Pediatric endocrinologist Tariq Ahmad, MD, FAAP, explains how to work up patients with suspected hormonal imbalances, including thyroid disorders, diabetes and growth disorders; discusses interpretation of common tests; clarifies when to refer; and provides guidelines for starting treatment while awaiting a consult. With obesity rates rising – even more so during COVID – he breaks down causes of weight gain in kids to show whether endocrinology – or another type of specialty care – is appropriate.
mm. So I just wanted to uh first disclosed that I don't have any financial gain to be earned from this presentation from pharmaceutical or big pharma. Um and I did want to preface this particular talk that the topic is primary care endocrinology um and a large part of it is due to uh sometimes The burden that we're getting uh in our referral uh packets that we get per week. I put here that we're getting about 35-45 referrals a week now. Um and um my beloved colleagues which are pictured here are are doing our very best to address the needs of the community. Uh Currently we have five pediatric endocrinologist. We are hiring one this summer, which is great news for us and we do have to nurse practitioners that help with this load. Um but I do want to make sure that everybody is aware that any urgent add on um is going to be seen um the week of the referral or within the week of a referral. Certainly there is any um issues that are coming up for the wait is too long. You know, as always you can call our office and speak to the on call endocrinologist so we can discuss what may be going on. But um despite this volume, um we are accommodating everybody. And then the purpose of this talk really is to make sure that I empower you as a pediatrician to at least start an initial work out for the most common endocrine referrals that I'm going to discuss and along with that become more comfortable with interpreting common in the laboratory results. And as I mentioned, um thankfully most of these referrals are able to wait a certain time period, but certainly the urgent ones that need to be seen right away um maybe even uh to go to an er um I want to have that ability for physicians to recognize when that scenario may arise. So the first subject will be thyroid which is one of the more common referrals and probably um the most tested for pathology in anyone's practice. A quick thing about um thyroid tests. And this goes for actually any endocrine tests. Or that labs end up being you know pretty important to establishing a diagnosis and the interpretation of labs can be very nuanced. Um Not all labs are perfect and there are unfortunately some laboratories that may be better than others. Um And there may be even antibodies that may cause false false negatives or false increases in false decreases. So you gotta have to you have to interpret the labs in context and be aware of what time the day a time of day. The lab was also drawn because they're also circadian rhythms with many hormones that can influence results. For example, getting a cortisol in the late afternoon or um, as you probably already know, getting random growth hormones levels, has no diagnostic uh influence, since it is pulsing tile throughout the day, and that labs that are slightly off really shouldn't cause any symptoms or rise for concern. Um This is an example um of january last year, um where we got a referral for hypothyroidism, and you can see here in this particular lab, which was quest diagnostics. Um the reference range was .5 and this had alerted um the referring doctor to establish whether there was a true thyroid disease or not. Um Long story short there was not, but these are things that are not gonna typically cause again, problems, you really have to have something that deviates far from the normal range to really um arise the symptoms. Um, and it's it's true, right? Even not just in pediatrics, but even in adults, everybody wants to blame the thyroid for something. I provided some statistics here from articles um, listening, you know how many adolescent females complain of fatigue and this was from dr gander. Uh, 30% of an adolescent females complain of fatigue. And if you consider the CDCs um, findings in 2017, About 20.6 of our adolescent community is obese. Um, and inevitably these kids are going to get TSH is at some point check, but the reality is in the same age group of adolescents, About one in 801 and 900 kids Are found to have hypothyroidism. Some studies will find it higher one in 500, but the point is that it's not as common as some people may think, and you will pick it up if you tested enough time. Um truly we can identify other reasons why kids are feeling tired. We can think of other reasons, particularly during covid and the shelter in place, um that we're getting into issues with obesity and I just gave one example there of the phone at bed and my wife is just as guilty as a lot of these adolescents um for those in the audience, you know, my wife, please don't tell her. I said that. Um so thyroid function test interpretation. Um I'm gonna start with the TSH Free T four. If you had to get one test, you really just need the TSH, that's the most important one in determining primary hypothyroidism disorders or primary thyroid disorders. Um It's also important to note that the free T. Four can be off or it can flex to it. But again, the TSH