Early Detection of Adrenal Insufficiency: The Impact of Newborn Screening for Adrenoleukodystrophy

CONTEXT

Males with adrenoleukodystrophy (ALD) have an 80% lifetime risk of developing adrenal insufficiency (AI), which can be life-threatening when undetected. Newborn screening (NBS) for ALD has been implemented in 29 states, yet the impact of NBS upon clinical management has not been reported.

OBJECTIVE

To investigate whether the implementation of NBS has altered the time to diagnosis of AI in children with ALD.

DESIGN

We conducted a retrospective medical chart review of pediatric patients with ALD.

SETTING

All patients were seen in a leukodystrophy clinic in an academic medical center.

PATIENTS

We included all pediatric patients with ALD who were seen between May 2006 and January 2022. We identified 116 patients (94% boys).

MAIN OUTCOME MEASURES

We extracted information about ALD diagnosis in all patients and AI surveillance, diagnosis, and treatment in boys with ALD.

RESULTS

Thirty-one (27%) patients were diagnosed with ALD by NBS, and 85 (73%) were diagnosed outside the newborn period. The prevalence of AI among boys in our patient population was 74%. AI diagnosis was made significantly earlier in boys diagnosed with ALD by NBS than in boys diagnosed outside the newborn period (median [IQR] age of diagnosis = 6.7 [3.9, 12.12] months vs 6.05 [3.74, 8.35] years) (P < .001). When maintenance dose of glucocorticoids were initiated, there were significant differences in ACTH and peak cortisol levels in patients diagnosed by NBS and outside the newborn period.

CONCLUSIONS

Our results suggest that implementing NBS for ALD leads to significantly earlier detection of AI and earlier initiation of glucocorticoid supplementation in boys affected by ALD.

International Recommendations for the Diagnosis and Management of Patients With Adrenoleukodystrophy: A Consensus-Based Approach

Pathogenic variants in the ABCD1 gene cause adrenoleukodystrophy (ALD), a progressive metabolic disorder characterized by three core clinical syndromes: a slowly progressive myeloneuropathy, a rapidly progressive inflammatory leukodystrophy (cerebral ALD), and primary adrenal insufficiency. These syndromes are not present in all individuals, and are not related to genotype. Cerebral ALD and adrenal insufficiency require early detection and intervention and warrant clinical surveillance because of variable penetrance and age of onset. Newborn screening has increased the number of presymptomatic individuals under observation, but clinical surveillance protocols vary.We used a consensus-based modified Delphi approach among 28 international ALD experts to develop best-practice recommendations for diagnosis, clinical surveillance, and treatment of ALD patients. We identified 39 discrete areas of consensus. Regular monitoring to detect the onset of adrenal failure and conversion to cerebral ALD is recommended in all male patients. Hematopoeitic cell transplant (HCT) is the treatment of choice for cerebral ALD. This guideline addresses a clinical need in the ALD community worldwide as the number of overall diagnoses as well as presymptomatic individuals is increasing due to newborn screening and greater availability of next generation sequencing. The poor ability to predict the disease course informs current monitoring intervals but remains subject to change as more data emerges. This knowledge gap should direct future research and illustrates once again that international collaboration amongst physicians, researchers and patients is essential to improving care.

Adrenal insufficiency updates in children

PURPOSE OF REVIEW

The current article will review the newest diagnostic tools, genetic causes, and treatment of adrenal insufficiency in children.

RECENT FINDINGS

It is common practice to perform an adrenocorticotropin hormone (ACTH) stimulation test when adrenal insufficiency is suspected. The indications for use of a high-dose or low-dose of synthetic ACTH in children have been refined. In addition, newer studies propose adding 15 and 30-min serum or salivary cortisol levels to the low-dose ACTH stimulation test to correctly identify adrenal insufficiency. Recent identification of genetic mutations in children with non-classic steroidogenic acute regulatory protein and other mutations associated with primary and secondary adrenal insufficiency have expanded the cause and pathophysiology of monogenic adrenal insufficiency. In addition, newer hydrocortisone formulations and delivery methods and medications to use in combination with hydrocortisone are being explored to improve treatment for children with adrenal insufficiency.

SUMMARY

Improved diagnostic aids, detection of newer genetic mutations, and better treatment options and delivery systems will help correctly identify and manage children with adrenal insufficiency to improve health outcomes and quality of life.

VIDEO ABSTRACT

http://links.lww.com/COE/A21.

Use of an aromatase inhibitor in children with congenital adrenal hyperplasia: Impact of anastrozole on bone mineral density and visceral adipose tissue

OBJECTIVE

Anastrozole, an aromatase inhibitor, has been used off-label in males with short stature to delay bone maturation. No studies have examined anastrozole's effect on bone mineral density (BMD) or body composition in children with congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency. Our objective was to evaluate anastrozole's effect on BMD and visceral adipose tissue (VAT) in children with CAH.

DESIGN

Total body BMD (TBMD) and L2-L4 BMD Z-scores were adjusted for height-for-age Z-scores (TBMD_HAZ and L2-L4_HAZ ). Hydrocortisone doses (mg/m² /d) were averaged over the previous year. Comparison of treated vs not treated with anastrozole used linear regression adjusting for age, pubertal status, sex, CAH type, years on hydrocortisone, BMI Z-scores and bone age Z-scores.

