Bone age advancement in prepubertal children with obesity and premature adrenarche: possible potentiating factors

Variant pubertal development in Prader-Willi syndrome: early and slow progression of pubarche with normal age at gonadarche

Introduction

Prader-Willi syndrome (PWS) is primarily caused by a paternal microdeletion of the 15q11-q13 region, maternal uniparental disomy (mUPD) or unbalanced translocations. The MKRN3 gene, located within 15q11-q13, is a master regulator of pubertal initiation. We aimed to compare variant pubertal onset and progression with recent normative data and to correlate it with abnormal MKRN3 gene status.

Methods

Age at pubarche, gonadarche, subsequent pubertal progression and bone age (BA) at gonadarche were investigated in 37 PWS patients (18 females) who already entered pubarche and/or gonadarche with median age 11.1 (95% CI: 6.4 - 18.8) years. All patients were re-tested to confirm genetic subtypes of PWS. The MKRN3 gene was analyzed using single gene sequencing.

Results

Out of 37 subjects, 22 had microdeletion and 15 mUPD. Regardless of genetic subtypes and MKRN3 gene status, no correlation between genotypes and the pubertal pattern was found. They initiated pubarche early - girls at 7.4 (95%CI:6.4-8.4), and boys at 9.2 (8.2-10.2) years. The subsequent progression from PH2 to PH4 (pubic hair development) was prolonged to 3.7 years in girls (1.5-5.9;p<0.05), and 2.9 in boys (2.2-3.6;p<0.001). The age at gonadarche was adequate - 10.0 years in girls (8.8-11.2), and 11.0 in boys (9.8-12.1). Progression rate of breast development from B2 to B4 was 3.9 (0.2-7.5) years in girls and of testicular volume from 4 ml to 15ml was 3.8 (0.0-8.1) years in boys. The BA at gonadarche is advanced by 0.6 ± 1.1 years (p<0.001).

Conclusions

Children with PWS, regardless of the genetic subtype and/or MKRN3 status, had an early pubarche and normally timed gonadarche. Pubarche progression was slower. Advanced BA was significantly correlated with gonadarche.

Correlation of bone age development with overweight and obesity in 23,305 children from Beijing

PURPOSE

The aim of this study was to observe the influence of differential nutritional status on bone age (BA) change according to body mass index (BMI) and analyze the risk of advanced bone age in children with overweight and obesity.

METHODS

In total 23,305 children from Beijing were included in this cross-sectional study. Childhood overweight and obesity were defined according to the China and World Health Organization growth criteria. The data were analyzed by the R coding platform version 4.3.0.

RESULTS

Under the Chinese criteria, 29%, 15%, and 4% of boys with overweight; 33%, 33%, and 3% of boys with obesity; 39%, 25%, and 2% of girls with overweight; and 37%, 42% and 1% of girls with obesity had advanced, significantly advanced and delayed BA, respectively. After adjustment, overweight (odds ratio, 95% confidence interval, P under the Chinese criteria: 2.52, 2.30-2.75, <0.001 and 4.54, 4.06-5.09, <0.001) and obesity (4.31, 3.85-4.82, <0.001 and 14.01, 12.39-15.85, <0.001) were risk factors for both advanced BA and significantly advanced BA.

CONCLUSIONS

Different nutritional statuses lead to differences in children's BA development. Children with overweight and obesity have higher rates of advanced BA under two growth criteria, and girls have more advances in BA than boys do. Overweight and obesity are risk factors for advanced BA.

Body composition in prepubertal children with idiopathic premature adrenarche: implications for cardiometabolic health

BACKGROUND

Premature adrenarche (PA) has been reported as a potential precursor of metabolic disease. We aimed to explore the interaction between body composition and cardiometabolic health of prepubertal children with PA.

METHODS

This observational study comprised of 87 children with PA (15 boys, 8.0 ± 1.2 years) and 87 healthy sex- and age-matched controls. Body composition was measured by bioelectrical impedance analysis.

RESULTS

Children with PA had a higher median BMI z-scores (P = 0.001), higher median fat percentage (P = 0.006), and lower muscle-to-fat z-scores (P = 0.050) compared to controls. There were no significant group differences in blood pressure percentiles and lipid profiles. Fat percentage of children with PA was positively correlated and the MFR z-score was negatively correlated with: BMI z-score, systolic blood pressure percentile, and atherogenic dyslipidemia index (P < 0.001 for all). There were significant correlations between parental and offspring MFR z-scores in the control group (father-child: r = 0.528, P = 0.020; mother-child: r = 0.359, P = 0.031), but none in the PA group.

CONCLUSIONS

Children with PA exhibited an unfavorable body composition in association with their metabolic health even before the onset of puberty. Furthermore, while healthy children displayed heritable body composition traits, children with PA did not, possibly suggesting a relatively greater role for environmental factors in the PA group.

IMPACT

Prepubertal children with premature adrenarche have a low muscle-to-fat ratio compared to healthy sex- and age- matched controls. The body composition of prepubertal children with premature adrenarche is associated with their systolic blood pressure percentile and atherogenic dyslipidemia index. Children with premature adrenarche and healthy weight exhibited higher adiposity compared to healthy weight controls, and those with overweight/obesity showed higher rates of elevated blood pressure and higher dyslipidemic atherogenic indices compared to overweight/obesity controls. These findings highlight the importance of early identification, intervention, and lifestyle changes for children with premature adrenarche to help prevent cardiometabolic complications.

Association between bone age maturity and childhood adiposity

BACKGROUND

Evidence shows that overweight and obesity are associated with advanced bone age (BA).

OBJECTIVE

To analyse the effect of adiposity on BA among Mexican children.

METHODS

This cross-sectional study included 902 children (5-18 years old). Anthropometric measurements, dual-energy X-ray absorptiometry (DXA) and automated hand X-ray-based BA measurements were obtained. BA curves of children stratified by sex and age were created based on nutritional status. We also calculated odds ratios for advanced BA associated with the body mass index (BMI), waist/height ratio and adiposity estimated using DXA (total and truncal fat mass).

RESULTS

Participants with overweight/obesity by BMI (SDS ≥1) advanced earlier in BA than did normal weight participants (6.0 vs. 12.0 years in boys and 6.0 vs. 10.3 in girls, p < 0.01); similarly, participants with a greater body fat percentage (SDS ≥1) exhibited earlier advanced BA (7.5 vs. 10.0 years in boys and 6.0 vs. 9.6 in girls, p < 0.01). Differences were also observed according to the waist/height ratio and truncal fat. Children with a BMI or DXA SDS ≥1 had greater odds of presenting an advanced BA of more than 1 year (OR 1.79-3.55, p < 0.05).

CONCLUSIONS

Increased adiposity in children, mainly in boys, is associated with advanced BA at earlier ages.

Association of childhood dehydroepiandrosterone sulfate concentration, pubertal development, and DNA methylation at puberty-related genes

OBJECTIVE

High concentrations of dehydroepiandrosterone sulfate (DHEAS) often precede premature puberty and sometimes polycystic ovary syndrome (PCOS). We hypothesized that the underlying mechanisms might involve DNA methylation. As an indicator of the downstream effects of DHEAS, we looked for associations between prepubertal DHEAS concentration, pubertal progression, and DNA methylation at puberty-related genes in blood cells.

DESIGN

Blood methylome and DHEAS concentration at 7.5 and 8.5 years, respectively, were analyzed in 91 boys and 82 girls. Pubertal development data were collected between 8.1 and 17 years (all from UK birth cohort, Avon Longitudinal Study of Parents and Children [ALSPAC]).

METHODS

Correlation between DHEAS and pubertal measurements was assessed by Spearman's correlation. DHEAS association with methylation at individual CpGs or regions was evaluated by linear regression, and nearby genes examined by enrichment analysis and intersection with known puberty-related genes.

RESULTS

Boys and girls with higher childhood DHEAS concentrations had more advanced pubic hair growth throughout puberty; girls also had advanced breast development, earlier menarche, and longer menstrual cycles. DHEAS concentration was associated with methylation at individual CpGs near several puberty-related genes. In boys, 14 genes near CpG islands with DHEAS-associated methylation were detected, and in girls, there were 9 which included LHCGR and SRD5A2; FGFR1 and FTO were detected in both sexes.

CONCLUSIONS

The association between DHEAS and pubertal development, as reported previously, suggests a physiological connection. Our novel findings showing that DHEAS concentration correlates negatively and linearly with DNA methylation levels at regulatory regions of key puberty-related genes, provide a mechanism for such a functional relationship.

Premature pubarche in Prader-Willi syndrome: Risk factors and consequences

OBJECTIVES

Children with Prader-Willi Syndrome (PWS) may develop premature pubarche (PP). We investigated the frequency of PP, and its potential precursors and sequelae, in PWS.

DESIGN, PATIENTS AND MEASUREMENTS

A chart review of children with PWS treated at our institution between 1990 and 2021 was performed. PP was defined as Tanner stage 2 (TS2) pubic hair in girls <8 and boys <9 years old. Demographic, anthropometric, and laboratory data were collected to assess predisposing factors and consequences of PP in comparison to patients with PWS who had normal pubarche (NP).

RESULTS

Analysis included 43 children with PWS, 23 (53.5%) with PP and 20 (46.5%) with NP. Median age at pubarche was 7.0 years in PP group and 10.0 years in NP group. Age at pubarche was not correlated with age of recombinant human growth hormone (rhGH) initiation, body mass index (BMI) z-score, or homeostasis model assessment of insulin resistance (HOMA-IR) at pubarche. BMI z-score at pubarche was modestly correlated with degree of pubarchal BA advancement (p = 0.033). Those with PP were more likely to have a lower high-density lipoprotein (HDL) (1.05 mmol/L vs. 1.41 mmol/L in the NP group, p = 0.041). The difference between target and final height did not differ between groups (p = 0.507).