is going to trump The 3- four. And then I provided these kind of flows where the TSH may be found to be elevated and respect the free T four, maybe lower normal. So you're thinking more of a primary hypothyroidism picture and then you have situations where the TSH might be low and you have a normal high free T four and now you're thinking hyperthyroidism and then for those who may have actually something like a sick you thyroid syndrome, um, the TSH may actually be the TSH may be low along with a lower normal free T four. This maybe in cases such as anorexia or someone who is severely ill um, or even may have covid considering the times right now. So hypothyroidism um, by far maybe the most common one that you'll see. And the first step to get in your office once the TSH is found to be elevated and on repeat may also still be elevated. Um, is to get these antibodies are approximate sense about and thyroid globulin antibody. And if they're positive one or both, then you've made your diagnosis. This kid has hashimoto's thyroid itis. Now there are situations if they don't, if they aren't positive and this is the most common reason why it may occur is really obesity. Um This deserves its own talk. I have my own obesity talk that I've given over the hour. But the thing that you need to know is that the TSH can physiologically rise in an effort to rev up the body's metabolism to burn the excess calories and that is not going to need treatment that's gonna need weight loss. There are things like medications, lithium being probably one of the more common ones that on the boards that are asked for but certainly respite all Depakote are other examples of medications that can cause um thyroid abnormalities and this could use thyroid medication to help balance it out. I mentioned before that the TSH is can be a little bit off from the normal range as it was in that example I provided earlier and that would be considered just a variant of normal um down syndrome. Kids are at risk for not just Hashimoto's thyroid ideas but also for congenital hypothyroidism. And they have also demonstrated a degree of TSH resistance so they can have um a normally elevated TSH values that weren't for further evaluation and then of course are congenital hypothyroidism. Kids will have negative thyroid antibodies. So here's an example of someone who had true hashimoto's thyroid itis not just the fatigue and tiredness and weight gain, but true um uh genotype of someone with mixed oedema even on presentation. And you can see the TSH was very high here. 750. Of course this is an exaggerated case. Uh something to keep in mind when you're managing hypothyroidism while they wait to see us. Um so the thyroid medications um to be taken on an empty stomach 30 minutes apart from fees and have provided here some dozing to kind of get um your patients started while they're waiting to see us for teens. Generally speaking, the dose can be somewhere between 44 50 50 micrograms once a day for the elementary school kids, we can start a little bit lower and then work our way up so it can start somewhere between 25 37.5 micrograms the thyroid medicine a day. And then what we're gonna do or even your office can do is that you can check the thyroid tests in about 5 to 6 weeks. It does take that long to reach steady state. Uh And then we can go from there within that window, we would be seeing that patient. Um But if for whatever reason the appointments pushed out or you happen to be checking the labs and you notice that they're off, then you can make the adjustment yourself. Um My colleagues maybe even mad that I'm empowering everybody to begin thyroid management, but it really is um As simple as that. Um The the dose adjustments are done every 5, 5-6 weeks after any time you've changed the medication. A little note about congenital hypothyroidism and babies. Um I provided a starting dose that I typically use and most positions will use, which is 10 micrograms per kilograms per day. And then you want to crush the medication between two spoons and then add water. I avoid using bottles or the nipples because then sometimes the medication can be caught there and then baby is a little bit different. Um We want to check the labs in two weeks to make sure the TSH levels are coming down and then every four weeks or every month um We we checked the levels to make sure that the levels are okay. So here's some pearls um of the hype authority. TSH elevation can be uh from obesity like I mentioned before, it doesn't warrant treatment. Um Human anti mouse antibodies can falsely elevated TSH in about 10% of cases. So I will get TSH that are hammer treated. They can do this at commercial laboratories like Question Lab Corps Also note that antibody thyroid antibodies themselves can be found in 10-11 of the population. And these are people without thyroid disease. So it may indicate that they are at risk for thyroid disease. But as long as the TSH is normal you're not gonna do anything about it. And it even it doesn't even warrant a referral because they don't have thyroid disease. They are at risk for it and they can be screened once a year twice a year but they don't need to have any treatment. And then there's no role for getting A. T. Three and hypothyroidism because of the short longevity in the blood medications also won't shrink the glider. I always tell the parents that we're