Reversibility of physiological growth hormone secretion in children with psychosocial dwarfism

Reversibility of disturbed pituitary function in pediatric conditions with psychological stressors: implications for clinical practice

The complex communication network between the central nervous system and the hypothalamic-pituitary axis forms the basis of endocrine functional plasticity, which facilitates adaptation to changing internal and external conditions, but also makes it vulnerable to the negative effects of stressful psychological factors. Herein, clinical conditions such as functional hypothalamic amenorrhea, eating disorders, growth faltering, post-traumatic stress disorder, and pubertal disorders that may emerge during childhood or adolescence, their origin possibly including psychological stressors, are analyzed regarding their genetic susceptibility and reversibility of endocrine function. A discussion on the optimization of therapeutic management defined by managing stress and maximizing the degree and rate of reversibility follows.

Endocrine Health and Health Care Disparities in the Pediatric and Sexual and Gender Minority Populations: An Endocrine Society Scientific Statement

Endocrine care of pediatric and adult patients continues to be plagued by health and health care disparities that are perpetuated by the basic structures of our health systems and research modalities, as well as policies that impact access to care and social determinants of health. This scientific statement expands the Society's 2012 statement by focusing on endocrine disease disparities in the pediatric population and sexual and gender minority populations. These include pediatric and adult lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA) persons. The writing group focused on highly prevalent conditions-growth disorders, puberty, metabolic bone disease, type 1 (T1D) and type 2 (T2D) diabetes mellitus, prediabetes, and obesity. Several important findings emerged. Compared with females and non-White children, non-Hispanic White males are more likely to come to medical attention for short stature. Racially and ethnically diverse populations and males are underrepresented in studies of pubertal development and attainment of peak bone mass, with current norms based on European populations. Like adults, racial and ethnic minority youth suffer a higher burden of disease from obesity, T1D and T2D, and have less access to diabetes treatment technologies and bariatric surgery. LGBTQIA youth and adults also face discrimination and multiple barriers to endocrine care due to pathologizing sexual orientation and gender identity, lack of culturally competent care providers, and policies. Multilevel interventions to address these disparities are required. Inclusion of racial, ethnic, and LGBTQIA populations in longitudinal life course studies is needed to assess growth, puberty, and attainment of peak bone mass. Growth and development charts may need to be adapted to non-European populations. In addition, extension of these studies will be required to understand the clinical and physiologic consequences of interventions to address abnormal development in these populations. Health policies should be recrafted to remove barriers in care for children with obesity and/or diabetes and for LGBTQIA children and adults to facilitate comprehensive access to care, therapeutics, and technological advances. Public health interventions encompassing collection of accurate demographic and social needs data, including the intersection of social determinants of health with health outcomes, and enactment of population health level interventions will be essential tools.

Emotional Deprivation in Children: Growth Faltering and Reversible Hypopituitarism

Emotional deprivation can lead to growth faltering of infants and children. The mechanism(s) involved differ in that for infants, the major metabolic problem is inadequate energy intake for growth. In young children, it is likely that the emotional deprivation causes a syndrome not only of growth faltering, but with bizarre behaviors, especially with regard to food: hoarding, gorging and vomiting, hyperphagia, drinking from the toilet, and eating from garbage pails. Other disturbed behaviors include, poor sleep, night wanderings, and pain agnosia. The pathophysiology appears to be reversible hypopituitarism, at least for the growth hormone and hypothalamic-pituitary- adrenal axes. The review begins with an historical perspective concerning stress, children and growth and then moves to the issue of hospitalism, where young infants failed to thrive (and died) due to inadequate stimulation and energy intake. Refeeding programs at the end of World Wars I and II noted that some children did not thrive despite an adequate energy intake. It appeared that in addition taking care of their emotional needs permitted super-physiologic (catch-up) growth. Next came the first notions from clinical investigation that hypopituitarism might be the mechanism of growth faltering. Studies that address this mechanism from a number of observational and clinical research studies are reviewed in depth to show that the hypopituitarism was relieved upon removal from the deprivational environment and occurred much too quickly to be due to adequate energy alone. These findings are then compared to those from malnourished children and adoptees from emerging countries, especially those from orphanages where their psychosocial needs were unmet despite adequate caloric intake. Together, these various conditions define one aspect of the field of psychoneuroendocrinology.