CONCLUSION

PP is common in PWS but does not compromise final height in comparison to the NP group. Obesity and insulin resistance were not associated with PP in children with PWS, contrary to what has been seen in obese children without PWS.

Association between sex hormones and bone age in boys aged 9-18 years from China

This study aimed to analyse the association between sex hormones and bone age (BA) in boys aged 9-18 years, both individually and interactively, and further to explore whether nutritional status may influence this association. A retrospective analysis was performed among 1382 Chinese boys with physical measurements, sexual characteristics, BA radiographs and sex hormone indicators from February 2015 to February 2022. A total of 470 (34.0%) boys had advanced BA. BA was positively associated with estradiol, luteinizing hormone (LH), follicle-stimulating hormone (FSH) and testosterone in both advanced and normal BA groups after adjusting for age, genetic height and body mass index. Multiple logistic regression showed that after adjusting for covariates, estradiol (odds ratio [OR] = 1.66, 95% confidence interval [CI]: 1.14-2.12), LH (OR = 1.43, 95% CI: 1.04-1.96), and testosterone (OR = 1.58, 95% CI: 1.17-2.13) were significantly associated with the increased risk of advanced BA in boys, and the association was reinforced when these hormones were interactively explored. Stratified by nutritional status, the interaction between estradiol, LH, and testosterone showed a strong association with advanced BA in boys with normal weight.

Comparing a common clavicle maturation-based age estimation method to ordinary regression analyses with quadratic and sex-specific interaction terms in adolescents

Established methods of age estimation are based on correlating defined maturation stages of bony structures with tables representing the observed range of biological ages in the majority of cases. In this retrospective monocentric study in southwestern Germany, common age estimation methodology was assessed in n = 198 subjects at the age of 25 or younger by analyzing the influence of age, quadratic age, biological sex and age-sex interaction on the ossification stages of the medial epiphysis fugue. Three readers (ICC ≥ 0.81 for left/right side) evaluated routine care computed tomography images of the clavicle with a slice thickness of 1 mm. By using least square regression analyses, to determine the real biological age a quadratic function was determined corrected for the age estimated by established methods and sex (R2 = 0.6 each side), reducing the mean absolute error and root mean squared error in the age estimation of women (2.57 and 3.19) and men (2.57 and 3.47) to 1.54 and 1.82 for women, and 1.54 and 2.25 for men. In women, the medial clavicle epiphysis seem to fuse faster, which was particularly observable from approximately 18 years of age. Before that age, the estimation method was relatively close to the ideal correlation between assessed and real age. To conclude, the presented new method enables more precise age estimation in individuals and facilitates the determination and quantification of additional variables, quantifying their influence on the maturation of the medial clavicle epiphysis based on the established ossification stages.

Beyond the Metabolic Syndrome: Non-Obvious Complications of Obesity in Children

Obesity is currently one of the most significant public health challenges worldwide due to the continuous increase in obesity rates among children, especially younger children. Complications related to obesity, including serious ones, are increasingly being diagnosed in younger children. A search was performed from January 2023 to September 2023 using the PubMed, Cochrane Library, Science Direct, MEDLINE, and EBSCO databases. The focus was on English-language meta-analyses, systematic reviews, randomized clinical trials, and observational studies worldwide. Four main topics were defined as follows: disorders of glucose metabolism; liver disease associated with childhood obesity; the relationship between respiratory disorders and obesity in children; and the effects of obesity on the hypothalamic-pituitary-gonadal axis and puberty. Understanding potential complications and their underlying mechanisms can expedite the diagnostic process and enhance the effectiveness of treatment. We aspire that this study will bring insight into the often-overlooked complications associated with obesity.

Ultra-processed foods in a rural Ecuadorian community: associations with child anthropometry and bone maturation

Frequent ultra-processed food (UPF) consumption is consistently associated with poor health outcomes. Little is known about UPF intake during early childhood and its effects on growth. We assessed UPF in relation to child anthropometry, bone maturation, and their nutrition profiles in a rural Ecuadorian community. Covariate-adjusted regression models estimated relationships between UPF intake from a 24-hour Food Frequency Questionnaire and three outcomes: linear growth, weight status and bone maturation. Nutrient Profiling Models (NPM) evaluated a convenience sample of UPF (n 28) consumed by children in the community. In this cohort (n 125; mean age = 33·92 (sd 1·75) months), 92·8 % consumed some form of UPF the previous day. On average, children consuming UPF four to twelve times per day (highest tertile) had lower height-for-age z-scores than those with none or a single instance of UPF intake (lowest tertile) (β = -0·43 [se 0·18]; P = 0·02). Adjusted stunting odds were significantly higher in the highest tertile relative to the lowest tertile (OR: 3·07, 95 % CI 1·11, 9·09). Children in the highest tertile had significantly higher bone age z-scores (BAZ) on average compared with the lowest tertile (β = 0·58 [se 0·25]; P = 0·03). Intake of savoury UPF was negatively associated with weight-for-height z-scores (β = -0·30 [se 0·14]; P = 0·04) but positively associated with BAZ (β = 0·77 [se 0·23]; P < 0·001). NPM indicated the availability of unhealthy UPF to children, with excessive amounts of saturated fats, free sugars and sodium. Findings suggest that frequent UPF intake during early childhood may be linked to stunted growth (after controlling for bone age and additional covariates), despite paradoxical associations with bone maturation.

The Sanders Classification and Obesity: Do Obese Kids With AIS Present With More Advanced Skeletal Maturity?

INTRODUCTION

Obese and overweight (OOW) patients with adolescent idiopathic scoliosis (AIS) have been shown to initially present with a more advanced Risser score compared to normal weight (NW) patients. The Sanders Maturity Scale (SMS) is now more commonly used by surgeons to assist with treatment decisions because it more reliably predicts skeletal maturity. However, the relationship between SMS and obesity has not been described. We hypothesize that in patients with AIS, OOW patients will have a higher SMS score on initial presentation when compared to NW patients.

METHODS

Billing data from 2 different institutions were used to identify patients with AIS presenting to a pediatric orthopaedic spine surgeon for an initial visit between July 2012 and March 2020. We excluded those without height/weight data, spine radiographs, or left-hand radiographs for measuring SMS stage. Body mass index-for-age percentiles were calculated and used to group patients into NW (<85th percentile) or OOW (85th percentile and above) per Centers for Disease Control guidelines. After collecting preliminary data, a power analysis was performed using average SMS scores between NW and OOW patients with an alpha of 0.5, determining a needed sample size of approximately 300 male and 300 female subjects.

RESULTS

Five hundred ninety patients (296 female, 294 male) were identified. The SMS stage at presentation was significantly greater in OOW compared to NW patients for both females (5.9±1.8 vs. 5.2±1.7; P =0.003) and males (4.9±1.9 vs. 4.1±1.8; P =0.002). The major curve magnitude for OOW females was significantly different from NW females (36±16 degrees vs. 30±16 degrees; P =0.004). The major curve magnitude was not different for OOW and NW males ( P =0.3).

CONCLUSION

At initial presentation, OOW patients present at a greater skeletal maturity as measured by the SMS compared with NW patients. OOW female patients present with a greater major curve magnitudes than NW female patients. These results highlight negative implications of the pediatric obesity epidemic as it relates to the AIS population. These findings can be used to counsel families and provide anticipatory guidance for the AIS treatment plan.

LEVEL OF EVIDENCE

Level III-cross-sectional study.

The skeletal and dental age advancements of children and adolescents with overweight and obesity: A systematic review and meta-analysis

INTRODUCTION

Over the past decades, a trend of increasing obesity among children has emerged. This study aimed to evaluate and summarize the impacts of overweight and obesity on children's and adolescents' skeletal and dental developmental advancement that may influence orthodontic management.

METHODS

Registered with the Prospective Register of Systematic Reviews (registration no. CRD42022347488), this study complies with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Particularly, relevant original studies on skeletal or dental age evaluation were screened from accessible electronic databases and supplemented by hand-searching. Meta-analysis was recruited to calculate differences (and their 95% confidence interval [CI]) between subjects with overweight or obese and normal-weight counterparts.

RESULTS

After applying the inclusion and exclusion criteria, 17 articles were selected for the final review. Two of the 17 selected studies were found to have a high risk of bias and moderate the other 15. A meta-analysis detected no statistically significant difference in skeletal age between children and adolescents with overweight and normal-weight counterparts (P = 0.24). However, the dental age of children and adolescents with overweight was found to be 0.49 years (95% CI, 0.29-0.70) advanced in comparison with normal-weight counterparts (P <0.00001). In contrast, children and adolescents with obesity were found to have advanced skeletal age by 1.17 (95% CI, 0.48-1.86) years (P = 0.0009) and dental age by 0.56 (95% CI, 0.37-0.76) years (P <0.00001) compared with their normal-weight counterparts.

CONCLUSION

Because the orthopedic outcomes of the orthodontic intervention are closely tied to the skeletal age of the patients, these results suggest that the orthodontic evaluation and treatment of children and adolescents with obesity might occur earlier than that of the normal-weight population.

Premature Pubarche: Time to Revise the Diagnostic Approach?