going to start treatment for hashimoto's thyroid itis but the goiter is still gonna exist eventually. It may burn out but the medication doesn't treat that now in the case of hyperthyroidism. When the TSH is low you can get antibodies just like we mentioned before. T. P. O. And our global an antibody. But in this case you're gonna want to get a C. S. I. R. Stimulating immunoglobulin to rule out Graves disease. All right now if the T. S. A. Is negative it could be a false negative. Um If you really think it's Graves we would do an update scan but you won't necessarily do that in your outpatient office. But if they're negative and the antibodies are positive then you may be dealing with something called hashtag psychosis. So this is the early phase of hashimoto's thyroid itis when they're releasing preformed thyroid hormone. Um Alternatively if the thyroid antibodies are all negative then you can actually think of something else like a hot thyroid nodule. Or if someone's getting into medications whether it's grandmother grandpas or someone else in the house was on thyroid medication. Um They may be uh taking the pills. Exogenous lee. So what do we do while we're waiting to have the kids see us? Um And they have graves. Um I I again provided some doses for you to pass all. An initial dose can range anywhere between .4 and .6 mics per kig per day when they're in the acute phase of the hyperthyroidism. So if you get your thyroid function tests and the T. S. I. Is positive, Certainly you can call us. But oftentimes we'll use a dose something around here. I tend to start on the lower side of .4 and simultaneously simultaneously. Uh We use a beta blocker because it takes about two weeks for the tough as all the kick in. So propranolol is the one I like to use. Um my colleagues would use a pen a law. Um and then here is a case where you like to get T3 levels because the TSH will remain suppressed for a long time. I was giving this talk just the other day to the residents and I was joking. The TSH is like the ever given and the Suez Canal, it takes a long time to kind of move around. So the free T four and T three will respond much faster once you start the treatment, the TSH while it may still remain low, you'll see um The normalization of the free T four and T three, uh side effects that you've always been taught to look for in med school with proposal is john Davis and neutropenia. However, they're quite rare thankfully. Um the most common one you'll see is rash and as long as you don't see tongue swelling or any kind of hives that will impede the airway, I just use Zyrtec and many times it will just get better with the Zyrtec along with the proposal, I did provide this for you as well, being in the community and doing amazing things you do for our newborns. You are going to come across moms who do have grave's disease And it's important that you be aware that there is a condition that can happen neonatal graves. It only happens in two of the pregnancies of moms with graves. But it is something that we have to look forward to avoid this uh scenario here. An undiagnosed neonatal hyperthyroidism. And in order in order to prevent it, you're gonna be looking for the antibodies in the cord blood or in the first day of life in the infant. And as long as the T. S. I. And the TSH receptor blocking antibodies are gone. You're in the clear. But certainly if they're there, even if the T. F. T. S. Are normal You're going to have to follow it every couple of weeks. The antibodies that are that is until they're gone and that can take up 6-8 weeks. Um So along with the antibodies as you're checking them you're gonna have TFT is done to. I provided a protocol here and I believe Maria will have all these slides available for you. So you can kind of look upon them now when the call ends or when is there an emergency? Certainly will always be available if you want help with dozing or to expedite an appointment that needs to be seen sooner. Um If there's an asymmetry to the thyroid on pal patient or if you notice a mass on a side then that will also lead to a little bit more urgency. And I would also even recommend an ultrasound to be done while waiting to see the kids. Even if it's the next day or two days, you might as well just get the thyroid ultrasound done. Um And when there's a storm, in the case of hyperthyroidism or in Graves disease, we considered a medical emergency. And oftentimes you'll hear my colleagues and myself just say send the kids to the er to determine whether they actually are stable fever, persistent sweating, intractable headaches. These are gonna be clues that they may be actually um having a storm um and it's always better to be safe than sorry. We find out that they're okay are stable in the er then we can send them home on top. Is all from there. Alright, obesity referrals. We have four topics, so this is the second one. Um The obesity by far has been so common right now in this covid epidemic. There was a recent thing on NPR I don't know if anybody heard um that there was about a £7 weight gain among among the pediatric population during the shelter in place. And even in our own clinic were actually diagnosing much more type two diabetes. Then we did compared to pre covid. And we have an abstract actually submitted to a. D. A. American diabetes association and hopefully that will get accepted. But the main cause