Reduced left ventricular dimension and function following early life stress: A thrifty phenotype hypothesis engendering risk for mood and anxiety disorders

Background

Early life stress (ELS) in macaques in the form of insecure maternal attachment putatively induces epigenetic adaptations resulting in a "thrifty phenotype" throughout the life cycle. For instance, ELS induces persistent increases in insulin resistance, hippocampal and corpus callosum atrophy and reduced "behavioral plasticity", which, taken together, engenders an increased risk for mood and anxiety disorders in humans but also a putative sparing of calories. Herein, we test the hypothesis whether a thrifty phenotype induced by ELS is peripherally evident as hypotrophy of cardiac structure and function, raising the possibility that certain mood disorders may represent maladaptive physiological and central thrift adaptations.

Methods

14 adult bonnet macaques (6 males) exposed to the maternal variable foraging demand (VFD) model of ELS were compared to 20 non-VFD adult subjects (6 males). Left ventricle end-diastolic dimension (LVEDD), Left ventricle end-systolic dimension (LVESD) and stroke volume (SV) were calculated using echocardiography. Blood pressure and heart rate were measured only in females. Previously obtained neurobehavioral correlates available only in males were analyzed in the context of cardiac parameters.

Results

Reduced LVESD (p < 0.05) was observed when controlled for age, sex, body weight and crown-rump length whereas ejection fraction (EF) (p = 0.037) was greater in VFD-reared versus non-VFD subjects. Pulse pressure was lower in VFD versus non-VFD females (p < 0.05). Male timidity in response to a human intruder was associated with reduced LVEDD (p < 0.05).

Conclusions

ELS is associated with both structural and functional reductions of left ventricular measures, potentially implying a body-wide thrifty phenotype. Parallel "thrift" adaptations may occur in key brain areas following ELS and may play an unexplored role in mood and anxiety disorder susceptibility.

The International Growth Standard for Children and Adolescents Project: Environmental Influences on Preadolescent and Adolescent Growth in Weight and Height

This review has two aims. The first is to identify important environmental influences on the growth of children aged 1 to 9 years and of adolescents, defined as those aged 10 to 19 years. The second is to identify possible environmentally based criteria for the selection of individuals and populations for data collection in the development of an international growth reference for these age ranges. There are many common environmental influences on the growth of children between the ages of 1 and 19 years; the examination and description of these forms the main body of this review. Subsequently, environmental factors influencing adolescent growth only are considered. In both cases, possible selection criteria are put forward. The most important inclusion criteria for both preadolescence and adolescence are good nutrition, lack of infection, and socioeconomic status that does not constrain growth. Additionally, low birthweight, catch-up growth, breastfeeding, and early adiposity rebound have impacts on growth and/or body composition into puberty. Exclusion of children born at low birth and/or experiencing catch-up growth could be most realistically operationalized if populations in which secular trends in growth were either completed or minimal were selected. Although an effect of hypoxia on child and adolescent growth, independent of nutrition, is small at most, many high-altitude populations have high prevalances of low birthweight and should be excluded on this basis. Since all populations are exposed to pollutants, contaminants, and toxicants in varying degrees, they cannot be realistically excluded from the sample frame. However, it may be desirable to exclude populations that are habitually exposed to extremely high levels of environmental pollution, including air pollution, and those living in close proximity to toxic waste. It is impossible to exclude populations and individuals on the basis of their exposure to aflatoxin contamination of food. However, exclusion on the basis of low socioeconomic status or poverty may well act as a proxy for this. There are a small number of populations that show extreme patterns of growth in body size and proportion in preadolescence and adolescence, and these should be excluded from the sample frame.