Premature pubarche (PP) could represent the first manifestation of non-classic congenital adrenal hyperplasia caused by 21 hydroxylase deficiency (NC21OHD) (10–30% of cases). In the last 20 years, the necessity of performing an ACTH test to diagnose NC21OHD in all cases with PP has been questioned, with conflicting results. This study aims to retrospectively evaluate the predictive value of the basal androgens, 17-OHP levels, and auxological features in suggesting the presence of NC21OHD and, thus, the need for a standard ACTH test to confirm the diagnosis. In all, 111 consecutive patients (87 females) with PP and advanced bone age underwent an ACTH test. Of these, 6/111 cases (1 male) were diagnosed with NC21OHD. The mean baseline 17 hydroxyprogesterone (17-OHP), dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEA-S), delta 4 androstenedione (Δ4A), and testosterone serum levels were higher in NC21OHD patients than in the others (p < 0.05). We found three predictive features for NC21OHD: basal 17 OHP of >200 ng/mL, bone age advance of >2 years, and DHEA-S levels of >228 ng/mL with sensitivity and specificity of 83.3% and 97.1%, 83.3% and 65.7%, and 83.3% and 96.2%, respectively. Our data confirm that the prevalence of NC21OHD is low among patients with PP. Serum 17-OHP of >200 ng/mL could be helpful to decide, in most cases, which patients should undergo the ACTH test. Bone age advance represented an inadequately specific predictive marker of NC21OHD.

DTI assessment of the maturing growth plate of the knee in adolescents and young adults

PURPOSE

To assess the growth plates of the knee in a healthy population of young adults and adolescents using DTI, and to correlate the findings with chronological age and skeletal maturation.

METHODS

A prospective, cross-sectional study to assess the tibial and femoral growth plates with DTI in 155 healthy volunteers aged between 14.0 and 21 years old. Echo-planar DTI with 15 directions and b value of 0 and 600 s/mm² was performed on a 3 T whole-body scanner.

RESULTS

A relationship was observed between chronological age and most DTI metrics (fractional anisotropy, mean diffusivity, and radial diffusivity), tract length and volume. (No significant relationship could be seen for axonal diffusivity and tract length.) Subdivision according to skeletal maturation showed the greatest tract lengths and volumes seen in stage 4b and not 4a. The intra-observer agreement was significant (P = 0.01) for all the measured variables, but agreement varied (femur 0.53 - 0.98; tibia 0.58 - 0.98). Spearman's correlation showed a significant correlation for age (P = 0.05; P = 0.01) as well as for the fractional anisotropy value within all variables in both femur and tibia. Tract number and volume had a similar correlation with most variables, especially the DTI metrics, and would seem to be interchangeable.

CONCLUSION

The current study indicates that DTI metrics could be a tool to assess the skeletal maturation process of the growth plate and its activity. Tractography seems promising to assess the activity of the growth plate in a younger population but must be used with caution in the more mature growth plate.

Just as Tall on Testosterone; a Neutral to Positive Effect on Adult Height of GnRHa and Testosterone in Trans Boys

CONTEXT

Growth is an important topic for many transgender boys. However, few studies have investigated the impact of puberty suppression (PS) and gender-affirming hormone treatment (GAHT) on growth and adult height.

OBJECTIVE

To evaluate the effect of PS and GAHT on growth and adult height.

DESIGN

Retrospective cohort study.

SETTING

Specialized gender identity clinic.

PARTICIPANTS

A total of 146 transgender boys treated with GnRH analogues and testosterone who reached adult height.

MAIN OUTCOME MEASURES

Growth, bone age (BA), adult height, and difference between adult height and predicted adult height (PAH) and midparental height.

RESULTS

In those with BA ≤14 years at start (n = 61), a decrease in growth velocity and bone maturation during PS was followed by an increase during GAHT. Adult height was 172.0 ± 6.9 cm; height SD score was similar to baseline (0.1; 95% CI, -0.2 to 0.4). Adult height was 3.9 ± 6.0 cm above midparental height and 3.0 ± 3.6 cm above PAH at start of PS. A younger BA at start PS was associated with an adult height significantly further above PAH.

CONCLUSION

During PS, growth decelerated followed by an acceleration during GAHT. Although adult height SD score was similar to baseline, adult height was taller than predicted based on BA at baseline, especially in those who started treatment at a younger BA. It is reassuring that PS and GAHT do not have a negative impact on adult height in transgender boys and might even lead to a slightly taller adult height, especially in those who start at a younger age.

High frequency of autoimmune thyroiditis in euthyroid girls with premature adrenarche

Objective

The purpose of this study was to investigate the frequency of autoimmune thyroiditis (AT) among euthyroid prepubertal girls presenting with premature adrenarche (PA). We also aimed to identify the clinical, metabolic, and endocrine profile of girls with AT and concurrent PA and compare them to girls with AT without PA, PA alone and healthy controls.

Methods

Ninety-one prepubertal girls aged 5-10 years, who attended our department for AT, PA and normal variants of growth and puberty were recruited for the study: 73 girls had PA, 6 AT without PA and 12 were referred for investigation of growth. All girls underwent clinical examination, detailed biochemical and hormonal screen. Standard dose Synachten stimulation test (SDSST) and oral glucose tolerance test (OGTT) were performed in all girls with PA. The whole study population was divided in 4 groups: Group PA-/AT+ included 6 girls with AT without PA; Group PA+/AT- PA subjects without AT; Group PA+/AT+ girls with PA and concomitant AT; Group PA-/AT- twelve healthy girls without PA nor AT (controls).

Results

Among 73 girls presenting with PA 19 had AT (26%). BMI, systolic blood pressure (SBP) and the presence of goiter significantly differed between the four groups (p = 0.016, p = 0.022 and p < 0.001, respectively). When comparing hormonal parameters among the four groups significant differences were found in leptin (p = 0.007), TSH (p = 0.044), anti-TPO (p = 0.002), anti-TG (p = 0.044), IGF-BP1 (p = 0.006), Δ4-Α (p = 0.01), DHEA-S (p = <0.001), IGF-1 (p = 0.012) and IGF-BP3 (p = 0.049) levels. TSH levels were significantly higher in Group PA+/AT+ compared to PA+/AT- and PA-/AT- (p = 0.043 and p = 0.016, respectively). Moreover, girls with AT (Groups PA-/AT+ and PA+/AT+) had higher TSH levels than those in Group PA+/AT- (p = 0.025). Girls in Group PA+/AT + showed higher cortisol response at 60 min post-SDSST than girls in Group PA+/AT- (p = 0.035). During the OGTT, insulin concentrations at 60 min were significantly higher in Group PA+/AT + compared to Group PA+/AT- (p = 0.042).

Conclusion

A high frequency of AT among euthyroid prepubertal girls with PA was observed. The combination of PA with AT even in euthyroid state may be associated with a greater degree of insulin resistance, than PA alone.

Evaluation of Glucose Metabolism and Cardiovascular Risk Factors in Prepubertal Girls with Premature Pubarche

OBJECTIVE

Premature pubarche (PP) is a risk factor for metabolic syndrome (MS). The aim was to evaluate if glucose-insulin metabolism, cardiovascular risk factors, familial cardiovascular risk factors (FCVRF) created a risk for insulin resistance (IR) and if PP was a risk factor alone for MS in normal weight prepubertal girls with PP.

METHODS

Thirty-five prepubertal, non-obese girls with PP with normal birth weight and 35 age-matched control girls were evaluated for FCVRF, anthropometric measurements, blood pressure, lipid profile, fasting blood glucose-insulin, hemoglobin A1c (HbA1c), sex hormone binding globulin (SHBG), leptin, adiponectin, tumor necrosis factor-alpha (TNF-α), androgen levels, and bone age. Oral glucose tolerance test was performed in PP participants. Homeostasis model of assessment of IR (HOMA-IR), fasting glucose/insulin ratio, atherogenic index (AI), and free androgen index (FAI) were calculated. PP participants were further stratified by FCVRF.

RESULTS

HbA1c, lipid profile, testosterone, leptin, adiponectin, TNF-α, HOMA-IR, glucose/insulin ratio, AI, and fasting glucose-insulin levels were similar. In the PP group FAI was significantly higher (p=0.001), whereas SHBG was significantly lower (p=0.010) than the control group. Leptin levels of FCVRF+ and FCVRF- subgroups were 15.2±9.1 and 9.7±7.2 ng/mL, respectively and the difference was significant (p=0.016).

CONCLUSION

As PP does not appear to be a risk factor alone for impaired glucose metabolism and IR in prepubertal non-obese girls with normal birth weight, it is our opinion that it is unnecessary to examine in detail such cases before puberty. Low SHBG levels in the PP group and high leptin levels in FCVRF+ subgroup might suggest that these may be predictive for MS in the future.