of obesity usually is still going to be exogenous obesity. That is to say that excess caloric intake is just in in uh is more than the caloric expenditure. And I provided here a graph of what is typically seen obesity here with the weight gain and but notice that the high velocity is unaffected. So if anything, the height actually may even increase. Um So the highest philosophy is unaffected you even sometimes we'll see that the height relative to the parental height is going to be taller. Um And then there's gonna be this history that's been happening for many, many years. It wasn't just over the last year or two. In other words, you may have other family members that may give a clue that there are, you know, uh certain surroundings and environmental cues that may be uh stimulating this kind of excess caloric intake. Um The body habit is overall is going to be a large unlike in cushing's or creator willy where the there's more thinning of the extremities with central obesity. Um and without any abnormal labs, there's really no reason to refer those kids because, you know, unfortunately, we are not a weight loss clinic. We really can only deal with this population should they have an existing in the Quran apathy. And so it does come to prevention. Of course we want to avoid that they're overweight. Um, at those teenage years or you know, even 10 or 12. And I wanted to just introduce the concept of out of poverty rebound if you, if you're not familiar with it already. And this is in reference to the lowering of the BME that occurs around 4 to 6 years old, um, kind of the loss of the baby fat if you will and then just kind of gradual games since after that. But there are studies that have looked at this data possibly rebound and found that you can actually have predictions of adult obesity if someone has the rebound occurred earlier, if they are overweight at the time of the rebound. And interestingly if even if they were normal at the time of the other, possibly rebound if one of the parents was overweight And they were normal at the time of the rebound, there's still a 4-5 times risk for adult obesity later in life. And of course if both parents are overweight, even if they're again have a normal, uh, possibly rebound, there's a 13 times risk. Um So I think again, starting as early as possible is the best way to prevent the obesity. Um so here I was mentioning earlier, the rising um, type twos that we're seeing in our clinic. Um this is the incidence of Type one is the maroon, uh sorry, Type one is the dark maroon type twos. This lighter purple. Uh and you can see Type one actually was pretty much unaffected um as we were going through this covid epidemic. But this little blip right here is indicative of the increase and incidents of our Type two diabetes population. You can see here um again, type two diabetes uh post covid this subtle increase that's been happening here. Pre Covid and post covid. And as the projections go further and like I said, we're seeing this in february and March. Um we're getting about 60 once that diabetes a week right now in the hospital. All right, So when to refer to endocrinology and here's a quandary, right? Because a lot of times the knee reflexes to just go to endo. But the truth is, and I'm sure many of the pediatrician, many of your community pediatricians are doing this already. There are so many organ systems affected when someone is overweight and G. I. Is certainly want to think about with none alcoholic Seattle hepatitis um or individuals who have Ortho problems like back problems and need problems. And certainly sleep studies have to be screened for um obstructive sleep apnea has to be screened for in this population. Uh It goes without saying that a lot of, especially again in the in covid and with the stress and the social isolation and anxiety that depression has increased as well as stressed. So there's so many other places to refer besides endocrinology. And as I mentioned before, really, the only time they refer to endocrinology is when there are sexually um that we're thinking about that are occurring from the obesity, whether it's pre diabetes, this lymphedema, as you know, or hopefully now we do have a pre diabetes clinic and a leopard E mia, this lymphedema clinic uh and of course type two diabetes. Um but probably said to Bulgarian syndrome is another one um that we tend to manage quite a bit the times that you think about genetic etiologies. Armani genic ideologies. The clues would be delayed milestones. Um This morph is um so these are gonna be like um Prader Willi syndrome or Beckwith Beckwith Wiedemann syndrome. Um Beckwith Wiedemann um we'll have the pollen actually. Prater willy will have may have micro penis or hippo Tonia when they were born. Um Sotos syndrome is another example of uh of obesity, but again, they're gonna have delayed milestones and that's the key right. If they are doing well in school and reaching the milestones appropriately it's not likely to be genetic. Um And then I mentioned here to obesity during the first three years of life, um there are things like empty for our mutations that think about which occur about 5% of the obese population. This like very obese population. The thing is, there is no treatment right for EMC for our mutations, you just gotta watch clerk intake and exercise. So as far as the initial screening we recommend