PATIENTS

We compared 25 children with CAH treated with anastrozole (mean age 11.3 [SD 3.0] years, 56% males) vs 31 children with CAH not treated with anastrozole (13.5 [SD 4.6], 29%). Participants underwent a pubertal exam, bone age X-ray and dual X-ray absorptiometry (DXA) scan.

RESULTS

Average bone age Z-score of 4.3 SDs on beginning anastrozole decreased to 1.9 SDs at time of DXA exam (P = 0.0004) 5.2 (SD 2.2) years later. TBMD Z-scores (P = 0.51), L2-L4 BMD Z-scores (P = 0.66), VAT (P = 0.38), TBMD_HAZ Z-scores (P = 0.66) and L2-L4_HAZ Z-scores (P = 0.41) did not differ between children treated vs not treated with anastrozole.

CONCLUSION

Anastrozole significantly reduced bone age advancement in children with CAH and advanced bone age (>2SDs) without adverse effects on BMD or VAT. Longitudinal studies of anastrozole in children with CAH are needed to validate these findings.

Establishing the incidence and timing of hypoglycemia at a residential diabetes camp

AIMS

To establish the incidence and timing of hypoglycemia at a week-long residential diabetes camp for children. We hypothesized that hypoglycemia would occur more frequently during the first two days of camp and following evening all-camp games.

METHODS

225 children (mean age 12.0 ± 2.3 years, 56% female, mean hemoglobin A1c 8.4% [71.6 mmol/mol]) had blood glucose (BG) levels obtained before meals, at bedtime, and as needed to detect hypoglycemia. Insulin adjustments were made by medical staff according to camp protocol and at the discretion of medical staff during camper check-in.

RESULTS

Mild hypoglycemia (BG 50-69 mg/dL [3.9 mmol/L]) occurred ≥ 1 time in 90% of campers while 43% had ≥ 1 episode of BG < 50 mg/dL (2.8 mmol/L). No episodes of hypoglycemia requiring glucagon occurred. More campers experienced ≥ 1 overnight hypoglycemia event during the first 48 hours of camp compared to later in the week (p = 0.01). Evening all-camp games did not impact hypoglycemia rates overnight.

CONCLUSIONS

Nocturnal hypoglycemia occurred more frequently during the first two nights, establishing this period as high risk and supporting implementation of a standard protocol to lower insulin doses. Rates of hypoglycemia were unaffected by all-camp games, indicating current practices are effective at minimizing hypoglycemia.

Bone mineral density and body composition in children with congenital adrenal hyperplasia

OBJECTIVE

Children with congenital adrenal hyperplasia (CAH) are exposed to fluctuating cortisol and androgen levels. The effects these hormonal states have on bone mineral density (BMD) and body composition are not well studied. The study's objective was to compare BMD and body composition, including visceral adipose tissue (VAT) and Android:Gynoid (A:G) ratio, in children with CAH vs healthy age-matched, sex-matched and BMI-matched controls.

DESIGN

Total body BMD (TBMD) Z-scores were adjusted for height-for-age Z-scores (TBMDHAZ). Hydrocortisone dose (mg/m2/d) was averaged over the past year. Bone age Z-scores were used as a surrogate for long-term androgen exposure in cases. Statistical analyses comparing cases and controls accounted for matched groups using mixed linear models.

PATIENTS

Forty-two cases with CAH (average age 12.3 years [SE 3]; 17 males) and 101 controls underwent a dual-energy X-ray absorptiometry scan.

RESULTS

Children with CAH had lower TBMD (0.81 vs 1.27, P = .003) and TBMD_HAZ Z-scores (-0.51 vs -0.01, P = .001) than controls. In CAH cases, TBMD and TBMD_HAZ Z-scores were positively correlated with bone age Z-scores (r = .63, P < .0001; r = .51, P = .001, respectively) but were not associated with HC dose. VAT and the A:G ratio did not differ significantly between children with CAH and controls and neither was associated with HC dose.VAT was not associated with bone age Z-score.

CONCLUSION

Lower BMD was observed in CAH cases compared with controls although no differences in body composition were identified. Among CAH cases, increased chronic androgen exposure, as measured by bone age Z-scores, was associated with higher BMD but was not associated with VAT.

Health-related quality of life in children with congenital adrenal hyperplasia

Background

Children with congenital adrenal hyperplasia (CAH) require life-long glucocorticoid replacement and have daily intermittent hyper/hypocortisolemia and hyperandrogenemia. Health-related quality of life (HRQL) is important for understanding the impact the disease and therapy have on physical, mental, emotional, and social functioning. Little is known about HRQL in CAH. We compared HRQL in children with CAH to healthy norms and examined how these scores related to physiologic variables.

Methods

A cross-sectional study examined 45 patients (mean age 8.2(4.5) years). Thirty-two self-reported their quality of life (QoL) on the PedsQL™ Generic Core Scale and PedsQL™ Fatigue Scale, and 44 parents completed a parent report. Bone age Z-scores were calculated from the most recent bone age.