Association between phthalate exposure and accelerated bone maturation in Chinese girls with early puberty onset: a propensity score-matched case-control analysis

Estrogen can promote the acceleration of bone maturation and phthalate esters (PAEs) have estrogen-mimicking effects. We investigated whether PAEs are associated with the acceleration of bone age (BA) in girls with early onset of puberty (EOP). This case–control study enrolled 254 girls with EOP from the Endocrinology Department at Shenzhen Children’s Hospital between December 2018 and August 2019. Ultra-performance liquid chromatography and tandem mass spectrometry were used to analyze the 10 metabolites of PAEs (mPAEs) in urine samples. BA was measured using an artificial intelligence system. BA exceeding the chronological age (CA) by > 2 years (BA-CA ≥ 2 years) was referred to as significant BA advancement. Participants were divided into groups A (BA-CA ≥ 2 years; case group) and B (BA-CA < 2 years; control group). Propensity score matching (PSM) was performed for both groups in a 1:2 ratio with a caliper of 0.25. To identify potential dose–response relationships between PAEs exposure and BA advancement, we grouped the participants after PSM according to the tertiles of the mPAE concentrations. After PSM, 31 and 62 girls in groups A and B were selected. The concentration of Mono-ethyl phthalate (MEP) in group A was significantly higher than in group B (11.83 μg/g vs. 7.11 μg/g, P < 0.05); there was no significant difference in the levels of other mPAEs between the groups. The degree of BA advancement and proportion of significantly advanced BA in the lowest, middle, and highest tertiles of the MEP sequentially increased, as well as in the lowest, middle, and highest tertiles of Mono-(2-ethyl-5-carboxypentyl) phthalate; however, these were only statistically different between the highest and lowest MEP tertiles (both P < 0.05). For the remaining mPAEs, differences in the degree of BA advancement among the lowest, middle, and highest tertiles, as well as differences in the proportion of significantly advanced BA among the lowest, middle, and highest tertiles, were not significant (all P > 0.05). Our findings suggested that MEP was positively associated with BA advancement in girls with EOP. Exposure to PAEs may promote accelerated bone maturation.

A preliminary study on the relationship between environmental endocrine disruptors and precocious puberty in girls

OBJECTIVES

To explore the associations of environmental endocrine disruptors on precocious puberty in girls.

METHODS

This was a case-control study in which 30 girls with precocious puberty and 46 age- and race-matched prepubertal females were enrolled. The concentrations of 10 environment endocrine disruptors (bisphenol A, bisphenol B, butylparaben, propylparaben, ethvlparaben, methylparaben, mono-butyl phthalate, mono-2-ethylhexyl phthalate, monoethyl phthalate, and monomethyl phthalate) in urine and 10 steroid hormones (dihydrotestosterone, corticosterone, hydrocortisone, 11-deoxycortisol, 17α-hydroxy progesterone, 4-androstene-3,17-dione, estrone, deoxycorticosterone, pregnenolone, and dehydroepiandrosterone) in serum were detected with the liquid chromatography-mass spectrometry (LC-MS).

RESULTS

According to the Mann-Whitney U test, urinary levels of bisphenol A, monobutyl phthalate, and monomethyl phthalate were significantly higher in the precocious group than in the prepubertal group, and blood levels of hydrocortisone, 11-deoxycortisol, corticosterone, deoxycorticosterone, and pregnenolone were significantly lower in the precocious group than in the prepubertal group (p<0.05, VIP>1).

CONCLUSIONS

Our findings confirm the association between phthalate exposure and the incidence of precocious puberty in girls. Control and reduction of children exposure to phthalate esters should be considered as a health priority.

Adiposity Metabolic Consequences for Adolescent Bone Health

Infancy and adolescence are crucial periods for bone health, since they are characterized by intense physical growth and bone development. The unsatisfactory acquisition of bone mass in this phase has consequences in adult life and increases the risk of developing bone diseases at more advanced ages. Nutrient deficiencies, especially calcium and vitamin D, associated with a sedentary lifestyle; lack of sun exposure; and epigenetic aspects represent some of the main risk factors for poor bone quality. In addition, recent studies relate childhood obesity to impaired bone health; however, studies on the adiposity effects on bone health are scarce and inconclusive. Another gap concerns the implications of obesity on child sexual maturity, which can jeopardize their genetic potential bone mass and increase fracture risk. Therefore, we reviewed the analyzed factors related to bone health and their association with obesity and metabolic syndrome in adolescents. We concluded that obesity (specifically, accumulated visceral fat) harms bones in the infant-juvenile phase, thereby increasing osteopenia/osteoporosis in adults and the elderly. Thus, it becomes evident that forming and maintaining healthy eating habits is necessary during infancy and adolescence to reduce the risk of fractures caused by bone-metabolic diseases in adulthood and to promote healthy ageing.

Relationship between height age, bone age and chronological age in normal children in the context of nutritional and pubertal status

INTRODUCTION

Bone age (BA) is a quantitative determination of skeletal maturation. The role of puberty in variations in BA is poorly understood as hypothalamic-pituitary-gonadal (HPG) axis maturation and skeletal maturation are regulated in parallel but independently by multiple different factors. In countries like India where there is rapid nutrition transition and increase in prevalence of obesity, their impact on height and BA is not well understood.

OBJECTIVES

To study if in 2-17 year old healthy children, the difference between chronological age (CA), height age (HA) and BA is less than 1 year on either side of the chronological age and to assess relationship of BA with height, weight and BMI with special reference to gender and puberty.

METHODS

This cross-sectional study included 804 preschool/school-going Indian children. Anthropometric measurements and pubertal assessments were performed using standard protocols and were converted to age and sex standardized z-scores using Indian references while BA was estimated by Tanner-Whitehouse (TW3) method. p<0.05 was considered statistically significant.

RESULTS

The mean age and gender standardized z-scores for height, weight, body mass index (BMI) and BA were -0.3 ± 0.7, -0.7 ± 0.8, -0.1 ± 1.0, and -0.2 ± 0.9 respectively. HA was more delayed in girls while BA was more delayed in boys. The mean BA z-score increased with increasing BMI. After the onset of puberty, there was higher increment in BA in girls and HA in boys (p<0.05).

CONCLUSIONS

HA, BA and CA were tightly correlated in healthy Indian children with a significant role of nutritional status and puberty in causing variation in the same.

Associations of Obesity with Linear Growth and Puberty

BACKGROUND

The prevalence of obesity in childhood has increased dramatically in recent decades with increased risk of developing cardiometabolic and other comorbidities. Childhood adiposity may also influence processes of growth and puberty.

SUMMARY

Growth patterns of obesity during childhood have been shown to be associated with increased linear growth in early childhood, leading to accelerated epiphyseal growth plate (EGP) maturation. Several hormones secreted by the adipose tissue may affect linear growth in the context of obesity, both via the growth hormone IGF-1 axis and via a direct effect on the EGP. The observation that children with obesity tend to mature earlier than lean children has led to the assumption that the degree of body fatness may trigger the neuroendocrine events that lead to pubertal onset. The most probable link between obesity and puberty is leptin and its interaction with the kisspeptin system, which is an important regulator of puberty. However, peripheral action of adipose tissue could also be involved in changes in the onset of puberty. In addition, nutritional factors, epigenetics, and endocrine-disrupting chemicals are potential mediators linking pubertal onset to obesity. In this review, we focused on interactions of obesity with linear growth and pubertal processes, based on basic research and clinical data in humans.

KEY MESSAGE

Children with obesity are subject to accelerated linear growth with risk of impaired adult height and early puberty, with its psychological consequences. The data highlight another important objective in combatting childhood obesity, for the prevention of abnormal growth and pubertal patterns.

Association between dehydroepiandrosterone sulphate levels at 7 years old and bone mineral density at 10 years old: a prospective cohort study

We aimed to explore the effect of dehydroepiandrosterone sulphate (DHEAS) at age 7 on areal bone mineral density (aBMD) at age 10 and to distinguish the direct and indirect effects (explained by sexual maturity and by aBMD at age 7), for each sex, after adjustment for body mass index (BMI) z-score. In a subsample of 274 children (139 girls, 135 boys) from Generation XXI cohort, aBMD was assessed with dual-energy X-ray absorptiometry (DXA) scan at ages 7 and 10. The increase in aBMD at age 10 for each 10 µg/dL increase in DHEAS levels at age 7 was estimated using path analysis. Both the direct and the indirect effects were calculated. In girls, higher DHEAS levels at age 7 were associated with higher aBMD at age 10. No direct effect was observed. The indirect effect via higher aBMD at age 7 explained 61% of the total effect, and the indirect effect via higher Tanner stage explained 21%. After adjustment for BMI, the total effect remained statistically significant, explained in 33% by the indirect effect of DHEAS on Tanner stage and Tanner stage on aBMD. In boys, no effect of DHEAS on aBMD was observed.

CONCLUSION

An indirect effect of DHEAS at age 7 on aBMD at age 10 was found in girls, but not in boys, as higher DHEAS levels were associated with more advanced sexual maturation at age 10, and more advanced sexual maturation to higher aBMD. No direct effect of DHEAS on aBMD was observed.

WHAT IS KNOWN

• Conditions associated with elevated DHEAS, adrenarche's biomarker, are accompanied by advanced bone maturity. • Whether adrenal androgens influence bone mineralization in childhood remains puzzling, and longitudinal data is scarce.

WHAT IS NEW

• In girls, but not in boys, higher DHEAS at age 7 was associated with higher aBMD at age 10. • This was partially explained by the indirect effect of DHEAS at age 7 on sexual maturity at age 10, as DHEAS at age 7 was positively associated with sexual maturity at age 10, which was further associated with aBMD.

The Interaction of Obesity and Reproductive Function in Adolescents

Obesity is increasing worldwide, including in pediatrics. Adequate nutrition is required for initiation of menses, and there is a clear secular trend toward earlier pubertal onset and menarche in females in countries around the globe. Similar findings of earlier pubertal start are suggested in males. However, as individuals and populations have crossed into over-nutritional states including overweight and obesity, the effect of excess weight on disrupting reproductive function has become apparent. Hypothalamic hypogonadism and polycystic ovary syndrome are two conditions where reproductive function appears to directly relate to excess weight. Clinical findings in individuals with certain polygenic and monogenic obesity syndromes, which also have reproductive disruptions, have helped elucidate neurologic pathways that are common to both. Clinical endocrinopathies such as hypothyroidism or panhypopituitarism also aide in the understanding of the role of the endocrine system in weight gain. Understanding the intersection of obesity and reproductive function may lead to future therapies which can treat both conditions.