New approaches to divorce with children: A problem of public health

This broad review elaborates on the most up-to-date knowledge on biochemical and psychobiological aspects of parental loss and other childhood adversities during divorce involving minor children. So far, divorce involving minor children was unfortunately considered by authorities only as a purely juridical problem, and this approach has often allowed a completely different approach according to the Courts. Now, scientific research, also making use of animal models, is demonstrating the biological basis of the problem and the indisputable consequences on the well-being and health of children. The innovative conclusion of this review is that this argument (because of its frequency and gravity) is primarily a question of public health and that it is necessary to further harmonize practices in this area.

Stress, the stress system and the role of glucocorticoids

All living organisms have developed a highly conserved and regulatory system, the stress system, to cope with a broad spectrum of stressful stimuli that threaten, or are perceived as threatening, their dynamic equilibrium or homeostasis. This neuroendocrine system consists of the hypothalamic-pituitary-adrenal (HPA) axis and the locus caeruleus/norepinephrine-autonomic nervous system. In parallel with the evolution of the homeostasis and stress concepts from ancient Greek to modern medicine, significant advances in the field of neuroendocrinology have identified the physiologic biochemical effector molecules of the stress response. Glucocorticoids, the end-products of the HPA axis, play a fundamental role in the maintenance of both resting and stress-related homeostasis and, undoubtedly, influence the physiologic adaptive reaction of the organism against stressors. If the stress response is dysregulated in terms of magnitude and/or duration, homeostasis is turned into cacostasis with adverse effects on many vital physiologic functions, such as growth, development, metabolism, circulation, reproduction, immune response, cognition and behavior. A strong and/or long-lasting stressor may precipitate and/or cause many acute and chronic diseases. Moreover, stressors during pre-natal, post-natal or pubertal life may have a critical impact on our expressed genome. This review describes the central and peripheral components of the stress system, provides a comprehensive overview of the stress response, and discusses the role of glucocorticoids in a broad spectrum of stress-related diseases. © 2014 S. Karger AG, Basel.

Isolated growth hormone deficiency (GHD) in childhood and adolescence: recent advances

The diagnosis of GH deficiency (GHD) in childhood is a multistep process involving clinical history, examination with detailed auxology, biochemical testing, and pituitary imaging, with an increasing contribution from genetics in patients with congenital GHD. Our increasing understanding of the factors involved in the development of somatotropes and the dynamic function of the somatotrope network may explain, at least in part, the development and progression of childhood GHD in different age groups. With respect to the genetic etiology of isolated GHD (IGHD), mutations in known genes such as those encoding GH (GH1), GHRH receptor (GHRHR), or transcription factors involved in pituitary development, are identified in a relatively small percentage of patients suggesting the involvement of other, yet unidentified, factors. Genome-wide association studies point toward an increasing number of genes involved in the control of growth, but their role in the etiology of IGHD remains unknown. Despite the many years of research in the area of GHD, there are still controversies on the etiology, diagnosis, and management of IGHD in children. Recent data suggest that childhood IGHD may have a wider impact on the health and neurodevelopment of children, but it is yet unknown to what extent treatment with recombinant human GH can reverse this effect. Finally, the safety of recombinant human GH is currently the subject of much debate and research, and it is clear that long-term controlled studies are needed to clarify the consequences of childhood IGHD and the long-term safety of its treatment.