Results

Children with CAH did not report lower QoL than healthy norms. However, their parents reported lower overall QoL and fatigue scores than parents of healthy norms. Children with CAH rated sleep poorer than their parents. QoL scores did not differ by sex or CAH subtype and were not associated with total daily hydrocortisone dose. Bone age Z-scores were negatively associated with child-reported emotional health and cognitive fatigue.

Conclusions

Parents of children with CAH reported a negative impact of disease on their children’s QoL, but their children did not. The negative associations between bone age Z-scores and emotional health and cognitive fatigue suggest an impact from chronic hypocortisolemia and hyperandrogenemia.

Effects of bolus volume, viscosity, and repeated swallows in nonstroke subjects and stroke patients

This study examined the effects of bolus volume and viscosity and the variability of repeated swallows in ten stroke patients and ten age-matched nonstroke subjects. The ten stroke patients demonstrated single unilateral cortical (three subjects), subcortical (six subjects), or brainstem (one subject) infarcts on computed tomography or magnetic resonance imaging scans at three weeks post-ictus. All subjects underwent videofluoroscopic swallow studies in which seven temporal pharyngeal swallow measures were examined. Despite the dissimilarity in lesion locations, the swallow physiology in the stroke patients was relatively homogeneous, ie, no swallowing disorders severe enough to prevent oral intake. As bolus volume increased, pharyngeal delay time diminished in stroke patients, but not in nonstroke subjects. Increasing bolus volume affected three other pharyngeal swallow measures similarly in nonstroke and stroke subjects: laryngeal closure durations and cricopharyngeal (CP) opening durations increased and duration of tongue base contact to posterior pharyngeal wall decreased. On viscosity comparisons (liquid vs paste), both subject groups displayed longer duration of base of tongue contact to posterior pharyngeal wall. On paste swallows, nonstroke subjects had longer CP opening and lower swallow efficiency, whereas stroke patients did not. This study found no statistically significant learning/repetition effect for repeated swallows in either subject group, or both groups combined.

Oropharyngeal swallowing after stroke in the left basal ganglion/internal capsule

One of the foci of Martin Donner's work was the neural control of swallowing. This present investigation continues that work by examining oropharyngeal swallowing in 8 patients identified with a single, small, left-basal ganglion/internal capsule infarction and 8 age-matched normal subjects. Stroke patients were assessed with a bedside clinical and radiographic swallowing assessment, and normal subjects received only the radiographic study. Results revealed disagreement between the bedside and radiographic assessments in one of the 8 stroke patients. Stroke and normal subjects differed significantly on some swallow measures on various bolus viscosities, but behaved the same as normal subjects on a number of measures. Differences in swallowing in the stroke subjects were not enough to prevent them from eating orally. The significant differences seen in the basal ganglia/internal capsule stroke subjects may result from damage to the sensorimotor pathways between the cortex and brainstem. These differences emphasize the importance of cortical input to the brainstem swallowing center in maintaining the systematic modulations characteristic of normal swallowing physiology.

Parent involvement with children's health promotion: a one-year follow-up of the Minnesota home team

This study compares the long-term outcomes of a school-based program to an equivalent home-based program with 2250 third-grade students in 31 urban schools in Minnesota and North Dakota in order to detect changes in dietary fat and sodium consumption. The school-based program, The Adventures of Hearty Heart and Friends, involved 15 sessions over five weeks in the third-grade classrooms. The home-based program, the Hearty Heart Home Team, involved a five-week correspondence course with the third graders, where parental involvement was necessary in order to complete the activities. Outcome measures included anthropometric, psychosocial, and behavioral assessments at school, and dietary recall, food shelf inventories, and urinary sodium data collected in the students' homes. Participation rates for all aspects of the study were notably high. Eighty-six percent of the parents participated in the Home Team and 71% (almost 1000 families) completed the five-week course. Students in the home-based program reported more behavior change at posttest, had reduced the total fat, saturated fat, and monounsaturated fat in their diets and increased their complex carbohydrate consumption. The changes derived from the dietary recall data did not maintain after one year. The data converge to suggest the feasibility and importance of parental involvement for initiating health behavior changes with children of this age.

The Communication Analysis System

The Communication Analysis System (CAS) was developed to facilitate efficient, effective treatment of conversational performance for persons with aphasia. The CAS provides frequent, objective, accurate, ratio-quality measures of ten classes of communicative behaviors for the patient and 11 for the clinician. The clinician using the CAS records the time of occurrence of communicative behaviors by a single keystroke on a keypad attached to an inexpensive microcomputer. The CAS software permits the analysis of data before the next clinical session and includes a method for assessing accuracy and reliability. Sample between-session data show the progress of one patient over several months, whereas within-session data illustrate a use of the CAS to measure a patient's performance under different communicative conditions. Simultaneously, measures of the clinician's communicative performance provide an accurate record of the treatment. This, in turn, allows observation of changes in the patient's behavior as a function of changes in the clinician's behavior. Clinical treatment can thereby be tailored precisely to the individual, optimizing the patient's rehabilitation.