Non-PCOS Hyperandrogenic Disorders in Adolescents

Hyperandrogenism-clinical features resulting from increased androgen production and/or action-is not uncommon in peripubertal girls. Hyperandrogenism affects 3 to 20% of adolescent girls and often is associated with hyperandrogenemia. In prepubertal girls, the most common etiologies of androgen excess are premature adrenarche (60%) and congenital adrenal hyperplasia (CAH; 4%). In pubertal girls, polycystic ovary syndrome (PCOS; 20-40%) and CAH (14%) are the most common diagnoses related to androgen excess. Androgen-secreting ovarian or adrenal tumors are rare (0.2%). Early pubic hair, acne, and/or hirsutism are the most common clinical manifestations, but signs of overt virilization in adolescent girls-rapid progression of pubic hair or hirsutism, clitoromegaly, voice deepening, severe cystic acne, growth acceleration, increased muscle mass, and bone age advancement past height age-should prompt detailed evaluation. This article addresses the clinical manifestations of and management considerations for non-PCOS-related hyperandrogenism in adolescent girls. We propose an algorithm to aid diagnostic evaluation of androgen excess in this specific patient population.

Pelvic and breast ultrasound abnormalities and associated metabolic disturbances in girls with premature pubarche due to adrenarche

OBJECTIVE

Premature adrenarche (PA) has been suggested as a risk factor for future health problems, such as metabolic syndrome and early menarche. However, not all girls with PA have these features and it is not certain who will develop them. We propose that these abnormalities might be identified earlier, even before they are visible.

DESIGN

Case-control study.

SETTING

Tertiary care hospital.

PARTICIPANTS

Forty-eight girls with premature pubarche due to PA and age (mean age 7.6 ± 1.0 years), weight, body mass index (BMI), birth weight and gestational age-matched 49 girls with no palpable breast tissue.

MEASUREMENTS

Early pubertal pelvic and breast ultrasonographic changes and their associations with obesity and metabolic parameters were evaluated. Blood samples were collected, breast and pelvic ultrasound examinations were performed and bone ages were assessed.

RESULTS

Girls with PA were taller and their bone ages were higher (p = .049 and p = .005). Fasting blood glucose, insulin, triglycerides, high-density lipoprotein and low-density lipoprotein cholesterol were not different between the groups. Luteinizing hormone (LH), follicle-stimulating hormone (FSH) and estradiol were not different either. Ultrasonography revealed breast gland tissue in 30% of girls with PA and 5% of controls (p = .006). Uterine volume and endometrial thickness were higher in girls with PA (p = .03 and p = .04). Endometrial thickness was positively associated with serum insulin levels in the whole study group and after adjusting for age, diagnosis, BMI, mean ovarian volume and LH, FSH, estradiol levels, this association remained with a borderline p-value (R2  = 0.486, p = .050).

CONCLUSIONS

We found early changes in uterus and breast glands of girls with PA and endometrial thickness was positively associated with insulin levels.

Case report: 11-ketotestosterone may potentiate advanced bone age as seen in some cases of Wiedemann-Steiner Syndrome

CONTEXT

Wiedemann-Steiner Syndrome (WSS) is a genetic disorder associated with an array of clinical phenotypes, including advanced bone age and short stature. 11-ketotestosterone (11KT) is a member of the group known as 11-oxygenated C19 androgens that are implicated in premature adrenarche.

CASE DESCRIPTION

Case 1: The patient is a 3 year and 11-month-old female diagnosed with WSS due to deletion of KMT2A detected on CGH microarray. At two years and 11 months, imaging revealed an advanced bone age. We obtained an 11KT level on this patient. 11KT in case 1 was elevated at 26.3 ng/dL, while the normal reference range is 7.3-10.9 ng/dL and the reference interval for premature adrenarche is 12.3-22.9 ng/dL, The repeat 11KT at follow up (chronological age 4 years and 6 months) was still elevated at 33.8 ng/dL Case 2: A second child with WSS and a 5kb intragenic KMT2A deletion was evaluated at 11 months of age; his 11KT was 4.5 ng/dL.

CONCLUSIONS

The elevated 11KT may indicate maturational changes related to increasing adrenal gland androgenic activation and may explain the advanced bone age seen in some patients with WSS. To our knowledge, this is the first case report that describes 11KT as a bioactive androgen potentially causing bone age advancement in WSS. Lack of elevation of 11KT in the second child who is an infant suggests increasing androgenic precursors and metabolites related to premature adrenarche may need to be longitudinally followed.

Factors affecting prepubertal and pubertal bone age progression

Bone age (BA) is a clinical marker of bone maturation which indicates the developmental stage of endochondral ossification at the epiphysis and the growth plate. Hormones that promote the endochondral ossification process include growth hormone, insulin-like growth factor-1, thyroid hormone, estrogens, and androgens. In particular, estrogens are essential for growth plate fusion and closure in both sexes. Bone maturation in female children is more advanced than in male children of all ages. The promotion of bone maturation seen in females before the onset of puberty is thought to be an effect of estrogen because estrogen levels are higher in females than in males before puberty. Sex hormones are essential for bone maturation during puberty. Since females have their pubertal onset about two years earlier than males, bone maturation in females is more advanced than in males during puberty. In the present study, we aimed to review the factors affecting prepubertal and pubertal BA progression, BA progression in children with hypogonadism, and bone maturation and deformities in children with Turner syndrome.

The Mediating Role of Endocrine Factors in the Positive Relationship Between Fat Mass and Bone Mineral Content in Children Aged 9-11 Years: The Physical Activity and Nutrition in Children Study

INTRODUCTION

We aimed to investigate whether the relationship between fat mass and bone mineral content (BMC) is mediated by insulin, leptin, adiponectin, dehydroepiandrosterone sulphate, testosterone and estradiol in children aged 9-11 years.

MATERIALS AND METHODS

We utilised cross-sectional data from the Physical Activity and Nutrition in Children study (n = 230 to 396; 112 to 203 girls). Fat mass and BMC were assessed with dual-energy X-ray absorptiometry. Endocrine factors were assessed from fasted blood samples. We applied the novel 4-way decomposition method to analyse associations between fat mass, endocrine factors, and BMC.

RESULTS

Fat mass was positively associated with BMC in girls (ß = 0.007 to 0.015, 95% confidence interval (CI) 0.005 to 0.020) and boys (ß = 0.009 to 0.015, 95% CI 0.005 to 0.019). The relationship between fat mass and BMC was mediated by free leptin index in girls (ß = -0.025, 95% CI -0.039 to -0.010) and boys (ß = -0.014, 95% CI -0.027 to -0.001). The relationship between fat mass and BMC was partially explained by mediated interaction between fat mass and free leptin index in boys (ß = -0.009, 95% CI -0.013 to -0.004) and by interaction between fat mass and adiponectin in girls (ß = -0.003, 95% CI -0.006 to -0.000).

CONCLUSION

At greater levels of adiponectin and free leptin index, the fat mass and BMC relationship becomes less positive in girls and boys respectively. The positive association between fat mass with BMC was largely not explained by the endocrine factors we assessed.

CLINICAL TRIAL REGISTRATION

[https://clinicaltrials.gov/ct2/show/NCT01803776], identifier NCT01803776.

An Approach to the Evaluation and Management of the Obese Child With Early Puberty

With the declining age at onset of puberty and increasing prevalence of childhood obesity, early breast development in young obese girls has become a more frequent occurrence. Here, we examine available literature to answer a series of questions regarding how obesity impacts the evaluation and management of precocious puberty. We focus on girls as the literature is more robust, but include boys where literature permits. Suggestions include: (1) Age cutoffs for evaluation of precocious puberty should not differ substantially from those used for nonobese children. Obese girls with confirmed thelarche should be evaluated for gonadotropin-dependent, central precocious puberty (CPP) to determine if further investigation or treatment is warranted. (2) Basal luteinizing hormone (LH) levels remain a recommended first-line test. However, if stimulation testing is utilized, there is a theoretical possibility that the lower peak LH responses seen in obesity could lead to a false negative result. (3) Advanced bone age (BA) is common among obese girls even without early puberty; hence its diagnostic utility is limited. (4) Obesity does not eliminate the need for magnetic resonance imaging in girls with true CPP. Age and clinical features should determine who warrants neuroimaging. (5) BA can be used to predict adult height in obese girls with CPP to inform counseling around treatment. (6) Use of gonadotropin-releasing hormone analogues (GnRHa) leads to increased adult height in obese girls. (7) Obesity should not limit GnRHa use as these agents do not worsen weight status in obese girls with CPP.