Understanding behavioral effects of early life stress using the reactive scope and allostatic load models

The mechanisms through which early life stress leads to psychopathology are thought to involve allostatic load, the "wear and tear" an organism is subjected to as a consequence of sustained elevated levels of glucocorticoids caused by repeated/prolonged stress activations. The allostatic load model described this phenomenon, but has been criticized as inadequate to explain alterations associated with early adverse experience in some systems, including behavior, which cannot be entirely explained from an energy balance perspective. The reactive scope model has been more recently proposed and focuses less on energy balance and more on dynamic ranges of physiological and behavioral mediators. In this review we examine the mechanisms underlying the behavioral consequences of early life stress in the context of both these models. We focus on adverse experiences that involve mother-infant relationship disruption, and dissect those mechanisms involving maternal care as a regulator of development of neural circuits that control emotional and social behaviors in the offspring. We also discuss the evolutionary purpose of the plasticity in behavioral development, which has a clear adaptive value in a changing environment.

Research, Practice, and Policy Perspectives on Issues of Children without Permanent Parental Care

This chapter presents conclusions, trends, conceptual analyses, hypotheses, and speculations regarding some fundamental issues of research, practice, and policy that are largely unsettled or controversial. As such, the chapter is not a summary of Chapters 1-8, but rather contains interpretations and opinions of the author intended to elevate the priority of certain issues, suggest hypotheses to be studied, and propose practice and policy steps to be considered.

Research, Practice, and Policy Perspectives on Issues of Children without Permanent Parental Care

This chapter presents conclusions, trends, conceptual analyses, hypotheses, and speculations regarding some fundamental issues of research, practice, and policy that are largely unsettled or controversial. As such, the chapter is not a summary of Chapters 1-8, but rather contains interpretations and opinions of the author intended to elevate the priority of certain issues, suggest hypotheses to be studied, and propose practice and policy steps to be considered.

Early experience and the development of stress reactivity and regulation in children

Children who spend early portions of their lives in institutions or those maltreated in their families of origin are at risk for developing emotional and behavioral problems reflecting disorders of emotion and attention regulation. Animal models may help explicate the mechanisms producing these effects. Despite the value of the animal models, many questions remain in using the animal data to guide studies of human development. In 1999, the National Institute of Mental Health in the United States funded a research network to address unresolved issues and enhance translation of basic animal early experience research to application in child research. Professor Seymour Levine was both the inspiration for and an active member of this research network until his death in October of 2007. This review pays tribute to his legacy by outlining the conceptual model which is now guiding our research studies.

Natural Parenting — Back to Basics in Infant Care

This review examines an age-old approach to parenting recently rediscovered in Western industrialized societies and known by names such as natural parenting, attachment parenting, and instinctive parenting. Its leading principle is utmost sensitivity to the child's innate emotional and physical needs, resulting in extended breastfeeding on demand, extensive infant carrying on the caregiver's body, and cosleeping of infant and parents. The described practices prevailed during the evolutionary history of the human species and reflect the natural, innate rearing style of the human species to which the human infant has biologically adapted over the course of evolution. An overview of research from diverse areas regarding psychological as well as physiological aspects of early care provides evidence for the beneficial effects of natural parenting. Cross-cultural and historical data is cited to reveal the widespread use of the investigated parenting style. It is concluded that the described approach to parenting provides the human infant with an ideal environment for optimal growth both psychologically and physiologically. It is yet to be determined how much departure from this prototype of optimal human parenting is possible without compromising infant and parental wellbeing. The review also invites a critical reevaluation of current Western childrearing practices.

Long-term growth and puberty concerns in international adoptees

Growth delay is one of the most common and persistent findings in children who have been adopted from abroad. Although the cause is not clearly understood, it may be related to the observed phenomenon of psychosocial short stature described in children from abusive and neglectful settings in western countries. Fortunately, adopted children generally experience significant improvement in growth after joining their new family, but this may put girls at risk for early and rapidly progressing puberty. This review should help the health care team to understand these issues and work better with the adoptive parents to ensure a child's smooth transition into family life.