um for the obese population is an A one C. And many. Uh the community physicians know this and this is how initially we're picking up so many um of our new onset tattoos particularly. Um we must be getting gush about. It seems like two or three new onset type twos in the outpatient setting. Um And so when you're during that screen, when you're doing that screen you're getting these A one CS that are greater than 6.5% um to try to help us uh and get things going. I think I might have it on a different side, but we're recommending that the primary care physician physician go ahead and get the type one antibodies just to rule it out. But then we give um I have it on a different side to kind of give some guidance on starting Metformin and and lifestyle changes. Other things to think about with the screening are the lipids that are fascinating and then a complete metabolic panel to check the liver. Um the thyroid as rare as it is. We still want to check it because we don't want to get burnt and has someone actually have a miss hypothyroidism. The way to check for ketones and glucose, There is no role for passing insulin. It's not gonna change anything. It's not going to change our management. If it's high it's because their insulin resistant and it's not a surprise the clue will be. They'll have the emphasis micro cans of the darkening and the Xeloda. Um and if the sugars are normal and a one C is normal and the insulin's high they are compensating they are doing the pancreas is working overtime in order to keep themselves from having diabetes. And hopefully they get to a point where they can either increase their sensitivity and avoid diabetes or they get to a point where they actually do get diabetes. Um Whereas it maybe cushing's um you've got to think about moon faces and strike. And I've even provided the protocol that I've given to many of you already, who I talked to. This is something that can be done in your clinic. You just give deca drawn one mg tablet at 11 PM chicken eight AM cortisol. You do a cortisol. That that's less than 1.8. You ruled out pushing the rarest of rare. So been here, what since 2006 like I mentioned and I've seen to cushing um out of all the obese patients that I have had now, polycystic ovarian syndrome um is also one that can be screened for. Um And the work up may include all this stuff that I mentioned here and then in the females who have a regular period, you may want to include these other laboratories I mentioned are lipid clinic. Um that's run by dr june june tester. Um I provided again these slides are available for you the criteria that she has given to us so that people can qualify to be seen in her clinic. Um I won't go through the details and the nuances of where the levels should be. But again these will be provided to you so that you have some guidance is what you need to do or whether they need repeat. Um triglycerides like here. If the triglyceride is 200-300 um to check it again and if it's still in that range, then go ahead and refer as far as the management like I mentioned. Um While we're waiting for them to see us whether it's pre diabetes clinic or to display academia clinic um lifestyle modification is not just for the patient but for the whole family. Um It's obviously important not to put a target or make someone feel like the black sheep and more often times than not it is that the whole family can benefit from the lifestyle modification. So I tend to push the mediterranean mediterranean diet, so more protein and then lower on the carbs and eliminating simple sugars and fructose, um smaller portions etcetera. And then over time you know hopefully the stomach starts to shrink so they feel more full more easily. Um and then as far as exercise it's not like they need to run marathons or they need to necessarily um if they join sports that's great. But just walking 20-30 minutes a day. Um it's less than what the ap dictates, which is an hour a day. But honestly um kids are just so busy and we got to be realistic To what they're um issues maybe as far as again homework and friends and social life etc. And I think 30 minutes is certainly more than they were probably doing before. As far as the pcos management, it's going to be all the same things as a lifestyle modification. Um But then we have some treatment um Again that can be started on the outpatient or in the pediatrician's office. They may include Metformin to sympathize uh the individual the insulin that could be OCP. So I tend to use this as my last line of treatment. The rural conscious of the bills and then if the her statism is really bad um or the facial hair growth for her statism, then I consider spironolactone or anti androgen as well. So managing type two diabetes, I mentioned the times the call Uh if you have an obese individual in your clinic and they actually have an a one c of 9%. The studies appear to show that Metformin by itself will probably not do the trick. And these kids generally will need insulin teaching. And as you know with our institution we do our insulin teaching and impatient. But if they happen to be less than 9%. Um and it really has a genotype of the 18th Asus and overweight and they're clinically stable, then I provided some guidelines to start the Metformin as long as the LFTs aren't too elevated. And again screen out the type one diabetes just in case they may be one of those