density. Promot- for side effects, suppression can usually prolonged inactivity, and cranial ing healthy lifestyle behaviors such as be safely maintained while adding thyrox- irradiation leading to multiple weight bearing activity, adequate ine to keep the patient euthryoid. hormonal deficiencies. nutrition, calcium and vitamin D intake is However, the major reason that I believe in important in the prevention of bone loss maintaining relatively high doses of anti- Other Chronic Illnesses: Chronic in children at risk. Initiating adequate thyroid drugs is the important reality that disorders resulting in vitamin D, and timely hormone replacement in Graves in children is really quite unlikely to calcium and other nutrient deficien- children with hormone deficiencies is permanently remit. This is particularly true cies may lead to reduced peak bone essential in preventing long-term in the young child, or the one with a large mass. Osteopenia is common in problems. In addition, quantitative goiter, whose thyroid functions are very cystic fibrosis due to both impaired measurement of bone density by DEXA abnormal and who is very symptomatic. It bone formation and increased bone should be considered in any child with is theoretically appealing to be able to loss. Poor bone mineralization is most one or more risk factors for osteoporo- titrate the dose of a single drug in the likely due to the combined effects of sis. Identifying those children at risk for treatment of a patient. However, in my low body mass, vitamin D deficiency, reduced bone mineral density and experience it is very difficult to maintain treatment with glucocorticoids, implementing appropriate measures to the euthryoid state and that frequent decreased physical activity, and modify those risks will help to ensure relapses and confusions regarding the delayed puberty/hypogonadism. bone mineral health in the present as current dose are the rule rather than the well as the future. exception. Therefore, I must respectfully disagree with my colleague. Your opinion counts! Additional references: Romaldini, Joao et al. Comparison of Effects of High and Low Dosage Regimens of Anitthyroid Drugs in the Management of Graves Hyperthyroidism. J Clin Endo Please complete and return the AAP Section on Metab 1983 ; 57 :563 Endocrinology Obesity and Reimbursement suvey Cooper, David S et al. Agranulocytosis Associated with Antithyroid Drugs: Remember - only one response per group! Effects of Patient Age and Drug Dose. Ann To request a survey, please contact Laura Laskosz at Intern Med 1983;98:26 800/433-9016, ext. 4928 or e-mail llaskosz@aap.org Section on Endocrinology Page10
  11. 11. When the Media Call Executive Commitee Interview tips and techniques Roster (adapted from the AAP Public Relations Handbook) 2001-2002 1. Talk from the viewpoint of your audience. Knowing your audience is Chairperson the first step for any effective interview. Every audience has knowledge; education Janet Silverstein, MD and socioeconomic differences. Your tone and manner should be tailored to the audience of the particular medium you’re communicating with. Members Kenneth Copeland, MD 2. Don’t use jargon. Explain any technical medical terminology. The majority of any layperson audience ismost likely a non-medical one; you’ll need to clarify Inger Hansen, MD and explain. 3. Speak in personal terms. A human example always helps readers, Francine Kaufman, MD viewers and listeners relate. Susan Rose, MD 4. If you don’t want a statement quoted, don’t make it. There is no such thing as “off the record.” Anything you say can be quoted. Surendra Varma, MD 5. State the most important facts at the beginning. Remember the Membership Chairperson inverted pyramid. Kenneth Copeland, MD 6. Don’t argue with the reporter or lose your cool. Newsletter Committee 7. If a question contains offensive or erroneous language, don’t Lilliam Gonzalez de Pijem, MD repeat the negative. If you say it, the statement becomes your quotable words. Paul Kaplowitz, MD It’s better to answer with a positive, correct statement. Nominations Committee 8. If a reporter asks a direct question, he is entitled to a direct Stephen LaFranchi, MD answer, generally. Edward Reiter, MD 9. If you don’t know, don’t say “no comment.” These are flag words for Program Chairperson reporters; they may believe you’re hiding something. Say you don’t know, and offer to find out and follow up. Surendra Varma, MD 10. Don’t exaggerate the facts. Pediatric Endocrine Nursing Society Liaison 11. Tell the truth even if it hurts. Deb Welch, RN, MS For more information about working with the media, and tips on generating local media coverage on issues you feel important, Visit us on the please log on to the Members-Only-Channel to access the AAP Public Relations Handbook. Web! The handbook is available at: www.aap.org/moc/pressroom/handbook.htm www.aap.org/sections/ endocrinology Section on Endocrinology Page 11