Normal and Premature Adrenarche

Adrenarche is the maturational increase in adrenal androgen production that normally begins in early childhood. It results from changes in the secretory response to adrenocorticotropin (ACTH) that are best indexed by dehydroepiandrosterone sulfate (DHEAS) rise. These changes are related to the development of the zona reticularis (ZR) and its unique gene/enzyme expression pattern of low 3ß-hydroxysteroid dehydrogenase type 2 with high cytochrome b5A, sulfotransferase 2A1, and 17ß-hydroxysteroid dehydrogenase type 5. Recently 11-ketotestosterone was identified as an important bioactive adrenarchal androgen. Birth weight, body growth, obesity, and prolactin are related to ZR development. Adrenarchal androgens normally contribute to the onset of sexual pubic hair (pubarche) and sebaceous and apocrine gland development. Premature adrenarche causes ≥90% of premature pubarche (PP). Its cause is unknown. Affected children have a significantly increased growth rate with proportionate bone age advancement that typically does not compromise growth potential. Serum DHEAS and testosterone levels increase to levels normal for early female puberty. It is associated with mildly increased risks for obesity, insulin resistance, and possibly mood disorder and polycystic ovary syndrome. Between 5% and 10% of PP is due to virilizing disorders, which are usually characterized by more rapid advancement of pubarche and compromise of adult height potential than premature adrenarche. Most cases are due to nonclassic congenital adrenal hyperplasia. Algorithms are presented for the differential diagnosis of PP. This review highlights recent advances in molecular genetic and developmental biologic understanding of ZR development and insights into adrenarche emanating from mass spectrometric steroid assays.

Role of Body Weight in the Onset and the Progression of Idiopathic Premature Pubarche

BACKGROUND

The term premature pubarche (PP) refers to the appearance of pubic hair before age 8 in girls and before age 9 in boys. Although idiopathic PP (often associated with premature adrenarche) is considered an extreme variation from the norm, it may be an initial sign of persistent hyperandrogenism. Factors contributing to PP onset and progression have not been identified to date.

AIMS

The objectives of this study are to describe a group of Italian children with PP, to identify potential factors for its onset, and to define its clinical and biochemical progression.

METHODS

We retrospectively enrolled all infants born between 2001 and 2014 with PP. Children with advanced bone age (BA) underwent functional tests to determine the cause of PP. Hormonal analysis and BA determination were performed annually during a 4-year follow-up period.

RESULTS

A total of 334 children with PP were identified: idiopathic PP (92.5%, associated with premature adrenarche in some cases); related to precocious puberty (6.6%); late-onset 21-hydroxylase deficiency (0.9%). Low birth weight was associated with premature adrenal activation. Body mass index (BMI) was the only factor that influenced the progression of BA during follow-up.

CONCLUSIONS

Low birth weight is a predisposing factor for premature adrenal activation. The increase in BMI in patients with idiopathic PP during the 4-years of follow-up was responsible for BA acceleration. We recommend prevention of excessive weight gain in children with PP and strict adherence to follow-up in order to prevent serious metabolic consequences.

Eating Disorders in the Adolescent Patient

Eating disorders such as anorexia nervosa, female athlete triad, bulimia nervosa, obesity, and binge eating initially emerge during adolescence. These disorders are present primarily in females, but males may also present with these conditions. Dentistry has a pivotal role in the management of patients with such diet-related disorders. Because dentists examine their patients at frequent intervals and may be the health care professionals with whom patients feel more comfortable discussing eating disorders, dentists must have knowledge of the etiology, diagnostic criteria, systemic effects, and intraoral manifestations of eating disorders. In addition, the dental professional may be the first health care provider to identify the condition and refer the patient appropriately to medical colleagues for subsequent treatment. This chapter provides dentists with current and relevant information to recognize, diagnose, and integrate dental treatment for their adolescent patients who may exhibit manifestations of an eating disorder.

Osteoblasts Generate Testosterone From DHEA and Activate Androgen Signaling in Prostate Cancer Cells

Bone metastasis is a complication of prostate cancer in up to 90% of men afflicted with advanced disease. Therapies that reduce androgen exposure remain at the forefront of treatment. However, most prostate cancers transition to a state whereby reducing testicular androgen action becomes ineffective. A common mechanism of this transition is intratumoral production of testosterone (T) using the adrenal androgen precursor dehydroepiandrosterone (DHEA) through enzymatic conversion by 3β- and 17β-hydroxysteroid dehydrogenases (3βHSD and 17βHSD). Given the ability of prostate cancer to form blastic metastases in bone, we hypothesized that osteoblasts might be a source of androgen synthesis. RNA expression analyses of murine osteoblasts and human bone confirmed that at least one 3βHSD and 17βHSD enzyme isoform was expressed, suggesting that osteoblasts are capable of generating androgens from adrenal DHEA. Murine osteoblasts were treated with 100 nM and 1 μM DHEA or vehicle control. Conditioned media from these osteoblasts were assayed for intermediate and active androgens by liquid chromatography-tandem mass spectrometry. As DHEA was consumed, the androgen intermediates androstenediol and androstenedione were generated and subsequently converted to T. Conditioned media of DHEA-treated osteoblasts increased androgen receptor (AR) signaling, prostate-specific antigen (PSA) production, and cell numbers of the androgen-sensitive prostate cancer cell lines C4-2B and LNCaP. DHEA did not induce AR signaling in osteoblasts despite AR expression in this cell type. We describe an unreported function of osteoblasts as a source of T that is especially relevant during androgen-responsive metastatic prostate cancer invasion into bone. © 2021 American Society for Bone and Mineral Research (ASBMR). This article has been contributed to by US Government employees and their work is in the public domain in the USA.

Linear growth and puberty in childhood obesity: what is new?

Pediatric obesity is a growing and alarming global health problem and represents an important determinant of morbidity. Since nutrition plays an important role in regulating growth and development, the excess weight gain related to overnutrition can affect growth patterns, bone maturation and pubertal development. The purpose of this review is to summarize the current knowledge about the effect of primary obesity on linear growth and pubertal development in children and adolescents. Evidences about regulatory hormones and adipokines that may be involved in the physiology of childhood growth in the context of obesity were also discussed. The most recent literature confirms previous studies indicating that linear growth is accelerated (mainly due to longer trunks rather than longer legs) and bone age is advanced in prepubertal children with obesity, while there is a reduction of pubertal height gain and attainment of normal adult height. Conflicting results are reported on the timing of puberty, specifically in boys. Indeed, previous studies suggested earlier onset of puberty in obese girls and overweight boys, and a delayed puberty in obese boys. Conversely, the most recent studies show more consistently an earlier onset and completion of pubertal development also in boys with obesity. Considering the false belief of health associated with transient taller stature in children and the adverse outcomes related to early puberty, interventions on diet and physical activity are urgently needed to tackle the epidemics of childhood obesity in public health and clinical setting.

A cross-sectional magnetic resonance imaging study of factors influencing growth plate closure in adolescents and young adults

Aim

To assess growth plate fusion by magnetic resonance imaging (MRI) and evaluate the correlation with sex, age, pubertal development, physical activity and BMI.

Methods

Wrist, knee and ankle of 958 healthy subjects aged 14.0‐21.5 years old were examined using MRI and graded by two radiologists. Correlations of growth plate fusion score with age, pubertal development, physical activity and BMI were assessed.

Results

Complete growth plate fusion occurred in 75%, 85%, 97%, 98%, 98% and 90%, 97%, 95%, 97%, 98% (radius, femur, proximal‐ and distal tibia and calcaneus) in 17‐year‐old females and 19‐year‐old males, respectively. Complete fusion occurs approximately 2 years earlier in girls than in boys. Pubertal development correlated with growth plate fusion score (ρ = 0.514‐0.598 for the different growth plate sites) but regular physical activity did not. BMI also correlated with growth plate fusion (ρ = 0.186‐0.384). Stratified logistic regression showed increased odds ratio (OR F: 2.65‐8.71; M: 1.71‐4.03) for growth plate fusion of obese or overweight subects versus normal‐weight subjects. Inter‐observer agreement was high (Κ = 0.87‐0.94).

Conclusion

Growth plate fusion can be assessed by MRI; occurs in an ascending order, from the foot to the wrist; and is significantly influenced by sex, pubertal development and BMI, but not by physical activity.

Evaluation of Bone Age in Children: A Mini-Review

Bone age represents a common index utilized in pediatric radiology and endocrinology departments worldwide for the definition of skeletal maturity for medical and non-medical purpose. It is defined by the age expressed in years that corresponds to the level of maturation of bones. Although several bones have been studied to better define bone age, the hand and wrist X-rays are the most used images. In fact, the images obtained by hand and wrist X-ray reflect the maturity of different types of bones of the skeletal segment evaluated. This information, associated to the characterization of the shape and changes of bone components configuration, represent an important factor of the biological maturation process of a subject. Bone age may be affected by several factors, including gender, nutrition, as well as metabolic, genetic, and social factors and either acute and chronic pathologies especially hormone alteration. As well several differences can be characterized according to the numerous standardized methods developed over the past decades. Therefore, the complete characterization of the main methods and procedure available and particularly of all their advantages and disadvantages need to be known in order to properly utilized this information for all its medical and non-medical main fields of application.

Accelerated skeletal maturation is associated with overweight and obesity as early as preschool age: a cross-sectional study

Background

Body mass index (BMI) and skeletal age (SA) are important indicators of individual growth and maturation. Although the results have not been unified, most studies indicated that accelerated skeletal maturation is associated with overweight/obesity. However, there have so far been insufficient studies about the association between accelerated skeletal maturation and overweight/obesity in preschoolers, particularly Asian children. A cross-sectional study was conducted on Chinese children to verify the association between accelerated skeletal maturation and overweight/obesity at preschool age.

Methods

The study involved 1330 participants aged 3.1–6.6 years old (730 males and 600 females) in Shanghai, China. The skeletal age was determined according to the method of TW3-C RUS. Accelerated skeletal maturation was defined as relative SA (SA minus chronological age [CA]) ≥1.0 years. BMI was classified as thinness, normal weight, overweight, and obesity according to the International Obesity Task Force (IOTF) BMI cut-offs. The Chi-square was performed to determine the statistically significant difference in the frequency of accelerated skeletal maturation in BMI and age categories. The logistic regression model analyzed the association between accelerated skeletal maturation and overweight/obesity.