ENDOCRINOLOGY OF THE STRESS RESPONSE

The stress response is subserved by the stress system, which is located both in the central nervous system and the periphery. The principal effectors of the stress system include corticotropin-releasing hormone (CRH); arginine vasopressin; the proopiomelanocortin-derived peptides alpha-melanocyte-stimulating hormone and beta-endorphin, the glucocorticoids; and the catecholamines norepinephrine and epinephrine. Appropriate responsiveness of the stress system to stressors is a crucial prerequisite for a sense of well-being, adequate performance of tasks, and positive social interactions. By contrast, inappropriate responsiveness of the stress system may impair growth and development and may account for a number of endocrine, metabolic, autoimmune, and psychiatric disorders. The development and severity of these conditions primarily depend on the genetic vulnerability of the individual, the exposure to adverse environmental factors, and the timing of the stressful events, given that prenatal life, infancy, childhood, and adolescence are critical periods characterized by increased vulnerability to stressors.

Transition from paediatric to adult endocrinology: hypopituitarism

For patients at the transition stage between childhood and adulthood, cooperation between paediatric and adult endocrinologists is essential for optimum care. Evaluations of patients in transition consist of retrospective assessments of what happened in childhood combined with prospective planning for treatment and follow up into adult life. Successful transfer of patients in transition from paediatric to adult care should follow a general sequence tailored to local circumstances. First, all patients with GH deficiency and their families should be informed by their paediatric endocrinologist about the long term consequences of GH deficiency in adulthood and the potential need for life-time GH replacement therapy. Second, retesting will be needed for evaluating hypothalamic pituitary function, re-evaluation of the need for replacement therapy for other pituitary hormone deficits, measurement of fasting lipid concentration and assessment of skeletal integrity. Third, the patient and physicians should consider the option of attending an out-patient clinic having both a paediatric and an adult endocrinologist. Regardless, the wishes of the patient should be respected as much as possible. It is essential that those patients who had childhood-onset GH deficiency and who were treated with GH be followed throughout adult life.

[Growth retardation and nutritional status in foster children]

BACKGROUND

Our main objective was to determine growth retardation in children entering a foster home and catch-up growth at the end of the stay. We also analyzed the nutritional status and its relationship with growth retardation.

SUBJECTS AND METHOD

Height and weight were determined in 118 children, aged between one month and fifteen years; they were examined at admission and at the time of leaving the center. In another group of 31 prepubertal children, we analized their nutritional status determining the body mass index, prealbumin, retinol binding protein, GHBP, IGF-1, IGFBP-3 and leptin at admission.

RESULTS

31 (26.2%) out of the of the 118 children group had a height deficit (height < 2 SDS) at admission. 32 (27.1%) of the overall group of children showed significant catch-up growth after their stay at the foster home, and 15 (46.8%) of them showed a catch-up growth > 0.5 SDS. Children below two years of age showed the most important growth deficit. The nutritional status study showed normal results in all parameters in the 31 children group. Significant correlations were observed between IGF-I and weight/height, IGFBP-3 and weight/height, GHBP and body mass index, and leptin and body mass index.

CONCLUSIONS

An important proportion of children showed significant growth retardation at entering a foster home, although a significant catch-up growth was observed at the end of their stay. Growth failure in this population does not appear to be related to the nutritional status.

Dysregulation of the hypothalamic-pituitary-adrenal axis in short children with and without growth hormone deficiency

The effects of L-dopamine (LD) administration and insulin-induced hypoglycemia in adrenocorticotropin (ACTH) and cortisol secretion were studied in 14 short boys. LD caused moderate changes in both hormones. The four boys with isolated, idiopathic growth hormone (GH) deficiency (IGD) demonstrated a greater cortisol increase in response to hypoglycemia than the 10 boys with normal GH secretion. In at least some short children with IGD, abnormal regulation of the hypothalamic-pituitary-adrenal axis may be present.