obese type ones. Um And then here the education things that I mentioned before reducing carbs to 60 g per meal. Um Trying to avoid bedtime snacks, eliminating simple sugars and then increasing your exercise and then to refer uh the patients to be educated and that and we'll see them as an outpatient in a month or so. Um So when the call endo again um if you're thinking about a syndrome or if the height velocity is falling you got to think more of a medical issue. S. A. One C. Is greater than 6.5% in obese and obese pre puberty child. So usually tattoos in puberty all kids. If you have a pre puberty child and it's greater than 6.5 even if they're obese you've got to think that it might be type one. Um bacteria policy area politics usually means the agency is going to be about 9%. Um And then if you have of course MSs with kitchen area you worry about D. K. A. Some of the pearls. There is no quick fix, right? You gotta tell this family is going to take some time to get to maybe the weight that they would like. You got to treat the family. I already mentioned before that the TSH can be normally elevated. Um But really it's about maintenance and maintaining that lifestyle and one important point you don't have to lose weight necessarily. As long as you do the carb decrease eliminating fructose, exercising more. Even if you don't lose weight you actually can still normalized by seeing the control and even improve lipid levels. All right. The third one short stature. Another very common referral thankfully a referral that usually is going to be with benign outcomes. That is to say they're either going to have familial short stature, the parents are short, um or they're going to have delayed puberty, okay? Or constitutional delay of growth. And there are some signs when you gotta think about pituitary problems, whether it's a central upper incisor, honestly, I've never seen it. Um but this is a central incisor, Here is an example. Um but more commonly that you might be wary of is a micro penis or a history of hypoglycemia. They have this kind of cherubic appearance as an infant, the michelin baby appearance or like those angels in the Raphael painting, The Falling Height Philosophy I mentioned before is always kind of a clue. Uh There's one caveat to that, remember in the first 2 to 3 years of life, you're born a reflection of your intra uterine environment. So your birth links maybe a certain length. But then genetics takes over after that. And then you start to shrink towards where you're supposed to be. Uh I don't have much time, but my kid is an example of this, right? My kid was born like the same height as Shaquille O'neal's kid, I like to say, but I warned my wife um that The kid my kid is going to fall to the 3rd%ile in no time. And sure enough, over the first year or so, he started falling. And it was normal. It's just genetics, The history of SDA is super important that I just want to. Um and I think I'll address it a little bit later. But those who are born small for gestational age, about 10 of these individuals may have growth failure and they may benefit from growth hormone. And if you have someone with severe short stature is defined by a 2.25 negative sts for height. Or if someone even is below two standard deviations below their mean parental target height, then I think it's worth uh endocrine evaluation. So what is the initial work up that we recommend? Um Again, these all can be done in the pediatrician's office. Growth hormone surrogates I G. F one I G F C. P three. Just be careful that the lab doesn't get the I. G. F. B. P. One. So it's the idea of one that you want. We evaluate the thyroid and certainly in females we don't want to miss Turner syndrome. Remember only about 50 of turner women will have the classic web neck. Um only about half of them will also have cardiac anomalies, but all of them will have short stature, 90 of them will also have ganado failure. But if you're making the diagnosis based on primary and gonorrhea, or delayed puberty development, you're going to miss the boat because by then they're already 12 or 13 and they missed out on growth hormones. Getting a bone age and again, following their growth velocity is super important. No role for random growth hormone levels because of the possibility. But consider the other system, whether it's G I like celiac or IBD, consider anemia, consider renal tubular acidosis is not just endocrine, right? But other systems that could affect growth have to be considered. So when the call endo fortunately there are no short stature emergencies when it comes to short stature. Um we will try to expedite those who do have an indication and maybe even coming to a slate, the average age of a girl diagnosed with Turner syndrome is nine years old. So I've seen girls even diagnosed by 12 years old and we're really trying to get them uh as soon as possible so that we can start them on growth hormone and get whatever benefit we can. Same thing goes with S. G. A. Kids with growth failure a lot of times they're following their growth velocity. Okay. And then what happens is they will accelerate through puberty really fast and their bones age accelerated really fast. And then you got to be careful because again, you missed the window when you could've treated them with growth hormones. Um some pearls regarding short stature, make sure the measurement technique