Results

The percentage of accelerated skeletal maturation increased with BMI (7.8% of children in thinness group had accelerated skeletal maturation; the percentage increased to 30.8% in obese group. x² = 89.442, df = 3, P < 0.01) and age group (at age 3.5, 3.5% of participants had accelerated skeletal maturation; at age 6.0 years, this increased to 27.8%. x² = 43.417, df = 5, P < 0.01). Logistic regression analysis showed that children with overweight and obesity are more likely to have accelerated skeletal maturation than children with normal weight after adjusting for gender and age (Overweight, odds ratio [OR] = 3.27, 95% confidence interval [CI]: 2.20–4.87; Obese, OR = 4.73, 95% CI: 2.99–7.48).

Conclusions

There is an association between accelerated skeletal maturation and overweight/obesity among preschool children. This study suggests that accelerated skeletal maturation might coexist with overweight/obesity in preschool children, and interventions, such as dietary modifications and increasing levels of physical activity, should be employed to prevent both accelerated skeletal maturation and overweight/obesity as early as preschool age.

Update on adrenarche

PURPOSE OF REVIEW

Adrenarche is the pubertal maturation of the innermost zone of the adrenal cortex, the zona reticularis. The onset of adrenarche occurs between 6 and 8 years of age when dehydroepiandrosterone sulfate (DHEAS) concentrations increase. This review provides an update on adrenal steroidogenesis and the differential diagnosis of premature development of pubic hair.

RECENT FINDINGS

The complexity of adrenal steroidogenesis has increased with recognition of the alternative 'backdoor pathway' and the 11-oxo-androgens pathways. Traditionally, sulfated steroids such as DHEAS have been considered to be inactive metabolites. Recent data suggest that intracellular sulfated steroids may function as tissue-specific intracrine hormones particularly in the tissues expressing steroid sulfatases such as ovaries, testes, and placenta.

SUMMARY

The physiologic mechanisms governing the onset of adrenarche remain unclear. To date, no validated regulatory feedback mechanism has been identified for adrenal C19 steroid secretion. Available data indicate that for most children, premature adrenarche is a benign variation of development and a diagnosis of exclusion. Patients with premature adrenarche tend to have higher BMI values. Yet, despite greater knowledge about C19 steroids and zona reticularis function, much remains to be learned about adrenarche.

Factors affecting bone maturation in Chinese girls aged 4-8 years with isolated premature thelarche

Background

In isolated premature thelarche (IPT) girls, bone age (BA) is considered consistent with chronological age. However, some IPT girls confirmed by gonadotropin-releasing hormone (GnRH) stimulation test could show another trend. We analysed BA and possible potentiating factors in a selected group of girls aged 4–8 years with IPT.

Methods

IPT girls confirmed by GnRH stimulation test aged 4–8 years hospitalized from January 2015 to April 2018 at Shenzhen Children’s Hospital were included in this retrospective study. They were divided into two groups with advanced BA of 2 years as the cut-off. Body mass index (BMI) and hormone levels were the main outcome measures, and regression analysis was used to identify independent risk factors. IPT girls were divided into subgroups according to the levels of BMI standard deviation score (SDS), insulin-like growth factor-1 (IGF-1) SDS and dehydroepiandrosterone sulfate (DHEAS) SDS for comparisons of advanced BA.

Results

Overall, 423 subjects were included and classified into the advanced BA group (48.7%, n = 206) and control group (51.3%, n = 217). The advanced BA group had significantly higher BMI SDS, serum DHEAS SDS, IGF-1 SDS, androstenedione and fasting insulin and significantly lower sex hormone binding globulin (all p < 0.001). Serum IGF-1 SDS (OR = 1.926, p<0.001), BMI SDS (OR = 1.427, p = 0.001) and DHEAS SDS (OR = 1.131, p = 0.005) were independent risk factors for significantly advanced BA. In the multiple linear regression model, serum IGF-1 SDS, BMI SDS and DHEAS SDS were the strongest predictors of advanced BA, accounting for 19.3% of the variance. According to BMI, 423 patients were classified into three groups: normal weight (56.03%, n = 237), overweight (19.15%, n = 81) and obesity (24.82%, n = 105). The proportion of advanced BA in obesity group was significantly higher than those of normal weight and overweight groups (χ² = 18.088, p<0.001). In the subgroup with normal weight, higher serum IGF-1 SDS (p = 0.009) and DHEAS SDS (p = 0.003) affected BA advancement independent of BMI SDS.

Conclusions

Girls with IPT confirmed by GnRH stimulation test aged 4–8 years might have significantly advanced BA. Obesity was highly associated with advanced BA. Age-specific serum IGF-1 SDS and DHEAS SDS were risk factors for BA advancement independent of BMI.

11-Oxygenated androgens in health and disease

The adrenal gland is a source of sex steroid precursors, and its activity is particularly relevant during fetal development and adrenarche. Following puberty, the synthesis of androgens by the adrenal gland has been considered of little physiologic importance. Dehydroepiandrosterone (DHEA) and its sulfate, DHEAS, are the major adrenal androgen precursors, but they are biologically inactive. The second most abundant unconjugated androgen produced by the human adrenals is 11β-hydroxyandrostenedione (11OHA4). 11-Ketotestosterone, a downstream metabolite of 11OHA4 (which is mostly produced in peripheral tissues), and its 5α-reduced product, 11-ketodihydrotestosterone, are bioactive androgens, with potencies equivalent to those of testosterone and dihydrotestosterone. These adrenal-derived androgens all share an oxygen atom on carbon 11, so we have collectively termed them 11-oxyandrogens. Over the past decade, these androgens have emerged as major components of several disorders of androgen excess, such as congenital adrenal hyperplasia, premature adrenarche and polycystic ovary syndrome, as well as in androgen-dependent tumours, such as castration-resistant prostate cancer. Moreover, in contrast to the more extensively studied, traditional androgens, circulating concentrations of 11-oxyandrogens do not demonstrate an age-dependent decline. This Review focuses on the rapidly expanding knowledge regarding the implications of 11-oxyandrogens in human physiology and disease.

Arachidonic acid status negatively associates with forearm bone outcomes and glucose homeostasis in children with an overweight condition or obesity

Long-chain polyunsaturated fatty acids are implicated in musculoskeletal health in adults. This study examined whether fatty acid status relates to bone health outcomes in children with overweight condition or obesity (body mass index z score, 3.1 ± 0.1; age, 9.0 ± 0.2 years; n = 108). Nondominant forearm bone density (distal one-third), geometry (4% site), and soft tissue composition (66%) were assessed using dual-energy X-ray absorptiometry and peripheral quantitative computed tomography. Red blood cell (RBC) fatty acid profile and indices of glucose homeostasis were measured. Differences in outcomes among RBC arachidonic acid (AA, C20:4n-6) tertiles were tested using mixed-model ANOVA. Ultra-, mid-, and total-distal forearm bone mineral content, adjusted for sex, age, percentage body fat, race, and forearm length, were 10% to 13% greater in children in the first AA tertile relative to the third. Children in the second tertile had the highest bone cross-sectional area and estimated strength at the 66% radius. Muscle cross-sectional area was 15% lower in the third tertile compared with the first, along with higher fasting insulin concentrations (27%) and homeostasis model of assessment estimate of insulin resistance (31%). Higher RBC AA status aligns with deficits in forearm bone mass, geometry, and muscle mass in children with excess adiposity and early signs of insulin resistance. Novelty Higher arachidonic acid status is associated with lower forearm bone mass in children with overweight condition or obesity. Children with higher arachidonic acid status had increased fasting insulin concentrations and indices of insulin resistance.

Factors associated with Advanced Bone Age in Overweight and Obese Children

PURPOSE

Obese children may often present with advanced bone age. We aimed to evaluate the correlation between factors associated with childhood obesity and advanced bone age.

METHODS

We enrolled 232 overweight or obese children. Anthropometric and laboratory data, and the degree of nonalcoholic fatty liver disease (NAFLD) were measured. We analyzed factors associated with advanced bone age by measuring the differences between bone and chronological ages.

RESULTS

The normal and advanced bone age groups were comprised of 183 (78.9%) and 49 (21.1%) children, respectively. The prevalence of advanced bone age significantly increased as the percentiles of height, weight, waist circumference, and body mass index (BMI) increased. BMI z-score was higher in the advanced bone age group than in the normal bone age group (2.43±0.52 vs. 2.10±0.46; p<0.001). The levels of insulin (27.80±26.13 μU/mL vs. 18.65±12.33 μU/mL; p=0.034) and homeostatic model assessment-insulin resistance (6.56±6.18 vs. 4.43±2.93; p=0.037) were significantly higher, while high density lipoprotein-cholesterol levels were lower (43.88±9.98 mg/dL vs. 48.95±10.50 mg/dL; p=0.005) in the advanced bone age group compared to those in the normal bone age group, respectively. The prevalence of advanced bone age was higher in obese children with metabolic syndrome than in those without (28.2% vs. 14.7%; p=0.016). The prevalence of advanced bone age was higher in obese children with a more severe degree of NAFLD.

CONCLUSION

Advanced bone age is associated with a severe degree of obesity and its complications.

A cross-sectional survey of adrenal steroid hormones among overweight/obese boys according to puberty stage

BACKGROUND

Obesity is associated with many chronic diseases including cortisol rhythm disorder and low testosterone. Furthermore, studies on obese children are quite limited and no concordance results have been obtained, especially for boys in puberty. Moreover, the sample sizes of previous studies were small, and were not representative.