The importance of neurobiological research to the prevention of psychopathology

There is both a biological and environmental component to the neural substrates for various forms of psychopathology. Brain dysfunction itself not only constitutes a formidable liability to psychopathology, but also has an impact on environmental and social responses to the individual, compounding the risk for an adverse outcome. Environmental conditions, such as social and physical stimulus deprivation, poverty, traumatic stress, and prenatal drug exposure, can further compromise brain function in the context of existing liabilities. The relationship between genetic and environmental processes is interactive, fluid, and cumulative in their ability to influence an individual's developmental trajectory and alter subsequent behavioral outcomes. Given the codependent relationship between these processes, brain function is now believed to be malleable via manipulations of the environment in ways that may decrease liability for psychopathology. Research that explores these relationships and ways in which interventions can redirect this developmental track may substantially advance both the science and practice of prevention. Studies attempting to isolate the neurobiological effects of socioenvironmental factors are reviewed, implications for intervention strategies are discussed, and a future research agenda is proposed to provide greater insight into specific brain-environment relationships. Armed with this knowledge, prevention scientists may eventually design programs that directly target these effects to reverse or attenuate negative outcomes.

Metaphyseal growth arrest lines in psychosocial short stature

Metaphyseal growth arrest lines are seen in children who experience significant physical stress such as infection or malnutrition over a sufficient period of time. These lines have not been reported previously in children with psychosocial short stature (PSS). Two boys and a girl with PSS with metaphyseal growth arrest lines on skeletal radiographs at the time of maximal stress in their homes are described. All three had reversible growth hormone insufficiency during admission, which is pathognomic for PSS. Multiple growth arrest lines in the distal end of the radius or vertebrae should alert clinicians to an alternative diagnosis in a child with growth hormone insufficiency. This may provide a clue to the diagnosis of occult PSS.

Non-organic failure to thrive complicated by benign intracranial hypertension during catch-up growth

Severe non-organic failure to thrive associated with physical and emotional abuse including food deprivation was diagnosed in a 9-y-old boy. Rapid catch-up growth (weight and height) followed change of carer. Recovery of poor growth hormone response to clonidine stimulation was associated with benign intracranial hypertension accompanied by headaches and vomiting. Possible mechanisms are discussed.

Neuroendocrinology and pathophysiology of the stress system

The human organism is in a state of dynamic equilibrium, homeostasis. The stress system is activated when homeostasis is challenged by extrinsic or intrinsic forces, the stressors. This system, whose central component is the central nervous system (CNS) and includes corticotropin-releasing hormone (CRH) and noradrenergic neurons, respectively, in the hypothalamus and the brain stem, has as its peripheral limbs the hypothalamic-pituitary-adrenal (HPA) axis and the autonomic (sympathetic) nervous system. Normal development and preservation of life and species are dependent on a normally functioning stress system. Maladaptive neuroendocrine responses, i.e., dysregulation of the stress system, may lead to disturbances in growth and development, and cause psychiatric, endocrine/metabolic, and/or autoimmune diseases or vulnerability to such diseases.

A boy with psychosocial short stature followed up from infancy to adulthood

A boy with psychosocial short stature who has been followed up from the age of 11 months to adulthood is described. The boy was the product of an unwanted pregnancy. The emaciated short boy gained weight and height markedly during a short-term stay at hospital, but lost weight and experienced minimal height gain at home. On the fourth hospital admission at the age of 6 years 3 months the boy weighed 10 kg and measured 85.7 cm, he was malnourished and exhibited strange behavior and had a voracious appetite. He was examined endocrinologically and provocative tests performed early after admission showed insufficient growth hormone secretion, although this recovered later at a time of catch-up growth. The boy was reared in an orphanage from the age of 6 years 5 months until the age of 15 years 3 months. His growth rapidly caught up to a normal rate, his abnormal behavior disappeared, and he demonstrated an increased IQ. He attained 169.5 cm at the age of 17.5 years and possessed normal secondary sexual characteristics. After graduating from senior high school the patient has been living happily by himself without intervention from his mother, and is working in a Chinese restaurant. The impaired relationship between the boy and mother has never been restored. The record of growth and development described in this case is the longest ever reported.