is right. Um My medical assistance outside the store, so I'm going to wait for this. But I always Have to measure my patients myself and often times I'll get different in measurements as much as one cm, believe it or not. Um and you can see the technique here and the biggest mistake or the most common mistake. What happens is that the kid kind of looked up at the person measuring them and the minute they look up they lose the crown. And that can change that half centimeter, one centimeter difference. So the octopus is touching the back, you're getting too high level. And then of course the hits and the heels are touching the back of the wall and then as far as the baby lying down, making sure that you have a lot of people keeping that spine straight. So I have one person taking the pips. The parents are taking the head of the baby and then I'm adjusting the block of the feet to make sure I have a straight spine on the uh supine baby. Um Other things to think about is using the right graph. So remember these E. M. R. S. Our electronic medical records, they don't distinguish between length and height. So when you measure a length and you plotted in the EMR it might be putting it on the height curve and then as you're following length and then you go to a height it will drop, Your height percentile will drop. So just think about how to interpret those graphs appropriately and also emphasizing to the families, you know like if they're not meant to be tall and you're speaking to a guy who's five ft six here, you can't tell on this uh on this remote zoom link, but I'm not the tallest guy in the world, taller is not necessarily better. We don't want to give kids a complex that it's an issue if they're not reaching a certain height. Um Growth hormone is unlikely to have any benefit once um on an end adult height once puberty has started. We often get referrals 13 years old or or whatnot for growth hormone options. There really isn't any growth hormone options because there's no data to suggest that they will benefit from growth hormone once puberty has started. Um and also insurances are no longer, this was different back in 2005 2006. I grant you um kids with ISS. already public service sector, we're getting covered with growth hormone that those days are gone. So um it is going to be something out of pocket generally um if kids are going to want growth hormone for idiopathic short stature and as I mentioned before being mindful of the sda kids. So in the last 5:10 minutes I just Wanna do the last common referral. Precocious puberty referrals. And um many of you already know that precocious puberty has been defined as less than eight years old. And females. And really the breast buzz or telarc er gonna what defines um on clinical exam uh puberty and a female. As for boys the age is a little bit later hired a nine years old. And boys and go net are key or the testicular enlargement greater than four CCs is going to be the indicator that they've started puberty. The key is that. Andrew anarchy which is very common, is not the same as going at Arche. So we get a lot of referrals for premature and anarchy. And I'm not I'm not saying that they're necessarily maybe uh an abnormality or I'm sorry that it is wrong to send someone with an anarchy to us but most of the time it's going to be a benign condition. Um And a lot of the work up can be done in the ambulatory setting. And then certainly if there are some laboratory uh labs that come back then you can have the endocrine kind of uh do further evaluation. Some risk groups for and anarchy include certain ethnicities like Latina, hispanic, uh South asian, um mediterranean, uh those with cns abnormalities, those with cerebral palsy. Um those who had prematurity and small for gestational age and the symptoms that you think about. Uh the kids are body odor, acne etcetera. But most importantly, no tail arche and females and no going that are key in males really. So it's going to be all kind of findings that would be associated with Andrew organization without the enlargement of the test. So I just pointed it out here again, no teller came and girls including vaginal spotting and no enlargement of the test. And in these individuals they do not seem to have an end adult height. That is different from where they were supposed to be. One of the concerns is that, well, if they're going through and anarchy early, their bone ages even advance, which it often is in and anarchy that they're going to be shorter. But if you look at their height relatives in the mid parental target height, more often times than not, they're actually going to be taller than where they're supposed to be compared to the mid parental target height. So they're just getting to where they're supposed to be faster as far as thing is that we still have to be careful about. Although we generally say it's a benign condition, we have to understand that there are studies that have shown that the there is an association with insulin resistance pcos and metabolic syndrome later in life and that may be related to the fact. Well first I should uh mention that we don't know what causes and monarchy premature and anarchy. But we do know other than the risk groups are involved that there are also certain pena types whether it's the overweight individual for example um that may have some risk for premature and anarchy. And of course