METHODS

We conducted a cross-sectional survey including 1148 boys aged 6-14 years, they were divided into overweight/obesity (OW/OB) group and normal weight (NW) group. Puberty status was assessed according to Tanner scale and testicular volume. Serum levels of pregnenolone, 17-OH progesterone, corticosterone, dehydroepiandrosterone (DHEA), and androstenedione were detected by LC-MS. Serum free testosterone and sex hormone-binding globulin (SHBG) levels were measured by chemiluminescence immunoassay.

RESULTS

The 17-OH progesterone, DHEA, androstenedione and free testosterone levels of OW/OB boys at prepubertal stage or at the age 6 = < 10 years group were higher than those of the NW boys (all the P values were < 0.01). Furthermore, androstenedione and free testosterone levels were lower in OW/OB boys at late puberty, and the trend continued at the post pubertal stage for FT (P < 0.01-0.05). DHEA, androstenedione, and FT levels persisted to be higher at the 10~ < 12 years in OW/OB boys but not for 17-OH progesterone. FT level was lower in the OW/OB group at the 12~ < 15 years group. The SHBG levels in the OW/OB boys were lower than those in the NW ones at the 6~12 years group, and prepubertal to early pubertal stage.

CONCLUSIONS

Premature adrenarche is more likely in OW/OB boys. More attention should be given to the lower androgen levels of OW/OB boys at late pubertal and post pubertal stages.

Adiposity and attained height in adolescents: a longitudinal analysis from the LabMed Physical Activity Study

Background To investigate the associations between adiposity and attained height over a 2-year period in healthy adolescents. Methods One thousand and seventeen adolescents aged 12-18 years participated in this cohort study; 893 (87.8%) were reevaluated 1 year later (T2) and 734 (72.2%) subjects 2 years later (T3). Body fat and anthropometry were measured according to standardized procedures. Socioeconomic status, pubertal stage and lifestyles determinants were gathered and used as confounders. Prospective associations between adiposity and height were examined using generalized linear models. Results Greater adiposity at T1 was significantly associated with a lower attained height over time, when adjusting for confounders, which varied between 0.03 and 1 cm in T2 and 0.1 and 1 cm in T3. Conclusions Excess of adiposity in early adolescence may exert an effect on attained height in late adolescence. This study supports future lifestyles intervention studies aiming at preventing overweight and obesity and improving attained height.

Bone age determination in eutrophic, overweight and obese Brazilian children and adolescents: a comparison between computerized BoneXpert and Greulich-Pyle methods

BACKGROUND

Bone age determination is usually employed to evaluate growth disorders and their treatment. The Greulich-Pyle method is the simplest and most frequently used type of evaluation, but it presents huge interobserver variability. The BoneXpert is a computer-automated method developed to avoid significant bone age variability among distinct observers.

OBJECTIVE

To compare the BoneXpert and Greulich-Pyle methods of bone age determination in eutrophic children and adolescents, as well as in overweight and obese pediatric patients.

MATERIALS AND METHODS

The sample comprised 515 participants, 253 boys (159 eutrophic, 53 overweight and 41 obese) and 262 girls (146 eutrophic, 76 overweight and 40 obese). Left hand and wrist radiographs were acquired for bone age determination using both methods.

RESULTS

There was a positive correlation between chronological age and Greulich-Pyle, chronological age and BoneXpert, and Greulich-Pyle and BoneXpert. There was a significant increase (P<0.05) in bone age in both the Greulich-Pyle and BoneXpert methods in obese boys when compared to eutrophic or overweight boys of the same age. In girls, there was an increase in bone age in both obese and overweight individuals when compared to eutrophic girls (P<0.05). The Greulich-Pyle bone age was advanced in comparison to that of BoneXpert in all groups, except in obese boys, in which bone age was similarly advanced in both methods.

CONCLUSION

The BoneXpert computer-automated bone age determination method showed a significant positive correlation with chronological age and Greulich-Pyle. Furthermore, the impact of being overweight or obese on bone age could be identified by both methods.

Obesity and Hypogonadism-A Narrative Review Highlighting the Need for High-Quality Data in Adolescents

The prevalence of obesity continues to rise in adult and pediatric populations throughout the world. Obesity has a direct impact on all organ systems, including the reproductive system. This review summarizes current knowledge about the effects of obesity on the male reproductive system across age, highlighting the need for more data in children and adolescents. Male hypogonadism is commonly seen in patients with obesity and affects the onset, duration, and progression of puberty. Different pathophysiologic mechanisms include increased peripheral conversion of testosterone to estrone and increased inflammation due to increased fat, both of which lead to suppression of the hypothalamic-pituitary-gonadotropin (HPG) axis and delayed development of secondary sexual characteristics in adolescent males. Evaluation of the HPG axis in obesity includes a thorough history to exclude other causes of hypogonadism and syndromic associations. Evaluation should also include investigating the complications of low testosterone, including increased visceral fat, decreased bone density, cardiovascular disease risk, and impaired mood and cognition, among others. The mainstay of treatment is weight reduction, but medications such as testosterone and clomiphene citrate used in adults, remain scarcely used in adolescents. Male hypogonadism associated with obesity is common and providers who care for adolescents and young adults with obesity should be aware of its impact and management.

Interpretation of androgen and anti-Mullerian hormone profiles in a Hispanic cohort of 5- to 8-year-old girls with premature adrenarche

PURPOSE

Premature adrenarche (PA) often leads to polycystic ovary syndrome (PCOS). Higher anti-mullerian hormone (AMH) levels are reported in PCOS. We studied the androgen profile and AMH profiles in Hispanic girls with PA (aged 5-8 years) and age and body mass index (BMI) matched controls.

METHODS

Retrospective review of electronic medical records of girls who met the inclusion criteria for premature adrenarche were done.

RESULTS

PA girls (n=76) were matched to control girls (n=12) for age (mean±standard deviation) (6.7±1 years vs. 6.2±1.3 years) and BMI (20±10 kg/m2 vs. 17.8±2.7 kg/m2). Dehydroepiandrostenedione sulfate (63.3±51.3 μg/dL vs. 29.8±17.3 μg/dL, P&lt;0.001) and testosterone levels (11.4±4.8 ng/dL vs. 8.2±2.9 ng/dL, P=0.001) were significantly higher in the PA group than controls. AMH values (&lt;14 years: reference range, 0.49-3.15 ng/mL) were 3.2±2.2 ng/mL vs. 4.6± 3.2 ng/mL respectively in the PA and control groups and were not different (P=0.4). AMH did not show a correlation with bone age (P=0.1), and testosterone (P=0.9) in the PA group. 17-hydroxyprogesterone levels (17-OHP ng/dL) were 39.5±30.5 ng/dL vs. 36.8±19.8 ng/dL in PA versus control girls. The concentration of 17-OHP was not statistically different between the control and PA groups.

CONCLUSION

Higher AMH was not observed in PA girls and no correlation with BA and androgen levels was observed.

Basal levels of 17-hydroxyprogesterone can distinguish children with isolated precocious pubarche

BACKGROUND

Basal levels of androgens, in particular 17-hydroxyprogesterone (17OHP), are widely debated as predictors of non-classical congenital adrenal hyperplasia (NCCAH) among patients with precocious pubarche (PP). Many authors have recommended the use of adrenocorticotropic hormone (ACTH) stimulation test in children with PP. The aim of our study was to identify clinical and biochemical predictors of NCCAH in children with PP.

METHODS

We conducted a prospective study of 92 patients with PP undergoing an ACTH stimulation test. We tested the association of basal clinical and biochemical parameters with NCCAH diagnosis. Patients were suspected to have NCCAH if their stimulated 17OHP plasma levels were >10 ng/mL. In these patients, the diagnosis was confirmed by genetic test.

RESULTS

Seven (7.6%) patients resulted having NCCAH. The best basal biochemical predictor for NCCAH was 17OHP level >2 ng/mL. In fact, a basal 17OHP level >2 ng/mL had 100% (95% confidence interval (CI), 59.04-100) sensitivity and 93% (95% CI, 85.3-97.37) specificity. The area under the receiver-operating characteristic curve for 17OHP was 0.99 (95% CI, 0.98-1.007).

CONCLUSIONS

Basal 17OHP cut-off of 2 ng/mL was very effective in predicting NCCAH among our patients with PP. Assay-specific cut-off would probably be the best strategy to avoid unnecessary ACTH test.

Slipped capital femoral epiphysis in children younger than 10 years old: clinical characteristics and efficacy of physeal-sparing procedures

We aimed to investigate the clinical characteristics of slipped capital femoral epiphysis (SCFE) in patients aged less than 10 years and identify the efficacy of physeal-sparing procedures in this age group. Demographic data of 18 SCFE patients aged less than 10 years were compared with those of 71 older patients to investigate the clinical characteristics. The efficacy of physeal-sparing procedures (n=5) was investigated compared with that of in-situ screw fixation (n=13). Obese children were noticeably more common among SCFE patients aged less than 10 years (P=0.034). The slip angle improved significantly more in the physeal-sparing subgroups (P=0.038) without the occurrence of further slippage. Moreover, physeal-sparing procedures allow persistent growth of the proximal femoral physis. However, most of the patients in the physeal-sparing subgroup needed additional surgeries when the proximal femoral physis outgrew the implant. Obesity may be associated more with early-onset SCFE (onset<10 years). Physeal-sparing procedures are safe and effective in preventing leg-length discrepancy and allowing the remodeling of the deformed proximal femur in this age group.