those are also people who are at risk for PCO. That's an insulin resistance. Same thing goes with SDA kids which are also more at risk for insulin resistance. So it does beg the question in premature and anarchy. Is there some relationship with insulin resistance and um the awakening of the adrenal glands? So the workout for premature and anarchy is to uh as I mentioned before, to get a bone AIDS which may be slightly advanced but at least give you a clue as to where they're heading as far as their end, adult height and A. D. H. D. H. S. The sulfate it form which occurs at the level of the adrenal gland. To rule out any kind of adrenal process the androgen um uh androgen uh precursors such as interesting die on. Uh And then of course the androgen itself testosterone as part of the work up. And then 17 HP will help rule out nonclassical adrenal hyperplasia. I mentioned before the end adult height is not impacted but they are at increased risk for these metabolic type syndromes. Um And these uh may indicate nonclassical adrenal hyperplasia, 17 oh HP. And elevations of the A. G. S. And testosterone. Now to work out for precocious puberty will include everything for premature and anarchy essentially. Plus the actual hormones that will lead to tailor key like extra dial and then LH and FSH in the morning to detect the pituitary gonadotropin in the boys. You would get the testosterone rather than extra dial of course. And then we get the A. C. G. And F. B. Tumor markers. Um And again this is all this can all be done on the outpatient while they're waiting to see us. Um And sometimes I will get or make mention to my colleagues in the community to consider getting a public ultrasound. Uh And that way we can check the ovarian volumes to look for puberty size and uterine length, which is also there are normal for age to determine that they have entered a pupil state. Um Getting a good history because of course someone that says that they had breast development let's say at 7.5 years old. They may have noticed that at 7.5. But truly the breast buds may have started even earlier than seven. And it's hard, it's hard to determine that and a lot of times that's what leads me to do head M. R. S. Even though generally uh females less than six are the ones that we worry about. Uh There are some studies that show if you get the precocious puberty, you know seven or after that, the likelihood of a central process is very low. It's hard without a good history. Um If someone says that they had to l arche at seven years old but you can't be sure I go ahead and get the head of my, it's not worth losing sleep over. Um And then for boys also consider getting scrotal ultrasound. So when the call indo um Precocious puberty and mailed always has to think about organic etiologies as opposed to females, which is usually idiopathic, You're gonna call um when you see a precocious puberty in the mail now in females, certainly if you have um the female who's younger than six years old or advanced development, like many men are key at an earlier age as well, then we want to intervene usually sooner rather than later in case there's some unfortunate psycho, social or psychological um issues that may occur with Covid. A lot has been done remote. So a lot of these kids have that I've seen has um opted not to do any treatment and just to kind of deal with it at home whether they change their mind once they go back to in person learning, I'm not sure. But the red flags headaches, eh missus vision problems, the propia bilateral home. And these are gonna be red flags that something is pushing on the pituitary axis or the optic nerves at the optic eye ASM um In which case we have to do an MRI and rule out some centrally theology. Um Just this week or not curious, sorry, as another red flag. Um So the precocious puberty pearls here that adopted Children are increased risk. Um because security females are generally benign phenomena. The red flags, we think about our headaches, factory of vision changes because it's puberty. In males, you've got to rule out pathology. You also want to differentiate between fat and glandular tissue um In are more overweight young kids. Um And generally an adult height appears to be normal. Uh Precocious puberty occurs after eight years old. So if you do use loop Ron or suppression or any kind of generate agonist. For those who started central precocious puberty and they're already eight or nine, um it's not going to improve their end adult height, but then you're treating them mostly for the psychosocial reasons whether they want to be more like their peers or, you know, go through puberty tempo along with their peers at the same time or so that they won't be um peas or picked on by their classmates. So I just want to thank everyone again for listening. Um I just hopefully uh will make everybody feel comfortable comfortable with the fact that they can start so much of this work up done in the in their clinic themselves, but we're always going to be available by phone call. Um I'd like to think that we're always available and certainly if we're not, please let me know personally, I speak to those who are not getting back to you. Um And with that I think I left enough time for some questions. So thank you again for all your support. We appreciate all the help that you give to our patients, uh an assistant in their care as well.